Discusses the ways hypnosis can be used for patient benefit in dental practice.
Briefly examines the two main theories behind what hypnosis is and their relevance to dentistry.
Discusses basic hypnotic language patterns and how these might be used in every patient encounter.
Provides a background for clinicians wanting to become more involved in hypnotic practice.
Hypnodontics, or the use of hypnosis in dentistry, is not widely used throughout the dental profession. Many patients seeking to use this therapy to help them access dental treatment are forced to seek treatment from non-clinically trained hypnotherapists. This article aims to explore what hypnosis is, its applications in dentistry and provide a brief insight into how these hypnotic concepts may be put to use in day-to-day dental practice.
Hypnosis has a poor reputation and a past chequered with controversy. This is mainly because it has become associated with stage performance and charlatanism. The 1952 Hypnotism Act came into force after a girl reportedly died after attending a stage hypnotism performance, yet whether it was the hypnosis or the fatally high alcohol level in her blood that killed her, we will never know. Despite this negative press, stage performers are wickedly clever. They have a group of people before them in the audience that at some level (consciously or subconsciously) want to believe and share in their advertised abilities. That is why they are able to produce fantastic results. The hypnotic technique used in clinical dentistry, whilst principally the same, is vastly more subtle and delicate, not to mention more ethical and, in some cases, more legal.1
In 1775, an Austrian physician by the name of Franz Mesmer was asked to give his medical opinion on exorcisms being carried out by a priest in Germany. His conclusion was that the ability of the holy man was due to 'animal magnetism' and whilst the priest's efforts were sincere, the process was due to automatism. 'Animal magnetism' is a now disproved theory, but provided the foundations of the hypnotic model. The idea being that through manipulation of a person's magnetic fields symptoms of intense heat, trembling and even seizures could be elicited. The phenomenon of automatism can be demonstrated very effectively by a technique called Chevreul's pendulum.2 I use this phenomenon to assess a patient's responsiveness to hypnosis. The technique involves a simple pendulum held straight between the forefinger and thumb. The patient is invited to concentrate on the pendulum, to notice its shape and colour. The patient is then asked to imagine that the pendulum is in fact an extension of their body and that they should attempt to cause the pendulum to swing from side to side with their mind. In the majority of cases after a matter of seconds the pendulum will begin to move in the suggested direction. I always find the patient's disbelief incredibly satisfying. The psychology behind automatism is simple, if a situation is imagined intensely enough the body will try to react in a way as if this imagined situation is reality. In this case, the body will cause subconscious and unnoticeable movements to cause the swinging. Out of interest, it is this same phenomenon that makes dowsing and Ouija boards work.
Hypnosis in dentistry
Ok, so very interesting, but what do swinging pendulums have to do with dentistry? The same idea of suggesting an imagined situation to elicit a physiological response can be utilised to reduce anxiety, prevent destructive behaviours (bruxism) and create sensory phenomena such as glove anaesthesia. Now if you take your average patient and tell them to imagine that they are really comfortable and calm as you load the anaesthetic syringe in full view of their widened eyes, you would not be surprised when they did not seem too relaxed. These techniques rely on a certain level of preparatory work to initiate a trance state in the patient's mind. This requires a procedure called hypnotic induction. In this procedure the patient is invited (or in some cases told in a more authoritative way) to relax and enter a trance state. Hypnosis in a stage show is done with the presentation that the hypnotist has absolute authority. Once upon a time, health professionals used to act in this way, but as the paternalistic culture of our predecessors gave way to a greater equality in the professional-patient relationship, so the language of hypnotherapists came to incorporate a more permissive style. For example, instead of 'close your eyes now' we would be more likely to use 'in a moment, if you wish, you may close your eyes'. This is also a better way of offering suggestions as it may accommodate patients who choose not to close their eyes at that point in the therapy.
Many people have difficulty with the concept of what a trance is because they believe they have never been in one. Hypnosis in the clinical environment is an artificial recreation of a process most of us enter several times a day. For example, if I asked you to think of how many times you changed gear on your journey to work this morning, you would most likely have no idea. This is because for most experienced drivers changing gear is a completely unconscious task. Another example that strikes fear into me when it comes to mind is the times at school (and there were many) when I would drift off, thinking about forbidden fruits and better things, to be roused with 'what did I just say?' from an irate teacher. The amnesia you suffer when you daydream is another example of 'raw hypnosis'.
Whilst there are many theories of hypnosis, the two main schools deal with hypnosis as either a state or a non-state phenomenon. State theories suggest that hypnosis is a separate state of consciousness to the normal waking state. They suggest that responses to hypnotic suggestions are the results of processes such as dissociation. These theories were supported by the works of psychologists such as Earnest Hilgard.3 Non-state theories deal with hypnosis as being the product of normal processes in a normal state, where expectations and experiences dictated the individual responses from 'hypnotic subjects'. These theories are supported by the works of Irving Kirsch4,5 among others. Deciding which theory is closest to explaining this phenomenon is beyond the scope of this article, but essentially it does not matter as principles of hypnosis in dentistry are the same regardless of the theory school one subscribes to. The general idea is still the same, involving the production of a hyper-suggestible state.
In day-to-day practice we are more likely to employ hypnotic language than full blown hypnotic inductions and deepeners. Sadly, this more comprehensive treatment option is only realistically available to those with a plethora of time or who are charging private fees. For those with time, anaesthesia may be elicited in a patient's hand and they may be then invited to transfer this to another part of their body by asking them to rub the desired area to 'pass on the numbness'. In dentistry this is useful before local anaesthetic placement in needle phobic patients. The principles of eliciting glove anaesthesia are extensive and best left to be discussed in a later article, but other, simpler hypnotic techniques may be used to reduce anxiety. Sometimes, patients are not afraid of the pain that dental treatment brings, but of the procedure itself. A needle-phobic patient of mine once remarked that he felt a long metal tube breaking the skin was 'unnatural' and that was the cause of his profound abreaction to needles.
With regard to hypnotic language, how much thought do we give to how we say things to patients? Consider the following phrase:
'I'm afraid it's bad news, you have extensive periodontal disease and you have missed a lot of plaque, let me show you.'
Sound familiar? It's not a bad phrase. It is giving the patient information and offering them help. However, consider this next phrase, which says the same thing only differently:
'Well the good news is you can have a healthy mouth; please allow me to show you how you can achieve this.'
Notice anything? The lack of negative language appeals more to patients and is more likely to gain a positive response. The language we use is crucial to patients' uptake of ideas and advice.
Do not think of a clown doing a handstand. I can guarantee you that you have just thought of an image you would not have conjured up today unless you were reading this. It seems obvious, but consider how many times you say to patients, 'don't worry, this won't hurt.' Or words to that effect? This phrase actually has the opposite effect. The patient may not have even been considering feelings of worry until you mention it. The subconscious effect of negative suggestions is so powerful that they are sometimes used to overcome the resistance some patients might show to suggestion, for example:
'I don't want you to feel more relaxed and feel as if your body is sinking into the chair, you mustn't allow your feeling of worry to leave your mind and be replaced by a comfortable feeling of calm.'
To the uninitiated, this approach can seem almost immature, but it is highly effective reverse psychology. At this point, by use of the term resistant, I mean patients who are consenting to hypnosis, but are having difficulty accepting the concept. By saying a statement the resistant patient is not adverse to, they are more likely to listen and be subconsciously suggestible to carrying it out. It would be prudent at this moment to stress that hypnosis is like any other treatment we might use to achieve oral health and if the patient expresses either reluctance or unwillingness to be treated, it is best avoided as a therapy. Another approach for treatment of patients resisting hypnosis would be to ask them to imagine a situation, rather than actually act it out in their mind. If you have just had to re-read that last statement because you cannot notice a difference, you are correct. There is no difference to actually going through the paces of a hypnotic induction and imagining you are going through the paces. This is a clever little tactic of letting the patient think they are resisting your techniques, when in fact they are carrying out your instructions just as you would like. For example:
'I want you to imagine that you are going to let yourself relax and breathe out deeply. With each breath I want you to imagine yourself to be becoming more and more relaxed.'
I would recommend that all dentists should try to employ hypnotic language in their practice and many I'm sure will use it naturally without giving it that label. The use of presuppositions and positive alternatives to harsh language (for example cool instead of cold) is extremely simple but can often seem an unnatural practice before the concept has been used and perfected. A master of hypnotic language was American psychiatrist Milton Erickson who is quite rightly seen as the father of modern hypnosis. In his book My voice will go with you6 Erickson gives many examples of speech patterns that can be used to great hypnotic experience, often delving into his own meandering experience to provide context.
A word of warning: hypnosis is a particularly powerful tool in patient management. If it is used inappropriately by a practitioner who is unable to elicit the desired response, it has the same effect as any other failed procedure, loss of confidence. Full and informed consent needs to be gained for any formal induction procedure. Possibly one of the most important factors in hypnodontics is the requirement for a chaperone. The clinician and the patient should never be left alone together during hypnotic procedures much in the same way as for sedation. Hypnosis is a controlled fantasy and as such, strong images may be produced that can lead to patients having feelings of confusion about what has exactly taken place.
In conclusion, hypnosis is lamentably under-used in British dental practice, often seen as a 'soft' subject. It also has a bad reputation due to occasions of misunderstanding and misuse. It has been reported that hypnosis is not taught to a standard where practitioners will feel that it is a tool they are confident to use to assuage the fears of the anxious patient.7 Most practitioners who decide they want to use hypnosis go on academic courses that offer an introduction to the subject. Anyone interested in undertaking further training should contact either the National Council for Hypnotherapy (www.hypnotherapists.org.uk) or the British Society of Clinical or Academic Hypnosis (www.bscah.com). The former believes hypnosis can be practiced by everyone who carries out any form of therapy; the latter believes that hypnosis should only be carried out by those with a primary clinical background such as doctors, dentists and clinical psychologists. Hypnosis is a wonderfully benign therapy that with the correct training and the right patient selection can bring so much added value to a professional's practice and skill set. I have found hypnosis to be extremely rewarding with its clinical results and hope that this article can inspire others to start to see the benefits for themselves.
Hypnotism Act. Online information available at http://www.legislation.gov.uk/ukpga/Geo6and1Eliz2/15-16/46/contents (accessed March 2012).
Easton R D, Shor R E. An experimental analysis of the Chevreul pendulum illusion. J Gen Psychol 1976; 95: 111–112.
Hilgard E R. A neodissociation interpretation of pain reduction in hypnosis. Psychol Rev 1973; 80: 396–411.
Kirsch I, Lynn S J. Altered state of hypnosis: changes in the theoretical landscape. Am Psychol 1995; 50: 846–858.
Kirsch I, Lynn S J. Dissociation theories of hypnosis. Psychol Bull 1998; 123: 100–115.
Erickson M, Rosen S. My voice will go with you: the teaching tales of Milton H. Erickson. London: W. W. Norton & Company, 1991.
Hill K B, Hainsworth J M, Burke F J, Fairbrother K J. Evaluation of dentists' perceived needs regarding treatment of the anxious patient. Br Dent J 2008; 204: E13.
Thank you to Dr Neil Holden for introducing me to such a wonderful subject and Vasiliki Karassellos for help with proof-reading.
About this article
Cite this article
Holden, A. The art of suggestion: the use of hypnosis in dentistry. Br Dent J 212, 549–551 (2012). https://doi.org/10.1038/sj.bdj.2012.467