When trauma affects the mouth: Oral health in domestic violence survivors
Key Highlights
- Domestic violence’s psychological toll often leads to neglected oral care, bruxism, and higher caries risk.
- Anxiety, depression, and PTSD strongly correlate with worsening oral health outcomes.
- Survivors frequently present with TMJ disorders, facial pain, and oral injuries from physical abuse.
- Many dental hygienists feel unprepared to ask about or report suspected DV cases.
- Improved training and clearer reporting guidelines can help hygienists confidently support DV-affected patients.
Editor's note: This article was written by five senior dental hygiene students, with oversight from their professor, Annie Walters, as part of their community oral health project for their capstone. They attend Northern Arizona University.
Domestic violence (DV) gained recognition as a public health issue in the 1970s, as advocacy efforts expanded legislation and resources for victims of DV.1 Affecting approximately 41% of women and 26% of men, the widespread effects of DV have been frequently recorded.2
Specifically, the literature offers more insight into the long-term psychological effects of DV. The mental struggles that come with escaping abusive environments have been repeatedly recorded as a causative agent in the decline of one’s self-care. The goal of this article is to explore an observed gap in research regarding this subject.
While there is much literature connecting DV to mental health struggles, there is very limited research into how DV affects oral hygiene. A better understanding will be gained of how the physical and psychological effects of DV impact oral hygiene.
Oral health-care professionals have been identified as important figures in recognizing domestic abuse. It’s only reasonable that clinicians should be accurately informed on how DV can impact a patient’s oral health.
Correlation between mental health and oral health
DV and mental health have a bidirectional relationship.3 Mental health can be the result or the catalyst of DV. The most frequently associated mental illnesses with DV are depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation.4
Statistical trends indicate that DV occurs more frequently in populations that experience poverty, discrimination, and substance abuse disorders.3 DV research also favors women and children in their samples. The lack of representation of male survivors of domestic abuse in research is most likely a result of the disproportional occurrences of DV between genders. Approximately one in three women and 1 in 10 men 18 years of age or older experience domestic violence.5
The willingness of participants to disclose personal information about their DV or associated mental health issues can act as a barrier for male study participants as these topics are often associated with shame, particularly for male victims.
Research on DV is isolated to female subjects because it’s often narrowed down to intimate partner violence (IPV). IPV implies the behavior of a current or previous partner that inflicts physical, sexual, or psychological harm.3
Studies on children imply that DV can cause an increased risk of psychiatric disorders as the victims mature. Witnessing acts of DV at a young age can increase a child's risk of PTSD, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, academic problems, and a high incidence of substance abuse.5 Mental health as a comorbidity of DV has a clear correlation across research, even if disproportional circumstances or subpopulations majorly restrict it.
Adverse mental health experiences can create barriers to sustaining oral health in many individuals. Not only is this due to a lack of oral home care, but there can be adverse side effects to these negative experiences. These participants were more likely to face issues such as bruxism or demineralization due to attrition or purging due to an eating disorder.6
With these dental implications, there’s an increase in decay and caries in participants' oral cavities.6 In patients who struggled with mental health, there was not only an increase in decay but in restorative needs as well.6
Psychological disorders such as anxiety and depression can create problematic circumstances for individuals that lead to tooth decay, gum disease, and other oral health issues. Compared to controls, people suffering from a mental illness had more surfaces that were filled, missing, and decayed.6
These findings created a direct correlation between common mental health disorders and more extreme oral disease. Tooth loss and decay were more common in participants with depression than in nonsmokers.6 This is due not only to a lack of oral home care and barriers to dental care, but also frequent use of medications.6
An individual with more intensive health disorders may be taking medications that have negative effects on the oral cavity. It is also seen that participants who internalize their disorders and do not treat them experience manifestations of oral disease over longer periods.7 Whether diagnosed or undiagnosed, mental health disorders are linked to negative oral health outcomes.
Risk factors
Along with the correlations between mental health and oral health, a correlation between DV and oral health issues is highlighted through research, particularly among women and children.8 Victims of DV are at an increased risk for a variety of oral health issues, such as temporomandibular joint disorders, facial pain, and injuries to the mouth and jaw.8
Bruxism is very common in DV survivors and can exacerbate issues with the TMJ and facial pain.9 These problems are often heightened by the psychological stress, anxiety, and trauma that many survivors experience. These mental disorders can lead to neglect of oral health, thus leading to increased susceptibility to caries and periodontal disease.
In cases of physical abuse, direct injuries to the oral cavity, including broken teeth, oral lacerations, and jaw fractures, are common.8 Anxiety is prevalent among DV survivors, and dental anxiety can alter a patient's willingness to seek dental care, making it challenging to address their oral health needs.9
Dental hygienists as mandated reporters
While the impact of DV on physical and mental health is well documented, oral health is often overlooked as a critical aspect of care for survivors. Dentists and other health-care providers are in a unique position to identify signs of abuse. These health professionals are encouraged to be vigilant for oral injuries and behavioral indicators that may signal DV and then apply their ethical duty of being a mandated reporter.
Addressing the oral health needs of DV survivors requires a multidisciplinary approach with enhanced education and training for health-care providers to better support individuals affected by DV.9
A recent pilot study in Minnesota explored dental hygienists' readiness to handle cases of DV, especially during the COVID-19 pandemic when cases increased.10 Using a survey, the study assessed the knowledge and attitudes of hygienists attending a professional meeting. Results showed moderate knowledge (average score: 11.6/17) but a lack of confidence in managing DV situations. Over 60% felt unprepared to ask patients about abuse, and only half knew how to respond or understand their legal reporting duties.10
Despite recognizing the importance of identifying DV, many hygienists lack the tools and training to act. The study emphasizes the need for improved education and clearer guidelines to help dental professionals confidently support victims and meet their legal and ethical responsibilities as mandated reporters.
Conclusion
The literature ultimately reveals the undeniable relationship between DV, mental illness, and poor oral health. People who have been exposed to DV are more likely to develop mental health disorders, which places them at a higher risk for neglect of their oral care.5
Victims of DV are also at risk for physical injuries that can negatively influence their ability to maintain sufficient oral health.8 More research about these topics would highlight the risks of dental neglect and raise awareness about the importance of oral health, as well as address the limitations of current research.
The oral cavity is the window to the body: it tells dental professionals about the overall well-being of their patients. Perhaps requiring training as part of continuing education requirements could be a way to improve dental professionals’ confidence in identifying signs of abuse and what actions to take. More research must be conducted to provide them with the knowledge to adequately care for these patients.
References
1. Kornblit AK. Domestic violence–an emerging health issue. Soc Sci Med. 1994;39(9):1181-1188. doi:10.1016/0277-9536(94)90350-6
2. National intimate partner and sexual violence survey. U.S. Centers for Disease Control and Prevention. May 16, 2024. https://www.cdc.gov/nisvs/documentation/index.html
3. White SJ, Sin J, Sweeney A, et al. Global prevalence and mental health outcomes of intimate partner violence among women: a systematic review and meta-analysis. Trauma Violence Abuse. 2023;25(1):494-511. doi:10.1177/15248380231155529
4. Pico-Alfonso MA, Garcia-Linares MI, Celda-Navarro N, et al. The impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. J Wom S Health. 2006;15(5):599-611. doi:10.1089/jwh.2006.15.599
5. Huecker MR, King KC, Jordan GA, Smock W. Domestic Violence. StatPearls. 2023. https://www.ncbi.nlm.nih.gov/books/NBK499891/
6. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders–a systematic review and meta-analysis. J Affect Disord. 2016;200:119-132. https://pubmed.ncbi.nlm.nih.gov/27130961/
7. Kalaigian A, Chaffee BW. Mental health and oral health in a nationally representative cohort. J Dent Res. 2023;102(9). https://doi.org/10.1177/0022034523117110
8. Hendler TJ, Sutherland SE. Domestic violence and its relation to dentistry: a call for change in Canadian dental practice. J Canad Dent Assn. 2007;73(7). https://www.cda-adc.ca/jcda/vol-73/issue-7/617.pdf
9. Kundu H. Domestic violence and its effect on oral health behaviour and oral health status. J Clin Diagnos Res. 2014;8(11). doi:10.7860/jcdr/2014/8669.5100
10. Clark BL, Arnett MC, O’Connell MS, Marka N, Reibel Y. Domestic violence knowledge and attitudes among Minnesota dental hygienists: a pilot study. J Dent Hyg. 20223;97(1):33-42. https://jdh.adha.org/content/97/1/33
About the Author
Annie Walters, MS, RDH
Annie Walters, MSDH, RDH, has extensive experience as an oral health-care provider. She has spent time caring for individuals in Guatemala and Indian Health Service sites and is passionate about advancing access to care for individuals with specialized health care needs. She is a published author and is trained in Orofacial Myofunctional Therapy. Annie received her graduate degree from the University of New Mexico and currently serves as an assistant clinical professor at Northern Arizona University. Reach her at [email protected].