1. Introduction
Scleroderma, or systemic sclerosis, is a chronic connective tissue disease generally
classified as one of the autoimmune rheumatic diseases. The word “scleroderma” comes from
two Greek words: “sclero” meaning hard, and “derma” meaning skin (1-3). Hardening of
the skin is one of the most visible manifestations of the disease. Internal organs are also
frequently affected with the systemic form.
People with scleroderma often have specific facial changes. The nose appears pinched and
thinned and the opening of the mouth might be decreased in size (“microstomia” or “small
mouth”). Often, the skin over the upper lip can become lined. The development of dilated
small blood vessels, called telangiectasia, affects the face and other parts of the body.
The appearance of the eyes can also alter, all of which can negatively impact the patient’s
appearance (4). The general tightening of the
skin over the face makes lip and mouth movements, as well as oral hygiene, difficult.
Microstomia may make it difficult to open the mouth wide enough for dental procedures or
even oral hygiene. Therefore, preventative dental care through regular flossing and
brushing of the teeth and gums after each meal is of utmost importance (5). The best approach to management is by means
of facial grimacing and mouth stretching exercises, performed daily. Regular dental visits
are also important to help prevent dental caries. The dentist can also recommend a
personalized program of good oral hygiene. Floss holders, pump toothpaste tubes, and
built-up handles on toothbrushes can help people with hand impairment, while an electric
toothbrush is strongly advised (6).
From the psychological aspect, a common reaction to being told that one has a disease such
as scleroderma is, “why me?” It is not clear why only several people develop the disease
and others do not. One does not bring scleroderma upon him or herself, and therefore,
should not feel guilty or responsible for the illness. A person newly diagnosed with
scleroderma may feel alone and uncertain about where to turn for help (7). Psychopatologically speaking, the majority of
the sclerodermatic patients may manifest mild anxiety due to apprehension and vigilance
related to the perceived threat from the illness and the uncertainties over etiology,
prognosis and outcome. Others may show depression, generally of moderate severity. He, or
she, may experience a number of other feelings and emotional reactions from time to time,
including initial shock or disbelief, fear, anger, denial, self-blame, guilt, grief,
sadness, somatization, profound feelings of generalized hostility, and interpersonal
sensitivity, which may be due to the gradual disfigurement resulted from skin thickening.
The severity of illness, and consequent disability, could be regarded as the central
factors contributing to the development of the psychiatric symptomatology. Paranoid
ideation and psychoticism of the sclerodermatic patients probably reflect a vulnerability
towards the manifestation of more serious, psychotic, psychopathology. Medication should
not be regarded as indifferent in this cumulus of psychological anxiety triggers (7, 8).
Family members may experience similar feelings. Feelings, in themselves, are neither good
nor bad; one simply “has” them. Sharing them with family members and friends, or with
others who have had the same experiences, can be helpful (1, 4). Other
factors, such as social support, may also play significant roles (8). Professional counseling can also help people with scleroderma
and their family members who are having difficulty coping with their feelings. Instead of
“scleroderma patient”, the term “person with scleroderma” should better be used. The person
with scleroderma may be a “patient” in the doctor’s office, hospital or clinic, but he or
she is much more than that. Thinking of oneself as a total person, with a full life, may
help to cope with scleroderma and enable one to maintain a positive, and also realistic
insight (9). Rebuilding thoughts is the key
step for such conditions (3).
Hypnosis is defined as an attentive, receptive, focal concentration, with diminished
peripheral awareness. Hypnotizability, expectancies, motivation, absorptive
capacity/fantasy proneness, and attitudes towards hypnosis are five psychological factors
most frequently mentioned as important. The rapport (also referred to as “resonance” and
“harmony”) and social context are identified as social factors.
Evidence supports the usefulness of hypnotic treatments, to address biological,
psychological and social factors, and their interactions in any medical condition. The
biopsychosocial model of hypnosis can help in understanding complex issues, such as
scleroderma. Importantly, this model allows the possibility for multiple factors to play a
role and contribute to hypnotic responding (10).
2. Case Presentation
While receiving dental services for prosthetic rehabilitation, our 58-year-old patient
referred to dermatologist just because of limitation of mouth opening, which is essential
for the optimal performance of dental treatment. A comprehensive battery of tests revealed
that she was suffering from Scleroderma. This was a major turning point, because both the
oral prosthetic service, and also several other aspects of her and her family life, got
affected. Therefore, we changed our plan from a regular somatic to a more comprehensive
biopsychological approach. The first measure implied in the management of this case was to
conducting a team work, including an endodontist who has been trained as an advanced
hypnotherapist, a restorative dentistand also prosthodontist for dental treatments.
Although, at first, five sessions were preplanned to complete whole levels of treatment,
fortunately, prior to commencing the fourth session, treatment finished convincingly with
optimal results. As a first step, a simple interview was performed to see if there is the
potential for a hypnosis intervention. Simultaneously, and also during pre-talk, several
myths in which the patients believed concerning hypnosis, were corrected. The Spiegel
biological scale of the patient scored as 3 out of 5. At the first one-hour session, all
activity had been targeted just for relaxation, anxiety management, attitude correction
about the new encountered unusual somatic condition, correction of coping skills for new
life, increasing self-confidence, and, eventually, conditioning with light folkloric music
and also, her very kind mother’s name. Two-week intervals were considered between all three
hypnosis sessions. During the second hypnosis session, which lasted 50 minutes, she was
fallen more easily and more deeply into trance, using the conditioning keys and suggested
specially for her dental treatment procedure, particularly useful cooperation with the
dentist to gain suitable results. Meanwhile, her attitude about her new facial appearance
and the others’ reactions were repaired. Surprisingly, less pain and discomfort would have
been felt thereafter, due to any joint movement throughout the body, especially in case of
the shoulder and temporomandibular joints. The third session, lasting for 40 minutes, was
spent for reinforcement of previous inductions and conditions, and a new induction was
performed for increasing the intention to help the other persons newly and unexpectedly
faced with disturbing conditions, such as scleroderma, or any other. Prior to the fourth
session, she obtained satisfactory psychological capabilities again, and hence, no need was
felt for continuing hypnotic interventions urgently. All the pre-desired dental treatments
were delivered to the subject, and she was also asked to use hypnosis any time needed.
Three follow up visits showed no relapse, although the disease itself had its ongoing
nature. Nevertheless, it was not detrimental psychologically, since the subject had learnt
new copping skills for such circumstances, emphasizing that the hypnotic inductions and
treatments must be promising and real, as well. Additionally, from that time on, the
subject herself did explain the benefits of hypnosis for the others in the society.
3. Discussion
Participating actively in one’s own healthcare is of prime importance to the person with
scleroderma. It is equally important to cooperate and communicate effectively with the
doctor who is managing the disease. While these two the person with scleroderma and the
doctor, are the focal point of the management “team”, multiple other individuals and
resources can be enlisted to form a health and support network (2).
Several skin conditions are well appreciated to resonate with the individual’s mental
climate. Among them, there is scleroderma, which is sensitive to psychological pressures
and possessing recognized immunological components. Using hypnosis, both somatic and
psychological elements of scleroderma can be covered and influenced by appropriate
suggestions (4).
Regarding the facts mentioned, our hypnotic intervention could effectively cover the
complex issues related to the patient with scleroderma: somatically, to provide a suitable
situation for conduction of dental treatments, and psychologically, to return the patient
to an acceptable level of expectation, and acceptation. This case report hopefully
lightened the missed, yet necessary chain of actions required the in treatment of any
psychosomatic impairment.
