Trauma Informed Dentistry

Photo by Bekky Bekks

 

Introduction

Welcome to this Trauma Informed Dentistry and Adverse Childhood Experiences (ACE) guide for dental professionals.
This document contains information, advice, hints and tips for professionals working directly with adults and adolescents who may have histories or current experiences of trauma or abuse.
Whilst professionals working in dental practices may not be the first person someone would disclose to, as many as 1 in 5 adults have been abused in childhood (Crime Survey England and Wales, 2017) and 1 in 3 women will experience rape or attempted rape in the lifetime (CDC, 2018; WHO, 2018).
This means that many of the patients attending the practice for appointments may have histories of abuse and sexual trauma, all at different stages of processing and coping with how they feel about what happened.
In this document, dental professionals can learn about common trauma responses after sexual trauma and abuse, the ways these responses manifest in behaviour, how to talk to patients who are triggered by dental treatment and how to respond if a patient discloses abuse to them.
In addition to this document, VictimFocus has designed free PDF downloadable posters for waiting rooms and a patient wellbeing form to leave on tables or to offer to new patients which can collect data about their triggers, trauma responses and how best to help them during an appointment.
Examples of the posters are here >

About trauma and abuse

Children and adults can be subjected to many forms of abuse including sexual, domestic, psychological, physical and financial abuse. Similarly, trauma comes in all shapes and sizes. People experience trauma when they lose someone close to them right the way through to witnessing a fatal car accident.
A trauma is an experience that overwhelms a person’s ability to cope. This might be because:

• It is so distressing

• It happens at a young age

• It happens over and over again

• It happens at the same time as other stressful life events

• It reminds the person of bad experiences in their past

Whilst both traumatic experiences and being subjected to abuse is very common in all cultures, religions, communities and regions; many people never disclose, and some do not understand or acknowledge what happened to them. Those who do understand what happened to them are still unlikely to report or disclose the abuse or trauma, with current reporting rates of sexual violence at less than 13% in the UK (CSEW, 2017).
This means that in your dental practice, you will be working with patients who have experienced a range of traumas and abuses. Within this large group, only a small amount of people would have disclosed, reported or sought help. The rest may not have been able to disclose or seek help yet, may not understand what happened to them, may blame themselves, may be scared of speaking out, or may be confused as to why they are traumatised or distressed.
Trauma and abuse do not need to be related to medical settings or dental care to affect the patient in their dental appointment. Many patients will experience fears and trauma responses about coming to the dentist that are linked to feelings, memories or sensory input. The way that each patient expresses and copes with their distress, fear or trauma responses may be very diverse and sometimes difficult to identify.

However, you can make a positive difference to patients with trauma and abuse histories by simply reading this guidance, taking some small steps to listen to patients and to give them the opportunity of being more in control of their treatment. It may also help you to feel more confident about knowing what to say or do if a patient discloses to you why they are scared or why they respond in a particular way when they come to the dentist.

Trauma responses

Trauma responses are all of the different ways people can respond to a traumatic experience. Some trauma responses are automatic and sub-conscious (the brain prioritising self-preservation by responding quickly to threat to life, perceived danger or injury) and some trauma responses are linked to perception, thoughts, feelings and sensory input, which require executive functioning and processing.
A trauma response could include any of the following reactions and behaviours (please note that this is not an exhaustive list):

• Flashbacks and nightmares

• Anger and defensiveness

• Shaking and crying

• Becoming illogical or irrational

• Feelings of extreme fear and doom

• Becoming confrontational

• Experiencing physiological symptoms such as racing heart, chest pains or tightness, shallow breathing, numbness, tingling, dizziness, sweating, feeling sick and headaches

• Shock and non-response

• Fainting or passing out

Trauma responses can feel uncontrollable to the patient, who may respond in these ways without warning. Whilst they mimic the types of automatic trauma responses that we might expect to see if someone was in immediate danger, people who have experienced abuse often experience these trauma responses for months or years after the immediate danger has ended. These responses are also commonly misdiagnosed as other health issues or as psychiatric diagnoses.

Trauma Triggers

A trauma trigger is an association between something in the environment and the memory or feeling of trauma and abuse.

Example 1

Fay* is 38 now but between the ages of 8 and 11 years old, she was sexually abused by her Uncle. Her Uncle was a wealthy man who owned a collection of classic cars. He would take her into the car garage and let her sit in the cars to groom and abuse her. To this day, she cannot stand the smell of leather polish. Whenever she feels the texture of a leather sofa or smells leather polish, she begins to feel sick and dizzy. She feels her heart begin to race and her muscles tense up.
In the real-life example above, Fay had developed an association between the leather seats in the cars, the smell and texture of the leather – and the trauma of the abuse. This was such a strong association, that thirty years later, she still reacts with trauma responses when she smells or feels leather. These are her trauma triggers. These sensory inputs trigger her trauma responses in her brain and body.
From an evolutionary and self-preservation perspective, the trauma association is very important to keeping the person alive and safe. The association is made so that in the future, the person could remember what
dangers to avoid or what signs might mean impending threat or injury. So whilst a strong trauma reaction to leather may appear to be irrational or illogical, it actually makes complete sense when considered in the context it developed in and why the brain has formed the association as an attempt at self preservation.
Trauma triggers may be particularly prevalent in medical procedures and settings, due to the interpersonal nature of abuse and trauma.

Example 2

Rob* is a 54-year-old forklift truck driver and you have been seeing him for many years, on and off. He only comes to see you when he is in severe pain or has a serious infection. He does not attend regular check ups and he seems very nervous, quiet and agitated when you see him. Rob was sexually abused in a care home when he was a child, but he has never told anyone. When you lean over him and place your fingers in his mouth to check his teeth, it causes him to have flashbacks to the abuse. He disassociates and becomes very quiet. He doesn’t tell you because he is too embarrassed, so he only ever comes to see you when it is urgent. He thanks you, doesn’t make eye contact, and leaves.
In the second real-life example above, Rob has trauma triggers that are not related to the medical setting or the procedure specifically. However, they are relevant to dental care because one of his triggers is people touching his mouth or leaning over his face, putting things in his mouth. This set of triggers causes him to experience flashbacks that he has never had support with.

Triggers can be anything at all, and often they are very diverse and unique to each person. They do not need to be related to interpersonal abuse, and could be related to previous dental or medical experiences, natural disasters, witnessing violence, illness or death, losing a loved one or even a reaction to traumatic imagery in films.

Coping mechanisms

Employing the social model of mental health, all coping mechanisms serve a purpose and make sense in the context they originally developed within.
A coping mechanism is a strategy for dealing with trauma responses in day to day life. Just like the trauma responses, coping mechanisms are unique to each person. Many coping mechanisms are positive and useful.
Positive or negative, research has shown that most coping mechanisms can be categorised to serve two main purposes:

• To avoid overwhelming feelings and memories

• To manage the feelings of powerlessness and helplessness by regaining some form of control
(Eaton and Paterson-Young, 2018; Morrow and Smith, 1995)

Avoidance coping mechanisms might include denying the abuse or trauma ever happened, blocking out thoughts and memories or avoiding situations that remind them of the trauma.
Control and power coping mechanisms might include refusing to trust someone with their body, rejecting intimacy or touch, resisting rules or instructions, controlling eating or medication or trying to regain control of a situation in other ways.

Some coping mechanisms can appear combative, when they are usually about control or avoidance. This might include patients who become confrontational or suddenly refuse a procedure, tell you to stop touching them, become angry or agitated or deliberately avoid coming back for treatment they need.
It is important to see coping mechanisms in context, but this requires knowing more about the patient.

How your patient might feel about coming to their dental appointment

Everyone is different, but a patient who is affected by current or historic trauma or abuse may have a range of feelings about coming to the dentist, some of which are not specifically related to dental surgery at all.
Below is a list of possible worries, feelings and responses to coming to the dentist that might be experienced by someone with a trauma or abuse history: • Feeling out of control or helpless during the procedure • Not feeling informed about what you are doing • Triggered by people touching their face or mouth/inserting items into their mouth • Not feeling assertive enough to stop you, even if it hurts or scares them • Feeling they are a ‘burden’ to your service because they are scared or perceive themselves to be difficult • Worried about pain and injury • Triggered by being made to lie down on a bed • Worried they will cry or not be able to cope with the appointment • Triggered by the setting, equipment, noises or smells that they cannot control
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Nervous patients are common, but patients whose fears are linked to abuse and previous traumas are triggered by and nervous about specific things.
They may be worried about trusting you to touch their body and not to hurt them. They may know that they become defensive and angry when they are particularly scared. They may be very embarrassed that they are scared and try to pretend they are comfortable. Finally, they might be worried that telling you to stop or asking you not to do something will be ignored.
For some patients, these worries will be enough to keep them away from dental treatment for decades, but for others, it will mean they have trauma responses to dental treatment that they may or may not understand to be related to their abuse or trauma. They may attend appointments or only come when in urgent need of care, whilst forcing themselves to cope with or mask their psychological and physiological responses to the appointment, setting or treatment.

It is important to note that some patients are worried about seeing particular people. For example, some people who have been subjected to abuse would be very uncomfortable with a male dentist touching them (this goes for men and women – and male and female dental professionals). People can be triggered by appearance, body language, tone of voice, accent, facial hair, clothing and even perfume or aftershave.
This is not something that a dental professional can control or help, but it is worth remembering, especially if one of your patients is expressing a need for a particular person to be present or to perform the dental work.
Supporting your patient

The support you can offer to your patient will vary depending on what information you have about them and whether they have ever spoken to you about their feelings or responses. However, there are some small things you can do to support your patient in the appointment, even if you don’t know anything about them.

• Begin each appointment by welcoming the person and asking if they are okay

• Ask them how they feel about the appointment and if they need regular breaks or support

• Consider asking patients whether they need a friend or family member with them for support

• Explain to them that they are in control of what happens and that you will explain everything you do before you do it

• Always ask their permission before touching them or starting a new procedure • Agree a signal or way of stopping the treatment or examination if they become distressed – if they show this signal, stop immediately

• Discuss a technique to approach the treatment in short bursts of 10 or 20 seconds at a time

• Listen to their worries and validate them. Try not to dismiss or minimise how they feel by saying things like ‘it’s not that bad’ or ‘you will be fine’.

• Consider extra pain relief for minor procedures

• Ask if the patient needs some one to sit with them after the appointment

Techniques to help your patient to communicate with you

To deliver the best support to patients with experiences of trauma or abuse, they need to feel confident enough to communicate with you or the reception team about their needs and concerns.
However, this can be difficult to do – both for the dental professionals and for the patient. Finding ways to encourage communication about their needs is the first step to improving practice or becoming a more traumainformed service.
Here are some techniques you could try to open up lines of communication with your patients:

1. Use the free VictimFocus form template to ask new and returning patients to fill in a short form about their triggers and what will help them to cope with the appointment

2. Send out an email survey to all patients registered at the practice, inviting them to submit information about their needs and triggers which can be held securely on their file

3. Conduct a patient consultation on this topic to learn how your practice is already performing with the patients who have abuse and trauma histories

4. Provide forms or leaflets on tables and in the waiting room about trauma or abuse support in your area

5. Display the free VictimFocus posters in the waiting room to raise awareness of trauma responses and abuse

6. Offer patients to ‘Write a Note to the Dentist’ on which they can tell you something embarrassing or personal without them having to explain it to you verbally

Responding to a disclosure

As a dental professional, you may not have envisioned yourself receiving disclosures of trauma, rape and childhood abuse. However, as you are in a privileged position to provide personal health care in a medical setting, some patients may disclose to you as a way to explain how they feel or to explain why they are scared or uncomfortable. If you have built up a good rapport with your patient and they feel they trust you, they may also choose to disclose problems, traumas or abuse to you because you make them feel safe and valued.
If you have never been in this situation, the prospect of a patient describing abuse or disclosing trauma to you might be quite daunting. The most important things to remember are to listen carefully, to allow the patient to express themselves and then to ask a few simple questions to ensure they know you have listened to them and care about their disclosure.
First, thank them for telling you. You do not need to pass any further comment, so refrain from saying things like ‘that’s terrible’ or ‘that’s shocking’ or ‘I feel so sorry for what you have been through’ – often, people are not telling you for an emotional response, they are telling you because they feel you need to know for some reason.
Second, ask them some brief questions to establish what they would like you to do with
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the information and how you can help them in your job role.

Possible questions to ask your patient: • Do you have someone to support you today? • Does anyone else know, or have you ever sought any support before? • How do you feel about coming to the dentist? • Is there anything I can do differently that will make you feel more comfortable or safer? • Is there anything about the treatment or about what I do that makes you feel uncomfortable or unsafe? • If you do begin to feel distressed or uncomfortable, what shall we agree to do? Would you like to agree a technique or a signal? • Do you have any particular triggers or boundaries that I should know about so I can try to support you? • Do you have any preferences about who does your treatment (for example male or female dentist)? • Are you feeling okay to continue?
Questions should be asked in a compassionate and interested manner, to learn more about the patient and what they need. You may also ask permission to add the conversation to their records, so you can remember the specifics of what was said or anything you agreed to do for or with them.
Responding to panic attacks or distress
In some circumstances, you may become aware that a patient is having a panic attack, anxiety attack or had become very distressed. This could happen in the waiting room, as they walk in to talk to you, during the treatment or after the treatment. It is an advantage if they have a friend or family
member with them, but if they don’t it is important to make sure they are okay and to support them through the attack or period of distress. They should not be left alone in a waiting room or left to drive/walk home if they are clearly distressed or traumatised.
If your patient begins to experience a panic attack or other trauma response, the best way to support them is to already know what helps to ground them out of an attack, by asking them at reception, using forms or by talking to them before the appointment. However, if you do not know any information about the patient, immediately stop what you are doing and make them comfortable.
Explain clearly and calmly that you have stopped what you are doing to give them some time. Call for assistance if they become dizzy, faint, begin to hyperventilate or become confused or agitated.
Grounding techniques work differently for different people, so some things may or may not be effective. This is why asking people before appointments can be so important.
Some basic techniques to try: • Talk calmly and reassuringly to the person, reminding them that they are safe and that you will look after them • Try to get the person to breathe with you, as this can focus their mind on you and the act of breathing instead of the trauma response/memory • If they are able to articulate to you, ask them what they need or what you can do to help them • Offer them some water to sip slowly, which may refocus their mind on the water and the cup rather than the trauma response/memory
It is important to understand that these techniques are general advice and may not be helpful to some people. The best approach is to gather information about what the patient would need in advance of the appointment.
Hints and Tips
This section contains some miscellaneous hints and tips about supporting patients with trauma and abuse. • Be careful not to give too much information to a person who is distressed or experiencing a trauma response as they may not remember what you said to them • Consider providing email advice or leaflets to patients at the time of booking an appointment that advise them about trauma, abuse and whether to bring someone for support on the day • Remember that trauma and abuse is taboo for lots of people. It is not easily discussed or disclosed. For some, the consequences of telling someone may be very serious. Find ways of supporting patients without asking them for any details of the abuse or trauma • You can effectively support a patient without ever knowing the details of the abuse or trauma they suffered • Some people may feel the dental surgery they are having or have had in the past is the trauma or cumulative traumas that they now struggle with • Trauma and abuse can be perpetrated by health and social care work professionals, which adds a level of complexity to the distrust and anxiety the patient might feel about coming to the dentist • Some groups may not usually engage with statutory services, including health services – and may find that accessing the practice is a new and frightening experience. • On top of trauma or abuse, if people have not been to the dentist in many years, they may also feel embarrassed or ashamed of their teeth or oral health
What to do if you think a patient is currently being abused, exploited or harmed
Sometimes you might get the feeling, learn something or hear something that makes you concerned for the safety of your patient. It might be that you think they are currently being harmed, abused or exploited – or they might disclose to you that an injury or experience has happened to them recently as part of a rape, domestic violence, homelessness, bullying, sexual exploitation or trafficking.
If at any point you are concerned about this, talk to your patiently privately and sensitively, and explain that you are worried about them. Remain vigilant to patients who seem to be chaperoned by people who will not allow you to talk to them alone or seem to speak for them.
If in any doubt or if you have concerns, call your local adult or children’s safeguarding team and share the information you have. Remember to ask for consent of the patient to share the information, or if they are in immediate danger, inform them that you will be sharing the information with the safeguarding team in order to get further advice and to support their safety.

Potential Triggers in a Clinical Setting for Children with Past Trauma

A clinical setting can inadvertently trigger past trauma in children due to various factors. Here are some potential triggers to be aware of:

Sensory Stimuli:

• Sounds: Loud noises, drills, or even the sound of a heartbeat monitor can evoke traumatic memories.
• Smells: Certain smells, such as medical antiseptic or a particular perfume, may be associated with a traumatic event.
• Sights: The sight of medical equipment, white coats, or even the sterile environment can be triggering.
• Touch: Painful procedures or invasive examinations can reawaken traumatic experiences.

Procedural Factors:

• Injections: The fear of needles can be heightened in children who have experienced painful injections in the past.
• Restraint: The use of restraints, even if necessary, can be perceived as a threat or control, evoking feelings of helplessness.
• Waiting Rooms: The waiting room environment, with its unfamiliar faces and potential for unexpected events, can be anxiety-inducing.

Interpersonal Factors:

• Authoritarian Figures: Children who have experienced abuse or neglect may have difficulty trusting authority figures, such as doctors or nurses.
• Lack of Control: Feeling powerless or out of control can be triggering for children who have experienced traumatic events.
• Dismissive Attitudes: Dismissing a child’s fears or concerns can reinforce feelings of being unheard or unimportant.

Emotional Triggers:

• Separation Anxiety: Children who have experienced separation trauma may struggle with being away from caregivers.
• Fear of Abandonment: The fear of being left alone or abandoned can be heightened in children with past trauma.
• Shame or Guilt: Feelings of shame or guilt associated with past experiences can be triggered by the clinical setting.

By being aware of these potential triggers and implementing trauma-informed care strategies, healthcare professionals can help create a safer and more supportive environment for children with past trauma.

 

Children specific considerations

Exploring associations between adverse childhood experiences and oral health among children and adolescents

Objectives: The aim of this article is to examine the association between preventive dental care and adverse childhood experiences (ACEs), and the association between tooth decay and ACEs, controlling for preventive dental care.

Methods: A cross-sectional study was conducted with a sample of 33,395 respondents from the 2016 National Survey of Children’s Health, a nationally representative sample of US children. Sociodemographic information, ACE questions, and oral health and health-care utilization information were used. Descriptive statistics, bivariate analyses, and multivariable regression models were performed.

Results: Children with four or more ACEs were less likely to have a preventive dental visit than children with less than four ACEs (79.7 percent versus 88.7 percent, P < 0.0001). Children with four or more ACEs were more likely to have tooth decay (26.7 percent versus 12.5 percent, P < 0.0001) than their counterparts. Children exposed to four or more ACEs had lower odds of receiving preventive dental visits than children exposed to less than four ACEs (aOR 0.67; 95 percent CI 0.50-0.89). Children with four or more ACEs had higher odds of decayed teeth than children exposed to fewer than four ACEs (aOR 2.08; 95 percent CI 1.61-2.70), even after controlling for preventive dental care.

Conclusions: Pediatricians, dental hygienists, and dentists need to be aware of how childhood trauma may hinder both caregivers and children from engaging in preventive oral health care or dental treatment. The information provided in our study can inform policies and programs that support children’s oral health, through the identification and mitigation of childhood trauma.

 

 

The journey to becoming trauma-informed – using pilot trauma training data to highlight the role of dental services in supporting patients affected by psychological trauma

Rates of psychological trauma are increasing in the community. Psychological trauma symptoms may prevent patients from being able to access or tolerate dental treatment. The importance of dental teams providing equitable person-centred care by adopting a trauma-informed approach is discussed. One way to support dental services to be trauma-informed is through training staff in psychological trauma. An example from a Scottish Dental Hospital is provided.

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About VictimFocus
VictimFocus is an independent research, consultancy and campaigning organisation founded by Jessica Eaton in 2016. Jessica has recently finished writing up a PhD in forensic psychology, specialising in the victim blaming and self-blame of women and girls who have been subjected to abuse. In 2018, she coauthored The Little Orange Book: Learning about abuse from the voice of the child.
In September 2018, VictimFocus launched the VictimFocus Independent Publishing House to enable the development and publication of free and affordable resources for the public and for professionals. In Summer 2019, VictimFocus is expanding to launch an affordable global E-learning platform and webinar series for professionals and the public.
The ethos of the organisation is to provide challenging, critical and influential research, resources, guides, materials and training to improve practice all over the world.
VictimFocus specialises in the psychology of sexual violence, abuse and trauma – with a special focus on the psychology of victim blaming and victim support.
The website provides a free blog with over 35,000 readers per month, a collection of free educational YouTube videos and a platform containing real life stories, free and affordable professional training and resources.
Finally, the website also hosts a number of initiatives including the VictimFocus Charter, the VictimFocus Grant Fund Scheme and the VictimFocus Research Programme.

References

The experience of adverse childhood experiences and dental care in childhood

Exposure to childhood adversity could be an important predictive factor for poor dental health. As
oral health is an important part of a child’s overall health status, approaches that seek to improve dental health across the life-course should start with safe and nurturing childhoods free from abuse and neglect. Given the growing role that dental professionals have in identifying violence and abuse, it seems appropriate to raise awareness in the field of dentistry of the potential for individuals to have suffered adverse childhood experiences, and the mechanisms linking childhood adversity to poor dental health.

Dental fear in sexually abused women

The aim of the present study was to investigate dental fear in women who have been exposed to different kinds of sexual abuse. In a cross-sectional questionnaire study, 99 sexually abused women were divided into three groups: one group who reported having been exposed to sexual touching (ST); one group who reported intercourse (IC); and one group who reported sexual abuse involving oral penetration (OP). The mean score on dental fear assessments was significantly higher for all groups than for Norwegian women in general. Women in the OP group scored significantly higher than women in other groups on dental fear. The majority of the women reported that they had experienced problems in relation to dental treatment situations. About half of the women in the OP group and one-third in the other groups reported that they had never considered that there was a relationship between the abuse and their problems with dental treatment situations. Significantly more women in the OP group reported that they had not been aware of the relationship, possibly because the abuse had been repressed. The majority of the women with extreme dental fear had never informed a dentist that they had been sexually abused.