A 3-year comparison of dental anxiety treatment outcomes: hypnosis, group therapy and individual desensitization vs. no specialist treatment

Efficacy of Hypnosis on Dental Anxiety and Phobia: A Systematic Review and Meta-Analysis

Hypnosis is a commonly used therapy option in dentistry and medicine for fear and pain reduction. Nevertheless, it is viewed very critically, as there is still insufficient evidence for a treatment effect. Specific phobia of dental treatment and dental anxiety are prevalent conditions that can cause an oral health impairment. This paper critically reviews 19 clinical trials aimed at reducing dental anxiety and fear avoidance in adults, published in peer-reviewed journals between 1979 and 2021. The search identified 257 papers; 223 were selected after removing duplicates. A total of 188 articles were excluded after title and abstract evaluation; 35 full text articles were assessed for eligibility. Another 10 papers were discharged after full text evaluation, as these were case reports and questionnaires. Six papers were discharged due to the lack of a comparable scale to measure dental anxiety. The following treatment techniques were reviewed: various forms of cognitive-behavioral therapy (CBT), relaxation training, benzodiazepine premedication, self-hypnosis by audio therapy, hypnotherapy, hypnosis, and nitrous oxide sedation. CBT delivered in a variety of formats, including one-session treatment, showed the most evidence for the efficacy of reducing anxiety. A wide heterogeneity of methods allowed only the inclusion of five studies to the performed meta-analysis, showing contrasting results for the application of hypnosis. The main reason for this issue is the great variety in methods used, making a distinct assessment of hypnotic interventions difficult. However, the results of the systematic review are promising in that hypnosis can also be regarded as powerful and successful method for anxiety reduction, while there are also studies with a small or even slightly negative effect. Therefore, further research is needed. Within the limitations of the current study, a more consistent use of methods to examine anxiety for hypnosis research is recommended.

Role of Hypnosis in Dental Treatment: A Narrative Review

Aim

This narrative aims to outline the use of hypnosis in managing dental anxiety in during dental treatment. The PICO used to answer the objectives are (P) dental patients, (I) hypnosis, (C) conventional behaviour management techniques & (O) reduced pain/anxiety.

Materials and Methods

An electronic search of three databases; PubMed, Scopus and EBSCOhost was conducted using the keywords "hypnosis or hypnotherapy" AND "dentistry or dental" between the year 2000 and 2020. A total of 19 studies were selected based on eligibility. Data extracted were study subject, design of study, parameters used to assess, type of hypnosis script used and the study outcome.

Results

The studies show that hypnosis is effective in pain management and dental anxiety. It can also be used for improving compliance in patients who are wearing orthodontic appliances (Trakyali et al, 2008) and reducing salivary flow during dental treatment (Satlz et al, 2014).

Conclusion

Hypnosis has the potential to be a useful tool in the management of children and adults.

The role of cognitive and non-cognitive factors in dental anxiety: A mediation model

Dental anxiety is a crucial problem for dentistry because it may represent a significant risk to oral health. Different factors, whether non‐cognitive (e.g., traumatic dental events) or cognitive (e.g., the patient's subjective perceptions), may cause dental anxiety. However, previous studies have assessed these factors as independent predictors of dental anxiety, without providing any exploration of potential mediational pathways. The current study assessed the role of certain cognitive dimensions (i.e., the dentist's perceived professionalism and communicational attitudes, and the patient's perceived lack of control) as mediators between traumatic dental events and dental anxiety. The sample comprised 253 patients who had accessed a public university hospital dental surgery. The mediation analysis used a structural equation modeling. Traumatic dental events were positively associated with dental anxiety but, among the cognitive factors, only lack of control was. Furthermore, lack of control mediated the relationship between traumatic dental events and dental anxiety, although this mediation was only partial. This study sheds light on the mechanisms through which non‐cognitive and cognitive factors may affect dental anxiety. The clinical implications for dental practice, in terms of improving the psychological well‐being of patients, are discussed.

FUNCTIONAL CHANGES IN BRAIN ACTIVITY AFTER HYPNOSIS: Neurobiological Mechanisms and Application to Patients with a Specific Phobia-Limitations and Future Directions

Studies of brain-plasticity changes in hypnosis using functional magnetic resonance imaging (fMRI), positron-emission-tomography (PET) and electroencephalography (EEG) were reviewed. The authors found evidence in those studies that hypnosis is a powerful and successful method for inhibiting the reaction of the fear circuitry structures. Limitations of the studies were critically discussed, and implications for future research were made. The authors are currently using a portable fNIRS apparatus to integrate the scanning device into real life situations in medical practice. Their aim is to disentangle the neuronal mechanisms and physiological correlates in patients with severe fear of medical treatments when directly confronted with anxiety-provoking stimuli and to assess the effects of a brief hypnosis. Drawing on evidence from several technological modalities, neuroimaging and physiological studies pave the road to a better scientific understanding of neural mechanisms of hypnosis.

Is there a relationship of negative oral health beliefs with dental fear and anxiety regarding diverse dental patient groups? A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to critically appraise the evidence on the relationship of oral health beliefs with dental fear and anxiety in distinct patient groups.

MATERIALS AND METHODS

Observational studies were retrieved by Cochrane, Embase Search, Portal BVS, Clinical Trials, Ovid, Open Gray, PubMed, Scopus, and Web of Science, and they were manually checked for the inclusion of additional articles of interest. The assessment of quality of studies was performed by the application of three different versions of the Newcastle-Ottawa Scale, for cohort, case-control, and cross-sectional studies. Only studies with low or unclear/moderate risk of bias contributed to meta-analyses, regarding the analysis of random effects of mean differences of dental beliefs scores between dental fear/anxiety and control groups, and the correlation of dental beliefs with dental fear and anxiety measures.

RESULTS

Of 276 articles initially retrieved, 10 were included in the systematic review, while only 6 studies with unclear/moderate risk of bias were considered in meta-analyses. The mean difference of dental beliefs effects was higher in patients with dental fear and anxiety compared to controls (1.20; 95% CI 0.27-2.14; P = 0.01). Additionally, a moderate positive correlation was observed between dental beliefs and dental fear measures (r = 0.54, 95% CI 0.47-0.60;P< 0.001).

CONCLUSIONS

Based on these results, the presence of negative health beliefs is directly related to the increase of dental fear and anxiety; however, these findings are supported in studies with unclear/moderate risk of bias.

CLINICAL RELEVANCE

Dental fear and anxiety is an important obstacle for the access of dental treatment and patient-dentist relationship, leading to inadequate oral health levels.

Large Group Exposure Treatment: A Feasibility Study of Exposure Combined with Diaphragmatic Breathing in Highly Dental Fearful Individuals

A large-group one session treatment (LG-OST) combining exposure and diaphragmatic breathing as a bodily coping element was carried out to investigate its feasibility and effectiveness in a sample of 43 highly dental fearful individuals treated simultaneously. We assessed subjective dental fear, dysfunctional dental-related beliefs, and perceived control pre- and post-intervention and at four-month follow-up. Participants additionally performed a behavioural approach test (BAT) pre- and post-intervention. During the applied exposure exercises, four participants (9.3%) discontinued the program all reporting too high levels of distress. Regarding subjective dental fear and dysfunctional dental related beliefs post treatment effects, LG-OST showed medium to large effect sizes, ranging from Cohen's d = 0.51 to d = 0.84 in the Intention-to-Treat analysis. Subjective dental fear improved clinically significantly in about one fourth (25.6%) of therapy completers. All post-treatment effects remained stable over time. Concerning the behavioral fear dimension, we observed a strong ceiling effect. Already at pre-assessment, participants accomplished more than six out of seven BAT-steps. Thus, behavioral approach did not increase significantly following treatment. Overall, the LG-OST protocol proved feasible and efficient. Compared to other one-session individual and multi-session group treatments the observed LG-OST effects were smaller. However, if LG-OST could match the efficacy of highly intensive short treatments delivered in an individual setting in the future, for example, by applying a wider array of exposure exercises, it could be a very useful treatment option as an intermediate step within a stepped care approach.

Efficacy of virtual reality exposure therapy for treatment of dental phobia: a randomized control trial

Background

Virtual Reality Exposure Therapy (VRET) is found to be a promising and a viable alternative for in vivo exposure in the treatment of specific phobias. However, its usefulness for treating dental phobia is unexplored. The aims of the present study are to determine: (a) the efficacy of VRET versus informational pamphlet (IP) control group in terms of dental trait and state anxiety reductions at 1 week, 3 months and 6 months follow-up (b) the real-time physiological arousal [heart rate (HR)] of VRET group participants during and following therapy (c) the relation between subjective (presence) and objective (HR) measures during VRET.

Methods

This study is a single blind, randomized controlled trial with two parallel arms in which participants will be allocated to VRET or IP with a ratio of 1:1. Thirty participants (18-50 years) meeting the Phobia Checklist criteria of dental phobia will undergo block randomization with allocation concealment. The primary outcome measures include participants’ dental trait anxiety (Modified Dental Anxiety Scale and Dental Fear Survey) and state anxiety (Visual Analogue Scale) measured at baseline (T0), at intervention (T1), 1-week (T2), 3 months (T3) and 6 months (T4) follow-up. A behavior test will be conducted before and after the intervention. The secondary outcome measures are real-time evaluation of HR and VR (Virtual Reality) experience (presence, realism, nausea) during and following the VRET intervention respectively. The data will be analyzed using intention-to-treat and per-protocol analysis.

Discussion

This study uses novel non-invasive VRET, which may provide a possible alternative treatment for dental anxiety and phobia.

Trial registration number

ISRCTN25824611, Date of registration: 26 October 2015.

A controlled trial on the effect of hypnosis on dental anxiety in tooth removal patients

OBJECTIVE

Empirical evidence concerning the efficacy of hypnosis to reduce anxiety in dental patients is limited. Hence we conducted a controlled trial in patients undergoing tooth removal. The study aims at assessing patient's attitude toward hypnosis and comparing the course of dental anxiety before, during and subsequent to tooth removal in patients with treatment as usual (TAU) and patients with treatment as usual and hypnosis (TAU+HYP).

METHODS

102 patients in a dental practice were assigned to TAU or TAU+HYP. Dental anxiety was assessed before, during and after treatment. All patients were asked about their experiences and attitudes toward hypnosis.

RESULTS

More than 90% of patients had positive attitudes toward hypnosis. Dental anxiety was highest before treatment, and was decreasing across the three assessment points in both groups. The TAU+HYP group reported significantly lower levels of anxiety during treatment, but not after treatment compared with TAU group.

CONCLUSION

Our findings confirm that hypnosis is beneficial as an adjunct intervention to reduce anxiety in patients undergoing tooth removal, particularly with regard to its no-invasive nature.

PRACTICAL IMPLICATION

The findings underline that hypnosis is not only beneficial, but also highly accepted by the patients. Implementation of hypnosis in routine dental care should be forwarded.

Hypnosis and dental anesthesia in children: a prospective controlled study

The authors of this prospective study initially hypothesized that hypnosis would lower the anxiety and pain associated with dental anesthesia. Thirty children aged 5 to 12 were randomly assigned to 2 groups receiving hypnosis (H) or not (NH) at the time of anesthesia. Anxiety was assessed at inclusion in the study, initial consultation, installation in the dentist's chair, and at the time of anesthesia using the modified Yale preoperative anxiety scale (mYPAS). Following anesthesia, a visual analogue scale (VAS) and a modified objective pain score (mOPS) were used to assess the pain experienced. The median mYPAS and mOPS scores were significantly lower in the H group than in the NH group. Significantly more children in the H group had no or mild pain. This study suggests that hypnosis may be effective in reducing anxiety and pain in children receiving dental anesthesia.

Needle phobia: etiology, adverse consequences, and patient management

Needle phobia has profound health, dental, societal, and legal implications, and severe psychological, social, and physiologic consequences. There is genetic evidence for the physiologic response to needle puncture, and a significant familial psychological component, showing evidence of inheritance. Needle phobia is also a learned behavior. The dental practitioner must recognize patients with needle phobia before the administration of local anesthetics to identify patients who are potentially reactive and to prevent untoward sequelae. Needle phobia is highly associated with avoidance behavior, and the dentist must exhibit compassion and respect. To avoid bradycardia, hypotension, unconsciousness, convulsions, and possibly asystole, oral premedication with benzodiazepines or other antianxiety agents must be considered for patients who are needle phobic. Management of needle phobiaeinduced syncope includes perioperative monitoring, oxygen administration, positioning, atropine, and vasopressors.

Dental beliefs: factor structure of the revised dental beliefs survey in a group of regular dental patients

The aim of this study was to investigate the factor structure of the revised dental beliefs survey (DBS-R) in a group of regular dental patients. The study group consisted of 278 patients (mean age 54 yr), 61% of whom were women. The DBS-R item mean value was 1.6. Principal component analysis (PCA) and confirmatory factor analysis (CFA) were performed. The initial PCA among the 28 DBS-R items showed four factors with eigenvalues of > 1 explaining 67% of the total variance. Five different CFA models were tested. The final model revealed a four-factor solution with one second-order factor (i.e. a hierarchical CFA). Thus, the latent second-order variable, 'dental beliefs', explains the variance from all DBS-R items through the four first-order factors labeled 'ethics', 'belittlement', 'communication and empathy', and 'control and anxiety'. The results suggest a somewhat different factor structure of DBS-R than previously reported for dental-fear patients. Hence, the underlying factor structure of the DBS-R may differ between different patient groups. The results point towards the use of the original 28-item DBS-R and interpreting the scale as measuring an overall construct of 'dental beliefs' and thus patients' attitudes and feelings related to dentists and dentistry.

Hypnosis as sole anesthesia for major surgeries: historical & contemporary perspectives

Hypnosis is a well validated treatment for acute and chronic pain (Montgomery, DuHamel, & Redd, 2000). It has been found capable of reducing inflammation, altering blood flow, and producing beneficial effects when hypnotic suggestions are provided during and prior to surgery (Frederick, 2001) and other painful medical procedures. This paper quotes extensively from historical examples of the use of hypnosis (mesmerism) as the sole anesthesia for major surgeries in the 1800's. These historic examples by themselves provide powerful documentation of the ability of the mind to influence the body, but they are then followed by a review of contemporary literature and controlled research on the use in hypnosis in relation to surgery and prior to medical procedures.

Psychological characteristics of Norwegian adolescents reporting no likelihood of visiting a dentist in a situation with toothache

OBJECTIVES

The aim of the present study was to explore and compare psychological characteristics in two groups of 18-year-old adolescents: (i) subjects reporting no likelihood of visiting the dentist in a situation with toothache (avoiders); and (ii) subjects who definitely would see the dentist in the same situation (non-avoiders).

METHODS

The study included a representative sample (n = 1385) of 18-year-old adolescents attending high schools in the county of Hordaland, Norway. Data were collected by use of questionnaires completed in classrooms.

RESULTS

The following factors increased the risk of being included in the avoider group: negative beliefs of the dentist (communication, trust and control) (OR = 4.3), high dental anxiety (OR = 3.5), and being a male (OR = 2.4). No predictive power for being included in the avoider group was found for general self-efficacy, coping style, multiple fears, or anxiety and depression.

CONCLUSIONS

Adolescents with avoidance behaviour have more negative beliefs of the dentist and higher dental anxiety compared to non-avoiders, but were found to have no other specific psychological characteristics. These results indicate a high potential for prevention of future avoidance of care for dentists that are focusing on patient communication and to give young patients perceptions of trust and control during dental treatment.

Attitudes to dental hygienists: evaluation of the Dental Hygienist Beliefs Survey in a Swedish population of patients and students

The aim was to evaluate and test the psychometric properties of the Dental Hygienist Beliefs Survey (DHBS) in a Swedish sample of different patient groups and students. It was hypothesized that negative dental hygienist beliefs would discriminate between fearful and non-fearful study groups. The DHBS was distributed together with the revised Dental Beliefs Survey (DBS-R) and the Dental Anxiety Scale (DAS). The study sample included 394 subjects (130 students, 144 general dental patients, 90 periodontal patients and 30 patients on a waiting list for dental fear treatment). The results verified that the DHBS discriminates well between dentally fearful and non-fearful study groups. The DHBS had high internal consistency (Cronbach's alpha = 0.96-0.98) in all the groups. The correlation between the DHBS and the DBS-R was high (rho = 0.82, P < 0.001). Furthermore, the DHBS correlated significantly with the DAS, as well as with a low but significant correlation to age (more negative attitudes in younger age groups) and gender (more negative attitudes amongst women). Regression analysis showed that gender and the DHBS items: 23, 16 and 28, i.e. items related to feeling helpless, worries/fears not being taken seriously and fear about 'bad news' possibly preventing treatment, were the most important predictors of dental fear. The results suggest that the DHBS may be a valid and reliable scale to use in order to assess patient's specific attitudes to dental hygienists. However, the psychometric properties including test-retest analysis and the underlying factor structure of the DHBS need to be further explored.

Rapid induction of hypnosis by finger elongation: a brief communication

This clinical pilot study on finger elongation for induction of hypnosis attempts to determine whether the observed response is a hypnotic phenomenon or a simple physiologic reaction. Sixteen volunteers participated in the 5-phase study, which measured relative and absolute changes in the length of each finger prior to and after each phase. A distinctive elongation was statistically significant for the hypnosis condition. In addition, findings suggest changes in the metacarpus. Further investigation is indicated to shed light on this apparent phenomenon.

Dental beliefs: evaluation of the Swedish version of the revised Dental Beliefs Survey in different patient groups and in a non-clinical student sample

The aim of this study was to evaluate and to test the psychometric properties of a Swedish version of the revised Dental Beliefs Survey (DBS-R) in different patient groups and in a non-clinical sample of students. It was hypothesized that negative dental beliefs, assessed using the DBS-R, would discriminate between fearful and non-fearful study groups. The questionnaire was distributed together with the Dental Anxiety Scale (DAS). The sample included 550 adults who responded to the questionnaires (206 students, 177 general dental patients, 105 periodontal patients and 62 patients at a waiting list for dental-fear treatment). The internal drop-out rate was low. The results confirmed that the DBS-R discriminates well between fearful patients and the other study groups. The DBS-R had a high internal consistency in all the study groups. Furthermore, the DBS-R correlated significantly with age (higher values in younger age groups) and the DAS. Regression analyses showed that the DBS-R subdimensions of 'communication' and 'control'/or 'trust', respectively, were significant predictors for dental fear. The results suggest that the DBS-R is a reliable and valid instrument for use in different Swedish patient- and non-clinical population groups in order to assess attitudes to dentists. However, the underlying factor structure of the DBS-R needs to be further explored and established.

Clinical management of dental anxiety: what works for whom?

This paper aims to provide an overview of the current knowledge regarding the management of adult dentally anxious patients. Furthermore, an attempt is made to formulate a number of preliminary clinical guidelines, based on the available literature. The findings are discussed in the light of the following four problem areas or types of patients, those with: 1) a mild form of fear or anxiety, 2) a phobia of specific dental procedures or situations, 3) interfering psychiatric symptoms and/or 4) a high treatment need. The literature suggests that particularly the implementation of a high level of predictability during treatment, the training of patients in the use of coping skills, and the application of in vivo exposure to anxiety provoking stimuli are the most appropriate options for the management of anxious dental patients and the reduction of their anxiety level.

Prediction of success and failure of behavior modification as treatment for dental anxiety

Behavior modification techniques are effective in the treatment of extreme dental anxiety, but their success is by no means absolute. In the present article, the Corah Dental Anxiety Scale (DAS), the self-report symptom inventory SCL-90R and a questionnaire accessing subjects' daydreaming styles (the Short Imaginal Process Inventory) were used to develop possible predictive measures for success and failure of behavior modification as a treatment for dental fear. The patients' level of distractibility and mind wandering, initial dental anxiety and somatization significantly predicted the success of therapy. The odds ratio indicated that the risk of therapy failure increased about 11 times with an increase of one scale of the Poor Attention Control Scale, about three times with an increase of one level of the mean DAS score, and 0.17 times with an increase of one level of somatization. The predictive value of the chosen scales was 80%. Thus, the use of these scales as part of an initial admittance process for patients who suffer from dental anxiety can enhance our ability to better recognize patients who are prone to fail behavior therapy as treatment for their problem, and enable their referral for other possible modes of treatment.