PEDIATRIC DENTISTRY V 35 / NO 1 JAN / FEB 13

Literature Review
Using Elements of Hypnosis Prior To or During Pediatric Dental Treatment
Benjamin Peretz, DMD1 • Roly Bercovich, DMD 2 • Sigalit Blumer, DMD3

Abstract: Most dental practitioners are familiar with pediatric patients expressing dental fear or anxiety. Occasionally, the dentist may encounter a situation
where all behavioral techniques fail, while, for some reason, premedication or general anesthesia are contraindicated or rejected by the patient or his/her
parents and a different approach is required. Hypnosis may solve the problem in some cases. The purpose of this study was to review the literature about
techniques that use elements of hypnosis and hypnotic techniques prior to or during pediatric dental treatment. There is a limited amount of literature
regarding the use of hypnosis and hypnotic elements in pediatric dentistry. Induction techniques, reframing, distraction, imagery suggestions, and hypnosis
are identified, although mostly anecdotally, while there are very few structured controlled studies. Nevertheless, the advantages of using hypnotic elements
and hypnosis in pediatric dentistry are evident. (Pediatr Dent 2013;35:33-6) Received February 7, 2011 | Last Revision April 17, 2011 | Accepted April 23, 2011

KEYWORDS: BEHAVIOR MANAGEMENT/PSYCHOLOGY, DENTAL EDUCATION, LOCAL ANESTHESIA

Most dental practitioners are familiar with pediatric patients
expressing dental fear or anxiety. Avoidance of regularly visit-
ing the dentist is strongly attributed to severe dental anxiety or
fear of painful procedures, particularly the administration of
local anesthesia.1-5 Anxious child patients are often difficult to
treat, and the dental literature contains a variety of techniques
to aid in providing treatment, from behavioral techniques such
as the basic “tell, show, do” to various combinations of sedative
drugs and general anesthesia.6-8 Occasionally, the dentist may
encounter a situation where all behavioral techniques fail, and,
for some reason, premedication or general anesthesia are con-
traindicated or rejected by the patient or his/her parents, and a
different approach is required.
It is generally accepted that in an adult population, hyp-
nosis is a method that may solve the problem of failure of
behavioral techniques or contraindication to premedication or
general anesthesia.3,9-12 Many attempts have been made to de-
fine hypnosis, both in terms of phenomena involved and pos-
sible causal mechanisms. A simple definition of hypnosis–
suggestions and repetitions–was given by Erickson. 12 A
suggestion is the process whereby an individual accepts a
proposition put to him by another, without having the slight-
est logical reason for doing so.10 Relaxation is one method of
inducing hypnosis. Suggestibility is the degree to which an
individual is inclined toward the uncritical acceptance of ideas
and propositions.
A more detailed definition of hypnosis was given by
Hartland, 10 who called it a particular state of mind that is
usually induced in one person by another. It is a state of mind
in which suggestions are not only more readily accepted than
in the waking state, but also acted upon much more powerful-
ly than would be possible under normal conditions. Successful
hypnosis relies primarily on the patient’s motivation 10 and a
1 Dr. Peretz is an associate professor and head; and 2Drs. Bercovich and 3Blumer are
senior staff members, Department of Pediatric Dentistry, The Maurice and Gabriela
Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
Correspond with Dr. Peretz at bperetz@post.tau.ac.il
thorough understanding by the operator of all nuances of the
technique.
Regarding hypnosis in children, Waxman 11 has recom-
mended that it not be used in individuals younger than 7 years
old. This argument, however, may be arbitrary, and evaluation
of a patient’s suitability for hypnosis should be based on the
following: chronological and mental age; intelligence; emotional
stability; and social environment. In addition, hypnotic ele-
ments are constantly used on children intuitively without them
being aware of these elements.
A dental treatment session typically includes a dental exam-
ination and, where appropriate, the administration of local
anesthesia. The child needs to cooperate at each treatment stage.
Hypnosis or its elements may be successfully used in every
stage. Efforts to apply the process of hypnosis and suggestion,
its principal component, in children often attempt to capitalize
on the fecundity of a child’s imagination.9,12 A comprehensive,
methodologically informed review of studies of the effectiveness
of hypnosis for reducing procedure-related pain in children and
adolescents found it to be effective in medicine. Furthermore,
hypnosis was found to be at least as effective as distraction.13
While it seems natural to use suggestions in children due
to their imagination, there is little information on the use of
hypnotic techniques when providing dental treatment to chil-
dren. Al Harasi et al.,14 conducted a systematic review of the
literature, which attempted to answer the question: What is
the effectiveness of hypnosis (with or without sedation) for be-
havior management of children who are receiving dental care
in order to allow successful completion of treatment? Only 3
randomized control studies (with 69 participants) fulfilled their
inclusion criteria. The authors concluded that, although there
were a considerable number of anecdotal accounts indicating
the benefits of using hypnosis in pediatric dentistry, on the basis
of the 3 studies meeting the inclusion criteria for this review,
there is not yet enough evidence to suggest its beneficial effects.
One of the studies included in Al Harasi et al.’s 14 report
was conducted by Gokli et al.,15 who investigated the accept-
ance of local anesthetic injection, utilizing hypnosis in 29 4-
to 13-year-olds. The results showed no statistically significant

HYPNOSIS IN PEDIATRIC DENTISTRY 33

PEDIATRIC DENTISTRY V 35 / NO 1 JAN / FEB 13
differences in oxygen saturation due to hypnosis condition,
order of treatment, sex, race, or age. Statistically significant
differences were found in pulse rate and behavior, attributable to
hypnosis condition and age, but not to sex, race, or order of
treatment. Pulse rate decreased with hypnosis, as did crying.
The hypnosis condition seemed to be more successful with
younger children (4-6 years old).
Shaw and Niven16 and Finkelstein17 stated that it was un-
fortunate that hypnosis was not more widely used, as it has the
potential for making conventional dental management more
acceptable and reducing the number of children requiring gen-
eral anesthesia. Finkelstein even claimed that there seemed to
be a reduction in the number of dentists using hypnosis, mainly
because of a mistaken belief that hypnosis takes too much time.
The author encouraged utilizing this useful and effective tool
of behavior management.17
A recent survey among dental practitioners in the UK
aimed to determine the views and experiences of dental practi-
tioners in their current use of anxiety management techniques
and their undergraduate and post-graduation training in these
techniques and future training needs. It was found that psy-
chological techniques and hypnosis were mainly reported as not
having been used due to the paucity of time available in prac-
tice and a lack of confidence in using these techniques. Also,
91% reported feeling stressed when treating anxious patients.
When asked about the quality of teaching they had received
(undergraduate and postgraduate), 65% considered the teach-
ing less than adequate in the use of psychological methods,
whereas 44% indicated they would be interested in further
training in psychological methods if financial support was
available.18 In medicine, a recent study, which evaluated the
efficacy of hypnosis during gastrointestinal endoscopy, found
that hypnosis, instead of sedation or general anesthesia, was
successfully used in the vast majority of patients.19
The purpose of the present article was to review the relevant
literature to explain and support some techniques that use
elements of hypnosis and hypnotic techniques, which have
been applied to managing children’s behavior during pediatric
dentistry treatment, and to report on their effectiveness, based
on findings from the literature.
Review of the Literature
Techniques using hypnosis elements.
Reframing. Getting the child to relax often requires that the
dentist create an environment other than the dental office or
space. This is often achieved by a main component of hypnosis:
imagery suggestions. It may involve asking the child to imagine
or describe play time at school or to remember his/her birthday
party or some other pleasant event other than the dental envi-
ronment (although the concrete situation obviously has not
changed). Word substitution refers to the use of terms such
as “sleepy water” or “raincoat” and “umbrella” instead of what
may sound like inoffensive language and fear-provoking words
such as “injection” or “rubber dam.”20,21
These latter 2 examples refer to a technique known as
“reframing.” Reframing means to change the conceptual and/or
the emotional setting or viewpoint in relation to which a situa-
tion is experienced and to place it in another frame which fits
the “facts” of the same concrete situation equally well or even
better, which thereby changes its entire meaning. With this
reframing, an original threat can be abandoned.22,23 The process
of reframing is not immediately obvious. When using the refra-
ming technique, it is not the facts that change but rather the
meaning attributed to them. Or, as the first century philosopher
34 HYPNOSIS IN PEDIATRIC DENTISTRY
Epictetus expressed it: “It is not the things themselves which
trouble us, but the opinion that we have about these things.”22
Reframing is useful in a situation where the rational, order-
ly way of thinking can result in the opposite of what one is
expected to achieve. For example, in the dental situation, ration-
ally telling a child that “the dentist is going to give a shot”
then showing the needle and injecting (tell-show-do approach)
may create anxiety and subsequent apprehensive behavior. This
approach may then become a problem.24 This kind of a solution
is the one that is known as a “first order change” or the “more-
of-the-same approach,” where the desired change in behavior
is achieved by applying the opposite of what produced the
deviance.22 This simple and logical problem-solving applies to
many situations in everyday life: When it is cold, people wear
warm clothing to remain comfortable, for example. If the
temperature falls even lower, warmer clothing is needed. If a
procedure to be carried out on a patient is unclear, more expla-
nation is needed. Therefore, the dentist tries to create a different
“reality,” and this reality is of “second order” after a “second
order change” has been created in the patient’s mind. Reframing
is a technique for achieving a “second order change.”
Distraction. It is reasonable to assume that many clini-
cians intuitively use relaxation techniques or methods to distract
a child’s attention prior to and during certain dental procedures,
for example, prior to and during the administration of local
anesthesia. The purpose of distraction is to divert the patient’s
attention from the dental treatment, aiming at the elimination
of the emotional perception of the pain or the stressful situation.25
Deep breathing and blowing air (as if one were blowing
bubbles) prior to and during injection are forms of active dis-
traction which, like any other active distraction, focus the
patient’s attention toward other areas; thus, sensation may be
decreased. This quick and simple pain intervention, when used
in 3- to 7-year-olds who received local anesthetic injections,
successfully reduced pain and distress.26 In this study, signifi-
cantly more children in the intervention group requested that
the distraction technique be used in the following visit.
Hypnosis techniques
Basic rules. There are several rules for appropriately imple-
menting hypnosis11: (1) Obtain the patient’s consent. (2) Lower
the patient’s expectations. (3) Begin with simple induction exer-
cises, then move to more complicated exercises. (4) Allow the
patient to emerge from the hypnotic state when necessary. (5)
Perform a reverse of the hypnotic state.
It is especially critical to lower the patient’s expectations.
This encourages the patient to submit to the induction of
hypnosis.
Induction techniques for hypnosis. Hypnosis generally
begins with induction. Simple induction techniques help to
identify the hypnotizable patients and then to gradually pro-
gress with the process. Induction may begin with a “magnetic
fingers” exercise.10 The wording for that exercise may be the
following: “Take two breaths, close yours eyes, hold your hands
straight in front of you, and imagine that the forefingers are
bending towards each other, as if there was a magnet between
them.” Another induction technique can be clasping hands.10
The following is an example of wording for the hand-clasping
exercise:
“Clasp your hands tightly together, and you will feel your
fingers gripping more and more firmly. As you do so, I
want you to imagine a huge magnet between your hands.
Concentrate on it. You will imagine that your hands are
becoming tighter and tighter together. When I reach the

count of five, they will be so tightly locked together, that
they will feel just like a solid block of metal. It will be
difficult or impossible for you to separate them. One–
tightly locked. Two–tighter and tighter. Three–very, very
tight. Your hands feel as if they are glued together. Four–
the palms of your hands are locked tightly together.
Five–they are so tightly locked that it will be impossible
for you to separate them. The harder you try to separate
the palms of your hands, the tighter your fingers will
press upon the back of your hands, and the fingers
will become locked together. Now I count from 5 to 1,
and when I reach 5, you will be able to separate your
hands, lay them on the side of the chair, and feel a
very pleasant feeling of calmness and relaxation. Five,
four, three, two, one. You can separate your hands, lay
them on the side of the chair; you can open your eyes
now.”
Very often, the induction itself creates a state of relaxation
and calmness in the pediatric patient, which is sufficient to
complete the dental procedure
Imagery suggestions. Since suggestions are the main com-
ponent of hypnosis, imagery suggestions can be used prior to
administration of local anesthesia.27 An investigation to evaluate
the use of imagery suggestions during administration of local
anesthesia was conducted on pediatric dental patients. 27 During
the first treatment session, prior to the injection, each child was
asked to select a favorite pleasant memory or image. Where chil-
dren had difficulty identifying an image, one was proposed by
the dentist. After an image had been chosen, the patients were
asked to concentrate on the image and visualize it during the
procedure. Most children chose their own image and signifi-
cantly visualized the same image throughout the injection pro-
cedure. Image selection and visualization had no association with
gender, age, the parent’s assessment of the child’s behavior, past
dental experience, behavior (both past and present), or manage-
ment techniques (both past and present).
Reactions to hypnosis. In one study, the reactions of hyp-
notized and nonhypnotized children were compared during the
administration of a local anesthetic by injection.15 It was found
that the pulse rates of hypnotized children decreased, and the
observed levels of crying were less intense. There were no differ-
ences by gender or type of treatment. In addition, hypnosis was
more successful among younger children. The last finding sup-
ported Lampshire,9 who observed that some children responded
positively to suggestions at the ages of 3 and 4 years old.
Hypnosis was utilized as a method to treat an 11-year-old-
boy who presented to the dental clinic with severe dental
anxiety. 28 This report described the technique in detail and
emphasized the importance of the first interview in taking the
patient’s dental history. The interview presented an opportu-
nity for developing a rapport with the patient. 9,12 It was ob-
served that a history of dental anxiety could be related to a
past episode of painful dental treatment. The patient manifested
several attempts to avoid dental treatment. The avoidance was
a learned response constantly reinforced by operant condition-
ing.29 The anticipation of pain enhanced the prospects of its
appearance. The patient fulfilled 2 of the important require-
ments for successful hypnosis: motivation and need for
dental treatment.10 He desperately wanted, however, to avoid
general anesthesia or any kind of sedation. The boy was given a
suggestion that he had anesthesia of the gingiva around the
tooth in question, which was followed by an injection of local
anesthetic. The boy claimed that he did not experience pain
during the injection. A posthypnotic suggestion about not
PEDIATRIC DENTISTRY V 35 / NO 1 JAN / FEB 13
feeling postoperative pain, and feeling relaxed and comfortable
on the next visits was necessary to reinforce the process. The
boy was made to feel that he had control of the treatment pro-
cess by allowing him to halt the treatment by raising the left
hand as suggested by Kleinhauz and Eli.30
Confusion technique for hypnosis. A case of using con-
fusion to induce hypnosis in an extremely anxious 13-year-old
girl in the dental office was reported.31 Confusion is a technique
that may also aid the practitioner in inducing hypnosis. It was
first introduced by Erickson,12 originally designed for the pur-
pose of age regression, but was later found to be applicable to
the induction of hypnosis. Confusion’s main object is to estab-
lish a situation in which the subject is never sure whether he/
she is actually cooperating or not; under these circumstances,
his/her defenses become ineffective.11 It is primarily a verbal
technique based upon 3 elements: (1) a play upon words; (2)
alterations in the tenses; and (3) the employment of irrelevancies.
This technique utilizes sentences which can be understood when
read but will cause confusion for the listener who may struggle
in vain for correct understanding. Alterations in the tenses will
also keep the patient constantly trying to discover the intended
meaning. Irrelevancies in the context of the dental situation add
to the confusion, distraction, and inhibition. The patient is given
a short time to comprehend, but never quite sufficient for him
to react fully before the next idea is presented. He consequently
becomes so confused that he feels a growing need for a clear-
cut communication to which he can respond; thus he is more
prone to hypnotic suggestion.10 Consequently, the procedure is
useful in circumventing unconscious resistance in a patient who
consciously wishes to be hypnotized. Confusion technique may
also be used when the patient is not fully aware of the precise
moment of hypnosis induction; therefore, it should be prac-
ticed with very careful consideration.12
Postoperative (anesthesia) behavior. Ketamine sedation
combined with hypnosis was used on a group of 4- to 11-year-
old pediatric dental patients who had previous histories of
violent emotional reactions before and after dental treatments.32
The author found hypnosis to be very useful for smooth se-
dation induction and reduction of postoperative violent emer-
gence from anesthesia in these patients.
Understanding the mechanism of action of all the techniques
described requires the recognition of the 2 hemisphere func-
tions of the human brain. The left hemisphere is more verbal
and intellectual, and the right hemisphere accounts for the
holistic perception of the individual. The common denominator
to all the techniques previously described is that they directly
address the patient’s right hemisphere or block the left hemi-
sphere. In children, the intellectual (left) hemisphere of the
brain is developed, but not to a level that blocks the right,
holistic, analog hemisphere; hence, the individual is more prone
to obey suggestions.33-36
There are many techniques for performing or using ele-
ments of hypnosis in pediatric patients. The aforementioned
techniques are only some that were anecdotally reported in the
literature.
Conclusions
Hypnosis may serve as a powerful tool to help treat imaginative
children or extremely anxious patients who desperately need
dental treatment but cannot overcome their anxiety by other
means. Hypnosis can be used in its full process, namely induc-
tion and repeated suggestion, but also by applying a partial
form involving hypnotic elements such as reframing, distrac-
tion, or imagery suggestions.
HYPNOSIS IN PEDIATRIC DENTISTRY 35
PEDIATRIC DENTISTRY V 35 / NO 1 JAN / FEB 13
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