CD 007154

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

Copyright 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
PLAIN LANGUAGE SUMMARY .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
RESULTS . . . . . . . . . .
DISCUSSION . . . . . . . .
AUTHORS CONCLUSIONS . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
CHARACTERISTICS OF STUDIES
DATA AND ANALYSES . . . . .
APPENDICES . . . . . . . .
HISTORY . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .
INDEX TERMS
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[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,
Health Services Research, Peninsula Dental School, Plymouth, UK.

UK
4 Division
London, UK. 3 Oral

of Psychology and Language Sciences, UCL, London,
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.
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.
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 understanding 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 technique 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 treatment. Alternatives to standard non-pharmacological techniques
include sedation or even general anaesthetic (GA). These techniques have their place, but can be associated with morbidity or
even mortality. One other possible alternative to standard nonpharmacological 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, feelings, 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 hypnotherapy 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).
Hypnotic techniques can be used to manage a range of common

problems relevant to dentistry such as dental anxiety, specific dental 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 modification 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 children 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 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.
METHODS
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
Criteria for considering studies for this review
Types of studies
Both randomised and quasi-randomised control trials were included. 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. repositioning of tooth, splinting, removal of nerve from tooth) and
orthodontic treatment. Children were included regardless of baseline 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.
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

Specialists in the field known to the review authors were contacted

for any unpublished data.
Data collection and analysis
Risk of bias was assessed for each included study. Studies were
considered to be at low risk of bias if there was adequate concealment 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.
Selection of studies
Investigation of publication bias
Selection of papers suitable for inclusion in the review were carried 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.
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 extraction and management
Data synthesis
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.
Data were divided into descriptive and quantitative methods.

Meta-analysis of the data was not applicable due to insufficient
number of studies.
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.
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% confidence intervals. Statistical heterogeneity will be assessed by calculation of the Q statistic and Cochranes I2 statistic. Analysis will

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 metaanalysis regression (STATA 9.0) will be utilized to explore, quantify 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 robustness of the review results by repeating the analysis with the following 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.
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 intervention (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 classification 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 dentistry); 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 unpublished 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 acceptance of local anaesthetic injection (LA), using hypnosis in children. 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

at that appointment. It was a double-blind study where children

were blinded to which group they were in and the intended procedure (administration of LA) was video taped for assessment of
behaviour by two assessors using the North Carolina Behaviour
rating scale. Physiological measures were also assessed looking at
oxygen saturation and heart rate via pulse oximeter. Both measures were checked at baseline and at injection twice; once with
hypnosis and once without. They used informal hypnosis with
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)
than those who did not undergo hypnosis. However, decreased
crying with hypnosis was the only behaviour found to be statistically 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 =
0.005). No significant difference was found due to gender, race
or treatment order. The effect of hypnosis was more pronounced
with younger children.
The Braithwaite study (Braithwaite 2005) aimed to compare the
behavioural and emotional response of a group of 10 young patients aged 10 to 16 years old undergoing orthodontic extractions
using an established anxiety control method (inhalation sedation
with behaviour management) versus hypnorelaxation.
This was a single blind cross-over study where patients were
blinded to which treatment group they were in, as on both occasions a nasal hood was placed. Patients were randomised to either
treatment A or B for the first period. Treatment A consisted of
inhalation sedation with nitrous oxide and oxygen + standardised
behaviour management technique. Treatment B consisted of hypnosis and oxygen. Behavioural scores were given at four stages: 5
minutes after placement of nasal hood, LA administration, extraction (XLA) and 5 minutes post-XLA.
The study found that hypnosis can control some of the patients
negative responses to dental treatment, such as movement and behaviour during administration of LA. However, it did not provide
sufficient anxiety control during tooth extraction and overall response to treatment remained statistically lower than response to
inhalation sedation. The majority of patients preferred inhalation
sedation.
The Trakyali study (Trakyali 2008) looked at the effect of hypnosis
on wearing time of orthodontic appliance. 30 patients (14 females
and 16 males) with a skeletal Class II division 1 malocclusion,
divided into two equal groups, a control and a study group. The
mean age was 10.78 1.06 years for the hypnosis, and 10.07
1.09 years for the control group. Both groups were treated with
cervical headgear containing a timer module. Patients were also
asked to record their actual wear time on timetables. The hypnosis
group patients were motivated with conscious hypnosis while the
control group were given verbal motivation by their orthodontist.
The timer modules were read at every visit and compared with
the timetables. A statistically significant decrease (P < 0.05) in
headgear wear was observed in the control group from the first to
the sixth month; however, the difference in the hypnosis group
was not significant. The result indicated that conscious hypnosis
was effective in this study for improving orthodontic patient cooperation.
Risk of bias in included studies
Sequence generation
Sequence generation was adequate in two studies (Gokli 1994;
Trakyali 2008) and unclear in one (Braithwaite 2005).
Allocation concealment
It was unclear in all studies as it was not reported.
Blinding
The Gokli 1994 study was double blind: assessors and patients.
In the Braithwaite 2005 study, only patients were blinded. None
were blinded in Trakyali 2008.
Use of intention-to-treat analysis (ITT)
Braithwaite 2005 gave a good account on the fate of all patients
though ITT analysis was not used. All patients in Gokli 1994
and Trakyali 2008 completed treatment although ITT was not
mentioned.
Overall risk of bias
Two studies were assessed as at high risk of bias (Braithwaite 2005;
Trakyali 2008) and one study as at moderate risk of bias (Gokli
1994).
Effects of interventions
From the limited number of available evidence from the
Braithwaite 2005 and Gokli 1994 studies, hypnosis may be beneficial in behaviour management during the administration of a local
anaesthetic (LA) in children (age range: 4.5 to 15 years) more than
a control group (no hypnosis, no sedation). This was consistent
with a recent review by The Cochrane Collaboration, which found
that various psychological interventions, particularly distraction,
combined cognitive-behavioural interventions, and hypnosis can
help children by reducing the pain and distress that accompany
needle-related procedures, with hypnosis being the most promising (Uman 2006). However, there is still not enough evidence to
prove its effectiveness during extraction. Trakyali 2008 showed an
increased likelihood of hypnosis improving orthodontic patients
co-operation.

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 controlled 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 effect 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 children 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 commitment to the patient.
Braithwaite 2005 found no significant difference in total treatment
time between inhalation sedation and hypnorelaxation i.e. hypnorelaxation demanded little additional time in order to complete
care.
Trakyali 2008 mentioned that the verbal motivation by the orthodontist 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
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 mentioned 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 without a sample calculation it is difficult to comment on the size of
these studies. However, there is a risk that they were underpowered.
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 management 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. Imagery 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 standardisation between subjects, it is possible that hypnosis would have
been more effective if techniques used were tailored to each patients 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

(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 difficult 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 (intention-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 excluded 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 participants 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 fulfilling the study eligibility criteria and was randomised to a treatment group? Patients should only be excluded from a trial prior to
randomisation, not afterwards. In this case, removing an uncooperative patient from one arm of the study has clearly introduced
bias.
With regards to Gokli 1994 and Trakyali 2008, they did not mention 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. Hypnosis 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 hypnosis. 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
parents in the study had increased expectation of inhalation sedation 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 recommended 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 information 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 hypnosis 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 limitations 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 dentistry, 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 patients (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 hypnotherapeutic interventions for the treatment of irritable bowel syndrome
(IBS) (NICE 2008). Whilst IBS is not clinically relevant to dentistry, dentists may be encouraged by the growing acceptance of
the use of clinical hypnosis that this demonstrates. The wider literature may thus indicate to dentists that hypnosis is worth investigating 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.

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).
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).
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.
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.
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.
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.
ii) Check self reported data against the observational

data. If bias is minimal they should be similar.
The two translators: G Rossi and Christina-Maria Georgopoulou.
Improved reporting of data to allow heterogeneity

assessment and meta-analysis between studies in future reviews
(Uman 2006).
The Cochrane Oral Health Group - in particular Sylvia Bickley,

Luisa M Fernandez Mauleffinch, Helen Worthington and Anne
Littlewood for their guidance and help.
REFERENCES
References to studies included in this review
Additional references
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.
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.
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.
BNF 2007
Joint Formulary Committee. British National Formulary (BNF 54).
4th Edition. London: British Medical Association and Royal
Pharmaceutical Society of Great Britain, 2007.
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.
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 metaanalysis 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.

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.cochranehandbook.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 procedurerelated 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.
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. Another 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 management script.
Treatment B: Hypnosis and oxygen via nasal hood.
Hypnotic technique: Hypnorelaxation script was created and followed; it included induction, 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); 6point scale for overall behaviour (aborted/no treatment to excellent/no crying or movement). 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?

11
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?
All outcomes
Unclear
Only patients blinded to therapy.
Incomplete outcome data addressed?

All outcomes
Yes
All patients were accounted for.
Intention to treat analysis?
No

12
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 anaesthetics. Specifically crying and pulse rate were found significantly decreased when hypnosis was utilised.
Notes

Ethical approval: Not reported.
Consent: Yes.
Risk of bias
Item
Authors judgement
Description
Yes
Quote: Flip of coin to determine whether

hypnosis was used at that appointment.

13
Gokli 1994
(Continued)
Blinding?
All outcomes
Yes
Quote: double blind research design was

used.
Patient blinded to therapy.
Assessors blinded to therapy.
Assessors blinded to therapy as patients
were video taped during intervention. Inter-rater reliability was assessed.

All outcomes
Yes
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 prognathism 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

14
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

Ethical approval: Yes.
Consent: Yes.
Risk of bias
Item
Authors judgement
Description
Yes
Quote: Forty consecutive patients with

a skeletal Class II division1 malocclusion
presenting maxillary prognathism were selected from the state-funded patient list.
Author was contacted for further clarification: 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 comprised the study group and those with even
numbers the control group.
Blinding?
All outcomes
No
Patients were aware of which group they

were in but were not aware that their wearing time was being monitored electronically.
The clinician was aware of which participants were in hypnosis or non-hypnosis
group.

All outcomes
Yes
No

15
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

16
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$).mp. [mp=title,
abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name]
5. or/1-4
6. Hypnosis/
7. Autogenic Training/
8. Guided imagery/
9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title,
device manufacturer, drug manufacturer name]
10. hypno$.ab,ti.
17
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/
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$).mp. [mp=title,
abstract, heading word, table of contents, key concepts]
title, abstract, heading word, table of contents, key concepts]
5. or/1-4
6. Hypnosis/ or hypnotherapy/
7. Autogenic Training/
8. Guided imagery/
9. (autosuggestion or auto-suggestion).mp. [mp=title, abstract, heading word, table of contents, key concepts]
10. hypno$.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/
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
18
#14
#15
#16
#17
#18
#19
#20
#21
#22
(#6 or #7 or #8 or #9 or #10 or #11 or #12 or #13)

MeSH descriptor Child explode all trees
MeSH descriptor infant this term only
MeSH descriptor adolescent this term only
(child* in Title, Abstract or Keywords or infant* in Title, Abstract or Keywords or adolescen* in Title, Abstract or Keywords)
(pediatric* in Title, Abstract or Keywords or paediatric* in Title, Abstract or Keywords)
MeSH descriptor Dental Care for Children this term only
(#15 or #16 or #17 or #18 or #19 or #20)
(#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 autogenic*)
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

19
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

20

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Hypnosis for children undergoing dental treatment (Review)

Al-Harasi S, Ashley PF, Moles DR, Parekh S, Walters V

Hypnosis for children undergoing dental treatment (Review)

Hypnosis for children undergoing dental treatment (Review)

Hypnosis for children undergoing dental treatment

Health Services Research, Peninsula Dental School, Plymouth, UK.

London, UK. 3 Oral

PLAIN LANGUAGE SUMMARY

Hypnotic techniques can be used to manage a range of common

Hypnosis for children undergoing dental treatment (Review)

What is the effectiveness of hypnosis (with or without sedation)

Search methods for identification of studies

Criteria for considering studies for this review

Types of outcome measures

The Cochrane Oral Health Groups Trials Register (11th

Hypnosis for children undergoing dental treatment (Review)

Specialists in the field known to the review authors were contacted

Data collection and analysis

Investigation of publication bias

In order to help overcome publication bias, we (1) imposed no

Data extraction and management

Data extraction was carried out on a specially designed paper form

Data were divided into descriptive and quantitative methods.

Assessment of risk of bias in included studies

Data were collated into evidence tables. A descriptive summary

Meta-analysis of the data was not applicable due to insufficient

Hypnosis for children undergoing dental treatment (Review)

be performed using RevMan Analysis software (RevMan 2008).

Investigation of heterogeneity and subgroup analysis

Results of the search

A total of 69 participants (34 male and 35 female) were recruited,

Design, methods and outcome measures

Hypnosis for children undergoing dental treatment (Review)

at that appointment. It was a double-blind study where children

Risk of bias in included studies

Hypnosis for children undergoing dental treatment (Review)

Summary of main results

Differences in treatment time with or without

Overall completeness and applicability of

Age range used

In all studies the age range was applicable to paediatric dentistry

Quality of the evidence

Hypnosis for children undergoing dental treatment (Review)

(Gandhi 2005). Milling 2000 has recommended that clinicians

Potential biases in the review process

Implications for research

Hypnosis for children undergoing dental treatment (Review)

Consideration should be given to exclusion criteria to

Given well-known developmental variations in

Blinding of coders: unless video recordings are used,

So far, no significant difference between male and female

i) Ask the observers, after they have completed the

ii) Check self reported data against the observational

The two translators: G Rossi and Christina-Maria Georgopoulou.

Improved reporting of data to allow heterogeneity

The Cochrane Oral Health Group - in particular Sylvia Bickley,

References to studies included in this review

Braithwaite 2005 {unpublished data only}

Gokli 1994 {published data only}

Trakyali 2008 {published data only}

References to studies excluded from this review

Hypnosis for children undergoing dental treatment (Review)

Indicates the major publication for the study

Hypnosis for children undergoing dental treatment (Review)