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DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 1

Running Head: DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE












Dental Distress and Co-Morbid PTSD and Dissociation in Middle Aged Women Survived of
Childhood Sexual Abuse.
By
Carrie Smith
Capella University









DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 2

Table of Contents
Abstract 4
Introduction 5
Childhood sexual abuse 5
Poor dental health 5
Dental patient care 6
Literature review 7
Importance of dental health 7
Dental fear and avoidance of dentist 7
Who fear the dentist and why 8
Oral sexual abuse 10
Poor dental health prompts dental intervention 11
Dissociation disorders and posttraumatic stress disorder 12
B.A.S.K. model 12
Dissociative symptoms and the dentist 13
Symptoms at dentist and the need to address it 15
Communication with dental health workers 15
Methods 18
Purpose of study 18
Target population and participant selection 18
Index of Dental Anxiety and Fear (IDAF-4C) 20
Multiscale Dissociation Inventory (MDI) 20
Childhood Trauma Questionnaire (CTQ) 20
Procedures 21
Expected Findings 23
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Childhood Trauma Questionnaire (CTQ) expected findings 23
Index of Dental Anxiety and Fear (IDAF-4C) expected findings 24
Multiscale Dissociation Inventory (MDI) expected findings 24
Summary of expected results 25
Discussion 26
Limitations 28
Conclusions 29
References 30

















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Abstract
The dental health care of individuals is related to overall physical health. Often fears and anxiety
will keep an individual from attending dentist appointments. Individuals who have a history of
sexual abuse have difficulty at the dentist, it may trigger past trauma. Some symptoms increase
related to the diagnosis of posttraumatic stress disorder and dissociative disorders. The
individuals, who have experienced emotional abuse, may have a history of poor role models who
may have added to the neglect of personal hygiene of an individual. Several tests, ADAF-4C,
MDI and CTQ were proposed of three different locations dental office, dental fear support group,
and trauma outpatient office for the population of white, middle age females to discover the fear
of dental health care, dissociation, and childhood trauma. The relationship is proposed to show
the fear of dental health care in the history of the women with childhood sexual abuse.












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Dental Distress and Co-Morbid PTSD and Dissociation in Middle Aged Women Survived of
Childhood Sexual Abuse.
Childhood sexual abuse affects a large percent of the population Maynes and Feinauer
(2013) reported that 25% of the population experienced childhood sexual abuse. The effects of a
history of childhood sexual abuse are prominent in situations that activate the memory, and cause
symptoms to arise. A person with childhood sexual abuse will have symptoms expressed from
the posttraumatic stress and dissociation disorders that may co-exist, co-morbid. One possible
example that may cause psychological suffering is the dentist, and more specifically being
hovered over in a dental chair at the dentists office. The fear of the dentist presents higher
within the population displaying poor dental hygiene (Wieland, Lau, Seifert and Siskind, 2010).
The problem to be addressed in this study is the prevalence of childhood abuse survivors who
suffer from poor dental health and are consequently in need of care from a psychologist and a
dental care provider.
The effects of poor dental health are not strictly related to tooth loss and decay esthetics,
but also concern issues with oral health problems leading to the illness that can be transferred
throughout the body effecting overall health. The reaction of the patient while in the dentist
office may indicate psychological distress. Some type of intervention is necessary to ensure it is
not the last time the patient has a dental visit. The personal history of the patient may not be
given, offered, or answered to ensure proper handling of the situation within in the dental office.
Lundgren, Carlsson, and Berggren (2006) reported the patients who have had a trauma
experience related to the fear of the dentist will have a severe functional response. The fear of
the dentist is between 5-20% of the population, and when combining the population with a
childhood sexual abuse history around 25% the probability of working with a patient with both is
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highly likely (Kessler & Bieschke, 1999). If a patient begins to dissociate it is usually not
visible, and it is a protective measure learned from their childhood trauma, but the patient may
not feel in their body, know where they are throughout the appointment, they would be
disoriented.
Though dental fear is one of the most common fears, Abrahamsson, Berggren, Hallberg
and Carlsson (2002) reported the fears are higher in women, usually originate in childhood, and
are the result of dental pain and dentist conduct. The personal component of being at the dentist
is directly related to the actions of the dentist towards the person in the chair who is expressing
the fear and anxiety of being at the dentist. The symptoms communicated through behavior can
be minimized when treated appropriately and managed with the reactions and actions of dentist
or oral health care professional working within the dental office. Awareness of the large number
of persons struggling with a dental fear as well as a history of childhood sexual abuse creates a
need to understand the symptoms expressed and how to assist the patient to decrease them.
Maintaining respect for the patient, demonstrating patience and utilizing relaxation and
cognitive- behavioral strategies may benefit the population in maintaining their oral health.
Teaming the dental industry and the psychological industry with the patient to protect their
mental and physical health will assist to gain a better way of life.




DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 7

Literature Review
Importance of Dental Health
The dental industry and the mental health industry would benefit from having the two
working together to ensure the health of the people who suffer from psychological distress with
the idea of attending a dentist appointment. Once these individuals who fear the dentist and have
increased anxiety actually make, and attend the appointment the reactions of to the environment
can cause another situation which can best be handled when feeling familiar with the distress and
helping to make the patient feel calm and safe.
Wieland, Lau, Seifert and Siskind (2010) affirmed the dental health effects the habits of
an individuals eating, as some foods may hurt to eat, and missing teeth may make it difficult to
bite or chew certain food. Also the effects of dental health can inhibit work opportunities when
the first impression may be unsettling for customer and co-worker relationships; this is
associated with dental health affecting the social aspects of someones life outside of the work
place and in romantic relationships. Severe health issues have been reported from individuals
who have had a traumatic history having an increased risk of heart disease, diabetes, skeletal
fractures, stroke and cancer, increased health risks associated with a traumatic history such as
childhood sexual abuse and fear of the dentist cardiovascular disease, respiratory illness, even
premature death (Monahan & Forgash, 2012).
Dental Fear and Avoidance of Dentist
A fear of the dentist causes an individual to avoid dental visits as often as possible, this is
also the case in appointments being missed. Bi-annual cleanings with a dental hygienist, in
which the hygienist educates patients in proper oral care, screening for oral cancer, and detecting
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 8

early decay, are then also being missed. When noticing mental health/illness as a reason behind
poor oral health care two categories emerge, one focusing on psychotic symptoms from disorders
as noted in the table from Wieland (2010) schizophrenia, schizoaffective disorder, bipolar
affective disorder and schizotypal personality disorder (p. 508). The other category is fear and
anxiety related to dentist or dental visit. The psychotic disorder patients have a disadvantage
with the anti-psychotic medications which affect the health of teeth, and dental staff has reported
the dental health was also affected by smoking cigarettes, and diet such as drinking soda.
Armfield, Slade and Spencer (2009) affirmed 23-25% of individuals have a moderate to
severe fear of the dentist that responded to inquiries, regular check-ups do not reporting
accurately. It is expressed the populations for dental fear is under-represented due to the fear of
research participants required to have a dental check, or procedure. The feeling of not having
control at the dentist, Logan, Baron, Keeley, Law, and Stein (1991) argue is a determining factor
behind the fear and anxiety invoked from the it. The determined felt control and the desired
control were specific to the patient wanting yet not actually feeling they were in control of the
dental environment; this led to the patient having increased anxiety and fear in the pairing of
these factors (p. 352). The memory of this occurrence in time to attend the next check-up
increases the result of the patient avoiding the appointment.
Who Fear the Dentist and Why
Monahan and Forgash (2012) report the survivors of childhood sexual abuses have
mental health issues, oral/dental health decline and the dental health affects their extended
physical health also. The post-traumatic stress obtained from sexual experiences robbed the
child of their innocence, their mentality of understanding the act being forced onto them, and the
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fear of punishment if refused. The length of time throughout the childhood of an individual with
sexual abuse causes lifelong effects diagnosed with post-traumatic stress.
The severity of the abuse, the length of time it occurred and the duration over the years
Monahan and Forgash (2012) asserted the abuse creates a sense of victimhood of feeling it is
never ending the idea of victimhood is expecting the abuse to continue and giving into it
rather than fighting it, and losing (p. 198). It effects how the child thinks about sexual behavior;
if the relationship of the abuser to the individual is family it will affect being able to trust others
(Monahan & Forgash, 2012). The individual may have suffered from having been genitally
harmed during the abuse, and the fear of sexual force and harm increase with those close to
them. Trusting someone at all subsequently will result in feelings of eventual harm, creating fear
and anxiety to the people close emotionally and those close proximally; trust is harmed the
greatest when it is a familial member that had been trusted rather than a stranger.
The dentist or dental care worker, who is trusted to have appropriate boundaries, creates a
fear from the innate feeling of trusting someone will result in being hurt by the person entrusted
to take care of the individual while a patient. Abrahamsson, Berggren, Hallberg and Carlsson
(2002) reported feelings of fear and anxiety related to the dentist were fear of being debased and
losing independence as prominent when attending a dental appointment. The participants in
Abrahamssons (2002) study reported the rapport with the dentist was a contributing factor in the
individuals fear and anxiety. The positioning of the dentist to the individual while in the dental
chair contribute to the personal space and needing to trust the dentist or dental care worker will
not hurt the patient.
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Monahan and Forgash (2012) stated having the dentist or hygienist working in the mouth
at any point can be triggering memories of oral rape. The entire component of being at the
dentist is working within the mouth such as x-rays, cleanings, fillings, checking for diseases and
cancers of the mouth area causes extreme reactions to survivors of childhood sexual abuse. The
lying back in a horizontal position and the slow recline in the chair may create similar biological
feedback to a past event of abuse, flashback. Flashbacks are a symptom of post-traumatic stress
disorder. Monahan and Forgash (2012) report the inability to assert their needs as a patient,
creates the feeling of not having control over the situation happening to the mouth area
increasing symptoms such as the flashback. Flashbacks can occur from being triggered with a
feeling, emotion, instrument, or touch and be a flashback to the response of each individually or
a full-fledged flashback losing orientation of person, place, time, and situation.
Monahan and Forgash (2012) explain the attachment theory of Bowlby who had
explained the child being reared will form an attachment to an adult in order to gain (role)
models to learn from in the unknown environment. An child even when abused needs the care of
the abusers when there is no other choice known such as child protective services, a child is
unaware such exist. The adults/parents who are the abusers do not model regular scheduled self-
care such as taking the patient as a child to have check-ups. This creates an unknown
environment of self-care when seeking dental care assistance as an adult. The lacks of care
towards the child creates inner feeling of being undeserved of care, and are unsure of the proper
care techniques taught by care providers. The lack of care from the providers throughout the
individuals life who survived childhood sexual abuse creates low self-esteem, unworthy, and
being undeserved of the dental care and oral health; the patient grew up without proper guidance
and modeling on how to care for teeth and gums (Monahan & Forgash, 2012).
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Poor Oral Health Prompts Dental Intervention
Poor dental health from lack of proper care and regular cleanings, along with dietary
intake, and smoking cigarettes can cause lasting effects on the teeth that at some point due to
pain, or physical health prompts an individual to make and attend a dentist appointment. When
an individual is in need of immediate dental care, it affects the metal state of the individual with
the fear and anxiety from triggers of their childhood sexual abuse. A white room with a person
in a white coat may evoke an image of abuse; also the gender of the dental health care worker
such as a man for a female patient of childhood sexual abuse would also increase the anxiety and
fear. The increase in the triggers of the environment then increases symptoms of the disorder(s)
in posttraumatic stress, dissociative and dissociative identity. An individual whose is a patient
and triggered may have flashbacks and in different forms, such as believing the abuse is
occurring in the moment and reacts to the environment and people in it as if they were the
abusers; dissociation may also occur in several different forms.
Monahan and Forgash (2012) reported on a case with a woman who had avoided the
dentist from a combination of terrible dental experiences with a childhood dentist who did not
use anesthesia, or other numbing agent, when working on dental issues such as cavities the
woman had. Added to the dental incidents were oral sexual abuse from her grandfather for years
as a child, Monahan and Forgash (2012) note the combination of the childhood sexual abuse
orally and the painful dental work kept the woman patient from going to the dentist as an adult.
The woman was forced to see a dentist as her gums were bleeding, had pain around the teeth and
gums, and from grinding her teeth they were cracked and broken adding to the dental pain.
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Dissociation disorders co-exist with post-traumatic stress disorder in survivors of
childhood sexual abuse. Maynes and Feinauer (1994) proclaim dissociation as a protected
measure the mind takes when encountered with severe, torturous sexual abuse as a child; the
dissociation is a self-hypnosis to take the attention away from the abusive situation, and not to
connect the mind with the body sensations. Freud was reported by Maynes and Feinauer (1994)
as dissociation and re-experiencing being ways of handling the traumatic sexual abuse.
Dissociation was described as losing time, feeling though things are not real, not feeling as if the
individual is in their body-rather watching themselves, distortion of the body, and reliving the
trauma at a later time, and not aware of the trauma in its actual time of occurrence.
Loewenstein (2004) also described dissociation as divided attention [on a] continuum
to protect the mind from the childhood sexual abuse; this separation of the abuse can allow the
child to see the good parent and dissociate from the bad parent. The dissociation allowing
the abuse to divide away from the parent permitted the child to attach to the only modeling in
their environment. Loewenstein (2004) also noted Freud and Janet brought about the terms
dissociation [and] repression as the mind disjointed from the abuse will have it resurface again,
it is a repressed memory effecting the mind and the body.
The B.A.S.K. model was defined by Loewenstein (2004) as behavior, affect, somatic
sensations, and knowledge each can be dissociated from individually, one occurring without the
other such as having an emotional reaction to something without knowledge of the reason the
emotion occurred. Also described by Loewenstein (2004) were somatoform symptoms related
to specific sexual abuse such as vomiting and choking to oral sexual abuse [] arm and leg
pain to being physically held down are all forms of somatoform symptoms that can be triggered
by environmental stimuli creating realistic sensations. The idea of re-victimization is qualified in
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how the individual internalizes the abuse as Loewenstein (2004) conveyed patients reported
being told by the abuser they were asking for it, and a little whore, leading the child to
believe it was them (p. 258). Loewenstein (2004) adds Hollanders claim of dissociative
amnesia occurring from childhood sexual abuse that had occurred from a trusted family member
to protect the image for attachment.
Everest (1999) described sessions with a patient with a diagnosis of dissociative identity
disorder, and relates these occurrences in her therapy appointments with the patient. The attire
of the patient was provocative and the patients speech was assertive and bold. The patient
changed her speech, and desired name to be addressed throughout the appointment(s). During a
session Everest (1999) painted the picture of the patient as she slid down onto the floor, and
talked like a child and told the therapist she was did not like her and hid her face. The patient
acted as a child and spoke of the sexual abuse from daddy as though it was recent or currently
happening to her continually. Everest (1999) described an incident where the patient came to the
therapists house in distress, and then later called to apologize for missing the appointment; the
patient had no memory of attending the appointment that day. The dissociation to a different
altered state can be embarrassing for the patient who is without memory of the entire
appointment. It also creates continued fear of an increased occurrence of some form of
maltreatment, or abuse haven taken place common to the patients history.
Dissociation during an appointment will cement the fear and anxiety of the dentist,
decreasing the event the individual will return to the dentist to attend to oral and health needs.
The post-traumatic stress symptoms of flashback may increase due to the stress and anxiety of
the appointment for the dentist and distort perception, whether or not there was fowl play by the
dentist. Dissociation is not always evident; including dissociation of identity, Everest (1999)
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noted a memorable dissociation of person and also affects in regards of sadness and dependence
at one moment to assertive and independent the next. One identity attending to the situation in
the current environment may perform, act, and speak in manners that another identity /altered
state would revolt against. Being re-victimized when dissociated to identity (person) is
important to the safety of the patient at the dentist and the dentist himself. The patient who may
appear to be consenting to a sexual act between two adults, against ethical standards, may result
in a lawsuit. The patient unknowingly when dissociated puts their life in a sense in someone
elses hands.
Poor dental health affects the overall health of an individual. Periodontal disease is a
gum disease, and is the result of poor oral health care, brushing and flossing every day is part of
maintaining oral health. Periodontal disease as reported by Monahan and Forgash (2012) has
been related to upper respiratory illnesses such as pneumonia and cardiac conditions, even
premature death (p. 144). Corbett (2012) reports poor dental health care results in dental pain,
and signs of gum disease called periodontitis with symptoms of swollen and bleeding gums; the
link to coronary disease with the belief in the bacteria entering the blood stream by blood vessels
from the mouth inflaming the artery walls creating clotting complications increasing the risk of
heart attack. Also found as a serious risk in poor dental care as stated by Corbett (2012) in a
study on elderly nuns recorded with loss of teeth, the more loss the higher the rate of dementia.
This is related to the harmful bacteria in the mouth being transferred through nerves in the brain
that are connected as well and result of the bacteria causing memory loss (Corbett, 2012). The
final mention by Corbett (2012) related to poor dental health care and the overall health of an
individual were findings that diabetes are higher in cases of those who have gum disease,
gingivitis or periodontitis, building a case which the gums play a role in blood sugar regulation.
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 15

Symptoms at Dentist and the Need to Address Them
The earlier description of the woman patient with both traumas involved in dental and
childhood sexual abuse has a severely high probability to express increased symptoms while at
the dentist adding to the aim for working with dental issues. Logan, Baron, Keeley, Law and
Stein (1991) declare the desire to feel control was a determining factor in the anxiety and fear at
the dentist; the desire for control and the amount of control the patient feels from the dentist or
dental care worker will affect the stress level. The relationship with the dentist will have a
weighted effect on the feeling of control, asking the client to raise her/his hand if they feel pain,
need to take a break, or say something. The ability to be able to do something to communicate to
the dentist or dental worker when inside the patients mouth gives the opportunity to assert needs
that may not have been able to be asserted in the past in relation to the childhood sexual abuse.
Communication with the dentist is part of the rapport, building a rapport with the dentist
will assist in the trust the patient needs to have to challenge the fear triggered by abuse.
Abrahamsson (2002) expressed if the rapport with the dentist or dental health care worker was
lacking than the patient felt more vulnerable to being abused, threatened by unpredictable
events, [] powerlessness, [] with a fear of dying, and suffocating or losing control (p. 191).
Part of the rapport with the dentist and the patient would encompass respect, empathy, and
existing skills for dental assistance, in the treatment with the patient by acknowledging the fear
and being understanding of the intensity of the patients feelings (Abrahamsson, 2002, p. 191).
The quotes from patients in how concerned the dentist was for the patient was described by one
as a dentist who was annoyed at her from reported pain or discomfort and began to ignore her
signals to stop and kept on working to quickly complete the job. Another patient described a
dentist who was disrespecting her and the assistant who was attempting to calm the dentist, and
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being talked over her head while in the reclined position about the past dental work being done
poorly (Abrahamsson, 2002).
Lundgren, Carlsson and Berggren (2006) declare interventions that have been helpful in
individuals with dental anxiety and fear include relaxation a method with deep breathes and
listening to music, methodical desensitization such as a tour of the office, equipment, staff, then
sitting in the chair doing each phase one day at a time , and demonstrating changed behavior.
Also cognitive methods of challenging the distorted thought, reciting the place, time, people are
different than those in the abusive past. Lundgren (2006) claimed the cognitive methods for
dealing with the fear and anxiety regarding the dentist was more productive in symptom
management than the methods expressed prior for behavioral intervention, however both were
able to predict a change in reaction.
Barnard-Thompson and Leichner (1999) researched residents and how they felt regarding
the preparation they received in working with patients with a history of childhood sexual abuse.
The residents responded to the surveys that more preparation would have helped them, and they
reported to have had one to under a dozen classes from pediatricians, forensic psychologists,
radiologists, and psychiatrists; the residents reported feeling the preparation needed to begin at
the undergraduate level. Recognizing childhood abuse victims and knowing how to work with
them was felt more insufficient by those residents who were females or mothers.
Kleinknech, Klepac and Bernstein (1976) report the necessity of having the psychology
industry and the dental industry in a relationship to prepare those working with patients who
have fear and anxiety concerning the dentist and have methods to better work with the patient
while in the office. The more efficient the dentist and dental care workers are in handling a
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 17

fearful patient it will increase the patient in attending the dentist regularly for cleanings and
check-ups.
















DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 18

Methods
Purpose of the Study
The purpose of this study is to show the relationship of dental fear and anxiety with
women who have a history of childhood sexual abuse. Also the presentation of the symptoms at
the dentist as a relation to triggers from the childhood abuse that would associate the people,
instrument, environment, or emotional reaction similar to the past trauma. The significance of
the dental fear and anxiety participants that express moderate to severe dissociation affects the
dental health visit, and childhood sexual abuse would trigger a more severe reaction to dental
settings. This articulates the need to address these symptoms at the dentist office, when they
occur due to situational prompts.
Target population and participant selection
The target population is forty to sixty year old white females, with a dental fear and
posttraumatic stress disorder. Middle age white females were the population chosen due to the
relationship in socioeconomic status. Trickett, Aber, Carlson and Cicchetti (1991) described
middle class child abuse is underreported, while low economic child abuse is reported often.
The population of the proposed study would be focusing on the middle class, middle aged white
females. The participants will be selected from three different locations using the same three
measurements for each group. One location will be a mental health office for trauma disorders
for outpatients at the mental health hospital, the second group will be a private dental office in a
suburban area. The last group will have participants from a dental fear and anxiety outpatient
support group. The target population will be posted on the flyer as the specified adult female
population with a phone number on slips of paper to phone in for more information. The
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 19

participants will be interviewed to qualify for the study; they will be listed with the location
where they received the number or study information; one group will be the dental office the
second group will be from outpatient trauma disorder, and the third group will be the dental fear
and anxiety support group. To qualify for the study the participants needed to be between forty
to sixty years old, and identify as white. Then for the outpatient trauma patients they must have
been in therapy for at least two years. The support dental fear and anxiety group must have been
with the support group for at least one month or eight groups. The dental office participants will
need to qualify by having been to the dentist at least four times in the past five years. The
participants must also provide the slip of paper with the phone number of the study which will
determined where they received the information and which group where they are from the dental
anxiety and fear support group, the suburban private dental office or mental health office for
trauma disorders. The participants are a total of 580 with 193 selected for each group; each
participant will have signed a consent form with regards to the information of the study (Creative
Research Systems, 2012).







DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 20

Instruments for Measure
IDAF-4C
The methods used for the population will be for testing the mental illness of PTSD and
dissociative disorder, level of dental fear and anxiety, and history of childhood sexual abuse.
The first measurement will be Index of Dental Anxiety and Fear (IDAF-4C). The Dental
Anxiety and Fear test measure three areas: dental fear and anxiety, dental phobia, and feared
dental stimuli (Armfield, 2010). The IDAF-4C has responses placed on a scale of one to five,
one is disagree and five for strongly agree (Armfield, 2010). Cronbachs alpha was .94 showing
internal consistency, test re-test was .82 for reliability, the IDAF-4C projected accurately the
dental phobia and dental visits related to the score of the dental fear and anxiety (DAF)
(Armfield, 2010).
MDI
The second measure will be the Multiscale Dissociation Inventory (MDI), it will evaluate the
intensity of dissociation the participate exhibits, and how often; the scale is one to five, one being
never and five being very often and is being used to review the past month (Briere, 2005). The
Cronbachs alpha for the scales report consistency: disengagement .89, depersonalization .90, de-
realization .91, numbing/ inhibiting affect .94, memory disturbance .74, identity dissociation .75,
and the total dissociation score for the general population .96, exhibiting the accountability for
the MDI (Briere, 2005).
CTQ
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 21

The third measure will be Childhood Trauma Questionnaire (CTQ). There are four areas
covered for trauma in childhood physical and emotional abuse, emotional neglect, sexual abuse,
and physical neglect; this test also has a scale of one to five, one representing never and five
representing very often true (Handelsman, Foote, Bernstein and Fink, 1994, p. 1). Cronbachs
alpha was .95 for consistency on the total scale, and the re-test reliability was .88, a good
standing for a two-eight month interval (Handelsman, Foote, Bernstein and Fink (1994). Each
participant will be given these three tests to test for childhood sexual abuse, dental fear and
anxiety, and dissociation.
Procedures
The proposed study will be posted in the dental office, the mental health office, and the
support group with the office professionals assisting by asking the patients if they would like to
be a part of the study. A phone number would be on paper slips the patients could take with
them if interested in the study. Each participant will be given an explanation for the reason of
the testing to determine the need for understanding dental fear, the symptoms evoked from the
setting, and the etiological reasoning. The participants will be asked if they would like to
participate and if so to sign a consent form. The participant may leave at any point without
repercussion. The participants will be informed they would only need to fill out three tests after
the consent form is signed; the consent form also will request the participant to refrain from
discussing the tests until after the study is complete. The results of each test will be offered to
the participants, they may either choose to have the results and explanation mailed to them or
they may meet in person for the results. The test will be available for the participants to take in
the following week after signing the consent form and will give the information to the
researchers of when they would like to take the tests. The first test will determine the anxiety
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 22

and fear level of the dentist, the second test will determine the level of dissociation the
participant expresses. The third will discover whether there were any childhood sexual abuses,
which may cause a dissociation level and produce stress around the dentist.















DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 23

Expected Findings
CTQ
A significant result is expected for the outpatient trauma program patients compared with
dental office participants. The results of the test from Ozcetin (2009) where a significant for the
sexual abuse subscale (SA), it was a high correlation between the sexual abuse results and the
dissociation results of a dissociation specific test. A significant result is predicted from the
trauma disorders outpatient program, where sexually abused survivors are attaining treatment for
childhood sexual abuse along with treatment for the other subscales in relation. The results of
the group of dental fear and anxiety support group is expected to be significant as anticipated
from the cause of dental fear and anxiety related to the triggers associated with the mouth
(Monahan & Forgash, 2012). The CTQ would expect to have results of the group from the
dental office in the suburban location to have milder results as the participants were obtained in
midst of attending to dental care.
The group of 60 female participants will each be asked to partake in three assessment
measures the CTQ, the MDI, and the IDAF-4C. After each participant signs the consent form
they will be asked to take the sequence of tests. The findings expected from the CTQ where they
rate on a five point scale of (1) never, (2) rarely, (3) sometimes, (4) common, and (5) very
common on the three subscales with the first being emotional abuse and emotional neglect (EA-
EN) with scores being between 19-95, the second subscale being physical abuse (PA) with
scores between 16-80, and the last subscale being sexual abuse (SA) with scores between 5-25
(Ozcetin, Belli, Ertem, Bahcebasi, Ataoglu & Canan, 2009).

DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 24

IDAF-4C
The support group is likely to have a significant score as they are actively admitting to
and working on their dental fear and anxiety, as compared to those of the dental office location.
The group of participants from the dentist office of the suburban area is expected to have a low
score from the measurement of the index of dental anxiety and fear. The expected results of the
childhood sexual abuse survivors participants from the trauma disorders outpatient office would
be to have a significant result. As the expected results of the study is proposing the dental fear
and anxiety are correlated with a history of childhood sexual abuse. The expected findings of the
index of IDAF-4C would be significant for the participants from the dental fear and anxiety
support group, as they had admittance of the fear and anxiety and would have been at the support
group to address it. The index of dental fear and anxiety has a rating scale of (1) disagree to (5)
strongly agree, inferring the middle scales as (2) sometimes disagree, (3) neutral, and (4) agree;
the three subscales are (1) dental fear and anxiety, (2) dental phobia, and (3) feared dental stimuli
(Armfield, 2010, p. 281).
MDI
The expected findings of the multiscale dissociation inventory will be assumed to
correlate with the CTQ with expected significant results of the participants of the outpatient
trauma disorders program, as dissociation is a symptom of trauma of childhood sexual abuse
(Loewenstein, 2004). Ozcetin (2009) made note of the significant correlation between
dissociation and childhood sexual abuse specifically. The expected findings of dissociation with
the participants of the dental anxiety and fear support group would be significant as the Monahan
and Forgash (2012) reported the relationship. The participants of the suburban private dental
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 25

office are not expected to have a significant results, it is imagined the results would be mild, as
they are actively attending to dental care, and able to orient themselves during the visit to the
dentist and acknowledge the office seeking participants for this proposed study. The scale for
identity dissociation would be the main focus of the dissociative disorder, but it is assumed that
participant may have this disorder of the dissociation disorder as a result of childhood sexual
abuse. The other scales that are exhibited in the multiscale dissociation inventory are
disengagement, derealization, memory disturbance and emotional constriction, they are rated
with the scale of (1) never to (5) very often and the higher the score the more the participant will
express the symptoms of significant dissociation (Briere, 2005).
Summary of Expected Results
The expected results will likely suggest that the relationships between the participants of
the dental anxiety and fear support group will have significant results on IDAF-4C and
significant results on the MDI such that the two score will be strongly correlated. The
participants of the outpatient trauma disorders program are expected to have significant results
relating to the dental anxiety and fear support group with the results of the CTQ in a history of
childhood sexual abuse, and a relationship expected of the dissociation of the MDI. The
participants of the private suburban dental office are in a sense a type of control group to give an
idea of the expected baseline for comparison, as the study is comparing dental distress and
trauma disorders.



DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 26

Discussion
This study is about awareness of a population that struggles with dissociation disorder
symptoms as a result of childhood sexual abuse. Monahan and Forgash (2012) referenced a
study in which 17,000 random adults were questioned using a phone survey on abuse and 19%
reported childhood sexual abuse; the authors also noted the correlational prevalence of those
with sexual abuse as a child as having increased influences on physical health and disease. The
relationship regarding the abuse and disease was investigated further as Monahan and Forgash
(2012) pointed out the physical detrimental effects of not attending to dental cares, without the
preventative treatment some issues can have serious risks to the health of the patient as infections
and bacteria in the mouth can transfer throughout the body to the brain, nervous system, heart,
lung and respiration functions.
Studying the relationship with trauma and dental fear and anxiety has been approached
only a few times per journal articles and this limits the amount of information on such an
important topic that would often appear to be overlooked by professionals on either end of the
patients care (Monahan & Forgash, 2012; Abrahamsson, Berggren, Hallberg & Carlsson, 2002).
A patient that is in a mental health hospital for suicidal ideation and self-harming behaviors will
be treated for the suicidal behavior. Treatment for a dental health issue would typically be put
off to a later time post inpatient treatment, unless there is an eminent need due to the level of
pain effecting being able to focus on the inpatient treatment. A dental patient whom experiences
significant anxiety and fear in the office will dissociate, disconnect from the situation and will be
approached for the dental health issues focus specifically. Psycho-education is appropriate for
the dental health care professionals to help patients and assist in normalizing triggers,
DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 27

flashbacks, dissociative symptoms and problems in controlling emotions as part of the normal
reaction to traumatic events (Monahan & Forgash, 2012, p. 146).
The statistics of the prior research on the subject are supporting the increases correlation
between the childhood sexual abuse and the increased health issues related to avoidance of the
dental care professionals. In turn this will help support the idea of being able to help a patient
who fears the dentist by assisting them in relaxation and calming techniques, modulating the
intensity of the expression of symptoms. Ideally this will help the professional assist a patient in
being mindful in the moment and identifying the environment as safe. The health care provider
whether in the dental health care office or the mental health care office needs to exhibit respect,
understanding, warmth, empathy, and genuineness (Monahan & Forgash, 2012).









DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 28

Limitations
The limitations of the proposed study are specific to one population of white woman, and
according to the organization Rape, Abuse, and Incest National Network (2009) black women
have a similar statistic to white women of about 18% of rape. The American Indian population
has the highest population at risk with a statistic of about 35% of rape victims. The American
Indian population would give a perceptive into the sample of health risks obtained with the high
rate of trauma and an increases risk of posttraumatic stress disorder noted victims of sexual
assault are 6 times more likely to suffer from posttraumatic stress (Rape, Abuse, and Incest
National Network [RAINN], 2009). The knowledge of this information in a field such as
dentistry is important to the patients overall health, and being able to address symptoms as they
arise to manage for the patient with posttraumatic stress disorder being triggered by the dental
care. As Barnard-Thompson and Leichner (1999) reported regarding patients that residents
worked with in training felt they were in greater need of preparation in knowing how to work
with the population of individuals who had a history of abuse, and being able to manage the
related symptoms of physical, sexual and emotional abuse of patients.
Limitations can also be part of the assessments, and the demographics for the sample
size. Though in the dissociation assessment the sample size in the was middle cl ass woman,
which was a benefit for this proposed study. Individually the person giving the tests to the
participant needs to create a sense of respect, and care in a short time for encouragement of the
participant to be at ease and answer honestly.


DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 29

Conclusions
Monahan and Forgash (2012) described a situation where a patient with dissociative
disorder and co-morbid posttraumatic stress disorder with a fear of the dentist with immediate
dental care needed the dental are worker used relaxation techniques of being able to listen music,
a discussed the procedure and encouraged to express to the dental care worker with a hand
gesture. Also helpful is imagery of a place that causes relaxation such as an ocean view from a
lanai or veranda incorporating all the senses of the image, and pictures that are calming to focus
on when in the dental chair. Following the dental work the dental health care worker would give
health care information to improve or maintain health of mouth which was also related to overall
physical health. The chair side manner between the individual and the dental care worker needs
to exhibit patient care with respect and empathy. A patient in distress would benefit in
relaxation techniques of music, relaxed breathing, and walking the patient through the dental
procedures. The evidence of support throughout the present research on the subject has provided
an anticipation of the projected study being able to provide support for the relationship between
childhood sexual abuse and the anxiety and fear about the dentist increasing physical health
problems. This is a worthy topic to continue to explore and search for solutions and ways to
prevent some problems.




DENTAL DISTRESS AND CHILDHOOD SEXUAL ABUSE 30

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