Dental Hygiene Care for Survivors of Childhood Abuse

We have all been mystified and even exasperated by our more challenging clients, for example: those with inadequate self-care despite having sufficient manual dexterity; and people who attend irregularly for dental care, or fail to show up for scheduled appointments. We might also encounter individuals who panic if reclined in the chair, or seem angry, or apathetic. I became aware that these behaviours could be related to mental health issues, like dental phobia.

Dental phobia is classified as a specific phobia within the Diagnostic and Statistical Manual of Mental Disorders. Dental phobia is frequently a consequence of previous negative experiences with dental care. 2,3 Others with dental phobia might have been childhood victims of violence, or sexual abuse. Survivors of abuse have experienced betrayal, trauma, and violation of their personal boundaries; they are often stigmatized, and made to feel powerless. Childhood sexual abuse, particularly of young children may also be oral in nature, causing survivors to experience difficulties tolerating various aspects of oral healthcare.

Prevalence of Childhood Abuse
The incidence of child abuse, especially sexual abuse, is under-reported because the victims are usually coerced into secrecy; most survivors maintain this silence into adulthood, often out of shame. A 2003 study found that 32.3% of women and 14. 2% of men reported sexual abuse in childhood, and 21% of adults who reported histories of childhood sexual abuse also experienced other physical maltreatment. 4 Research has shown that child abuse occurs in all countries studied 5, and is not limited by ethnicity or socio-economic status; children with disabilities are more likely to be abused. 6 Studies suggest that sexual abuse of male children by adult females occurs more frequently than was previously thought. Sadly, this might be taken less seriously, although males experience as much trauma as female survivors.

Factors Which Might Compromise Self-Care and Regular Attendance
A history of trauma or abuse could lead to depression and low self-esteem, causing survivors to feel unworthy of proper health care. They might have an aversion to being touched, and to having their personal space invaded. Certain aspects of a dental visit could trigger flashbacks: this can manifest as distrust, anxiety, hypersensitivity, irritability and a tendency to startle easily. Some individuals also display anger, or aggression. Triggers vary, from sights, sounds and smells, to something about a clinician’s appearance which reminds a survivor of their abuser. The view of the ceiling while lying in the dental chair could be a trigger, which reminds the survivor of the position they were forced into while being abused.

Some victims cope with the violation of their body by entering a dissociative state, in order to detach themselves from the abuse they are powerless to fight off. During dissociative episodes, they experience altered perception, sensation and sense of time. These individuals have also learned to dissociate from pain, which could lead them to ignore symptoms of disease and delay seeking help, thus delaying an accurate diagnosis. If they are stressed during their dental appointments, they might become dissociative, causing them to appear inattentive or apathetic.

How We Can Help
Understanding how these factors affect our clients is termed trauma-informed practice 7: this integrates with the principles of sensitive practice 8, to create an environment in which clients feel safe.

Trauma-Informed Practice
The principles of trauma-informed practice were distilled from the literature, and clinician input.

• Trauma Awareness—the foundation of trauma-informed care begins with awareness of the commonness of traumatic experiences, and how the impact of trauma can profoundly affect one’s development. We also need to be aware of the various adaptations people make to cope and survive after trauma, and the relationship of trauma to substance use, physical health, and mental health concerns.
• Emphasis on Safety and Trustworthiness—Physical, emotional, and cultural safety for clients is crucial to trauma-informed practice, because trauma survivors often feel unsafe. They are likely to have experienced abuse of power in important relationships, and may currently be in unsafe situations. Facilitate safety and trustworthiness by making the office environment welcoming and non-threatening, providing clear information, and ensuring informed consent.
• Opportunity for Choice, Collaboration, and Connection—the trauma-informed approach creates safe environments that foster a sense of efficacy, dignity, and personal control for clients. This includes open communication, providing choices as to treatment preferences, and working collaboratively with clients.
• Strengths Based and Skill Building—Helps clients to identify their strengths and develop coping skills by recognizing triggers, calming, centering, and staying present.

The Principles of Sensitive Practice form The Umbrella of Safety 9:

1. Respect means acknowledging the inherent value of each individual, and suspending critical judgement. Respect means a great deal to survivors of abuse; we can show respect by listening to the client, and heeding their concerns.
2. Taking time to make the client feel genuinely heard and not rushed.
3. Rapport is built by showing caring, concern and empathy, and using active listening techniques.
4. Sharing Information: Being transparent, by informing clients of their choices so they can give us their informed consent. They also need to know what to expect during their treatment, and the rationale for each procedure. Follow up verbal oral health counseling with written materials.
5. Sharing Control: Helping clients to feel a sense of control during treatment by working with, not just on the client addresses abuse-related fears and facilitates compliance. In addition to obtaining informed consent before a procedure, we should ask our clients what they can tolerate, and reaffirm consent at different stages of the appointment. They should be assured that they can stop for a break at any time, and they can indicate if they are not comfortable by communicating with previously agreed hand signals.
6. Respecting Boundaries: The disregard of personal boundaries during abuse teaches victims that their wants and needs are of no consequence. We should ask for consent before entering the client’s personal space, as well as before beginning a procedure.
7. Fostering Mutual Learning: Many survivors of trauma have learned not to question professionals, and may need encouragement to assert their autonomy and participate fully in their own health care. We clinicians can also learn from our clients how best to manage their care.
8. Understanding non-linear healing: The ability of a survivor to tolerate examination and treatment might vary from one visit to the next, as they experience good days, and bad days.
9. Demonstrating awareness and knowledge of interpersonal violence by having educational materials in the office to show victims and survivors that they are not alone.

Recording a Disclosure
If a client chooses to disclose their history to us, we must ask them whether they want other healthcare providers to be informed, and if so, ensure that they are comfortable with how we record the disclosure in our notes. For example, one male survivor spoke of health care professionals who wrongly assumed he was a perpetrator because of an ambiguous entry in his clinical notes stating “history of sexual abuse”, an assumption also made because of his gender.

Management of Anxiety and Pain During Treatment
Stress is known to precipitate medical emergencies 10,11 due to sympathetic stimulation, and pain during treatment is a significant stressor. Clients with dental phobia frequently decline local anaesthetic injections: alternative modalities to relieve sensitivity during scaling include pre-treatment application of a rapid-acting desensitizing paste, for example: one containing bio-available calcium and phosphate, or Pro-Argin. 12 Another option is Non–Injectable Local Anesthesia (NILA): such as a thermosetting liquid gel mixture of lidocaine 2.5% and prilocaine, 2.5%, delivered subgingivally. 13

Nitrous oxide and oxygen sedation might be administered by the dentist during treatment, but many survivors dislike the feeling of loss of control they experience under sedation. Drug-free options for management of dental anxiety and pain include eupnea (deep breathing); 14 and sensory modulation in the form of a weighted blanket 15; or virtual reality. 16 Psychology plays a significant role in pain perception: in order to experience pain, conscious attention is required. 17 Eupnea reduces pain, and calms by means of distraction, and parasympathetic stimulation. This increases levels of oxygen and melatonin, while decreasing cortisol and blood pressure. Weighted blankets relieve anxiety by deep pressure stimulation, which activates the parasympathetic nervous system. 18 Virtual Reality (VR) utilizes advanced technologies to immerse clients in an interactive, virtual environment, which distracts their attention from pain perception, and allays anxiety. 19

Motivational Interviewing for Oral Health Counseling
Motivational interviewing 20 integrates well with the principles of trauma-informed, sensitive practice, because it is a non-judgmental and non-confrontational technique that promotes client autonomy. Knowledge alone of the dire consequences of lack of care is not sufficient to motivate change; instead we emphasise the positive results clients can achieve by improving their self-care. Empathy from us is necessary to facilitate change. Active listening techniques include open-ended questions to encourage clients to do most of the talking, affirmations to validate their feelings, reflective listening to show that we respect what they have to say, and summarizing to demonstrate that we have been listening carefully. We collaborate with our clients to find doable solutions which aid effective day-to-day care, and facilitate regular attendance for continuing care and support. The client’s personal desire for better health, and their participation in finding solutions delivers more lasting and effective motivation to change behaviour.

Conclusion
We can screen for anxiety by utilizing a questionnaire 21, however, we cannot always distinguish clients who are survivors of abuse; because child abuse, especially sexual abuse is under-reported, with less than half of survivors disclosing their experiences to anyone. Therefore, creating a comfortable office environment which facilitates trauma-informed, sensitive practice will benefit all of our clients.

References

1. DSM5, 2013
2. Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health. 1996;13(2):86-92.
3. Humphris G, King K. The prevalence of dental anxiety across previous distressing experiences. J Anxiety Disord. 2011;25(2):232-6
4. Brier, J, & Elliott, D.M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect, 27(10), 1205-22.
5. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18(5), 409-417.
6. Hibbard, R.A., Desch, L.W.,American Academy of Committee on Child Abuse and Neglect, and American Academy of Pediatrics Council on Children With Disabilities. (2007). Maltreatment of children with disabilities (Clinical report). Pediatrics. 119(5),1018-25.
7. Trauma-Informed Practice Guide bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf
8. Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse
   Researched and Written by…
   Candice L. Schachter, DPT, PhD Adjunct Professor, School of Physical Therapy University of Saskatchewan, Saskatoon, SK
   Carol A. Stalker, PhD, RSW Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON
   Eli Teram, PhD Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON
   Gerri C. Lasiuk, RN, PhD Assistant Professor, Faculty of Nursing University of Alberta, Edmonton AB
   Alanna Danilkewich, MD, FCFP Associate Professor, College of Medicine University of Saskatchewan, Saskatoon, SK
9. Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse
   Researched and Written by…
   Candice L. Schachter, DPT, PhD Adjunct Professor, School of Physical Therapy University of Saskatchewan, Saskatoon, SK
   Carol A. Stalker, PhD, RSW Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON
   Eli Teram, PhD Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON
   Gerri C. Lasiuk, RN, PhD Assistant Professor, Faculty of Nursing University of Alberta, Edmonton AB
   Alanna Danilkewich, MD, FCFP Associate Professor, College of Medicine University of Saskatchewan, Saskatoon, SK
10. Fehrenbach MJ. Stress reduction for the oral health care patient at high risk for medical emergency. Access (ADHA). July 2004.
11. Fehrenbach MJ. ASA Physical Status Classification System for Dental Patient Care 2018. Updated January 5, 2018. Available from: http://www.dhed.net/ASA_Physical_Status_Classification_SYSTEM.html
12. Desensitizing Agents, In-Office: https://www.ada.org/en/publications/ada-dental-product-guide/product-category?catid=117
13. Oh Canada! Volume 1 Issue 4: Non Injectable Local Anesthesia (NILA) for Periodontal Debridement: A Review and Discussion for Subgingival Application by Dani Botbyl, RDH: https://www.cdha.ca/AM/images/OhCanada_winter_28-30.pdf
14. Can J Dent Hyg 2018;52(2): 140-143 Eupnea prior to oral injection Sameep S Shetty*,MDS; Nancy Agarwal§, MDS; Premalatha Shetty‡, MDS
15. Australas Psychiatry. 2012 Oct;20(5):401-6. doi: 10.1177/1039856212459585. Epub 2012 Sep 26. Pilot study of a sensory room in an acute inpatient psychiatric unit. Novak T1, Scanlan J, McCaul D, MacDonald N, Clarke T.
16. Stud Health Technol Inform. 2014;199:94-7.Quantifying the effectiveness of virtual reality painmanagement: a pilot study. Sulea C1, Soomro A2, Wiederhold BK1, Wiederhold MD3.
17. Locker D. Psychosocial consequences of dental fear and anxiety. Community Dental Oral Epidemiology 2003; 31:144–151
18. Brian Mullen BS, Tina Champagne MEd, OTR/L, Sundar Krishnamurty PhD, Debra Dickson APRN, BC & Robert X. Gao PhD (2008) Exploring the Safety and Therapeutic Effects of Deep Pressure Stimulation Using a Weighted Blanket, Occupational Therapy in Mental Health, 24:1, 65-89, DOI: 10.1300/ J004v24n01_05
19. Cyberpsychol Behav Soc Netw. 2014 Jun 1; 17(6): 359–365. doi: 10.1089/cyber.2014.0203 PMCID: PMC4043252
    Clinical Use of Virtual Reality Distraction System to Reduce Anxiety and Pain in Dental Procedures Mark D. Wiederhold, MD, PhD, FACP, Kenneth Gao, BS, and Brenda K.
    Wiederhold, PhD, MBA, BCB, BCN Virtual Reality Medical Center, San Diego, California.
    Interactive Media Institute, San Diego, California. Virtual Reality Medical Institute, Brussels, Belgium. Corresponding author. Address correspondence to:, Prof. Mark D.
    Wiederhold, Virtual Reality Medical Center, 9565 Waples St., Suite 200, San Diego, CA 92121, Email: mwiederhold@vrphobia.com Copyright 2014, Mary Ann Liebert, Inc.
20. Motivational Interviewing: Helping People Change; William R. Miller and Stephen Rollnick; Guilford Press, Sep 1, 2012.
21. The Prevalence of Dental Anxiety in Dental Practice Settings: Angela M. White, Lori Giblin and Linda D. Boyd American Dental Hygienists’ Association February 2017, 91 (1) 30-34;

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About the Author
Linda M. Douglas, RDH, BSc graduated as a dental hygienist from the Royal Dental Hospital in London, England. After graduation she worked in periodontology before moving to Toronto, where she has worked in private practice since 1990. Linda is also the Clinical Director for Hygienetown, a supportive online community for dental hygienists. Linda’s desire to help anxious patients has instigated in-depth study of the issues faced by survivors of childhood abuse, and other individuals with dental phobia. Linda also writes and speaks on xerostomia management, and caring for dental patients with eating disorders.

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