Providing Safe and Compassionate Care for Trauma Survivors

Post-traumatic stress disorder (PTSD) is a lifelong psychiatric condition that may develop after traumatic, life-threatening, or unsettling incidents that elicit emotional or physical harm.^1-3 Common causes include war; physical, emotional, or sexual abuse; severe accidents; natural disasters; domestic abuse; acts of terrorism; and medical ailments.

The dental setting may be a stressful, triggering environment for those living with PTSD. To provide the best individualized care for those with this psychiatric disorder, oral health professionals need to be knowledgable about PTSD, including clinical symptoms, potential triggers while in the dental office, patient communication strategies, and opportunities for interprofessional collaboration.

With PTSD affecting six out of every 100 people, oral health professionals will likely treat many individuals with PTSD throughout their careers.³ It impacts individuals of all races, ethnicities, gender identities, and ages. Among American adults, the lifelong prevalence of PTSD is 6.8% with women twice as likely to develop the condition than men.^3,4 Oral health professionals should be familiar with PTSD in the dental setting and use culture sensitivity if they suspect a history of mental illness relating to trauma in order to provide appropriate care.

Recognition of Symptoms and Treatment

When individuals experience a traumatic incident, they experience strong feelings of terror, defenselessness, and panic. Common recurring manifestations after the initial event include flashbacks of the traumatic incidents, nightmares, extreme anxiety, and uncontrollable thoughts.^2,5 This chronic heightened emotional state leads to physiological responses. Continual stress increases the release of cortisol and adrenaline, impeding the body’s immune response.⁶

The active treatment of PTSD involves medication that often coincides with therapeutic interventions. Selective serotonin reuptake inhibitors and atypical antidepressants are frequently used to address PTSD. Potential intraoral adverse effects related to these medications include xerostomia, which impacts 15% to 25% of patients,5 along with dysgeusia, glossitis, and stomatitis, which affect about 10% to 40% of patients.¹ Additional oral side effects include gingival hyperplasia, discolored tongue, sialadenitis, and dysphagia.

Exposure and cognitive therapies may be used in conjunction with medication. Exposure therapy includes guiding patients through exercises to confront the traumatic incident, typically with images or asking about the experiences, such as what they saw, heard, smelled, or tasted. Cognitive therapy, which can be used alongside exposure therapy or alone, instructs patients on how to recognize the automatic, irrational, and negative thought patterns that have emerged following the traumatic incident.¹

Unfortunately, less than half of those affected by PTSD seek treatment.^6-8 Traditional referral models for mental health may not be successful among individuals with PTSD.⁴ Oral health professionals should be able to identify what and if patients are undergoing any active therapies, while also recognizing potential oral manifestations relating to the use of specific PTSD medications.

Oral Findings and Preventive Strategies

Existing dental conditions, such as caries, periodontal diseases, and bruxism, may worsen for individuals with PTSD due to the impact of trauma in their daily lives. High decayed, missing, and filled teeth scores and periodontal disease prevalence of more than 62% have been observed in populations with PTSD.⁵ Basic oral self-care habits may be neglected due to a lack of motivation related to the patient’s mental state. Lack of confidence and poor self-image from toothaches or tooth loss may increase seclusion and impair basic functions including talking and chewing food.⁹

Risk factors associated with oral diseases become compounded by the complexity of the mental condition and daily self-care.^1,6 Diet and proper self-care habits are essential for disease prevention and control. Individuals with PTSD are also more likely to engage in substance misuse and smoking. Tobacco use, recreational drugs, and poor diet all increase risk for many oral conditions and impact biofilm accumulation. Additionally, medication-induced xerostomia is common among individuals with PTSD and is a significant, comorbid risk factor for oral diseases.^1,6,10

A study by Tagger-Green et al⁵ compared the oral health of three groups: a control group, a group of individuals with diagnosed PTSD taking medication to manage the mental condition, and a group with diagnosed PTSD not taking medication. The plaque index for each of the PTSD groups was significantly higher than the control group, with the medication group recording the highest result, 80% to 67% to 45%, respectively. The highest percentage of heavy tobacco smoking was found in the PTSD group that was taking medication. While the frequency and severity of the risk factors of smoking, drug use, poor diet, and dry mouth may vary by individual, the amalgamation of any of these multiple risk factors together necessitates preventive care, self-care education on oral diseases, and biofilm control.

The multifactorial nature of PTSD makes the identification and management of oral diseases complex for any oral health professional. Additionally, the pathogenesis of periodontal conditions may be altered by the mental condition. In a review of mental health disorders and oral microbiota, an association between periodontal conditions and PTSD were observed, but there is a lack of diverse studies to explore the correlation.¹⁰ However, constant low-grade inflammation is a risk factor for trauma-related mental conditions.¹¹

Traumatic experiences may trigger chronic stress and the release of specific stress hormones related to oral conditions such as periodontal diseases. Thus, oral health professionals should consider a possible oral systemic link to an altered immune system relating to neuropsychiatric conditions, such as PTSD, and their role in periodontal conditions.¹⁰ The combination of neglect and an altered immune response may speed up the breakdown of dental tissues.¹

The stress related to PTSD can manifest itself as bruxism, leading to facial and temporomandibular joint (TMJ) pain.⁵ Bruxism, or clenching and grinding of the teeth, may damage the teeth in addition to causing orofacial pain. Stress and emotional disturbances, such as those caused by traumatic experiences associated with PTSD, may increase abnormal, habitual bruxism.⁶ Studies have found up to 88% of patients with PTSD exhibited early signs of headaches with increased muscle pain on extraoral structures, increased observed TMJ sounds, and movement limitation with pain upon movement.^5,12 Dental hygienists play a significant role in the early detection of these symptoms via thorough head and neck examinations.

Patient Management and Treatment Modifications

Oral health professionals should treat patients with PTSD similar to other patients with special needs, identifying risks and triggers in the dental office and utilizing communication strategies to open a conversation with patients. Questions related to acoustic and visual prompts or other triggers when individuals reveal PTSD during medical and social history intake may assist the provider in planning and modifying treatments and appointments.¹³ However, some individuals may not be forthcoming in the medical history questionnaire about their PTSD.¹⁴

The dental setting can be a stressful environment for these patients, regardless of formal diagnosis. The very thought of dental treatment may elicit triggers or distressing memories for patients with PTSD.⁴ Common triggering aspects in the dental setting include, but are not limited to, lying in a supine position, “looming over” or “hovering” above the patient, placement of the patient napkin around the neck, the inability to effectively communicate during treatment, local anesthetic administration, the dental light, equipment noise, being touched and the fear of pain during treatment or postoperative pain. Actions that elicit the feeling of gagging or choking may inadvertently remind patients of the traumatic past experiences.¹⁴

Head and neck exams, including oral cancer screenings, require manipulation of the patient’s tongue and palpation of the hard palate, floor of the mouth, or oropharynx. Patients may perceive this as intrusive and forceful. Mouth props, although useful, can cause anxiety because patients cannot close their mouth and make communication challenging. Alginate impressions may elicit a gag reflex and the saliva ejector can cause patients to have difficulty breathing.¹⁵

Offering patients an overview of each step will help to ease their worry. Examples include, advising patients that they may experience a feeling of being out of breath when the saliva ejector is placed in their mouths or demonstrating the use of the air water syringe on their hands before using it intraorally.

An additional strategy to reduce anxiety is to directly ask patients what would make them feel more at ease during their dental visit. At the start of each appointment, clear consent should be obtained as well as a thorough understanding of all planned procedures. A step-by-step explanation of the appointment should also be discussed to ease any potential apprehension and anxiety. Collaborating with the patient to create signals and informing patients that they may use a signal (or a simple raise of the hand) if in need of a break or to pause during their treatment enables patients to feel more in control. Patients may be asked if anything eases their anxiety such as listening to music or visualization.¹⁵

According to a study by Simone et al² that evaluated practicing dental hygienists’ knowledge of PTSD and dental care, the majority acknowledged a link between dental anxiety and PTSD, yet more than 68% did not use any specific strategies during dental hygiene appointments. The study further identified that almost half of participants had no experience during their dental hygiene education treating individuals with a history of trauma and associated conditions. A 2025 study surveying dentists and dental hygienists found that while they believed mental health screening was important, only a small number of providers thought application into practice was feasible.¹⁶

Successful treatment and acceptance of dental care for individuals with PTSD require oral health professionals to potentially screen for these conditions and modify treatment based on the severity of symptoms and triggers. Common recommendations include active listening, careful attention to both verbal and nonverbal cues and actions, asking permission during various times of the appointment when assessing the patient, slow movement of the chair when moving from supine to upright, and adjusted appointment times.^13,14

Short, flexible appointment times and consistency with clinicians and staff provide stability in desensitizing to the dental environment. Building rapport with patients and prioritizing their safety, although time-consuming, may be a pivotal factor in increasing the likelihood of them continuing with treatment and building positive health behaviors.^13,14 Psychological obstacles faced by trauma survivors may result in an underutilization of preventive healthcare services. Depression and anxiety can cause patients to cancel, miss, or reschedule their hygiene appointments. That being said, the use of empathy and sensitivity from providers during treatment has been shown to increase the chances of follow up appointments and engagement from those who have experienced traumatic events. When treated without proper consideration and compassion, this can bring on feelings of revictimization and discourage a patient from seeking help in all aspects of the healthcare system over time.¹⁴

Oral health professionals should include the patient in determining the best methods for individualized care.^6,14 According to a study by Kisely et al⁹ findings included an increased risk of tooth loss and dental caries. Dental hygiene care plans must include therapeutic, evidence-based strategies to match a patient’s risk level. Incorporating salivary stimulating therapies may be necessary depending on the severity of xerostomia and use of medication for management of PTSD. Chewing sugar-free gum to help increase salivary flow, reducing caffeine consumption, and sipping water at regular intervals may help alleviate symptoms.

The use of remineralization treatments, such as topical fluoride application, should coordinate with nutritional education relating to diet and dental caries. Because patients with PTSD may experience challenges with focus, memory and long-term recall, all self-care instructions should be provided in writing for easy reference.¹³ Lastly, discussions on oral disease risks associated with alcohol, tobacco, and recreational drug use are necessary for comprehensive dental hygiene care. When discussing these topics, oral health professionals should recognize that these coping mechanisms are typically related to the patient’s prior traumatic experiences. The conversations should be positive and nonjudgmental. This will help patients become more comfortable talking about their habits and behavior changes, as well as remaining involved in their treatment.¹⁵

Future Considerations

Because of the high incidence of traumatic events, oral health professionals are likely to treat many patients with PTSD. Any experience that violated individuals’ autonomy may play a role in their outlook on dental and medical treatment. Frequently, oral health professionals see their patients more often than medical providers. In addition, patients often remain in the same dental practice from childhood throughout adulthood, therefore oral health professionals may be more attuned to changes in their patients’ behavior or obvious trauma.¹⁵

Medical history intakes should include tailored questions regarding all mental health conditions, but specifically inquire about PTSD. Some evidence suggests that interprofessional collaboration with providers, such as social workers, mental health providers, and other primary care providers, promotes more collaborative care.^6,13 This collective approach may include education for other members of the healthcare team on the oral manifestations associated with medication use. Collaboration may improve access to care and reduce obstacles for those with histories of trauma.⁹ However, this may not be feasible for individual practice settings or all providers. Continuing education on mental health, trauma, and conditions such as PTSD may promote awareness of the individual needs of this patient population.

Oral health professionals should maintain a list of local resources and referrals for patients with PTSD as well as those who may experience potential ongoing trauma. A general knowledge of these resources can help to encourage patient involvement in their dental care and help to support a trusting and lasting relationship with their dental professional. If ongoing trauma is a concern, oral health professionals should be knowledgeable about their legal obligations and each state’s mandated reporting requirements.

References

1. Friedlander AH, Friedlander IK, Marder SR. Post-traumatic stress disorder: psychopathology, medical management, and dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97:5-11.
2. Simone CB, Smallidge DL, Libby L, Vineyard J. Experiences, knowledge and perceptions of dental hygienists, in the treatment of patients with post-traumatic stress disorder. J Dent Hyg. 2022;96:35-42.
3. United States Department of Veteran Affairs. How Common Is PTSD in Adults? Available at ptsd.va.gov/understand/common/common_adults.asp. Accessed June 8, 2026.
4. Hoeft TJ, Stephens KA, Vannoy SD, Unützer J, Kaysen D. Interventions to treat post-traumatic stress disorder in partnership with primary care: A review of feasibility and large randomized controlled studies. Gen Hosp Psychiatry. 2019;60:65-75.
5. Tagger-Green N, Nemcovsky C, Fridenberg N, Green O, Chaushu L, Kolerman R. Oral and dental considerations of combat-induced post traumatic stress disorder (ptsd)-a cross-sectional study. J Clin Med. 2022;6:3249.
6. Xu Q, York JA, Yuan S. Trauma’s impact on oral healthcare: a biopsychosocial and trauma-informed approach. J Calif Dent Assoc. 2024;52:1.
7. Hoge CW, Auchterlonie JL, Milliken CS. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298:2141-2148.
8. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629–640.
9. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders – a systematic review and meta-analysis. J Affect Disord. 2016;200:119-132.
10. 10 Martínez M, Postolache TT, García-Bueno B, et al. The role of the oral microbiota related to periodontal diseases in anxiety, mood and trauma- and stress-related disorders. Front Psychiatry. 2022;12:814177.
11. Loupy KM, Luczynski CA. Post-traumatic stress disorder and the gut microbiome. In: Oxford Handbooks Online in Neuroscience. Oxford, United Kingdom: Oxford University Press; 2019.
12. de Oliveira Solis AC, Araújo ÁC, Corchs F, et al. Impact of post-traumatic stress disorder on oral health. J Affect Disord. 2017;219:126-132.
13. Kelsch, N. Treatment considerations for post-traumatic stress disorder dental patient. Journal of the California Dental Hygienists’ Association. 2017;35(1):16-24.
14. Heaton L, Cheung H. Trauma-informed care in oral health care: the role of dental hygienists. J Dent Hyg. 2024;98:50-55.
15. Raja S, Hoersch M, Rajagopalan CF, Chang P. Treating patients with traumatic life experiences: Providing trauma-informed care. J Am Dent Assoc. 2014;145:238-245.
16. Mishler O, Trembley C, Oates TW, et al. Dental providers’ perceptions toward mental health screening at routine practices: a mixed-methods approach. BMC Oral Health. 2025;25:1208.

From Dimensions of Dental Hygiene. July/August 2026; 24(4):32-35