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The role of hypnosis and suggestion in dentistry
M ARCU S . . . VOLU M E 59, DECEM BER 1959 • 1149
here have been dem onstrated to a num ber of leading dentists and arrangements have been m ade to provide several of them w ith A udio Analgesiacs for test and experim entation. A t the present tim e five other dentists have gained a sizable body of experience from the use of an A udio A nalgesiac, covering test periods ranging from six weeks to five months. Each has reported successful results with over 90 per cent of his patients, with the total num ber of patients involved am ounting to over 1,000. 1791 M assachusetts A v en u e
*P s y c h o lo g is t , B o lt B e ra n e k a n d N e w m a n In c . 1. D u n c k e r, K . S o m e p r e lim in a r y e x p e rim e n ts o n th e m u tu a l in flu e n c e o f p a in s . P s y c h o l. F o rs c h . 2 1 :3 1 1 , 1937. 2 . B e e c h e r, H . K . T h e m e a s u re m e n t of^ p a in ; p r o t o ty p e f o r t h e q u a n t it a t iv e s tu d y o f s u b je c tiv e resp o n s e s . P h a r m . R e v . 9 :59 M a r c h 1957. 3 . H i l l , H . E ., a n d o th e r s . E ffe c ts o f a n x ie ty a n d m o r p h in e o n d is c r im in a tio n o f in te n s itie s o f p a in fu l s t im u li. J . C l in . In v e s t. 31:4 73 M a y 1952. 4 . K o rn e ts k y , C . E ffe c ts o f a n x ie ty a n d m o rp h in e ^ o n t h e a n t ic ip a t io n a n d p e r c e p t io n o f p a in fu l r a d ia n t t h e r m a l s t im u li. J . C o m p . P h y s io l. P syc h o l. 47:1 30 A p r i l 1954. 5 . H a r d y , J . D .; W o lf f , H . G . , a n d G o o d e ll, H . P ain s e n s a tio n s a n d re a c tio n s . B a ltim o r e , W illia m s and W ilk in s C o ., 1952. 6. C h e r r y , H . , a n d P a llin , I . M . M u s ic as a s u p p le m e n t in d e n t a l n itro u s o x id e -o x y g e n a n e s th e s ia . 0 . D ig e s t 54:4 55 O c t . 1948. 7 . B urgess, T . O . H y p n o s is in d e n tis tr y . In E x p e r i m e n ta l h y p n o s is . L e C ro n , L. M ., e d . N e w Y o rk , M a c m illa n C o ., 1952.
T he role o f h yp n o sis an d su g g e stio n in d e n tistry
H ow a rd W . M a rcu s ,* M .D ., D .M .D ., N e w Y ork
H yp n osis can be a valuable asset to the d en tist; it can be used to help bridge the gap b etw een the dentist’s ability to ad minister
his services
and
the patient’s
refusal, fo r psychological reasons, to ac cept th em . H yp n osis should be used only w h en oth er standard procedures do not lead to desired results, or w hen the d e sired results can be facilitated by the use o f hypnosis. T h e proper use o f hypnosis enables the dentist to perform
a m ore
co m p lete health service, and perm its a greater
n u m ber
of
patients
to
benefit
fr o m dental services.
In the n ot too distant past, dentists who were known to use hypnosis were called on at tim es to administer hypnosis for
problems not strictly confined to the d en tal field. T h e reason for this was that there were not enough, if any, profes sional m en available w ho could use hyp nosis in their respective field of com petence. O ften, such requests or referrals for treatm ent were preceded by a remark that everything else had been tried w ith out results. It m ust be adm itted that the dentist faced w ith such a request for treatm ent, especially if it cam e from a physician or from another dentist, was faced w ith som e soul searching; m any times he m ight have been inclined to subm it to the d ic tates o f his heart rather than to the objective considerations o f his profes sional lim itations. This era of conflict is reflected in some of the early writings on hypnosis in dentistry.
1150 • TH E JO U R N A L O F TH E A M E R IC A N DENTAL A S S O C IA T IO N
T h e era of “conflict of interest” has m edication and administration of anes passed by now. T here are today com pe thetics, still appears to represent a threat tent professional m en in every branch to the m ajority of the adult population, of m edicine w ho are able to administer and the m ere sight of the dental chair hypnosis if and where indicated in their still provokes anxiety. respective fields, and because of the T here has been great interest on the broader recognition o f hypnosis in the part of dentists in finding ways and m éans profession, their num ber is increasing at to cope w ith those factors that inter a steady rate. fere with the administration of good den tal services and w hich cannot be con W hereas this developm ent relieves the dentist trained to use hypnosis of the trolled by the m any physical and phar burden to choose betw een his professional m acological m eans at the disposal o f the com petency and other considerations, dentist. H ere is w here the use of hypnosis there rem ains a need to define clearly comes in ; nam ely, to help bridge the where the dentist should and should not gap between the dentist’s ability to ad use hypnosis w ithin his ow n field. There minister his good services and the pa are, of course, borderline cases and con tient’s refusal to accept them , for no siderations w hich cannot be classified, other than psychological reasons. but have to be considered on their indi O pportunities for the use of hypnosis vidual merits. Experience and judgm ent exist in every practice, regardless o f the w ill be the only guide here, as in any specialty involved. T his, o f course, does other professional activity. not im ply that it should be used in a H ypnosis in dentistry often is referred routine fashion. Q uite to the contrary, to as “dental hypnosis” or “hypnodonhypnosis should be used only if and w hen tics.” T here is a danger that a too literal needed; if and w hen other standard pro and confining interpretation of those cedures at the disposal of the dentist do terms ignores the fact that hypnosis, even not lead to desired results ; or if and w hen if used in dentistry and for dental pur the desired results of treatm ent can be poses only, involves the total personality facilitated or im proved by the use of o f the patient. This undeniable fact may hypnosis. startle some and discourage others from Hypnosis therefore is used in addition the use of hypnosis. Y et all dentists realize to, and not instead of, established dental that m odern dentistry is no longer con procedures. fined to the m echanical aspects of the profession, that broader m edical as w ell W H E N H Y P N O S IS IS U SE D as surgical and psychological consider ations form an inseparable and important Hypnosis is used, in a selective fashion, part o f its daily practice. for the follow ing specific purposes: In addition to these general consider ations, ever since Freud, special psycho 1. It is used to reach those patients dynam ic significance has been attributed w ho do not submit to dental treatm ent, to the oral region. Therefore, today’s even the routine dental exam ination, dentist can no longer afford to confine under any circumstances. T hese patients his thoughts to the teeth alone. H e is generally are not seen by the practicing com pelled to consider the surrounding dentist. T h ey are the patients w ho finally tissues, soft and hard, the patient as a arouse the ire or the compassion o f one w hole, body and soul. of their close relatives, w ho then makes It m ust be adm itted that dentistry, in the appointm ent for them. T h ey are the spite of all technological advances re patients w ho usually do not keep such garding equipm ent and technics, pre appointm ents. T h ey are the patients who
M ARCUS . . . VO LUM E 59, DECEMBER 1959 • 1151
are referred to in the profession as “den tal cripples.” A nd let there be no mis understanding by those in the profession whose activities are concentrated on the m ore m echanistic aspects o f dentistry and who never see such patients: those of us who do see them know that they represent a m uch larger contingent than is realized generally. 2. Hypnosis is used to overcom e fear and tension, to counteract previous u n pleasant experiences or negative influ ences w ith regard to the dental situation; it is used to raise the threshold of pain, and to relax patients w ho are undergoing treatment. 3. Hypnosis is used for prem edication in operative and surgical procedures, either in addition to or instead o f chem ical prem edication, depending on need and circumstances. 4. It is used to allow for a reduction of chem ical anesthetic agents such as procaine, nitrous oxide or others and to reduce the unpleasant after-effects of chem ical anesthesia. 5. It is used to replace chem ical anes thesia w here the administration of such anesthesia is contraindicated for m ed ical reasons, such as allergies, heart dis ease and others.
6 . Hypnosis is used to overcom e h an dicaps to the perform ance of proper dental service and to the normal dentistpatient relationship, such as gagging while roentgenograms are being taken; gagging w hile impressions are taken ; gagging w hile dentures or other appli ances are worn; gagging during the rou tine exam ination of the oral cavity for diagnostic purposes; gagging during rou tine dental treatm ent or during the rou tine use o f th e toothbrush at home. 7. It is used to overcom e lack of proper cooperation during such procedures as bite registration, or in the w earing of appliances, such as bite planes or other orthodontic or prosthetic appliances
(provided, of course, that this lack of cooperation is not due to faulty construc tion o f the appliance).
8 . Hypnosis m ay be used for the con trol o f flow of saliva and capillary bleed ing to som e extent, if desirable, although its effectiveness in controlling capillary bleeding has been questioned. 9. Hypnosis can be used to neutralize the com m only encountered objections to the noise and vibration caused by the dental drill. 10. Hypnosis can be used further in the form of posthypnotic suggestion, for the control of postoperative sequelae such as pain and bleeding. R econditioning patients through posthypnotic suggestions to accept dentistry in the future w ithout prejudice is one of the im portant and m ost rewarding applications of hypnosis in dentistry. 11. Finally, hypnosis can be used for the correction o f habits w hich interfere directly or indirectly w ith dental treat m ent, and w ith the health, function or esthetics o f the dental apparatus and the soft tissues o f the oral cavity. T hese habits include thumb, finger, cheek or tongue sucking; pencil, nail, lip or tongue biting; bruxism, excessive smoking and m any others. H abits centered in and around the oral cavity ought to be handled with discrim ination and judgm ent and, gen erally speaking, ought to be treated by a com petent psychotherapist. T h is is not the place to discuss this very im portant aspect o f the dentist’s position in deal ing w ith habits centered in and around the oral cavity, in as m uch detail as the subject warrants. H ow ever, a few gen eral statem ents m ay be in order. A n en couraging remark, a positive statement as to the effect of treatm ent, the treat m ent proper, the relief o f pain, anxiety and tension— all these and m any other aspects of the dentist’s daily routine are psychotherapy to some degree. O f course, it is not the dentist’s place
1152 • THE JO U R N A L OF THE A M ERICAN DENTAL ASSO CIATIO N
to adm inister psychotherapy as such any m ore than it w ould be his place to open surgically and curet the antrum to recover a broken root tip. O n the other hand, if the dentist could pick up the broken root tip w hile it is accessible from the oral cavity and all he had to do is to reach for it w ith a college plier, and if by such relatively m inor interven tion he could protect his patient from m ajor surgical procedure later on, he w ould n ot only use good judgm ent, but stay w ell w ithin the area of his com pe tence, by doing so. A lthough not gen erally recognized, the sam e criterion ap plies to the question o f the handling of habits in the dental office by the properly trained dentist. T h e scope of this discussion m eans that the problem of habits and sym ptom re m oval by the dentist can be touched on in a very general m anner only. This is always dangerous and leaves room for m isunderstanding and misinterpretation. Therefore, I w ould like to stress that any habit that is deeply im bedded should be treated by the psychotherapist and should not be handled by the dentist. Som e o f the habits dealt w ith in den tistry appear not to be deeply im bedded, and over the years they m ay have ac quired the character o f a conditioned reflex. For exam ple, the sucking of the thum b m ay have had a great psycho dynam ic significance and m eaning to the child w hen he was an infant. It may have been a replacem ent outlet for his w ant of the m other’s breast. But if the child has reached the age o f 8 or 9 or 10 or 14, the original m eaning of this habit often has been lost over the years; it has changed direction and purpose, and by now m ay have becom e a condi tioned reflex. If the habit n o longer has psycho dynam ic m eaning, if it is not deeply im bedded but is superficially attached, it often w ill yield to the use of suggestion. If this sim ple approach is not successful and suggestion does not relieve the habit,
this serves as a m eans of differential diag nosis and the patient ought to be re ferred for treatm ent to a com petent psychotherapist. T h e point is that any habit w hich is deeply im bedded and psychodynam ically m eaningful to the pa tient w ill not yield readily to simple suggestions of any type. T h e preponderance of com petent opin ion expressed in the past has frowned on the use o f the direct approach of sym ptom rem oval w ithout full evalua tion of the total personality factors in volved and the underlying psychody namics of the patient. O ne of the main objections to the direct approach has been the possibility o f release o f other, and at times less desirable, outlets for the underlying disturbance. O f late, however, more and more workers in the field have expressed a dis senting view. T h ey point out that few practical cases have been cited to justify a ‘rigid position. O n the other hand, cases have been reported where a direct approach has served n ot only to remove the sym ptom for w hich it was intended, but at the sam e tim e, other coexisting undesirable symptoms and personality disorders. Furthermore, some m en have pointed out that only after the elimi nation o f a sym ptom by the direct ap proach have they been able to reach the underlying personality disorder through psychotherapy. Thus, the elim ination of the habit has served to cut through the patient’s defense system and to open the avenue for broader therapy. A gain, the dentist ought to have the necessary background to enable him to be selective, and to use good judgm ent and proper procedure, before dealing w ith this com plex problem. T here is no reason w hy the dentist should n ot en large his horizon to enable him to deal w ith psychological problems that occur in his field in the same m anner as he has learned to deal w ith m edicosurgical problems that occur in today’s practice of dentistry.
MARCUS
C O N T R A IN D IC A T IO N S F O R U S E O F -H Y P N O S IS
So far, this article has dealt m ainly with the indications for the use o f hypnosis in dental practice. T here are also definite contraindications for the use of hypnosis by the dentist: 1. Hypnosis is not to be used if the dentist lacks training in, and familiarity with, the subject jnatter as a whole. H ere the same lim itations apply as in any other area o f professional activity. It is at times as easy to hypnotize a patient as it is to put a patient to sleep w ith a bottle o f ether— yet in order to use anesthesia or hypnosis in the dental office, the den tist should have acquired a thorough knowledge of, and background in, all aspects which enter into the adm inistra tion of either. 2. Hypnosis is not to be used if the dentist has em otional problems concern ing his attitude toward the patient or toward hypnosis, or both. T h e dentist using hypnosis ought to have enough in sight into his ow n em otions to enable him to desist from using hypnosis under circumstances w hich w ould not allow him to use it in an objective and pro fessional m anner. T h e same lim itations' apply here in the em otional area as w ould apply to the dentist w ho m ight be physi cally handicapped to perform certain m echanical functions. 3. Hypnosis is to be discouraged if the patient has em otional problem s concern ing his attitude toward the dentist or hypnosis, or both. T h e dentist using hyp nosis ought to be able to recognize em o tional problems in his patients w hich call for a “hands off” attitude on his part. H ere again the same applies as in any other area o f his activities. I f the prob lem goes beyond the scope o f the d en tist’s training and experience, referral to a competent- specialist is the required procedure. 4. Any deep-seated or psychodynamically m eaningful condition w hich the d en
VOLUME 59, DECEMBER 1959 • 1153
tist m ay encounter in his area of contact w ith the patient should not be treated by the dentist. Referral to the psycho therapist is imperative. 5. Any m anifestation o f dependency on hypnosis ought to be recognized and counteracted promptly. 6 . Hypnosis should not be used if the dental services required in the specific case can be equally w ell performed w ith out the use o f hypnosis. U nless there are definite indications for the use of hyp nosis, its use is contraindicated, as w ould be the use o f procaine for the prepara tion of a devitalized tooth. 7. Hypnosis should not be used by the dentist to probe or explore the m ind o f his patient. 8 . Hypnosis should n ot be used by the dentist on m entally aberrated persons, except with the consent and cooperation o f a psychiatrist, and then all other con ditions should be as given for any other patient. 9. Hypnosis should not be used by the dentist for any m anipulation w hich is outside his sphere o f interest and com petency. P R O C E D U R E I N D E N T A L O F F IC E
A thorough history-taking should precede any clinical contact. Special interest should be paid to the patient’s previous experiences w ith dentistry and dentists, and the patient’s attitude toward both; previous experiences w ith hypnosis and the reasons for the present use o f hyp nosis should be explored. Q uestions as to past or present psychotherapy should be asked and, where possible, consultation w ith the therapist should precede any clinical procedure. T h e existence o f functional diseases, allergies, and so forth, should be covered in the interview, in addition to all other aspects o f interest within the frame of a general case history. After the history-taking, tim e should be spent on eliciting and correcting m is
1154 • THE JO U R N A L OF THE A M ERICAN DENTAL ASSOCIATION
conceptions and to establish rapport with the patient. T h is helps to assure the pa tient’s cooperation and allows the dentist to becom e acquainted w ith the psycho logical m ake-up o f his patient. O nce all m isconceptions are dispelled and the patient has expressed his w ill ingness to enter the hypnotic state, he m ay be tested as to his susceptibility and cooperation. T hese tests serve to show the patient how suggestion works, and they allow the dentist to get m ore insight into his patient’s degree of suggestibility— his general attitude and reaction. T h ey allow the dentist to adapt his future procedures accordingly. T h e next step is the induction proper. T h e m ethod o f induction should vary according to patient and circumstances. M any tim es a com bination o f several technics w ill be used in practice. T h e m ethod chosen preferably should be non authoritarian, permissive in nature. T h e dentist is naturally m ost interested in having the patient sufficiently relaxed in the chair to enable work to be done w ithout interference. A t the sam e tim e, he likes to see the patient in a cooper ative m ood and free o f unfavorable phys ical and m ental reactions. A ll this usually can be achieved w ithout using the deeper stages o f hypnosis. As a rule, therefore, induction is carried no further than is necessary to accom plish the m ain goal, w hich is good dentistry and not deep hypnosis. T h e properly m anaged patient generally enjoys the calm ing, relaxing effect of hypnosis and looks forward to its future application. H ow ever, once the existing obstacle to the administration of good dental services has been removed by the use of hypnosis, it often becom es unnecessary to em ploy hypnosis in future sessions. Patients are prepared for this during the initial interview, w hile in the hypnotic state, through posthypnotic suggestion and by casual suggestions given during the w aking stage.
T h e m ore familiar the dentist is with the technics and principles underlying the use of hypnosis, the less he actually needs to em ploy rigid hypnotic proce dures. H e often will get almost equal results w ith the constant and purposeful use o f controlled suggestion, w hich then assumes the character o f w aking hypnosis. SU M M A RY
Hypnosis can be a valuable asset to the m od em and properly trained dentist. It should never be used w ithout definite indication for its use. It is an adjunct to, and not a replacem ent for, other valuable dental procedures. It is not a panacea. O nce the obstacle to the use of standard dental procedures is overcom e, there is no further need for the use of hypnosis in treatm ent o f the particular patient. T h e m ore fam iliar the dentist is w ith the technics and principles underlying the use of hypnosis, the less need there appears to be for rigid hypnotic proce dures. Hypnosis should never be allow ed to becom e a crutch on w hich dentist or patient depends. If such dependency exists, it should be recognized and coun teracted. T h e evaluation and proper use of psy chodynam ic factors involved in the d en tist-patient relationship, including the use of hypnosis and suggestion in dentistry, will enable the dentist to perform a m ore com plete health service. It w ill enable a greater num ber of patients to benefit from m odern dental services. I t w ill lift the dentist’s horizon and elevate dentistry from the m echanistic plateau of the past to a position of a truly respected and com petent m em ber of the h ealing arts. 200 Central Park South
*Member Hypnosis.
of
faculty,
Institute
for
Research
in
here have been dem onstrated to a num ber of leading dentists and arrangements have been m ade to provide several of them w ith A udio Analgesiacs for test and experim entation. A t the present tim e five other dentists have gained a sizable body of experience from the use of an A udio A nalgesiac, covering test periods ranging from six weeks to five months. Each has reported successful results with over 90 per cent of his patients, with the total num ber of patients involved am ounting to over 1,000. 1791 M assachusetts A v en u e
*P s y c h o lo g is t , B o lt B e ra n e k a n d N e w m a n In c . 1. D u n c k e r, K . S o m e p r e lim in a r y e x p e rim e n ts o n th e m u tu a l in flu e n c e o f p a in s . P s y c h o l. F o rs c h . 2 1 :3 1 1 , 1937. 2 . B e e c h e r, H . K . T h e m e a s u re m e n t of^ p a in ; p r o t o ty p e f o r t h e q u a n t it a t iv e s tu d y o f s u b je c tiv e resp o n s e s . P h a r m . R e v . 9 :59 M a r c h 1957. 3 . H i l l , H . E ., a n d o th e r s . E ffe c ts o f a n x ie ty a n d m o r p h in e o n d is c r im in a tio n o f in te n s itie s o f p a in fu l s t im u li. J . C l in . In v e s t. 31:4 73 M a y 1952. 4 . K o rn e ts k y , C . E ffe c ts o f a n x ie ty a n d m o rp h in e ^ o n t h e a n t ic ip a t io n a n d p e r c e p t io n o f p a in fu l r a d ia n t t h e r m a l s t im u li. J . C o m p . P h y s io l. P syc h o l. 47:1 30 A p r i l 1954. 5 . H a r d y , J . D .; W o lf f , H . G . , a n d G o o d e ll, H . P ain s e n s a tio n s a n d re a c tio n s . B a ltim o r e , W illia m s and W ilk in s C o ., 1952. 6. C h e r r y , H . , a n d P a llin , I . M . M u s ic as a s u p p le m e n t in d e n t a l n itro u s o x id e -o x y g e n a n e s th e s ia . 0 . D ig e s t 54:4 55 O c t . 1948. 7 . B urgess, T . O . H y p n o s is in d e n tis tr y . In E x p e r i m e n ta l h y p n o s is . L e C ro n , L. M ., e d . N e w Y o rk , M a c m illa n C o ., 1952.
T he role o f h yp n o sis an d su g g e stio n in d e n tistry
H ow a rd W . M a rcu s ,* M .D ., D .M .D ., N e w Y ork
H yp n osis can be a valuable asset to the d en tist; it can be used to help bridge the gap b etw een the dentist’s ability to ad minister
his services
and
the patient’s
refusal, fo r psychological reasons, to ac cept th em . H yp n osis should be used only w h en oth er standard procedures do not lead to desired results, or w hen the d e sired results can be facilitated by the use o f hypnosis. T h e proper use o f hypnosis enables the dentist to perform
a m ore
co m p lete health service, and perm its a greater
n u m ber
of
patients
to
benefit
fr o m dental services.
In the n ot too distant past, dentists who were known to use hypnosis were called on at tim es to administer hypnosis for
problems not strictly confined to the d en tal field. T h e reason for this was that there were not enough, if any, profes sional m en available w ho could use hyp nosis in their respective field of com petence. O ften, such requests or referrals for treatm ent were preceded by a remark that everything else had been tried w ith out results. It m ust be adm itted that the dentist faced w ith such a request for treatm ent, especially if it cam e from a physician or from another dentist, was faced w ith som e soul searching; m any times he m ight have been inclined to subm it to the d ic tates o f his heart rather than to the objective considerations o f his profes sional lim itations. This era of conflict is reflected in some of the early writings on hypnosis in dentistry.
1150 • TH E JO U R N A L O F TH E A M E R IC A N DENTAL A S S O C IA T IO N
T h e era of “conflict of interest” has m edication and administration of anes passed by now. T here are today com pe thetics, still appears to represent a threat tent professional m en in every branch to the m ajority of the adult population, of m edicine w ho are able to administer and the m ere sight of the dental chair hypnosis if and where indicated in their still provokes anxiety. respective fields, and because of the T here has been great interest on the broader recognition o f hypnosis in the part of dentists in finding ways and m éans profession, their num ber is increasing at to cope w ith those factors that inter a steady rate. fere with the administration of good den tal services and w hich cannot be con W hereas this developm ent relieves the dentist trained to use hypnosis of the trolled by the m any physical and phar burden to choose betw een his professional m acological m eans at the disposal o f the com petency and other considerations, dentist. H ere is w here the use of hypnosis there rem ains a need to define clearly comes in ; nam ely, to help bridge the where the dentist should and should not gap between the dentist’s ability to ad use hypnosis w ithin his ow n field. There minister his good services and the pa are, of course, borderline cases and con tient’s refusal to accept them , for no siderations w hich cannot be classified, other than psychological reasons. but have to be considered on their indi O pportunities for the use of hypnosis vidual merits. Experience and judgm ent exist in every practice, regardless o f the w ill be the only guide here, as in any specialty involved. T his, o f course, does other professional activity. not im ply that it should be used in a H ypnosis in dentistry often is referred routine fashion. Q uite to the contrary, to as “dental hypnosis” or “hypnodonhypnosis should be used only if and w hen tics.” T here is a danger that a too literal needed; if and w hen other standard pro and confining interpretation of those cedures at the disposal of the dentist do terms ignores the fact that hypnosis, even not lead to desired results ; or if and w hen if used in dentistry and for dental pur the desired results of treatm ent can be poses only, involves the total personality facilitated or im proved by the use of o f the patient. This undeniable fact may hypnosis. startle some and discourage others from Hypnosis therefore is used in addition the use of hypnosis. Y et all dentists realize to, and not instead of, established dental that m odern dentistry is no longer con procedures. fined to the m echanical aspects of the profession, that broader m edical as w ell W H E N H Y P N O S IS IS U SE D as surgical and psychological consider ations form an inseparable and important Hypnosis is used, in a selective fashion, part o f its daily practice. for the follow ing specific purposes: In addition to these general consider ations, ever since Freud, special psycho 1. It is used to reach those patients dynam ic significance has been attributed w ho do not submit to dental treatm ent, to the oral region. Therefore, today’s even the routine dental exam ination, dentist can no longer afford to confine under any circumstances. T hese patients his thoughts to the teeth alone. H e is generally are not seen by the practicing com pelled to consider the surrounding dentist. T h ey are the patients w ho finally tissues, soft and hard, the patient as a arouse the ire or the compassion o f one w hole, body and soul. of their close relatives, w ho then makes It m ust be adm itted that dentistry, in the appointm ent for them. T h ey are the spite of all technological advances re patients w ho usually do not keep such garding equipm ent and technics, pre appointm ents. T h ey are the patients who
M ARCUS . . . VO LUM E 59, DECEMBER 1959 • 1151
are referred to in the profession as “den tal cripples.” A nd let there be no mis understanding by those in the profession whose activities are concentrated on the m ore m echanistic aspects o f dentistry and who never see such patients: those of us who do see them know that they represent a m uch larger contingent than is realized generally. 2. Hypnosis is used to overcom e fear and tension, to counteract previous u n pleasant experiences or negative influ ences w ith regard to the dental situation; it is used to raise the threshold of pain, and to relax patients w ho are undergoing treatment. 3. Hypnosis is used for prem edication in operative and surgical procedures, either in addition to or instead o f chem ical prem edication, depending on need and circumstances. 4. It is used to allow for a reduction of chem ical anesthetic agents such as procaine, nitrous oxide or others and to reduce the unpleasant after-effects of chem ical anesthesia. 5. It is used to replace chem ical anes thesia w here the administration of such anesthesia is contraindicated for m ed ical reasons, such as allergies, heart dis ease and others.
6 . Hypnosis is used to overcom e h an dicaps to the perform ance of proper dental service and to the normal dentistpatient relationship, such as gagging while roentgenograms are being taken; gagging w hile impressions are taken ; gagging w hile dentures or other appli ances are worn; gagging during the rou tine exam ination of the oral cavity for diagnostic purposes; gagging during rou tine dental treatm ent or during the rou tine use o f th e toothbrush at home. 7. It is used to overcom e lack of proper cooperation during such procedures as bite registration, or in the w earing of appliances, such as bite planes or other orthodontic or prosthetic appliances
(provided, of course, that this lack of cooperation is not due to faulty construc tion o f the appliance).
8 . Hypnosis m ay be used for the con trol o f flow of saliva and capillary bleed ing to som e extent, if desirable, although its effectiveness in controlling capillary bleeding has been questioned. 9. Hypnosis can be used to neutralize the com m only encountered objections to the noise and vibration caused by the dental drill. 10. Hypnosis can be used further in the form of posthypnotic suggestion, for the control of postoperative sequelae such as pain and bleeding. R econditioning patients through posthypnotic suggestions to accept dentistry in the future w ithout prejudice is one of the im portant and m ost rewarding applications of hypnosis in dentistry. 11. Finally, hypnosis can be used for the correction o f habits w hich interfere directly or indirectly w ith dental treat m ent, and w ith the health, function or esthetics o f the dental apparatus and the soft tissues o f the oral cavity. T hese habits include thumb, finger, cheek or tongue sucking; pencil, nail, lip or tongue biting; bruxism, excessive smoking and m any others. H abits centered in and around the oral cavity ought to be handled with discrim ination and judgm ent and, gen erally speaking, ought to be treated by a com petent psychotherapist. T h is is not the place to discuss this very im portant aspect o f the dentist’s position in deal ing w ith habits centered in and around the oral cavity, in as m uch detail as the subject warrants. H ow ever, a few gen eral statem ents m ay be in order. A n en couraging remark, a positive statement as to the effect of treatm ent, the treat m ent proper, the relief o f pain, anxiety and tension— all these and m any other aspects of the dentist’s daily routine are psychotherapy to some degree. O f course, it is not the dentist’s place
1152 • THE JO U R N A L OF THE A M ERICAN DENTAL ASSO CIATIO N
to adm inister psychotherapy as such any m ore than it w ould be his place to open surgically and curet the antrum to recover a broken root tip. O n the other hand, if the dentist could pick up the broken root tip w hile it is accessible from the oral cavity and all he had to do is to reach for it w ith a college plier, and if by such relatively m inor interven tion he could protect his patient from m ajor surgical procedure later on, he w ould n ot only use good judgm ent, but stay w ell w ithin the area of his com pe tence, by doing so. A lthough not gen erally recognized, the sam e criterion ap plies to the question o f the handling of habits in the dental office by the properly trained dentist. T h e scope of this discussion m eans that the problem of habits and sym ptom re m oval by the dentist can be touched on in a very general m anner only. This is always dangerous and leaves room for m isunderstanding and misinterpretation. Therefore, I w ould like to stress that any habit that is deeply im bedded should be treated by the psychotherapist and should not be handled by the dentist. Som e o f the habits dealt w ith in den tistry appear not to be deeply im bedded, and over the years they m ay have ac quired the character o f a conditioned reflex. For exam ple, the sucking of the thum b m ay have had a great psycho dynam ic significance and m eaning to the child w hen he was an infant. It may have been a replacem ent outlet for his w ant of the m other’s breast. But if the child has reached the age o f 8 or 9 or 10 or 14, the original m eaning of this habit often has been lost over the years; it has changed direction and purpose, and by now m ay have becom e a condi tioned reflex. If the habit n o longer has psycho dynam ic m eaning, if it is not deeply im bedded but is superficially attached, it often w ill yield to the use of suggestion. If this sim ple approach is not successful and suggestion does not relieve the habit,
this serves as a m eans of differential diag nosis and the patient ought to be re ferred for treatm ent to a com petent psychotherapist. T h e point is that any habit w hich is deeply im bedded and psychodynam ically m eaningful to the pa tient w ill not yield readily to simple suggestions of any type. T h e preponderance of com petent opin ion expressed in the past has frowned on the use o f the direct approach of sym ptom rem oval w ithout full evalua tion of the total personality factors in volved and the underlying psychody namics of the patient. O ne of the main objections to the direct approach has been the possibility o f release o f other, and at times less desirable, outlets for the underlying disturbance. O f late, however, more and more workers in the field have expressed a dis senting view. T h ey point out that few practical cases have been cited to justify a ‘rigid position. O n the other hand, cases have been reported where a direct approach has served n ot only to remove the sym ptom for w hich it was intended, but at the sam e tim e, other coexisting undesirable symptoms and personality disorders. Furthermore, some m en have pointed out that only after the elimi nation o f a sym ptom by the direct ap proach have they been able to reach the underlying personality disorder through psychotherapy. Thus, the elim ination of the habit has served to cut through the patient’s defense system and to open the avenue for broader therapy. A gain, the dentist ought to have the necessary background to enable him to be selective, and to use good judgm ent and proper procedure, before dealing w ith this com plex problem. T here is no reason w hy the dentist should n ot en large his horizon to enable him to deal w ith psychological problems that occur in his field in the same m anner as he has learned to deal w ith m edicosurgical problems that occur in today’s practice of dentistry.
MARCUS
C O N T R A IN D IC A T IO N S F O R U S E O F -H Y P N O S IS
So far, this article has dealt m ainly with the indications for the use o f hypnosis in dental practice. T here are also definite contraindications for the use of hypnosis by the dentist: 1. Hypnosis is not to be used if the dentist lacks training in, and familiarity with, the subject jnatter as a whole. H ere the same lim itations apply as in any other area o f professional activity. It is at times as easy to hypnotize a patient as it is to put a patient to sleep w ith a bottle o f ether— yet in order to use anesthesia or hypnosis in the dental office, the den tist should have acquired a thorough knowledge of, and background in, all aspects which enter into the adm inistra tion of either. 2. Hypnosis is not to be used if the dentist has em otional problems concern ing his attitude toward the patient or toward hypnosis, or both. T h e dentist using hypnosis ought to have enough in sight into his ow n em otions to enable him to desist from using hypnosis under circumstances w hich w ould not allow him to use it in an objective and pro fessional m anner. T h e same lim itations' apply here in the em otional area as w ould apply to the dentist w ho m ight be physi cally handicapped to perform certain m echanical functions. 3. Hypnosis is to be discouraged if the patient has em otional problem s concern ing his attitude toward the dentist or hypnosis, or both. T h e dentist using hyp nosis ought to be able to recognize em o tional problems in his patients w hich call for a “hands off” attitude on his part. H ere again the same applies as in any other area o f his activities. I f the prob lem goes beyond the scope o f the d en tist’s training and experience, referral to a competent- specialist is the required procedure. 4. Any deep-seated or psychodynamically m eaningful condition w hich the d en
VOLUME 59, DECEMBER 1959 • 1153
tist m ay encounter in his area of contact w ith the patient should not be treated by the dentist. Referral to the psycho therapist is imperative. 5. Any m anifestation o f dependency on hypnosis ought to be recognized and counteracted promptly. 6 . Hypnosis should not be used if the dental services required in the specific case can be equally w ell performed w ith out the use o f hypnosis. U nless there are definite indications for the use of hyp nosis, its use is contraindicated, as w ould be the use o f procaine for the prepara tion of a devitalized tooth. 7. Hypnosis should not be used by the dentist to probe or explore the m ind o f his patient. 8 . Hypnosis should n ot be used by the dentist on m entally aberrated persons, except with the consent and cooperation o f a psychiatrist, and then all other con ditions should be as given for any other patient. 9. Hypnosis should not be used by the dentist for any m anipulation w hich is outside his sphere o f interest and com petency. P R O C E D U R E I N D E N T A L O F F IC E
A thorough history-taking should precede any clinical contact. Special interest should be paid to the patient’s previous experiences w ith dentistry and dentists, and the patient’s attitude toward both; previous experiences w ith hypnosis and the reasons for the present use o f hyp nosis should be explored. Q uestions as to past or present psychotherapy should be asked and, where possible, consultation w ith the therapist should precede any clinical procedure. T h e existence o f functional diseases, allergies, and so forth, should be covered in the interview, in addition to all other aspects o f interest within the frame of a general case history. After the history-taking, tim e should be spent on eliciting and correcting m is
1154 • THE JO U R N A L OF THE A M ERICAN DENTAL ASSOCIATION
conceptions and to establish rapport with the patient. T h is helps to assure the pa tient’s cooperation and allows the dentist to becom e acquainted w ith the psycho logical m ake-up o f his patient. O nce all m isconceptions are dispelled and the patient has expressed his w ill ingness to enter the hypnotic state, he m ay be tested as to his susceptibility and cooperation. T hese tests serve to show the patient how suggestion works, and they allow the dentist to get m ore insight into his patient’s degree of suggestibility— his general attitude and reaction. T h ey allow the dentist to adapt his future procedures accordingly. T h e next step is the induction proper. T h e m ethod o f induction should vary according to patient and circumstances. M any tim es a com bination o f several technics w ill be used in practice. T h e m ethod chosen preferably should be non authoritarian, permissive in nature. T h e dentist is naturally m ost interested in having the patient sufficiently relaxed in the chair to enable work to be done w ithout interference. A t the sam e tim e, he likes to see the patient in a cooper ative m ood and free o f unfavorable phys ical and m ental reactions. A ll this usually can be achieved w ithout using the deeper stages o f hypnosis. As a rule, therefore, induction is carried no further than is necessary to accom plish the m ain goal, w hich is good dentistry and not deep hypnosis. T h e properly m anaged patient generally enjoys the calm ing, relaxing effect of hypnosis and looks forward to its future application. H ow ever, once the existing obstacle to the administration of good dental services has been removed by the use of hypnosis, it often becom es unnecessary to em ploy hypnosis in future sessions. Patients are prepared for this during the initial interview, w hile in the hypnotic state, through posthypnotic suggestion and by casual suggestions given during the w aking stage.
T h e m ore familiar the dentist is with the technics and principles underlying the use of hypnosis, the less he actually needs to em ploy rigid hypnotic proce dures. H e often will get almost equal results w ith the constant and purposeful use o f controlled suggestion, w hich then assumes the character o f w aking hypnosis. SU M M A RY
Hypnosis can be a valuable asset to the m od em and properly trained dentist. It should never be used w ithout definite indication for its use. It is an adjunct to, and not a replacem ent for, other valuable dental procedures. It is not a panacea. O nce the obstacle to the use of standard dental procedures is overcom e, there is no further need for the use of hypnosis in treatm ent o f the particular patient. T h e m ore fam iliar the dentist is w ith the technics and principles underlying the use of hypnosis, the less need there appears to be for rigid hypnotic proce dures. Hypnosis should never be allow ed to becom e a crutch on w hich dentist or patient depends. If such dependency exists, it should be recognized and coun teracted. T h e evaluation and proper use of psy chodynam ic factors involved in the d en tist-patient relationship, including the use of hypnosis and suggestion in dentistry, will enable the dentist to perform a m ore com plete health service. It w ill enable a greater num ber of patients to benefit from m odern dental services. I t w ill lift the dentist’s horizon and elevate dentistry from the m echanistic plateau of the past to a position of a truly respected and com petent m em ber of the h ealing arts. 200 Central Park South
*Member Hypnosis.
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