Journal of Disability and Oral Health (2006) 7/1 2934

The use of hypnosis and systematic

desensitisation in the management of
dental phobia: a case report
K E Wilson
South Tyneside Primary Care Trust, Community Dental Service

Abstract
This case report presents a patient with dental phobia, which reportedly developed at the age of 9
years of age, following a traumatic dental experience. It describes the use of hypnosis and a programme
of systematic desensitisation in the management of dental and needle phobia.

Key words: anxiety, hypnosis, needle phobia, dental care

Introduction including conscious sedation and general anaesthesia (Levitt

The prevalence of dental anxiety and phobia in the United
Kingdom is high. For many people even the thought of a
check-up can be traumatic. The presence of dental anxiety
and the avoidance of dental care can have a wide-ranging
and dynamic impact on peoples daily living (Cohen et al.,
2000). Cohen and co workers identified five main areas
affected by dental anxiety including physiological, cognitive,
behavioural, health and social. Physiological responses
included symptoms of the fright and flight response and
subsequent feelings of exhaustion following a dental visit.
The cognitive impacts reported included a range of nega-
tive beliefs, thoughts and fears while the behavioural
impacts included avoidance, as well as behaviours related
to oral hygiene, eating, self-medication, aggression and sleep
disturbance. It was also reported that dental anxiety can have
an impact on social interactions and work performance. It
follows that reduction in the level of anxiety and tension in
dental patients is desirable, increasing the acceptability of
dental care to the patient, so enhancing their daily living.
It will also result in greater job satisfaction for the dental
team (Nicolaou, 1993).
The profession is well aware of its obligation to manage
pain and anxiety amongst dental patients and to this end
has developed a wide range of management modalities for
this purpose, including both non-pharmacological and
pharmacological techniques. Current non-pharmacological
treatment methods for dental anxiety/phobia include
cognitive and behavioural management techniques, hypno-
sis, acupuncture and aromatherapy. The aim of such
techniques is to help the patient develop coping skills in
order to be able to accept dental care in the long term.
Where patient co-operation is not achieved using such
techniques pharmacological adjuncts are often necessary,
et al., 2000). However, the use of conscious sedation and
general anaesthesia leaves little scope for the patient to
develop coping strategies which will help them overcome
their fears and manage with dental treatment independently
in the long term.
The use of dental hypnosis in Britain gained popularity
in the 1940s and 1950s with the establishment of the British
Society for Dental Hypnosis (Nicolaou, 1993). Hypnosis
has since been widely used in dental settings, although few
robust clinical trials have been published to provide an
evidence base for its use. The technique is considered to be
most effective in those patients committed to overcoming
their fears and co-operating with treatment.
Aims of Hypnosis
The aim of the use of hypnosis in dentistry is to teach the
patient to cope with the dental situation to the best of his or
her ability. The starting point is the reduction of fear and
tension thereby minimising the effect of anything that is
potentially painful or perceived as such. Reduction of
tension cuts down the amount of fear and pain perceived
or anticipated; so by producing relaxation and breaking the
fear-tension-pain-fear cycle, hypnosis can break the vicious
circle at any of the three points (Nicolaou, 1993). Manage-
ment with hypnosis can range from simple relaxation
techniques to treatment involving several sessions which may
include behaviour modification, imagery conditioning or the
rehearsal technique
Before starting any programme of hypnosis/relaxation
it is important to consider the patients feelings about the
word hypnosis and to allay any concerns over the use of
this technique emphasising that medical hypnosis is a
professionally accepted and endorsed method. It is also
30 Journal of Disability and Oral Health (2006) 7/1
important to reassure the patient that they will feel in
control and that during the session the dentist may provide
several suggestions which the patient is at liberty to accept
or reject. Once the patient has learnt a way of reducing their
anxiety and so accepting dental care, they can continue to
employ this new skill for subsequent dental treatment with-
out any formal induction. Indeed, they can also use their
new skills to benefit many other areas of their life.
Case report
Relevant personal details
The patient Miss A, is a 25 year old female who works in
administration and is unmarried with no children. She is fit
and healthy with no relevant medical history.
Previous dental history
As a childthe patient attended the dentist on a regular basis.
At 9 years of age she received her first restoration when no
local analgesia was used. The procedure was very uncom-
fortable and the patient found the experience so traumatic
she did not visit a dentist again until she was 16 years of
age. At this stage, due to her then severe anxiety, the dental
treatment was carried out under general anaesthesia.
Unfortunately the patient did not return for any follow-up
care.
In September 2002, now 23 years of age Miss A had
become very self conscious of her deteriorating oral health
and although still extremely anxious, was very keen to
access dental care. She was referred to the Community Dental
Service to be seen by a dental clinician with a special interest
in the management of anxious patients.
First dental visit
At her first visit the patient was very tearful and would not
enter the dental department. The initial consultation was
therefore carried out in a non-clinical environment. A full
past dental history was taken with details of the patients
anxieties, which included a general anxiety about all forms
of dental care but more specifically a phobia of injections
extra-orally and intra-orally. The patient was asked to
complete a Corah Dental Anxiety Score (Corah, 1969) and
a Visual Analogue Scale (Hosey and Blinkhorn, 1995) rang-
ing from Very Calm to Extremely Anxious. The Corah
score was 25, the highest level of dental anxiety and the
Visual Analogue score was 98 out of 100, again indicating a
very high level of anxiety.
Presenting complaint
Intermittent generalised pain particularly on eating and with
hot and cold, teeth cracking and breaking and bleeding gums.
The patient admitted to drinking excessive amounts of fizzy
drinks on a regular basis.
Intra oral examination
The patient was too self conscious to allow a thorough
oral examination, however, it was obvious that her denti-
tion was in a neglected state. A dentalpantomogram was
Figure 1. Dentalpantomogram at initial assessment
arranged in order to fully assess the condition of individual
teeth (Figure 1). On assessing the radiograph the following
was noted:
Caries present in teeth: 15, 14, 12, 11, 23, 26, 37, 36, 34, 45, 47
Retained roots: 16
Crown fractured: 22
A provisional treatment plan was formulated:
Oral hygiene and dietary advice
Extraction of teeth: 16, 14, 22, 23, 36, 45
Scale and polish
Restorations in teeth: 12, 11, 26, 37, 34, 46, 47
Provision of upper partial cobalt chrome denture.
Various management options were then discussed.
Management options
The initial priority for the patient was to relieve her symp-
toms of pain and discomfort by extracting the necessary
teeth. The options of local analgesia, local analgesia and
sedation and general anaesthesia, were all discussed with
the patient. Owing to her severe phobia and the need for
several extractions it was considered most appropriate to
provide a general anaesthetic for this stage of her dental
care. It was suggested that the restorations could be carried
out under sedation, however the patient felt that her second
priority was to overcome her fear. The use of hypnosis
was therefore suggested as a means of long term anxiety
management.
Second visit
The patient attended for a general anaesthetic where the
aforementioned teeth were extracted. An inhalation induc-
tion was provided and recovery was uneventful. The
patients dental appearance postoperatively is illustrated in
Figure 2 and 3.
Third visit
This visit was undertaken in a non clinical room as Miss A
still felt extremely anxious about entering the dental surgery.
She had been asked to produce a hierarchy of dental anxi-
eties which would be used in the hypnosis sessions as a plan
of issues to work through (Table 1).
 Wilson: Hypnosis in dental phobia management 31

Figure 2. Before treatment under hypnosis Figure 3. Intraoral view, after dental treatment under
general anaesthesia and before treatment under hypnosis

Table 1. Hierarchy of Dental Anxieties

Level of threat Stages of dental visit

(1=least 8=most)
1 Sitting in waiting room
2 Sitting in the dental chair
3 The smell of the surgery
4 Sight of the dental equipment
5 The drill
6 Extractions
7 Pain
8 Injections

Table 2. Trance Induction

Just concentrate on your breathing, breathing in and out, in and out very slowly. I am going to count down from 5 to 1 and each time
I say a number I would like you to take a deep breath. Hold the breath for a few moments and listen to my voice following my
directions.
5 Just hold the breath for a few moments and now let that breath go. As you let the breath go feel all the tension in your forehead,
eyes, cheeks and jaw starting to flow away down towards your neck, leaving your whole head and face feeling so very relaxed and
comfortable.
4 Just hold that breath for a few moments and now let that breath go. As you do so feel any tension in your neck, your shoulder,
and your upper arm flowing away down into your chest, lower arm and hands, leaving your head, face and neck now very relaxed
and comfortable.
3 Just hold that breath for a few moments and now let that breath go. As you do so feel any tension in your chest and hands flowing
away down to your legs and out through your fingers, leaving your whole upper body now so very relaxed and comfortable.
2 Just hold that breath for a few moments and now let that breath go. As you do so feel the tension in your legs moving down to
your feet and flowing away through your toes at the end leaving your whole body feeling very relaxed and comfortable.
And 1 Just hold that breath for a few moments. Now let that breath go and as you do so feel yourself sinking down into the chair
feeling so very relaxed, comfortable and calm; relaxed, comfortable and calm.
Now just enjoy that lovely relaxed, comfortable, calm feeling for a few more moments.

The first hypnosis session was then commenced which
involved the following steps:
a) Trance induction and deepening by Progressive Relaxation.
The patient was asked to sit in an arm chair and encouraged
to make herself comfortable. She was then asked to close
her eyes and the clinician commenced trance induction and
deepening using specific instructions and words in a soft
monotone voice (Table 2).
In order to deepen the trance she was asked to think of
a special place. The clinician used further directions to
assist the patient (Table 3).
The patient was now in a state of total relaxation. It is
32 Journal of Disability and Oral Health (2006) 7/1

Table 3. Deepening of the trance state

Now I would like you to think of a special place where you would feel relaxed, comfortable and calm. This might be a place in the
sun, in the countryside or just somewhere where you know you would feel relaxed. When you have an image of this place in your
mind just nod and let me know
The clinician then waits for this signal prior to proceed. When the patient gives the signal the following words are used by the
clinician;
Just enjoy being in this special place for a few moments. In this place you can feel so very relaxed, comfortable, calm and confident.
I want you to think about how good you can feel in yourself when you are in your special place. Any time you need to feel more
relaxed, comfortable, calm and confident you can think of your special place to bring these feelings into you mind.
The clinician now assists the patient in establishing a Positive Anchor
To help you to do this I would like you to think of these good feelings and imagine them in the palm of one of your hands. Now, to
keep these feelings make a fist with that hand. There they are safely held in your right/left hand. Remember, any time you want to
bring these feelings back into your mind you can think of your special place and make a fist with your right/left hand. This will bring
back these feelings of being relaxed, comfortable and calm and will help you to feel confident in many situations. Just think of those
feelings again for a few more moments and enjoy that lovely relaxed, comfortable, calm state.

Table 4. Trance awakening

I am now going to count from 1 to 5 and as I do so you will start to feel more alert, you will become more aware of your
surroundings and the noises in the room. When I get to 5 you will open your eyes and be fully alert; you will remain very relaxed and
calm, but not at all sleepy. You will be able to go about the rest of the day normally, but feeling more relaxed and calm. When you
return to the clinic the next time you will feel much more confident, relaxed and calm.
1 Starting to feel a little more alert and aware of the noises around and the light in the room.
2, 3
4 Your eyelids starting to feel lighter, just flickering there a little.
And 5 Just allowing your eyes to open in their own time, now you are alert and aware of everything around you. Awake but still very
relaxed and calm.

important that the patient can assume this state by them-
selves and therefore the clinician gave instruction to the
patient on self hypnosis.
As this was the first visit no further work was planned
and the patient was brought round from the trance state.
The clinician used the appropriate words in order to bring
the patient out of trance in a controlled manner (Table 4).
Miss A was allowed time to come around from the
trance state in her own time and was asked for feedback
about the session.
Fourth visit
The patient was again seen in a non clinical environment
and the trance state was induced using the Progressive
Relaxation process described above and deepening was
achieved by use of the special place. Once in a deep trance
state the patient was asked to imagine the various stages
in her hierarchy commencing with being in the waiting
room. The clinician asked if this image felt comfortable
and a positive nod from the patient indicated that it was
appropriate to move to the next stage of the hierarchy. This
process carried on through the hierarchy, the patient feeling
comfortable with all images up to imagining having a
dental examination and a simple polish. At each stage if the
patient felt comfortable with the image the clinician praised
her and reinforced the feelings of relaxation, calm and
confidence. It was suggested to the patient that at her next
visit she would feel more comfortable about coming into
the dental surgery and sitting in the chair. The trance was
reversed as before and the positive thoughts and feelings
reinforced.
Fifth visit
The patient was asked if she would be happy to come into
the dental surgery and she agreed. She was able to sit in the
dental chair without becoming distressed. The trance state
was induced and deepened. The patient was asked to imag-
ine having a simple polish which she felt relaxed about. With
the image of having a simple polish the clinician asked her
to imagine asking the dentist to stop the procedure by rais-
ing her hand as a form of stop signal. This was suggested
to allow the patient to feel more in control of the proce-
dure. The patient was encouraged to think of this image
several times as a means of reinforcement. As the patient
was feeling very comfortable with this image it was
suggested that she may like to try to have a polish carried
out knowing that she could use the stop signals. She was
also encouraged to use her positive anchor (Table 3) if she
started to feel anxious.
A dental exam and simple polish were successfully
carried out. The clinician than asked her to imagine being
told she required a filling which would involve an injection
and drilling. At this thought Miss A became visibly anxious
and slightly distressed. In this situation it is important to take

the patient back to a comfortable place and therefore the
clinician asked her to imagine only the image of the simple
polish where she was in full control. This she did and
returned to a more relaxed state. It was agreed that the next
visit would be devoted to working on her anxieties about
oral injections.
Sixth visit
The patient entered the dental surgery without hesitation
and sat on the dental chair. She reported feeling much
happier about the dental visit and more confident in herself.
It was planned to commence the desensitisation programme
for the patients needle phobia. Such a programme involves
inducing the trance state, after which the following steps are
carried out:
1. The patient is introduced to topical anaesthetic
An explanation of how topical anaesthetic works and why
it is used is given to the patient. A small amount is then
placed on dry labial mucosa for 2 minutes. The patient is
asked how it feels and confirmation that the patient is
comfortable with this is gained. The area is then tested with
a probe to demonstrate the numbing effect achieved.
2. Components of the local anaesthetic syringe
The patient is shown the separate components of the local
anaesthetic syringe. An explanation of each component is
given and the patient shown how everything fits together.
The patient is encouraged to hold the equipment and famil-
iarise themselves with it. The clinician asks the patient how
they feel about this stage.
3. The Needle
The patient is then shown the needle unsheathed. It is
explained that only a very small section would be placed in
the gum during the administration of the local anaesthetic.
With the patients permission the unsheathed needle is placed
beside the area of gingivae which has received the topical
anaesthetic. Again the patient is asked if they feel comfort-
able with this.
4. Using the local anaesthetic syringe
The syringe is assembled and with the needle sheathed, held
beside the patients mouth for 10 seconds. The patient is
asked if they feel comfortable. If the answer is yes the
syringe is then placed next to the numbed area of gingival
with the needle sheathed for 10 seconds and the patient
again asked if they feel comfortable. These two steps are
repeated with the needle unsheathed.
5. Giving the local anaesthetic
The needle is then held against the gingivae without injecting
any solution again for 10 seconds. With the patients
permission the needle is placed in the gingivae and a small
amount of anaesthetic injected.
At the end of each stage of this programme the patient
is asked if they feel comfortable. If so then it is appropriate
to move on to the next stage. If not, then further reassur-
ance is given. The length of time to complete the programme
Wilson: Hypnosis in dental phobia management 33
Figure 4. Extra-oral view after treatment under hypnosis
will depend on how the patient feels at each stage. It is
possible to desensitise the patient at one visit but it may take
up to two or three visits.
In the case reported, the patient arrived at the stage of
having the syringe held in her mouth with the needle sheathed
in one visit and was able to manage this successfully. Still
in the trance state she then asked the clinician to place a
temporary filling in teeth 12 and 11. Glass ionomer cement
was subsequently placed. Prior to reversing the trance the
clinician praised Miss A for allowing the procedures to be
carried out and reinforced the feelings of relaxation, confi-
dence and control. The trance was then reversed as before.
Seventh visit
Progressive relaxation and trance deepening were employed
and the final steps of the needle desensitisation programme
successfully completed. A small composite restoration was
placed in tooth 24 and the patient again praised and rein-
forced with words of confidence and control.
Subsequent visits
Miss A returned on five subsequent visits when the remain-
der of the restorative treatment was completed under local
analgesia, with the patient employing self hypnosis to achieve
relaxation. A cobalt chrome upper partial denture was
constructed and fitted on the last visit . At this visit the
patient completed further anxiety questionnaires. The Corah
Dental Anxiety Score was recorded as 8, compared to 25
at the initial visit and the Visual Analogue Anxiety Scale was
18 compared with 98 at the first visit. Miss A reported
feeling confident in herself and commented that her self
esteem was much greater owing to her improved appear-
ance (Figure 4). She was now prepared to register with a
dentist in the General Dental Service for her future care.
Discussion
This case report has presented a patient with dental phobia,
which reportedly developed at the age of 9 years of age,
34 Journal of Disability and Oral Health (2006) 7/1
following a traumatic dental experience. It describes how
the use of hypnosis and a programme of systematic desen-
sitisation was successful in the management of dental and
needle phobia.
Needle phobia is one of the leading causes of dental
anxiety and phobia and many patients will go to extreme
lengths to avoid exposure to dental needles, which can ulti-
mately lead to a deterioration of dental health (Gow, 2002).
Many management options are available for anxious
patients including pharmacological and non pharmacologi-
cal methods. Pharmacological methods, such as sedation
and general anaesthesia, are useful for the emergency treat-
ment of phobic patients but will not resolve the patients
phobia in the long term and may even lead to dependency
(Levitt and McGoldrick, 2000). Several non-pharmacological
management options are available and the choice of tech-
nique will depend on the severity of the patients anxiety
and the needs of the patient. Those with severe anxiety and
phobia will require more in depth management techniques
such as hypnosis and systematic desensitisation (Newton et
al., 2003).
In managing patients with dental anxiety and phobia it is
important to carry out an assessment of the patients level
of anxiety prior to commencing any treatment. In the case
presented the Corah Dental Anxiety Scale and a Visual
Analogue Scales were used (Corah, 1969; Hosey and
Blinkhorn, 1995). As well as giving a measure of the
patients level of anxiety pre-operatively, using these tools
during the course of treatment can help to measure
improvement in the patients feelings about the dental situa-
tion. It allows the patient to realise any improvements they
are making which can boost their confidence and self
esteem.
Hypnosis has been shown to be a valuable technique in
patient management (Nicolaou, 1993; Patel et al., 2000; Gow
et al., 2002) however, there are many myths surrounding
hypnosis which need to be dispelled to enable the patient to
appreciate the therapeutic benefits (Nicolaou, 1993). Before
starting a hypnosis programme the dentist must consider
the patients feelings about the word hypnosis and what
that means to them. Using the term deep relaxation might
sit more comfortably with many patients.
As part of the hypnosis programme post hypnotic
suggestion is used and self hypnosis taught. This will help
the patient to feel better on leaving the dentist, to have
increased confidence in his or her ability to cope with
difficult situations and will allow them to feel more
comfortable and relaxed on the subsequent dental visit
(Nicolaou, 1993). In the case presented the patient was
visibly more relaxed on each visit and reported that she felt
more confident in herself and in attending the dental
surgery.
The use of systematic desensitisation has been shown to
be extremely effective (Levitt et al., 2000; Newton et al.,
2003) and this has been demonstrated in the case. The
advantage of carrying out this technique combined with a
state of hypnosis is that the patient can experience the
desensitisation programme in an extremely relaxed state
which enhances the effect of the procedure. On comple-
tion of treatment the patient reported her level of dental
anxiety to be significantly reduced, when measured objec-
tively using the dental anxiety scales. On a subjective level it
was obvious that she was more relaxed in herself and that
her self esteem was significantly improved. Her general
appearance had changed and she was now able to smile
and communicate confidently. The patients agreement to
seek care within the general dental service was testament to
the effectiveness of the management techniques used in
allowing her to overcome her fears on a long term basis.
In summary, this case has demonstrated how different
management strategies can be used in the overall care of
patients with dental anxiety and phobia. It has highlighted
the effective use of non-pharmacological methods namely
hypnosis and systematic desensitisation in the long term
management of dental phobia.
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Hosey MT, Blinkhorn AS. An evaluation of four methods of assessing
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Levitt J, McGoldrick P, Evans D. The management of severe dental
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Address for correspondence
Dr K Wilson
Dental Department
Palmer Hospital
Wear Street, Jarrow
NE32 3UX, UK
E-mail: kathy.wilson@sthct.nhs.co.uk