This year, I am celebrating 40 years as a dental hygienist. It wasn’t until a few years ago, however, that I began to understand how trauma can play a role in patients’ anxiety and fear of dental treatment. Realizing our patients may have experienced life traumas and adverse childhood experiences (ACEs) can help us deliver compassionate, trauma-informed care (TIC). There is a lot we can do as dental professionals to help make patients’ appointments as comfortable and safe as possible to effect better health outcomes. Equally important is to recognize that dental providers may also have experienced ACEs, and we must take care of ourselves if we want to help others.
Abuse is a global issue. In 2020, the World Health Organization (WHO) reported that 1 billion children between ages 2 and 17 had experienced some type of abuse, including sexual, physical, and emotional abuse.1 WHO also stated that 20% of women and 7.5% of men reported having been sexually abused as children.2
Cause and effect of trauma
ACEs were first defined in 1995. The concept originated in a groundbreaking study conducted in 1995 by the Centers for Disease Control and the Kaiser Permanente health-care organization in California. The study looked at three categories of possible adverse experiences that included physical and emotional abuse, neglect and household dysfunction (including caregiver mental health issues), and family violence.3 Evidence demonstrates that children with more ACEs also have more caries, and adults with more ACEs likewise experience more caries and periodontal disease.1 For kids, it is possible that their caregivers are not aware of the state of their oral/overall health, thus contributing to a higher risk for caries.1
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In addition to the ACEs, other factors can contribute to poor health: exposure to war, death of a parent, community violence, racism, and lack of support often leading to toxic stress.3 Toxic stress is prolonged activation of the stress response when there are no protective factors or healthy relationships. ACEs and toxic stress affect one’s ability to thrive and increase the risk for many physical, emotional, and mental health issues that can be lifelong. Not only can these experiences be costly in terms of negative health consequences, but also in monetary costs associated with chronic illnesses, fewer job/educational opportunities, a harder time staying employed, sexually transmitted diseases (STDs), teen pregnancies, and the fact that children of those with ACEs are more likely to follow suit.4
The more traumas a person experiences and the earlier they experience them, the higher the risk for severe outcomes.5 Children who identify as LGBTQ are at greater risk for experiencing trauma, as are Black and Hispanic children.5 Depending on their age, some signs of ACEs can include: fear of strangers, anxiety, difficulty eating and sleeping, difficulty with relationships, aggressiveness, stunting of developmental growth, nightmares, withdrawal, participating in risky behaviors, feelings of guilt and shame, suicidal ideation, and difficulty in school.5 Language delays can occur in younger children, causing difficulty in communicating.1
Know the signs
Recognizing the signs that a child may be experiencing ACEs should raise a red flag for practitioners. Survivors of trauma are more likely to smoke, drink alcohol, overeat, use drugs, and take part in other self-destructive behaviors that offer some short-term relief but lead to poor health outcomes in the long term.6 If we are not aware of the signs and symptoms, we are more apt to retrigger the toxic stress, making these patients even more afraid of seeing us. There are more than 40 different health-related problems connected with ACEs: depression, anxiety, heart disease, COPD, cancer, diabetes, lung disease, liver disease, and obesity, to name a few.7
Instead of seeing these patients as difficult, let’s start looking at them from a unique perspective, knowing something deeper may be causing their behaviors. Maybe they chronically cancel, reschedule, or miss their appointments. Maybe they don’t want the chair reclined very far. Or maybe they talk a lot, making it difficult for us to do our jobs.
Treating patients who’ve experienced trauma
More than likely, we treat patients who have a history of trauma but do not exhibit any signs.8 If we don’t understand how to provide empathic care, these patients can easily be retriggered during an appointment, increasing the likelihood of anxiety and fear.8 We need to be careful with our language. Jeanne Bereiter, MD, at the department of psychiatry and behavioral sciences at the University of New Mexico, suggests saying: “What happened to you?” instead of “What’s wrong with you?”9 This puts the onus on the experience rather than judgment.
Patients who have had traumatic experiences in the dental office find it difficult to commit to appointments. What about patients who have not had bad experiences, yet they still fret about seeing us? Any kind of bad experience—not just dentally related—can reactivate the initial trauma during a dental appointment. We can’t prevent everything, but we can listen and take a few extra minutes to check in with our patients. Assume that everyone walking into your office has had some sort of stress or trauma in their life.10 This will help us be in the habit of using trauma-informed practices with all our patients.
Never assume that just because a patient is sitting in the dental chair, they are giving consent for us to put our hands in their mouth. Sexual abuse is one of many types of possible abuse. When a child is sexually abused, the abuser is in a position of authority, often manipulating the child into a false trust.11 This type of relationship can bring up a multitude of emotions and challenges that can include guilt and shame.11 Sexual abuse survivors have difficulty being assertive and worry that they will be judged, because their perpetrator likely made them feel that way.11
When I go to schools to do sealants, I ask each kid first if it’s okay for me to look in their mouth with my hands or fingers. One kid said no, so I said, “No problem; maybe next year you will be ready for me to look.” When we ask, listen, and care, we are empowering our patients, giving them a positive experience and a feeling of safety. Survivors of sexual abuse often have low self-esteem and believe that they are bad, because in the past they have been blamed by their perpetrators.11 This vicious cycle keeps them from coming to see us on a regular basis as they suffer more fear and anxiety. Since they often don’t take good care of themselves, there is more oral disease in these patients.11
Effective communication helps with patient engagement, but it’s even more important with those who have experienced trauma. Knowing your patient as well as possible—i.e., what medications they’re taking, any chronic health issues, mental health issues, and other behaviors that might indicate that they have experienced trauma—is imperative.
So, what is trauma? According to the Trauma-Informed Care Implementation Resource Center, “Trauma is a pervasive problem.12,13 It results from exposure to an incident or series of events that are emotionally disturbing or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, and/or spiritual well-being.”13 TIC teaches people to recognize, understand, and respond to trauma in a positive way that does not trigger previous experiences.9 It includes six core principles for patients and providers: physical and mental safety, decision-making that builds trust and transparency, peer support, collaboration on all levels, empowerment, and humility and responsiveness.13
The trauma patient in your chair
What can we do to make appointments more comfortable so that our patients make return visits and take care of their oral health? By utilizing the TIC approach, we can support and build healthy relationships between provider and patient. This results in better health outcomes and helps prevent retraumatization; it can also increase patients’ joy.13
We ask our patients to trust us that the treatment we provide is in their best interests. Unfortunately, trust is a huge issue for those who have experienced ACEs, making it more difficult for them to seek health care and compounding their health issues.14 Anxiety is easily triggered, especially in a dental office where we have to touch our patients’ lips, tongue, head, and put our fingers in their mouth.14,15 The head and neck are the areas on the body that comprise more than half of all abuse cases in children, and when there is sexual abuse, the oral cavity is a prime target by the perpetrator.6
Think about other aspects of dentistry, like putting the saliva ejector or HVE suction tip in the patient’s mouth and how this may trigger thoughts of old abuse. Even a bite block and impressions can elicit fear and anxiety as the patient feels a loss of control because they can’t close, breathe, or swallow.6 Performing an intra-/extraoral cancer screening can also elicit a negative response if we don’t ask permission and explain what we’re doing and why.6 Trust must be established over time; it can never be assumed.9
People with a history of abuse may have more difficulty forming healthy relationships, including those with health-care providers. Because shame and guilt are often the aftereffects of abuse, many people will partake in self-destructive behaviors such as self-medicating with drugs and alcohol.14 These behaviors can increase the risk for oral disease and make it likely that oral care is not high on their priority list. Having the patient recline in the dental chair and look up at the ceiling while we peer down upon them might be similar to the position they were placed in while being abused.11 This places us in authority, leaving the patient feeling vulnerable.11
Toxic stress can initiate the fight-or-flight response. If the stress is chronic, the patient may experience large amounts of cortisol, which affect the developing brain.7 Such stress can provoke the individual to be quick to anger and have social, behavioral, cognitive, and physical challenges.7
What can we do as practitioners? First, get TIC-trained. Simple things can make a big difference. Make sure your office environment is warm and friendly, and that the patient understands the procedures so they can make an informed consent. Check with them about what they cannot manage and see if there is a way to respect those wishes.16 I ask my patients to raise their hand if they need me to stop or if something is bothering them; offering breaks during treatment can be helpful.11 You might need to ask permission to proceed before each step of the procedure.17 Giving trauma survivors the power to decide helps them feel more in control.
We can have younger kids come in before their appointment to get used to the office, take a ride in the chair, see the polisher, smell the paste, and hold the mirror. For all ages, tell-show-do is important to prevent shock and surprise.6 Ask the parent or guardian if they know what has helped in the past. After setting rules and boundaries, if the parent or caregiver is in the treatment room, let them know that they cannot interrupt the procedure.1 You might need to sign a pretreatment contract.
Collaborating with other health-care providers to learn more about the patient’s history can be valuable. Cognitive behavioral therapy (CBT) has been shown to help reduce fear and anxiety during dental treatment.1 We can also offer shorter appointments and do the most minimally invasive dentistry possible depending on the diagnosis.1
Creating a safe environment with respect includes active listening, demonstrating care and empathy, and respecting boundaries.16 TIC involves the patient and provider working together with not only safety in mind but also enabling the patient to take responsibility for their care and decisions.9 The patient will then be an active participant of their treatment plan.16
According to Stalker et al., survivors of sexual abuse benefit from questions such as: “Are there any parts of dental treatment that are particularly difficult for you? Is there anything we can do to help you feel more comfortable?” One survivor said, “Just ask that question: Are you comfortable? Is there anything you need?”11 Find out what might have helped them in the past; maybe it’s listening to music or a book, having their eyes covered with an aromatherapy cloth, sitting under a weighted blanket, using an essential oil they bring with them to calm or to help with dental office smells.
As providers, it’s imperative that we do not judge our patients, especially if it’s been a long time since they have seen us and they have a lot of oral disease. Even our tone/loud voice can trigger past traumas and fears.1 Best communication practices include active listening, eye contact, and facing the patient.1 Sometimes touching the patient’s shoulder can offer comfort. Be careful though, because with trauma survivors, extra touching can also retrigger traumatic experiences.1
TIC can increase better health outcomes for patients and provide more enjoyable working conditions for dental professionals. Both can also benefit from self-care, such as exercise, meditation, work-life balance, reading, or even trying something new. To learn more about trauma-informed care, visit the Trauma-Informed Care Implementation Resource Center at rdhmag.com/traumainformedcare.
Editor's note: This article appeared in the June 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
- Oh JE, Lopez-Santacruz HD. 2020. Adaptation measures in dental care for children with history of adverse childhood experiences: a practical proposal. Spec Care Dentist. 2021;41(1):3-12. doi:10.1111/scd.12527
- Violence against children. World Health Organization. June 8, 2020. https://www.who.int/news-room/fact-sheets/detail/violence-against-children
- ACEs and toxic stress: frequently asked questions. Center on the Developing Child. Harvard University. 2020. https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/
- Preventing adverse childhood experiences (ACEs): leveraging the best available evidence. Division of Violence Prevention. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention. 2021. https://www.cdc.gov/violenceprevention/pdf/preventingACES.pdf
- Bartlett JD, Steber K. How to implement trauma-informed care to build resilience to childhood trauma. Child Trends. May 9, 2019. https://www.childtrends.org/publications/how-to-implement-trauma-informed-care-to-build-resilience-to-childhood-trauma
- Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: providing trauma-informed care. J Am Dent Assoc. 2014;145(3):238-245. doi:10.14219/jada.2013.30
- We all have a role in preventing ACEs. Injury Prevention and Control: Division of Violence Prevention. Centers for Disease Control and Prevention. October 19, 2018. https://vetoviolence.cdc.gov/apps/aces-training/#/
- Raja S, Rajagopalan CF, Kruthoff M, Kuperschmidt A, Chang P, Hoersch M. Teaching dental students to interact with survivors of traumatic events: development of a two-day module. J Dent Educ. 2015;79(1):47-55.
- Bereiter J. 2017. Vicarious trauma and burnout in healthcare providers and how a trauma informed system can help. IHS Trauma Informed Care & Historical Trauma Informed Care Webinar Series: Part III in 3 part series for healthcare providers. Division of Community Behavioral Health. Department of Psychiatry and Behavioral Sciences. University of New Mexico Health Sciences Center. https://www.ihs.gov/sites/telebehavioral/themes/responsive2017/display_objects/documents/slides/traumainformedcare/ticmedicalthree082417.pdf
- Trauma informed care in the dental office. Pennsylvania Academy of General Dentistry. October 7, 2021. https://pagd.mynewscenter.org/trauma-informed-care-in-the-dental-office/
- Stalker CA, Carruthers Russell BD, Teram E, Schachter CL. Providing dental care to survivors of childhood sexual abuse: treatment considerations for the practitioner. J Am Dent Assoc. 2005;136(9):1277-1281. doi:10.14219/jada.archive.2005.0344
- What is trauma? Trauma-Informed Care Implementation Resource Center. Center for Health Care Strategies. 2021. https://www.traumainformedcare.chcs.org/what-is-trauma/
- What is trauma-informed care? Trauma-Informed Care Implementation Resource Center. Center for Health Care Strategies. 2021. https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/
- Abuse/survivors of abuse. Good Therapy. Updated November 21, 2019. https://www.goodtherapy.org/learn-about-therapy/issues/abuse
- Willumsen T. The impact of childhood sexual abuse on dental fear. Community Dent Oral Epidemiol. 2004;32(1):73-79. doi:10.1111/j.1600-0528.2004.00120.x
- Douglas LM. Dental hygiene care for survivors of childhood abuse. Oral Health. September 26, 2018. https://www.oralhealthgroup.com/features/dental-hygiene-care-for-survivors-of-childhood-abuse/
- Larijani HH, Guggisberg M. Improving clinical practice: what dentists need to know about the association between dental fear and a history of sexual violence victimisation. Int J Dent. 2015;2015:452814. doi:10.1155/2015/452814