Trauma-Informed Care in Oral Health Care: The role of dental hygienists
=======================================================================

* Lisa J. Heaton
* Hannah J. Cheung

## Abstract

Traumatic experiences can impact individuals’ oral health and how they experience dental treatment in ways patients and their dental providers may or may not initially anticipate. As approximately half of children and two-thirds of adults in the United States have experienced some type of traumatic event, it is critically important for providers to be aware of patients’ trauma histories and to appropriately provide trauma-informed care to their patients when needed. Individuals with a trauma history may experience significant anxiety and distress in the dental setting, even for treatment many providers and patients consider to be “simple,” such as a brief intraoral examination, radiographs, or prophylaxis. Such aspects of the dental setting may trigger memories and emotions related to the original trauma and may re-traumatize patients. This short report introduces links between traumatic history, poor oral health, and dental care-related fear and anxiety. Additionally, this paper briefly describes how dental hygienists can provide compassionate trauma-informed care to their patients with the goal of providing whole-person care that considers patients’ comfort, health goals, and prior experiences. Specific recommendations for providing trauma-informed care to children and adults within the scope of dental hygiene practice are provided, as is suggested wording for acknowledging a patient’s prior trauma and tailoring dental care to accommodate patient experiences and concerns. As dental hygienists are often the oral health providers spending the most time with patients, they are uniquely positioned to provide compassionate effective trauma-informed care to patients with past traumatic experiences.

Keywords
*   trauma-informed care
*   Adverse Childhood Experiences
*   abuse
*   dental care-related fear and anxiety
*   trust

## INTRODUCTION

Traumatic experiences – regardless of when they occur – are capable of impacting individuals in a variety of ways throughout their lives. People do not leave their trauma histories at the door when they enter the dental office for care; these traumatic memories can impact how they experience dental treatment in ways patients and their providers may or may not initially anticipate. As dental hygienists aim to provide comprehensive, whole-person care, it is critically important for providers to be aware of patients’ trauma histories and to appropriately provide trauma-informed care to their patients when needed.

### Adverse Childhood Experiences and Their Impact Throughout Life

Approximately half (45%) of children and adolescents in the United States (US) are reported by a parent or guardian to have experienced at least one Adverse Childhood Event (ACE), and about one in ten are estimated to have experienced three or more ACEs.1 Approximately two-thirds (63.9%) of adults report experiencing at least one ACE, and 17.3% report experiencing four or more ACEs.2 Adverse Childhood Events are negative experiences occurring during childhood or adolescence that include, but are not limited to, “physical abuse, verbal abuse, sexual abuse, and household dysfunction such as domestic violence, household substance abuse, mental illness, and criminal activity,” as well as physical and emotional neglect and parental separation.3 As the number of ACEs experienced increases, so does the likelihood of experiencing chronic health effects and negative socioeconomic impacts such as cardiovascular disease; use of tobacco, alcohol, and illicit drugs; depression; and unemployment.3, 4

A subset of individuals with a trauma history will go on to develop posttraumatic stress disorder (PTSD), a response to experiencing or witnessing a traumatic event including, but not limited to, recurrent and intrusive memories of the event; distressing and recurring dreams about the event; and dissociative reactions or flashbacks in which the individual re-experiences the event.5 An estimated five percent of individuals will have a diagnosis of PTSD during their lifetime.6

### How Does Trauma Manifest in Oral Health and in the Dental Setting?

Traumatic experiences can impact a person’s oral health, even if the trauma does not occur in the dental setting or does not involve a person’s oral cavity. Children and adolescents with a trauma history are more likely to have dental caries, gingival bleeding, and self-reported fair or poor oral health compared with those without a trauma history.7 Adults who have experienced trauma have less frequent dental cleanings and fewer dental visits overall compared to adults who have not experienced trauma.8-10

Further, trauma history is linked with increased dental care-related fear and anxiety.11 Individuals with high levels of dental anxiety report experiencing significantly more dental and non-dental-related traumatic events and PTSD symptoms than individuals with lower anxiety.12 Sexual abuse places victims at significantly higher risk for developing dental anxiety.13, 14 Individuals with a trauma history may experience significant anxiety and distress in the dental setting, even for treatment many providers and patients consider to be “easy,” such as a brief intraoral examination, radiographs, or oral prophylaxis. Aspects of the dental setting that may trigger memories and emotions related to the original trauma and may re-traumatize patients with a trauma history include, but are not limited to:

*   Reclining in the dental chair

*   Having the patient napkin placed around their neck

*   Having dental team members “hovering” over them

*   Not being able to speak or effectively communicate

Given how many individuals experience traumatic events and how impactful traumatic experiences can be on patients’ oral health and ability to receive regular dental care, it is critically important for dental hygienists to be knowledgeable about, and able and prepared to provide trauma-informed care for their patients with a trauma history.

### Trauma-Informed Care and Its Use in the Dental Setting

Trauma-informed care is clinical care that considers and accounts for trauma that patients have experienced, regardless of when or how the trauma occurred. Dental hygienists providing trauma-informed care “recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services”.15 Specifically, a trauma-informed approach emphasizes the need for a supportive and compassionate means of providing oral health care that avoids re-traumatizing the patient.16 Failure to provide trauma-informed care to patients with a trauma history risks invalidating the patients’ experiences, negatively impacting rapport with patients, and re-traumatizing patients.17

Trauma-informed care mirrors the treatment of individuals with dental care-related fear and anxiety in many ways.18 Trauma-informed care additionally includes considering how a specific patient’s past trauma currently interferes with their ability to receive dental treatment and then tailoring care to avoid re-traumatizing the patient. As an example, a patient who has experienced an assault in which they were choked may feel significant stress when the patient napkin is placed around their neck. In a case like this, the dental hygienist could suggest simply resting the napkin on the patient’s chest when reclined or clipping the napkin to the patient’s clothing. The patient should be an active participant in determining what works best for them.

### What Role Does the Dental Hygienist Play in Trauma-Informed Care?

The Commission on Dental Accreditation requires graduates of accredited dental hygiene programs to be competent in providing dental hygiene care to all populations, including child, adolescent, adult, geriatric, and special needs populations.19 As such, dental hygienists are trained to identify and tailor treatment plans to a variety of patients according to their specific needs and conditions, including recognizing patients who have experienced trauma that impacts their comfort in receiving dental care.

Oh and López-Santacruz emphasize the importance of a provider being familiar with a patient’s medical history prior to any dental treatment.20 Frequently canceling, rescheduling, or missing appointments may indicate a patient who might be avoiding dental care due to a traumatic stress reaction.21 Patients with past traumatic experiences may be more prone to stress reactions such as self-medicating, compulsive, impulsive, and/or self-injurious behaviors.21 These behaviors, if reported in the patient’s medical history, can provide the dental hygienist with a better understanding of how to tailor treatment for that patient.

Dental hygienists begin their extraoral assessment by observing a patient’s overall physical appearance, gait, and affect when walking to the dental operatory. If a patient seems aggressive (e.g., argumentative or irritated with no apparent reason) or withdrawn (e.g., unusually quiet or avoiding eye contact) upon meeting,21 this can signal to the dental hygienist that the patient may be experiencing a traumatic stress reaction. The dental hygienist should establish a physically and psychologically safe space in the privacy of the dental operatory that allows the patient to feel more secure with sharing sensitive information, such as past traumatic experiences.

Asking the patient if they would prefer to review their medical history in a separate, private office (e.g., a conference room) can be less intimidating for the patient in which to share information. If such a room is unavailable, the dental hygienist can verbally reassure the patient that what they choose to share in the dental operatory is confidential. To this end, the dental hygienist should be mindful of the volume of the discussion to prevent people in surrounding operatories from hearing their conversation. They should also ask if the patient is comfortable with the dental hygienist sharing the patient’s history with the dentist who will be providing care to the patient. If the patient does not wish the details of the trauma to be shared, the dental hygienist should respect this wish and suggest that they can share what accommodations to treatment would be helpful for the dentist to know (e.g., not placing the patient napkin around the patient’s neck) without disclosing specific details of the trauma.

When the patient first sits in the dental chair, the dental hygienist should face the patient with the patient chair slightly elevated to reduce the power differential and provide the patient with a sense of control. Asking questions in a non-confrontational and non-judgmental manner allows patients to discuss their prior trauma in a safe setting, encourages better communication, and helps establish trust between the provider and patient. It is important to note that patients with past trauma may be less likely to report their history on a clinic questionnaire.22 Provider comfort with asking about abuse is a predictor for patient comfort in disclosing information.23 Ensuring the dental hygienist is comfortable with asking about prior trauma enables better communication and increased trust between patient and provider. Patients who trust their providers are more likely to engage with their care, follow through with recommended treatment, and better control their chronic conditions, which leads to better health outcomes.24-28

As with all communication during dental treatment, effective trauma-informed care must be tailored to the age of the patient. Oh and López-Santacruz provide valuable recommendations for treating pediatric patients with a history of trauma.20 Similar to treating very young and/or anxious children, they recommend introducing a child with a trauma history to the dental setting through a treatment-free desensitization visit. When treatment is being provided, these authors suggest using Tell-Show-Do and providing the child with control and autonomy using a pre-established hand signal to stop treatment as needed. For children with a trauma history, this model also suggests avoiding physical contact not needed for treatment (e.g., touching a child on the shoulder) and allowing a trusted adult to accompany the child during treatment.20

Raja and colleagues provide a helpful framework for providing trauma-informed care to adults with a trauma history.29 Their framework takes the form of a pyramid, in which the bottom and most comprehensive portion represents patient-centered active listening skills that providers should use with all patients. As the provider moves up the pyramid toward screening patients at risk for trauma, the model recommends being aware of the impact of trauma on patients, as well as a provider’s own trauma history. This model also suggests that oral health providers not screen all patients for a trauma history. Instead, they recommend only screening those patients at risk for trauma (e.g., at-risk children and adults, including those with acute or other orofacial injuries).29

A key aspect of trauma-informed care in the oral health care setting is that the dental hygienist’s role is ***not*** that of a therapist. Delving deeply into the patient’s trauma falls outside the dental hygienist’s scope of practice and the dental setting. Further, it leaves the patient without the support of a trained therapist to cope with the negative emotions that come up with discussing the trauma in detail. Instead, the dental hygienist should focus on listening to the patient’s story and providing supportive and compassionate oral health care. It is within the dental hygienist’s role to identify potential signs of past trauma; create a safe environment for patients to discuss this trauma; be aware of laws in their state regarding mandated reporting of current suspected abuse;30 and collaborate with the patient and dental team to provide a behavioral health referral when appropriate.

If a patient shares that they have experienced trauma, the dental hygienist should thank them for sharing their story and focus on how the dental team can help them feel more comfortable in the dental setting and with dental treatment. This may sound something like:

> *“I want to thank you for sharing your experience and trusting me with your story. It sounds like that was a really difficult (frightening, stressful; mirror the patient’s descriptive words here) situation, and I’m sorry to hear you went through that. It makes sense that, having gone through that, coming to the dental office can also be difficult (again, mirror the patient’s words). We all want you to be able to feel more comfortable receiving care here. What are some things you think might be helpful to make you feel more comfortable receiving dental care going forward? Is there anything you would like us to be sure to do, or try to avoid doing if we can?”*

In addition to engaging in active listening, dental hygienists should request permission from the patient throughout the appointment, such as when reclining the chair and performing intraoral and extraoral examinations. Asking permission to proceed at all stages of care signals to the patient that the dental hygienist values and cares about their comfort. The goal of the clinical interaction should be to make sure the patient feels heard, not rushed, and not judged for their past experiences.

It may be tempting to focus on the dental treatment needs at hand and “not open a can of worms” if a patient mentions having a trauma history. However, by ignoring a patient’s trauma history, the dental hygienist risks alienating the patient, making the patient feel uncomfortable, and helping to prevent the patient from returning for future treatment. Providing trauma-informed care helps to ensure patients will feel heard and understood and increases the likelihood they will feel comfortable enough to return for regular dental care.

## CONCLUSION

Trauma experience can significantly impact individuals’ oral health and how they experience dental care. As dental hygienists often spend significant time with patients, it is critically important for them to be prepared to provide compassionate, trauma-informed care to their patients. Being aware of potential signs of a trauma history, engaging in active, non-judgmental listening, providing a physically and psychologically safe space for patients to express their concerns and needs, and tailoring treatment to accommodate patients’ fear and anxiety into account are all key aspects of providing trauma-informed care in the dental setting. The dental hygienist’s role is not that of a trained therapist, but as a trusted health professional who can help identify how a patient’s trauma history currently impacts their ability to tolerate dental care and tailor their treatment to maximize each patient’s comfort. Dental hygienists should seek out continuing education opportunities to learn about and improve their competence in providing whole-person, supportive care to patients with a trauma history. As dental hygienists aim to provide compassionate, whole-person care, it is critically important for them to be aware of patients’ trauma histories and to appropriately provide trauma-informed care to help their patients achieve and maintain good oral health.

## Footnotes

*   NDHRA priority area, **Professional development: Education** (educational models).

*   **DISCLOSURES**
    
    Dr. Heaton affirms that she does not have any conflicts of interest to disclose. Ms. Cheung is the current Vice President of the North Carolina Dental Hygienists’ Association.

*   Received June 15, 2024.
*   Accepted July 2, 2024.


*   Copyright © 2024 The American Dental Hygienists’ Association

This article is open access and may not be copied, distributed or modified without written permission from the American Dental Hygienists’ Association.

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