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Identifying and

Treating Patients with

PTSD Noel Kelsch RDH, RDHAP, AS, BS

&Marhya Kelsch LCSW, MSW, BSW, AA

3JUNE 2014

EDUCATIONAL OBJECTIVES

The overall goal of this course is to provide the reader with information on posttraumatic stress disorder and its implica-tions for the professional dental care of patients with this condition. On completion of this course, participants will be able to:

1. Describe the symptoms and symptom clusters of posttrau-matic stress disorder;

2. List the oral signs and symptoms of posttraumatic stress disorder;

3. Review behaviors associated with posttraumatic stress disor-der that patients may exhibit in the dental setting; and

4. List and describe the methods and sequences that may be used to enable dental treatment of patients with posttrau-matic stress disorder.

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Den-tal Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and online activity. Information shared in this course is based on current information and research based evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: June, 2014. EXPIRATION DATE: May, 2017. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEG-RITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the fi eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Casey Warner, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfi ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net to take this course. © 2014

Posttraumatic stress disorder is a complex condition, with associated systemic and oral signs and symptoms. Oral signs and symptoms include, but are not limited to, higher levels of plaque, periodontal disease and sensitivity, as well as the presence of muscle spasms, temporomandibular joint disor-ders, and abfractions. Screening patients for posttraumatic stress disorder, and knowledge of the behaviors that patients with this condition may exhibit, are important in identifying these patients. For patients identifi ed as having posttraumatic stress disorder, the dental professional can help them develop coping mechanisms that enable treatment and can stage their dental care.

ABSTRACT

Identifying and Treating Patients with PTSD

Posttraumatic stress disorder (PTSD) is a complex neurological, biochemical, and psychological disorder that impacts the oral health and dental

care of patients; it was even referenced in ancient Egyp-tian writings.1,2 The Centers for Disease Control and Prevention describes PTSD as “an intense physical and emotional response” to thoughts and reminders of a traumatic event. Arguably, no other anxiety disorder has as many potential triggers leading to its development.2

Events that can lead up to this disorder include sexual abuse, exposure to war, mental abuse, and even dental trauma. In fact, it can result from any occurrence that results in feelings of being out of control, powerless, or betrayed.3,4 Symptoms of PTSD may occur years after the

CE EditorFIONA M. COLLINS

Director of ContentJULIE CULLEN

Creative DirectorMICHAEL HUBERT

Art DirectorMICHAEL MOLFETTO

Copyright 2014 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without written permission from the publisher.

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DENTAL LEARNING

ABOUT THE AUTHORS

Noel Kelsch RDH, RDHAP, AS, BS Noel Kelsch is an international speaker, writer, re-searcher and Registered Dental Hygienist in Alterna-tive Practice. She maintains a private Dental Hygiene practice serving a broad range of clients from the underserved on the streets to those in hospice care. She is the Infection Control Columnist for a national magazine, a syndicated newspaper columnist, has been

published in books and brought the message of oral health to networks from Disney Radio to ESPN. She has received national awards for her efforts. Noel can be reached at [email protected].

Marhya Kelsch LCSW, MSW, BSW, AAMarhya Kelsch is a licensed psychotherapist in the states of Colorado and California, with a certifi cate in EMDR Basic Training. Marhya is currently a hospital Social Worker, presenter and author specializing on topics of trauma, domestic violence and mental illness especially as it affects patient care. Marhya works with patients from a strengths-based perspective – focusing

on internal and external resource building, psych education, wellness, self-effi cacy, community awareness and public advocacy. Marhya can be reached at [email protected]. Neither Noel Kelsch nor Marhya Kelsch have any confl ict of interest to declare.

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4

traumatic event, although they can start within days. People working in high-risk jobs are at higher risk, while cultural factors also play a role. The National Center for PTSD estimates that 7.8% of Americans will be affected by PTSD in their lifetime, with women twice as likely as men to develop the disorder and to be affected for longer.2 The projected lifetime risk at 75 years-of-age, using the current criteria used for all recognized mental health disorders (DSM-IV), is 8.7%.2

Symptoms of PTSDThe symptoms of PTSD fall into three distinct clusters, any

one of which may dominate depending on the individual, and in some individuals combinations of these are exhibited2,5:

1. Intrusive memories or re-experiencing events, including flashbacks and nightmares, and extreme emotional and physical reactions to reminders of the event. Reactions can include feeling guilty, extreme fear of harm, and numbing of emotions.

2. Avoidance behaviors including staying away from activi-ties, places, thoughts; feelings related to the trauma; or feeling detached or estranged from others.

3. Persistent elevated arousal,6 including being overly alert or easily startled; sleep disturbances; irritability or outbursts of anger; and lack of concentration.

Other symptoms include panic attacks, depression, suicidal thoughts, drug abuse, memory problems, and cognitive difficul-ties.7 Patients have difficulty describing or even being aware of their feelings, emotions, or mood, making this a difficult medical situation.8 Individuals with PTSD are 80% more likely than the general population to have symptoms that meet the diagnostic criteria for at least one other mental disorder, and there is consid-erable comorbidity and overlapping symptoms between PTSD and major neurological disorders.2 Comorbid substance use and conduct disorders are more common among males than females, while 48% of US military personnel deployed to recent wars expe-rience a co-occurrence of PTSD and mild traumatic brain injury.

Shakiness/uncontrollable shaking, a racing heartbeat, chills or palpitations, TMJ disorder, chronic pain, breathlessness, tension headaches, and agitation are all possible signs and symptoms of PTSD.9 It is associated with high levels of social, occupational, and

physical disability, as well as considerable economic costs and high levels of medical utilization.7

The Physiological (Stress) Response and Signs of PTSD

When stress occurs, the hypothalamic-pituitary-adrenal axis is activated, resulting in higher levels of cortisol, nor-epinephrine, and epinephrine — this is the “fight or flight” response. Cortisol augments energy resources by reducing the activity of bodily systems, including the immune system, and elevates blood glucose levels. These mechanisms are protective if the stressor is acute; however, if chronic, they can increase risk for inflammation and associated health risks.10 An excessive, often incalcitrant, inflammatory response may occur as a result of insufficient immuno- regulation. Endothelial inflammation, altered cytokine bal-ance, carbohydrate intolerance, dyslipidemia, and insulin resistance have been associated with PTSD, as well as chronic pain and an increased risk for rheumatoid arthri-tis, diabetes types 1 and 2, cardiovascular disease, multiple sclerosis, and treatment avoidance in medical and dental settings.7,11,12 Patients with PTSD also experience more sudden onset and sound-triggered tinnitus than the general population.9,13 Medical screening for PTSD followed by treatment can help to prevent and treat physiological and psychological problems.

Pain (including dental pain) can serve as a traumatic stimulus for the onset of PTSD symptoms such as hyperarous-al, stress intolerance, selective attention, and acute pain. Individuals with a lifetime of PTSD report significantly greater current bodily pain than others, as well as major depression and psychosocial factors often correlated with chronic pain;6 patients also may demonstrate a diminished capacity to employ adaptive and coping strategies.14 Patients with PTSD who are treated in an outpatient setting report a reduction in physical pain.15

Oral Signs and Symptoms of PTSDSignificant differences have been observed between dental

patients with and without PTSD. Vertical tooth wear averaged

5JUNE 2014


1.35 mm vs. 0.36 mm; horizontal wear averaged 1.26 mm vs. 0.29 mm; and the depth of wear averaged 0.70 mm vs. 0.05 mm; and wear patterns were found mainly along the cervical area with loss of tooth structure near the gingival margin that “looked like grooves but with no pattern.”16 These signs were consistent with documented habitual brux-ing and clenching by patients with PTSD, and associated periodontal, abfraction, and occlusal wear problems.17 Other findings included significantly higher plaque and gingivitis scores (183% and 140% higher, respectively) in patients with PTSD (Table 1).16 Given the physiological response to excessive or prolonged stress, it is hypothesized that PTSD can increase the risk of periodontal disease. Other issues may include orofacial TMJ pain.

Identifying and Treating Patients with PTSDScreening patients for PTSD

Including a section on PTSD on health history forms can help identify patients with PTSD and potential triggers. Ques-tions to ask can include: Do you have any auditory or visual triggers, or physcial triggers, or sensitivities?; Have you ever been diagnosed with posttraumatic stress disorder?; Have you

ever been apprehensive or fearful of dental treatment?; Do you have TMJ pain or grind your teeth?; Have you ever had shaki-ness, a racing heartbeat, or feelings of the room closing in on you, being out of your own body or anxiety in the dental office? Each patient must then be assessed for his/her ability to tolerate treatment in the dental environment.

The first symptoms of PTSD may be oral pain or dis-comfort, before other physical or psychological signs and symptoms appear. In addition, dental treatment has been identified as a trigger for memories of the traumatic event and PTSD.9,16,18 Understanding this disorder and the role of the dental health care professional is core to providing high-quality patient care. Patients with PTSD experience higher levels of pain and distress than other patients, and they exhibit behaviors that can make their treatment challenging (Table 2). They may react in an exaggerated manner or out of context to the treatment being provided or exhibit a startle response, and many report auditory sensitivity.12,13,19 Pa-tients with PTSD should be referred to a mental health care professional for behavior assessment if this has not already occurred, and dental treatment provided working in tandem with the patient’s medical team.21 Asking the patient who his/

Table 1. Oral Signs and Symptoms of PTSD

High plaque levels

Periodontal diseases

Sensitivity

Increased caries and chronic caries

Hyposalivation during episodes and as a result of medication for treating PTSD

Bruxism

Abfractions, occlusal wear facets, and recession

Increased tooth loss

Muscle spasms due to para-functional jaw movement

TMJ pain

Reports of high pain levels with or without known cause

Table 2. Experiences of patients with PTSD in the dental office

Tension

Marked irritability

Exaggerated or startled response

Trouble swallowing or a lump in the throat

Inability to tolerate oral procedures

Delayed onset of sedation, adverse reactions

Unprovoked cardiac/respiratory symptoms19,20

Frequent urination

Difficulty concentrating or “mind goes blank”

Non-compliance with home care recommendations

Nonattendance/frequent cancellations


6

her therapist or prescribing psychiatrist is and requesting a re-lease of information to coordinate care helps address and avoid possible triggers or adverse interactions of medications such as analgesics, sedatives, and antibiotics.19

Pre-treatment assessment for patients with PTSDEstablishing a relationship and rapport with the patient and

their community support person is essential, and both verbal and nonverbal interactions are important.20 Asking non-judg-mental questions, assessing a patient’s ability to receive treat-ment, and making patients extra aware of your concern for their comfort can help relieve anxiety and allow them to share their needs. Asking whether there is any part of dental treatment that is particularly difficult for a given patient, what the patient’s trig-gers and coping mechanisms are, and whether there is anything you can do to make him/her more comfortable also helps. Invit-ing patients before treatment to bring in items that help them stay calm and feel safe is helpful, as is discussion on the possibil-ity of premedication if needed and whether they have a mindful-ness or relaxation exercise that they could do if prompted during treatment. Patients should be asked about past experiences and responses, if any, to nitrous oxide, local and general anesthesia. Plans for desensitization and premedication, if indicated, should occur at this meeting. In most cases this phase will occur in a meeting room rather than in the operatory, to allow patients to adapt and develop a relationship of trust. Some desensitization therapy can be presented at this time, if patients agree, such as a brief tour of the office. Patients also can develop a stop signal at this appointment, which also can be broken into two ap-pointments if they are unable to tolerate a lengthier visit. Plans for disease prevention also should be introduced, and patients permitted to set their goals for oral health.22

Diagnostics PhaseDuring this phase, simple diagnostic tools are introduced

and patients are desensitized to the operatory if possible. Dental charting, X-rays, and possibly study model impressions are undertaken. These procedures should be performed slowly and patients must feel a sense of control over the continua-tion of procedures. It is vital to have a staff member stay with

patients for support and to monitor patients’ visual cues as they may struggle to express themselves. An assessment of oral conditions also can occur at this appointment if patients can tolerate it. Simple noninvasive preventive measures such as the application of fluoride varnish can be provided, and can build a sense of trust and safety. Patients with PTSD may re-quire additional preventive, restorative, and maintenance care.

The Treatment PhaseThe treatment phase can be challenging. Time in the chair

may need to be adjusted, and the plan should incorporate flexible, short appointments. Frequent breaks and adapting to patient requests is required. Simple adjustments in treatment and the environment can help patients feel safe and in control.

Reclining and adjusting the chair as patients wish may prevent them from reliving past experiences. The supine position can be difficult for some patients and elicit threat cues, while confin-ing procedures such as rubber dams may not be possible, and especially initially. Oxygen hoods also can elicit a feeling of being trapped and their potential use should be discussed with the patient. Simple reassuring stimuli such as headphones, head-gear movies, or a warm blanket can distract patients, give them comfort, and help them avoid re-experiencing or emotional flooding. Treatment should start slowly, include patient input, and unless they are in pain should begin with procedures that are less distressful (for example, fabrication of a night guard). Simple explanations of the steps in a procedure before they occur can increase patients’ feelings of safety and control. Success at one ap-pointment does not guarantee success at another appointment, and patients may take one step forward and then two steps back.

Discussing and addressing one treatment goal at a time may help. All patients should have an understanding of the tools and time frame of visits to prevent dental diseases; fre-quent follow-ups are necessary. To help patients tolerate treat-ment, it can be helpful if they perform exercises that induce relaxation and a sense of being in control, and perform titrat-ing (distracting) activities (such as walking or drinking a hot or cold beverage) which help them switch gears periodically. Creating a nonthreatening (nonstimulating) environment in a quiet room also is helpful for patients (Table 3). Encouraging


7JUNE 2014

patients with PTSD to breathe gently through the nose helps clear their thoughts and removes them from the event — this should be practiced before procedures begin. Ways to let pa-tients take control include letting them determine the position of the chair, whether to have aromatherapy and, if so, which scent, and the flavor of prophy paste. Taking a break for a titrating activity can be pre-arranged for when patients use a pre-determined stop signal. After this, it is important to check with patients if they can continue with treatment or need to schedule for another day. There are additional ways to help create a safer environment for patients with PTSD (Table 4).

Emergencies: If dental emergencies occur, treatment plans may need to be superseded and it may be necessary to work directly with the therapist or existing medical provid-ers to help the patient minimize possible PTSD symptoms. Anti-anxiety premedication such as Xanax or Ativan (after confirming with the medical team that this is appropriate) re-quires pre- and postprocedure patient supervision. A support person such as a friend or spouse needs to be with the patient before and after treatment.

After each appointment: Patients with PTSD may have difficulties with memory, long-term recall, and sustained attention. All postoperative instructions should be in writ-ten form, and it is also vital to provide handouts and treat-ment plans that review the dental needs and plan. Studies have shown that patients with PTSD may not recover from anesthesia in the same way as the general population, and pre-release observation is critical.

Case StudyLarry, age 53, presented with a chief complaint of intermit-

tent pain in teeth #2 and #31, generalized sensitivity, and a “rough spot” on tooth #18. He also reported that during his last visit to the dentist 3 years earlier, he had swung his arm out and hit the dentist in a ‘fight or flight’ response when a rubber dam was placed (which he had experienced as a restraint). He had ‘revisited a traumatic experience from 20 years earlier while a prisoner of war’ and then experienced a dry mouth, racing heart, cold sweats, trembling, felt he could not swallow and was unable to complete treatment. Larry had only returned now

Table 3. Relaxation and distracting techniques in the dental office

Full body relaxation exercise – controlling breathing

Have the patient breathe in through his/her nose and think

the word “Feeling” then have the patient breathe out

through their mouth and think he work “Calmer”

If the patient is anxious or has an out of body feeling, focus

his/her 5 senses by asking the patient:

What do you see in this room? What colors? What objects?

What do you feel on your hands? On your feet?

How does your chair feel?

What does the temperature of the room feel like?

What sounds do you hear in the room?

What style of music is on?

What do you taste?

Are there any textures in your mouth?

If the patient cannot answer due to the treatment, he/she

can answer the questions in his/her mind. The patient can

also be asked to focus on the sense that is most appealing.

Creating a nonthreatening environment

Offering a blanket

Covering instruments

Limiting use of devices that make the patient feel trapped

(e.g., oxygen masks, rubber dams)

Positioning the chair with patient input

Offering the patient distraction items such as headphones

Limiting loud or irritating noises

Offering aromatherapy

Titrating activities

Drinking a warm or cool beverage

Taking a walk outside

Using a hand held electronic device for distraction (there are

many programs that assist persons struggling with PTSD)

Reading a magazine or observing things in the lobby such

as a fish tank


8

because he was forced to by pain, encouraged by his spouse (who had accompanied him) and had a strong referral from his physician. With motivational interviewing, the dental team was able to assess Larry’s trigger points.

Visit 1 Assessment (Interview): Larry revealed his history of PTSD and reported that no one in the dental setting had ever asked him about it so he had not previously revealed the condition. People with PTSD are prone to a high level of sensory sensitivity when hyperaroused and Larry reacted to a loud sound coming from another room. The stop signal of raising his left hand and/or repeatedly blinking his eyes was developed. During the assessment Larry was taken

to a quiet separate room with limited stimuli. Larry was asked questions that allowed him to make choices and feel in control such as “Would you prefer to sit up or recline?” “Headphones have been shown to help limit your exposure to noises that might trigger events, would you prefer to have headphones or no headphones?” Larry shared that he needed to stand up, was allowed to do so and the first ap-pointment ended there. Larry gave the dentist permission to work with his medical team. Larry’s therapist confirmed the diagnosis of PTSD and helped develop a plan for desensiti-zation. Antianxiety premedication was discussed and Larry declined, stating he had a history of “self-medication” and did not want to use drugs.

Visit 2 Assessment and Examination: Larry brought headphones and a blanket from home to limit stimuli and help him feel safe, but declined aromatherapy and explained that odors from encampment mimicked these smells. Larry gave permission for desensitization therapy in the dental setting, and was then slowly shown the equipment and exposed to the sounds that would occur during treatment. When the sound of the handpiece occurred, Larry became reactive and asked to have a drink of water. After sitting up and having a drink of water Larry agreed to allow the dentist to evaluate his condition. Larry put on his head-phones and the dentist performed the examination standing up. The assistant was then able to obtain X-rays while using a distraction technique by having Larry rinse with salt water between each film. All instructions were given to Larry, his spouse, and in writing.

Clinical findings included deep wear facets on the occlusal surfaces of #2 and #31, moderate periodontitis with general-ized recession averaging 2 mm to 3 mm, and abfractions on all posterior teeth. Tooth #18 had extensive caries and a fracture, necessitating a crown. Larry complained of dentinal sensitivity to cold air, allowed a desensitizer to be “painted on,” and ex-perienced immediate relief. First warming up the desensitizer in your hand or placing it under a warm tap while still in the packaging may help reduce any sensation (pain) experienced during its application. The instructions for use should first be read to check if this is permissible.

Table 4. Relaxation and distracting techniques in the dental office

Let the patient talk a little more than you might normally

Take extra care to avoid placing things down accompanied by noise (or dropping things) behind the patient

Be clear in what is to be expected

Ask if there are any situations the patient would like to avoid

Be aware of PTSD-like signs and symptoms

Let the patient be responsible for treatment of his/her condition

As much as possible, have the same staff members interact with the patient at each visit

Pose open questions that invite the patient to explain situations that make him/her uncomfortable

Talk in a low voice and in a positive manner

Speak of things that are reassuring and distracting

Do not surprise the patient or try to “sneak in procedures”

Talk about what is going to happen and ask the patient how much he/she wants to know

Allow the patient to hear what he/she is capable of hearing

Give the patient choices in anything that he or she can control

Praise the patient for coming to the appointment and for making small strides in treatment23


Larry got up from the chair for frequent breaks during which he paced the front of the office, utilized the restroom, and requested several drinks of water. Larry’s wife reported that Larry ground his teeth at night and clenched during the day. Nightguard therapy was recommended. The process was explained and the equipment was shown to Larry. He asked about antianxiety drugs, as he had discussed this with his therapist who had recommended them. The appointment stopped at that point; Larry was able to tolerate this visit for 28 minutes. An appointment with a visiting periodontist that used the same facility was made for the next visit.

Visits 3 and 4 Assessment and Treatment: Larry came in with his spouse and was premedicated with Ativan as directed by his outpatient psychiatric medical provider. Larry stepped outside with his wife after the drug was administered and walked around the block. Larry brought his blanket, headphones, and a “lucky rabbit foot” that he rubbed during treatment. Desensitization of sights and sounds were performed and nightguard impressions were taken. He was introduced to the periodontist who provided motivational interviewing and desensitization therapy at the end of the visit. Larry was able to stay in the environment for 41 minutes at Visit 3. He requested a drink of water, got up 2 times, and paced. During visit 4, the same protocol was followed and the nightguard was fitted. Larry was apprehensive about seeing the periodon-tist because there was an assistant he had not seen before. The general dentist’s assistant came into the room to assist, enabling the periodontist to complete the exam and pro-vide desensitization therapy with instruments and proce-dures. The periodontist’s assistant stayed in the room for the entire procedure so that Larry could become familiar with her and feel safe. All instructions were again given to Larry, his spouse, and in writing.

Visits 5 through 11 Treatment Phase: Visits 5 through 9, Larry came in with his spouse and was premedicated with Ativan. Due to the reactions that patients with PTSD have to general anesthesia, it was determined not to sedate him. This was first confirmed by consulting with Larry’s thera-pist. Half-hour appointments were made and periodontal

treatment was performed in one sextant per visit, letting Larry slowly feel safe in the environment and able to toler-ate many of the stimuli that had previously triggered him. Restorative care was provided after periodontal treatment was completed. Due to Larry’s previous reaction to the rub-ber dam, this was not utilized. By visit 10, Larry wanted to try the next procedure without antianxiety premedication. He was able to tolerate treatment but requested a drink of cold water during the procedure and had to stand up and “stretch” while drinking the water. Visits averaged 30 minutes each. Visit 11 also included a break but Larry was able to handle the treatment and asked to have treatment completed because he was able to tolerate a longer period of time even without antianxiety premedication.

Maintenance Phase: Larry worked with the dental team to determine his future care. This included periodon-tal maintenance visits every 3 months as well as routine examinations, treatment, and preventive care. Larry has been able to return for treatment and maintain his oral health. Patients with PTSD typically have a high propensity to avoid returning after the initial visit, and the approach described will not work with all patients. Larry’s support system helped him be able to return to the dental setting with limited reaction. He has continued to utilize coping techniques.

ConclusionPTSD has the potential to impact systemic and oral health.

Identifying symptoms and having treatment protocols in the dental setting helps patients accept dental care, receive much-needed treatment and preventive care, and improve their oral health outcomes.

References1. Rauch SA1, Eftekhari A, Ruzek JI. Review of exposure ther-apy: a gold standard for PTSD treatment. J Rehabil Res Dev. 2012;49(5):679-87.2. DiCecco K. Post-traumatic stress disorder. J Leg Nurs Consult. 2011;22(3):20-2. 3. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing.

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4. Sherman J, Carlson C, Wilson J, Okeson J, McCubbin J. Post- traumatic stress disorder among patients with orofacial pain. J Orofac Pain. 2005;19(4):309-17. 5. Centers for Disease Control and Prevention. Coping with a traumatic event. Available at: http://www.cdc.gov/masstrauma/factsheets/public/coping. pdf. Accessed 4/23/2014.6. Bryant RA. Posttraumatic stress disorder and traumatic brain injury: can they co-exist? Clin Psychol Rev. 2001;21(6):931- 48.7. Frewen PA, Lanius RA. Toward a psychobiology of post-traumatic self-dysregulation: reexperiencing, hyperarousal, dissociation, and emotional numbing. Ann NY Acad Sci. 2006;1071:110-24.8. SharpTJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev. 2001;21(6): 857-77.9. Buchwald D, Goldberg J, Noonan C, Beals J, Manson S. Rela-tionship between post-traumatic stress disorder and pain in two American Indian tribes. Pain Med. 2005 Jan-Feb;6(1):72-9. 10. Gill J, Saligan L, Woods S, Page G. PTSD is associated with an excess of inflammatory immune activities. Perspect Psychiatr Care. 2009;45(4):262-77.11. Villano C, Rosenblum A, Magura S, Fong C, Cleland C, Betzler T. Prevalence and correlates of posttraumatic stress disorder and chronic severe pain in psychiatric outpatients. J Rehabil Res Dev. 2007;44(2):167-78. 12. Delahanty D, Bogart L, Figler J. Posttraumatic stress disorder symptoms, salivary cortisol, medication adherence, and CD4 levels in HIV-positive individuals. AIDS Care. 2004;16(2):247-60. 13. Fagelson MA. The association between tinnitus and post-traumatic stress disorder. Am J Audiol. 2007;16(2):107-17.14. Bertoli E, de Leeuw R, Schmidt JE, Okeson JP, Carlson CR. Prevalence and impact of post-traumatic stress disorder symp-toms in patients with masticatory muscle or temporomandibular joint pain: differences and similarities. J Orofac Pain. 2007;21 (2):107-19.15. Magruder K, Yeager D. Patient factors relating to detection of posttraumatic stress disorder in Department of Veterans Af-fairs primary care settings. J Rehabil Res Dev. 2008;45(3):371-81.16. Baker L. PTSD patients damage teeth through involuntary grinding, clenching, UB study finds. Availablate at: http://www.buffalo.edu/news/releases/2001/03/5063.html. Accessed 8/11/201317. Vanguard. http://www.va.gov/opa/publications/archives/vanguard/01MayVG.pdf. Accessed 8/12/2013

18. McLean SA, Caluw DJ, Abelson JL, Liberzon I. The develop-ment of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress re-sponse systems into a biopsychosocial model. Psychosom Med. 2005;67(5):783-90. 19. Friedlander AH, Friedlander IK, Marder SR. Posttraumatic stress disorder: psychopathology, medical management, and dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):5-11.20. Stalker CA, Russell BD, Teram E, Schachter CL. Provid-ing dental care to survivors of childhood sexual abuse: treat-ment considerations for the practitioner. J Am Dent Assoc. 2005;136(9):1277-81.21. Olszewski TM, Varrasse JF. The neurobiology of PTSD: implications for nurses. J Psychosoc Nurs Ment Health Serv. 2005;43(6):40-7. 22. Jeffreys M, Capehart B, Friedman M. Pharmacotherapy for posttraumatic stress disorder: Review with clinical applications. J Rehabil Res Dev. 2012;49(5):703-15. 23. Wright E, Thompson R, Paunovich E. Post-traumatic stress disorder: considerations for dentistry. Quintessence Int. 2004;35(3):206-10.

Additional ResourcesBussey M, Wise J. Trauma transformed an empowerment response. New York: Columbia University Press. 2007.Herman J. Trauma and recovery. The aftermath of violence - from domestic abuse to political terror. New York: Basic Books. 1997.Miller W, Rollnick, S. Motivational interviewing. Preparing people for change. Second Edition. NewYork: The Guilford Press. 2002.The body remembers. Casebook unifying methods and models in the treatment of trauma and PTSD. New York: WW Norton & Company. 2003.

WebliographyNational Institute of Mental Health. Post-Traumatic stress disor-der. Available at: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml. Accessed 7/10/2013.National Alliance on Mental Illness. http://www.nami.org/ Template.cfm?Section=posttraumatic_stress_ disorder. Accessed 7/10/2013.


11JUNE 2014

1. People can experience symptoms of PTSD ____________ after the traumatic event.a. years b. daysc. monthsd. any of the above

2. PTSD has the potential to____________ a patient’s oral health.

a. slightly impact b. strongly impactc. positively d. b and c

3. ____________ is an oral sign/symptom of PTSD. a. Hyposalivationb. Muscle tensionc. Abfractiond. all of the above

4. The stress response can ____________ the risk for oral and systemic inflammation.

a. decreaseb. increasec. stabilized. none of the above

5. A non-stimulating environment can include ____________.a. offering the patient a blanketb. choosing a busy time of day so that noises will distract

the patientc. limiting procedures that make the patient feel trappedd. a and c

6. Patients with PTSD can experience ____________ in the dental setting.

a. shakiness b. a racing heartbeatc. breathlessness and/or agitationd. all of the above

7. Treatment time in the chair for patients with PTSD ____________.a. is the same as for the general populationb. should be lengthened compared to the general populationc. needs to be dictated by the patient’s needsd. none of the above

8. In patients with PTSD, the fight or flight response cannot be triggered ____________.a. unless the patient allows it to beb. without a true danger being presentc. unless the patient is in the environment that triggered the initial eventd. none of the above

9. Behaviors observed and reported by patients with PTSD include ____________.a. a startled responseb. anxietyc. misperceptionsd. all of the above

10. Patients with PTSD can be desensitized through ____________ exposure to dental procedures.a. slowb. intensec. rapidd. none of the above

CEQuiz

To complete this quiz online and immediately download your CE verification document, visit www.dentallearning.net/PTSD-ce, then log into your ac-count (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification document. We accept Visa, MasterCard, Discover and American Express.


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11. The stop signal should be established ____________.a. when the patient is ready to stopb. before treatment has startedc. when the treatment is completedd. only if the patient brings it up

12. Coping skills can include ____________. a. controlling breathingb. focusing on the five sensesc. taking a breakd. all of the above

13. Verbalizing each step of a procedure before it is performed ____________.a. can increase the patient’s feelings of safety and controlb. can cause a patient to avoid the appointmentc. is not recommendedd. a and b

14. Verbiage to calm the patient should include a ____________ voice.a. low tone ofb. variable tone of c. high pitchedd. any of the above

15. Using an oxygen hood or rubber dam may make a patient with PTSD feel ____________.a. calmb. trappedc. that he or she can always handle more treatmentd. none of the above

16. Titrating activities in the dental setting can include ____________.a. taking a blood pressure readingb. the patient taking a walk outsidec. having the patient drink a beveraged. all of the above

17. Patients with PTSD ____________ the general population.a. may not recover from anesthesia in the same way as b. accept treatment more readily than c. exhibit lower levels of anxiety thand. all of the above

18. During treatment, exercises that induce relaxation and a feeling of being in control, as well as titrating (distracting) activities, ____________.a. allow patients to switch gears periodicallyb. help to create a nonthreatening environmentc. help deliver dental care to patientsd. all of the above

19. Success at one appointment ____________.a. does not guarantee success at another appointmentb. guarantees success at the next appointmentc. means it should have been lengthenedd. b and c

20. Identifying symptoms and having treatment protocols in the dental setting for patients with PTSD ____________.a. help patients accept dental careb. help patients receive much-needed treatmentc. make treatment more workabled. all of the above

CEQuiz

13JUNE 2014

Identifying and Treating Patients with PTSD www.dentallearning.netCE ANSWER FORM (E-mail address required for processing)

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QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES• Describe the symptoms and symptom clusters of posttraumatic stress disorder;• List the oral signs and symptoms of posttraumatic stress disorder;• Review behaviors associated with posttraumatic stress disorder that patients may exhibit in the dental

setting; and• List and describe the methods and sequences that may be used to enable treatment of patients with

posttraumatic stress disorder.

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