Michelle Strange, MSDH, RDH, discusses how implementing trauma-informed care (TIC) practices in our clinics can have a marked effect on the patient experience, potentially improving treatment adherence and health outcomes and the overall wellness and health of staff and practitioners.
Q: What is the correlation between a patient’s exposure to adverse childhood experiences (ACEs) and his or her long-term health, including dental health?
A: Exposure to traumatic events or ACEs is proven to increase a person’s overall risk of severe long-term health issues and at-risk behaviors.1 Acknowledging these experiences can improve patient-clinician engagement and increase the likelihood of provision of the most effective treatment while also avoiding unintentional re-traumatization. These adverse experiences may include, but are not limited to, childhood sexual abuse, neglect, discrimination, combat history, and domestic violence, leaving patients with long-lasting psychological effects.2
There are strong associations between poor dental health and exposure to ACEs. Research shows that tooth loss is significantly higher in those with 4 or more adverse childhood experiences. They are also more likely to have teeth that need filling and restorations.3 Those with high dental anxiety also often report higher pain levels during dental visits.4 However, despite this, TIC is not routinely taught in undergraduate education.5
Q: What is trauma-informed care, and how does it help clinicians adapt their approach to avoid re-traumatizing patients with a history of ACEs?
A: Poor oral health-related quality of life (OHRQoL) is closely associated with dental pain and anxiety, which, as clinicians, falls within our scope of practice to attempt to reduce.6 This does not mean we need to remedy the underlying trauma but to instead adapt our approach and responses by implementing TIC-focused practices. Women with sexual ACEs have reported suffering from memories of their original abuse during treatment. They have expressed their belief that the dentist should have known about their history before treatment to avoid it becoming a re-traumatizing experience.7
TIC involves education to realize the impact, signs, and symptoms of trauma and integrate that knowledge into not just the dental practice but also the policies and procedures of all aspects of the patient experience.
Q: What are some TIC strategies that clinicians can implement?
A: There are 6 key principles of TIC defined by the Substance Abuse and Mental Health Services Administration.8
- Safety (physical and psychological)
- Trustworthiness and transparency (being transparent in the decision-making process to build trust)
- Peer support (mutual support for healing/recovery)
- Collaboration and mutuality (ensuring little to no power differentials)
- Empowerment, voice, and choice (promoting individuals’ strengths and autonomy)
- Cultural, historical, and gender issues (acknowledging and addressing the impact of historical trauma, overt discrimination, and biases)
Adopting trauma-informed approaches based on these principles can avoid adding to the trauma burden of patients.9
Some TIC strategies suggested include creating a soothing office space, training staff to validate concerns, giving your patient as much control over what happens and when it happens as possible, explaining each procedure, and asking for consent before beginning.10 The prescreening of patients to gather information about potential traumatic history should be employed. Staff should receive training to recognize re-traumatization and, through coaching, attain de-escalation skills.
Q: How can dental professionals promote a culture of awareness, understanding, and action that upholds trauma-informed principles?
A: Patient-centered and trauma-informed care do not cease once the client has left the clinic. Fostering a sense of empathy requires patients to be understood and not dehumanized, which is a cohesive effort and the duty of all staff at all times. Understanding a patient’s healthcare beliefs and values cultivates an increased sense of compassion, leading to greater patient adherence to treatment protocols and client satisfaction.11
Awareness, understanding, and action are critical to a trauma-informed clinical approach that begins and ends with the culture upheld within a clinic as a whole, not just while the patient is in attendance.12
While we may not know which patients come to us with trauma history and which of those may not feel comfortable disclosing it during the prescreening process, assume that everyone has, at some point, experienced an adverse event that may impact his or her response to treatment. This is the best way to ensure the application of trauma-informed care as standard practice. This approach, in turn, will help us to do our part as ethical and responsible clinicians to increase OHRQoL for our clients.
MORE ABOUT MICHELLE STRANGE, MSDH, RDH
Ms. Strange is a practicing hygienist, speaker, writer, content developer, and owner of Level Up Infection Prevention. She has a master’s in dental hygiene education, a certificate in dental infection control and prevention, and a belief in lifelong learning. She has also served in her community and on global mission trips. She believes deeply in sustainable, charitable dentistry and serves to bridge the gap in access to care.
She can be reached at levelupip.com or michellestrangerdh.com.
- What is Trauma-Informed Care? University at Buffalo: Buffalo Center for Social Research. Accessed September 22, 2022.
- Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: providing trauma-informed care. J Am Dent Assoc. 2014;145(3):238–45. doi:10.14219/jada.2013.30
- Ford K, Brocklehurst P, Hughes K, et al. Understanding the association between self-reported poor oral health and exposure to adverse childhood experiences: a retrospective study. BMC Oral Health. 2020;20(1):51. doi:10.1186/s12903-020-1028-6
- Nermo H, Willumsen T, Rognmo K, et al. Dental anxiety and potentially traumatic events: a cross-sectional study based on the Tromsø Study-Tromsø 7. BMC Oral Health. 2021;21(1):600. doi:10.1186/s12903-021-01968-4
- Brown T, Mehta PK, Berman S, et al. A trauma-informed approach to the medical history: teaching trauma-informed communication skills to first-year medical and dental students. MedEdPORTAL. 2021;17:11160. doi:10.15766/mep_2374-8265.11160
- Svensson L, Hakeberg M, Wide U. Dental pain and oral health-related quality of life in individuals with severe dental anxiety. Acta Odontol Scand. 2018;76(6):401–6. doi:10.1080/00016357.2018.1473892
- Leeners B, Stiller R, Block E, et al. Consequences of childhood sexual abuse experiences on dental care. J Psychosom Res. 2007;62(5):581–8. doi:10.1016/j.jpsychores.2006.11.009
- U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration. Kap Keys for Clinicians based on TIP 57: Trauma-informed care in behavioral health services. Accessed September 22, 2022.
- McCarthy J. Trauma-informed dental care. Healthcentric Advisors. Accessed September 22, 2022.
- Kennedy BM, Rehman M, Johnson WD, et al. Healthcare providers versus patients’ understanding of health beliefs and values. Patient Exp J. 2017;4(3):29-37.
- Champine RB, Hoffman EE, Matlin SL, et al. “What does it mean to be trauma-informed?”: A mixed-methods study of a trauma-informed community initiative. J Child Fam Stud. 2022;31(2):459–72. doi:10.1007/s10826-021-02195-9