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American Journal of Clinical

Hypnosis
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Control of Fear Reaction in Dental

Patients by Hypnosis: Three Case
Reports
Harold P. Golan D.M.D.
Published online: 20 Sep 2011.

To cite this article: Harold P. Golan D.M.D. (1971) Control of Fear Reaction in Dental Patients
by Hypnosis: Three Case Reports, American Journal of Clinical Hypnosis, 13:4, 279-284, DOI:
10.1080/00029157.1971.10402125

To link to this article: http://dx.doi.org/10.1080/00029157.1971.10402125

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 T a m AMBRICANJOUBNAL OF CL~ICAL Hmolns
Volume 18, Numbea 4, April 1071
Priniedin U.8.A.
Control of Fear Reaction in Dental Patients by Hypnosis:
Three Case Reports
HAROLD P. GOLAN, D.MD.
Boston, Mamachusstts‘
Downloaded by [Australian National University] at 19:03 03 January 2015
Fear ie one of the four baaic drives in humans. Various case histories illus-
trate how hypnosie can aid in alleviating fear and ameliorating dijlicult
operative situations.
Fear is present in many dental situations.
How hypnosis aided in overcoming this fear
syndrome will be illustrated by three cases
seen and treated at The Boston City Hospi-
tal.
CASE1
The fist patient is R.W., a 29 year old,
white, overweight female, referred by a hos-
pital social worker. I saw a trembling
woman, who was sweating profusely, and in
considerable pain from an acute alveolar
abscess in one of her few remaining molar
teeth. She had not been to a dentist in nine
years and was “frightened to death.” I n
many surgical patients this literally hap-
pens when a general anaesthesia is used.
When a patient is in this extreme situation
of fear and pain, each feeding the other in
an endless chain, the problem is one in
which hypnosis is not only called for but is
relatively easy to introduce and induce.
A brief case history revealed a negative
medical background, no contraindications
for anaesthetics; divorce, a six-year-old
son, specialized medical technician training,
financial problems, and past traumatic den-
tal experiences. Not only is this short per-
sonal history necessary for the doctor to
* 77 Bay State Road.
understand the present behavior of the pa-
tient in the light of the patient’s past exper-
iential learning, but it also gives the patient
the feeling that you, the doctor, are genu-
inely interested in her as something more
than a case with an alveolar abscess.
At this time a brief hypnotic session was
carried out, during which the patient’s fear
was explained to her a t the subconscious
level. It is most interesting to note that
whatever the patient is experiencing before
relaxation almost immediately ceases : the
trembling, sweating, rapid heart rate, agita-
tion of body and skeletal muscle action.
Make the patient understand that whatever
happened in the past occurred many years
ago and it is no longer necessary for her to
have a reflex action based on the past. An
explanation of psychosomatic disease is
touched on so that the patient realizes that
emotional reactions do cause body changes
(in this instance the fact that fear kept her
from dentistry and the restoration of her
teeth, which subsequently became dis-
eased). Now, for the first time, she, as a
patient, can do something for herself in a
medical or dental situation.
This point can not be stressed too highly:
the patient now is part of the healing expe-
rience. I n past situations, the patient ap-
proached the doctor, who assumed the
 280
whole burden of treatment, whether it was
pills, medication, or tooth care. Now, the
doctor does his part, the patient her part;
and together treatment is successfully exe-
cuted.
Motivation for the procedure was en-
hanced during hypnosis by mentioning good
health along with the fact that an active
infection is within the vital systems of the
body. The necessity for eradicating these
poisons (since preservation is the first rule
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of life) was stressed. The need for strong
teeth (natural or artificial) to allow masti-
cation to start the digestive process neces-
sary for life was explained. Aesthetics were
mentioned, with specific objects in mind, by
statements such as these: “You will want
your son to be proud of a mother who will
smile and not hide her mouth,” and “When
you work in a medical office or hospital,
think of how many people you will meet.
Certainly you will want to give as good an
appearance as possible without spaces
where you are missing teeth. You will want
to make yourself as attractive as possible.”
Some mention was made of the fact that
with relaxation the pain threshold is raised.
Most of the time we do not use the word
pain at all, instead using a synonym such as
“discomfort” or “bother,” but here the pa-
tient was familiar with injections, and un-
derstood the meaning of pain threshold.
(Positive approaches and manner are used
in which we tell the patient that we expect
her to do well. Usually she will live up to
expectations. Do not promise the patient
complete, unqualified perfection, but be
professionally competent, cheerful, enthu-
siastic; and a good result will usually fol-
low.)
At this juncture the trance state was ter-
minated with positive posthypnotic sugges-
tions that whatever would be done would
result in a minimum of trouble. Good heal-
ing was mentioned. Full mouth x-rays were
then taken by the technician, but now on a
GOLAN
patient who was not trembling, sweating, or
in a state of extreme fear and excitement.
The x-rays revealed that an alveolar ab-
scess of a left mandibular molar was caus-
ing the present pain. Hypnosis was again
induced. An inferior alveolar block with
novocaine was made. During the time we
waited for the local anaesthesia to traverse
the inferior dental canal to the area of
infection, reiteration was made that the
whole procedure would be quick, efficient,
with a minimum of trouble, and that she
would heal well, practicing relaxation at
home, and looking forward to the finish
when she would look well, eat well, and feel
comfortable both socially and within her-
self.
At no point during the whole treatment
do I play psychiatrist, trying to gain insight
into past psychological trauma or events. It
certainly is enough for me as a dentist to
use a broad approach stressing that past
experiences were to be relegated to the past
and a new start was being made. No trans-
ference is sought, and, if some small degree
of it does develop, I quickly point out to the
patient that she is the one who is fulfilling
the psychological task with me as the
teacher and dentist.
Further visits were now continued at my
office where extractions, restorations, and
periodontal scalings were performed, with
very simple induction techniques requiring
little effort and time. Praise for the pa-
tient’s part was liberally mentioned, and a
positive approach for impression-taking
and utilization of partial dentures was
made. The patient was very impatient for
the healing to take place so that she could
again be eating comfortably and looking at-
tractive.
The thought is very often mentioned, es-
pecially by people uninitiated in hypnosis,
that hypnosis is time-consuming. It is not.
Besides ameliorating the dental situation as
it exists, hypnosis provides a time-saving
device. Think of the time and effort needed
 CONTROL OF FEAR IN DENTISTRY
to calm a chronically fearful patient, the
time consumed in the subterfuges by the
patient such as broken appointments or
hesitating behavior. Not only that, but the
result here is assured, a happy, confident
patient who is satisfied physically and emo-
tionally about the whole dental process.
CASE2
Another interesting situation was one of
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R.W., a 29 year old, white male who pre-
sented himself to the accident floor of the
Boston City Hospital three days after a se-
vere fall. He had a fracture of the left angle
of the mandible, the bone visible and com-
pounded into the mouth, and moderate tris-
mus and mobility. A considerable amount
of pain was present.
Just a week or so after giving a series of
hypnosis lectures to our interns and resi-
dents one of the residenh approached me
and said that our service had a patient
now on the ward who was literally “raising
Cain.” He was slapping nurses and aides,
was extremely obnoxious, obstreperous, and
hostile, and had threatened to sign out of
the hospital without treatment. The whole
group gave me a case history and pertinent
negative medical findings and said, “We bet
you can’t use hypnosis on this man.”
I asked them to bring the patient to our
operating treatment area. When the patient
arrived in a wheel chair, the first sight that
struck me was the fact that the patient had
only one leg, having had an amputation
just below the knee some years previously.
Not one of the six or seven house officers
had deemed i t important enough to mention
to me. This fact was the key to the whole
situation. With the patient sitting in the
wheel chair in the 0. R. corridor, I drew up
an operating stool, quietly spoke to him,
asking him to rest his head on the back of
the chair and to shut his eyes so that he
could hear me better. I spoke to him for
about 15 or 20 minutes with the trance (or
reIaxation) going deeper as I spoke.
281
Through brief questioning, I had discov-
ered that he had had previously a similar
fall fracturing his leg while working as a
stevedore in a ship’s hold. At that time, he
was taken to the hospital and, when he
awoke, his leg had been amputated. In the
light of this man’s experiential learning, he
was fearful that the same thing was going
to happen in his mouth. He was given as-
surance that after his operation he would
have a normal functioning mouth, that he
would look good with the scar being tucked
under the bone of the mandible, and that he
would be able to eat well and talk properly.
He was assured that properly trained sur-
geons would take particularly good care of
him, and then the operation was completely
described to him. Each thing that would
happen during the following morning was
mentioned. He was given positive sugges-
tions for rapid, uneventful recovery.
A combination of progress notes and per-
tinent hospital orders follows. When the pa-
tient was first brought in on 12/11, his max-
illary and mandibular teeth were wired
under local anaesthesia and tooth %16 (in
the line of fracture) was removed. Demerol
75 mg., intramuscularly, every four hours
was ordered. The next day, the patient was
“very obnoxious and irritated” and com-
plained he could not stand to be in bed; 100
mg. of Nembutal was given without effect.
Then Paradehyde, 10 cc., was immediately
given and repeated, as necessary, every four
hours. The following day the patient was
still very obnoxious, cursing nurses and
aides. Thorazine 50 mg. twice a day was
tried and discontinued, and Chloral Hy-
drate 0.5 gm. (knock-out drops) was given.
On the morning of 12/14, I saw the pa-
tient in the operating room corridor as was
previously described. That evening he was
calm with regular pre-operative order and
no sedatives. On December 15, his operation
(open-reduction) was carried out. Elastics
were added to the wired teeth, immobilizing
the jaws. His remaining post-operative
 282 GOLAN

course was uneventful, with the wound pain may be so intolerable as to lead to
healing nicely. He was discharged on 12/21 suicide. The most common trigger zone is in
to return on an outpatient basis for follow- the upper lip just lateral to the aIa of the
UP. nose, although it may occur anywhere in
This was a patient whose extreme fear, the V nerve distribution, and secondary
hidden below the conscious surface, caused trigger areas may develop.
him to behave as he did in a most agitated, Many treatments have been used medi-
violent manner. Once this fear was recog- cally without too much success. Morphine,
nized, explained, and reassured a t the sub- amyl-nitrate, trichlorothylene, ferrous car-
conscious level, his behavior pattern was al- bonate, vitamin B complex, diothermy, x-
tered in the direction of good healing and ray, all of which never give more than tran-
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preservation of body integrity. One hyp- sient relief. Other therapies are nerve blocks
notic session was enough to change the and surgical intervention. Injections are
course of this case. done with local anaesthesia and absolute al-
cohol. The effect of the alcohol is to produce
CAsn 3 local destruction by coagulation a t the
Major trigeminal neuralgia, otherwise point of injection, that is a neurolysis which
known as tic doulourew, Fothergill’s Dis- is followed by degeneration of the axis cyl-
ease, is a very serious disease. It has an inder peripheral to the point of injection.
unknown etiology and is characterized by However, since the sensory cells are located
episodes of severe, lancinating pain in the in the Gasserian Ganglion and remain un-
distribution of the trigeminal (V) nerve damaged (except in the Gasserian Ganglion
and/or its branches, and is one-sided. I n injection), the nerve regenerates and its
most cases gross and microscopic examina- powers of conduction reestablish in about
tion of the Gasserian Ganglion, sensory root six months to three years. Thereafter peri-
or peripheral branches reveal no pathologic ods are less because of scar tissue building
changes. This is a most important fact to UP.
remember in our discussion. There are many operations whose side ef-
Typically there is no history of illness or fects and complications are very serious
trauma and no previous signs or symptoms, since the V nerve must be cut within areas
the pain occurring suddenly while the pa- that are indeed very sensitive and hidden
tient is eating, drinking, talking, washing within the skull or spinal cord. Complica-
his face or teeth, or immediately following tions of injections are very serious because
sudden exposure to cold. The pain is so vio- of the delicate areas and nerves which may
lent that the patient is stunned by it, ceases be injured by spillage.
to talk, and does not dare move. There may All of the operative treatments are very
be violent movements of the face, mumping serious ones and unsatisfactory whether op-
of the jaw, smacking of the lips into unfor- erations or injections are used. J.M., 77-
gettable grimaces, thus the term “tic.” I n year-old retired white male, five years ago
the early stages paroxysms are brief, then had sudden onset of shooting pain (jumping
continue longer. Remissions may occur and pain) in the left forehead and left maxillary
the pain may disappear for long periods of regions lasting about ten minutes with com-
time. Then the pain occurs more often. Pa- plete remission until the next attack. He
tients live in fear of a return of the pain, received an alcohol injection following a
because the paroxysms may run into each procaine (infraorbital) block which made
other, and appear to be continuous for an his cheek and jaw numb. Pain was relieved
hour or more at one time. I n some cases, the for two years, then suddenly a pain of a
 CONTROL OF m A R IN DENTISTRY
shooting, paroxysmal quality returned, but
only in opthalmic division. He had three
further alcohol injections, with progres-
sively shorter periods of relief from pain
but complete relief while it lasted. The last
alcohol injection was about one and one-
half years ago, gave about one year relief,
and for the past four to five months he has
had pain of a jumping character.
Physical, x-ray, and neural exams were
negative except for slight s h d i n g and lost
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sense of smell, but normal taste. Neurology
service diagnosis: tic douloureux; Rx. Tol-
seram 500 mg. T.I.D. He was seen monthly
for nine months, then began having three to
four sharp paroxysms daily, lasting five to
ten minutes. Then, within a short time the
pain began occurring many times a day, in-
terfering with sleeping and eating. Dilantin
100 mg. Q.I.D. was given, but the patient,
because of a rubbery feeling in legs and
dizzy spells, discontinued it. Dizzy spells
ceased.
The patient came to dental service re-
ferred by the neurology service, had teeth
#27, 28, 29, and 31 removed and experi-
enced attack at suture removal. Infraorbi-
tal procaine helped immediate attack, fol-
lowed by 0.5 cc. ethyl alcohol. Within one
week, paroxysms were as severe as ever.
The patient was now called to my atten-
tion by one of our residents and received
hypnotic instruction. As in many patients
with serious disease this patient proved to
be an excellent subject for relaxation exer-
cises. Motivation, I am certain, is one of the
key factors in the response to our sugges-
tions.
In our first session, general relaxation
principles were taught. These included the
fact that he could instantaneously relax
himself, and that he would substitute a very
heavy feeling lasting only a moment or
two for the severe paroxysms that were
lasting anywhere from 15 to 60 minutes. He
was told that no medication would now be
necessary (the medication was taking a
283
good part of his Social Security budget
every month) and that he would again start
viewing life as a pleasant experience, enjoy-
ing his daughter, granddaughters, ‘IT, and
whatever other nice things life had to bring
him.
On his next visit ti week later, the patient
did not accept our suggestion of heaviness
but translated the tic into a “momentary
feeling of pickiness” (choosing his own
pathway). No medication was now neces-
sary since the patient felt he was now about
60% improved. During the hypnotic trance
the physiology of pain and emotional em-
phasis was thoroughly explored, as well as
the fact that pain has an organic compo-
nent and an emotional component in vary-
ing degrees, with the emotional overlay
being a contributing factor to pain. Relaxa-
tion, by raising pain threshold and causing
the pain to be more readily tolerated, was
emphasized. He was told he would be able
to shave, talk, or eat without setting off
severe reactions. Additional motivation was
mentioned in that sleep and nutrition were
necessary to life itself.
Weekly visits were now instituted. At
each visit some new concept was mentioned,
such as suggesting that he would be happy
that he was helping himself for the first
time and proud of the fact that he was
doing this without medication. Since the pa-
tient needed a full maxillary denture and a
partial lower denture, positive suggestions
for ease of mouth manipulation were made.
Post-hypnotic suggestions that dental im-
pressions could be taken, and that he would
wear his new appliances comfortably and
eat well again, were made. He was edentu-
lous in the upper arch, and had only two
remaining cuspids in the mandible. Impres-
sions and bite registration were taken; the
old maxillary denture was moved and re-
moved a t will without any paroxysms.
A week later, try-in of lower partial, dur-
ing which his mouth was freely manipu-
lated, brought no paroxysms. Finally, his
 284
new dentures were in position and being
used very well. A few days following, our
patient’s daughter called saying her father
was having almost constant paroxysms of
pain since he had struck his nose with his
fist during sleep and was awakened by it. I
saw him immediately, but this time he was
much easier to treat. We used verbaliaa-
tions such as, “Now that you have learned
this so well in the past, the following times
will be easier and better.” He was also
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taught that he could sleep on his back, rest-
ing the back of his head on the pillow, with-
out having to turn.
During our weekly sessions all tics disap-
peared during the hypnotic trance ;this par-
ticular fact was the true turning point in
our treatment. During trance it was sug-
gested that he could actually touch the trig-
ger points of the infraorbital area of the
gingiva and the eyebrow without causing
any paroxysms. Hand levitation was used
to achieve this result. He was then told that
if he could do this in his relaxed state, he
could also do this consciously whenever he
wanted.
Shortly following this rather dramatic
episode, our patient felt he did not need his
weekly sessions. Then monthly, bi-monthly ,
and longer intervals were used. Now I have
not seen him for some years, but his son-
in-law reports to me that he is currently
functioning very well.
Since there is no pathology (microscopic
or gross) found in the Gasserian Ganglion
or anvwhere else in the V nerve (shown in
GOLAN
autopsy) , the mechanism for this nerve dis-
ease is not yet understood. It seems to me
that any disease which cannot adequately
be explained in a scientific, medical ap-
proach might be approached in a less ra-
tional way or in an emotional way. In these
patients, I feel emotional factors are ex-
tremely important in reaction to the dis-
ease. Fear of what might and does happen
then becomes a paramount issue, making
the patient afraid to eat, sleep, and carry
out natural functions necessary to life.
Hypnosis is not a panacea for all pa-
tients, but this case illustrates how one pa-
tient who was in a very active phase of the
disease of major trigeminal neuralgia was
helped when other methods had failed, and
operation was ruled out because of his age
and frailty.
The patients I have presented illustrate
how fear caused physiologic and psycholog-
ical changes in their lives. Hypnosis, used
in a confident, sympathetic manner, was an
adjunct of treatment to alleviate fear, re-
sulting in adequate resolution of their medi-
cal problems.
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CHEEK,D. 9. and LECRON, L. M. Clinical Hypno-
therapy. New York: Grune and Stratton, 1963.
EEICKSON, M. H. and HEBSHW, 5. and SECTER, I. I.
Medical and Dental Hypnosis. New York: Julian
Press, 1961.
LECRON,L. M. Experimental Hypnosis. New York: