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Application of Hypno-Dissociative Strategies During Dental Treatment of Patients With Severe Dental Phobia
Application of Hypno-Dissociative Strategies During Dental Treatment of Patients With Severe Dental Phobia
Dental phobia is a well-known condition that may prevent patients from receiving adequate dental care. Dentists offer varied methods to help their patients overcome their phobic reactions and to enable them to proceed with needed dental treatment. These methods include diverse medical and behavioral interventions that are generally intended to regulate physiological, behavioral, cognitive, and emotional expressions of stress. Some patients with severe dental phobia together with actual or assumed traumatic background are only minimally responsive to these stress management procedures. The authors propose hypnotically induced dissociative strategies as a model of intervention for this category of dental phobic patients. The proposed model can help reduce or even suspend symptomatic behavior during dental treatment.
Dental phobia is a well-known specific phobic disorder (American Psychiatric [ 2]; ) that usually expresses itself in verbal utterances of fears connected with dental care procedures, in stressful and interruptive behaviors during dental treatment, and in avoidant behaviors concerning dental management opportunities ([ 7]; ). The treatment offered these patients, usually includes a variety of pharmacological and behavioral strategies ([ 9]). Although approximately 80% of patients with dental phobia receive suitable treatment by dentists, some 15% to 30% of them remain unmanaged (Kent, 1997; ; ). In the present article, we refer to this unmanaged patient population as patients with severe dental phobia.
Patients with severe dental phobia usually avoid treatment opportunities, but once they do seek dental care they may present symptoms resembling those of posttrauma. Intense abreactive and withdrawal responses typically characterize their behavior, and if their anxiety is measured by the Dental Anxiety Scale (DAS), their scores are usually high (DAS > 17) ([ 5]; [ 8]).
Most of the aforementioned treatment approaches that are usually useful with dental phobia are not as effective in these severe cases ([ 9]; ). In our clinical experience, these approaches at times can actually intensify their symptomology.
Some authors have proposed that traumatic experiences are the basis of most dental phobias ([ 5]). These authors propose further that dental phobias must be treated by referring patients to mental health professionals who specialize in the treatment of traumatic responses, including posttraumatic stress disorder (PTSD).
We agree with these authors regarding the need for specialized approaches oriented to posttrauma among acute phobic patients. Nevertheless, we believe that dentists who are equipped with the appropriate tools described in this article can deal successfully (e.g., provide appropriate dental care) with most of these problematic patients during dental treatment.
Dissociative strategies combined with hypnosis are already used extensively by dentists acquainted with hypnosis ([ 6]; ; ). These interventions are used in dental settings, usually for pain reduction ([ 6]). In the present article, we propose using hypnotically induced dissociative strategies for making dental treatment more feasible among severe dental phobic patients. The proposed method is not intended to cure the posttraumatic etiology of these patients but rather to suspend their symptomatic behavior during dental management (; ).
Proposed Hypno-Dissociative Strategy
Hypnotic treatment of dental phobias can be considered as framed by two major approaches: the direct approach and the uncovering approach ([ 3]). The direct approach tends to treat dental phobia directly and symptomatically and uses various stress-reduction and cognitive behavior therapy-oriented techniques, including hypnosis ([ 9]; ). The primary aim of these techniques is to reduce stress by soothing the behavioral, physiological, and emotional reactions and by ameliorating irrational thoughts. This soothing orientation usually used with phobic patients is neither effective nor sufficient among patients with severe dental phobia due to the strength and persistence of their symptomology ([ 9]; ).
The uncovering approach aims to uncover and neutralize unconscious or semiconscious motives for phobic behavior. This technique, although effective in the management of severe dental phobia, is rarely used by dentists as it requires special psychological and psychotherapeutic training ([ 3]; ; ).
That is to say that dentists who use hypnosis in their practice usually lack compatible hypnotic techniques and strategies to manage severe dental phobics. Apparently, such dentists need a special strategy that is sufficiently potent to help patients suffering from severe dental phobia but at the same time enables them not to digress from practicing dentistry. The hypno-dissociative technique presented in this article introduces some solutions to this requirement.
In the context of hypnotic literature, Yapko (1995, p. 117) defined dissociation as "the ability to break a global experience into its component parts, amplifying awareness for one part while diminishing awareness of the others."
Hypno-dissociative interventions can be used in three main areas of implementation: (a) for rehabilitation or establishment of natural/positive dissociations (), (b) for regulation and control of existing pathological dissociation ([ 1]; ), and (c) for acquiring temporary dissociation for therapeutic purposes (). This third implementation of hypno-dissociative techniques is frequently used by dentists in an attempt to dissociate patients from pain or from the dental clinic environment ([ 4]; [ 6]).
Based on the posttraumatic etiology of severe dental phobia cases ([ 5]), we propose using temporal hypnotically induced dissociation (THID) as a therapeutic strategy that can help dentists treat severe dental phobics by suspending their posttrauma-like symptomatic behaviors during dental treatment. This repeated suspension can in fact serve as a behavioral reconditioning intervention that can intensify the disruption created between the dental situation and the initial supposed traumatic experience () or the noticeable traumatic memory ().
The following clinical cases were chosen to illustrate implementation of the proposed hypno-dissociative interventions in a dental setting with patients exhibiting symptoms of severe dental phobia.
Case Presentation Unidentified Trauma (DAS = 18)
A 27-year-old single female client contacted the clinic for Oral Psychophysiology at the School of Dental Medicine at Tel Aviv University with complaints concerning her fears of injections. During the intake interview, she reported that she is afraid of dental treatment in general (not only injections). This fear has prevented her from receiving adequate dental care since she was a child.
During that initial interview the client described herself as having some acquaintance with psychologically oriented thinking due to her work as a dog trainer and as a therapeutic horseback riding instructor for children. She explained that she has no clues concerning why she has avoided dental treatment. Her oral examination indicated that she needed urgent root canal treatment.
During her first appointment, she started to cry in the dental chair, curled up almost into a fetal position and refused to continue treatment. Hypnotically enhanced desensitization, relaxation, and cognitive restructuring techniques were attempted during this treatment session but did not prove effective. During a complementary interview with the staff psychologist (J.M.), attempts to inquire about the traumatic origin of her behavior did not yield any significant advancement. This traumatic-like reaction of crying, curling up, and avoiding dental treatment persisted for a few sessions without any progress in her dental treatment.
At this point, we decided to use a hypnotically induced dissociative technique to temporarily alleviate her symptomatic behavior and to facilitate her dental treatment. Hypnotic trance was initiated in a similar manner as in the initial session, using her pleasant memories of a trip to the deserts of Australia and her love of horses. She was encouraged to imagine herself horseback riding in Australia as she experienced deep feelings of calmness and wonder. After she was sufficiently immersed in the experience she was asked "to put all (her) old worries, unpleasant feelings, anxieties that arise in association with dental treatment into an old crate, to lock it and to keep the key until it is needed." At the end of the session, she was given the following posthypnotic suggestion:
In this way you can be treated, leaving your unpleasant past experiences in the crate during your dental treatment, thus giving you the opportunity to experience healing of your teeth and mouth. ... and in the future, if needed, the crate can be opened at a place and time that will allow giving proper treatment to its contents.
During the next visit, she was laconic and asked for treatment in a very task-oriented manner. While in the hypnotic trance, she insisted on receiving an injection and commencing treatment. The temporary hypnotically induced dissociation (THID) of the "old crate" was again initiated. After that, she was injected with the anesthetic and the dentist began the root canal treatment while the patient was without behavioral manifestations of her dental phobia.
We made two more appointments during which the THID technique was used to reinforce the change in her behavior during dental management. She was then referred to an endodontist, who completed the root canal treatment without any complications.
Her Father's Teeth (DAS = 19)
A 40-year-old single female contacted the clinic for Oral Psychophysiology at the School of Dental Medicine at Tel Aviv University with complaints concerning her fears about dental treatment. During the intake interview, she reported a fear of dental treatment that began during her childhood. Oral clinical inspection revealed general periodontitis, including oral malodor and a need for fillings, extractions, and root canal treatments.
She also stated that when she was a child her father underwent several surgeries due to suspected palatoglosse syndrome and gingival problems. She recalled that at that time he was "dripping blood from his mouth." During her first appointment, she refused to leave the waiting room and to sit in the dental chair. During the following sessions, systematic desensitization using hypnosis was carried out along with the use of nitrous oxide. After 20 sessions, the only progress evident was her agreement to receive an injection and some cooperation exhibited while her teeth were being cleaned. She concluded those treatment sessions by saying that, although she usually cooperates with the dentist during the sessions, she feels as bad and as fearful as at the beginning of treatment.
At this point, we decided to use a THID technique to temporarily alleviate her symptomatic behavior and thus to allow her dental treatment to continue. Hypnosis was induced and deepened while she was seated in a dental chair. Then she was given the suggestion to imagine that next to her is an additional dental chair on which her father is seated. She was asked to see that the sick father from your childhood is sitting on this chair from your childhood. Slowly the chair and everything connected to it is drawn away ... blurred ... and eventually you find yourself treated in the present on the "grown-up" dental chair.
At the end of the session, she was given the following posthypnotic suggestions:
From now on when you need dental management you can find yourself sitting in an appropriate "grown up" dental chair in an appropriate dental clinic, without any distractions from your past experiences and memories. ... and if, in the future, you need to deal with these or other matters from your past, you can do so at the appropriate time and appropriate place.
The dissociative technique was used during two more appointments to strengthen the change in her behavior. She came to the subsequent appointments well dressed and exceptionally trim looking, and she smiled and encouraged the dentist to continue with the treatment. In subsequent treatments she successfully underwent extractions and fillings without any signs of phobic reaction.
Dental management of patients suffering from severe dental phobia (SDPh) is a challenging task ([ 9]; ). The posttraumatic origin of SDPh and PTSD-like symptoms that determine this type of patient behavior (, [ 4]) leave dentists without suitable behavioral interventions to manage these patients. The hypno-dissociative techniques proposed by the authors can be useful instruments in the hands of professionals who use hypnosis in their practice. These hypno-dissociative techniques have been largely acknowledged in hypno-dentistry but are presented here using a new and strategically oriented implementation.
In the first case presented in the article, the hypnotically induced metaphor of an old crate was used to dissociate supposedly posttraumatic emotional reactions from dental situational cues. This made the dental treatment feasible and positively cued to horseback riding, a familiar and calming experience for the patient.
The second case demonstrated the dissociation of a traumatic childhood memory connected with dental problems experienced by the patient's father. The child's identification with her father's suffering, amplified by visual memories of his bleeding teeth, transformed her dental experience into a very harsh and fearful event. Hypno-dissociative intervention to separate the actual grown-up dental treatment from the traumatic childhood memories paved the way for her to receive appropriate dental care.
We propose using the presented hypnotic methodology specifically for suspension of a patient's symptomatic behavior during dental management. This approach can usually lead to alleviation of phobic behavior but can only sometimes actually treat the phobia.
If presented to the patient several times, this suspension may be utilized as behaviorial intervention of reconditioning between patients' fears and anxieties and the dental care situation.
It should be noted that the crucial element of dentist intervention is to offer the patient an opportunity to address this troublesome behavior and symptoms outside the dental situation in an appropriate professional setting, when needed. This could be done using posthypnotic suggestion and posttreatment explanations.
Dentists who use hypnosis are acquainted with these dissociative techniques. Nevertheless, the specific uses proposed and described in this article—in simple metaphorical ("old crate") or in more advanced (memory suspension) applications—can be very useful in work with SDPh patients. If, as we hope, more dentists will use the hypno-dissociative strategies described here, more SDPh sufferers should be able to receive appropriate dental treatment.
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By Joseph Meyerson and Nir Uziel
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