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 . . . . . . . . . . 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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Hypnosis for children undergoing dental treatment (Review) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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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. [email protected]. 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 Group’s 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) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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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 children’s 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 person’s focus of attention to shift towards inner experiences in order to influence the subject’s 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:

Hypnosis for children undergoing dental treatment (Review) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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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 Group’s 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

Hypnosis for children undergoing dental treatment (Review) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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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 other’s 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 author’s 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 Cochrane’s I2 statistic. Analysis will

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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

Hypnosis for children undergoing dental treatment (Review) Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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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 patient’s 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 patient’s co-operation.

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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 patient’s 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 child’s 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 patient’s 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

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(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 patient’s 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 patient’s 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 patient’s 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 UK’s 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 patient’s 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.

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• 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 patient’s 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. Guy’s, King’s and St Thomas’ Dental Institute of King’s 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):328–39.

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):272–5.

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): 147–52.

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):406–11. 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): 629–34. 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):294–8. Fromm 1992 Fromm E, Nash M. Contemporary Hypnosis Research. New York: Guilford Press, 1992.

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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):304–15. Heap 1991 Heap M, Dryden W (eds). Hypnotherapy: A Handbook. Milton Keynes: Open University Press, 1991. Heap 2002 Heap M, Aravind KK. Hartland’s 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):214–20. 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):4–28. Liossi 2006 Liossi C. Psychological interventions for acute and chronic pain in children. Pain: Clinical Updates 2006;14(4):1–4. 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):113–37. Moore 1990 Moore R. Dental fear - relevant clinical methods of treatment. Tandlaegebladet 1990;94(2):58–60.

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):198–202. Reid 1988 Reid A. Some suggestion techniques for dental anxiety in children. The Australian Journal of Clinical Hypnotherapy and Hypnosis 1988; 9(2):85–8. 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):371–2. 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;4:165–7. ∗ Indicates the major publication for the study

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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 patient’s overall level of sedation (irritated to sleepy); 4-point scale for patient’s 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?

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Braithwaite 2005

(Continued)

(In hindsight, the trial author wished she had asked about the reason for preference). - Treatment length. Outcome measures: Assessor’s 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 patient’s 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

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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

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”.

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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.

Incomplete outcome data addressed? All outcomes

Yes

All patients were accounted for.

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 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

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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 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.

Incomplete outcome data addressed? All outcomes

Yes

All patients were accounted for.

Intention to treat analysis?

No

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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

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

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

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#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

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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

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