This is an abridged version of an interview by Jack Bynes, DDS of dentalfear.com with Dr Carmen Santos. Carmen is a licensed clinical psychologist with over 25 years of clinical experience. She received her doctorate from The University of Hartford School of Professional Psychology in 1997. Her dissertation topic was “The Identification and Treatment of Adult Female Survivors of Sexual Abuse with Dental Anxiety”.
Is dental anxiety more common among men or women?
Surveys estimate that approximately 80% of the adult population in the United States report some level of anxiety regarding dental treatment. A significantly large percentage of females report higher levels of dental fear on standardized measures of dental anxiety than men. There are also high prevalence rates in the area of sexual abuse and dental anxiety among women. Among those reporting dental fear and a history of sexual abuse, the fear was not always related to fear of pain nor was the fear precipitated by a traumatic dental experience. Although there is a high prevalence of dental fear among women, this is not to suggest that all women with dental anxiety have also been abused.
What are some of the basic similarities between those with dental anxiety and those who have experienced sexual abuse?
Varying forms of abuse that inflict pain or create problems of lack of control and powerlessness may have a dramatic impact on the individual’s ability to manage routine activities that may involve physical discomfort. Often fear of loss of control, vulnerability, and the anticipation of pain have been closely identified as issues affecting dental phobics. Similar issues have been found to be true of trauma survivors. Again, this is not isolated to sexual trauma, but can include varying forms of other physical and emotional trauma, where feelings of powerlessness and helplessness are common.
What are some of the symptoms reported by those with dental anxiety who are also sexual abuse survivors?
The symptoms typically reported consisted of fear, anxiety, nausea, dissociation, flashbacks and feelings of shame. The shame can be about being anxious, about their poor oral health, or about having someone find out about the abuse.
How could a visit to the dentist trigger memories or feelings of past abuse?
Many aspects of dental treatment have been found to symbolically represent sexual abuse for many survivors. The following conditions may trigger a repetition of earlier trauma:
- being alone with a person more powerful than oneself,
- being placed in a horizontal position,
- having someone nearby and touching you,
- having objects placed in one’s mouth,
- being unable to talk or swallow, and
- experiencing or anticipating pain.
Many dental experiences may remind the patient of their abuse experience in that they produce awkward sensations of suffocation, such as in the use of rubber dams, or gagging sensations, or feeling restrained in their movement.
What constitutes sexual abuse?
There is much disagreement about what defines sexual abuse and what constitutes molestation and how a severity index can be applied to an individual’s trauma experience. Sexual abuse may involve any number of behaviors, not all of them include actual body contact. Abuse may be considered on a continuum that may range from exhibitionism to actual intercourse, moving from nudity, to the exposure of genitals, kissing, fondling, masturbation, oral sex, digital penetration to penile penetration.
Is it possible for someone to experience dental fear and not understand its relationship to previous abuse?
Yes. Given the high numbers of women affected by sexual abuse in the population, it seems quite likely that many of these women are receiving treatment for various unrelated medical and dental issues. Their prior traumatization may have a significant impact on these treatments and yet may go unrecognized or misunderstood by all those involved in the health care delivery system. Many survivors are unaware of the potential long term consequences of abuse or may fail to associate difficulties in receiving needed treatment as related to their abuse histories. As a result, dental treatment is often avoided without a clear understanding of why, and even if the patient is aware, they may not disclose the information.
What would a dissociative episode or “flashback” look like?
Dissociation may be one coping strategy used by trauma survivors to try and cope with overwhelming anxiety. A person may show signs of dissociation when they become unresponsive to questions or commands, stare blankly into space or appear dazed, appear suddenly startled, spontaneously cry or are unable to explain why they are crying, or seem confused about where they are or what is going on. A patient may even indicate that they feel as if they are watching from a distance or that the experience feels unreal and they may show changes in their breathing.
Is sedation appropriate in the reduction of dental anxiety for someone with a sexual abuse history?
Although this is a helpful tool for many anxious patients, most sexual abuse survivors prefer not to be sedated. For many who have experienced sexual trauma the use of sedation may raise the likelihood of increased feelings of loss of control and helplessness, especially in a situation where they already may feel vulnerable. When sedation is necessary, arrangements with the patient to allow a family member, close friend or at least the presence of someone they trust in the room during the procedure may be helpful.
What do patients with trauma histories and dental fear find most helpful in reducing their anxiety?
Many patients report that having an empathic and understanding dentist who is patient and willing to listen to their concerns and having control over how their dental treatment proceeds were key in the reduction of their dental anxiety. Therefore, having a dentist who listens and is willing to help them feel comfortable, and being able to stop procedures or have control can enhance the patient’s ability to tolerate and participate cooperatively even during difficult dental procedures.
What are some helpful tips for coping with dental fear?
Although treatment recommendations are speculative at best and not meant to be clinical prescriptions, one study provided some helpful tips, here are a few of them:
- Let your dentist know that you are anxious. This does not mean you have to tell them about past issues if you choose not to do so.
- Agree on a non-verbal signal to indicate increased anxiety and a message to stop treatment.
- Use relaxation aids such as headphones with music or other soothing recordings.
- Ask your dentist to provide regular reassurance and explanations regarding the procedures being performed, especially when a procedure is almost completed.
- Ask that you be allowed to handle the suction instrument whenever possible.
- Ask to bring a friend or family member to the appointment with you when possible or have another staff member present during exams.
- Ask for extra time for your appointments.
© Jack Bynes, DDS and Dr Carmen Santos, PsyD. Reprinted with permission.