Hypnosis and Suggestion in the Treatment of Pain

MR. PLUM, a 62-year-old man, had been nursing a nagging jaw pain for some months before finally visiting his neighborhood dentist, who prescribed antibiotics and recommended a return visit in two weeks. There was no discussion about what options would be possible for Mr. Plum at the end of the antibiotic course of treatment, so he called me for a second opinion. When I saw Mr. Plum, he had only been on the antibiotics for four days. His pain had grown worse over the last few days and he was anxious to know the cause and to decide what should be done about it. When I examined him, I could see that one of his teeth was chronically infected and needed to be extracted. Typically, such infections are isolated from the rest of the body and their main effect is to destroy tissue, which, over time, can become extensive. Antibiotics will not cure the situation but are given initially, as they improve the effectiveness of local anesthetics when the tooth is subsequently extracted. For this reason, patients are frequently more comfortable during the extraction if it follows a full course of antibiotic therapy. I suggested that Mr. Plum continue taking antibiotics and return in a few days, when I would extract the tooth. However, Mr. Plum was exasperated by the pain and by the previous clinician’s failure to relieve it. He did not want to wait. Given Mr. Plum’s motivation, I agreed to extract the tooth that day.

Because Mr. Plum’s blood pressure was elevated, I wanted to calm him before we commenced. I asked, “Mr. Plum, would you like me to help you become more relaxed, and more comfortable, so you will be ready to have your treatment?”

He did not hesitate. “No, I can do that myself.”

I suggested, then, that he do what he needed to get ready, and I left him alone for a few minutes. Looking into the room, I watched him settling himself into the dental chair. His body language implied to me that he was focusing his attention inwardly to prepare himself for the procedure.

When I returned to his side, he indicated that he was ready. I injected local anesthetic into the tissues, checked for the onset of numbness, and, when it was evident, I began the process of extracting the tooth.

Initially, everything went well. My suggestions for reinterpretation of the sensations that he was likely to be feeling, along with whatever preparation Mr. Plum had done for himself, seemed effective. He appeared quite comfortable until the actual elevation of the tooth was begun, when he indicated, with a grimace, that he was hurting. Two supplemental local anesthetic doses were given, but were not effective.

It was clear to me that Mr. Plum could not remain comfortable while I extracted the tooth, and I was more concerned than I might have been otherwise because of his hypertension. I explained that I could not complete the procedure that day, as I had reached the limit of the local anesthetic appropriate for him and, moreover, that more local anesthetic would not help. Mr. Plum urged me to continue, assuring me that he would just “hang tight” through the pain. Mindful that such distress would further elevate his blood pressure, possibly creating an emergency, I declined his offer to be stoic and said that we would stop now and continue on another day. (Aside from Mr. Plum’s hypertension, I would be unwilling to unnecessarily cause a patient pain. Dental treatment does not need to be painful.)

Mr. Plum reluctantly departed, armed with a prescription for an analgesic and my invitation to return at the end of the week. He was disappointed that he still carried the painful tooth but understood that I was acting in his best interests.

Three hours later, I received an urgent call from Mr. Plum. The anesthetic had worn off, he had not filled the analgesic prescription, he was in terrible pain, his bite was no longer comfortable, and he wanted the tooth removed!

Now, four hours after his previous visit, I again assessed Mr. Plum’s vital signs and found that his blood pressure was further elevated. Though this was a concern to me, I nevertheless felt that the extraction could be safely accomplished. Moreover, this increasing blood pressure gave me even greater reason to relieve Mr. Plum’s pain by successfully (and painlessly) extracting the tooth. If ever there was a time for “painless dentistry,” this was it!

I explained to Mr. Plum that, since I had used a particular brand of local anesthetic in the morning, which we both knew was not that effective for him, this afternoon I was going to use an entirely different method I was confident would be successful, especially since we had already completed so much of the preliminary work that morning.

I then began the procedure by suggesting “… the anesthetic I am using penetrates to the nerves, entering the roots by the access we have already provided by our work this morning.… Now, I’m going to use an instrument to push the material all around the tooth … so you will probably feel pressure and, too, a pushing sensation … as I work the material around. But you will continue to feel comfortable and pleased at how well the process is working.”

Actually, I was using only a topical anesthetic paste, which creates a numbing sensation at the surface of the gums, and a surgical instrument to manipulate the tissues, to create the pressure and “pushing sensation.” Of course, this topical anesthetic cannot produce adequate anesthesia for an extraction. However, the sensations I was creating with the topical, in combination with the suggestions I continued to give for comfort and a sense of well-being, were intended to produce a hypnotic experience that would produce adequate anesthesia. Mr. Plum responded to these suggestions by closing his eyes and becoming very relaxed and quiet.

When I began to apply pressure to elevate the tooth—the point of the procedure that causes the greatest level of noxious stimulation—Mr. Plum remained quiet and relaxed, and he did not grimace. I completed the extraction quickly, and within a few minutes was performing the postoperative closure and clean-up. All the while, I continued to talk to Mr. Plum, offering suggestions for comfort and, as we finished, for rapid, uneventful healing.

If Mr. Plum was aware of any of these events, he did not show it. I specifically told him that we had finished, that the tooth was out, and that he could open his eyes and see it. He opened his eyes with a dazed look, and said, in a voice full of surprise, “You’re already finished? I didn’t feel anything at all!”

In dentistry, perhaps more than in other fields, it often happens that patients’ expectation of pain and therefore their pain perception are not closely correlated with the severity of the actual physiological event. Quite often projected fears, anxieties, and phobias of the anticipated procedure have a major impact on the pain experience. When the actual painful event occurs, the resulting suffering of the patient may seem totally out of proportion to the physical injury or treatment. The patient experiences distress. The dentist’s typical response to such distress during routine dental appointments is to deny the patient’s experience either by actions (an unwillingness to stop and allow the patient time-out to regain composure) or by statements (“Oh, that can’t hurt that much”). In the first case, the dentist may be perceived as sadistic; in the second, as unable to feel empathy. Neither perception is likely to be accurate. What is usually occurring is that the dentist is responding to his or her knowledge of the actual physiological stimulation that he or she is inflicting.

Frequently, well-meaning dentists attempt to relieve patients’ anxieties by employing a cognitive strategy of describing the care being provided and then rationalizing the magnitude of its impact. For a considerable number of patients, such an approach is not helpful and may even have the opposite effect. The dentist’s description of what is occurring stimulates the patient’s imagination about the extent of the procedure, and the patient becomes even more frightened. The patient may understand the logic of the explanation, but the fearful interpretation of the impending hurt typically outweighs rationality.

All of us have experienced discomfort in our mouths, beginning with the eruption of teeth during infancy. It is unlikely that individuals with highly charged negative feelings about oral health care would choose a career in dentistry. One might reasonably conclude, therefore, that dental care providers as a group are probably better responders (i.e., have less of the affective component of pain) to oral care treatment than the general population. This may partly explain why they do not always recognize or understand when a patient is experiencing anguish and suffering independent of the intensity of physiological stimulation.

It is unfortunate that dentists use their perceptions of how much physiological pain a procedure is likely to cause as the chief criterion by which to judge how a certain patient will react. It is common to hear a practitioner rationalize that he or she is performing “only” a particular treatment, the unspoken implication being that “only” means a routine, commonly practiced procedure—it may have negative sensations, but they are usually tolerated by most people. In fact, patients who don’t fit into this typical pattern of accepting behavior are often labeled “problem patients” by clinicians.

The modern dentist is quite mindful of the sensory component of pain and has at his or her fingertips a variety of pain reduction modalities. These include anesthetics of a topical, regional, or systemic nature that can be utilized for diminishing sensation. Unfortunately, not every dentist is as well trained in managing the affective component of pain. And such management is not nearly as easy to accomplish. Blockage of the sensory component of pain is fairly predictable once the patient variables (weight, presence or absence of infection), drug variables (type, dosage, and modality), and delivery variables (site, technique) are considered. Of course, this is not the case with the affective component of pain.

For many years, a stress reduction protocol has been advocated for use in dental practices with medically or psychologically compromised patients (McCarthy, 1989, pp. 41–43). Typically, this protocol considers such factors as the time of day of the appointment (morning is when the patient is most rested) and length of appointments (shorter is better). Assessment of the need for pre- and postoperative anxiolytic agents is another component of this protocol. These management techniques focus on modifying the physiological milieu through manipulation of the physical environment or through medications that act on the central nervous system. No attention is given to any type of behavioral management of psychological stress, which can have a far greater and more immediate impact on the patient’s well-being.

This is not to imply that psychological screening and patient management techniques are not employed by dentists or taught as part of dental school curricula in the United States. The reality, however, is that students are exposed to a limited number of psychological methods, and certainly not to the extent that they receive instruction in pharmacological techniques. Additionally, such training may be only didactic, rather than experiential, and may include interactions in “nonconfrontational” or simple situations with conventional patients, but not with patients in distress, unduly fearful patients, or patients for whom analgesia has been inadequate.

The environment of the mouth and teeth is a very richly innervated part of the body. We need to fully appreciate that manipulations in that location can elicit a variety of responses both physiological and psychological. It is the rare patient who is as blasé about routine dental treatment as the typical dental practitioner. To the contrary, anticipatory anxiety is the most frequent reason that dentists are asked to provide pretreatment anxiolytic agents. Additional requests for postoperative analgesics may also result from the patient’s expectation of postoperative pain.

Because most patients are anxious about dental care, they frequently respond readily to psychological interventions preparatory to treatment or during a procedure itself. Those individuals who are highly responsive to hypnotic methods may have little need for an actual hypnotic induction. In fact, the highly responsive patient may already be absorbed in a hypnotic state by the time he or she reaches the dental practice. An astute clinician can readily recognize such a state and use it by giving thoughtful suggestions to prevent discomfort during and after treatment. This process of psychological comfort and support should begin at the first contact between the patient and the clinician’s office. Office staff can be trained to be supportive and involved in the therapeutic goals of the practitioner.

Hypnosis can be extremely effective when utilized in dentistry. Unlike most psychological management techniques, it can be introduced into the treatment forum by a variety of agents: the patient, the dental practitioner, or another health-care provider. Furthermore, it can be used to alleviate either the sensory and/or the affective components of pain as well as to fulfill a variety of other applications in dentistry (Auld, 1989; Eli, 1992; Erickson, Hershman, & Secter, 1990; Finkelstein, 1991).

Typically, my first appointment with a new patient involves minimal or no invasive procedures. It is an information-gathering, rapport-building opportunity, which for some highly phobic patients occurs in a less anxiety-provoking setting: my office rather than the treatment room. The next appointment takes place in the treatment room and often begins with a hypnotic induction that I record and give to the patient for daily practice at home. At subsequent visits, I hypnotize the patient, observing his or her ease or difficulty in developing a hypnotic experience and general facility with acquiring self-hypnotic skills. These observations guide my subsequent behavior with the patient.

The particular approach used to treat a dental patient is determined by the patient’s need, motivation, and expectations, as well as the invasiveness of the particular procedure to be accomplished. For those patients who arrive anticipating a hypnotic induction, anything short of that may be unsuccessful. Other patients may arrive already experiencing a hypnotic state, in response to the anxiety or the pain they are suffering or to free-floating anxiety. In any case, the total medical and psychological context must be taken into account.

Mrs. White presented for routine dental care at a clinic for quasi-independent elderly individuals. She was having no pain at the time she first presented for treatment, but confided to me that she had been negligent in caring for her mouth. Since the clinic was now so convenient, she decided it was time to seek care. During the initial consultation, Mrs. White demonstrated that she was quite aware and fully oriented.

Throughout the gathering of the diagnostic data and the review of our findings, Mrs. White was cooperative and pleasant. Reviewing her vital signs and medical history, I concluded that her placement in a residential facility related to her physical condition. She was a slightly built Caucasian woman, weighing less than 100 pounds, who had a history of nonspecific cardiac problems, chest pain, dizziness, and falls. My impression was that of a physically frail individual. Observation of her vital signs revealed her to be borderline hypertensive. Behaviorally, she appeared somewhat tentative and concerned about who would be providing her care. I called her primary physician, who confirmed the patient’s cardiac problems as atherosclerosis, mild congestive heart failure, and stress-induced angina pectoris, for which he had prescribed nitroglycerin as needed.

Two appointments in the dental clinic were necessary in order to acquire and review all the diagnostic data and to develop and discuss a treatment approach with Mrs. White. At each appointment she appeared to be comfortable and cooperative with the process, and a treatment schedule was set up. We agreed that during her next appointment, treatment would begin, involving placement of her new fillings.

When Mrs. White arrived for her next visit, Spencer, the dental student who would be providing her care, confirmed that medical status had remained stable since we had previously reviewed her history, and that her vital signs remained similar to the baseline readings. After Spencer and I reviewed Mrs. White’s case, I gave him permission to begin the treatment.

My attention was occupied with other patients for about 25 minutes, at which time I looked in on Mrs. White and Spencer. It was immediately evident to me that something was wrong. Spencer was engrossed in the procedure he was performing, focusing his attention on the oral environment, and seemed fully unaware of Mrs. White’s difficulty. Her hands were grasped tightly across her chest. Remembering her cardiovascular disease history, including angina, I asked Spencer to advise me of her status.

Reflecting no concern, Spencer replied that he had asked Mrs. White what the problem was and she had responded that she was having chest pain. He had decided that the chest pain either was a figment of her imagination or was of a noncardiac nature—because the treatment he was performing was not stressful. In either case, he did not stop the dental treatment.

Clearly, Spencer’s interpretation of the magnitude of his treatment and Mrs. White’s experience of it were not the same. Unfortunately, Spencer believed his own interpretation and discounted her experience. I immediately stopped the dental treatment and assessed the patient’s status, noting the presence of eyelid flutter. In response to my direct question about pain, Mrs. White briefly opened her eyes, but did not make eye contact, and whispered “Yes” before again closing her eyes. I understood that she was experiencing angina, so I quickly delivered a sublingual dose of nitroglycerin, while simultaneously having Spencer reassess her vital signs. Moving close to the patient’s ear so she could hear me easily, I began speaking to her calmly but firmly:

Mrs. White, listen to me very carefully. You will probably be surprised at how quickly you notice the relief from discomfort spread across your chest, perhaps more quickly then you have ever felt before … and with every breath you take, being aware of an easing of the tightness and restraint previously experienced in your chest … just noticing the comfort taking its place. With each breath let that comfort grow and flow throughout every part of your chest, bringing relief and a wonderfully relaxed feeling. And isn’t it interesting to note that this wonderfully comfortable and relaxed feeling can spread quite beyond your chest into other parts of your body … with every breath … into your arms and hands, neck and jaw, and, in fact, your entire head. Now isn’t it surprising, but absolutely wonderful at the same time, the speed at which this remarkable, relaxing comfort can spread.

Within little over a minute Mrs. White indicated that she could feel the relief spreading and that the chest pain was almost gone. Since Mrs. White was reclined in a dental chair, I continued these suggestions, focusing upon relaxation, encouraging Mrs. White to feel “even more comfortable, perhaps more comfortable than you have ever felt before.”

My goal in including suggestions for general comfort was to prevent the occurrence of a severe, rapid-onset headache, which can be a side-effect of sublingual nitroglycerin. After a short time, Mrs. White was quite comfortable, the chest pain was completely gone, no headache was present, the vital signs were established as stable and consistent with her history, and no other medical intervention was required. I then focused on the interrupted dental procedure.

It was important to redefine this episode. It had appeared that the dental procedure had precipitated the anginal attack. I first acknowledged that the difficult part of the procedure was over. (Spencer had interpreted the procedure correctly in that technically it was not difficult and was likely to have involved only a very small amount of noxious sensory stimulation; however, Mrs. White’s perception was the critical factor governing the episode.)

I recognized Mrs. White’s experience of difficulty (no matter what the technical level of treatment or sensory involvement may have been). She may or may not have heard Spencer’s opinion of the relative ease of the procedure when I asked him for Mrs. White’s status. Whether or not she heard this is really irrelevant—it was quite obvious to Mrs. White from Spencer’s behavior (e.g., his disinterest in the chest pain and his continuation of the dental procedure), that he was denying her experience. Since I was the teacher of this student and, therefore, in Mrs. White’s eyes a seasoned practitioner, she would give more weight to my interpretation of the event than to Spencer’s interpretation. Therefore, my acknowledgment that the procedure had been difficult was important for the continuing rapport between us and my subsequent credibility.

I then made suggestions relating to Mrs. White’s interest in caring for herself (an example of which was her coming to the dental clinic of her own accord to seek out care). I complimented her on her interest in taking care of her body and reminded her that she was the best authority on her body and therefore the one who could advise us if she would like to proceed with finishing the treatment we had already begun right then—or at the next clinic session the following week.

1. I was concerned about her angina, but not unduly frightened by the fact that she had an episode of chest pain while undergoing dental care.

2. I felt capable of managing any future anginal attacks she might have during treatment.

3. I thought her teeth (and, by inference, her total health) were important and worth caring for.

4. I did not think that her cardiovascular condition was so serious that it would preclude her receiving dental care.

5. I gave control of the treatment situation back to her.

Since direct assertion of these ideas might have seemed paternalistic to Mrs. White, I embedded them in a general hypnotic discussion about comfort, laced with compliments to her for taking the initiative in caring for and about herself. By providing only two options concerning treatment, either continuing right then or the following week, I was purposely limiting Mrs. White’s choices so that, no matter which option she chose, she would finish the procedure (which was a real dental necessity), even though it had precipitated the anginal attack. (It bears mentioning here that this experience was sufficiently traumatizing that she might have avoided further dental care.)

Before ending the hypnotic experience, I suggested to Mrs. White how comfortable she could feel at each successive appointment. “And I don’t know when you might begin to feel as relaxed and comfortable as you do right now.… It may be each time you enter the doorway to the dental clinic, or when you sit in the dental chair and your head touches the headrest, or perhaps when the dental light is turned on.… It doesn’t really matter when … just know that you can feel even more relaxed and comfortable than you do right now … and with every visit you can feel that relaxation growing even greater.” I also suggested that, in the future, when I touched her on her shoulder, she could become deeply relaxed and comfortable. Using posthypnotic suggestions in this way greatly facilitates future hypnotic work.

Mrs. White decided to continue treatment that day. After that, she returned regularly to the clinic for her dental work. At each subsequent visit, as she was adjusting herself in the dental chair, and while we were exchanging pleasantries, I would touch her shoulder and suggest that she could do whatever she needed to become comfortable. Each time she responded by quickly becoming deeply relaxed and absorbed in the experience of comfort. There were no further episodes of angina while undergoing dental treatment. Thus, I was able to attract Mrs. White’s attention, assess and avoid what might have become a medical emergency, and cement a rapport that stood us in good stead for future stressful procedures.

One might argue that Mrs. White was not hypnotized, since no formal induction was provided. Further, one might say that it was the nitroglycerin and not hypnosis that had the hoped-for effect on her symptoms. Remember, though, that individuals who are highly responsive to hypnotic suggestion may not need an actual induction in order to develop a hypnotic state (Hilgard & Hilgard, 1994, p. 15). In fact, Hilgard and Hilgard write that in such situations the formal induction is far less important than the therapeutic suggestions to reduce the pain. That Mrs. White was already in a hypnotic state was clear from the physical manifestations seen: the eyelid flutter; the quiet, abbreviated speech; the glazed look when she opened her eyes; the spontaneous eye closure, and the rapidity with which relief of her chest pain occurred.

Mrs. White’s anginal attacks usually required her to take more than one sublingual nitroglycerin dose in order to lessen the chest pain. Commonly, the relief of her chest pain occurred only after 10 to 15 minutes of repeated nitroglycerin dosage, and the use of the nitroglycerin would be followed by a headache. Since this anginal episode did not follow that course, one could conclude that the hypnotic suggestions had a positive effect in modifying the extent and severity of the attack and in facilitating her future benign responses to the stress of receiving dental care.

Naturally occurring hypnotic phenomena should not be overlooked. In some cases, individuals may use the refuge of a hypnotic state as a coping mechanism. This spontaneous hypnotic state has been well-documented in the hypnotic literature (Barabasz & Barabasz, 1992; Spiegel & Spiegel, 1987). Given the generally fearful attitude toward dental care, the dental patient may already be experiencing a hypnotic condition by the time he or she reaches the dental practice or may lapse into this state during a dental procedure, particularly if difficulties arise. An astute clinician can readily recognize such a state and use it to the patient’s advantage by providing appropriately worded suggestions regarding the reduction of discomfort, as well as positive suggestions for subsequent recovery and posttreatment course.

Some might dismiss the previous example as being an unusual occurrence, one that was solely the result of an inexperienced practitioner, a student still in the throes of learning. Experienced dental practitioners, they might claim, would not make such mistakes. Although there is some merit to that argument, it does happen that some practitioners may yield to the desire to complete treatment and ask a patient who is expressing discomfort to “Hang on, we’re almost through!” In such a case, the patient may feel left alone without the anesthetic support and with no psychological supports to tolerate the pain or fear.

In my experience, spontaneous hypnotic experiences occur in significant numbers of fearful and phobic dental patients, sometimes even when discussing their dental needs far from the dental office. Whenever this happens, the patient is likely to be receptive to therapeutic suggestions to help tolerate the stress that dentistry evokes. When a patient is actually sitting in the dental chair and difficulty occurs, obviously the patient’s motivation to diminish the pain and increase comfort is particularly strong. As a result, an actual hypnotic induction may be unnecessary or quite brief, requiring only a few sentences to support and encourage the patient’s natural inclinations. I might say:

You really don’t need to be here. Why don’t you go somewhere else, where you would rather be, and can be relaxed and comfortable. While you are there, I will take care of everything here, and I will let you know when I am finished so that you can come back.

Some people find it a lot easier to see where they are going if they just let their eyes close.

Observing the eyelid flutter, eye roll, and other physiologic manifestations of the patient’s readiness to experience the hypnotic state will provide important clues about the patient’s condition.

What happens to an adult patient who has a traumatic experience in a dental office? Does the patient brush off the experience as just another episode of life, or does it permanently affect his or her ability to manage any discomfort associated with dental care or to tolerate any future treatment, no matter how benign? Hilgard and Hilgard (1994, p. 145) posit that severe dental phobias are likely to have as their bases either an earlier traumatic episode in a dental office or a projection of someone else’s experience onto themselves, with either situation most likely occurring during childhood. It is likely that the susceptible child is one who has yet to have his or her own positive experiences of dental treatment with which to compare exaggerated stories enthusiastically recited by others.

While it is true that dental fears and phobias are quite prevalent during childhood, in a substantial number of people such fears persist into adulthood (Dworkin, 1986). Studies show that from 8 to 16 percent of the population reports fear as the reason why they do not seek dental care (Gerschman, 1988). In a study surveying dentists, physicians, and psychologists about the origins of their patients’ dental anxieties and phobias, single or multiple traumatic events were thought to be equal to childhood trauma as the most common cause of these conditions (Rodolfa, Kraft, & Reilley, 1990).

Some patients acknowledge that a previously frightening dental experience has resulted in a dental anxiety or phobia, while others do not have a clear understanding of why they now anguish over impending dental treatment. Still other individuals do not report fear of dental treatment but do not seek care because the dental experience constitutes a challenge to an unrelated phobia. For example, claustrophobic patients may find the dental treatment room and the prolonged proximity of the treatment team intolerably confining.

It has been my experience that women who report sexual or physical assault, as children or adults, are more likely to develop extreme phobias regarding their oral health. This phobia may be so intense that it even affects their ability to provide their own regular oral health care (e.g., tooth brushing). An exaggerated gag reflex may be a manifestation of such a history, as may the patient’s grabbing of the hands of the dental practitioner to stop the treatment or a complete inability to tolerate any oral pain or treatment.

From early infancy, the mouth is the center of the sensory world, the medium for eating, play, vocalization, and exploration. A richly innervated structure, the mouth is the source of much stimulation for the person. Since the mouth is a highly charged emotional area, and since it is an “erotogenic zone” (Gerschman, 1988), we can readily understand the significance of events involving the oral cavity. It is not surprising that many patients approach dental care in a highly charged emotional state.

Fear of loss of control is a frequent concern of dental patients (Lightfoot, 1994). The actual positioning of the patient places him or her in a physically and emotionally vulnerable position. Lying supine in a modern dental chair requires one to place a great deal of trust in the practitioner, who sits in a superior position to the patient and wields sharp instruments in front of the patient’s vigilant eyes. Allowing entry into the mouth and tolerating protracted treatment in an anatomical site that has life-prolonging functions (nutrition and respiration), as well as emotionally fulfilling ones (communication and sexual pleasure), can be overwhelming to some, thereby further heightening their fears.

As growing numbers of people recognize the need for a lifetime of preventive dental care, it is likely that more and more psychotherapists will be consulted by patients wishing to receive dental care but fearing to do so. Hypnotic treatment, of course, can be helpful in managing these patients. Various strategies that have been reported to be successful for patients with dental fears and phobias, ranging from relaxation to incorporating systematic desensitization with hypnotic methods, will be discussed later in this chapter (Rodolfa, Kraft, & Reilley, 1990).

Recently a group of researchers at the University of Alabama found that among females with histories of sexual or physical abuse, a very high rate suffer from gastrointestinal conditions such as gastroesophageal reflux disease (92 percent) and irritable bowel syndrome (82 percent). They measured pain thresholds in the patients with abuse histories and found significantly lower thresholds than in a comparison group of patients who had not reported abuse (Scarinci, McDonald-Haile, Bradley, & Richter, 1994). In considering these results, one should remember that, in addition to its other functions, the oral cavity is the gateway to the gastrointestinal tract. Various muscles in the mouth provide chewing and swallowing functions; the temporomandibular joints are also actively involved in chewing of food for further action by the digestive tract. Therefore, all of these structures are considered part of the first functional unit of the gastrointestinal tract. It is important to appreciate that dysfunction of these joints results in oral or facial pain experienced by five to seven million people in the U.S.

Although chronic orofacial pain may be the result of conditions such as atypical odontalgia,¹ most commonly it involves the previously named anatomic structures and includes such nonodontogenic conditions as atypical facial pain, regional myofascial pain, and temporomandibular joint dysfunction (Van der Bijl, 1995). These afflictions, which cause debilitating pain and prolonged disability, are most often seen in women. Frequently, these patients require psychotherapy in addition to physical medicine modalities to achieve effective pain control (Van der Bijl, 1995).

Few controlled clinical studies have examined the efficacy of hypnotic treatment for psychiatric disorders (Brown, 1992); therefore, it is not surprising that little evidence can be found concerning the efficacy of hypnosis for the management of patients with chronic orofacial pain. A recent bibliographic review of the English language scientific literature on pain and anxiety control in dentistry identified 71 articles concerned with chronic oral facial pain, none of which referenced hypnosis (Hassett, 1994). Most descriptions of hypnotic treatment for orofacial pain deal with a reduction of the chronic physical tension held in the muscles of the face (Glazer, 1990; Neiburger, 1990). When orofacial pain is due to stress and anxiety, hypnotic techniques can be useful in managing stress responses. In the one abbreviated case report found, describing the use of hypnosis in the treatment of myofascial pain and temporomandibular joint clicking, relaxation and imagery were used and the patient reported some improvement. It is difficult to interpret this report, however, because it involves only one patient, the actual methods are not described in detail, and there was no follow-up (Simpson, Goepferd, Ogesen, & Zach, 1985).

Any discussion of orofacial pain must include the topic of bruxism. A condition involving the grinding of the teeth with a great deal of force, typically occurring during sleep, bruxism has been implicated as the etiologic precipitant in some types of chronic orofacial pain conditions. For years, it has been know that hypnotic treatment is effective in eliminating oral habits such as bruxism. Success was demonstrated by two different studies examining electromyographic evaluations of nighttime masseter muscle activity in bruxism patients recorded before and after hypnotic treatment intended to decrease muscle activity. These evaluations identified a significant decrease in masseter muscle activity levels, as well as decreases in subjective reports of facial discomfort (Clarke & Reynolds, 1991; Mulligan & Clark, 1979). Various texts and manuals provide samples of inductions helpful for treating patients who demonstrate bruxism (Erickson, 1990; Golan, 1990; Neiburger, 1990; Reaney, 1990; Simpson, Goepferd, Ogesen, & Zach, 1985), as well as those patients needing help with stress and anxiety reduction (Field, 1990; Reaney, 1990; Wright, 1990).

A variety of approaches may be used to achieve the goal of preparing the patient to manage oral pain or to be comfortable during dental treatment. In some cases, the dentist may work directly with the patient; in other cases, the dentist and the psychotherapist might work together; if dental treatment has been concluded, the psychotherapist may work with the patient alone. The arrangement used, just like the treatment approach used, is tailored to the needs of the patient. The patient’s point of entry into the health-care system will also affect the arrangement, as a result of the relationship and rapport established with the initial practitioner.

A patient who has acquired a dental phobia as a result of a previously difficult dental experience can frequently be managed quite easily by the dentist. When a dental phobia is only one aspect of complex psychological problems, a psychotherapist needs to be involved. A diagnosis of multiple phobias or other psychiatric disorders may not be initially obvious to the dentist. It may be only when the attempt to use hypnotic methods fails that the dentist realizes the complexity of the patient’s underlying problem, and the need for a referral to a psychotherapist. It may be obvious that a psychotherapist should not attempt dental treatment. It may be less obvious, but just as important to recognize, that a dentist should not attempt to discover the nature of the underlying phobia. The hidden complexity may be a very unpleasant surprise.

For patients who come to me directly for help in dealing with their dental fears and phobias, my goal is to teach them to cope with their fears, not to uncover the source of their fear. Teaching the patient self-hypnosis can be an easy way to accomplish this. I begin by tape recording our hypnosis sessions. I then instruct the patient to take the tape home and use it to practice becoming deeply relaxed. I prescribe at least one practice session a day. My observation is that the more often the patient practices, the better he or she is able to become quickly absorbed in a hypnotic experience, at a deeper level, and with less intervention on my part. This is consistent with Hilgard and Hilgard’s finding that practicing self-hypnosis allows an individual to acquire greater facility in using it (1994, p. 73). Following this protocol, the patient learns to accept much more rapidly the ownership of the hypnotic state, and thereby learns to produce it when needed, whether it be for comfort in the dental chair or at another time.

I adjust my hypnotic induction method at subsequent sessions by closely observing the patient. As he or she becomes more adept at the unassisted self-hypnosis skill, I modify the help I provide appropriately. In addition to the therapeutic suggestions regarding relaxation and comfort in dealing with all aspects of the dental environment, at each encounter I routinely include ego-strengthening suggestions in the hypnotic state to reinforce the fact that the patient can and will become master of herself, with the unspoken suggestion being that the patient can control her fears.

Ideally, dentist and psychotherapist will cooperate. The therapist’s consultation with the dentist about the general needs and concerns of the patient before the patient arrives in the dental office facilitates the dentist’s successful management of that and subsequent dental visits. It is especially pleasing, to both dentist and psychotherapist, to have a collaboration that can carry them through the treatment of future patients. The source of a dental phobia may be unrelated to any previous dental care; instead, it may be related to some other perceived or real traumatic occurrence(s) in the patient’s life. The symbolism as well as the reality of the role of the mouth in a person’s life needs to be understood.

As we all know, dental patients do not anticipate visiting a dental office with pleasure. Commonly, dental patients are anxious and uncomfortable when they present for dental treatment. Some may even be irritable. In many cases, their pain perception is amplified by such a state of mind. Conveniently for dental practitioners, one of the most common feelings expressed by individuals who have been hypnotized is a sense of relaxation and banishment of tension, oftentimes unlike anything they have ever felt before (Hilgard & Hilgard, 1994, p. 17). Obviously, such a perception can help to ameliorate the aversive feelings people often have about dental treatment.

Frequently, in dentistry we target the reduction of anxiety, coupled with the achievement of comfort, as primary goals in the hypnotic induction. If the clinician links the two suggestions together, this allows the patient to do whatever he or she needs to do to maintain a comfortable state during the impending care. This is frequently achieved without direct suggestions, by using a permissive approach that allows the patient to do whatever is necessary to be comfortable during and after the course of therapy. This type of approach is also successful for those who are highly anxious about the implications of their pain (e.g., is the mouth ulcer some type of cancer?), whatever the level of pain being experienced.

Similarly, we can facilitate the reinterpretation of experiences. For example, what was formerly a feared experience (lying in the dental chair, feeling exposed and vulnerable) can be reframed as soothing and nonthreatening. I particularly like to use such imagery with children, suggesting, for example, that they imagine snuggling into their comfortable beds at home, or that the vibration of the handpiece feels like a tickle machine that makes them giggle, but not too much! Adults might be more amenable to the fantasy of swinging in a hammock on a deserted beach or floating on a fleecy, soft cloud.

The therapeutic goals of relaxation and hypnoanalgesia occur at a readily accessible level of hypnotic absorption, even in patients who are capable of achieving very profound hypnotic states (Hilgard & Hilgard, 1994, p. 80). At such a minimal depth, the patient stays involved, and helps to direct the pain reduction. This has two benefits for dental practitioners:

1. It minimizes the time needed to induce the hypnotic experience.

2. It significantly reduces those uncommon but untoward events, such as loss of contact with the dentist, that can occur with deepening the experience to a profound state.

Some patients may resist relaxing, feeling that they need to remain vigilant. A comment such as “you may now wish to watch your eyes close,” frequently reduces vigilance by gently suggesting that the patient continue to “watch,” at the same time that it facilitates eye closure and supports greater internal absorption, an important step toward developing a hypnotic experience.

I prefer that all of my patients close their eyes for safety reasons, since I am working in such close proximity to their eyes with materials that sometimes get splashed or splattered. If patients do not respond to my indirect suggestions to close their eyes, I may offer them a mirror (and safety glasses) to watch what is occurring in their mouths.

For vigilant patients, I frequently point out the areas of the mouth I am working in and engage their involvement in making certain areas numb so that the work can proceed. Using a direct reduction method, I draw parallels between the sensation of numbness of a local anesthetic used at some time during a prior dental experience and the current goal of numbness. As I move from one section of the mouth to another, I suggest that the patient move the numbness to the new area. Rarely do patients question how this is possible. Nor do I offer them further suggestions on how to accomplish this unless they ask. I never chat with the patient or my assistant when I am treating a patient who is hypnotized. All of my remarks are directed toward maintaining the patient’s experience, providing therapeutic suggestions, and giving instructions to my assistant. Most commonly, the patient eventually puts the mirror down and closes his or her eyes, becoming fully involved in a hypnotic experience.

Approaches to modifying pain can be taught to the dental patient by the treating dentist, a psychologist, or another health-care provider with training in hypnosis. Some patients are quite capable of learning hypnotic phenomena that will help them during dental care at a site quite removed from the dental office (e.g., the psychologist’s office). An independent self-hypnotic induction may then be accomplished by the patient in the dental office. For those who are not as comfortable with the self-hypnotic induction process, the psychotherapist might provide a tape recording of the hypnotic treatment, again recommending that the patient use the tape for daily practice. Such practice helps patients develop their self-hypnosis skills. Bringing the tape and a cassette player to the dental office and listening to it in the waiting room, as well as throughout the dental procedure, may be an effective way for the patient to develop an absorbing hypnotic experience.

With some patients, I use a formal induction. For instance, a modification of the glove anesthesia induction, and one which I believe is easier for a patient to accept, requires the patient to use his or her hands to remove the pain from the head and face. For further explanation of the glove anesthesia method see Bassman and Wester (1991) and Mulligan and Lindeman (1979).

Mrs. Scarlatti’s case illustrates this effective hypnotic approach. Mrs. Scarlatti was a very lonely woman; she told us that, although many of her family members lived within 50 miles of her, they rarely visited. However, her son characterized her as a complainer who exaggerated to get attention. Mrs. Scarlatti gave a history of chronic facial pain and temporomandibular joint involvement, although she had not sought care for those symptoms in the last several years, as she was essentially housebound.

Having neglected her oral health, she had developed a toothache, causing her to arrange a trip to see me at great inconvenience to her. I performed the appropriate treatment; when I was finished, she advised me that she had developed neck pain as a result of the dental appointment.

Because Mrs. Scarlatti’s medical history included an extensive history of severe arthritis, I had provided a special neck roll for additional support to her neck during the treatment. In spite of this precaution, however, she complained quite vehemently about tremendous neck pain when the treatment was completed. Because of her significant arthritic condition, Mrs. Scarlatti was unable to hold her hands up to the back of her neck, the site of her pain. Therefore, I had her guide me to the exact location of her pain as I placed my hands on her neck. Then I asked Mrs. Scarlatti if she would be interested in my helping her to have relief from the pain. She responded quite positively. I asked her to focus on her breathing while I began talking to her.

In a moment, but not yet, I’m going to ask you to take three very deep, very satisfying breaths, breathing in deeply and exhaling slowly … begin now with the first very deep, very satisfying breath, breathing in deeply and exhaling slowly . .. and as you exhale, noticing, just noticing how you can become more relaxed and comfortable … with each and every exhalation, feeling your back against the very comfortable dental chair … now take a second very deep, very satisfying breath … breathing in deeply and exhaling slowly … and noticing again how you can feel even more comfortable than you did just a moment ago … and isn’t it interesting how you already know, even though I haven’t yet told you, that at the end of the third very deep, very satisfying breath you will feel more relaxed and more comfortable than you ever thought possible … and why don’t you go ahead and feel that way now by taking that third very deep, very comfortable breath, noticing the feeling of the comfortable dental chair against your back … and you can continue to become more relaxed and comfortable with each subsequent breath even as I continue to talk to you about other things.… And isn’t it interesting that before I mentioned the feeling of your back against the dental chair, you had not even noticed that sensation … but once I mentioned it, you became aware of the comfortable sensation of your back against the chair.… At times we tune in to one part of the body and ignore the rest … and sometimes when we ignore the rest of the body a part of it may respond by causing pain … but now that you are no longer ignoring your neck, the pain does not need to bother you … so as you continue your nice, comfortable, satisfying breaths, every time you exhale just let that pain go from your neck into my hands, knowing that once the pain is all gone from your neck, and into my hands, I will be able to shake it loose from my hands and onto the floor … where it will be swept up and discarded … with every breath let the pain flow out of your neck and into my hands. [The patient can be encouraged to have the pain flow faster if it seems to be taking awhile.]

I continued to encourage Mrs. Scarlatti to let the pain flow into my hands. When this was accomplished, and before alerting her, I gave her posthypnotic suggestions so that she could remove pain in a similar manner for herself, whenever she wanted to, just by imagining the feeling of my hands on her neck. After becoming alert, Mrs. Scarlatti remarked that she was pain-free. She was amazed at the rapidity of the pain removal, particularly because previous pain episodes had been severely debilitating, lasting all day, sometimes even several days.

It is easy to follow the progress of a patient when one is using this type of induction, because the patient is instructed to hold his or her hand over the painful site until the pain is gone from the site and moved into the hand. When that occurs, the hand will fall away from the site. This allows me to know when the hypnotic experience can be comfortably brought to an end. Since, due to the location of her pain, Mrs. Scarlatti wasn’t able to use her own hands, I helped her learn the amount of pain removal she could expect at a particular time. I did this by suggesting to Mrs. Scarlatti (at what, through observation, I perceived to be appropriate intervals) that one-quarter, one-half, two-thirds, and seven-eighths of the pain were gone, and commenting that she was probably eagerly looking forward to all of the pain being gone.

Once Mrs. Scarlatti acknowledged that all of the pain was gone and I had provided the appropriate concluding suggestions, I alerted her. At the same time, and within her view, I began shaking my hands with some vigor, clearly appearing as if I was “shaking off” something that was actually there. A staff member who walked by the door of the dental suite at the time brought towels to me, thinking that the treatment room must be without towels. When I waved her away, she was perplexed. However, Mrs. Scarlatti did not find my behavior strange. In fact, if I had not kept my part of the bargain, shaking off the pain that she sent from her neck to my hands, it is likely that trust would have been compromised, rendering similar hypnotic strategies in subsequent appointments less effective. Interestingly, Mrs. Scarlatti never commented on the unusual sight of her dentist standing in front of her, discussing posttreatment instructions and her future dental needs while “shaking off” her neck pain.

I used this induction technique on two additional visits with Mrs. Scarlatti. On the last occasion she arrived with neck pain, so I induced the hypnotic state prior to the treatment and provided suggestions that she could maintain her comfort not only during the entire procedure, but also throughout the day. Each time I performed this induction with Mrs. Scarlatti, her pain was successfully eliminated within approximately five minutes.

Although glove anesthesia and the induction used for Mrs. Scarlatti are both very effective, it is rare that I use such inductions. This is because I find that a generalized relaxation induction frequently accomplishes the dual goals of reducing anxiety and preparing the patient for the sensory stimulation of the dental procedure. Since relaxation facilitates my therapeutic goals, I find it beneficial to teach it to my patients by using it as a common induction technique.

I substitute other approaches when I believe the patient is uncomfortable experiencing relaxation. Typically, arthritic patients such as Mrs. Scarlatti say that they cannot find any comfortable position. Consequently, suggestions for progressive relaxation do not seem plausible (since these suggestions depend on such comfort). With Mrs. Scarlatti, I linked comfort to her breathing, which she obviously was accomplishing without difficulty. I also linked comfort to those inanimate objects with which her body was in contact, such as the dental chair.

Whether the patient is needle-phobic, has a hyperactive gag reflex, or is extremely sensitive to oral pain, relaxation techniques are generally quite effective. (Some typical relaxation inductions can be found in Erickson, Hershman, & Secter, 1990, and Wester & Smith, 1990.)

Individuals who readily develop a hypnotic state without assistance may do so as an automatic defense when they confront a stressful situation, though even these patients can profit from training in self-hypnosis. This may explain the diminished responsiveness to pain demonstrated by some patients. Quite often, patients with increased pain threshold will explain this phenomenon by suggesting that the procedure accomplished was simply not painful. These patients are not without any sensation in the treated area; rather, they describe feeling something, but they remark, tellingly, that the sensation was not troublesome. The sensory component remains, but the affective component is reduced.

Mrs. Marple had significant systemic diseases of the connective tissues, which required her to be on a wide variety of medications. Whether because of adverse interactions as a result of so many drugs, or her systemic disease, or a combination of both, Mrs. Marple insisted that she had an allergy to all local anesthetics and therefore needed to be treated using hypnosis. Mrs. Marple was well-oriented and very pleasant. She indicated she was seeing several different physicians for all her different ailments but no practitioners for her mental health. She carried a tripod cane, although she appeared not to rely on it. She said that her physical activity was quite reduced from what it had been previously, although she felt she had adapted well to the change. She did not appear to be depressed and frequently brought a puzzle book to pass the time while waiting for the transportation service to take her home.

Mrs. Marple’s myriad physical problems were very real; anyone could notice several physical signs, including disseminated vascular lesions on her face, hands and arms, and deformity of her fingers, all of which were manifestations of her diseases. I determined that appropriate dental treatment for Mrs. Marple would require extraction of 18 teeth and extensive restorative and prosthetic care. Because of her systemic conditions, I elected to extract three and four teeth at each visit. At each appointment, I hypnotized Mrs. Marple using a relaxation induction. Each induction became shorter and shorter as she became more adept at the process. At her request, guided imagery was employed to help her develop a “getaway” place on the beach where she could go while her treatment was being accomplished. Everytime the student practitioner or I extracted her teeth, Mrs. Marple asked if she could have them so that during practice at home, she could focus on the teeth as part of her induction. All of her dental work was successfully accomplished, including the extractions, using hypnosis as the sole anesthetic agent. She was very relaxed, calm, and comfortable during each procedure.

Yet to this day (and we still see Mrs. Marple regularly for all her oral health needs), she claims that she was never hypnotized. I believe that this is because her perception of hypnosis was that she expected to feel nothing. This was not the case; she felt “something,” although she reported that what she was feeling was not troublesome to her. She also had the impression that hypnosis would be more dramatic, similar to what she had seen on stage and television. Although I had initially described to her what hypnosis was and was not, she was not dissuaded. I did not attempt to change her beliefs, of course. The procedure was accomplished, the patient was comfortable, the therapeutic outcome was achieved—and that, of course, was the objective.