The following information is intended as a guide for both those people who are survivors of abuse, and all dental and medical professionals who wish to gather more information on how to better assist and treat their patients prior to having dental treatment.
Warning to Survivors of Abuse:
For survivors of abuse, if you experience any feelings of extreme anxiety, recalls / flashbacks, depression, or similar, please immediately stop reading. Take deep slow breaths, go and do an enjoyable activity or just try and relax, and come back to reading when you feel able.
Perhaps have a close friend or family member assist you or be with you whilst reading these pages if this helps. If you have not done so as yet, please consider seeing your GP or a psychologist for assistance regarding your history or situation. Please always remember that extreme emotions are a very normal reaction for survivors of abuse. It is how you manage these emotions that counts toward improving your life.
Forms of Abuse
Unfortunately child abuse exists in different forms and includes neglect, sexual, physical and emotional abuse. Each may have their own severity and chronicity (duration), and therefore long-term outcome for the child in terms of psychological trauma that typically extends well into adulthood.
Neglect
Continued failure by a parent or caregiver to provide a child with the basic necessity of life needed for his or her proper growth and development such as food, clothing, shelter, medical and dental care and adequate supervision. Some child psychology experts argue that a child not shown regular love and care in a stable home is also a victim of low grade neglect and this can have long-term negative effects on an adult. Others include it under psychological abuse.
Sexual abuse
Sexual abuse is when another person engages a child or young person in a sexual activity by using their power over them or taking advantage of their trust. Children are often bribed or threatened physically and psychologically to make them participate in the activity against their will. Sexual abuse of a child is a serious crime and is subject to mandatory reporting.
Physical abuse
Physical abuse is the non-accidental injury or repeated pattern of injuries to a child caused by a parent, caregiver or any other person. It includes but is not limited to injuries which are caused by excessive discipline, severe beatings or shakings, cigarette burns, attempted strangulation and female genital mutilation. Injuries include bruising, lacerations or welts, burns, fractures or dislocation of joints. Hitting a child around the head or neck and/or using a stick, belt or other object to discipline or punishing a child (in a non-trivial way) is a crime.
Psychological abuse or harm
Serious psychological harm can occur to a child when the behaviour of their parent or caregiver damages the confidence and self esteem of the child or young person, resulting in serious emotional deprivation or trauma. In general it is the frequency, persistence and duration of the parental or carer behaviour that is instrumental in defining the consequences for the child. This can include a range of behaviours such as excessive criticism, withholding affection, exposure to domestic violence and drug/alcohol abuse, intimidation or threatening behaviour.
Sexual abuse survivors and dental fear
Unfortunately, it is reported that as high as 1 in 4 females have been sexually abused in childhood and for men it is 1 in 7. Whilst survey estimates show that approximately 80% of the adult population report some level of anxiety regarding all forms of dental treatment.
Among those reporting dental fear and a history of sexual abuse, the fear may not always be related to fear of pain nor the fear precipitated by a traumatic dental experience.
A history of sexual abuse, especially the severity of abuse, has been found to be predictive of different patterns or behaviours, such as:
- Not being able to make and keep dental appointments
- Stress-related dental problems such as bruxism and excessive tooth wear and sensitivity, headaches, poor sleep patterns, and periodontal disease
- PTSD-type symptoms during the dental treatment. These symptoms may include fear, anxiety, nausea, dissociation, flashbacks and feelings of shame. The shame may be about being anxious in the dental chair, about having poor oral health, or simply about having someone else find out about the history of sexual abuse.
Strategies reported to be endorsed by survivors of sexual abuse include empowerment of the patient by being provided with an increased sense of control during the dental procedure, and being provided with a feeling of protection or safety in a trusting environment.
When searching web pages for information on dental phobias, there is typically a tendency to focus on the fear of dental treatment that includes mainly the fear of needles and pain. Although for many survivors of sexual abuse a fear of needles and pain may be very real anxieties they have, but their fear or feelings toward dental treatment in general often run much deeper and may also include:
- Having to lie back or horizontal for treatment.
- Having objects such as instruments and cotton rolls placed into the mouth.
- Having a dentist’s hand(s) over the mouth and / or nose. Even another person’s hands anywhere near the face can provoke a panic attack.
- Extreme difficulty or anxiety with certain types of treatment being performed such as impressions, or the use of rubber dam.
- A fear of not being able to breathe.
- A fear of not being able to swallow.
- A fear of severe gagging or being sick during the treatment.
- A fear that the treating dentist may get angry or become impatient with them during treatment.
- A fear that an anxiety or panic attack may occur that cannot be controlled and the patient may behave in an irrational manner resulting in extreme embarrassment.
- A feeling of being ‘naked’ in a dental chair due to the loss of control that being in the horizontal position invokes.
- Being alone in a room with a person who is perceived socially or professionally to be ‘more powerful or educated’ than oneself.
Stop signals
For many patients, knowing they can use a ‘stop signal’ such as raising a hand/finger if they want the dentist to stop the procedure can be very reassuring. However, for many abuse survivors they may find it impossible to give any kind of “stop” signal.
Common cues that require treatment to stop without the use of a signal may be:
- The patient initially appears exceptionally compliant, and is sitting or lying but is completely still and not able to ‘move a muscle’.
- A patient’s breathing will often become quick and shallow, irregular, or ‘stop / start’.
- A patient may make a small movement or a small sound, but when asked if they are ok, they simply do not respond.
- Spontaneous tears with no accompanying sounds such as sobbing or whimpering.
- A patient may “stare” at the dentist throughout the treatment, and “follow” them with their eyes, because losing contact may become very distressing.
- Display an extreme startle response to sudden noises and movements.
These are all signs that treatment needs to stop whether the patient has raised a hand / finger or not. In many cases it may be that the patient is not responding because they are so frightened that they have literally lost the ability to speak, they cannot nod nor shake their head, or in some cases are not even able to make one voluntary muscle movement.
Dental treatment with IV sedation for survivors of sexual abuse
Although IV sedation is a very helpful procedure for many people with dental anxieties, most sexual abuse survivors prefer not to be sedated. For these persons, the use of sedation may raise the likelihood of increased feelings of loss of self-control and helplessness, especially in a situation where they already may feel vulnerable such as having treatment in a dental chair.
However, if a sexual abuse survivor requires or would prefer a form of sedation including IV sedation, then it is absolutely no problem for arrangements to be made with the patient to allow a family member, close friend or at least the presence of someone they trust to be in the room during the entire procedure from the time of arriving to the practice to the time they depart to go home.
All appointments at the Hobart Orofacial Pain and Special Needs Clinic begin with a consultation held in a relaxed non-threatening office environment where the complete needs of the patient are discussed in full, and a thorough evaluation of any proposed treatment and all available options can be established well before any treatment is conducted. Typically the entire needs of the person are considered and arranged for prior to making an appointment for any further treatment.