Annie needed a dental procedure and showed up early for her appointment. Annie is thought of by her dentist as a compliant patient, the kind of patient most dentists and orthodontist wished would be in their chairs every day. She lay down as she was told, opened her mouth as wide and for as long as she was told to do, and barely moved a muscle throughout her procedure. The dentist kept talking while working, as dentists often do, reassuring Annie that it shouldn’t really hurt, as the tears silently escaped the corners of her eyes and slid down Annie’s face. Annie is a childhood sexual abuse survivor. The “compliance” Annie is exhibiting is a freeze response that is all too familiar to Annie’s nervous system when in a defenseless position like lying in the dentist’s chair. Annie’s dentist had no idea and probably would be pretty upset if he knew how difficult the visit was for her. The facts are that patients are highly unlikely to disclose that they were abused or are currently being abused and yet the numbers indicate that 1 in 10 children will be sexually abused before their eighteenth birthday. That is a pretty high statistic and translates into the fact that for those of you that see at least 10 patients a day can bet that they have at least one victim or survivor of sexual abuse in your dentist chair.
This may be a difficult topic but, it puts dental professionals in a position of potentially contributing to the disclosures of abuse and in assisting in steps towards healing. Oral health can be very affected by abuse and care in the dental field is of utmost importance. Every professional should be able to hear an individual’s story and remain calm. In addition, every professional should have tools at their disposal to work with even the most fearful and difficult patients and I do not mean dental instruments.
While you may not notice some of these patients, others may exhibit what you might view as unusual behavior. Patients may be extremely fearful of objects being put into their mouths, may feel triggered just at the thought of lying down for treatment, they may have an extreme fear of suffocating including having the dentist’s hands over their mouth or nose especially if the patients abuse included being held down or immobilized. They may have a fear of gagging or becoming sick and they may be extremely worried that the dentist will get mad at them for having any of these feelings.
Trauma responses are triggered by all sorts of things. A sound, a smell, a touch or even a certain word or sentence. Once this happens a cascade of events takes place withing the brain and body that is extremely difficult to stop unless the patient has the tools and support to do so. Their sympathetic nervous system will mobilize to help them get away from the danger they perceive in the situation. This may cause them to have what looks like an anxiety attack, with heart racing, breathing becoming shallow and possible shaking throughout their body. When there does not seem to be a way out, the dorsal vagal response, also known as the freeze response, sets in. This can feel like a helplessness which on the outside, may appear as a calm quiet patient but, in fact there is a panic brewing just under the surface with what feels like a life threat. The main objective in a trauma response is to help the patient return to an experience of social engagement, which means they can connect to the here and now and recognize that they are in fact safe.
This brings us to the question what can the dental community do to help this already vulnerable population feel safer and more cared for? I am aware that time can be an issue when trying to implement new ways to help patients feel more settled but, the benefits are invaluable. Trauma impacts people across all parts of their lives including school, family, work, health and more. The cost to society is enormous in the amount of money spent on alcohol and drug abuse treatment, psychiatric visits, behavioral health clinics, public mental health care and more. In addition, children who have had traumatic experiences are twice as likely to have chronic health conditions. The impact of trauma reaches into almost every aspect of our lives including the dental chairs your patients sit it. Implementing a few changes can ultimately help your work go smoother and help an already hurting patient feel calmer.
Most patients will not disclose past traumas and will not be able to verbalize their fears. It is therefore, incumbent upon the dentist to set the tone of safety. Asking questions, explaining things and asking permissions can go a long way in helping a patient relax and be more comfortable. Some examples include, “I am going to ask you a few questions, let me know when you are ready,” “are you comfortable being touched?” “can we come up with a signal to let me know that you want me to stop and we can take a break.” Giving patients a menu of options can be helpful in letting them know that they can have some control over their own care, a feeling that is lost with sexual abuse.
Investing the time to have a patient feel settled in the beginning of a visit will help the procedures go smoother and keep your patient coming back to your office for further treatments. Some ideas for implementing this is making sure the patient understands the language you are using, asking if the patient wants a blanket to cover up while in the chair, dimming the harsh fluorescent lighting, having objects for them to hold like a rock or a soft piece of material can help calm a patients nerves and help them feel more grounded. Even your position in the room can make a big difference to creating safety. Sitting eye level instead of standing over a patient will feel more collaborative instead of authoritarian and allow for the patient to feel like he or she can ask questions or make requests.
The trauma of sexual abuse affects not only the victim but all of society. It affects children and adults from all ethnic groups, races and socioeconomic backgrounds. In order to help with prevention and treatment we need to be willing to discuss this topic without shame and with the utmost sensitivity. We all have an obligation to do our part wether that entails educating ourselves, advocating for victims or tweaking the way we work to help build safety in our individual offices. Listening to what a patient needs and giving them a sense of collaboration and control over the pacing and ways they are treated will go a long way in helping with healing and will ultimately help your own dental practices thrive as well. If healthy patients is the goal this is the path to achieving just that.
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