Trauma Informed Care in a Dental Setting Why

Trauma Informed Care in a Dental Setting: Why it Matters/Things You Can Do 2 November 2018 Teri Pettersen, MD teri. pettersen@gmail. com

I have no commercial conflicts of interest

Goals and Objectives • Be aware of the incidence of traumatic experiences in Oregon • Recognize current manifestations of trauma– How does this look ‘walking through your office door’ or ‘in the chair’? • Feel motivated and more comfortable in implementing aspects of trauma informed care in your own setting

In the Next 45 Minutes Trauma: Definitions Statistics How it shows up Trauma Informed Care Definitions Why it is important What you can actually do in your setting

Trauma • Physical Trauma • Emotional/Psychological Trauma

Domestic Violence in Oregon • One in three Oregon women report domestic violence: stalking, physical and/or sexual assault • In 2016, Oregon sexual and domestic violence services answered 139, 580 calls for help • Intimate partner violence accounts for 15% of all violent crime.

In Dental Offices • 87% of dentists do not screen for trauma even when presented with physical signs • • Lack of Education Embarrassment Fear of Offending Patient Partner or children present or in waiting room

The Adverse Childhood Experiences (ACE) study • Vince Felitti, Kaiser • Rob Anda, CDC 17, 421 Kaiser adults

What are ACES? • Abuse of child • Neglect of child • Household dysfunction

What is an ACE Score? • 10 questions • Each positively answered question worth 1 point • Total number of points is your ACE Score

• • • • • Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy Psychotropic Medications Prescribed

ER visits Medical office visits Fractures EARLY DEATH FROM MI

Other recognized traumas • • • Bullying Discrimination Violent neighborhood Foster Care Refugee/Immigrant Status Natural Disasters Person-powered disasters Historical Trauma Medical Trauma

ACE Pyramid

Epigenetics

Gross anatomy

Hypothalamus CRH Cortisol NE DHEA Neuropeptide Y Galanin Testosterone Estrogen PFC CRH Cortisol NE Dopamine 5 -HT GABA Galanin Nucleus Accumbens CRH Dopamine Glutamate Oxytocin Hippocampus Thalamus CRH Cortisol NE 5 -HT GABA BDNF Estrogen Neuropeptide Y Galanin ? DHEA VTA Dopamine Amygdala CRH, Cortisol NE, 5 -HT Dopamine, Glutamate Oxytocin, Galanin Neuropeptide Y • Charney 2004. • Feder A 2009. • Gillespie C 2009. NEUROCHEMISTRY Locus Ceruleus CRH NE Neuropeptide Y Galanin

ACEs are common Household Exposures Alcohol Abuse 24% Mental Illness 19% Drug Abuse 5% Incarceration 3. 4% Childhood Abuse Physical 28% Emotional 11% Sexual 22% (28% women, 16% men) ACE Study

ACEs Cluster 40% reported 2 or more ACEs 12. 5% reported 4 or more ACEs ACE Study

Oregonians with ACE score of Four or Higher: 22%

ACEs Have a dose response relationship with many health problems and behaviors

What We See Is Behavior

What We See is Behavior

What We See Is Behavior

What We See Is Behavior

What We See Is Behavior

“It's hard to get enough of something that almost works. ” - V. Fellitti

Trauma Survivors Are Often High utilizers of sick visits and emergency care Avoidant of preventive care

How This Shows Up • • Poor self-esteem Depression/Anxiety An aversion to being touched Sensitive to boundaries, personal space Distrust Irritability Easily Startled

Trauma Informed Care

Why Trauma Informed Care? • You and your staff can be part of a patient’s healing process • Your patients will have better outcomes • Success begats success

What Gets In The Way?

Personal Sources of Concern • I wasn’t trained to do this • I don’t have time to address this • It is just too complicated • Our own trauma history

NOT ROCKET SCIENCE

A Process Not An Endpoint

• Trauma Sensitive Care • Trauma Informed Care • Trauma Specific Care

Trauma-Sensitive Care A shift from wondering what is wrong with a person that would have them act the way they do to asking what happened to a person that would have them react the way they do.

A Public Health Framework Larger Community Clinic Self Other

Self

Self Care as a practice Erin Fairchild, MSW

And Then There Are Two Self Other

Avoid Re-traumatization

“One does not need to be a therapist to be therapeutic J. Ford, C. WIlson

Radical acceptance

Judgments?

Judgments?

The ‘difficult’ patient/parent • Chronically late or ‘no shows’ • ‘Loses it’ with the front office staff • Complains about anything and/or everything • • Short tempered with their children ‘Non-compliant’ patients Refuse to recline Poor Dental Hygiene

What Can You Do? Understand trauma and triggers: Sights Smells Sounds Body position

What Can You Do? • Acknowledge that some people have dental anxiety/phobia: ASK **Also ask what may have helped in the past**

Then

“Slowly, I have come to see that Asking, and Listening, and Accepting are a profound form of Doing” -Vincent J. Felitti, M. D.

What Can You Do? • • Take Time Active Listening Develop Rapport Share information: rationale for procedures, length of time

Respect Boundaries • Explain who is present • Define roles • Ask if ready to begin

Share Control • Be clear you are working WITH the patient, not simply ON the patient • Ask permission to start • Explain transitions in the procedures and what will come next • Allow breaks • Encourage hand signals

Other Tips Consider blankets Consider weighted blankets Allow support person Offer headphones with music or guided meditation • Acknowledge all success • •

In A Dental Office Clinic Self Other

Trauma Informed Care Not so much about WHAT we do in providing care, but more about HOW we provide that care. Attitudes Language and Cultural Barriers Policies Physical Environment

How a Trauma Informed Office is Different u. Knowledge: All Staff are aware of: vthe prevalence of trauma vits impact on health and well-being u. Safety: All Staff are able to communicate with: v. One another v. Patients v. Families In a manner that feels safe and respectful

u. The Physical Environment: v. Welcoming and Calm u. Patients are Involved and Empowered: v. Clinical decision making v. Feedback is solicited

“The world is moved not only by the mighty shoves of the heroes, but also by the aggregate of the tiny pushes of each honest worker. ” - Helen Keller

Every contact

The Community Larger Community Clinic Self Other

Who Is On Your Side? • • ADA CDC TIO OHA NCTSN AAP AAFP AMA

OPAL Oregon Psychiatric Access Line Psychiatric phone consultation for medical practitioners who treat children, adolescents & adults 9 am to 5 pm, Monday through Friday 855 -966 -7255 (toll-free) or 503 -346 -1000 (Portland metro) register online: www. ohsu. edu/opal fax: 503 -346 -1389 email: opal@ohsu. edu

Thank You