Provide a relaxed, unhurried attention to the patient, a sense that you have time for her. Talk about concerns and procedures before beginning the procedure. Give her as much control and choice as possible about what happens and when. Validate and concerns she might have as understandable and normal.
Now, I know that this is challenging because I know these rooms are small, but be flexible about her having a support person in the room. Explain, of course, before the procedure, what’s going to happen and obtain her consent as you go along. Ask if she’s ready for you to begin, and be clear that she can pause or end the exam or procedure at any time. So, again, encourage questions, maintain a personable, friendly manner. Be straightforward and generous with information. Talk to her throughout and let her know what you are doing and why.
Here’s some ways that when we talked with some of our survivors, here are some techniques that dentists have used that women found particularly helpful. One woman wore her coat. Another woman asked to keep the x-ray apron on. A couple of women wanted friends or allies available to them. Bringing a pillow or a blanket, we’ve talked about. My dentist, actually the dental assistant, puts lavender oil on the bib. She also asks me if I want my hand held. They put music on and ask me what kind of music during the procedure.
There are some times in order for women to stay in the dental chair need the dental chair upright as possible, and I appreciate how challenging that is at times. Again, books on tape, visualization or meditation CD, and squeezing a ball. There are these great squeeze balls, and then, if there is a television in the room, let the patient identify the channel.
Post-appointment procedure is make a follow-up call to determine the immediate outcomes. The most important thing is developing a relationship with the woman. It is a relationship that bring women from a place of fear that freezes to a place of relaxation to open their mouths and not clench up. It’s all about relationship and safety.
So, we recommend staff development. Make trauma-informed practice training available to your staff through community resources, professional development resources. Sheela Raj at the University of Illinois in Chicago has done some wonderful work and has a book that explores relationship between physical and psychological health and traumatic events, and it has a wonderful training tool. You could have the staff read articles that might be helpful and then discuss that. For example, there was an article in Community Dentistry called The Impact of Childhood Sexual Abuse on Dental Fear by Tiril WiIllumsen. That’s something the staff could read and discuss.
Another thing is to make the staff aware of the prevalence of trauma in the lives of women and girls. In other words, discuss the centrality of trauma with the staff. Make resources on trauma-informed practice available to staff for further reading and train staff to respond appropriately when a patient is distressed.
For more information on women’s dental experience, there is an article called The impact of childhood sexual abuse on women’s dental experiences in the Journal of Child Sexual Abuse. There’s a brochure, and we’ve given you the website, Trauma Survivors in Medical and Dental Settings, and another brochure put up by the Sidran Board of Organization and Dentistry, Dental Tips for Trauma Survivors. Now, both of these are more directed to survivors and can be very available for reading in your office. Just as you have brochures from the ADA, these brochures can be made available for people in the waiting room.
Massachusetts Department of Public Health has done a bit of work also on dentistry and trauma. All in all, what I want to say is that trauma is not in the event, it is in the reaction and the response. So, what you observe when the woman is in the chair and she can’t open her mouth or if she’s rigid and she’s shallow-breathing is the reaction to her being retraumatized by the position she’s in at that point. She feels powerless, unable to fight or flee, and the dental chair replicates that position.
So, relationship, relationship, relationship. Continue to talk to make the woman feel comfortable. I want to thank you so much, and I’m sorry for that break in the connection. We missed those eight slides, but thank you.
I’m going to turn this over to Dr. DeFrancesco.
Dr. DeFrancesco:
And I’ll turn it over to Jennifer.
Jennifer:
Well, thank you all very much. I really do appreciate all these great presentations, and thank you all very much. So, we do have a couple of questions that have come in through the presentation. There was one specifically with regards to the safety of x-rays with pregnant women. Perhaps, Dr. DeFrancesco, you might like to answer that question.
Dr. DeFrancesco:
Certainly. I don’t have actual data in front of me, but what I know is we’ve always taught our patients from what we’ve been taught that between the proper usage of shielding and the relatively low radiation levels, there’s very little scatter, if any, during an oral x-ray. They’re not contraindicated, generally speaking. I think, in terms of radiation, in general, so much of this is time-dependent, where you are in the pregnancy, but for the most part, x-rays can technically be done anytime during pregnancy.
Dr. Hilton:
Hello? Hi, this is Dr. Hilton. I want to follow-up in what Dr. DeFrancesco. He is correct. If a pregnant woman presents to you in an emergency, abscess or caries, the proper amount of x-rays, the proper number of x-rays have to be taken in order to be able to arrive at the correct diagnosis. This is an issue of the standard of care.
The ADA has guidelines on the proper number of x-rays that should be taken for an emergency and a comprehensive exam visit. A pregnant woman should be treated any differently than any other patient. That means the appropriate shielding, x-ray standard precautions that are always used, which is thyroid and a body shield and proper [1:21:55] on your cones, and the proper speed, high speed exposure. In fact, the majority of dental offices are now using digital x-rays, which is much even lower dose of radiation.
So, really, in terms of the safety, same procedures and risks apply to pregnant women as with any other person. Any human being wants to have the minimum amount of radiation exposure. You never see articles about x-rays and getting as much exposure of your client. If you’re lying on a plane, you get more exposure than you do if you’re using the standard four [1:22:40] and two [1:22:41].  So, it’s sort of a non-issue.
Jennifer:
Thank you both of you. I really appreciate that. There is a question also about the safety of anesthesia with pregnancy. I’m not sure who would like to tackle that one.
Dr. DeFrancesco:
This is Dr. DeFrancesco, again. I don’t have statistics in front of me, but, again, we always go through the same risk versus benefit analysis. Depending on which anesthesia agent you’d be using and why you’re using it, you’ve got to oftentimes forget the fact that someone is pregnant. Many of these medications can be very safely during pregnancy at any time.
I think if somebody has appendicitis going on or some acute trauma, there’s absolutely no question they need to have anesthesia. There’s no way to delay that. So, we do know from enough cases where this had to be done in the past that there are a few things that you can do in pregnancy and still not endanger the pregnancy. So, again, you, at that point, check the various agents that you have available. Look for the ones that are least worrisome from the teratogenic point of view, but again, for most pregnancies, you’re not going to hit it at that time in the pregnancy as far as development goes.
I think we would never suggest that you need to delay something that’s must be done from a health point of view. Most of these things are done, and most of these agents are used in pregnancy, judiciously, of course.
Dr. Hilton:
And to follow-up on that, if you look at the California Perinatal Health Guidelines, they had 250 references cited precisely in order to address concerns like this. I’m going to assume that the question was related to standard dental anesthesia. Again, for routine with the guidelines, we’ll tell you. The guidelines were written by a group of expert physicians, dentists, OB GYN, family medicine, neonatologist, again, looking at the research on these very questions, and we’re not able to say. Routine, standard, you have to present lidocaine with epinephrine. In a routine pregnancy, there’s absolutely no contraindication, and, again, this is shown by the randomized clinical trial in the OTP and the anesthesia was used.
Again, routine anesthesia, standard anesthesia to do the scaling and planning and the fillings and extractions on the participants. There was no difference in the outcomes relating to that.
Now, once you get into the other levels of anesthesia for dental treatment like nitrous or if you have to do sedation, then start getting into, as Dr. DeFrancesco said, the cost-benefit analysis on why you would need to use higher level management anesthesia and again the cost-benefit that is the condition that you’re trying to treat versus the potential effects on the mother and child. Now, this is when you would have a consult with the perinatal health provider.
Jennifer:
Great. Thank you so much Drs. Hilton and DeFrancesco very much for answering those questions. I am afraid that’s all we a have time for today. I would just like to respond to a couple of questions about getting copies of the slides. As I mentioned, the webinar itself and the PDF of the presentation on the National Healthy Mothers Healthy Babies Coalition website, and that website is www.hmhb.org, and you will receive a follow-up e-mail with the link to our website as well as the link to our Survey Monkey.
I would really appreciate it if you would all take a moment to share some feedback. We would like to know your thoughts about the presentation today. Would you like more of these kinds of presentations and just to hear a little bit more from all of you. That was extremely helpful.
I would also like to say a very special thank you to today’s speakers, Mark DeFrancesco, Irene Hilton, Amy Gagliardi, and Rene Andersen. I thank you all so much for your time today for putting this presentation together, and I also want to say a special thanks, once again, the Office of Women’s Health Region 1 for making today’s presentation possible. We really do appreciate it.
Thank you all for attending, and we look forward to sharing all of these presentations on our website within the next day or so. Thank you all so much. Have a great day.
