Patients presenting with extreme dental phobia may, in fact, be exhibiting symptoms of post-traumatic stress and therefore require special consideration. Julie Miller reports
Words of reassurance, a gentle touch on the arm, a calm demeanour—all good practice for a dental clinician when it comes to dealing with nervous patients. But what if your attempt to comfort a patient actually triggers their fear as a result of a prior traumatic event?
According to the Australian Research Centre for Population Oral Health (ARCPOH), one in six Australians experience dental anxiety, with five percent of that number having a strong fear or phobia that will impact on their dental health regime.
For some of those patients, however, an avoidance of dental treatment is due to a deeper underlying issue—post traumatic stress. According to Beyond Blue, one in 12 Australians will experience PTSD in their lifetime, with symptoms developing after a traumatic event including serious accidents, assault, crime, torture, natural disasters or sexual abuse.
Symptoms of PTSD include depression, reliving the traumatic event through flashbacks or nightmares, sleeping difficulties, detachment and avoiding reminders of the event. Fifty per cent of people who have been raped or tortured will suffer from PTSD; it is also common in children who have been removed from their families due to abuse or neglect.
It was through dealing with these children and their carers that Dr Merrilyn Hooley, senior lecturer in psychology at Deakin University became aware of the effect of PTSD on dental health.
“When talking to carers of children in out-of-home care, it was coming up that the children were having real dental issues,” Dr Hooley says.
“Carers were having trouble keeping appointments and making reappointments, because there were often behavioural issues affecting the children’s attendance, and clinicians had problems with children’s cooperation when they did attend. We thought some professional development training around the issue of PTSD would be useful.”
According to a paper written by Brigitte Leeners et al published in the Journal of Pyschosomatic Research in 2007, around 20 per cent of female patients seeking dental care may have experienced childhood sexual assault alone. This suggests that dentists may work with sufferers of PTSD on a regular basis without any knowledge of their history.
PTSD signs and triggers
“People might not want to necessarily disclose that they are a victim of abuse to their dental professional,” Dr Hooley explains. “But there are signs you can look for.
“People who have PTSD might spontaneously recoil when you touch them—it’s part of a ‘fight or flight’ response.”
Other symptoms include hyper-vigilance, spontaneous cringing or crying, being unable to speak, gagging, dissociation and even loss of bladder control. Patients suffering from PTSD may also present with specific dental problems—myofascial pain, tooth bruxism, TMJ disorders and tooth sensitivity.
Unlike dental anxiety, PTSD cannot be managed by avoiding a situation that makes the sufferer fearful. And according to the aforesaid paper, there are unfortunate similarities between “going to the dentist” and “situations of sexual abuse”, with the former favouring memories of the original abuse situation.
“In both situations, the child/patient is often left with a person seen as more powerful than herself, she is placed in a horizontal position, and she experiences or anticipates pain,” the paper states.
Other potential triggers for PTSD sufferers include having to remain motionless, being in an unequal power relationship, intrusion in the mouth, not being able to talk, fear of not being able to breathe or swallow, and even the smell of latex gloves. Most of the issues are based around loss of control and a sense of powerlessness, rather than pain.
“It curdles your blood to think that [dental procedures] can have such a strong affect,” says Dr Hooley. “But it does. For victims of sexual abuse, for example, it can be a real issue when medical professionals are trying to develop rapport with them, being very nice and speaking in a pleasant voice—but that can come across as grooming.
“Even what might seem good practice amongst dentists— giving reassurance—can be a problem,” Dr Hooley continues. “Being told ‘this won’t hurt’, or ‘this will be over soon’—that sort of phrasing can be problematic if you’ve been a victim of child abuse.”
According to Dr Hooley, dental clinicians need to be aware that extreme reactions to treatment might be due to more than just anxiety—it may be them that the patient is actually afraid of.
“If it’s possible for the practitioner to identify some of the triggers, then they can develop some sort of plan to avoid those triggers,” she says. “If I was picking up some of those signs, I would say to the patient, ‘I can see these things concern you, are there any other things that worry you that I can try to avoid?”
In order to help these vulnerable patients, Dr Hooley suggests approaching each case with flexibility, taking treatment very slowly and allowing the patient as much control as possible. Explaining each step in the treatment is recommended, as well as asking the patient if it’s okay to proceed.
She also suggests developing a sign system with the patient so they can signal when they need to sit up or swallow; they may also want to be treated in an upright or semi-reclined position, with one foot on the floor. Some may want to be accompanied by a friend, to give them some power; or they may want to bring a blanket, to act as a barrier between them and the practitioner. Post-treatment instructions should always be written down, particularly for patients who dissociate and shut down on the chair.
In the case of patients with PTSD, flexibility, empathy and a clear treatment plan are key to helping them deal with the challenges of a dental visit. Recognising the signs of a trauma victim and avoiding triggers will not only improve their oral health, but also may contribute to their overall recovery.