Hypnosis in Dentistry
Even professional persons frequently become confused about what dentists achieve with hypnosis as compared with what they can achieve with drugs. It is true that sedation can be accomplished chemically. But there has never yet been a chemical that can re-educate the patient, help him to respond more positively to dental treatment. Many dentists use drugs to get the patient into a relaxed condition, and must continue to use drugs each time the patient returns. After employing hypnosis for five or six sessions, however, a dentist frequently finds that the patient no longer needs it (hypnosis). He has learned a new pattern of response to the stimulus of dental treatment.
FOR THE PATIENT
In reducing patient apprehension
The person whose dental office behavior is not what one would like it to be frequently reacts as he does because of the apprehensions he has about treatment. Even the patient who appears stoic usually has some manner of demonstrating his fears apart from actual flinching from treatment. Many dentists have begun to discontinue placing a cup of water at the side of the patient. The tendency, in so many patients, is to spend an inordinate amount of time in rinsing. Such patients are not wasting moments washing their mouths because they have no appreciation of time; they are employing a defense mechanism to postpone the dentist’s resumption of treatment.
CASE OF MR. EDWARD B.
It is common dental experience that as soon as one removes his fingers and instruments from the mouths of some patients, the patients will almost invariably bring their heads forward and away from the headrest. Thus, each time the dentist returns to the patient, he must reposition the patient’s head. But Edward B demonstrated a new variety of delaying tactic. He not only brought his head forward; he also had to perform certain compulsive gyrations before returning it to the head rest. What in essence did these represent? Nothing more than a postponing of dental treatment. The induction of only light hypnosis is usually enough to handle such cases. If there is any fear in the dentist’s mind that he is going to spend so much time using hypnosis that he won’t have any time to practice dentistry, he can be assured that with a patient like Mr. Edward B hypnosis will be the most time-saving method he can employ.
Hypnoanesthesia can be employed in dentistry as a substitute for, or as an adjunct to, chemoanesthesia. While many patients never reach the depth of hypnosis at which hypnoanesthesia may be obtained, it seems logical to use it when they can reach that depth. It certainly must be attempted in those individuals for whom all other varieties of anesthesia are contraindicated. In general anesthesia, the amount of anesthetic may be significantly reduced when it is augmented with hypnosis.
Some persons are motivated to study hypnosis in dentistry because they expect to be able to find a substitute for anesthesia. They hope that in hypnosis they will find a medium which will allow them to throw out their syringes, their ampules, and their inhalant anesthetics. One seminarian once announced, “The only reason I came here is to learn to pull teeth with hypnosis.” One doesn’t extract teeth with hypnosis. During hypnosis, however, routine dental procedures are facilitated.
Gagging and nausea can be controlled or minimized during hypnosis. (See demonstration of the technique to be used on a patient with an exaggerated gagging reflex, page 390).
In eliminating patient fatigue
Even where hypnosis is no longer needed for elimination of apprehension, it does offer an additional advantage in that it may be employed to reduce or eliminate patient fatigue. Without hypnosis, the patient is often fatigued by long-drawn-out sessions in the dental chair. In this regard Erickson has mentioned the studies made in laboratories of the hypnotized patient’s ability to keep his arm elevated for extended periods. The same thing is accomplished by the dentist who suggests to the patient that his open mouth can lock in that position. The mouth does lock and the patient is completely unaware of any resultant fatigue. In Erickson’s work on time distortion, he has shown that the patient frequently has a completely distorted idea of the length of time his mouth has been open. An hour and a half of dentistry may be accomplished, but as far as the patient is concerned, he may feel that his mouth has been open for only five minutes.
Much has been written about the possibilities of facilitating postoperative healing. The verbalization following tooth extraction may be as follows: “Mrs. Patient, your tooth has been removed successfully, but I want you to relax for a little while longer as I talk to you. The socket from which your tooth was removed is clean and the gum seems to be in fine condition. I believe that when you return here next you will tell me that you had uneventful healing following removal of a tooth.”
FOR THE DENTIST
As an aid to ordinary procedures
Some dentists approach hypnosis with the idea that perhaps they will be able to cancel, through a knowledge of this art, the effects of defective inlay margins, incompletely filled root canals, overextended borders, or premature contacts in dentures. Hypnosis is not going to substitute for good dentistry.
If, however, the dentist approaches hypnosis with the idea that it is another method for amplifying the good he can already do, he has the right approach. There are areas in which hypnosis can be used in varying degrees on most patients: removing fears and apprehensions, persuading the patient to accept the treatment he fears, helping to obtain impressions and bite registrations, and for suggestions (posthypnotic) to ensure correct follow-up by the patient in the management of dentures, orthodontic appliances, and oral hygiene. In other words, a dentist can do far more good for many more people if he accepts hypnosis as an adjunct to, and not as a substitute for, any technique of dentistry. Correctly viewed, hypnosis is a means of assistance in performing the dentistry that one already does, a means of doing it more easily, more quickly, and more comfortably, both for the patient and the dentist.
As an aid to reduction of tension on the part of the dentist
The dentist who works on tense and nervous patients absorbs these tensions. The cumulative effect of working on several such patients is detrimental to his health and emotional stability. A dentist who teaches his patients to relax and also applies the techniques to himself will preserve his health and prolong his usefulness. At the very least, he will improve his relationships with his patients and his family.
FOR THE DENTIST
How should the dentist approach induction procedures? In the first place, every normal person can be hypnotized under proper conditions by a skilled operator. But the dentist must clearly realize that the patient who resists hypnosis cannot be readily hypnotized. This should be emphasized with the patient; he should know that he actually hypnotizes himself and can do so when hypnosis is indicated and when he is working with a qualified operator. In stressing this point, a better relationship is established with patients.
FOR THE PATIENT
Reactions to the term “hypnosis”
Some patients do not feel at home with the word “hypnosis.” Some dentists feel the same way. They are afraid that if they use the word, they may antagonize their patients. If they feel this way and use the word with this feeling, the probability is that they will prejudice their patients. They need to find a euphemism until they can get over this feeling. One doctor in Illinois was so uncomfortable about “hypnosis” that he renamed the process. He told his patients, “You seem to be tense. I am going to teach you countertension.” He taught his patients “countertension” successfully. During a recent meeting, he was asked, “How are you getting along with countertension?” “Oh,” he replied, “I don’t use that term any more. My patients like hypnosis!” His patients began to understand what it was; more important, the dentist came to understand what it was.
If patients are apprehensive, it is better not to talk directly about hypnosis. One merely observes that they are nervous and gives them a reason for it. The patient might be asked, “Wouldn’t you like me to show you a way of getting rid of that tension, so that you can have your dentistry done without pain?” When they say “yes,” they can be started off with what is described as a relaxation technique. It is a trial run on hypnosis. The disadvantage in this approach is that a patient may not cooperate as fully and the technique may be a little slower. On the other hand, some of the usual interferences and resistances may not be encountered.
Obstacles may present themselves. A patient may say, “Did you use hypnosis on me?” The reply could be, “The extreme of this could be hypnosis. Perhaps, though, you weren’t in hypnosis. Were you unconscious?” The patient answers, “No.” “Could you have opened your eyes and awakened any time you wanted?” The patient says, “Yes, I could have.” Then the answer might be, “It was a nice feeling, wasn’t it? Do you feel any harm as a result of relaxing so completely?” By this time, the patient gets the idea and drops the subject. He is usually very happy, even if it was hypnosis.
Patient doubts about hypnotizability
Patients will come in and ask, “Can you hypnotize me, Doctor?” The answer should be, “No, but I can teach you how to go into hypnosis,” or, “I can teach you hypnosis.” Remember that the patient should be in readiness to be hypnotized before one starts the actual technical procedure. Ensure his readiness through orientation and through removal of his doubts about going into hypnosis.
Conserving time in patient orientation
The phrase “mind-set”, appears frequently in the hypnosis literature. It usually refers to the creation of a favorable atmosphere for the induction of hypnosis. The expression infers power by the hypnotist over the individual. On the principle that the responsibility for entering hypnosis belongs to the patient, the term “patient preparation” or “patient orientation” is preferred. It seems better to think in terms of achieving “a state of readiness” to be hypnotized. Once this state has been reached, entering hypnosis is quick and simple.
Achieving a state of readiness can be a time-consuming affair. In the dentist’s early use of hypnosis, he may find himself tempted to spend two or three, sometimes more hours giving patients education and orientation on hypnosis. The use of informational booklets can minimize the time factor. The booklet entitled “An Old Art Returns to Dentistry” by William T. Heron is especially useful.
The doctor states: “The answers to any question you may have on this subject are contained in this little booklet. Take this copy of ‘An Old Art Returns to Dentistry’ and read it. When you have finished, call me for an appointment and we will discuss it.”
HOW TO PRESENT HYPNOSIS TO THE PATIENT
One’s own attitude in approaching the patient should be that of strong, firm, positive conviction. Do not say to patients, “Would you like to try hypnosis?” or, “Maybe we’ll try hypnosis and see if that will work for you.” That is about as negative an approach as can be made. There should be no question in the dentist’s mind that hypnosis is going to work on the patient. “We will use hypnosis” expresses the attitude that should be taken.
THE SEMANTICS OF HYPNOSIS
A dentist using hypnosis must exercise unusual care in his choice of words. People often say one thing and mean another. In ordinary conversation, that is generally understood and no harm or confusion results. But in hypnosis one must take into consideration the literalness of the subconscious. A concrete illustration is: “Doctor, do you mind telling me your name?” He will almost invariably answer, “Doctor Jones.” Actually, his name was not requested at all. He was asked if he would mind giving his name. If he were in hypnosis and he were asked that question, his literal subconscious would probably say “yes” or “no.” He would have to be asked directly, “Tell me your name.” Only then, would his reply be “Jones.”
In working with another patient, the dentist could not induce a trance and the effort had to be abandoned finally. He was told later why his patient would not go into hypnosis. The dentist had told her that her legs were getting heavy and she was at that plump stage where she did not want to be reminded of this fact. Many personality factors need to be taken into consideration in the choice of words to be used.
VALUE OF SIMILES OR ILLUSTRATIONS
The use of simile or illustration: Phrases vivid with simple imagery, such as, “Your arm as straight and stiff as an iron bar,” “Your arm as if floating in the air like a feather on a breeze,” “limp as a wet dish cloth,” “limp as a piece of tired lettuce,” are of great value in trance induction.
VARYING APPROACH TO SUIT PATIENT
No one stereotyped approach should be used in trance induction. It is necessary to vary hypnotic technique from patient to patient. Even with the same patient, different situations may demand variations in approach. If, for instance, the patient will not levitate his arm after an attempt has been made to get him to do so, there are other ways of developing hypnosis or deepening his trance. The patient who refuses to produce an arm levitation may have some subconscious concern about his arms.
CASE OF MRS. GERTRUDE F.
When Mrs. Gertrude F was regressed to her childhood, it was found that she had a vivid memory of a housemaid employed by an old aunt. The maid was sixty or seventy years of age and carried her arm in the Kaiser Wilhelm II paralysis. As a child the patient had been fascinated by this arm. In the hypnotic treatment of Mrs. F, the dentist met absolute refusal whenever he tried anything in the way of arm levitation. The patient seemed to equate arm levitation with arm paralysis.
ONE SPECIALIZED TECHNIQUE (PEN FLASH)
Various methods of trance induction have been presented in the earlier chapters. One doctor worked out his own variation of the eye fixation technique. He uses a pen flashlight, with a little light bulb on the end as a fixation point. When he sees that the patient’s eyes are getting ready to close, he says, “Now, just watch the light; closer and closer; your eyelids are getting heavier and heavier; soon, you will see two lights. When you see two lights, close your eyes and be deeply relaxed.” As the patient reaches the point of muscular divergence, he does have a diplopia, of course, and he does see two lights.
For the dentist’s own protection, his nurse should be present. It is true there are some nurses who appear to work against hypnosis by making themselves too obvious. They stand in front of the dental chair, or a little to one side, watching the patient as the operator is working. Many people resent the presence of a third person during the trance induction. One possible compromise is to see to it that the nurse is in the room immediately adjacent to the one in use at the time, and that she makes little, calculated noises. She may open or close a door—just to be sure that the patient senses that someone else is in the area. After the desired depth of hypnosis has been obtained, the nurse can be called in for direct assistance at the chair side. It is best to warn the patient about the nurse’s impending arrival, merely by announcing, “And now the nurse is going to join us.”
Operations should be carried through to completion before arousing the patient. Many dentists make the mistake of bringing the patient out of hypnosis at the end of cavity preparation, for instance. They then place the matrix band inch into the soft tissue and wonder why the patient didn’t have an entirely enjoyable experience. There is no reason to hurry. Let the patient stay in hypnosis as long as there is any possible need for it. Hypnosis is not a general anesthetic and does not impose the time limits of a general anesthetic. Maintenance of trance depth does not require a continued flow of words from the operator. An occasional “That’s fine” or “Sleep deeply” will suffice.
LEAVING THE PATIENT FOR A SHORT TIME
The question is often asked, “May I leave the patient alone, or will the trance state be interrupted if I am called from the room?” Of course, the patient can be left alone, but if the dentist does not announce that he is leaving, it is very possible that the patient will arouse himself. When he misses the dentist, the rapport may be broken. The situation can be handled very simply. One need only say, “And now, Mrs. Patient, you won’t hear my voice for the next two minnutes,” (or five minutes—whatever it is going to be) “and in the quiet here in the office, you will find that you will be able to relax even more deeply. Remember, I will be back in five minutes.” It is important to get back within the time limits set.
HANDLING PATIENT RESISTANCES
Sometimes the patient is given a signal to awaken or a suggestion to alert himself, and he does not respond. A prepsychotic or abnormal patient may sometimes use the hypnotic state as an excuse or as a means of withdrawing from a situation, but such patients are encountered relatively rarely in the dental situation. More often seen are those normal patients who enjoy the hypnotic situation so much that they do not want to leave it and in not wanting to leave it, they may become refractory in following suggestions for awakening.
Making use of the resistances
Erickson has mentioned that patient resistances can often be used to help the patient. He reverses the procedure by saying, “Well, you are trying to stay asleep and I don’t think you can awaken; try to awaken, but you can’t. The harder you try to open your eyes, the more difficult it becomes.” Because he is now refractory, the patient may say to himself, “I’ll show him. He can’t make me stay asleep if I don’t want to,” and he awakens.
One can put the matter on another basis. The patient can be told, “Mr. Smith, we are using this technique because it is a cooperative venture. We need 100 per cent cooperation at all times. If you refuse to cooperate, we can no longer use this technique for you in the future.” Here, of course, one risks the possibility that hypnosis may have to be discontinued with that patient in the future.
Charging the patient for extra time
If one attempts to awaken the patient and he just smiles as if to say, “I’m going to stay right here, because I’m enjoying it,” one can then say, “You are perfectly welcome to stay in this chair and enjoy the situation as long as you like, but my next patient is already here. If you choose to use his time, it is all right but you will have to pay for it.” Patients usually arouse after this statement.
Inquiry has been made as to what kind of posthypnotic suggestions can be given and when they are considered most useful. One of the most important is some type of signal for reinduction of the trance. The signal should be, first of all, one that suits the practitioner. Further, it should be a signal that can be used for everyone. If one uniform signal is employed, the dentist doesn’t have to think, “Now what did I tell Mrs. Jones? Was it the following of a finger, or the touch on the shoulder, or the counting method?” The signal can be a simple touch on the right shoulder. Or, one might prefer to say, “When you sit in this chair—every time you sit in this chair—and your head touches the headrest, you will be reminded of what it is that you need to do to become deeply relaxed, go into a comfortable state where you can enjoy your anesthesia, or your dentistry.”
For transfer of anesthesia
Posthypnotic suggestions can be given so that the anesthesia that a patient has been able to induce in one area can be transferred to another any time that it becomes necessary.
For removal of discomfort on waking
Another suggestion given is for the purpose of ensuring comfort on awakening. For instance, “In a few moments you will receive the signal to alert yourself; you will then proceed to become wide awake, feeling fine in every respect. This has been a completely enjoyable experience.” If the patient was given eye strain in an eye fixation procedure, if he has catalepsy, or if he has remained a long time in a fixed position that may produce bodily fatigue, one must be sure to suggest away that fatigue.
At the completion of the operation, one must either remove the patient’s hypnoanesthesia or set a time limit for the termination of the posthypnotic anesthesia. It is possible that four days later the patient may wind up in the hospital with an abscess because he has had no warning of discomfort. If, for any reason, patients are sent out of the office with a posthypnotic anesthesia, a specific time limit must be set: “… and your jaw can continue to stay as numb as it is now until you walk in here tomorrow morning.”
For pleasant memories
Suggestions may be given in regard to pleasant memories of the dental experience. The patient who is in a deep trance may have a spontaneous amnesia, with no memory of anything that occurred and that fact may disturb him. He or she would really like to know what happened during the elapsed time. The following statement is offered for that particular situation, especially where the situation may have some traumatic aspects—an especially unpleasant bit of surgery, gross tooth reductions, or the like. The patient can be assured, “Now isn’t this a pleasant way to have dentistry done? This is really like a dream. Sometimes it is difficult to remember dreams, even just after you waken, isn’t it? Well, this may fade away from you like a dream and you may forget about the dream, but I would like you to remember the pleasant part. It has been pleasant, hasn’t it? You will remember the pleasant part for me, won’t you? I will appreciate it if you will remember the pleasant part.”
Promising to remember the pleasant part gives the patient the permission to forget those things that he does not want to remember.
For recall or return appointment
Patients can be told that when they receive the dentist’s communication verbally, by telephone, or in the mail, it will serve as a reminder to them of the very pleasant experience they had in the dental office. “It is a pleasant situation, isn’t it? Wouldn’t you like to remember that? You will remember that the next time you receive the communication, whatever sort it may be.”
Protecting patient from unqualified hypnotists
Some patients who have learned to enter hypnosis readily may be imposed upon by friends, entertainers, or charlatans for questionable purposes. The following statement may help to protect the patient:
“You have been a very good patient. Don’t you think that you should restrict your use of hypnosis to medical, dental, or scientific purposes?” (Patient agrees.) “I would feel better if you would promise me that you will enter hypnosis only for proper purposes and only with properly qualified persons.” (Patient promises.)
The above is more likely to be effective than would an authoritarian prohibition of the use of hypnosis in which specific instances or persons are proscribed.
THE EMOTIONAL PATIENT AND THE DENTIST
If the patient has a problem that involves psychotherapy, has had a record of psychotic episodes, or seems to be prepsychotic, it would be wise to avoid using hypnosis with him until clearance is obtained from the psychotherapist. How can the prepsychotic patient be recognized? Though it is sometimes difficult to be certain about such patients, it is best not to attempt hypnosis on those who behave strangely, who laugh when there is nothing to laugh about, cry when there is nothing to cry about, who are completely at odds with their environment and everyone in it.
THE STAGE HYPNOTIST
The stage hypnotist creates a situation in which he may arouse patient negativism. The patient sees a subject being made to feel ants crawling up his legs and acting in ways calculated to amuse an audience. When this patient comes to the dental office, his attitude is likely to be, “None of that stuff for me. I’ve seen it and I don’t like it.” The likelihood of this patient’s availing himself of a therapeutic aid that may have been exceedingly helpful to him may be lost. We need to protect the therapeutic use of hypnosis. A promise obtained from the patient that he will use his abilities for constructive purposes and not for entertainment should be obtained on a permissive and voluntary basis.
Although the Roman Catholic Church approves the use of hypnosis for necessary therapeutic purposes, it absolutely forbids its use for entertainment. If the patient is a Roman Catholic, one may therefore secure his cooperation easily.
CONTROL OVER THE LAY USE OF HYPNOSIS
In some communities it occasionally happens that youngsters of junior high and high school age become interested in hypnosis, distribute literature on the subject, and practice it in large groups. The parents may become concerned and call on professional men for help with the problem. One of the things the parents should be told is that no amount of professional knowledge of hypnosis is going to substitute for parental discipline. One constructive approach that physicians, dentists, and psychologists can make is to go to their libraries and request that books on hypnosis, trance induction techniques, and the like be kept on a restricted shelf. Their use should be limited to adults only. Concerning the 25¢ and 35¢ books that one can buy on hypnosis, there appears to be no easy answer. The local Better Business Bureau, Chamber of Commerce, or some similar agency might want to cooperate in trying to keep them out of the community. Such books are not illegal; about all that can be done is to ask for cooperation from the stationery store owners in not stocking these items.
Malpractice insurance companies recognize hypnosis today as a legitimate, therapeutic technique. But the dentist who uses hypnosis for a nondental situation, to cure a stomach ache or to do psychotherapy for a nondental problem, may find himself in serious difficulties in the event of litigation. The underwriters may say, “Yes, we protect you in the use of hypnosis, but not in a situation that does not involve the practice of dentistry.” It is inadvisable to experiment with patients in the office, eliciting phenomena, just to see how deep a trance can be obtained with them. Suggestions should be limited to those necessary for the trance induction and those necessary for accomplishing therapeutic purpose. If these precautions are observed, there will be no difficulties, either interpersonally or interprofessionally, with colleagues in the allied professional fields, or medicolegally.
The liability insurance companies provide no difference in premiums for those who employ hypnosis. Hypnosis is accepted by the insurance companies as a legitimate dental adjunct, as long as it is connected with the practice of dentistry.
Elaborate hypnotic records are not necessary, but marking the patient’s record card with pertinent bits of information is helpful. An “H” could designate the use of a hypnotic technique. “L,” “M,” or “D” could indicate depth of trance. Notations of the likes and dislikes of the patient and material described by him in visual imagery should be noted. Information of this sort is useful in re-establishing rapport with the patient after unusually long intervals between visits.
RECORDING OTHER HYPNOTIC INFORMATION
Other pertinent information should, of course, also be noted. If the patient is a child and the “Sleep Game” approach has been used, that fact should be recorded. It is also frequently helpful to note particular interests of the patient. One dentist has an eleven-year-old patient who is a very competent bowler. Another child likes to see Mickey Mouse in purple buttons. Another wants to be a space cadet. These pertinent facts, jotted down in a couple of words, often afford a cue with which satisfactory interpersonal relationships can be re-established quickly.
Cards are also useful in furnishing information concerning patient referrals. If an old patient refers an acquaintance, the referring individual is recorded on both the new and the old patient’s cards. A glance at the cards reminds the dentist to ask about the other patient and helps him to build up the little ties that make interpersonal relationships much stronger and more pleasant.
MEMO CARDS FOR BEGINNERS