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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: 1–8. ©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
1
, Siri
Søftestad
1
, Therese V. Fredriksen
1
,
Tiril Willumsen
1,2
1
Oral Health Centre of Expertise in Southern
Norway, Arendal;
2
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
E-mail: vibkra@online.no
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.
Analysis
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
study.
Results
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.’
(ID3)
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 patient–dentist 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-
mants.
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
helpful.
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.
(ID14)
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
abuser.
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-
lenging.
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
treatment.
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.’
(ID12)
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.
(ID1)
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 patient–dentist 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-
ate.
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.
(ID8)
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.
(ID14)
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.
Discussion
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
patients.
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
trauma-informed.
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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