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DENTAL LEARNING
A PEER-REVIEWED PUBLICATION
Knowledge for Clinical Practice
Identifying
and
Treating Patients
with
PTSD
Noel Kelsch RDH, RDHAP, AS, BS
&
Marhya Kelsch LCSW, MSW, BSW, AA
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Identifying and Treating Patients
with PTSD
EDUCATIONAL OBJECTIVES
ABSTRACT
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 disorders, 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 identified as having posttraumatic
stress disorder, the dental professional can help them develop
coping mechanisms that enable treatment and can stage their
dental care.
ABOUT THE AUTHORS
Noel Kelsch RDH, RDHAP, AS, BS
Noel Kelsch is an international speaker, writer, researcher and Registered Dental Hygienist in Alternative 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, AA
Marhya Kelsch is a licensed psychotherapist in the
states of Colorado and California, with a certificate 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-efficacy, community awareness and public advocacy. Marhya can be
reached at [email protected].
Neither Noel Kelsch nor Marhya Kelsch have any conflict of interest to
declare.
The overall goal of this course is to provide the reader with
information on posttraumatic stress disorder and its implications 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 posttraumatic stress disorder;
2. List the oral signs and symptoms of posttraumatic stress
disorder;
3. Review behaviors associated with posttraumatic stress disorder 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 posttraumatic stress disorder.
P
osttraumatic 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 Egyptian 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
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. Dental 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.
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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 INTEGRITY 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 field 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].
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JUNE 2014
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DENTAL LEARNING
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 PTSD
The 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 activities, 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 difficulties.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 considerable 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 experience 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
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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, norepinephrine, 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 immunoregulation. Endothelial inflammation, altered cytokine balance, carbohydrate intolerance, dyslipidemia, and insulin
resistance have been associated with PTSD, as well as
chronic pain and an increased risk for rheumatoid arthritis, 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 hyperarousal, 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 PTSD
Significant differences have been observed between dental
patients with and without PTSD. Vertical tooth wear averaged
Identifying and Treating
Patients with PTSD
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 bruxing 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 PTSD
Screening patients for PTSD
Including a section on PTSD on health history forms can
help identify patients with PTSD and potential triggers. Questions 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
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
ever been apprehensive or fearful of dental treatment?; Do you
have TMJ pain or grind your teeth?; Have you ever had shakiness, 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 discomfort, 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 highquality 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 Patients 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 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
Bruxism
Delayed onset of sedation, adverse reactions
Abfractions, occlusal wear facets, and recession
Unprovoked cardiac/respiratory symptoms19,20
Increased tooth loss
Frequent urination
Muscle spasms due to para-functional jaw movement
Difficulty concentrating or “mind goes blank”
TMJ pain
Non-compliance with home care recommendations
Reports of high pain levels with or without known cause
Nonattendance/frequent cancellations
JUNE 2014
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her therapist or prescribing psychiatrist is and requesting a release 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 PTSD
Establishing 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-judgmental questions, assessing a patient’s ability to receive treatment, 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 triggers and coping mechanisms are, and whether there is anything
you can do to make him/her more comfortable also helps. Inviting patients before treatment to bring in items that help them
stay calm and feel safe is helpful, as is discussion on the possibility of premedication if needed and whether they have a mindfulness 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 appointments 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 Phase
During 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 continuation of procedures. It is vital to have a staff member stay with
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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 require additional preventive, restorative, and maintenance care.
The Treatment Phase
The 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 confining 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, headgear 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 appointment 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; frequent follow-ups are necessary. To help patients tolerate treatment, it can be helpful if they perform exercises that induce
relaxation and a sense of being in control, and perform titrating (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
Identifying and Treating
Patients with PTSD
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
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 patients 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 providers 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) requires 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 written form, and it is also vital to provide handouts and treatment 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.
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
JUNE 2014
Case Study
Larry, age 53, presented with a chief complaint of intermittent 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
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DENTAL LEARNING
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
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
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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 appointment 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 desensitization. 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 headphones 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 generalized 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 experienced 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.
Identifying and Treating
Patients with PTSD
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 periodontist 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 provide desensitization therapy with instruments and procedures. 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 therapist. Half-hour appointments were made and periodontal
JUNE 2014
treatment was performed in one sextant per visit, letting
Larry slowly feel safe in the environment and able to tolerate 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 rubber 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 periodontal 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.
Conclusion
PTSD 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 muchneeded treatment and preventive care, and improve their oral
health outcomes.
References
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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. Posttraumatic 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 posttraumatic self-dysregulation: reexperiencing, hyperarousal,
dissociation, and emotional numbing. Ann NY Acad Sci.
2006;1071:110-24.
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disorder: mutual maintenance? Clin Psychol Rev. 2001;21(6):
857-77.
9. Buchwald D, Goldberg J, Noonan C, Beals J, Manson S. Relationship 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 posttraumatic 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 symptoms 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 Affairs 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
8/11/2013
17. Vanguard. http://www.va.gov/opa/publications/archives/
vanguard/01MayVG.pdf. Accessed 8/12/2013
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18. McLean SA, Caluw DJ, Abelson JL, Liberzon I. The development of persistent pain and psychological morbidity after motor
vehicle collision: integrating the potential role of stress response 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. Providing dental care to survivors of childhood sexual abuse: treatment 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 Resources
Bussey 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.
Webliography
National Institute of Mental Health. Post-Traumatic stress disorder. Available at: http://www.nimh.nih.gov/health/topics/posttraumatic-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.
Identifying and Treating
Patients with PTSD
CEQuiz
To complete this quiz online and immediately download your CE verification
document, visit www.dentallearning.net/PTSD-ce, then log into your account (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.
1.People can experience symptoms of PTSD ____________ after
the traumatic event.
a.years
b.days
c.months
d. any of the above
6. P
atients with PTSD can experience ____________ in the dental
setting.
a.shakiness
b. a racing heartbeat
c. breathlessness and/or agitation
d. all of the above
2. P
TSD has the potential to____________ a patient’s oral
health.
a. slightly impact
b. strongly impact
c.positively
d. b and c
7. T
reatment time in the chair for patients with PTSD ____________.
a. is the same as for the general population
b. should be lengthened compared to the general population
c. needs to be dictated by the patient’s needs
d. none of the above
3. _ ___________ is an oral sign/symptom of PTSD.
a.Hyposalivation
b. Muscle tension
c.Abfraction
d. all of the above
8. In patients with PTSD, the fight or flight response cannot
be triggered ____________.
a. unless the patient allows it to be
b. without a true danger being present
c. unless the patient is in the environment that triggered the initial event
d. none of the above
4. T
he stress response can ____________ the risk for oral and
systemic inflammation.
a.decrease
b.increase
c.stabilize
d. none of the above
9. Behaviors observed and reported by patients with PTSD include
____________.
a. a startled response
b.anxiety
c.misperceptions
d. all of the above
5. A
non-stimulating environment can include ____________.
a. offering the patient a blanket
b.choosing a busy time of day so that noises will distract
the patient
c. limiting procedures that make the patient feel trapped
d. a and c
10. Patients with PTSD can be desensitized through ____________
exposure to dental procedures.
a.slow
b.intense
c.rapid
d. none of the above
JUNE 2014
11
DENTAL LEARNING
www.dentallearning.net
CEQuiz
11.The stop signal should be established ____________.
a. when the patient is ready to stop
b. before treatment has started
c. when the treatment is completed
d. only if the patient brings it up
16.Titrating activities in the dental setting can include ____________.
a. taking a blood pressure reading
b. the patient taking a walk outside
c. having the patient drink a beverage
d. all of the above
12.Coping skills can include ____________.
a. controlling breathing
b. focusing on the five senses
c. taking a break
d. 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 than
d. 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 control
b. can cause a patient to avoid the appointment
c. is not recommended
d. a and b
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 periodically
b. help to create a nonthreatening environment
c. help deliver dental care to patients
d. all of the above
14.Verbiage to calm the patient should include a ____________
voice.
a. low tone of
b. variable tone of
c. high pitched
d. any of the above
19.Success at one appointment ____________.
a. does not guarantee success at another appointment
b. guarantees success at the next appointment
c. means it should have been lengthened
d. b and c
15.Using an oxygen hood or rubber dam may make a patient
with PTSD feel ____________.
a.calm
b.trapped
c. that he or she can always handle more treatment
d. none of the above
20.Identifying symptoms and having treatment protocols in the
dental setting for patients with PTSD ____________.
a. help patients accept dental care
b. help patients receive much-needed treatment
c. make treatment more workable
d. all of the above
12
Identifying and Treating Patients with PTSD
CE ANSWER FORM (E-mail address required for processing)
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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.
COURSE EVALUATION
Please evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor.
QUIZ ANSWERS
Fill in the circle of the appropriate
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2.
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3.
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1.Clarity of objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
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2
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10.
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2
2
1
8.Relevance of quiz questions. . . . . . . . . . . . . . . . . . . . . . 3
2
1
11.
A
9.Rate your overall satisfaction with this course . . . . . . . . 3
2
1
12.
A
B
C
D
No
13.
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14.
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B
C
D
15.
A
B
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D
16.
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17.
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D
18.
A
B
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19.
A
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20.
A
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D
10.Did this lesson achieve its educational objectives?
Yes
11.Are there any other topics you would like to see presented
in the future? ___________________________________________________________________________
________________________________________________________________________________________
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either pen or pencil.
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complete the evaluation included with the course. INSTRUCTIONS: All questions have only one answer. Participants will receive confirmation of passing by receipt of a verification certificate. Verification certificates will be processed within two weeks after submitting a
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of the author(s) of the course and do not necessarily reflect those of Dental Learning. Completing a single continuing education course does not provide enough information to make the participant an expert in the field 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. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a CE verification certificate. Dental Learning, LLC is an ADA
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