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Being considerate every step of the way: a qualitative study analysing trauma‐sensitive dental treatment for childhood sexual abuse survivors



This qualitative study aimed to obtain a deeper understanding of what makes adult dentistry possible for child sexual abuse survivors. Sixteen adult informants were recruited from four Centres against Sexual Abuse and interviewed. Qualitative analysis of the transcribed interviews was conducted consecutively until thematic saturation was reached at 16 informants. A conceptual framework was generated, and informants’ experiences of what makes dental treatment achievable were summed as the dentist working in a trauma‐sensitive way, captured by the core category: Being considerate every step of the way. The underlying categories are: (i) offering a good start; (ii) being competent; (iii) being aware of the influence of staff behaviour; (iv) building a safe relationship; (v) arranging a secure treatment situation; and (vi) exploring individual triggers. The findings revealed that dental staff should have adequate competence to build secure relationships and explore individual triggers in dental treatment situations when treating child sexual abuse survivors. Dentists should have a trauma‐sensitive approach to all patients. When treating child sexual abuse survivors, dentists should demonstrate utmost consideration every step of the way, building long‐term solid relationships, and discussing and testing coping strategies individually adapted to the specific needs of the child sexual abuse survivors, in a safe environment.
Being considerate every step of the
way: a qualitative study analysing
trauma-sensitive dental treatment for
childhood sexual abuse survivors
Kranstad V, Søftestad S, Fredriksen TV, Willumsen T. Being considerate every step
of the way: a qualitative study analysing trauma-sensitive dental treatment for
childhood sexual abuse survivors.
Eur J Oral Sci 2019; 000: 18. ©2019 The Authors. Eur J Oral Sci published by
John Wiley & Sons Ltd
This qualitative study aimed to obtain a deeper understanding of what makes adult
dentistry possible for child sexual abuse survivors. Sixteen adult informants were
recruited from four Centres against Sexual Abuse and interviewed. Qualitative anal-
ysis of the transcribed interviews was conducted consecutively until thematic satura-
tion was reached at 16 informants. A conceptual framework was generated, and
informants’ experiences of what makes dental treatment achievable were summed as
the dentist working in a trauma-sensitive way, captured by the core category: Being
considerate every step of the way. The underlying categories are: (i) offering a good
start; (ii) being competent; (iii) being aware of the influence of staff behaviour; (iv)
building a safe relationship; (v) arranging a secure treatment situation; and (vi)
exploring individual triggers. The findings revealed that dental staff should have
adequate competence to build secure relationships and explore individual triggers in
dental treatment situations when treating child sexual abuse survivors. Dentists
should have a trauma-sensitive approach to all patients. When treating child sexual
abuse survivors, dentists should demonstrate utmost consideration every step of the
way, building long-term solid relationships, and discussing and testing coping strate-
gies individually adapted to the specific needs of the child sexual abuse survivors, in
a safe environment.
Vibeke Kranstad
, Siri
, Therese V. Fredriksen
Tiril Willumsen
Oral Health Centre of Expertise in Southern
Norway, Arendal;
Institute of Clinical
Dentistry, University of Oslo, Oslo, Norway;
Vibeke Kranstad, Oral Health Centre of
Expertise in Southern Norway (TkS), Post:
PO Box 783 Stoa, NO-4809 Arendal, Norway
Key words: child sexual abuse; dental
anxiety; dental care; qualitative research;
trauma-informed care
This is an open access article under the
terms of the Creative Commons Attribution
License, which permits use, distribution and
reproduction in any medium, provided the
original work is properly cited.
Accepted for publication August 2019
People suffering from traumatic life events, including
childhood sexual abuse (CSA), often experience difficul-
ties with receiving dental treatment. In 1996, WALKER
et al. (1) found that a history of childhood trauma,
such as sexual abuse, was significantly associated with
elevated dental anxiety. This has been supported in an
epidemiological study (2). DEJONGH et al. (3) found
that having been a victim of a violent crime as well as
having bad dental treatment experiences was predictive
for dental phobia and a post-traumatic stress disorder
(PTSD) diagnosis.
In a study, published in 2001, of 99 women with
CSA experience, WILLUMSEN (4) found that the mean
score on dental anxiety assessments was significantly
higher than for Norwegian women in general. Among
women with sexual abuse experiences involving oral
penetration, 85% reported very high dental anxiety.
Dental anxiety is also associated with experiences of
pain and distress from the anticipation of painful den-
tal procedures (5, 6). However, among the same sample
of CSA survivors, it was found that interpersonal
factors concerning communication, trust, fear of nega-
tive information, and lack of control, were rated as
much more fear-evoking for CSA survivors than for
women who had dental anxiety but no CSA experience
(7). In a study from 2007, 111 women with CSA were
found to exhibit higher psychological strain during
dental treatment, and CSA survivors often preferred a
female dentist, and reported reminiscing about the orig-
inal abuse situation to be a considerable problem (8).
In addition, women exposed to CSA seemed to have a
high level of avoidance behaviours, demonstrating a
large number of irregular recall examinations.
Considering the obvious challenges faced by sexual
abuse survivors in coping with dental treatment situa-
tions, there are surprisingly few scientific reports
addressing relevant coping strategies.
In a theoretical paper, RAJA et al. (9) describe a
framework demonstrating how dentists can use a
trauma-informed care pyramid to help interact with
traumatized patients and to help patients cope with
dental treatment situations. DOUGALL &FISKE (10) also
Eur J Oral Sci 2019; 1–8
DOI: 10.1111/eos.12661
Printed in Singapore. All rights reserved
©2019 The Authors. Eur J Oral Sci published by John Wiley & Sons Ltd
European Journal of
Oral Sciences
describe how the consequences of prior sexual abuse
may affect the dental treatment situation, and they give
advice similar to those of RAJA et al. on how dentists
can best help their patients through establishing a posi-
tive rapport, sharing control, treating the client as a
partner, recognizing difficulties, and showing flexibility
in problem solving.
To increase our understanding of this complex topic,
qualitative research methods have high value. Despite
their relevance, very few qualitative studies have been
carried out, and only one such study [STALKER et al.
(11)] could be found in a systematic library search. In
this Canadian study, the researchers interviewed 58
men and 19 women with self-reported histories of CSA
(11). They suggested how dentists could make dental
treatment tolerable for patients with a history of CSA,
how dentists might respond sensitively to patients’
needs, and highlighted the patients’ need to feel in con-
trol through, for example, control of body position or
use of a hand mirror.
The aim of the present qualitative study was to
obtain a deeper understanding of what makes dental
treatment possible for CSA survivors by exploring how
they experience dental treatment and the behaviour of
the dental staff, as well as describing their coping
strategies associated with dental treatment. With
expanded knowledge in this area, dentists may be able
to adapt the dental care situation more effectively to
the traumatized patients’ needs.
Material and methods
A grounded theory (GT) approach following the princi-
ples set out by CHARMAZ (12), which includes guides on
reading, re-reading, and coding the interviews, was cho-
sen as the research method. Memo writing was used to
aid data collection. This variant of GT is useful in
research fields where theory surrounding the phe-
nomenon has not been fully developed. Patterns and
synthesized themes were constructed from the infor-
mants’ experiences and perspectives.
Enrolment procedures
Employees from four Centres against Sexual Abuse
(SMSO), selected among the 22 such centres in Nor-
way, were invited to recruit informants. The SMSOs
provide a low-threshold service that is free of charge,
and clients can remain anonymous. The informants
were informed verbally and in writing about the study,
and gave their written consent. The inclusion criterion
was CSA experiences. Exclusion criteria were symptoms
of psychosis, ongoing drug addiction, cognitive disabili-
ties, and difficulties expressing oneself in Norwegian.
Description of informants
Twelve women and four men were interviewed. All
reported multiple sexual abuse incidents. The number
of abuse incidents varied from three different rape
situations to daily sexual abuse over several years. The
abusers were reported to be father (n=4), mother
(n=1), stepfather (n=2), uncle (n=4), brother
(n=2), friend of family (n=4), social service worker
(n=1), cousin (n=1), boyfriend (n=1), friend/neigh-
bour (n=5), and grandfather (n=2). One reported
gang rape. Four informants reported one abuser; the
others reported two or three different abusers. Thirteen
informed of a male abuser, and three reported both
female and male abusers. Ten informants reported that
abuse started before the age of 6, five before age 12,
and one at age 15 yr. All except one reported both sex-
ual contact and penetration. Six informants reported
regular dental treatments and 10 reported irregular den-
tal treatments. Self-reported oral health was good in
nine informants and poor in seven.
Data generation
As a foundation for the research the authors discussed
relevant issues of dental treatment in CSA survivors
using their clinical experience. From these discussions,
the key concept for this study was decided to be recom-
mendations for dental practice based upon CSA sur-
vivors’ experiences.
The interview guide was constructed by a multidisci-
plinary research team consisting of two dentists, a psy-
chologist, and a social worker, based on a review of the
literature as well as on clinical practice of the research-
ers. The two major open-ended questions regarding
experiences of dental treatment were: ‘Tell me what
you remember from your experiences of dental treat-
ment as a child (up to 18 yr of age)’ and ‘Tell me about
your experiences of dental treatment as an adult’. Six
informants were interviewed by the first author (a den-
tist), four by the social worker, and six by the psychol-
ogist, all for approximately 1h 30 min to 2 h. The
interviews were audiotaped, and verbatim transcripts
were compiled. After the first few interviews, the inter-
viewers were calibrated by listening to each other’s
tapes. The interview guide was rechecked, discussed,
and revised to ensure minimal deviation in interview
focus and style. The data collection continued until the
point of thematic saturation, where new interviews
failed to provide any new or thematically different
information (13). NVIVO 11 PRO Software (QSR Inter-
national, Daresbury, UK) was used for the analyses.
All transcripts were analysed by the authors, as sug-
gested by CHARMAZ (12). Analyses were performed con-
secutively and were continued until saturation was
reached after having analysed 16 transcripts. First, all
authors read and then discussed the interviews. The
focus was an open-minded awareness in the search for
a holistic view and an overall first impression of each
interview (14). Second, the initial coding, separation,
sorting, and synthesis of the data were undertaken by
the first author. Preliminary categories were developed
by the first author based on the experiences described
2Kranstad et al.
by informants. These preliminary categories were dis-
cussed in the research team. The third stage of the
analysis included comparisons of the tentative cate-
gories in all interviews according to the constant
comparative method, first by the first author, then dis-
cussed in the research team. The analytic process com-
prising re-reading of data, arranging and re-arranging
tentative categories, then led to the construction of six
main categories. The categories were considered as sat-
urated when the data material no longer yielded new
theoretical insight or revealed new properties within the
category. All authors were active in all stages to ensure
multiple perspectives and to reduce subjective bias (15,
16). Lastly, the core concept of ‘being considerate every
step of the way’ was constructed, capturing the six
main categories with properties that gave an overall
analytic impression of a trauma-sensitive dental treat-
ment for CSA survivors (see Table 1).
The Regional Committee for Medical and Health
Research Ethics, South East Norway, approved the
The informants had a considerable amount of experi-
ence with dental treatment, both positive and negative.
The findings of this study highlighted that issues had
arisen before, in all stages of treatment as well as after
the consultation. Many informants had experiences
where dentists had shown consideration during part of
the treatment but not throughout the entire course, as
preferred. Thus, the core category developed was
entitled Being considerate every step of the way, based
on the following six main categories with their charac-
teristic properties (see Table 1).
Offering a good start
Adjusting appointment procedures to individual needs
was of vital importance according to the informants.
Some informants wanted to make the next appointment
before leaving the office to prepare themselves in
advance and in order to feel in control. Others pre-
ferred to be called at short notice.
I received the appointment in the post and immedi-
ately began to panic. I was probably totally exhausted
long before I showed up at the dentist. To me, it
would be preferable if I received a message like:
‘Tomorrow you have an appointment at the dentist’s.’
Offering frequent appointments was important. Many
informants expressed the need to attend regularly, some
as often as every 3 months, in order to avoid an
increase in anxiety.
Yes, what is really important to me, is to come for a
check regularly, more often than needed, because my
anxiety reaches a peak again if the next treatment is
too far ahead in time. The more often I go, the lower
the anxiety. (ID1)
Providing a welcoming reception was highlighted as a
factor that contributed to informants feeling welcome
upon entering the clinic.A befitting, friendly, helpful
dental assistant who smiled when following the patient
Table 1
Main categories and properties of ‘Being considerate every step of the way’
Core category Categories Properties
Being considerate
every step of the way
Offering a good start Adjusting appointment procedures to individual needs
Offering frequent appointments
Providing a welcoming reception
Proposing a non-treatment pre-visit
Being competent Providing quality dental treatment
Having a general knowledge of sexual abuse
Knowing about the patient being a CSA survivor
Being aware of the influence of staff behaviour Presenting a warm and calm attitude
Understanding the importance of gender
Comprehending the importance of mood
Obtaining awareness on influence of bodily characteristics
Building a safe relationship Being a fellow human
Paying attention to non-verbal signals
Exchanging mutual information
Respecting individual needs of CSA survivors
Offering a long-term patientdentist relationship
Arranging a secure treatment situation Entering agreements
Offering time
Striving for patient control and use of coping strategies
Giving the opportunity to bring a support person
Focussing on pain relief
Exploring individual triggers Investigating the dental chair position
Reducing possible perceptions of being trapped
Explaining the smell of dental equipment and materials
Finding solutions to mouth-related obstacles
Child abuse survivors and dental care 3
into the treatment room was desirable for most infor-
It’s okay if it is in a welcoming way, not dangerous,
in a way, and colours contribute as well as music play-
ing and nice people. (ID7)
Proposing a non-treatment pre-visit without any den-
tal treatment being carried out was perceived as very
They would not have to do much treatment, but hav-
ing the opportunity to use a visit or two on getting to
know each other!Because I think that is very impor-
tant, being familiar with the persons (dental person-
nel). (ID6)
Being competent
Different aspects of competence were highlighted as
important for trusting the dentist and feeling safe.
Providing quality dental treatment by having good
knowledge of their profession and superior skills in
dentistry was important for many informants.
He was very competent too. When I sat in the chair,
the phone rang and I overheard how a dentist asked
him for advice, so I became aware of his competence.
In addition, he had a calming effect on me. (ID1)
Having a general knowledge of sexual abuse was con-
sidered to be helpful.
And to know that the dentist is familiar with the rea-
sons for... removes many of the difficulties and emo-
tional obstacles, and things like that. (ID9)
Knowing about the patient being a CSA survivor was
a desire by most informants, but some would not or
could not tell about this. Some expressed a desire for
the dentist to understand, without them having to dis-
close their trauma history.
It would have meant a lot to me if I was asked early
in the process, so I could ... I think it would be easier
to connect my dental anxiety to the experiences of
abuse. It would have given me a feeling of being seen,
and of having a dentist who cared for how I am...
and, knowing one is being taken care of. (ID16)
Being aware of the influence of staff behaviour
Almost all informants had opinions about the impact
of dental staff behaviour.
Presenting a warm and calm attitude by the staff was
important to the majority of informants, and a sooth-
ing atmosphere was expressed to be advantageous.
The atmosphere is essential. To find rest and, ‘We are
going easy, we are proceeding at your tempo.’ He is
so good at making me feel safe!Not just throwing me
in the chair, pulling me backwards, and brrrrrr.
Understanding the importance of gender can be deci-
sive for managing dental treatment as CSA survivors
often do not wish to be treated by dentists of the same
gender as the sexual abuser.
I prefer a female dentist. That feels safer because I
hate male professionals, I don’t trust men. (ID7)
A few expressed that gender was irrelevant. The gen-
der of the dentist was reported to be less important
when the informant was accompanied by a supporting
friend or family member.
Comprehending the importance of mood was impor-
tant as many had experiences of being reprimanded by
the dentist during treatment, and felt the dental staff to
be harsh, authoritarian, and have an unfriendly tone.
It was so overwhelming, very authoritarian, and
very... military, in a way. Yes, when they are leaning
over you and are giving you a powerful speech, yes,
with angry power, in a way... (ID15)
Dentists and dental assistants who laughed and made
some jokes during treatment were considered calming
by some; others felt overlooked and not taken seriously
if the staff talked too much among themselves or used
much humour.
Obtaining awareness on the influence of bodily charac-
teristics was reported as crucial because certain hall-
marks of the dentist reminded many informants of the
Likewise, when a person is breathing close to you, the
sound of heavy breathing from people working, it is
awful to me. Heavy breathing, I can sit in the dental
chair and remember what happened... I can be
brought back in a way that makes me feel it is hap-
pening all over again. (ID3)
Some informants expressed that the odour of a male
dentist would evoke memories of a male abuser. One
male informant preferred to be treated by a large male
dentist to prevent himself from punching the dentist
when memories were triggered during treatment.
Building a safe relationship
The informants reported that establishing a good rela-
tionship with the dentist, based around a sense of
safety, security, and open communication, was chal-
Being a fellow human was considered a decisive fac-
tor, meaning that dentists saw the person for who they
are, without making them feel objectified as ‘a mouth’
or ‘teeth’.
Yes, she is not really a dentist; she is a more of a fel-
low human. ‘I will take care of you, even though I’m
doing this.’ (ID6)
Paying attention to non-verbal signals was important
because the majority of informants reported having
problems with expressing themselves verbally during
4Kranstad et al.
I know I just have to look at her, and she will under-
stand that I need a break. It’s not easy for me to say
‘May I have five minutes break?’. I can’t manage to
do that. (ID3)
Exchanging mutual information was considered to
improve treatment.
We are communicating about what is going on. ‘Now
I’ll do this and that. I know you will react in this or
that way, and I will take this into consideration.’
Respecting individual needs of CSA survivors was
reported as very important and the informants’ needs
were very individual.
It’s not obvious that the things that are helpful to me
will be helpful to others who were sexually abused. It
might be advantageous for someone to be distracted,
to watch a TV-screen, or to use sedatives or other
things that are not good for me. This is individual.
Another example was that some informants felt more
secure when there were two dental staff in the treat-
ment room,while others wanted just one. A third
example was that some informants wanted a closed
door to the treatment room while others preferred an
open door to avoid feeling locked inside the room.
Offering a long-term patientdentist relationship was
highlighted. A specific dentist, with whom the infor-
mant had the right chemistry, was preferable. Infor-
mants felt sceptical and sensitive concerning a change
of dentist.
What I think would have been helpful is to go on a
regular basis, to develop trust in the dentist, and so
on. Yes, to be followed up. It has to be on a long-term
basis, not ending the relationship after just one treat-
ment. It is also about the follow-up on the teeth,
because the problems do not suddenly disappear when
you have new teeth. I don’t believe so. (ID15)
Arranging a secure treatment situation
Making dental treatment a good experience for the
informants presupposed that they perceived it as safe
and foreseeable and that dentists were being consider-
Entering agreements, such as deciding on a stop sig-
nal, were reported by the informants to increase a feel-
ing of control. But this was based on the assumption
that the dentist kept their promise, and several infor-
mants did not feel worthy of attention, which made it
difficult to raise their voice in treatment situations.
‘I’ll only count to three’, and you are lying in the
chair, terrified, stiff with horror, ‘One, two... and
threeeeee!’. Number three was delayed in a way that
made me push her away from me, because she never
stopped, and it was so painful. Yes, she was not to be
trusted at all. (ID7)
Offering time was emphasized as significant.
They have to be calm and signalize that they have a lot of
time. ‘We will do this in your tempo.’ Giving me a feeling
that what will be going on is up to me (laughing). (ID3)
Striving for patient control and use of coping strategies
was important for receiving treatment in a good man-
ner. Coping strategies include thinking of pleasant
things, holding hands tightly, use of breathing and
relaxation techniques, closing the eyes, concentrating
on the dentist talking, or listening to music. A radio or
headphones with music could be of help. One infor-
mant said she focussed internally on a line of words
that made her feel good. However, negative coping
techniques, which were difficult for dentists to detect,
were also frequently reported.
I’m not present at all. When they come close to my
mouth or when I’m told to open my mouth, it is like
my body is swelling, I can hardly breathe and it is like
I’m disappearing, in a way. (ID6)
Giving the opportunity to bring a support person made
the informant feel more in control and protected. This
could be auxiliary personnel or a friend who can help
to explain the patient’s needs and interrupt the dentist
when necessary.
When I was going to dental treatment, I brought a
trusted person (from the SMSO), and then I felt safe.
Focussing on pain relief with different perspectives
was highlighted. Some informants tolerated consider-
able pain because they recognized agony too well and
were used to handling it, while others wanted to avoid
pain. Yet others struggled with having injections and a
feeling of numbness.
I prefer to feel nothing, so that means I got to have a
local anaesthesia.... I really hate local anaesthesia.
Well, number one is, it is painful, and I don’t like the
feeling of... you can feel the poison being pushed
into... Suddenly you can’t feel your face. Oh, I can’t
stand it!(ID7)
Exploring individual triggers
‘Trigger’ is a term used to describe sensations, images,
or experiences that provoke a traumatic memory.
Avoiding or minimizing these reminders of trauma that
might arise during dental treatment was reported to be
very important to informants.
Investigating the dental chair position was important
as several informants felt vulnerable and exposed when
being pulled back in the dental chair and lying in a
horizontal position. The feeling of being under the
command of somebody was reported as being less
oppressive when sitting in a more upright position.
To be pulled back (in the dental chair). Imagine the
feeling. You have no control. They have the control
over me. I can’t handle that situation. (ID14)
Child abuse survivors and dental care 5
Reducing possible perceptions of being trapped was
emphasized. Most informants had previously been held
down physically or experienced the feeling of being
restrained in the dental chair. The dental staff, parents
and equipment had all contributed to this feeling. One
informant sensed that the whole treatment room was
closing in on him.
You are really exposed in the dental chair, with the
tray right over your stomach, and things like that.
The possibilities to escape are minimal, with armrests
on both sides too. (ID8)
Explaining the smell of dental equipment and materials
can counteract negative sensations of the distinct den-
tistry smell.
Everybody knows the dental odour. And I associate
dentists with something frightening a frightening
odour is taking me back to the abuse. Thus, it is just
another warning sign starting to flash. (ID3)
Finding solutions to mouth-related obstacles can help
in overcoming problems with opening the mouth and
having fingers or dental equipment put inside it.
Putting things in the mouth. My mouth is the prob-
lem, sort of, yes, it was there everything was going
on; it was in the mouth he (the abuser) was active.
Retching, vomiting, and panic attacks were all
described as reactions experienced to things being inside
or near the mouth. One informant described rubber
gloves as being particularly problematic because they
reminded him of condoms that were used during his sex-
ual abuse. On the other hand, though, another informant
had differing experiences with rubber, believing that the
rubber dam had positive connotations, because of the sen-
sation that the dentist was working ‘outside’ the mouth.
Efficient removal of fluids by an attentive dental assistant
and allowing pauses in treatment for spitting and calming
down were reported as being advantageous.
The data analysis generated a conceptual framework
capturing how dental treatment is made achievable for
CSA survivors through showing consideration every step
of the way in the treatment. This implies dental staff who
pay detailed attention to every part of the dental consul-
tation, adjusting routines and behaviour to meet the indi-
vidual needs of the CSA survivors from the first contact.
All informants in this study were open to themselves and
the interviewers about their history of CSA. However,
within standard dental practice it is almost certain that
many CSA survivors will feel unable to share any CSA
history with their dentist. Therefore, dental personnel
should bear this in mind during consultations with all
The six categories (offering a good start, being com-
petent, being aware of the influence of staff behaviour,
building a safe relationship, arranging a secure
treatment situation, and exploring individual triggers)
all support the use of trauma-sensitive approaches in
dental care.
Howard BATH (17, 18) has described a model known
as ‘the three pillars of trauma-informed care’, and the
results of the present study support the concept of these
three pillars. The first pillar is safety. Our informants
expressed a need to feel secure in the dental treatment
situation (arranging a secure treatment situation), and
to establish this they needed to feel that they were in
control. They expressed a need to be included in deci-
sion making regarding treatment choice and the execu-
tion of the treatment. Several reported a safe
environment to involve avoidance of feeling of being
trapped by staff and equipment, and to be heard
regarding their needs; for example, being allowed to
bring a support person. Safety itself depends on the
development of a solid relationship between the CSA
survivor and the dentist.
The second pillar is a healing relationship (building a
safe relationship). The informants reported needs
related to being treated as humans, and the need to feel
that all dental staff were interested in them from their
very first contact with the clinic (offering a good start).
To achieve this, informants highlighted the need for
dental staff to be mindful of how they may affect inter-
personal trust and respect, through their communica-
tion, gender of dentist, and other attributes (being
aware of the influence of staff behaviour). The majority
reported that a stressed-out dentist exerted a particu-
larly negative influence. These observations are sup-
ported by the findings of BERNSON et al. (19), who
found that a respectful, empathetic interaction with
staff is a precondition for patients with dental anxiety
daring to undergo treatment. They also found humour
to be a positive factor during treatment. In our study,
a light atmosphere was reported as being useful by
some informants, but others reported that humour
should be used with caution as it was felt that their
issues were heeded less if humour was prominent.
The third pillar described by BATH (20) is affect regu-
lation, referring to the skills needed to handle trauma
reactions that arise during dental treatment. Informants
in this study reported that a warm, calm attitude from
the dentist had a soothing effect when they felt negative
triggers, and that this assisted them in calming down.
Bringing along a support person may also help to reas-
sure informants when feelings of disappearing (hypoac-
tivation) occur. The informants also underline the
importance of being allowed by the dentist to use their
own personally preferred coping techniques (e.g., listen-
ing to music on headphones and counting to three
before opening the mouth).
Acknowledging individual patient needs during treat-
ment was reported to be very important. The dentist
and the CSA survivor must always discuss individual
triggers (exploring individual triggers) and agree upon
how treatment procedures can be best carried out. The
results also supported that dental anxiety is a common
problem for CSA survivors (2, 4, 21). Thus, treatment
of dental anxiety needs to be addressed in CSA
6Kranstad et al.
survivors, with this study showing that while frame-
works for anxiety management (22) and standard treat-
ments for dental anxiety (23, 24) and sedation may be
used, even this anxiety treatment ought to be based on
individual needs.
Furthermore, several experts (25, 26) have empha-
sized the need for education of dentists on the topic of
sexual abuse (being competent). This is supported by
the informants in the present study. Most informants
expressed that they would like the dentist to have a
general understanding of sexual abuse. Some reported
it as unimportant that the dentist knew about them
personally being a CSA survivor as long as the dentist
revealed competence on handling reactions and situa-
tions that could arise during treatment. However, as
highlighted by some informants, a dentist’s knowledge
of sexual abuse was of little benefit to them if they did
not experience a relationship of trust and good connec-
tion with the dentist.
A strength of this study is that three of the research
members undertook all interviews and transcribed the
material themselves. This contributed to additional famil-
iarity and intimate knowledge of the data. A multidisci-
plinary research team ensures different perspectives and
identifies nuances in informants’ stories, thereby detecting
matters that might otherwise be missed (15, 16). One pos-
sible limitation may be that informants recruited from the
SMSO population differ considerably from CSA sur-
vivors who do not use such a Centre because they experi-
ence long-term consequences of abuse to a lesser degree.
Another limitation may be that the informants did not
have an opportunity to comment on the codes or results.
The key clinical aim of this study should be to highlight
the importance of dentists having a general knowledge of
CSA and implementing trauma-sensitive approaches. The
dentists need to know how to assess CSA survivors and
openly ask about difficulties with managing dental care.
They also need sufficient time to put this into practice.
Based on current knowledge of CSA survivors and dental
treatment, not taking enough time to build a trusting rela-
tionship and failure to perform dental treatment based on
an individual’s needs should be regarded as malpractice,
equivalent to failing to take the necessary time to perform
root canal treatment in all canals of an infected tooth.
It seems that the CSA survivors, from their extreme
experiences, can make very valuable points that are useful
for most dentists and other dentally anxious patients.
Thus, the three pillars of trauma-informed care may con-
stitute general principles that should be borne in mind
during all dental treatment situations. According to the
MISSOURI MODEL (27), a ‘trauma-informed approach’ is
not simply a framework that can be implemented and
deemed successful based on adherence to set guidelines.
Rather, it is a profound paradigm shift in knowledge, per-
spective, attitudes and skills among clinicians and staff
that continues to deepen and unfold over time. Leaders in
the field talk about a ‘continuum’ of implementation
where organizations move through stages; these stages
start by becoming trauma-aware, before moving to
trauma-sensitive, to responsive, and finally to being fully
All dental patients must feel safe enough, they must
have relationships with the clinicians that are solid
enough, and their affect regulation must be adequate
enough to be able to cope with the situation.
Dentists should have a trauma-sensitive approach to
all patients, and when treating CSA survivors, dentists
should demonstrate utmost consideration every step of
the way. Dentists need to build long-term solid rela-
tionships with CSA survivors, discuss and test coping
strategies that are adapted to their specific needs, and
perform treatment in a safe environment.
Acknowledgements – We thank the informants who generously
shared their experiences with us, and Anne Birgit Vintermyr and
Margrethe Vika for engaging in the development of the study.
This research received no specific grant from any funding.
Conflicts of interest – The authors declare that they have no con-
flict of interest.
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8Kranstad et al.
... After overcoming the difficulty of booking and attending an appointment, an underlying sense of helplessness is reported by survivor-patients through feeling disempowered and out of control in the dental chair. 5,6 Specific aspects of the appointment, such as having implements in the mouth and feeling claustrophobic, link to past experiences of being in danger and pain. 7 Overall, survivors may be observed by dental practitioners as anxious but their dental care experiences are often more complex in nature, as there is a link to previous trauma. ...
... 17,18 The themes of panic in the dental encounter, dilemmas around disclosure and choice and control, indicate that a multitude of difficulties are present for survivors attempting to access the dentist. This supports the findings from other studies 5,6,7 and contributes to the conclusions of other studies that there is a link between CSA and dental fear. 5,7,19,20 The current study also links with broader dentistry research which considers the specific needs of patients with complex mental health needs, including those with traumatic stress. ...
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Introduction Seven percent of the adult population in the UK, including one in six women, report unwanted sexual experiences before the age of 16. The impacts of psychological trauma following child sexual abuse (CSA) creates difficulties for many survivors in accessing dental care due to fears of reminders of abuse, the power imbalance with the dentist and triggered traumatic responses. Aims To analyse and report CSA survivor perspectives of dental care and offer suggestions for practice. Method Qualitative semi-structured interviews of 17 CSA survivors generated data as part of a broader study investigating trust and trustworthiness in survivor-professional relationships. The range of dental interactions and the needs survivors described when receiving dental treatment are presented. Transcripts were analysed using NVivo software and thematic analysis methodology. Results Three main themes were identified: the dental encounter ('it really panics me'); the opportunity to disclose; and choice and control. Conclusion This is the first UK study to present qualitative data from CSA survivors about their experiences of dental care. Survivors wish to access dental care but tailored support is needed to ameliorate reminders of abuse and traumatic stress triggers. Trauma-informed care may address difficulties with treatment if dental staff adopt flexible approaches and work collaboratively with survivors to facilitate relational safety. (Please note, in this paper, 'survivors' refers to those sexually abused as children).
... Hence, symptoms of depression and anxiety could intermediate the association between traumatic events and dental anxiety. Since a dental treatment situation is arguably a highly relational, intimate and interpersonal circumstance [42], it comes as no surprise that dental experiences are inevitably coloured by the interpersonal relationship between the dental caregiver and the recipient [47][48][49][50]. ...
... This could point to sexual abuse experiences being somehow directly conditional on dental anxiety [42] and clarify the lack of conscious awareness of the link between sexual abuse and dental anxiety, which might be evident in some survivors of sexual abuse [40]. Evidence shows that many aspects of dental treatment can trigger memories and flashbacks from sexual abuse within the concept of trauma coupling [42,50,65]. Crossing lines of intimacy in the dental setting can be difficult in itself, but the oral cavity may have been violated directly, which could make the dental setting even more challenging [40,66]. ...
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Objective The objectives of the study were to describe the prevalence of dental anxiety and the possible associations between dental anxiety and potentially traumatic events in an adult population. Method The study is based on cross-sectional questionnaire data from the 7th wave of the Tromsø Study, a study of the adult general population in the municipality of Tromsø carried out in 2015–2016. The Modified Dental Anxiety Scale was used to measure dental anxiety across potentially traumatic events, oral health, dental attendance (avoidance) and current mental health symptoms (Hopkins Symptom Checklist). Individuals with high and low dental anxiety scores were compared to investigate differences in the distribution of potentially traumatic events, current mental health symptoms, avoidance, sex and oral health, and hierarchical multivariable regression was used to study the influence of traumatic events on dental anxiety. Results High dental anxiety was reported by 2.9% of the sample and was most prevalent among females and in the youngest age groups. Individuals with high dental anxiety reported more current mental health symptoms, and they were more likely to report poorer oral health and more irregular dental visits compared to individuals with no or lower dental anxiety scores. Concerning traumatic events, the reporting of painful or frightening dental treatment showed the biggest difference between those with high dental anxiety and low dental anxiety scores (a moderate effect). The hierarchical regression model indicated that reporting sexual abuse, traumatic medical treatment in hospital and childhood neglect significantly predicted dental anxiety in the step they were entered in, but only sexual abuse remained a significant individual contributor after controlling for current mental health symptoms. Conclusions The prevalence of high dental anxiety was lower than expected (2.9%), but dentally anxious individuals expressed a high burden of mental health symptoms, poor oral health and the avoidance of dental care. The regression analysis indicated that experiences with sexual abuse could affect dental anxiety levels in the absence of generalised symptoms of anxiety and depression.
... Healthcare practitioners trained in sensitive practice, and grounded in trauma-informed care (TIC), can enhance the experience of survivors in healthcare settings and ultimately lead to improved patient experiences [3] . Given that many patients may not disclose their SV history in healthcare settings (and that many providers do not ask) [5] , it is recommended that sensitive practice principles be applied as the standard of care for all healthcare professionals [5][6][7] . ...
Introduction: Research shows that for survivors of sexual violence (SV), cancer procedures can be retraumatizing due to perceived similarities to the original SV. To date, there is no training program designed specifically for the radiation therapist (RTT) on how to deliver care sensitively to survivors of SV. A key component of sensitive practice is working with patients to identify and develop strategies to manage situations that could be triggering. The goal of this study was to understand the RTT recognition of potential sensory/environmental, relational, and mixed triggers in radiation oncology settings. Methods: This quantitative research study conducted a secondary analysis on RTT responses to a learning activity from an online cancer education training program. The first section of the activity asked trainees to identify two potential triggers in a brachytherapy video, and the second portion of the activity asked trainees to describe two potential triggers in their own work. Results: Descriptive statistics, χ2 tests, and t tests were used to analyze 50 RTT responses. RTTs tended to identify different types of triggers depending on the question (brachytherapy video vs. self-reflection). Data indicated that despite a lack of formal didactic training in trigger management, RTTs could identify triggers, and were most likely to recognize "mixed" type triggers. Discussion: Triggers identified are consistent with past research on childhood sexual abuse survivors' healthcare retraumatization in obstetrics and gynecology, and cancer care. As in past research, invasive techniques, and situations where the patient was in a submissive position were identified as triggering aspects of care. It is interesting to note when reflecting on their own practice, the least identified triggers all fell under the environmental/sensory trigger category. RTTs may not fully appreciate a variety of potential triggers such as sounds of treatment or silence because they are outside of the room administering the beam when the machine is delivering treatment. Thus, they may not hear certain sounds or silence during their daily routine. Conclusions: Relatively few trainees identified sensory/ environmental triggers (e.g., restricted visibility and sounds of treatment, including silence) when reflecting on their own practice, which could potentially reduce their likelihood of helping patients minimize the impact of (or avoid) such triggers. Future research should identify a comprehensive list of triggers and then develop a training specific to the RTT focused on identifying environmental/sensory triggers from the perspective of the patient in the often unfamiliar and frightening radiotherapy suite.
... According to Bryne et al., dentists that aim to treat dental anxiety must look beyond the technicalities of restoring oral pathologies and become able to create a safe space for the patient [39]. Kranstad et al. found that patients with a history of sexually abuse want a stable long-term relationship with a dentist [40]. Use of systematized evidence-based methods in a general dental practice by dentists adequately trained in relational skills may represent a viable treatment option for this patient group. ...
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Background Educating dentists in treatment methods for dental anxiety would increase the patients’ access to treatments that are important to their oral health. However, to avoid adverse effects on comorbid symptoms, involvement by a psychologist has been considered necessary. The objective of the present paper was to evaluate whether a dentist could implement systematized treatments for dental anxiety without an increase in comorbid symptoms of anxiety, depression or PTSD. Methods A two-arm parallel randomised controlled trial was set in a general dental practice. Eighty-two patients with self-reported dental anxiety either completed treatment with dentist-administered cognitive behavioural therapy (D-CBT, n = 36), or received dental treatment while sedated with midazolam combined with the systemized communication technique “The Four Habits Model” (Four Habits/midazolam, n = 41). Dental anxiety and comorbid symptoms were measured pre-treatment (n = 96), post-treatment (n = 77) and one-year after treatment (n = 52). Results An Intention-To-Treat analysis indicated reduced dental anxiety scores by the Modified Dental Anxiety Scale (median MDAS: 5.0 (-1,16)). The median scores on the Hospital Index of Anxiety and Depression (HADS-A/D) and the PTSD checklist for DSM-IV (PCL) were reduced as follows: HADS-A: 1 (-11, 11)/HADS-D: 0 (-7, 10)/PCL: 1 (-17,37). No between-group differences were found. Conclusions The study findings support that a general dental practitioner may treat dental anxiety with Four Habits/Midazolam or D-CBT without causing adverse effects on symptoms of anxiety, depression or PTSD. Establishing a best practice for treatment of patients with dental anxiety in general dental practice should be a shared ambition for clinicians, researchers, and educators. Trial registration The trial was approved by REC (Norwegian regional committee for medical and health research ethics) with ID number 2017/97 in March 2017, and it is registered in 26/09/2017 with identifier: NCT03293342.
... A key principle of TIC is resisting re-traumatization of patients who have experienced TLE (Gerber et al., 2019;SAMHSA, 2014). Dental treatment techniques may cause anxiety and re-traumatization due to the powerlessness experienced when dental patients are placed in a supine position and are unable to communicate while a provider works within their mouth (Kranstad et al., 2019;Raja et al., 2014). Creating an environment that is empowering and safe while fostering trust, choice, and collaboration is paramount. ...
Background: Traumatic life experiences (TLE) are common and can affect a person's physical being and health-related behaviors, including those related to oral health. This scoping review aimed to identify evidence exploring the implementation and provision of trauma-informed care (TIC) in oral health services delivery. Methods: Arksey and O'Malley's framework with enhancements proposed by Levac et al. and Peters et al. was used. Studies were selected based on a preset inclusion and exclusion criteria and the population/concept/context framework. Primary charting of descriptive data was conducted, followed by thematic analysis to identify ideas common within the included literature. Searches were conducted in Medline (via Ovid), APA PsycINFO (via Ovid), Embase (Elsevier), Scopus, CINAHL (via EBSCO), and Cochrane databases. Google Scholar and ProQuest were used to identify grey literature. Results: The search identified 251 records, with fifteen records meeting the inclusion criteria. Limited models, frameworks, and recommendations for trauma-informed practices in oral health services were identified. Recommendations for TIC practices were identified, and clinical practice adjustments for dental practitioners were described to improve service delivery for patients who may have experienced trauma. Avenues for future research were identified. Conclusions: Limited evidence exists to guide trauma-informed practice in oral health service delivery. This scoping review highlights the need for further research into approaches and practices of TIC for oral health services delivery to assess their efficacy and the need to develop evidence-based TIC frameworks to meet the unique needs of oral health service providers and populations.
... Therefore, traumatic experiences are a serious risk factor for dental anxiety, fear, and phobia [16]. Overall, people with severe mental disorders like schizophrenia show high levels of unmet dental needs [17,18]. However, increasing attention is paid not only to dental patients with anxiety, especially heavily burdened patients, but also to the risk of burnout by dentists themselves due to emotional dysregulation and the social cognitive function of empathy with patients [19,20]. ...
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Background Dental anxiety is of public health importance because it leads to postponed dental treatment, which comes with health complications. The present study investigated whether there is a correlation between the degree of dental anxiety and other kinds of anxiety and whether there are prognostic factors for the different kinds of anxiety. Method In the sample (N = 156) from a dental practice in a large German city, 62% of patients received a check-examination and 38% received dental surgery. The target variables were recorded with validated questionnaires: dental anxiety (IDAF-4c+), subclinical anxiety (SubA), anxiety of negative evaluation (SANB-5), current general anxiety (STAI state), loneliness (LS-S) and self-efficacy (GSW-6). The applied statistics were: t-tests for 31 variables, correlation matrix and multivariate and bivariate regression analyses. Results The dental surgery patients displayed more dental anxiety and more dental interventions than the check-examination group. The main result was a positive correlation of all kinds of anxiety with each other, a positive correlation of loneliness and neuroticism with all forms of anxiety and a negative correlation between all forms of anxiety and self-efficacy. Especially dental anxiety is positively associated with other kinds of anxiety. In multivariate regression models only neuroticism is associated with dental anxiety, but feelings of loneliness are positively associated with with the other kinds of anxiety assessed in this study. The higher the self-efficacy, the lower the level of general anxiety. Conclusions In dentistry, anxiety from negative experiences with buccal interventions should be distinguished from anxiety caused by personality traits. Self-efficacy tends to protect against anxiety, while loneliness and neuroticism are direct or indirect risk factors for anxiety in this urban dentistry sample. Dental anxiety seems to be independent from biographical strains but not from neuroticism. In practice, more attention must be paid to anxiety control, self-management and efforts to improve the confidence of patients with emotional lability, less self-confidence and propensity to shame.
It is important to have in mind that dental treatment always include a risk of re-traumatization of CSA survivors. In CSA survivor’s trauma-driven dental anxiety, the resemblance between the patient’s experiences in the present and traumatic events experienced in the past is relevant. Experienced stimuli, frightening emotions and memories, involve responses that might lead to dissociation and loss of memory from the dental visit. Feelings of control and predictability are important. Dentists should be considerate every step of the way, building long-term solid relationships, discuss and test out coping strategies individually in a safe environment.KeywordsChild sexual abuseTrauma-driven dental anxietyDissociationCoping strategiesCoping plan
This chapter provides an overview of self-determination theory (SDT) used in oral healthcare practice and research. Interventions promoting autonomy-supportive dental competence, relative to standard care, yielded increase in autonomous motivation, perceived dental competence, and oral hygiene behaviours (e.g. brushing, flossing, more regular meals), decrease in dental plaque and improved oral health. Moreover, the interventions affected more frequent dental attendance and oral health-related quality of life. SDT provides a strong empirical basis that demonstrates the importance of operationalising the core principles of autonomy support, basic psychological needs and motivation to enhance patients’ oral health and oral health-related quality of life.KeywordsAutonomy supportive and controlling oral healthcare professionalsBasic psychological need satisfaction and frustrationAutonomous motivationControlled motivationOral health behaviourOral healthOral health-related quality of life
“You won’t see it until you believe it.” Patients in dental treatment may suffer from severe psychological trauma, still the source of their troubles is often hidden. Typically, the dentist will perceive the patient as “difficult” when struggling with psychological and/or physical reactions during dental procedures. As it is challenging to believe that anyone has been traumatized, dentists often neither see the patient’s needs nor know what may be helpful interventions in treatment. Hence, some trauma theory and at least a few principles of trauma-sensitive techniques should be a part of all ordinary health practice.KeywordsTraumatic life experiencesTrauma-sensitive careWindow of toleranceTriune brainDissociationCommunicationRelationAlliance
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Patients with a trauma history, whether sexual abuse or torture, or dental phobia, tend to avoid dental services due to severe dental anxiety. Subsequently, they experience poor oral health, lower quality of life, and poorer general health. In Norway, a specific service (torture, abuse, and dental anxiety [TADA]) targets these patients’ dental anxiety through cognitive behavioural therapy (CBT) prior to dental restoration. By exploring patients’ experiences with TADA services using a realist evaluation approach, this paper aims to increase our understanding of how this type of service addresses patients’ dental anxiety in terms of its mechanisms and contextual factors. Interviews with TADA patients (n = 15) were analysed through a template analysis driven by context‐mechanism‐outcome heuristics. The analysis revealed that patients value a dental practitioner who provides a calm and holistic approach, positive judgements and predictability elements that lean towards a person‐centred care approach. Provided this, patients felt understood and cared for, their shame was reduced, self‐esteem emerged, and control was gained, which led to alleviation of dental anxiety. Therefore, our findings suggest that combining CBT with a person‐centred care approach helps alleviate patients’ dental anxiety. This provides insights into how dental services could be executed for these patients.
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The authors discuss the components of consensual qualitative research (CQR) using open-ended questions to gather data, using words to describe phenomena, studying a few cases intensively, recognizing the importance of context, using an inductive analytic process, using a team and making decisions by consensus, using auditors, and verifying results by systematically checking against the raw data. The three steps for conducting CQR are developing and coding domains, constructing core ideas, and developing categories to describe consistencies across cases (cross analysis). Criteria for evaluating CQR are trustworthiness of the method, coherence of the results, representativeness of the results to the sample, testimonial validity, applicability of the results, and replicability across samples. Finally, the authors discuss implications for research, practice, and training.
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Both oro-related behavioural and sexual dysfunctions are non-life-threatening conditions which can have an impact on individual well-being. Possible common features include intra-body penetration, giving control to another person, and experiencing encounters that can sometimes be subjectively experienced as aggressive and/or abusive. The present study examined possible sexual correlates of dental anxiety and gagging. A total of 448 individuals, who applied for sex therapy at the Sexual Medicine Center, Sheba Medical Center, Tel-Hashomer, Israel, completed the following sexual and dental functioning questionnaires: International Index of Erectile Function (men only), Female Sexual Function Index and difficulties with sexual penetration (women only), dental anxiety, gagging reflex and dentist preference (entire population). Higher gagging reflex was associated with problems in sexual penetration and history of sexual abuse in women (especially one that included vaginal penetration). It was also associated with dental anxiety and higher preference for dentist of the same gender for both genders. The study shows that gagging reflex can bear sexual connotations, especially in women.
Objective: To describe the prevalence of dental anxiety (DA) among adolescents in Tromsø and Balsfjord region in northern Norway and present a multivariate logistic regression model to predict high dental anxiety scores (DASs) among these adolescents. Materials and methods: We used self-report questionnaires and clinical dental examination data from adolescents registered in upper secondary school (15–18 years of age) in this region (n = 986). Logistic regression was used to estimate odds ratios and their 95% confidence intervals (CI) when using Corah’s DAS as a dichotomous dependent variable. Results: Twelve percent of the respondents reported a DAS score ≥13, indicating high DA. The strongest predictors for reporting high DA were anticipated pain at the dentist, ‘external control belief’, avoidance, low social motivation on oral health behaviour and sex. In this population, dental caries (DMFS), symptoms of psychological distress (HSCL-10) and self-motivation concerning oral health behaviour did not differ significantly between those reporting high DA (DAS ≥13) and those that reported low DA (DAS ≤12). Conclusions: Severe DA in adolescence is a dental public health challenge and this study shows that DA is a hindrance to seeking dental treatment irrespective of dental status. Dental anxiety should have a higher focus on preventive oral health strategies and have a higher priority in public dentistry to avoid this problem to escalate into adulthood.
and Overview Dentists frequently treat patients who have a history of traumatic events. These traumatic events (including childhood sexual abuse, domestic violence, elder abuse and combat history) may influence how patients experience oral health care and may interfere with patients' engagement in preventive care. The purpose of this article is to provide a framework for how dentists can interact sensitively with patients who have survived traumatic events. /st> The authors propose the trauma-informed care pyramid to help engage traumatized patients in oral health care. Evidence indicates that all of the following play an important role in treating traumatized patients: demonstrating strong behavioral and communication skills, understanding the health effects of trauma, engaging in interprofessional collaboration, understanding the provider's own trauma-related experiences and understanding when trauma screening should be used in oral health practice. Practical Implications Dental patients with a history of traumatic experiences are more likely to engage in negative health habits and to display fear of routine dental care. Although not all patients disclose a trauma history to their dentists, some patients might. The trauma-informed care pyramid provides a framework to guide dental care providers in interactions with many types of traumatized patients, including those who choose not to disclose their trauma history in the context of oral health care.
People who are highly anxious about undergoing dental treatment comprise approximately one in seven of the population and require careful and considerate management by dental practitioners. This paper presents a review of a number of non-pharmacological (behavioural and cognitive) techniques that can be used in the dental clinic or surgery in order to assist anxious individuals obtain needed dental care. Practical advice for managing anxious patients is provided and the evidence base for the various approaches is examined and summarized. The importance of firstly identifying dental fear and then understanding its aetiology, nature and associated components is stressed. Anxiety management techniques range from good communication and establishing rapport to the use of systematic desensitization and hypnosis. Some techniques require specialist training but many others could usefully be adopted for all dental patients, regardless of their known level of dental anxiety. It is concluded that successfully managing dentally fearful individuals is achievable for clinicians but requires a greater level of understanding, good communication and a phased treatment approach. There is an acceptable evidence base for several non-pharmacological anxiety management practices to help augment dental practitioners providing care to anxious or fearful children and adults.
The aim was to investigate the efficacy of behavioural interventions as treatment of dental anxiety/phobia in adults, by conducting a systematic review of randomized controlled trials (RCTs). The inclusion criteria were defined according to the Patients, Interventions, Controls, Outcome (PICO) methodology. The study samples had documented dental anxiety, measured using validated scales [the Dental Anxiety Scale (DAS) or the Dental Fear Survey (DFS)], or fulfilled the psychiatric criteria for dental phobia. Behavioural interventions included were based on cognitive behavioural therapy (CBT)/behavioural therapy (BT), and control conditions were defined as information, sedation, general anaesthesia, and placebo/no treatment. The outcome variables were level of dental anxiety, acceptance of conventional dental treatment, dental treatability ratings, quality of life and oral health-related quality of life, and complications. This systematic review identified 10 RCT publications. Cognitive behavioural therapy/behavioural therapy resulted in a significant reduction in dental anxiety, as measured using the DAS (mean difference = -2.7), but the results were based on low quality of evidence. There was also some support that CBT/BT improves the patients' acceptance of dental treatment more than general anaesthesia does (low quality of evidence). Thus, there is evidence that behavioural interventions can help adults with dental anxiety/phobia; however, it is clear that more well-designed studies on the subject are needed.
The past decade has brought with it a greatly increased awareness about the impact of trauma on children, which has, in turn, led to a focus on the treatment of trauma-related conditions. Much of the recent literature describes different approaches to therapy. However, there are a few consistent propositions arising from the research and clinical literature which suggest that much of the healing from trauma can take place in non-clinical settings. There is some evidence to suggest that trauma-informed living environments in which healing and growth can take place are a necessary precursor to any formal therapy that might be offered to a traumatised child. It stands to reason that the treatment of children exposed to complex trauma will itself be complex and long-lasting. However, there appears to be a remarkable consensus about the key prerequisites for healing--those critical factors or therapeutic pillars that need to be in place if healing is to take place. Although there is debate about the number of critical factors, there are three that are common to most approaches. This article outlines the three pillars of trauma-informed care: (1) safety; (2) connections; and (3) managing emotional impulses. (Contains 1 footnote.)
Neuroscience shows that humans develop their abilities for emotional self-regulation through connections with reliable caregivers who soothe and model in a process called "co-regulation." Since many troubled young people have not experienced a reliable, comforting presence, they have difficulty regulating their emotions and impulses. Co-regulation provides a practical model for helping young people learn to manage immediate emotions and develop long term self-control.