CD 007154

Hypnosis for children undergoing dental treatment (Review)

Al-Harasi S, Ashley PF, Moles DR, Parekh S, Walters V

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2010, Issue 8

http://www.thecochranelibrary.com

Hypnosis for children undergoing dental treatment (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iHypnosis for children undergoing dental treatment (Review)


[Intervention Review]

Hypnosis for children undergoing dental treatment

Sharifa Al-Harasi1, Paul F Ashley2, David R Moles3, Susan Parekh2, Val Walters4

1Military Dental Centre, PO Box 454, Seeb, Oman. 2Unit of Paediatric Dentistry, UCL Eastman Dental Institute, London, UK. 3Oral

Health Services Research, Peninsula Dental School, Plymouth, UK. 4Division of Psychology and Language Sciences, UCL, London,

UK

Contact address: Sharifa Al-Harasi, Military Dental Centre, PO Box 454, PC 121, Seeb, Oman. [email protected].

Editorial group: Cochrane Oral Health Group.

Publication status and date: New, published in Issue 8, 2010.

Review content assessed as up-to-date: 14 June 2010.

Citation: Al-Harasi S, Ashley PF, Moles DR, Parekh S, Walters V. Hypnosis for children undergoing dental treatment. CochraneDatabase of Systematic Reviews 2010, Issue 8. Art. No.: CD007154. DOI: 10.1002/14651858.CD007154.pub2.


A B S T R A C T

Background

Managing children is a challenge that many dentists face. Many non-pharmacological techniques have been developed to manage

anxiety and behavioural problems in children, such us: ’tell, show & do’, positive reinforcement, modelling and hypnosis. The use of

hypnosis is generally an overlooked area, hence the need for this review.

Objectives

This systematic review attempted to answer the question: What is the effectiveness of hypnosis (with or without sedation) for behaviour

management of children who are receiving dental care in order to allow successful completion of treatment?

Null hypothesis: Hypnosis has no effect on the outcome of dental treatment of children.

Search strategy

We searched the Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE (OVID), EMBASE (OVID), and PsycINFO.

Electronic and manual searches were performed using controlled vocabulary and free text terms with no language restrictions. Date of

last search: 11th June 2010.

Selection criteria

All children and adolescents aged up to 16 years of age. Children having any dental treatment, such as: simple restorative treatment

with or without local anaesthetic, simple extractions or management of dental trauma.

Data collection and analysis

Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate,

by two review authors. Authors of trials were contacted for details of randomisation and withdrawals and a quality assessment was

carried out. The methodological quality of randomised controlled trials (RCTs) was assessed using the criteria described in the CochraneHandbook for Systematic Reviews of Interventions 5.0.2.

Main results

Only three RCTs (with 69 participants) fulfilled the inclusion criteria. Statistical analysis and meta-analysis were not possible due to

insufficient number of studies.

1Hypnosis for children undergoing dental treatment (Review)


mailto:[email protected]

Authors’ conclusions

Although there are a considerable number of anecdotal accounts indicating the benefits of using hypnosis in paediatric dentistry, on the

basis of the three studies meeting the inclusion criteria for this review there is not yet enough evidence to suggest its beneficial effects.

P L A I N L A N G U A G E S U M M A R Y

Hypnosis for children undergoing dental treatment

Children are often anxious or non-compliant during dental treatment. Anecdotal evidence as well as published articles indicate hypnosis

can be used with great effect in paediatric behavioural management. The aim of this review was therefore to see what evidence there is

to support the use of hypnosis with children and adolescents undergoing dental procedures. Only three randomised controlled trials

(with 69 participants) fulfilled the inclusion criteria for this review. Two of these three studies reported positive outcomes in favour of

hypnosis however statistical analysis and meta-analysis were not possible due to insufficient studies meeting the inclusion criteria.

B A C K G R O U N D

Treating children is often a challenge for dentists. Many techniques

have been developed to help children cope with dental treatment

and to reduce the stress experienced. Part of the solution is under-

standing the reasons behind the unwanted behaviour (e.g. fear of

the unknown) and then addressing these issues using techniques

such as ’tell, show & do’ or positive reinforcement (Fayle 2003).

However, due to the variation in children’s personalities, one tech-

nique of behaviour management may work with some children

but not with others. Therefore, the more knowledge we gain about

other available techniques and how to apply them practically, the

more effective we can be in helping children cope with dental treat-

ment. Alternatives to standard non-pharmacological techniques

include sedation or even general anaesthetic (GA). These tech-

niques have their place, but can be associated with morbidity or

even mortality. One other possible alternative to standard non-

pharmacological techniques is the use of hypnosis.

Heap and Aravind (Heap 2002) define hypnosis as an interaction

in which the hypnotist uses suggested scenarios (“suggestions”)

to encourage a person’s focus of attention to shift towards inner

experiences in order to influence the subject’s perceptions, feel-

ings, thinking and behaviour. Response to hypnotic suggestion is

characteristically experienced by a person as feeling involuntary or

effortlessness (Fromm 1992). Used as an adjunctive procedure in

medicine, dentistry and applied psychology, hypnosis can enhance

the efficacy of various treatment interventions (Kirsch 1995). In

recognising the need to use hypnosis as an adjunct to established

treatments, many health professionals consider the labels ’hyp-

notherapy’ and ’hypnotherapist’ to be unhelpful and potentially

misleading as they suggest that hypnosis is a form of treatment or

therapy in its own right (Vingoe 1987).

Hypnotic techniques can be used to manage a range of common

problems relevant to dentistry such as dental anxiety, specific den-

tal phobia, pain control in conservative treatment and extractions,

improved tolerance for orthodontic appliances, as an adjunct to

inhalation sedation, or as part of the induction of GA and modi-

fication of unwanted oral habits such as thumb sucking, bruxism,

gagging and smoking (Patel 2000; Reid 1988; Simons 2007).

A number of advantages of using hypnosis in dentistry have been

mentioned in the literature and include the following:

• No requirement for specialist equipment

• The patient remains conscious

• Non-pharmacological approach so no side effects or

associated environmental pollution

• Combines well with nitrous oxide inhalation sedation

(Rosen 1983)

• Safe.

Hypnotic techniques are particularly effective when used with chil-

dren between 8 and 12 years however children as young as 4 years

old can be responsive to hypnosis (Olness 1996), yet hypnosis as

an adjunct to paediatric dental procedures is generally underused,

hence the need for this review.

O B J E C T I V E S

This systematic review attempted to answer the following ques-

tion:



What is the effectiveness of hypnosis (with or without sedation)

for behaviour management of children who are receiving dental

care in order to allow successful completion of treatment.

Null hypothesis

Hypnosis has no effect on the outcome of dental treatment of

children.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Both randomised and quasi-randomised control trials were in-

cluded. Case control studies were not included to avoid bias.

Types of participants

- All children and adolescents up to 16 years of age.

Ages were subdivided according to the age bands used by in the

British National Formulary (BNF 2007):

• under 5 years of age

• 6 to 12 years

• more than 12 years up to 16 years old.

- Children having any dental treatment such as:

Simple restorative treatment with or without local anaesthetic (LA)

or simple extractions or management of dental trauma (e.g. repo-

sitioning of tooth, splinting, removal of nerve from tooth) and

orthodontic treatment. Children were included regardless of base-

line anxiety.

Types of interventions

Test group: Any hypnotic technique with or without any sedative

agent (sedation could be inhalation, oral or intravenous).

Control group: No hypnotic intervention or sedative agent alone.

Types of outcome measures

(1) Completion of treatment (yes/no).

(2) Measures of behaviour between test and control groups (scales

used may vary between studies).

(3) Difference in post-operative anxiety between test and control

groups (scales used may vary between studies).

(4) Adverse events.

Search methods for identification of studies

For the identification of studies included or considered for this

review, detailed search strategies were developed for each database

searched. These were based on the search strategy developed for

MEDLINE via OVID (Appendix 1) but revised appropriately

for each database. The search strategy was not combined with

the Cochrane Highly Sensitive Search Strategy for identifying

randomised trials in MEDLINE: sensitivity-maximising version

(2008 revision). A trial search was performed to check for adverse

effects but it yielded similar results and it was advised by an expert

in the field (The Cochrane Collaboration) that there was no need

to do a specific one.

Electronic searches

• The Cochrane Oral Health Group’s Trials Register (11th

June 2010) (Appendix 5)

• The Cochrane Central Register of Controlled Trials

(CENTRAL) (The Cochrane Library 2010, Issue 2) (Appendix 4)

• MEDLINE (OVID) (from 1950 to 11th June 2010)

(Appendix 1)

• EMBASE (OVID) (1974 to 11th June 2010) (Appendix 2)

• PsycINFO (OVID) (1887 to 11th June 2010) (Appendix

3).

Language

The search attempted to identify all relevant studies irrespective

of language. Non-English papers were translated.

Handsearching

The following journals were identified as being important to be

handsearched for this review. The journals were handsearched by

the review authors for the period between 1996 to 2006:

International Journal of Paediatric DentistryPediatric DentistryJournal of Dentistry for ChildrenAmerican Academy of Pediatric DentistryJournal of the American Dental AssociationBritish Dental JournalDental UpdateContemporary HypnosisThe International Journal of Clinical and Experimental HypnosisAmerican Journal of Clinical HypnosisAustralian Journal of Clinical and Experimental Hypnosis.The reference lists of all eligible trials were checked for additional

studies.

Unpublished studies



Specialists in the field known to the review authors were contacted

for any unpublished data.

Data collection and analysis

Selection of studies

Selection of papers suitable for inclusion in the review were car-

ried out independently by two review authors (Sharifa Al-Harasi

(SAH) and Paul Ashley (PA)). Titles and abstracts were assessed

and full copies of all relevant and potentially relevant studies, those

appearing to meet the inclusion criteria, or for which there were

insufficient data in the title and abstract to make a clear decision,

were obtained. The full text papers were assessed independently

by these two review authors. All irrelevant records were excluded

and details of the studies with the reasons for their exclusion were

noted. Agreement was assessed by calculating Kappa scores and all

disagreements were resolved by discussion.

A third review author (Susan Parekh (SP)) was available to resolve

any issues or selection discrepancies that arose.

Data extraction and management

Data extraction was carried out on a specially designed paper form

(available from the review authors) independently by two review

authors (SAH and PA) and again authors were blinded to each

other’s data. Results were compared to check for inconsistencies

and disagreements resolved by discussion. Review authors were

not blinded to the journal of publication or the author’s names on

the papers.

Assessment of risk of bias in included studies

The assessment of risk of bias for included trials was undertaken

independently and in duplicate by two review authors. Studies

were analysed for the following to assess validity as a threshold for

inclusion of the studies, which is described as one of the options

in the Cochrane Handbook for Systematic Reviews of InterventionsVersion 5.0.2 (Higgins 2009) on the following individual quality

criteria:

• Adequate sequence generation: Yes, No, Unclear

• Allocation concealment: Yes, No, Unclear

• Blinding of participants and outcome assessors: Yes, No,

Unclear

• Incomplete outcome data addressed: Yes, No, Unclear

• Intention-to-treat analysis: Yes, No, Unclear

’Yes’ indicates a low risk of bias, ’No’ indicates high risk of bias

and ’Unclear’ indicates either lack of information or uncertainty

over the potential for bias. A risk of bias table was completed for

each included study.

Risk of bias was assessed for each included study. Studies were

considered to be at low risk of bias if there was adequate conceal-

ment of allocation, blinded outcome assessment and information

on the reason for withdrawal provided by trial group. If one of

these criteria was not met, a study was considered at moderate risk

of bias, otherwise at high risk of bias.

Investigation of publication bias

In order to help overcome publication bias, we (1) imposed no

language barriers in our search, (2) contacted specialists in the field

for any published, unpublished, and in-progress studies, and (3)

contacted the authors with missing data for further clarification.

It was intended to assess publication bias and other possible biases

relating to the size of trials by graphical methods and via the Begg

and Mazumdar adjusted rank correlation test and the Egger et al

regression asymmetry test (Egger 1997). Effect size versus standard

error was to be drawn. Asymmetry of the funnel plots would have

indicated publication bias, though it may also represent a true

relationship between trial size and effect size.

However, the above was not possible due to the small number of

studies.

Data synthesis

Data were divided into descriptive and quantitative methods.

Meta-analysis of the data was not applicable due to insufficient

number of studies.

Descriptive methods

Data were collated into evidence tables. A descriptive summary

was formulated to determine the quantity of data, checking further

for study variations in terms of study characteristics, study quality

and results. This assisted in confirming the suitability of further

synthesis methods.

Quantitative methods

Meta-analysis of the data was not applicable due to insufficient

number of studies. If data do subsequently become available then

analysis will be carried in the following order:

- Hypnosis versus no hypnosis

- Hypnosis combined with sedation versus sedation only

- Hypnosis versus sedation.

Random-effects meta-analyses will be used provided there are more

than three trials included in the meta-analysis. For continuous

data, pooled outcomes will be expressed as mean differences with

their associated 95% confidence intervals. For binary data, these

will predominately be pooled risk ratios and associated 95% con-

fidence intervals. Statistical heterogeneity will be assessed by cal-

culation of the Q statistic and Cochrane’s I2 statistic. Analysis will



be performed using RevMan Analysis software (RevMan 2008).

Data will be presented as an overall comparison and as subgroups.

Investigation of heterogeneity and subgroup analysis

It was not possible to work out which factors might be causing

any differences between the studies due to insufficient studies.

If data become available heterogeneity in the results of the trials

will be assessed by inspection of a graphical display of the results

and by formal tests of heterogeneity. Subgroup analyses and meta-

analysis regression (STATA 9.0) will be utilized to explore, quan-

tify and control for sources of heterogeneity between studies on

those occasions where it is possible to do so. Planned analyses for

heterogeneity are outlined below.

a) Patient characteristics

Age, gender, baseline anxiety, whether subjects have special needs.

b) Treatment characteristics

- Type of hypnotic technique such as: hypnotic relaxation, anxiety

management, hypnoanalgesia, future rehearsal.

- Additional use of a sedative agent.

- Type of dental treatment.

- Length of the two treatment modalities.

Sensitivity analysis

If a sufficient number of trials had been included in this review,

we planned to conduct sensitivity analyses to assess the robust-

ness of the review results by repeating the analysis with the follow-

ing adjustments: exclusion of studies with unclear or inadequate

randomisation, allocation concealment, blinding, completeness of

follow-up, length of follow-up, and source of funding.

In addition to that already outlined the following descriptive data

were also included:

(1) Year study started, if not available, year it was published

(2) Country study was carried out in

(3) Previous treatment of patient

(4) Monitoring used

(5) Difference of time for completion of treatment between the

test and control groups

(6) Patient satisfaction/acceptance.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

Two hundred and seventy-seven papers were retrieved using the

search strategy described above. For most of these papers, it was

clear from the abstract whether they failed to meet some or all

of the inclusion criteria, and therefore were excluded. Only three

randomised controlled trials (RCTs) met the inclusion criteria.

For all abstracts that were relevant, potentially relevant, or where

relevance to the current review was unclear, the full articles were

obtained. Two Italian papers were translated. Two review authors

(Sharifa Al-Harasi (SAH) and Paul Ashley (PA)) decided which

studies met the inclusion criteria and which did not. Inter-rater

reliability assessed using a Kappa coefficient was (K = 0.46) and

all disagreements were resolved by discussion.

Excluded studies

Reasons for exclusion were mainly because of inappropriate inter-

vention (Characteristics of excluded studies).

Included studies

Only three RCT studies were found to fit the inclusion criteria of

which one was unpublished (Characteristics of included studies).

Participants

A total of 69 participants (34 male and 35 female) were recruited,

age range between 4.5 to 15 years. Health status ASA I and II (the

American Society of Anesthesiologists (ASA) physical status clas-

sification system: I, patients normal and healthy; II, patients with

mild to moderate systemic disease or are healthy ASA I patients

who demonstrate a more extreme anxiety and fear toward den-

tistry); the Trakyali 2008 study did not mention anything about

the participants’ health.

Design, methods and outcome measures

One of the studies was a parallel design and the other two were

cross-over trials. The Gokli study (Gokli 1994) was from the USA,

the Trakyali study (Trakyali 2008) from Turkey and the unpub-

lished study (Braithwaite 2005) was from the UK (MSc project).

All were hospital/university based. The trials used two treatment

arms: hypnosis versus no hypnosis (Gokli 1994; Trakyali 2008) or

hypnosis versus inhalation sedation with nitrous oxide and oxygen

(Braithwaite 2005).

The Gokli et al trial (Gokli 1994) aimed to ascertain the accep-

tance of local anaesthetic injection (LA), using hypnosis in chil-

dren. 29 healthy children (11 boys and 18 girls) between the ages

of 4 and 13 years participated in this cross-over study. Each child

had no previous dental experience, spoke English as their first

language and each needed at least two restorative appointments.

The flip of a coin determined whether or not hypnosis was used



at that appointment. It was a double-blind study where children

were blinded to which group they were in and the intended pro-

cedure (administration of LA) was video taped for assessment of

behaviour by two assessors using the North Carolina Behaviour

rating scale. Physiological measures were also assessed looking at

oxygen saturation and heart rate via pulse oximeter. Both mea-

sures were checked at baseline and at injection twice; once with

hypnosis and once without. They used informal hypnosis with

breathing and relaxation techniques. They found that patients who

were hypnotised demonstrated fewer undesirable behaviours (i.e.

crying, hand movement, physical resistance and leg movement)

than those who did not undergo hypnosis. However, decreased

crying with hypnosis was the only behaviour found to be statisti-

cally significant (P = 0.02), 17% crying in hypnosis, 41% crying

non-hypnosis). With regards to oxygen saturation and pulse rate,

only the latter was significantly lower in the hypnosis group (P =

0.005). No significant difference was found due to gender, race

or treatment order. The effect of hypnosis was more pronounced

with younger children.

The Braithwaite study (Braithwaite 2005) aimed to compare the

behavioural and emotional response of a group of 10 young pa-

tients aged 10 to 16 years old undergoing orthodontic extractions

using an established anxiety control method (inhalation sedation

with behaviour management) versus hypnorelaxation.

This was a single blind cross-over study where patients were

blinded to which treatment group they were in, as on both occa-

sions a nasal hood was placed. Patients were randomised to either

treatment A or B for the first period. Treatment A consisted of

inhalation sedation with nitrous oxide and oxygen + standardised

behaviour management technique. Treatment B consisted of hyp-

nosis and oxygen. Behavioural scores were given at four stages: 5

minutes after placement of nasal hood, LA administration, extrac-

tion (XLA) and 5 minutes post-XLA.

The study found that hypnosis can control some of the patient’s

negative responses to dental treatment, such as movement and be-

haviour during administration of LA. However, it did not provide

sufficient anxiety control during tooth extraction and overall re-

sponse to treatment remained statistically lower than response to

inhalation sedation. The majority of patients preferred inhalation

sedation.

The Trakyali study (Trakyali 2008) looked at the effect of hypnosis

on wearing time of orthodontic appliance. 30 patients (14 females

and 16 males) with a skeletal Class II division 1 malocclusion,

divided into two equal groups, a control and a study group. The

mean age was 10.78 ± 1.06 years for the hypnosis, and 10.07 ±

1.09 years for the control group. Both groups were treated with

cervical headgear containing a timer module. Patients were also

asked to record their actual wear time on timetables. The hypnosis

group patients were motivated with conscious hypnosis while the

control group were given verbal motivation by their orthodontist.

The timer modules were read at every visit and compared with

the timetables. A statistically significant decrease (P < 0.05) in

headgear wear was observed in the control group from the first to

the sixth month; however, the difference in the hypnosis group

was not significant. The result indicated that conscious hypnosis

was effective in this study for improving orthodontic patient co-

operation.

Risk of bias in included studies

Sequence generation

Sequence generation was adequate in two studies (Gokli 1994;

Trakyali 2008) and unclear in one (Braithwaite 2005).

Allocation concealment

It was unclear in all studies as it was not reported.

Blinding

The Gokli 1994 study was double blind: assessors and patients.

In the Braithwaite 2005 study, only patients were blinded. None

were blinded in Trakyali 2008.

Use of intention-to-treat analysis (ITT)

Braithwaite 2005 gave a good account on the fate of all patients

though ITT analysis was not used. All patients in Gokli 1994

and Trakyali 2008 completed treatment although ITT was not

mentioned.

Overall risk of bias

Two studies were assessed as at high risk of bias (Braithwaite 2005;

Trakyali 2008) and one study as at moderate risk of bias (Gokli

1994).

Effects of interventions

From the limited number of available evidence from the

Braithwaite 2005 and Gokli 1994 studies, hypnosis may be benefi-

cial in behaviour management during the administration of a local

anaesthetic (LA) in children (age range: 4.5 to 15 years) more than

a control group (no hypnosis, no sedation). This was consistent

with a recent review by The Cochrane Collaboration, which found

that various psychological interventions, particularly distraction,

combined cognitive-behavioural interventions, and hypnosis can

help children by reducing the pain and distress that accompany

needle-related procedures, with hypnosis being the most promis-

ing (Uman 2006). However, there is still not enough evidence to

prove its effectiveness during extraction. Trakyali 2008 showed an

increased likelihood of hypnosis improving orthodontic patient’s

co-operation.



D I S C U S S I O N

Summary of main results

The main question addressed by this review was to find out the

effectiveness of hypnosis (with or without sedation) for behaviour

management of children who are receiving dental care in order to

allow successful completion of treatment.

Despite growing interest in paediatric clinical hypnosis few con-

trolled studies have been carried out (Milling 2000) and only three

studies investigating the efficacy of paediatric dental hypnosis met

the inclusion criteria for this review. Although both Braithwaite

2005 and Gokli 1994 found hypnosis to have some beneficial ef-

fect in behaviour management during the administration of a local

anaesthetic (LA) in children (age range: 4.5 to 15 years) it was not

as effective during the extraction of teeth. The majority of chil-

dren in the Braithwaite study preferred inhalation sedation with

nitrous oxide and oxygen over hypnosis. Trakyali 2008 showed an

increased likelihood of hypnosis improving orthodontic patient’s

co-operation. None of the studies mentioned any adverse effects

regarding hypnosis.

Differences in treatment time with or without

hypnosis

Gokli 1994 did not look at time taken with or without hypnosis.

However, it was mentioned in the discussion that the hypnosis

procedure did require some adjustments in routine: “a relatively

quiet environment is needed to capture effectively and to maintain

the child’s attention. Moreover, the time involved in introducing

the hypnotic suggestion to the patient must be considered and

although relatively brief, does represent an additional time com-

mitment to the patient”.

Braithwaite 2005 found no significant difference in total treatment

time between inhalation sedation and ’hypnorelaxation’ i.e. ’hyp-

norelaxation’ demanded little additional time in order to complete

care.

Trakyali 2008 mentioned that the verbal motivation by the or-

thodontist lasted 15 minutes and that hypnosis with the hypnotist

lasted 20 minutes at each visit.

However, even if treatment time is reasonably extended, it could be

justified that the treatment is completed successfully at the end, as

many visits may be wasted in an attempt to modify the behaviour

of an unco-operative child for acceptance of treatment.

Overall completeness and applicability ofevidence

Age range used

In all studies the age range was applicable to paediatric dentistry

i.e. up to 16 years of age. However, it is appropriate to confine

studies to limited age ranges or to include sufficient numbers of

children from various age groups to permit analysis of adequate

statistical power within age categories (Olness 1996).

Quality of the evidence

Study designs

Two of the studies were cross-over trials and one parallel. Parallel

studies are preferred in hypnosis studies in order to avoid the carry

over effect from the first period on the control group that can

occur in cross-over studies. Interestingly, in Braithwaite 2005 the

effect of visit one on visit two was not significant.

Calculation of sample size

No sample size calculation was mentioned although it was men-

tioned in all studies that their sample sizes were small. Braithwaite

2005 specifically mentioned that they were unable to do a sample

size calculation due to a lack of previous studies. Obviously with-

out a sample calculation it is difficult to comment on the size of

these studies. However, there is a risk that they were underpow-

ered.

Comments on the studies with regards to the use of

scripts

Gokli 1994 grouped many induction procedures as mentioned in

Characteristics of included studies. However, they did not mention

which technique of behaviour management was utilised in the

non-hypnotic group.

Braithwaite 2005 had developed a script for both behaviour man-

agement techniques to be followed during inhalation sedation with

nitrous oxide, as sedation without accompanying reassurance from

the dentist is not as effective (Rosen 1983).

However, the ’hypnorelaxation’ script in the Braithwaite study

used very specific imagery associated with being in a garden. Im-

agery that has not previously been negotiated with the patient may

not fully engage the child and furthermore may increase the risk

of a negative response to suggestion. The overall efficacy of the

Braithwaite intervention may thus have been reduced by the script

that was used.

Whilst use of a script allows better comparability and standard-

isation between subjects, it is possible that hypnosis would have

been more effective if techniques used were tailored to each pa-

tient’s needs and preferences instead of using the same technique

for every patient as part of a research protocol (Milling 2000).

It has been shown that labelling of procedures as hypnosis increases

the response over and above the same procedure not so named



(Gandhi 2005). Milling 2000 has recommended that clinicians

use the term hypnosis with children as this may increase efficacy

of hypnotic interventions. However, patients taking part in the

Braithwaite study were not informed that the intervention used

was hypnosis and this may have reduced its effectiveness.

Analysing data

Braithwaite 2005 mentioned that two patients from the hypnosis

group were given nitrous oxide to provide anxiolysis during diffi-

cult extractions and they were included in the final analysis. This is

where data from all patients were included in the analysis and the

data are analysed according to which arm patients were originally

allocated to, even if they did not finish or swapped arms (inten-

tion-to-treat analysis). It is considered the least biased and fairest

way of assessing the effectiveness of an intervention. Braithwaite

2005 reported this clearly.

However, one patient from the inhalation sedation group was ex-

cluded part way through treatment, which was later completed

under general anaesthesia (GA) (reason given: “autistic child who

became very uncooperative”). Was it appropriate to include an

autistic child in a hypnotic trial as hypnosis depends on partic-

ipants having vivid imagination while it is known that autistic

children have limited imagination ability? (Deudney 2006). What

was the consequence of excluding a patient part way through the

treatment, who had presumably, originally been considered as ful-

filling the study eligibility criteria and was randomised to a treat-

ment group? Patients should only be excluded from a trial prior to

randomisation, not afterwards. In this case, removing an uncoop-

erative patient from one arm of the study has clearly introduced

bias.

With regards to Gokli 1994 and Trakyali 2008, they did not men-

tion any difficulties faced in the two treatment groups.

Patient follow-up

None of the studies followed up their patients. Follow-up may be

advantageous to find out if the effect of hypnosis has modified

the patient’s perception towards having dental treatment. Hypno-

sis attempts to help the patient to restructure negative thinking,

ideally it should improve their ability to cope and give them some

more positive expectations from treatment (Heap 1991; Moore

1990). Conversely, it is possible that patient’s attitudes to dental

treatment may be more negative following treatment under hyp-

nosis. Without follow-up, it is impossible to assess any long term

effect on behaviour or attitudes.

Potential biases in the review process

Braithwaite 2005 intended that patients remained unaware of

which of the two behaviour management techniques were to be

used. However, it was described that two of the patients and their

parents in the study had increased expectation of inhalation se-

dation effectiveness and showed bias towards this type of dental

care before any treatment commenced. This reflected the patient’s

previous dental experience of inhalation sedation and could have

influenced their preference of care. The study protocol recom-

mended that children with such previous experience be excluded

to eliminate bias, however this did not appear to happen.

Having access to the whole Braithwaite study may have introduced

bias from the review authors side as a far greater amount of infor-

mation was available for critical appraisal, compare to the Gokli

and Trakyali studies where journal articles were used.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There is considerable anecdotal evidence of the benefits of hyp-

nosis in paediatric dentistry, however, on the basis of the three

studies that were eligible to be included in this review there is not

yet enough evidence to claim it is empirically supported. The lim-

itations of this review are noted by the review authors.

Implications for research

This review highlights the need for further randomised controlled

trials to be conducted into the use of hypnosis in paediatric den-

tistry, not least because empirical support for the use of hypnosis

in the treatment of clinical problems has generally grown over the

last decade. For example empirical support has been established for

the use of hypnosis to manage procedural pain with paediatric pa-

tients (Accardi 2009; Liossi 2006). Since procedural discomfort is

frequently associated with dental procedures, this is highly relevant

to dentists. In addition, the UK’s National Institute for Health and

Clinical Excellence (NICE) guidelines recommend hypnothera-

peutic interventions for the treatment of irritable bowel syndrome

(IBS) (NICE 2008). Whilst IBS is not clinically relevant to den-

tistry, dentists may be encouraged by the growing acceptance of

the use of clinical hypnosis that this demonstrates. The wider liter-

ature may thus indicate to dentists that hypnosis is worth investi-

gating as an adjunct to treatment strategies and moreover provides

examples of the stringent methodology required.

The following research suggestions are given.

• Follow-up of patients is required to find out if the effect of

hypnosis has modified the patient’s perception towards having

dental treatment.

• Study design must be parallel to avoid the carry over effect

from the first period on the control group.

• Sample size calculation should be carried out and reported.



• Consideration should be given to exclusion criteria to

prevent contamination from previous treatment experience e.g.

patients with experience of inhalation sedation (Braithwaite

2005) or patients with previous hypnosis treatment (Liossi

2003).

• Blinding of coders: unless video recordings are used,

observer blinding is difficult in these kinds of studies and they

will be aware of which children in which group. Observer bias

may therefore have an influence in the behaviour distress ratings.

Techniques used by Liossi et al (Liossi 2003) may allow the effect

of the observer bias to be assessed. They suggest the following.

•

i) Ask the observers, after they have completed the

measurements, to guess the patient’s group membership. Liossi et

al found that observers could not discriminate between the test

and control groups.

ii) Check self reported data against the observational

data. If bias is minimal they should be similar.

• Improved reporting of data to allow heterogeneity

assessment and meta-analysis between studies in future reviews

(Uman 2006).

• Given well-known developmental variations in

suggestibility, researchers may wish to confine studies to limited

age ranges or to include sufficient numbers of children from

various age groups to permit analysis of adequate statistical

power within age categories (Olness 1996).

• So far, no significant difference between male and female

concerning hypnotic ability was found. However, gender should

be included in research with other patient characteristics such as

age to confirm that it is the case within all age groups.

A C K N O W L E D G E M E N T S

Wendy Bellis for guiding the review authors to the unpublished

study and K Braithwaite for providing a copy of her study and

answering queries.

The two translators: G Rossi and Christina-Maria Georgopoulou.

The Cochrane Oral Health Group - in particular Sylvia Bickley,

Luisa M Fernandez Mauleffinch, Helen Worthington and Anne

Littlewood for their guidance and help.

R E F E R E N C E S

References to studies included in this review

Braithwaite 2005 {unpublished data only}

Braithwaite K. Hypnorelaxation versus inhalation sedation in

orthodontic extractions. MSc project. Department of Sedation and

Special Care Dentistry. Guy’s, King’s and St Thomas’ Dental

Institute of King’s College 2005.

Gokli 1994 {published data only}

Gokli MA, Wood AJ, Mourino AP, Farrington FH, Best AM.

Hypnosis as an adjunct to the administration of local anesthetic in

pediatric patients. ASDC Journal of Dentistry for Children 1994;61

(4):272–5.

Trakyali 2008 {published data only}

Trakyali G, Sayinsu K, Muezzinoglu AE, Arun T. Conscious

hypnosis as a method for patient motivation in cervical headgear

wear- a pilot study. European Journal of Orthodontics 2008;30(2):

147–52.

References to studies excluded from this review

Howitt 1967 {published data only}

Howitt JW. An evaluation of audio-analgesia effects. Journal of

Dentistry for Children 1967;34(5):406–11.

Jerrell 1983 {published data only}

Jerrell R, Klingman A, Melamed B, Cathbert M, Bennett C. Skills

training for children facing dental restorative treatment. AADR

Abstract 1983; Vol. 62:175.

Additional references

Accardi 2009

Accardi MC, Milling LS. The effectiveness of hypnosis for reducing

procedure-related pain in children and adolescents: a

comprehensive methodological review. Journal of Behavioral

Medicine 2009;32(4):328–39.

BNF 2007

Joint Formulary Committee. British National Formulary (BNF 54).

4th Edition. London: British Medical Association and Royal

Pharmaceutical Society of Great Britain, 2007.

Deudney 2006

Deudney C, Tucker L. Autistic Spectrum Disorders in Young

Children. London: The National Autistic Society, 2006.

Egger 1997

Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-

analysis detected by a simple, graphical test. BMJ 1997;315(7109):

629–34.

Fayle 2003

Fayle S, Tahmassebi JF. Paediatric dentistry in the new millennium:

2. Behaviour management - helping children to accept dentistry.

Dental Update 2003;30(6):294–8.

Fromm 1992

Fromm E, Nash M. Contemporary Hypnosis Research. New York:

Guilford Press, 1992.



Gandhi 2005

Gandhi B, Oakley DA. Does ’hypnosis’ by any other name smell as

sweet? The efficacy of ’hypnotic’ inductions depends on the label

’hypnosis’. Consciousness and Cognition 2005;14(2):304–15.

Heap 1991

Heap M, Dryden W (eds). Hypnotherapy: A Handbook. Milton

Keynes: Open University Press, 1991.

Heap 2002

Heap M, Aravind KK. Hartland’s Medical and Dental Hypnosis. 4th

Edition. London: Churchill Livingston / Harcourt Health

Sciences, 2002.

Higgins 2009

Higgins JPT, Green S (eds). Cochrane Handbook for Systematic

Reviews of Interventions version 5.0.2 (updated September 2009).

The Cochrane Collaboration, 2009. Available from www.cochrane-

handbook.org.

Kirsch 1995

Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an adjunct to

cognitive-behavioural psychotherapy: a meta-analysis. Journal of

Consulting & Clinical Psychology 1995;63(2):214–20.

Liossi 2003

Liossi C, Hatira P. Clinical hypnosis in the alleviation of procedure-

related pain in pediatric oncology patients. The International

Journal of Clinical and Experimental Hypnosis 2003;51(1):4–28.

Liossi 2006

Liossi C. Psychological interventions for acute and chronic pain in

children. Pain: Clinical Updates 2006;14(4):1–4.

Milling 2000

Milling LS, Costantino CA. Clinical hypnosis with children: first

steps towards empirical support. The International Journal of

Clinical and Experimental Hypnosis 2000;48(2):113–37.

Moore 1990

Moore R. Dental fear - relevant clinical methods of treatment.

Tandlaegebladet 1990;94(2):58–60.

NICE 2008

National Institute for Health and Clinical Excellence (NICE).

Irritable bowel syndrome in adults: Diagnosis and management of

irritable bowel syndrome in primary care. Available from http://

guidance.nice.org.uk/CG61 2008.

Olness 1996

Olness K, Kohen DP. Hypnosis and Hypnotherapy with Children. 3rd

Edition. New York: Guilford Press, 1996.

Patel 2000

Patel B, Potter C, Mellor AC. The use of hypnosis in dentistry: a

review. Dental Update 2000;27(4):198–202.

Reid 1988

Reid A. Some suggestion techniques for dental anxiety in children.

The Australian Journal of Clinical Hypnotherapy and Hypnosis 1988;

9(2):85–8.

RevMan 2008

The Nordic Cochrane Centre, The Cochrane Collaboration.

Review Manager (RevMan). 5.0. Copenhagen: The Nordic

Cochrane Centre, The Cochrane Collaboration, 2008.

Rosen 1983

Rosen M. Hypnotic induction and nitrous oxide sedation in

children. Journal of the Dental Association of South Africa 1983;38

(6):371–2.

Simons 2007

Simons D, Potter C, Temple G. Hypnosis and Communication in

Dental Practice. UK: Quintessence Publishing Co. Ltd, 2007.

Uman 2006

Uman LS, Chambers CT, McGrath PJ, Kisely S. Psychological

interventions for needle-related procedural pain and distress in

children and adolescents. Cochrane Database of Systematic Reviews

2006, Issue 4. [DOI: 10.1002/14651858.CD005179.pub2]

Vingoe 1987

Vingoe F. When is a placebo not a placebo? That is the question.

British Journal of Experimental and Clinical Hypnosis 1987;4:165–7.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Braithwaite 2005

Methods Cross-over study. No follow-up. Hospital/university setting. Country: UK.

Participants N = 10 completed the study (M = 7, F = 3).

Age range 12-15 years (mean age: 13 years and 4 months).

Previous treatment of patients: Yes.

1 patient was excluded before commencing any treatment because of latex allergy. An-

other one excluded from the inhalation sedation group, half way through treatment,

which was then completed under GA (reason given: autistic child who became very

uncooperative).

2 participants from hypnosis group were given nitrous oxide to provide anxiolysis during

difficult extractions.

Inclusion criteria:

- Patients needing orthodontic extraction

- Paired quadrant extractions to allow comparable treatment over 2 visits

- ASA I or II

- Good understanding of English

- No contra-indication to the use of LA, IS or hypnosis.

Interventions Treatment A: Inhalation sedation with nitrous oxide and oxygen + behaviour manage-

ment script.

Treatment B: Hypnosis and oxygen via nasal hood.

Hypnotic technique: Hypnorelaxation script was created and followed; it included in-

duction, deepening, special place/garden imagery and awakening.

Outcomes - Behavioural measures:

(1) Houpt: 3-point scale for sleep (awake to asleep); 4-point scale for movement (violent

movement to no movement); 4-point scale for crying (hysterical crying to no crying); 6-

point scale for overall behaviour (aborted/no treatment to excellent/no crying or move-

ment). Score given at 4 stages: 5 mins after placement of nasal hood; LA administration;

extraction (XLA); 5 mins post XLA.

(2) Modified anxiety and behaviour rating scales (Houpt, Wilson and Frankl): 4-point

scale for patient’s overall level of sedation (irritated to sleepy); 4-point scale for patient’s

overall response to treatment (Rx) (refusal of Rx to good rapport with dentist).

- Self report: VAS pre- and post-treatment:

Linear 10 cm in length. Patient marked along the line the level of response usually

corresponding from negative through to positive. Pre-treatment feeling about the visit.

10 mins after Rx about their feelings towards: 1. Nasal hood, 2. Dental instruments in

mouth, 3. Injection, 4. Extraction.

- Parental questionnaire:

Has your child ever had any difficulties, or been impossible to carry out dental treatment?

Has your child ever shown fear of going to the dentist? (To establish the possibility that

the child had behaviour management problems).

- Patient preference:

Which treatment modality is preferable: hypnorelaxation or nitrous oxide and oxygen?



Braithwaite 2005 (Continued)

(In hindsight, the trial author wished she had asked about the reason for preference).

- Treatment length.

Outcome measures: Assessor’s interpretation analysed using Wilcoxon signed ranks

matched pairs test.

Results:

Only significant difference was found in the following:

- Score of patient sleep/relaxation at tooth extraction (XLA): IS = 1.5 (sd 0.5), Hypnosis

= 1.1 (sd 0.3), P = 0.046

- Overall patient response to treatment: IS = 3.7 (sd 0.5), Hypnosis = 3.2 (sd 0.4), P =

0.025

- How patient felt about having XLA: IS = 71 (sd 28.5), Hypnosis = 36.1 (sd 34.8), P

= 0.014.

Interesting finding: Average length of treatment: IS: 31.75 mins, Hypnosis: 32.5 mins

(insignificant).

Authors’ conclusion:

“Hypnorelaxation is an inexpensive alternative anxiety control method, but it demanded

greater input from the clinician in addition to carrying out the extraction procedure.

It can control some of the negative patient’s responses to dental treatment, such as

movement and behaviour during administration of LA. However, in this study, it does

not provide sufficient anxiety control during tooth extraction and overall response to

treatment remains statistically lower than response to inhalation sedation. Majority of

patients preferred inhalation sedation”.

Notes Source of funding: Not reported.

Ethical approval: Yes.

Consent: Yes.

Risk of bias

Item Authors’ judgement Description

Adequate sequence generation? Unclear Quote: “Blind selection”.

Author contacted for further clarification,

who mentioned the use of sealed envelope

i.e. either treatment A or B but it is unclear

how sequence was generated.

Blinding?

All outcomes

Unclear Only patients blinded to therapy.

Incomplete outcome data addressed?

All outcomes

Yes All patients were accounted for.

Intention to treat analysis? No



Gokli 1994

Methods Cross-over study. No follow-up. Hospital/university setting. Country: USA.

Participants N = 29 (M = 11, F = 18).

Age range: 4.5-13.5 years (mean age 7.8 years).

Previous treatment of patients: No.

All participants completed treatment.

Inclusion criteria:

- Each patient needed at least 2 restorative appointments with local anaesthetic

- No previous dental experience

- ASA I (healthy)

- Speaking English as first language.

Interventions Administration of LA with or without hypnosis.

Hypnotic technique: Breathing technique, relaxation and favourite visual imagery or

sensations. Stories or adventures were individually tailored and elaborated with direct,

indirect and ego strengthening suggestions to create absorbing and pleasant experiences.

Outcomes Behavioural measures:

North Carolina behaviour rating scale (NCBRS): Presence of high hand movements, leg

movements, crying or verbal protests and/or orophysical resistance.

Physiological measures:

Pulse rate; oxygen levels: Transcutaneous pulse oximeter and readings were taken at

baseline (before hypnotic suggestion or any other procedure) and at tissue penetration

on administration of LA.

Outcome measures:

Physiological parameters were analysed using MANOVA. NCBRS was analysed using

McNemar.

Results:

- Significant difference only in number crying (P = 0.0196): 17.2% crying in hypnosis;

41.4% crying non-hypnosis.

- No other significant difference in behaviour measures.

- Significant differences in pulse rate in hypnosis (F(1,24) = 9.7, P < .0047) and age (F

(1,24) = 6.1, P < .0210) but not to sex, race nor order to treatment (P > .15). The effect

of hypnosis was more pronounced with younger children i.e. ages 4 to 6.


“Hypnosis can have a positive impact on paediatric patients for injection of local anaes-

thetics. Specifically crying and pulse rate were found significantly decreased when hyp-

nosis was utilised”.


Ethical approval: Not reported.

Consent: Yes.

Risk of bias


Adequate sequence generation? Yes Quote: “Flip of coin to determine whether

hypnosis was used at that appointment”.



Gokli 1994 (Continued)

Blinding?

All outcomes

Yes Quote: “double blind research design was

used”.

Patient blinded to therapy.

Assessors blinded to therapy.

Assessors blinded to therapy as patients

were video taped during intervention. In-

ter-rater reliability was assessed.


All outcomes



Trakyali 2008

Methods Parallel study. No follow-up. Hospital/university setting. Country: Turkey.

Participants N= 30 (M = 16, F = 14).

Mean age was 10.78 ± 1.06 years for the hypnosis, and 10.07 ± 1.09 years for the control

group.

Previous treatment of patients: No.

All participants completed treatment.

Inclusion criteria:

- Patients with a skeletal Class II division 1 malocclusion presenting maxillary prog-

nathism were selected from the state-funded patient list.

Interventions - Subjects in both groups were treated by the same orthodontist (GT). The study group

patients were motivated at each monthly visit, with conscious hypnosis for 20 minutes

by a hypnotist. The control group patients were given only verbal motivation by their

orthodontist for 15 minutes at every visit.

- Subjects in both groups were instructed to wear a cervical headgear for 16 hours per

day and to record their actual wear time on a timetable.

- The headgear contained a timer module (patients were not informed that their headgear

wear time was being recorded). The timer modules were read at every visit and compared

with the timetables that patients provided.

Hypnotic technique: Relaxation, breathing, imagery visualization of favourite places.

Followed by suggestions to accept the orthodontic apparatus and encourage co-operation.

Outcomes - A timer module: Headgear contained a timer module (patients were not informed that

their headgear wear time was being recorded).

- Timetables that patients provided: Patient has to record the wearing time per day?

The timer modules were read at every visit and compared with the timetables that patients

provided.

Outcome measures:

Analysis of variance was used to determine the differences in measurements at each time

point. For comparison of the groups, an independent t -test was used.

Results:

- A statistically significant decrease (P < 0.05) in headgear wear was observed in the



Trakyali 2008 (Continued)

control group from the first to the sixth month; however, the difference in the hypnosis

group was not significant. This result indicates that conscious hypnosis is an effective

method for improving orthodontic patient co-operation.

- There was a low correlation between actual headgear wear indicated by the patient and

that recorded by the timing modules, which showed that, timetables are not consistent

tools for measuring patient co-operation.


“This pilot study indicates that conscious hypnosis is an effective method for improving

orthodontic patient co-operation. Timetables are not robust tools for measuring patient

co-operation during treatment”.


Ethical approval: Yes.

Consent: Yes.

Risk of bias


Adequate sequence generation? Yes Quote: “Forty consecutive patients with

a skeletal Class II division1 malocclusion

presenting maxillary prognathism were se-

lected from the state-funded patient list”.

Author was contacted for further clarifica-

tion: The clinician wrote the names of all

participants on separate batches of paper

and folded them and then gave them all to

the secretary. The secretary, who was not

aware of the severity of the malocclusions,

unfolded the papers one by one and wrote

the names on a list (not alphabetically but

randomly). Those with odd numbers com-

prised the study group and those with even

numbers the control group.

Blinding?

All outcomes

No Patients were aware of which group they

were in but were not aware that their wear-

ing time was being monitored electroni-

cally.

The clinician was aware of which partic-

ipants were in hypnosis or non-hypnosis

group.


All outcomes





ASA = American Society of Anesthesiologists physical status classification system; GA = general anaesthesia; IS = inhalation sedation;

LA = local anaesthetic; sd = standard deviation; VAS = visual analogue scale

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Howitt 1967 RCT, inappropriate intervention.

Jerrell 1983 AADR abstract 1983, not published and review authors could not get it for appraisal.

AADR = American Association for Dental Research; RCT = randomised controlled trial



D A T A A N D A N A L Y S E S

This review has no analyses.

A P P E N D I C E S

Appendix 1. MEDLINE via OVID search strategy

1. exp Dentistry/

2. (dental$ or dentist$ or “oral surg$” or orthodont$ or pulpotom$ or pulpect$ or endontont$ or “pulp cap$”).mp. [mp=title,

original title, abstract, name of substance word, subject heading word]

3. ((dental or tooth or teeth) and (fill$ or restor$ or extract$ or remov$ or “cavity prep$” or caries or carious or decay$)).mp. [mp=

title, original title, abstract, name of substance word, subject heading word]

4. (“root canal therapy” or “tooth replant$”).ab,sh,ti.

5. or/1-4

6. Hypnosis, Dental/

7. exp Hypnosis/

8. exp Hypnosis, Anesthetic/

9. “Imagery (Psychotherapy)”/

10. Relaxation Therapy/

11. (autosuggestion or auto-suggestion).mp. [mp=title, original title, abstract, name of substance word, subject heading word]

12. hypno$.ab,ti.

13. “autogenic$ train$”.mp. [mp=title, original title, abstract, name of substance word, subject heading word]

14. or/6-13

15. exp child/

16. infant/

17. Adolescent/

18. (child$ or infant$ or adolescen$).ab,sh,ti.

19. (pediatric$ or paediatric$).ab,sh,ti.

20. Dental Care for Children/

21. or/15-20

22. 5 and 14 and 21

Appendix 2. EMBASE via OVID search strategy

1. exp Dentistry/ or exp Dental Care/

2. (dental$ or dentist$ or “oral surg$” or orthodont$ or pulpotom$ or pulpect$ or endodont$ or “pulp cap$”).mp. [mp=title,

abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]


title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]


5. or/1-4

6. Hypnosis/

7. Autogenic Training/

8. Guided imagery/

9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,

device manufacturer, drug manufacturer name]

10. hypno$.ab,ti.



11. “autogenic$ train$”.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device

manufacturer, drug manufacturer name]

12. or/6-11

13. child/

14. infant/

15. Adolescent/



18. or/13-17

19. 5 and 12 and 18

Appendix 3. PsycINFO via OVID search strategy

1. exp Dentistry/ or exp Dental Care/

2. (dental$ or dentist$ or “oral surg$” or orthodont$ or pulpotom$ or pulpect$ or endodont$ or “pulp cap$”).mp. [mp=title,

abstract, heading word, table of contents, key concepts]


title, abstract, heading word, table of contents, key concepts]


5. or/1-4

6. Hypnosis/ or hypnotherapy/

7. Autogenic Training/

8. Guided imagery/

9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, heading word, table of contents, key concepts]

10. hypno$.ab,ti.

11. “autogenic$ train$”.mp. [mp=title, abstract, heading word, table of contents, key concepts]

12. or/6-11

13. child/

14. infant/

15. Adolescent/



18. or/13-17

19. 5 and 12 and 18

Appendix 4. CENTRAL search strategy

#1 MeSH descriptor Dentistry explode all trees

#2 (dental* in All Text or dentist* in All Text or “oral surg*” in All Text or orthodont* in All Text or pulpotom* in All Text or

pulpect* in All Text or endodont* in All Text or “pulp cap*” in All Text)

#3 ((dental in All Text or tooth in All Text or teeth in All Text) and (fill* in All Text or restor* in All Text or extract* in All Text or

remov* in All Text or “cavity prep*” in All Text or caries in All Text or carious in All Text or decay* in All Text))

#4 (“root canal therapy” in All Text or “tooth replant*” in All Text)

#5 (#1 or #2 or #3 or #4)

#6 MeSH descriptor Hypnosis, Dental this term only

#7 MeSH descriptor Hypnosis explode all trees

#8 MeSH descriptor Hypnosis, Anesthetic explode all trees

#9 MeSH descriptor relaxation therapy this term only

#10 (autosuggestion in All Text or auto-suggestion in All Text or “auto suggestion” in All Text)

#11 hypno* in Title, Abstract or Keywords

#12 “autogenic* train*” in All Text

#13 MeSH descriptor Imagery (Psychotherapy) this term only



#14 (#6 or #7 or #8 or #9 or #10 or #11 or #12 or #13)

#15 MeSH descriptor Child explode all trees

#16 MeSH descriptor infant this term only

#17 MeSH descriptor adolescent this term only

#18 (child* in Title, Abstract or Keywords or infant* in Title, Abstract or Keywords or adolescen* in Title, Abstract or Keywords)

#19 (pediatric* in Title, Abstract or Keywords or paediatric* in Title, Abstract or Keywords)

#20 MeSH descriptor Dental Care for Children this term only

#21 (#15 or #16 or #17 or #18 or #19 or #20)

#22 (#5 and #14 and #21)

Appendix 5. Cochrane Oral Health Group Trials Register search strategy

(hypnosis or hypnotherapy or imagery or “relaxation technique*” or autosuggestion or auto-suggestion or “auto suggestion” or auto-

genic*)

H I S T O R Y

Protocol first published: Issue 2, 2008

Review first published: Issue 8, 2010

C O N T R I B U T I O N S O F A U T H O R S

Sharifa Al-Harasi (SAH), Paul Ashley (PA) and Val Walters (VW): conceiving the review, designing the review, co-ordinating the review.

SAH and PA: undertaking searches, data collection and extraction for the review.

SAH and Susan Parekh (SP): writing to authors of papers for additional information.

SAH: obtaining and screening data on unpublished studies, entering data into RevMan.

PA, SP, SAH, David Moles (DM): analysis of data, interpretation of data.

SAH: writing the review.

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T



Internal sources

• Nil, Not specified.

External sources

• Nil, Not specified.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Adolescent; Dental Anxiety [∗therapy]; Dental Care [∗methods]; Hypnosis [∗methods]; Randomized Controlled Trials as Topic

MeSH check words

Child; Child, Preschool; Humans



CD 007154

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