Introduction
Fear and anxiety toward the dentist and dental treatment are the two most common factors responsible for missed dental appointments. Anxiety is an emotional aspect that anyone experiences before any imminent stimulus, which at times is not even detectable. Usually, it can be encountered at periodic intervals, such as while appearing in interviews or during examinations, while making important decisions in life, in the office, and in various other situations.1 As dentists, we all are acquainted with patients displaying dental fear or anxiety in a dental environment. Dental anxiety applies to being extremely fearful of dental procedures, an emotional or physical condition which occurs before experiencing any phenomenon or treatment. Some authors have reported the prevalence of dental anxiety ranges from 10% to 20%, but there have been studies suggesting that 58% of patients have anxiety toward dental treatment.2 Dental anxiety and phobia can affect anyone’s life negatively and hence it is essential to analyse and lessen these significant barriers to oral health and help in achieving a satisfactory and healthy life.1
Dentists have been using traditional nonpharmacological and pharmacological behaviour management techniques to manage patients with dental anxiety and enhance pain tolerance.2 The use of pharmacological measures like deep sedation or general anaesthesia, however, requires the use of expensive equipment, requiring time and workforce. Also, it has associated risks and side effects and requires intensive monitoring and care.3 There may arise a situation when we fail to manage a patient by all behaviour management means, premedication or general anaesthesia are contraindicated or unaccepted, and we seek a different approach urgently. Among the extensive list of therapies available, ranging from compelling communication to protective restraining, an age-old but infrequently practised procedure, lying in the dark is hypnosis,4, 5 which may help in solving the problem in such cases.
A significant reduction in acute anxiety levels in individuals has been reported with the use of psychological interventions like meditation and Yoga. A recent study found that yoga breathing (pranayama) and meditation activities calm and focus the mind and have therapeutic effects on cognition.6
‘Hypnosis’ originated from the Greek word ‘hypnos’ meaning sleep and this is the reason there is a major misconception related to this technique. There is no denial of the fact that hypnosis involves an altered frame of mind that is neither awake nor asleep but closely midway, with a significant scope of liability to external forces and biases5, 7 We frequently experience hypnosis in our daily lives without even realizing it. An accurate illustration of this can be daydreaming where we can perceive our changing surroundings while being in a state of altered consciousness.8
Several misinterpretations are associated with the world of hypnotism. The word "hypnosis" is frequently associated with theatrical performances, magic, and swinging pendulums5 Many are unfamiliar with the therapeutic values of hypnosis in the field of medicine, dentistry and psychology. Akin to an on-demand state of meditation hypnosis may be deliberately and consciously tapped into, by the patient. We can make the patient accept the therapeutic affiliation of hypnosis during the very first visit by making them aware of its benefits. In medical terms, “Hypnosis is referred to as a distinctive, trance-like mental state induced by an organized pattern of suggestions, usually verbal in nature, beginning with the suggestion of relaxation”. The suggestions may be stated verbally by a hypnosis expert to the patient directly or using imagery, directed at the desired outcome. Hypnosis can also be self-induced. Patients can learn self-hypnosis and voluntarily move into this phase wishfully, to apply imagery and suggestion to ease themselves 9 Another important aspect is that the patients cannot be forced to do or say something that they do not wish to and always have charge of the session which they can terminate anytime willingly even when into the deepest hypnotic stage. 10
The use of hypnosis in curing ailments is quite ancient. Cuneiform tablets dating from 4000 BC reveal that Sumerians were aware of hypnosis. It is a technique that can alter phenomenological characteristics, alleviate pain, lessen anxiety and depression, promote comfort, and be used as an analgesic before and after surgery.11, 12 Hypnosis is efficient in the treatment of various conditions including acute pain, and a huge amount of literature supports this hypothesis. Currently, hypnosis is used to treat a wide range of medical conditions, including acute pain, labour pain, pain associated with the neck and back region, a variety of surgical procedures, migraine and tension headaches, chronic pain syndromes, chronic pain from cancer, arthritis, asthma, paediatric medicine, burn injuries, and diabetic neuropathy. Hypnosis usually results in numbness in an area that can eradicate the requirement for local anaesthesia. With its potential effectiveness and positive effects, and being very economical, the evidence suggests self-hypnosis should be taught and promoted as a “first-line” therapy for various chronic medical ailments. 13
Process of hypnosis induction
Hypnosis is therapy without side effects for patients. The first step in the hypnosis involves initiation of action by telling the patient about an imaginative experience. The hypnotist tells the patient to imagine something pleasant. The following stage is induction, where a basic idea is elaborated upon through creative thinking and additional introduction elaboration. Hypnosis is used to support and evaluate suggestion responses. When the patient is hypnotized, the patient will be directed by the therapist to acknowledge the suggestions for transformations in subjective experiences and changes in consciousness, feelings, emotions, thoughts, or behaviour. Hypnosis can also be done independently by the patient; this is known as self-hypnotized.14 In many situations, scripts are advantageous, as written instructions, scenarios and the use of metaphors can boost the interpersonal morale between the patient and the provider. A universally accepted therapeutic script used by dentists involves the use of a computer-based metaphor system. As the subject enters into a trance (mostly verified with rapid eye movement beneath the eyelids), we can incorporate further treatment steps per the requirement. These include anaesthesia, pain control, management of swellings or bleeding, and any of the aforesaid indications.15, 16
Hypnodontics
The history of hypnodontics, or hypnosis in dentistry, dates back to 1829 when dentists used this therapy to induce anaesthesia and reduce anxiety while performing extraction procedures.13 This led to pioneers in hypnodontics supporting it as a practical and safe treatment option in managing patients. By the turn of the 20th century, a lot of dentists promoted hypnotic suggestions as the primary mode of patient management and control.17 Some dental professionals apply hypnotic suggestions either as an anaesthetic agent alone for extractions or along with local and general anaesthetics for cavity preparations and restorations to reduce anxiety in patients and make them relaxed in a dental clinic.17 Many dentists practice a few styles of hypnosis by using fine pleasant language and positive reinforcement which we have been trained to follow and is part of the “chairside mannerism.” The tone of voice and vocabulary used in addressing the patient can induce a state of relaxation without formal initiation of hypnosis. Hypnosis can aid in allaying fear or increase patient cooperation while administering local anaesthesia. Additional uses of hypnosis involve (but are not confined to), bleeding and swelling; treating bruxism, abnormal gag reflex and salivary production; and guiding in achieving good self-care habits.18 The application of hypnosis will make the patient cooperative, and receptive during painful procedures, leading to a lower heart rate and better recovery through post-hypnosis.7 Eventually this makes the dental experiences more pleasant and easy-going. The anti-anxiety effects achieved with hypnosis, decrease their refusal of future intervention if required.
Hypnosis: Ethics and Limitations
Regardless of the profession or process, the potential issues with using hypnosis are frequently caused by a lack of formal education and a lack of awareness of one's boundaries when offering therapeutic solutions. Dentists must understand the ethical and legal ramifications of engaging in hypnotherapy without justification. 16
Although we can say that hypnosis can bring several positive changes in our life. But still, it has its limitations. We cannot treat every known psychological or medical problem with hypnosis. Like any procedure, there are chances of risks with hypnosis in dentistry, usually when applied unwisely. Various issues that can arise with hypnosis are spontaneous regression (the patient regressing to when fear was prevalent); abreactions (encountering erratic emotions); symptom substitutions (experiencing anaesthesia in regions not anaesthetized); confabulations (imagining that something happened in the dental operatory that did not happen); and failing to eradicate suggestions (e.g., lingering of numbness by the patient).16, 19 Most of these risks are easily managed by obtaining detailed informed consent which must be an inalienable component of any session. Also, disengaging along with re-inducing a patient often helps in alleviating the situation. Video recording of the sessions along with the presence of a witness help in reducing or eliminating confabulations. Lastly, the dental team needs to work within the area of their comfort and core competence and anything outside of this must be referred to other relevant experts without any hesitation.16
Regulations in the use of hypnotherapy
For some unknown reason, hypnosis is portrayed as manipulative therapy. Hypnosis to date is associated with apprehensions, as it has usually been involved in stage performances by non-medico professionals. Since hypnosis involves medical applications, understanding the mind and body, if not correctly used and guided, may lead to undesired reactions in patients. In 1892 British Medical Association (BMA) was the first board in the world to legally accept hypnosis. It was accepted as a mode of therapy for overcoming psychosomatic issues. In 1955, hypnosis was allowed to be used clinically only in certain cases of pain management like childbirth and dentistry. American Medical Association (AMA) accepted the legal use of hypnosis as a therapeutic tool in the United States of America in 1958. One either requires to be licensed or be listed in the Unlicensed Psychotherapists Database to practice hypnosis.20
In 1983, World Health Organization (WHO) accepted hypnosis as a therapeutic process worldwide. The Ministry of Health & Family Welfare, Government of India, in an official declaration dated 25 November 2003, has established that hypnotherapy is an approved method of treatment in India, to be practised only by properly trained professionals.21 In Brazil, the Federal Council of Dentistry (CFO) demands that all health professionals who want to practice hypnotherapy, are bound legally to go through updated training workshops for a minimum of 180 hours period.22 In India also we have an Indian Hypnosis Academy that offers courses on hypnosis.22
Conclusion
Hypnosis is an easy, painless, inexpensive non-pharmacological technique which is still underused. It is a wonderful therapeutic tool that with adequate training and suitable patient choice will add quality to a professional's career and expertise. Dental professionals keen to use hypnosis should undergo clinical training for their understanding and applications.
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