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Dr Sharonne Zaks works with survivors of sexual assault and trauma. She also educates dentists on how to interact with these vulnerable patients, and provide sensitive care. By Frank Leggett
Melbourne dentist Dr Sharonne Zaks has always had an interest in working with anxious and phobic patients, and survivors of trauma. She has a natural rapport with these patients, in part due to her desire to connect without judgement. Her unhurried approach and ability to develop trusting relationships led to a positive reputation, and a busy practice built solely on word-of-mouth referrals. Patients from all over Australia travel to see her at her East St Kilda practice, Sharonne Zaks Dental. Today, she works extensively with sexual assault survivors, collaborates with the Victorian Centres Against Sexual Assault, and passionately advocates for a trauma-informed approach to dentistry.
“During a dental appointment, survivors of trauma often feel they have no agency or control over what’s about to happen to them,” she says. “That unpredictability creates intense anxiety which can manifest in many ways—often as a panic attack or dissociation.”
One of the most common reasons why survivors of sexual assault forgo proper dental care is that the appointment triggers memories of the assault, activating intense anxiety and panic. There are many parallels between the two experiences. These include—but are not limited to—lying underneath an authority figure in the horizontal position, penetration of the mouth with fingers and instruments, accidental touching due to the proximity of bodies, and latex as a reminder of condoms.
Once a procedure begins, the patient often feels like they can’t move or speak. They’re stuck holding one position for a long time; a reminder of being pinned down. The numbness of local anaesthetic is another aspect of losing control. Overall, patients feel helpless due to the large power imbalance dental treatment creates physically, emotionally and psychologically. As Dr Zaks points out, “Sexual assault is as much about power as it is about sex.” When people are placed in the same physical position as when they were assaulted, memories often surface; it’s a survival mechanism.
There are other reasons survivors avoid the dentist. Offenders usually teach them that the abuse is all their fault; that they’re dirty, broken and damaged goods. This leads to low self-worth, usually from a young age, which includes the belief that they don’t deserve any type of care.
Survivors become extra sensitive to blame and fear judgement, anger and criticism, especially from authority figures such as dentists. For example, they fear being told off for the neglected state of their mouths. ‘Why aren’t you flossing? How often do you clean your teeth? You should have seen me sooner!’ In a survey of Victorian survivors’ dental experiences, one wrote, “I know my teeth are bad and I don’t want a lecture that makes me cry.”
“Another major reason survivors can’t access dental care—and it’s a massive one—is the financial barrier.” Dr Zaks continues: “Many survivors suffer from such severe depression or PTSD that they can’t work, so they live on a very limited income. Together with low self-worth, this often leads to a poor diet, high in sugar and cheaper processed foods, which further worsens their oral and general health. Although they’re eligible for the public system, survivors tell me about their negative experiences and say they don’t want to go back.”
Poor oral health in survivors can create, what Dr Zaks calls, a shame spiral. It’s a vicious cycle of shame and fear of judgement about the state of their mouths. This leads to avoidance of dental care, further oral deterioration over time and then more shame.
Survivors are often too embarrassed to smile, which prevents them from being able to fully connect with people, leading to difficulty forming social and intimate relationships. This is isolating and worsens depression and anxiety. All of this further limits their ability to get a job.
Dentists are in a unique position to identify potential survivors and can look out for common dental fears and behaviors. These include fear of the loss of control, of panic attacks, vomiting and being drugged, criticism and judgement. A trauma history usually manifests in the mouth as grinding and clenching, and the oral effects of addictive coping strategies such as smoking and comfort eating. The mouth is usually involved in sexual assault, and the gag reflex is commonly heightened due to forced oral sex.
So, how does a dentist broach the subject if they think their patient may have suffered sexual abuse? “It’s considered best practice not to ask directly,” says Dr Zaks. “Most survivors prefer to stay undisclosed, and we don’t need details of their history to help them just as well.
“In Australia, it’s believed that at least one in three women and one in six men have experienced sexual abuse by the age of 18. So as dentists, we’re already seeing survivors as our regular patients without any awareness of their history.”
This approach takes account of the effects of trauma on a person, and recognises how it can impact their behaviours, decisions and life circumstances. Instead of asking, ‘What’s wrong with you?’, the question becomes, ‘What happened to you?’
“This broader understanding of a person’s history allows for much more compassion,” says Dr Zaks. “A patient’s behaviours may seem a bit bizarre until you put the lens of trauma on them, and then they make perfect sense.”
Dr Zaks has taken the trauma-informed approach and adapted it to dentistry. It centres around giving back power, control and choice to the patient at every stage of the interaction. The most important aspects, which underpin the success of everything else, are establishing trust and a sense of safety. This is built in many ways. For example, asking open questions and offering your full unhurried attention with compassion and empathy, taking care to avoid assumptions.
“If a patient opens up, stay with them, and allow any tears and emotions to surface,” says Dr Zaks. “This is part of accepting people fully without judgement and results in a much deeper connection and a higher quality of care.”
Good boundaries are essential to building trust. Keeping your word so that patients can believe what you say is a vital part of this. If you say the drilling will take another five seconds, then that must be true. If you say you’re going to call them the next day, you really need to do that.
“To build trust, it’s incredibly important to stay humble and open to input, so patients feel comfortable enough to bring anything up,” says Dr Zaks. “A lot of patients tell me that their old dentist talked down to them and didn’t listen. Modelling a calm state while staying open and curious and relaxed is critical.”
Communication is mainly non-verbal, so tone of voice and body language really matter; likewise picking up nonverbal cues from patients.
When a dentist believes in a survivor’s capability to be successful, it is very empowering for the survivor. It helps them move away from a victim mindset and feelings of hopelessness. Gradually, they learn that they can cope with much more than they ever imagined, and this builds confidence which then extends beyond dental visits. Giving patients choices wherever possible is another way of giving back control. It can be as simple as asking if they would like the door open or shut. Patients learn that they can influence what’s happening to them.
Moving away from the old medical model of being the caretaker who fixes the patient to being a collaborator is an essential paradigm of the trauma-informed approach.
“Instead of doing something ‘to’ or ‘for’ a patient, we do it with them,” says Dr Zaks. “It’s a much more satisfying approach because the relationship is reciprocal. You’re consulting with patients, getting their input, and treating them as an expert on themselves. They feel heard and understood and we get to know their interests and priorities.”
Dr Zaks has produced a series of free videos for dentists and survivors. These are available on her practice website, Sharonne Zaks Dental.
They have been a great success and are currently being used all around the world. The third lecture for dentists contains a comprehensive toolbox of practical clinical strategies dentists can use when working with survivors.
Dr Zaks’ future projects include in-depth workshops for dentists, a training manual, and lectures for undergrad students.
Another goal is the creation of a purpose-built, trauma-informed dental clinic staffed by dentists, sexual assault counsellors and trained support staff. If you are interested in further information or could help provide support or funding, Dr Zaks can be contacted through her website or email: email@example.com.