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. ifaharasi@hotmail.com.

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 strategy
We searched the Cochrane Oral Health Groups 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
Treating children is often a challenge for dentists. Many techniques
have been developed to help children cope with dental treatment
and to reduce the stress experienced. Part of the solution is under-
standing the reasons behind the unwanted behaviour (e.g. fear of
the unknown) and then addressing these issues using techniques
such as tell, show & do or positive reinforcement (Fayle 2003).
However, due to the variation in childrens personalities, one tech-
nique of behaviour management may work with some children
but not with others. Therefore, the more knowledge we gain about
other available techniques and how to apply them practically, the
more effective we can be in helping children cope with dental treat-
ment. Alternatives to standard non-pharmacological techniques
include sedation or even general anaesthetic (GA). These tech-
niques have their place, but can be associated with morbidity or
even mortality. One other possible alternative to standard non-
pharmacological techniques is the use of hypnosis.
Heap and Aravind (Heap 2002) define hypnosis as an interaction
in which the hypnotist uses suggested scenarios (suggestions)
to encourage a persons focus of attention to shift towards inner
experiences in order to influence the subjects perceptions, feel-
ings, thinking and behaviour. Response to hypnotic suggestion is
characteristically experienced by a person as feeling involuntary or
effortlessness (Fromm 1992). Used as an adjunctive procedure in
medicine, dentistry and applied psychology, hypnosis can enhance
the efficacy of various treatment interventions (Kirsch 1995). In
recognising the need to use hypnosis as an adjunct to established
treatments, many health professionals consider the labels hyp-
notherapy and hypnotherapist to be unhelpful and potentially
misleading as they suggest that hypnosis is a form of treatment or
therapy in its own right (Vingoe 1987).
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hypnotic techniques can be used to manage a range of common
problems relevant to dentistry such as dental anxiety, specific den-
tal phobia, pain control in conservative treatment and extractions,
improved tolerance for orthodontic appliances, as an adjunct to
inhalation sedation, or as part of the induction of GA and modi-
fication of unwanted oral habits such as thumb sucking, bruxism,
gagging and smoking (Patel 2000; Reid 1988; Simons 2007).
A number of advantages of using hypnosis in dentistry have been
mentioned in the literature and include the following:
No requirement for specialist equipment
The patient remains conscious
Non-pharmacological approach so no side effects or
associated environmental pollution
Combines well with nitrous oxide inhalation sedation
(Rosen 1983)
Safe.
Hypnotic techniques are particularly effective when used with chil-
dren between 8 and 12 years however children as young as 4 years
old can be responsive to hypnosis (Olness 1996), yet hypnosis as
an adjunct to paediatric dental procedures is generally underused,
hence the need for this review.
OBJECTIVES
This systematic review attempted to answer the following ques-
tion:
2
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.
METHODS
Criteria for considering studies for this review
Types of studies
Both randomised and quasi-randomised control trials were in-
cluded. Case control studies were not included to avoid bias.
Types of participants
- All children and adolescents up to 16 years of age.
Ages were subdivided according to the age bands used by in the
British National Formulary (BNF 2007):
under 5 years of age
6 to 12 years
more than 12 years up to 16 years old.
- Children having any dental treatment such as:
Simple restorative treatment with or without local anaesthetic (LA)
or simple extractions or management of dental trauma (e.g. repo-
sitioning of tooth, splinting, removal of nerve from tooth) and
orthodontic treatment. Children were included regardless of base-
line anxiety.
Types of interventions
Test group: Any hypnotic technique with or without any sedative
agent (sedation could be inhalation, oral or intravenous).
Control group: No hypnotic intervention or sedative agent alone.
Types of outcome measures
(1) Completion of treatment (yes/no).
(2) Measures of behaviour between test and control groups (scales
used may vary between studies).
(3) Difference in post-operative anxiety between test and control
groups (scales used may vary between studies).
(4) Adverse events.
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Search methods for identification of studies
For the identification of studies included or considered for this
review, detailed search strategies were developed for each database
searched. These were based on the search strategy developed for
MEDLINE via OVID (Appendix 1) but revised appropriately
for each database. The search strategy was not combined with
the Cochrane Highly Sensitive Search Strategy for identifying
randomised trials in MEDLINE: sensitivity-maximising version
(2008 revision). A trial search was performed to check for adverse
effects but it yielded similar results and it was advised by an expert
in the field (The Cochrane Collaboration) that there was no need
to do a specific one.
Electronic searches
The Cochrane Oral Health Groups Trials Register (11th
June 2010) (Appendix 5)
The Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library 2010, Issue 2) (Appendix 4)
MEDLINE (OVID) (from 1950 to 11th June 2010)
(Appendix 1)
EMBASE (OVID) (1974 to 11th June 2010) (Appendix 2)
PsycINFO (OVID) (1887 to 11th June 2010) (Appendix
3).
Language
The search attempted to identify all relevant studies irrespective
of language. Non-English papers were translated.
Handsearching
The following journals were identified as being important to be
handsearched for this review. The journals were handsearched by
the review authors for the period between 1996 to 2006:
International Journal of Paediatric Dentistry
Pediatric Dentistry
Journal of Dentistry for Children
American Academy of Pediatric Dentistry
Journal of the American Dental Association
British Dental Journal
Dental Update
Contemporary Hypnosis
The International Journal of Clinical and Experimental Hypnosis
American Journal of Clinical Hypnosis
Australian Journal of Clinical and Experimental Hypnosis.
The reference lists of all eligible trials were checked for additional
studies.
Unpublished studies
3
Specialists in the field known to the review authors were contacted
for any unpublished data.
Data collection and analysis
Selection of studies
Selection of papers suitable for inclusion in the review were car-
ried out independently by two review authors (Sharifa Al-Harasi
(SAH) and Paul Ashley (PA)). Titles and abstracts were assessed
and full copies of all relevant and potentially relevant studies, those
appearing to meet the inclusion criteria, or for which there were
insufficient data in the title and abstract to make a clear decision,
were obtained. The full text papers were assessed independently
by these two review authors. All irrelevant records were excluded
and details of the studies with the reasons for their exclusion were
noted. Agreement was assessed by calculating Kappa scores and all
disagreements were resolved by discussion.
A third review author (Susan Parekh (SP)) was available to resolve
any issues or selection discrepancies that arose.
Data extraction and management
Data extraction was carried out on a specially designed paper form
(available from the review authors) independently by two review
authors (SAH and PA) and again authors were blinded to each
others 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 authors names on
the papers.
Assessment of risk of bias in included studies
The assessment of risk of bias for included trials was undertaken
independently and in duplicate by two review authors. Studies
were analysed for the following to assess validity as a threshold for
inclusion of the studies, which is described as one of the options
in the Cochrane Handbook for Systematic Reviews of Interventions
Version 5.0.2 (Higgins 2009) on the following individual quality
criteria:
Adequate sequence generation: Yes, No, Unclear
Allocation concealment: Yes, No, Unclear
Blinding of participants and outcome assessors: Yes, No,
Unclear
Incomplete outcome data addressed: Yes, No, Unclear
Intention-to-treat analysis: Yes, No, Unclear
Yes indicates a low risk of bias, No indicates high risk of bias
and Unclear indicates either lack of information or uncertainty
over the potential for bias. A risk of bias table was completed for
each included study.
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Risk of bias was assessed for each included study. Studies were
considered to be at low risk of bias if there was adequate conceal-
ment of allocation, blinded outcome assessment and information
on the reason for withdrawal provided by trial group. If one of
these criteria was not met, a study was considered at moderate risk
of bias, otherwise at high risk of bias.
Investigation of publication bias
In order to help overcome publication bias, we (1) imposed no
language barriers in our search, (2) contacted specialists in the field
for any published, unpublished, and in-progress studies, and (3)
contacted the authors with missing data for further clarification.
It was intended to assess publication bias and other possible biases
relating to the size of trials by graphical methods and via the Begg
and Mazumdar adjusted rank correlation test and the Egger et al
regression asymmetry test (Egger 1997). Effect size versus standard
error was to be drawn. Asymmetry of the funnel plots would have
indicated publication bias, though it may also represent a true
relationship between trial size and effect size.
However, the above was not possible due to the small number of
studies.
Data synthesis
Data were divided into descriptive and quantitative methods.
Meta-analysis of the data was not applicable due to insufficient
number of studies.
Descriptive methods
Data were collated into evidence tables. A descriptive summary
was formulated to determine the quantity of data, checking further
for study variations in terms of study characteristics, study quality
and results. This assisted in confirming the suitability of further
synthesis methods.
Quantitative methods
Meta-analysis of the data was not applicable due to insufficient
number of studies. If data do subsequently become available then
analysis will be carried in the following order:
- Hypnosis versus no hypnosis
- Hypnosis combined with sedation versus sedation only
- Hypnosis versus sedation.
Random-effects meta-analyses will be used provided there are more
than three trials included in the meta-analysis. For continuous
data, pooled outcomes will be expressed as mean differences with
their associated 95% confidence intervals. For binary data, these
will predominately be pooled risk ratios and associated 95% con-
fidence intervals. Statistical heterogeneity will be assessed by cal-
culation of the Q statistic and Cochranes I2 statistic. Analysis will
4
be performed using RevMan Analysis software (RevMan 2008).
Data will be presented as an overall comparison and as subgroups.
Investigation of heterogeneity and subgroup analysis
It was not possible to work out which factors might be causing
any differences between the studies due to insufficient studies.
If data become available heterogeneity in the results of the trials
will be assessed by inspection of a graphical display of the results
and by formal tests of heterogeneity. Subgroup analyses and meta-
analysis regression (STATA 9.0) will be utilized to explore, quan-
tify and control for sources of heterogeneity between studies on
those occasions where it is possible to do so. Planned analyses for
heterogeneity are outlined below.
a) Patient characteristics
Age, gender, baseline anxiety, whether subjects have special needs.
b) Treatment characteristics
- Type of hypnotic technique such as: hypnotic relaxation, anxiety
management, hypnoanalgesia, future rehearsal.
- Additional use of a sedative agent.
- Type of dental treatment.
- Length of the two treatment modalities.
Sensitivity analysis
If a sufficient number of trials had been included in this review,
we planned to conduct sensitivity analyses to assess the robust-
ness of the review results by repeating the analysis with the follow-
ing adjustments: exclusion of studies with unclear or inadequate
randomisation, allocation concealment, blinding, completeness of
follow-up, length of follow-up, and source of funding.
In addition to that already outlined the following descriptive data
were also included:
(1) Year study started, if not available, year it was published
(2) Country study was carried out in
(3) Previous treatment of patient
(4) Monitoring used
(5) Difference of time for completion of treatment between the
test and control groups
(6) Patient satisfaction/acceptance.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Results of the search
Two hundred and seventy-seven papers were retrieved using the
search strategy described above. For most of these papers, it was
clear from the abstract whether they failed to meet some or all
of the inclusion criteria, and therefore were excluded. Only three
randomised controlled trials (RCTs) met the inclusion criteria.
For all abstracts that were relevant, potentially relevant, or where
relevance to the current review was unclear, the full articles were
obtained. Two Italian papers were translated. Two review authors
(Sharifa Al-Harasi (SAH) and Paul Ashley (PA)) decided which
studies met the inclusion criteria and which did not. Inter-rater
reliability assessed using a Kappa coefficient was (K = 0.46) and
all disagreements were resolved by discussion.
Excluded studies
Reasons for exclusion were mainly because of inappropriate inter-
vention (Characteristics of excluded studies).
Included studies
Only three RCT studies were found to fit the inclusion criteria of
which one was unpublished (Characteristics of included studies).
Participants
A total of 69 participants (34 male and 35 female) were recruited,
age range between 4.5 to 15 years. Health status ASA I and II (the
American Society of Anesthesiologists (ASA) physical status clas-
sification system: I, patients normal and healthy; II, patients with
mild to moderate systemic disease or are healthy ASA I patients
who demonstrate a more extreme anxiety and fear toward den-
tistry); the Trakyali 2008 study did not mention anything about
the participants health.
Design, methods and outcome measures
One of the studies was a parallel design and the other two were
cross-over trials. The Gokli study (Gokli 1994) was from the USA,
the Trakyali study (Trakyali 2008) from Turkey and the unpub-
lished study (Braithwaite 2005) was from the UK (MSc project).
All were hospital/university based. The trials used two treatment
arms: hypnosis versus no hypnosis (Gokli 1994; Trakyali 2008) or
hypnosis versus inhalation sedation with nitrous oxide and oxygen
(Braithwaite 2005).
The Gokli et al trial (Gokli 1994) aimed to ascertain the accep-
tance of local anaesthetic injection (LA), using hypnosis in chil-
dren. 29 healthy children (11 boys and 18 girls) between the ages
of 4 and 13 years participated in this cross-over study. Each child
had no previous dental experience, spoke English as their first
language and each needed at least two restorative appointments.
The flip of a coin determined whether or not hypnosis was used
5
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 patients 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 patients
the timetables. A statistically significant decrease (P < 0.05) in
co-operation.

Hypnosis for children undergoing dental treatment (Review) 6

Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DISCUSSION
Summary of main results
The main question addressed by this review was to find out the
effectiveness of hypnosis (with or without sedation) for behaviour
management of children who are receiving dental care in order to
allow successful completion of treatment.
Despite growing interest in paediatric clinical hypnosis few con-
trolled studies have been carried out (Milling 2000) and only three
studies investigating the efficacy of paediatric dental hypnosis met
the inclusion criteria for this review. Although both Braithwaite
2005 and Gokli 1994 found hypnosis to have some beneficial ef-
fect in behaviour management during the administration of a local
anaesthetic (LA) in children (age range: 4.5 to 15 years) it was not
as effective during the extraction of teeth. The majority of chil-
dren in the Braithwaite study preferred inhalation sedation with
nitrous oxide and oxygen over hypnosis. Trakyali 2008 showed an
increased likelihood of hypnosis improving orthodontic patients
co-operation. None of the studies mentioned any adverse effects
regarding hypnosis.
Differences in treatment time with or without
hypnosis
Gokli 1994 did not look at time taken with or without hypnosis.
However, it was mentioned in the discussion that the hypnosis
procedure did require some adjustments in routine: a relatively
quiet environment is needed to capture effectively and to maintain
the childs attention. Moreover, the time involved in introducing
the hypnotic suggestion to the patient must be considered and
although relatively brief, does represent an additional time com-
mitment to the patient.
Braithwaite 2005 found no significant difference in total treatment
time between inhalation sedation and hypnorelaxation i.e. hyp-
norelaxation demanded little additional time in order to complete
care.
Trakyali 2008 mentioned that the verbal motivation by the or-
thodontist lasted 15 minutes and that hypnosis with the hypnotist
lasted 20 minutes at each visit.
However, even if treatment time is reasonably extended, it could be
justified that the treatment is completed successfully at the end, as
many visits may be wasted in an attempt to modify the behaviour
of an unco-operative child for acceptance of treatment.
Overall completeness and applicability of
evidence
Age range used
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
In all studies the age range was applicable to paediatric dentistry
i.e. up to 16 years of age. However, it is appropriate to confine
studies to limited age ranges or to include sufficient numbers of
children from various age groups to permit analysis of adequate
statistical power within age categories (Olness 1996).
Quality of the evidence
Study designs
Two of the studies were cross-over trials and one parallel. Parallel
studies are preferred in hypnosis studies in order to avoid the carry
over effect from the first period on the control group that can
occur in cross-over studies. Interestingly, in Braithwaite 2005 the
effect of visit one on visit two was not significant.
Calculation of sample size
No sample size calculation was mentioned although it was men-
tioned in all studies that their sample sizes were small. Braithwaite
2005 specifically mentioned that they were unable to do a sample
size calculation due to a lack of previous studies. Obviously with-
out a sample calculation it is difficult to comment on the size of
these studies. However, there is a risk that they were underpow-
ered.
Comments on the studies with regards to the use of
scripts
Gokli 1994 grouped many induction procedures as mentioned in
Characteristics of included studies. However, they did not mention
which technique of behaviour management was utilised in the
non-hypnotic group.
Braithwaite 2005 had developed a script for both behaviour man-
agement techniques to be followed during inhalation sedation with
nitrous oxide, as sedation without accompanying reassurance from
the dentist is not as effective (Rosen 1983).
However, the hypnorelaxation script in the Braithwaite study
used very specific imagery associated with being in a garden. Im-
agery that has not previously been negotiated with the patient may
not fully engage the child and furthermore may increase the risk
of a negative response to suggestion. The overall efficacy of the
Braithwaite intervention may thus have been reduced by the script
that was used.
Whilst use of a script allows better comparability and standard-
isation between subjects, it is possible that hypnosis would have
been more effective if techniques used were tailored to each pa-
tients needs and preferences instead of using the same technique
for every patient as part of a research protocol (Milling 2000).
It has been shown that labelling of procedures as hypnosis increases
the response over and above the same procedure not so named
7
(Gandhi 2005). Milling 2000 has recommended that clinicians
use the term hypnosis with children as this may increase efficacy
of hypnotic interventions. However, patients taking part in the
Braithwaite study were not informed that the intervention used
was hypnosis and this may have reduced its effectiveness.
Analysing data
Braithwaite 2005 mentioned that two patients from the hypnosis
group were given nitrous oxide to provide anxiolysis during diffi-
cult extractions and they were included in the final analysis. This is
where data from all patients were included in the analysis and the
data are analysed according to which arm patients were originally
allocated to, even if they did not finish or swapped arms (inten-
tion-to-treat analysis). It is considered the least biased and fairest
way of assessing the effectiveness of an intervention. Braithwaite
2005 reported this clearly.
However, one patient from the inhalation sedation group was ex-
cluded part way through treatment, which was later completed
under general anaesthesia (GA) (reason given: autistic child who
became very uncooperative). Was it appropriate to include an
autistic child in a hypnotic trial as hypnosis depends on partic-
ipants having vivid imagination while it is known that autistic
children have limited imagination ability? (Deudney 2006). What
was the consequence of excluding a patient part way through the
treatment, who had presumably, originally been considered as ful-
filling the study eligibility criteria and was randomised to a treat-
ment group? Patients should only be excluded from a trial prior to
randomisation, not afterwards. In this case, removing an uncoop-
erative patient from one arm of the study has clearly introduced
bias.
With regards to Gokli 1994 and Trakyali 2008, they did not men-
tion any difficulties faced in the two treatment groups.
Patient follow-up
None of the studies followed up their patients. Follow-up may be
advantageous to find out if the effect of hypnosis has modified
the patients perception towards having dental treatment. Hypno-
sis attempts to help the patient to restructure negative thinking,
ideally it should improve their ability to cope and give them some
more positive expectations from treatment (Heap 1991; Moore
1990). Conversely, it is possible that patients attitudes to dental
treatment may be more negative following treatment under hyp-
nosis. Without follow-up, it is impossible to assess any long term
effect on behaviour or attitudes.
Potential biases in the review process
Braithwaite 2005 intended that patients remained unaware of
which of the two behaviour management techniques were to be
used. However, it was described that two of the patients and their
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
parents in the study had increased expectation of inhalation se-
dation effectiveness and showed bias towards this type of dental
care before any treatment commenced. This reflected the patients
previous dental experience of inhalation sedation and could have
influenced their preference of care. The study protocol recom-
mended that children with such previous experience be excluded
to eliminate bias, however this did not appear to happen.
Having access to the whole Braithwaite study may have introduced
bias from the review authors side as a far greater amount of infor-
mation was available for critical appraisal, compare to the Gokli
and Trakyali studies where journal articles were used.
AUTHORS CONCLUSIONS
Implications for practice
There is considerable anecdotal evidence of the benefits of hyp-
nosis in paediatric dentistry, however, on the basis of the three
studies that were eligible to be included in this review there is not
yet enough evidence to claim it is empirically supported. The lim-
itations of this review are noted by the review authors.
Implications for research
This review highlights the need for further randomised controlled
trials to be conducted into the use of hypnosis in paediatric den-
tistry, not least because empirical support for the use of hypnosis
in the treatment of clinical problems has generally grown over the
last decade. For example empirical support has been established for
the use of hypnosis to manage procedural pain with paediatric pa-
tients (Accardi 2009; Liossi 2006). Since procedural discomfort is
frequently associated with dental procedures, this is highly relevant
to dentists. In addition, the UKs National Institute for Health and
Clinical Excellence (NICE) guidelines recommend hypnothera-
peutic interventions for the treatment of irritable bowel syndrome
(IBS) (NICE 2008). Whilst IBS is not clinically relevant to den-
tistry, dentists may be encouraged by the growing acceptance of
the use of clinical hypnosis that this demonstrates. The wider liter-
ature may thus indicate to dentists that hypnosis is worth investi-
gating as an adjunct to treatment strategies and moreover provides
examples of the stringent methodology required.
The following research suggestions are given.
Follow-up of patients is required to find out if the effect of
hypnosis has modified the patients perception towards having
dental treatment.
Study design must be parallel to avoid the carry over effect
from the first period on the control group.
Sample size calculation should be carried out and reported.
8
 Consideration should be given to exclusion criteria to
prevent contamination from previous treatment experience e.g.
patients with experience of inhalation sedation (Braithwaite
2005) or patients with previous hypnosis treatment (Liossi
2003).
Blinding of coders: unless video recordings are used,
observer blinding is difficult in these kinds of studies and they
will be aware of which children in which group. Observer bias
may therefore have an influence in the behaviour distress ratings.
Techniques used by Liossi et al (Liossi 2003) may allow the effect
of the observer bias to be assessed. They suggest the following.
i) Ask the observers, after they have completed the
measurements, to guess the patients group membership. Liossi et
al found that observers could not discriminate between the test
and control groups.
ii) Check self reported data against the observational
data. If bias is minimal they should be similar.
Improved reporting of data to allow heterogeneity
assessment and meta-analysis between studies in future reviews
(Uman 2006).
REFERENCES
References to studies included in this review
Braithwaite 2005 {unpublished data only}
Braithwaite K. Hypnorelaxation versus inhalation sedation in
orthodontic extractions. MSc project. Department of Sedation and
Special Care Dentistry. Guys, Kings and St Thomas Dental
Institute of Kings College 2005.
Gokli 1994 {published data only}
Gokli MA, Wood AJ, Mourino AP, Farrington FH, Best AM.
Hypnosis as an adjunct to the administration of local anesthetic in
pediatric patients. ASDC Journal of Dentistry for Children 1994;61
(4):2725.
Trakyali 2008 {published data only}
Trakyali G, Sayinsu K, Muezzinoglu AE, Arun T. Conscious
hypnosis as a method for patient motivation in cervical headgear
wear- a pilot study. European Journal of Orthodontics 2008;30(2):
14752.
References to studies excluded from this review
Howitt 1967 {published data only}
Howitt JW. An evaluation of audio-analgesia effects. Journal of
Dentistry for Children 1967;34(5):40611.
Jerrell 1983 {published data only}
Jerrell R, Klingman A, Melamed B, Cathbert M, Bennett C. Skills
training for children facing dental restorative treatment. AADR
Abstract 1983; Vol. 62:175.
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Given well-known developmental variations in
suggestibility, researchers may wish to confine studies to limited
age ranges or to include sufficient numbers of children from
various age groups to permit analysis of adequate statistical
power within age categories (Olness 1996).
So far, no significant difference between male and female
concerning hypnotic ability was found. However, gender should
be included in research with other patient characteristics such as
age to confirm that it is the case within all age groups.
ACKNOWLEDGEMENTS
Wendy Bellis for guiding the review authors to the unpublished
study and K Braithwaite for providing a copy of her study and
answering queries.
The two translators: G Rossi and Christina-Maria Georgopoulou.
The Cochrane Oral Health Group - in particular Sylvia Bickley,
Luisa M Fernandez Mauleffinch, Helen Worthington and Anne
Littlewood for their guidance and help.
Additional references
Accardi 2009
Accardi MC, Milling LS. The effectiveness of hypnosis for reducing
procedure-related pain in children and adolescents: a
comprehensive methodological review. Journal of Behavioral
Medicine 2009;32(4):32839.
BNF 2007
Joint Formulary Committee. British National Formulary (BNF 54).
4th Edition. London: British Medical Association and Royal
Pharmaceutical Society of Great Britain, 2007.
Deudney 2006
Deudney C, Tucker L. Autistic Spectrum Disorders in Young
Children. London: The National Autistic Society, 2006.
Egger 1997
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-
analysis detected by a simple, graphical test. BMJ 1997;315(7109):
62934.
Fayle 2003
Fayle S, Tahmassebi JF. Paediatric dentistry in the new millennium:
2. Behaviour management - helping children to accept dentistry.
Dental Update 2003;30(6):2948.
Fromm 1992
Fromm E, Nash M. Contemporary Hypnosis Research. New York:
Guilford Press, 1992.
9
Gandhi 2005
Gandhi B, Oakley DA. Does hypnosis by any other name smell as
sweet? The efficacy of hypnotic inductions depends on the label
hypnosis. Consciousness and Cognition 2005;14(2):30415.
Heap 1991
Heap M, Dryden W (eds). Hypnotherapy: A Handbook. Milton
Keynes: Open University Press, 1991.
Heap 2002
Heap M, Aravind KK. Hartlands Medical and Dental Hypnosis. 4th
Edition. London: Churchill Livingston / Harcourt Health
Sciences, 2002.
Higgins 2009
Higgins JPT, Green S (eds). Cochrane Handbook for Systematic
Reviews of Interventions version 5.0.2 (updated September 2009).
The Cochrane Collaboration, 2009. Available from www.cochrane-
handbook.org.
Kirsch 1995
Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an adjunct to
cognitive-behavioural psychotherapy: a meta-analysis. Journal of
Consulting & Clinical Psychology 1995;63(2):21420.
Liossi 2003
Liossi C, Hatira P. Clinical hypnosis in the alleviation of procedure-
related pain in pediatric oncology patients. The International
Journal of Clinical and Experimental Hypnosis 2003;51(1):428.
Liossi 2006
Liossi C. Psychological interventions for acute and chronic pain in
children. Pain: Clinical Updates 2006;14(4):14.
Milling 2000
Milling LS, Costantino CA. Clinical hypnosis with children: first
steps towards empirical support. The International Journal of
Clinical and Experimental Hypnosis 2000;48(2):11337.
Moore 1990
Moore R. Dental fear - relevant clinical methods of treatment.
Tandlaegebladet 1990;94(2):5860.
Hypnosis for children undergoing dental treatment (Review)
Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NICE 2008
National Institute for Health and Clinical Excellence (NICE).
Irritable bowel syndrome in adults: Diagnosis and management of
irritable bowel syndrome in primary care. Available from http://
guidance.nice.org.uk/CG61 2008.
Olness 1996
Olness K, Kohen DP. Hypnosis and Hypnotherapy with Children. 3rd
Edition. New York: Guilford Press, 1996.
Patel 2000
Patel B, Potter C, Mellor AC. The use of hypnosis in dentistry: a
review. Dental Update 2000;27(4):198202.
Reid 1988
Reid A. Some suggestion techniques for dental anxiety in children.
The Australian Journal of Clinical Hypnotherapy and Hypnosis 1988;
9(2):858.
RevMan 2008
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.0. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2008.
Rosen 1983
Rosen M. Hypnotic induction and nitrous oxide sedation in
children. Journal of the Dental Association of South Africa 1983;38
(6):3712.
Simons 2007
Simons D, Potter C, Temple G. Hypnosis and Communication in
Dental Practice. UK: Quintessence Publishing Co. Ltd, 2007.
Uman 2006
Uman LS, Chambers CT, McGrath PJ, Kisely S. Psychological
interventions for needle-related procedural pain and distress in
children and adolescents. Cochrane Database of Systematic Reviews
2006, Issue 4. [DOI: 10.1002/14651858.CD005179.pub2]
Vingoe 1987
Vingoe F. When is a placebo not a placebo? That is the question.
British Journal of Experimental and Clinical Hypnosis 1987;4:1657.
Indicates the major publication for the study
10
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 patients overall level of sedation (irritated to sleepy); 4-point scale for patients
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: Assessors 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 patients 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)

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

MeSH check words

Child; Child, Preschool; Humans

Hypnosis for children undergoing dental treatment (Review) 20

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