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 Library
2010, Issue 8
http://www.thecochranelibrary.com

Hypnosis for children undergoing dental treatment (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Hypnosis for children undergoing dental treatment (Review) i

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Hypnosis for children undergoing dental treatment

Sharifa Al-Harasi1 , Paul F Ashley2 , David R Moles3 , Susan Parekh2 , Val Walters4
1 Military Dental Centre, PO Box 454, Seeb, Oman. 2 Unit of Paediatric Dentistry, UCL Eastman Dental Institute, London, UK. 3 Oral
Health Services Research, Peninsula Dental School, Plymouth, UK. 4 Division 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. Cochrane
Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007154. DOI: 10.1002/14651858.CD007154.pub2.

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

ABSTRACT
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 methods
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 Cochrane
Handbook 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.
Hypnosis for children undergoing dental treatment (Review) 1
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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.

PLAIN LANGUAGE SUMMARY

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.

BACKGROUND
Hypnotic techniques can be used to manage a range of common
Treating children is often a challenge for dentists. Many techniques problems relevant to dentistry such as dental anxiety, specific den-
have been developed to help children cope with dental treatment tal phobia, pain control in conservative treatment and extractions,
and to reduce the stress experienced. Part of the solution is under- improved tolerance for orthodontic appliances, as an adjunct to
standing the reasons behind the unwanted behaviour (e.g. fear of inhalation sedation, or as part of the induction of GA and modi-
the unknown) and then addressing these issues using techniques fication of unwanted oral habits such as thumb sucking, bruxism,
such as ’tell, show & do’ or positive reinforcement (Fayle 2003). gagging and smoking (Patel 2000; Reid 1988; Simons 2007).
However, due to the variation in children’s personalities, one tech-
nique of behaviour management may work with some children A number of advantages of using hypnosis in dentistry have been
but not with others. Therefore, the more knowledge we gain about mentioned in the literature and include the following:
other available techniques and how to apply them practically, the
more effective we can be in helping children cope with dental treat- • No requirement for specialist equipment
ment. Alternatives to standard non-pharmacological techniques • The patient remains conscious
include sedation or even general anaesthetic (GA). These tech-
niques have their place, but can be associated with morbidity or • Non-pharmacological approach so no side effects or
even mortality. One other possible alternative to standard non- associated environmental pollution
pharmacological techniques is the use of hypnosis. • Combines well with nitrous oxide inhalation sedation
Heap and Aravind (Heap 2002) define hypnosis as an interaction (Rosen 1983)
in which the hypnotist uses suggested scenarios (“suggestions”) • Safe.
to encourage a person’s focus of attention to shift towards inner
experiences in order to influence the subject’s perceptions, feel- Hypnotic techniques are particularly effective when used with chil-
ings, thinking and behaviour. Response to hypnotic suggestion is dren between 8 and 12 years however children as young as 4 years
characteristically experienced by a person as feeling involuntary or old can be responsive to hypnosis (Olness 1996), yet hypnosis as
effortlessness (Fromm 1992). Used as an adjunctive procedure in an adjunct to paediatric dental procedures is generally underused,
medicine, dentistry and applied psychology, hypnosis can enhance hence the need for this review.
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-
OBJECTIVES
notherapy’ and ’hypnotherapist’ to be unhelpful and potentially
misleading as they suggest that hypnosis is a form of treatment or This systematic review attempted to answer the following ques-
therapy in its own right (Vingoe 1987). tion:
Hypnosis for children undergoing dental treatment (Review) 2
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
What is the effectiveness of hypnosis (with or without sedation) Search methods for identification of studies
for behaviour management of children who are receiving dental
For the identification of studies included or considered for this
care in order to allow successful completion of treatment.
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
Null hypothesis for each database. The search strategy was not combined with
Hypnosis has no effect on the outcome of dental treatment of the Cochrane Highly Sensitive Search Strategy for identifying
children. 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.
METHODS

Electronic searches
Criteria for considering studies for this review • The Cochrane Oral Health Group’s Trials Register (11th
June 2010) (Appendix 5)
• The Cochrane Central Register of Controlled Trials
Types of studies (CENTRAL) (The Cochrane Library 2010, Issue 2) (Appendix 4)
Both randomised and quasi-randomised control trials were in- • MEDLINE (OVID) (from 1950 to 11th June 2010)
cluded. Case control studies were not included to avoid bias. (Appendix 1)
• EMBASE (OVID) (1974 to 11th June 2010) (Appendix 2)
• PsycINFO (OVID) (1887 to 11th June 2010) (Appendix
Types of participants 3).
- 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): Language
• under 5 years of age The search attempted to identify all relevant studies irrespective
• 6 to 12 years of language. Non-English papers were translated.
• more than 12 years up to 16 years old.

- Children having any dental treatment such as:

Handsearching
Simple restorative treatment with or without local anaesthetic (LA)
or simple extractions or management of dental trauma (e.g. repo- The following journals were identified as being important to be
sitioning of tooth, splinting, removal of nerve from tooth) and handsearched for this review. The journals were handsearched by
orthodontic treatment. Children were included regardless of base- the review authors for the period between 1996 to 2006:
line anxiety. International Journal of Paediatric Dentistry
Pediatric Dentistry
Journal of Dentistry for Children
Types of interventions American Academy of Pediatric Dentistry
Test group: Any hypnotic technique with or without any sedative Journal of the American Dental Association
agent (sedation could be inhalation, oral or intravenous). British Dental Journal
Control group: No hypnotic intervention or sedative agent alone. Dental Update
Contemporary Hypnosis
The International Journal of Clinical and Experimental Hypnosis
Types of outcome measures American Journal of Clinical Hypnosis
(1) Completion of treatment (yes/no). Australian Journal of Clinical and Experimental Hypnosis.
(2) Measures of behaviour between test and control groups (scales The reference lists of all eligible trials were checked for additional
used may vary between studies). studies.
(3) Difference in post-operative anxiety between test and control
groups (scales used may vary between studies).
(4) Adverse events. Unpublished studies

Hypnosis for children undergoing dental treatment (Review) 3

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Specialists in the field known to the review authors were contacted Risk of bias was assessed for each included study. Studies were
for any unpublished data. 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
Data collection and analysis these criteria was not met, a study was considered at moderate risk
of bias, otherwise at high risk of bias.

Selection of studies Investigation of publication bias

Selection of papers suitable for inclusion in the review were car- In order to help overcome publication bias, we (1) imposed no
ried out independently by two review authors (Sharifa Al-Harasi language barriers in our search, (2) contacted specialists in the field
(SAH) and Paul Ashley (PA)). Titles and abstracts were assessed for any published, unpublished, and in-progress studies, and (3)
and full copies of all relevant and potentially relevant studies, those contacted the authors with missing data for further clarification.
appearing to meet the inclusion criteria, or for which there were It was intended to assess publication bias and other possible biases
insufficient data in the title and abstract to make a clear decision, relating to the size of trials by graphical methods and via the Begg
were obtained. The full text papers were assessed independently and Mazumdar adjusted rank correlation test and the Egger et al
by these two review authors. All irrelevant records were excluded regression asymmetry test (Egger 1997). Effect size versus standard
and details of the studies with the reasons for their exclusion were error was to be drawn. Asymmetry of the funnel plots would have
noted. Agreement was assessed by calculating Kappa scores and all indicated publication bias, though it may also represent a true
disagreements were resolved by discussion. relationship between trial size and effect size.
A third review author (Susan Parekh (SP)) was available to resolve However, the above was not possible due to the small number of
any issues or selection discrepancies that arose. studies.

Data extraction and management Data synthesis

Data extraction was carried out on a specially designed paper form Data were divided into descriptive and quantitative methods.
(available from the review authors) independently by two review Meta-analysis of the data was not applicable due to insufficient
authors (SAH and PA) and again authors were blinded to each number of studies.
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 Descriptive methods
the papers.
Data were collated into evidence tables. A descriptive summary
was formulated to determine the quantity of data, checking further
Assessment of risk of bias in included studies for study variations in terms of study characteristics, study quality
and results. This assisted in confirming the suitability of further
The assessment of risk of bias for included trials was undertaken
synthesis methods.
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 Quantitative methods
in the Cochrane Handbook for Systematic Reviews of Interventions
Meta-analysis of the data was not applicable due to insufficient
Version 5.0.2 (Higgins 2009) on the following individual quality
number of studies. If data do subsequently become available then
criteria:
analysis will be carried in the following order:
• Adequate sequence generation: Yes, No, Unclear
- Hypnosis versus no hypnosis
• Allocation concealment: Yes, No, Unclear
- Hypnosis combined with sedation versus sedation only
• Blinding of participants and outcome assessors: Yes, No,
- Hypnosis versus sedation.
Unclear
Random-effects meta-analyses will be used provided there are more
• Incomplete outcome data addressed: Yes, No, Unclear
than three trials included in the meta-analysis. For continuous
• Intention-to-treat analysis: Yes, No, Unclear
data, pooled outcomes will be expressed as mean differences with
’Yes’ indicates a low risk of bias, ’No’ indicates high risk of bias their associated 95% confidence intervals. For binary data, these
and ’Unclear’ indicates either lack of information or uncertainty will predominately be pooled risk ratios and associated 95% con-
over the potential for bias. A risk of bias table was completed for fidence intervals. Statistical heterogeneity will be assessed by cal-
each included study. culation of the Q statistic and Cochrane’s I2 statistic. Analysis will

Hypnosis for children undergoing dental treatment (Review) 4

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
be performed using RevMan Analysis software (RevMan 2008). Results of the search
Data will be presented as an overall comparison and as subgroups. 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
Investigation of heterogeneity and subgroup analysis of the inclusion criteria, and therefore were excluded. Only three
It was not possible to work out which factors might be causing randomised controlled trials (RCTs) met the inclusion criteria.
any differences between the studies due to insufficient studies. For all abstracts that were relevant, potentially relevant, or where
If data become available heterogeneity in the results of the trials relevance to the current review was unclear, the full articles were
will be assessed by inspection of a graphical display of the results obtained. Two Italian papers were translated. Two review authors
and by formal tests of heterogeneity. Subgroup analyses and meta- (Sharifa Al-Harasi (SAH) and Paul Ashley (PA)) decided which
analysis regression (STATA 9.0) will be utilized to explore, quan- studies met the inclusion criteria and which did not. Inter-rater
tify and control for sources of heterogeneity between studies on reliability assessed using a Kappa coefficient was (K = 0.46) and
those occasions where it is possible to do so. Planned analyses for all disagreements were resolved by discussion.
heterogeneity are outlined below.
a) Patient characteristics
Excluded studies
Age, gender, baseline anxiety, whether subjects have special needs.
b) Treatment characteristics Reasons for exclusion were mainly because of inappropriate inter-
- Type of hypnotic technique such as: hypnotic relaxation, anxiety vention (Characteristics of excluded studies).
management, hypnoanalgesia, future rehearsal.
- Additional use of a sedative agent.
Included studies
- Type of dental treatment.
- Length of the two treatment modalities. Only three RCT studies were found to fit the inclusion criteria of
which one was unpublished (Characteristics of included studies).

Sensitivity analysis Participants

If a sufficient number of trials had been included in this review, A total of 69 participants (34 male and 35 female) were recruited,
we planned to conduct sensitivity analyses to assess the robust- age range between 4.5 to 15 years. Health status ASA I and II (the
ness of the review results by repeating the analysis with the follow- American Society of Anesthesiologists (ASA) physical status clas-
ing adjustments: exclusion of studies with unclear or inadequate sification system: I, patients normal and healthy; II, patients with
randomisation, allocation concealment, blinding, completeness of mild to moderate systemic disease or are healthy ASA I patients
follow-up, length of follow-up, and source of funding. who demonstrate a more extreme anxiety and fear toward den-
In addition to that already outlined the following descriptive data tistry); the Trakyali 2008 study did not mention anything about
were also included: the participants’ health.
(1) Year study started, if not available, year it was published
(2) Country study was carried out in
(3) Previous treatment of patient Design, methods and outcome measures
(4) Monitoring used One of the studies was a parallel design and the other two were
(5) Difference of time for completion of treatment between the cross-over trials. The Gokli study (Gokli 1994) was from the USA,
test and control groups the Trakyali study (Trakyali 2008) from Turkey and the unpub-
(6) Patient satisfaction/acceptance. 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).
RESULTS 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
Description of studies had no previous dental experience, spoke English as their first
See: Characteristics of included studies; Characteristics of excluded language and each needed at least two restorative appointments.
studies. The flip of a coin determined whether or not hypnosis was used

Hypnosis for children undergoing dental treatment (Review) 5

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
at that appointment. It was a double-blind study where children headgear wear was observed in the control group from the first to
were blinded to which group they were in and the intended pro- the sixth month; however, the difference in the hypnosis group
cedure (administration of LA) was video taped for assessment of was not significant. The result indicated that conscious hypnosis
behaviour by two assessors using the North Carolina Behaviour was effective in this study for improving orthodontic patient co-
rating scale. Physiological measures were also assessed looking at operation.
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 Risk of bias in included studies
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) Sequence generation
than those who did not undergo hypnosis. However, decreased Sequence generation was adequate in two studies (Gokli 1994;
crying with hypnosis was the only behaviour found to be statisti- Trakyali 2008) and unclear in one (Braithwaite 2005).
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 = Allocation concealment
0.005). No significant difference was found due to gender, race It was unclear in all studies as it was not reported.
or treatment order. The effect of hypnosis was more pronounced
with younger children.
Blinding
The Braithwaite study (Braithwaite 2005) aimed to compare the
behavioural and emotional response of a group of 10 young pa- The Gokli 1994 study was double blind: assessors and patients.
tients aged 10 to 16 years old undergoing orthodontic extractions In the Braithwaite 2005 study, only patients were blinded. None
using an established anxiety control method (inhalation sedation were blinded in Trakyali 2008.
with behaviour management) versus hypnorelaxation.
This was a single blind cross-over study where patients were Use of intention-to-treat analysis (ITT)
blinded to which treatment group they were in, as on both occa-
Braithwaite 2005 gave a good account on the fate of all patients
sions a nasal hood was placed. Patients were randomised to either
though ITT analysis was not used. All patients in Gokli 1994
treatment A or B for the first period. Treatment A consisted of and Trakyali 2008 completed treatment although ITT was not
inhalation sedation with nitrous oxide and oxygen + standardised mentioned.
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- Overall risk of bias
tion (XLA) and 5 minutes post-XLA. Two studies were assessed as at high risk of bias (Braithwaite 2005;
The study found that hypnosis can control some of the patient’s Trakyali 2008) and one study as at moderate risk of bias (Gokli
negative responses to dental treatment, such as movement and be- 1994).
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 Effects of interventions
inhalation sedation. The majority of patients preferred inhalation
From the limited number of available evidence from the
sedation.
Braithwaite 2005 and Gokli 1994 studies, hypnosis may be benefi-
The Trakyali study (Trakyali 2008) looked at the effect of hypnosis
cial in behaviour management during the administration of a local
on wearing time of orthodontic appliance. 30 patients (14 females
anaesthetic (LA) in children (age range: 4.5 to 15 years) more than
and 16 males) with a skeletal Class II division 1 malocclusion,
a control group (no hypnosis, no sedation). This was consistent
divided into two equal groups, a control and a study group. The
with a recent review by The Cochrane Collaboration, which found
mean age was 10.78 ± 1.06 years for the hypnosis, and 10.07 ±
that various psychological interventions, particularly distraction,
1.09 years for the control group. Both groups were treated with
combined cognitive-behavioural interventions, and hypnosis can
cervical headgear containing a timer module. Patients were also
help children by reducing the pain and distress that accompany
asked to record their actual wear time on timetables. The hypnosis
needle-related procedures, with hypnosis being the most promis-
group patients were motivated with conscious hypnosis while the
ing (Uman 2006). However, there is still not enough evidence to
control group were given verbal motivation by their orthodontist.
prove its effectiveness during extraction. Trakyali 2008 showed an
The timer modules were read at every visit and compared with
increased likelihood of hypnosis improving orthodontic patient’s
the timetables. A statistically significant decrease (P < 0.05) in
co-operation.

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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DISCUSSION 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
Summary of main results children from various age groups to permit analysis of adequate
statistical power within age categories (Olness 1996).
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
Quality of the evidence
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 Study designs
the inclusion criteria for this review. Although both Braithwaite Two of the studies were cross-over trials and one parallel. Parallel
2005 and Gokli 1994 found hypnosis to have some beneficial ef- studies are preferred in hypnosis studies in order to avoid the carry
fect in behaviour management during the administration of a local over effect from the first period on the control group that can
anaesthetic (LA) in children (age range: 4.5 to 15 years) it was not occur in cross-over studies. Interestingly, in Braithwaite 2005 the
as effective during the extraction of teeth. The majority of chil- effect of visit one on visit two was not significant.
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 Calculation of sample size
co-operation. None of the studies mentioned any adverse effects No sample size calculation was mentioned although it was men-
regarding hypnosis. 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-
Differences in treatment time with or without out a sample calculation it is difficult to comment on the size of
hypnosis these studies. However, there is a risk that they were underpow-
Gokli 1994 did not look at time taken with or without hypnosis. ered.
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 Comments on the studies with regards to the use of
the child’s attention. Moreover, the time involved in introducing scripts
the hypnotic suggestion to the patient must be considered and Gokli 1994 grouped many induction procedures as mentioned in
although relatively brief, does represent an additional time com- Characteristics of included studies. However, they did not mention
mitment to the patient”. which technique of behaviour management was utilised in the
Braithwaite 2005 found no significant difference in total treatment non-hypnotic group.
time between inhalation sedation and ’hypnorelaxation’ i.e. ’hyp- Braithwaite 2005 had developed a script for both behaviour man-
norelaxation’ demanded little additional time in order to complete agement techniques to be followed during inhalation sedation with
care. nitrous oxide, as sedation without accompanying reassurance from
Trakyali 2008 mentioned that the verbal motivation by the or- the dentist is not as effective (Rosen 1983).
thodontist lasted 15 minutes and that hypnosis with the hypnotist However, the ’hypnorelaxation’ script in the Braithwaite study
lasted 20 minutes at each visit. used very specific imagery associated with being in a garden. Im-
However, even if treatment time is reasonably extended, it could be agery that has not previously been negotiated with the patient may
justified that the treatment is completed successfully at the end, as not fully engage the child and furthermore may increase the risk
many visits may be wasted in an attempt to modify the behaviour of a negative response to suggestion. The overall efficacy of the
of an unco-operative child for acceptance of treatment. 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
Overall completeness and applicability of
been more effective if techniques used were tailored to each pa-
evidence
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
Age range used
the response over and above the same procedure not so named

Hypnosis for children undergoing dental treatment (Review) 7

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Gandhi 2005). Milling 2000 has recommended that clinicians parents in the study had increased expectation of inhalation se-
use the term hypnosis with children as this may increase efficacy dation effectiveness and showed bias towards this type of dental
of hypnotic interventions. However, patients taking part in the care before any treatment commenced. This reflected the patient’s
Braithwaite study were not informed that the intervention used previous dental experience of inhalation sedation and could have
was hypnosis and this may have reduced its effectiveness. 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.
Analysing data Having access to the whole Braithwaite study may have introduced
Braithwaite 2005 mentioned that two patients from the hypnosis bias from the review authors side as a far greater amount of infor-
group were given nitrous oxide to provide anxiolysis during diffi- mation was available for critical appraisal, compare to the Gokli
cult extractions and they were included in the final analysis. This is and Trakyali studies where journal articles were used.
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 AUTHORS’ CONCLUSIONS
2005 reported this clearly.
However, one patient from the inhalation sedation group was ex- Implications for practice
cluded part way through treatment, which was later completed There is considerable anecdotal evidence of the benefits of hyp-
under general anaesthesia (GA) (reason given: “autistic child who nosis in paediatric dentistry, however, on the basis of the three
became very uncooperative”). Was it appropriate to include an studies that were eligible to be included in this review there is not
autistic child in a hypnotic trial as hypnosis depends on partic- yet enough evidence to claim it is empirically supported. The lim-
ipants having vivid imagination while it is known that autistic itations of this review are noted by the review authors.
children have limited imagination ability? (Deudney 2006). What
was the consequence of excluding a patient part way through the Implications for research
treatment, who had presumably, originally been considered as ful-
filling the study eligibility criteria and was randomised to a treat- This review highlights the need for further randomised controlled
ment group? Patients should only be excluded from a trial prior to trials to be conducted into the use of hypnosis in paediatric den-
randomisation, not afterwards. In this case, removing an uncoop- tistry, not least because empirical support for the use of hypnosis
erative patient from one arm of the study has clearly introduced in the treatment of clinical problems has generally grown over the
bias. last decade. For example empirical support has been established for
With regards to Gokli 1994 and Trakyali 2008, they did not men- the use of hypnosis to manage procedural pain with paediatric pa-
tion any difficulties faced in the two treatment groups. 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
Patient follow-up Clinical Excellence (NICE) guidelines recommend hypnothera-
None of the studies followed up their patients. Follow-up may be peutic interventions for the treatment of irritable bowel syndrome
advantageous to find out if the effect of hypnosis has modified (IBS) (NICE 2008). Whilst IBS is not clinically relevant to den-
the patient’s perception towards having dental treatment. Hypno- tistry, dentists may be encouraged by the growing acceptance of
sis attempts to help the patient to restructure negative thinking, the use of clinical hypnosis that this demonstrates. The wider liter-
ideally it should improve their ability to cope and give them some ature may thus indicate to dentists that hypnosis is worth investi-
more positive expectations from treatment (Heap 1991; Moore gating as an adjunct to treatment strategies and moreover provides
1990). Conversely, it is possible that patient’s attitudes to dental examples of the stringent methodology required.
treatment may be more negative following treatment under hyp- The following research suggestions are given.
nosis. Without follow-up, it is impossible to assess any long term
effect on behaviour or attitudes.
• Follow-up of patients is required to find out if the effect of
hypnosis has modified the patient’s perception towards having
dental treatment.
Potential biases in the review process
• Study design must be parallel to avoid the carry over effect
Braithwaite 2005 intended that patients remained unaware of
from the first period on the control group.
which of the two behaviour management techniques were to be
used. However, it was described that two of the patients and their • Sample size calculation should be carried out and reported.

Hypnosis for children undergoing dental treatment (Review) 8

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Consideration should be given to exclusion criteria to • Given well-known developmental variations in
prevent contamination from previous treatment experience e.g. suggestibility, researchers may wish to confine studies to limited
patients with experience of inhalation sedation (Braithwaite age ranges or to include sufficient numbers of children from
2005) or patients with previous hypnosis treatment (Liossi various age groups to permit analysis of adequate statistical
2003). power within age categories (Olness 1996).
• Blinding of coders: unless video recordings are used, • So far, no significant difference between male and female
observer blinding is difficult in these kinds of studies and they concerning hypnotic ability was found. However, gender should
will be aware of which children in which group. Observer bias be included in research with other patient characteristics such as
may therefore have an influence in the behaviour distress ratings. age to confirm that it is the case within all age groups.
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 ACKNOWLEDGEMENTS
measurements, to guess the patient’s group membership. Liossi et
al found that observers could not discriminate between the test Wendy Bellis for guiding the review authors to the unpublished
and control groups. study and K Braithwaite for providing a copy of her study and
answering queries.
ii) Check self reported data against the observational
data. If bias is minimal they should be similar. The two translators: G Rossi and Christina-Maria Georgopoulou.

• Improved reporting of data to allow heterogeneity The Cochrane Oral Health Group - in particular Sylvia Bickley,
assessment and meta-analysis between studies in future reviews Luisa M Fernandez Mauleffinch, Helen Worthington and Anne
(Uman 2006). Littlewood for their guidance and help.

REFERENCES

References to studies included in this review Additional references

Braithwaite 2005 {unpublished data only} Accardi 2009
Braithwaite K. Hypnorelaxation versus inhalation sedation Accardi MC, Milling LS. The effectiveness of hypnosis for
in orthodontic extractions. MSc project. Department of reducing procedure-related pain in children and adolescents:
Sedation and Special Care Dentistry. Guy’s, King’s and St a comprehensive methodological review. Journal of
Thomas’ Dental Institute of King’s College 2005. Behavioral Medicine 2009;32(4):328–39.
Gokli 1994 {published data only} BNF 2007
Gokli MA, Wood AJ, Mourino AP, Farrington FH, Best Joint Formulary Committee. British National Formulary
AM. Hypnosis as an adjunct to the administration of local (BNF 54). 4th Edition. London: British Medical
anesthetic in pediatric patients. ASDC Journal of Dentistry Association and Royal Pharmaceutical Society of Great
for Children 1994;61(4):272–5. Britain, 2007.
Trakyali 2008 {published data only} Deudney 2006
Trakyali G, Sayinsu K, Muezzinoglu AE, Arun T. Deudney C, Tucker L. Autistic Spectrum Disorders in Young
Conscious hypnosis as a method for patient motivation in Children. London: The National Autistic Society, 2006.
cervical headgear wear- a pilot study. European Journal of Egger 1997
Orthodontics 2008;30(2):147–52. Egger M, Davey Smith G, Schneider M, Minder C. Bias
in meta-analysis detected by a simple, graphical test. BMJ
References to studies excluded from this review
1997;315(7109):629–34.
Howitt 1967 {published data only} Fayle 2003
Howitt JW. An evaluation of audio-analgesia effects. Journal Fayle S, Tahmassebi JF. Paediatric dentistry in the new
of Dentistry for Children 1967;34(5):406–11. millennium: 2. Behaviour management - helping children
Jerrell 1983 {published data only} to accept dentistry. Dental Update 2003;30(6):294–8.
Jerrell R, Klingman A, Melamed B, Cathbert M, Bennett Fromm 1992
C. Skills training for children facing dental restorative Fromm E, Nash M. Contemporary Hypnosis Research. New
treatment. AADR Abstract 1983; Vol. 62:175. York: Guilford Press, 1992.
Hypnosis for children undergoing dental treatment (Review) 9
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gandhi 2005 NICE 2008
Gandhi B, Oakley DA. Does ’hypnosis’ by any other National Institute for Health and Clinical Excellence
name smell as sweet? The efficacy of ’hypnotic’ inductions (NICE). Irritable bowel syndrome in adults: Diagnosis and
depends on the label ’hypnosis’. Consciousness and Cognition management of irritable bowel syndrome in primary care.
2005;14(2):304–15. Available from http://guidance.nice.org.uk/CG61 2008.
Heap 1991 Olness 1996
Heap M, Dryden W (eds). Hypnotherapy: A Handbook. Olness K, Kohen DP. Hypnosis and Hypnotherapy with
Milton Keynes: Open University Press, 1991. Children. 3rd Edition. New York: Guilford Press, 1996.
Heap 2002 Patel 2000
Heap M, Aravind KK. Hartland’s Medical and Dental Patel B, Potter C, Mellor AC. The use of hypnosis in
Hypnosis. 4th Edition. London: Churchill Livingston / dentistry: a review. Dental Update 2000;27(4):198–202.
Harcourt Health Sciences, 2002. Reid 1988
Higgins 2009 Reid A. Some suggestion techniques for dental anxiety in
Higgins JPT, Green S (eds). Cochrane Handbook for children. The Australian Journal of Clinical Hypnotherapy
Systematic Reviews of Interventions version 5.0.2 (updated and Hypnosis 1988;9(2):85–8.
September 2009). The Cochrane Collaboration, 2009.
RevMan 2008
Available from www.cochrane-handbook.org.
The Nordic Cochrane Centre, The Cochrane Collaboration.
Kirsch 1995 Review Manager (RevMan). 5.0. Copenhagen: The Nordic
Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an Cochrane Centre, The Cochrane Collaboration, 2008.
adjunct to cognitive-behavioural psychotherapy: a meta- Rosen 1983
analysis. Journal of Consulting & Clinical Psychology 1995; Rosen M. Hypnotic induction and nitrous oxide sedation
63(2):214–20. in children. Journal of the Dental Association of South Africa
Liossi 2003 1983;38(6):371–2.
Liossi C, Hatira P. Clinical hypnosis in the alleviation of Simons 2007
procedure-related pain in pediatric oncology patients. The Simons D, Potter C, Temple G. Hypnosis and Communication
International Journal of Clinical and Experimental Hypnosis in Dental Practice. UK: Quintessence Publishing Co. Ltd,
2003;51(1):4–28. 2007.
Liossi 2006 Uman 2006
Liossi C. Psychological interventions for acute and chronic Uman LS, Chambers CT, McGrath PJ, Kisely S.
pain in children. Pain: Clinical Updates 2006;14(4):1–4. Psychological interventions for needle-related procedural
Milling 2000 pain and distress in children and adolescents. Cochrane
Milling LS, Costantino CA. Clinical hypnosis with children: Database of Systematic Reviews 2006, Issue 4. [DOI:
first steps towards empirical support. The International 10.1002/14651858.CD005179.pub2]
Journal of Clinical and Experimental Hypnosis 2000;48(2): Vingoe 1987
113–37. Vingoe F. When is a placebo not a placebo? That is the
Moore 1990 question. British Journal of Experimental and Clinical
Moore R. Dental fear - relevant clinical methods of Hypnosis 1987;4:165–7.
treatment. Tandlaegebladet 1990;94(2):58–60. ∗
Indicates the major publication for the study

Hypnosis for children undergoing dental treatment (Review) 10

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

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?

Hypnosis for children undergoing dental treatment (Review) 11

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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? Unclear Only patients blinded to therapy.

All outcomes

Incomplete outcome data addressed? Yes All patients were accounted for.
All outcomes

Intention to treat analysis? No

Hypnosis for children undergoing dental treatment (Review) 12

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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
Authors’ conclusion:
“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”.

Notes Source of funding: Not reported.

Ethical approval: Not reported.
Consent: Yes.

Risk of bias

Item Authors’ judgement Description

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

hypnosis was used at that appointment”

Hypnosis for children undergoing dental treatment (Review) 13

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gokli 1994 (Continued)

Blinding? Yes Quote: “double blind research design was

All outcomes 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

Incomplete outcome data addressed? Yes All patients were accounted for.
All outcomes

Intention to treat analysis? No

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

Hypnosis for children undergoing dental treatment (Review) 14

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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
Authors’ conclusion:
“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”

Notes Source of funding: Not reported.

Ethical approval: Yes.
Consent: Yes.

Risk of bias

Item Authors’ judgement Description

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? No Patients were aware of which group they

All outcomes 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

Incomplete outcome data addressed? Yes All patients were accounted for.
All outcomes

Intention to treat analysis? No

Hypnosis for children undergoing dental treatment (Review) 15

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

Hypnosis for children undergoing dental treatment (Review) 16

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
This review has no analyses.

APPENDICES

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$”).mp. [mp=title,
abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
3. ((dental or tooth or teeth) and (fill$ or restor$ or extract$ or remov$ or “cavity prep$” or caries or carious or decay$)).mp. [mp=
title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
4. (“root canal therapy” or “tooth replant$”).ab,sh,ti.
5. or/1-4
6. Hypnosis/
7. Autogenic Training/
8. Guided imagery/
9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,
device manufacturer, drug manufacturer name]
10. hypno$.ab,ti.
Hypnosis for children undergoing dental treatment (Review) 17
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
11. “autogenic$ train$”.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device
manufacturer, drug manufacturer name]
12. or/6-11
13. child/
14. infant/
15. Adolescent/
16. (child$ or infant$ or adolescen$).ab,sh,ti.
17. (pediatric$ or paediatric$).ab,sh,ti.
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$”).mp. [mp=title,
abstract, heading word, table of contents, key concepts]
3. ((dental or tooth or teeth) and (fill$ or restor$ or extract$ or remov$ or “cavity prep$” or caries or carious or decay$)).mp. [mp=
title, abstract, heading word, table of contents, key concepts]
4. (“root canal therapy” or “tooth replant$”).ab,sh,ti.
5. or/1-4
6. Hypnosis/ or hypnotherapy/
7. Autogenic Training/
8. Guided imagery/
9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, heading word, table of contents, key concepts]
10. hypno$.ab,ti.
11. “autogenic$ train$”.mp. [mp=title, abstract, heading word, table of contents, key concepts]
12. or/6-11
13. child/
14. infant/
15. Adolescent/
16. (child$ or infant$ or adolescen$).ab,sh,ti.
17. (pediatric$ or paediatric$).ab,sh,ti.
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
Hypnosis for children undergoing dental treatment (Review) 18
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
#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*)

HISTORY
Protocol first published: Issue 2, 2008
Review first published: Issue 8, 2010

CONTRIBUTIONS OF AUTHORS
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.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Hypnosis for children undergoing dental treatment (Review) 19

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Internal sources
• Nil, Not specified.

External sources
• Nil, Not specified.

INDEX TERMS

Medical Subject Headings (MeSH)

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

MeSH check words

Adolescent; Child; Child, Preschool; Humans

Hypnosis for children undergoing dental treatment (Review) 20

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