Effect of hypnosis on induction of local anaesthesia, pain perception, control of haemorrhage and anxiety during extraction of third molars: A case–control study

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Abstract

Introduction

Systemic conditions are considered limiting factors for surgical procedures under local anaesthesia in the oral cavity. All the pharmacological methods to control pain in patients have some disadvantages, such as side effects and extra costs for rehabilitation. Therefore, in such cases alternative treatment modalities are considered, such as hypnosis in dentistry. The aim of the present study was to evaluate the effect of hypnosis on haemorrhage, pain and anxiety during the extraction of third molars.

Materials and methods

In this case–control study, 24 female and male volunteers were included. The subjects had been referred to the Department of Oral and Maxillofacial Surgery, Kerman University of Medical Sciences, for extraction of third molars. Demographic data for all the subjects were recorded. Patients with chronic medical conditions were excluded. The patients were used as their own controls, with the third molars on one side being removed under hypnosis and on the opposite side under local anaesthetic.

Hypnosis was induced by one of the two methods, either fixing the gaze on one point or Chiasson's technique; both these methods are appropriate for patients in the dental chair. The Spielberger State-Trait Anxiety Inventory was used to determine patient anxiety levels before hypnosis and anaesthesia. Pain was scored using VAS (visual analogue scale). After surgery the patient was asked to bite on a sterile gauze pad over the surgical site for 30 min when haemorrhage from the area was evaluated. If there was no haemorrhage the patient was discharged. If haemorrhage persisted, the gauze pad was left in place for another 30 min and the area was re-evaluated. Any active oozing from the area after 30 min was considered haemorrhage. Haemorrhage, anxiety and pain were compared between the two groups. Data was analyzed using the t-test, McNemar's test and Wilcoxon's signed rank test using SPSS 18 statistical software.

Results

Twenty-four patients were evaluated; there were 14 males (58.3%) and 10 females (41.7%). The mean age of the subjects was 24.1 ± 2.7 years (age range = 18–30 years). A total of 48 third molars were extracted. In each patient, one-third molar was extracted under hypnosis and the other under local anaesthesia. All the patients were in the ASA 1 category (normal) with no significant medical history.

Of the subjects who underwent hypnosis, only two subjects (8.3%) reported pain after induction of hypnosis. In the local anaesthetic group, 8 subjects (33.3%) reported pain. There was a significant difference between the two groups. The results of the study showed that patients in the hypnosis group had less pain during the first few hours post-operatively. Anxiety scores in the two groups were very close to each other and no statistically significant differences were observed in general and when each person was compared with himself or herself. Pain intensity in the two groups at 5- and 12-h post-operatively exhibited significant differences. In the hypnosis group, 10 patients (41.7%) took analgesic medication; in the local anaesthesia group, 22 patients (91.7%) took the analgesic medication (P = 0.0001). In other words, patients reported less pain when they were under hypnosis.

Conclusion

The results of the study showed that hypnosis can effectively reduce anxiety, haemorrhage and pain. More studies are necessary to collect data on the effect of hypnosis on oral and maxillofacial surgeries.

Introduction

Hypnosis has a long history in the treatment of diseases. Cuneiform tablets dating from 4000 BC show that Sumerians knew about hypnosis. Persian Moghans or Iranian religious leaders before Islam used hypnosis in the treatment of diseases. The first academic treatment centre to officially use hypnosis to treat patients was the Nancy Medical Faculty. The dean of this French medical institution was Professor Hippolyte Bernheim (1840–1919), the prominent neurologist, who instituted the application of hypnosis in the various clinics of Nancy Medical Faculty after becoming acquainted with hypnosis and realizing its efficacy in the treatment of some medical conditions. In 1953 a committee was established by the British Medical Association, which consisted of several psychologists and psychiatrists, to carry out serious and detailed investigations into hypnosis and its therapeutic applications. The investigations of the committee showed that hypnosis can be used as a thoroughly scientific technique, not only in the treatment of psychosomatic and psychoneurotic conditions, but also in dental procedures, painless parturition, relief of pain and in surgery (Ross, 1981). At present, hypnosis has a large number of applications in medicine, including alleviation of acute pain, decrease in labour pain, treatment of trigeminal neuralgia, paediatric medicine, asthma, various surgical procedures, burns, migraine and tension headaches, neck and back pain, a wide range of chronic pain syndromes, chronic pain of cancer, arthritis and diabetic neuropathy (Rosen and Harold, 1954; Andrew and Welbury, 1996). Hypnosis can negate the need for local anaesthetic agents; in other words, it results in a feeling of anaesthesia in an area (Joseph, 1998).

Hypnodontics is a branch of dentistry, in which use of hypnosis for dental procedures is discussed (Joseph, 1998). Some people talk about dental visits in a manner as if they were the most painful experiences on earth.

The majority of dental patients referred to a dental office for the first time or those who have experienced great pain during previous dental visits and almost all the children and adolescents, visit dental offices with a degree of panic and great anxiety. If patients' fears can be quelled, therapeutic procedures will be carried out in a more acceptable atmosphere and the pain threshold of these patients will increase to a higher level (Islam et al., 2012; Habal, 2009). If patients undergo hypnosis, it will be possible to make some suggestions and under such conditions they will have no fear of dental visits. The patients will then be able to tolerate dental procedures and will not experience any anxiety or fear in the dental chair. Fortunately, such suggestions are very effective even under light hypnosis. The majority of patients referred to dental offices can be easily put under this level of hypnosis (Joseph, 1998). Sometimes it is not possible or advisable to use local anaesthetic agents; in such cases hypnosis can be highly successful.

Local anaesthesia may fail due to technical errors, such as the absence of teeth used as guides during injection.

The injection of local anaesthetic may be accompanied by complications, such as lingual nerve damage (Erdogmus et al., 2008) or pseudoaneurysm of the facial artery (Choi et al., 2012).

There are some studies on the use of hypnosis for some procedures, including reducing patients' anxieties and fears, prevention of excessive haemorrhage during tooth extraction in patients with haemophilia or high blood pressure, preparation of patients for induction of anaesthesia, decreasing or inhibiting salivary flow, taking impressions without nausea and vomiting for prosthetic and orthodontic procedures, treatment of some adverse oral habits such as bruxism, thumb sucking and nail biting, disorders of the temporomandibular joint, promotion of oral hygiene and increasing patient tolerance during long periods of mouth opening (Gerschman, 1989; Chaves, 1997a, 1997b; Bassi et al., 2004; Cuellar, 2005; Hermes et al., 2005).

The first documented case of the use of hypnosis in dentistry to induce anaesthesia and ease patient fear was reported by Jean-Victor Oudet who, in 1829, used hypno-anaesthesia to facilitate a dental extraction. In 1847 two more pioneering French doctors (Ribaud and Kiaro) used hypnosis for anaesthesia to be able to remove a tumour of the jaw (Chaves, 1997a, b).

One of the reasons for not attending dental offices is patient anxiety and fear of dental procedures, including the injection of local anaesthetic agents. In some cases it is difficult or even impossible to achieve proper anaesthesia and patients may feel pain even with multiple and consecutive injections of local anaesthetic agents, disrupting the treatment procedure. In some cases the use of local anaesthetic agents is contraindicated. In order to address these issues this study aimed to evaluate the success rate of hypnosis in inducing local anaesthesia, decreasing haemorrhage, pain perception and reducing anxiety during surgical extraction of the third molars.

Section snippets

Materials and methods

This case–control study was approved by the ethics committee of the Kerman University of Medical Sciences (No.k.90.140). The study was carried out in the Department of Maxillofacial Surgery, Faculty of Dentistry, Kerman University of Medical Sciences. A purpose-oriented sampling procedure was used and only patients who needed bilateral surgical extraction of mandibular or maxillary third molars were included in the study. The subjects were all over 18 years of age from both sexes. Demographic

Results

In this study 24 patients were evaluated; there were 14 men (58.3%) and 10 women (41.7%). The mean age of the subjects was 24.1 ± 2.7 years, with mean ages of 23.6 ± 1.9 and 24.7 ± 3.7 for males and females, respectively. The age range of the subjects was 18–30 years, with 21–27 and 18–30 years for males and females, respectively. A total of 48 third molars were extracted: 15 right upper third molars, 15 left upper third molars, 9 right lower third molars and 9 left lower third molars. In each

Discussion

Hypnosis has been a worldwide controversial issue in dentistry in recent times; the controversy has spread to the academic circles in Iran.

Hypnosis influences perceptions and behaviours of individuals with the help of two factors: use of suggestibility rules and achieving a state referred to as hypnotic trance. A trance is a state beyond consciousness, which is different from normal sleep, unconsciousness and coma, during which there is a high level of suggestibility (Chaves, 1997a, 1997b;

Conclusion

The results of this study show that hypnosis might be used as an adjunctive method in dental procedures of anxious patients or patients who cannot be treated using conventional methods. It should be pointed out that hypnosis is possible when the dental practitioner is adequately experienced in this respect and the patients are carefully selected.

Acknowledgements

This study was supported by Kerman University of Medical Sciences. The authors would like to thank the Research Deputy for their financial support (Thesis No: 721).

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