Naval Postgraduate Dental School Clinical Update National Naval Medical Center Bethesda, Maryland Vol. 30, No. 4 2008 Post traumatic stress disorders (PTSD) and dental practice Lieutenant Colonel Sara A. Dixon, USAF, DC and Captain Morris A. Branch, DC, USN Introduction PTSD can negatively impact a patient’s overall health status and challenge the ability of health care providers to provide As a military dental provider, it is important to have an effective symptom management. awareness concerning post traumatic stress disorders (PTSD), a “signature injury” of service members return- Although the biology of PTSD is not fully understood, neu- ing from Iraq and Afghanistan.1 Unlike conventional robiologic research has demonstrated problems with dyfunc- traumatic injuries, PTSD is not apparent on visual exam; tional stress systems and altered limbic, paralimbic and pre- however, PTSD patients often present with increased frontal brain function. PTSD has been associated with de- anxiety, fear, general arousal, pain and dysfunction creased hippocampal volume, increased amygdalar response, which present management challenges for the dental diminished prefrontal cortex activity and changes in neuro- health care team. transmitter systems.8,9 All of the aforementioned provide the physiologic basis to explain the enhanced anxiety and fear PTSD is categorized as an anxiety disorder and may de- seen in PTSD. Research has also shown a significant overlap velop following exposure to an event that is perceived to between the neurobiology of PTSD and chronic pain.10 The- be life-threatening or traumatic, i.e. sexual or physical ories to explain the relationship between the two disorders abuse, assault, serious accidents, natural disasters, ter- suggest that the affective, physiologic and avoidance ele- rorist attacks and combat.2 The characteristics of PTSD ments of PTSD may maintain and worsen chronic pain while fall into three distinct symptom clusters: 1.) intrusive the cognitive, affective and behavioral components of chron- memories or re-experiencing events, 2.) avoidance be- ic pain may exacerbate PTSD.9 haviors, and 3.) persistent elevated arousal.2 Other symptoms may include mood disturbances, memory Clinical Considerations problems and cognitive difficulties.3 Patients who develop PTSD may initially seek health care The likelihood of a military dental provider encounter- for physical rather than psychological complaints, thus the ing a patient with PTSD is high. It is estimated that 1.5- first provider they encounter might be in a dental setting.11 1.64 million military personnel have been deployed to Although dentists do not diagnose and treat PTSD, it is im- Iraq or Afghanistan since 2001.1,4 A RAND Corporation portant that dental providers have a basic understanding of study reported 14% of soldiers returning from the com- the risk factors and symptoms. Patients with a history of bat zone screened positive for PTSD.1 Another investi- deployment or traumatic life events who also report prob- gation showed approximately 78% of injured personnel lems with sleeplessness, anxiety, depression, mood changes, experienced mental health problems with PTSD being flashbacks or intrusive thoughts may have PTSD and should the most common diagnosis (44%).1,4 An increased be referred to an appropriate medical or behavioral health prevalence of PTSD is not unique to the Iraq and Af- provider for further assessment.12 ghanistan conflicts. A recent study found an 18.7% life- time rate of PTSD for veterans of the Vietnam War.5 By With regard to orofacial pain complaints, PTSD is associat- comparison, PTSD has a lifetime prevalence of 1-14% ed with higher levels of pain and affective distress, both of in the general population.6 which can complicate clinical management.11 This is of special importance considering the high prevalence of head In addition to affective symptoms, patients with PTSD pain in the military.13 Head and neck injuries have been re- often possess a variety of other comorbid conditions ported in one quarter of service members evacuated from the such as temporomandibular disorders, headache, fi- conflict in Afghanistan and Iraq.14 The head was either the bromyalgia, gastrointestinal disorders and cerebrovascu- primary (32%) or secondary (22%) pain location identified lar disease. 5,7 PTSD patients also frequently present in soldiers returning from Iraq.15 with comorbid chronic pain complaints. A 2007 report indicated that 66% of treatment-seeking veterans with PTSD patients may have difficulty in describing or being PTSD had a chronic pain complaint at their initial eval- aware of their emotions or mood. Likewise they may uation.5 Many PTSD patients experience difficulty cop- demonstrate a diminished capacity to employ adaptive and ing and adapting to their pain.6 It is clearly apparent that coping strategies.9 Patients with PTSD and high levels of anxiety may respond with increased fear and avoidance 4. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro behaviors. When faced with arousing stimuli, such as CA. Mild traumatic brain injury in U.S. soldiers returning from pain or psychosocial stressors, they may exhibit disturb- Iraq. N Engl J Med 2008 Jan 31;358(5):453-63. 5. Shipherd JC, Keyes M, Jovanovic T, Ready DJ, Baltzell D, ances in affective control and display increased irritabil- Worley V, Gordon-Brown V, Hayslett C, Duncan E. Veterans ity, anger, sense of loss or shame.3 It is prudent therefore seeking treatment for posttraumatic stress disorder: what about for providers to be mindful of both verbal and nonverbal comorbid chronic pain? J Rehabil Res Dev 2007;44(2):153-66. interactions with PTSD patients and avoid sounding 6. Bertoli E, de Leeuw R, Schmidt JE, Okeson JP, Carlson CR. judgmental or condescending.16 Additionally PTSD pa- Prevalence and impact of post-traumatic stress disorder symptoms tients may have difficulties with sustained attention and in patients with masticatory muscle or temporomandibular joint working memory that impair long term recall.17 It is im- pain: differences and similarities. J Orofac Pain 2007 Spring;21 portant to ensure that such patients leave with written (2):107-19. copies of any home care recommendations or post oper- 7. Spiro A 3rd, Hankin CS, Mansell D, Kazis LE. Posttraumatic ative instructions for them to refer to later.16 stress disorder and health status: the veterans health study. J Ambul Care Manage 2006 Jan-Mar;29(1):71-86. 8. Etkin A, Wager TD. Functional neuroimaging of anxiety: a me- It is estimated that approximately 80% of the United ta-analysis of emotional processing in PTSD, social anxiety disor- States population has some anxiety about dental treat- der, and specific phobia. Am J Psychiatry 2007 Oct;164 (10):1476- ment.18 Due to their higher levels of anxiety, PTSD pa- 88. tients may require even more time and patience to estab- 9. Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress lish a positive working relationship. As with all anxious disorder: mutual maintenance? Clin Psychol Rev 2001 Aug;21(6): patients, asking generalized questions such as “are there 857-77. any parts of dental treatment that are particularly diffi- 10. McLean SA, Caluw DJ, Abelson JL, Liberzon I. The develop- cult for you?” or “is there anything we can do to make ment of persistent pain and psychological morbidity after motor you feel more comfortable?” may help patients to better vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model. Psychosom Med 2005 Sep- focus and respond in a more appropriate manner. Sim- Oct;67(5):783-90. ple, subtle adjustments in the dental environment may 11. Sherman JJ, Carlson CR, Okeson JP, McCubbin JA. Post- improve a patient’s sense of safety and self control. For traumatic stress disorder among patients with orofacial pain. J example, it is not unusual for PTSD patients to perceive Orofac Pain 2005 Fall;19(4):309-17. supine positioning in the dental chair or facing away 12. Olszewski TM, Varrasse JF. The neurobiology of PTSD: im- from a room door as threats. Small changes in the ar- plications for nurses. J Psychosoc Nurs Ment Health Serv 2005 rangement of the dental operatory may help to reduce Jun;43(6):40-7. such threat cues. Taking breaks during prolonged proce- 13. deLeeuw R, Schmidt JE, Carlson CR. Traumatic stressors and dures and establishing designated signals for “stop” are post-traumatic stress disorder symptoms in headache patients. Headache 2005 Nov-Dec;45(10):1365-74. two other beneficial techniques to use with PTSD and other highly anxious patients.16 14. Xydakis MS, Fravell MD, Nasser KE, Casler JD. Analysis of battlefield head and neck injuries in Iraq and Afghanistan. Oto- laryngol Head Neck Surg 2005 Oct;133(4):497-504. The prevalence of PTSD in the military population 15. Clark ME, Bair MJ, Buckenmaier CC, Gironda RJ, Walker RL. makes it important for dental providers to have a basic Pain and combat injuries in soldiers returning from Operation En- understanding of the disorder and refer symptomatic during Freedom and Iraqi Freedom: implications for research. J patients for evaluation. Dentists also need to be aware Rehabil Res Dev 2007;44(2):179-94. of the potential impact of PTSD on the provision of den- 16. Stalker CA, Russell BD, Teram E, Schachter CL. J. Providing tal care in this special patient population, especially with dental care to survivors of childhood sexual abuse: treatment con- regard to the management of anxiety and pain. Failure to siderations for the practitioner. J Am Dent Assoc 2005 Sep;136 (9):1277-81. recognize and address psychological distress concerns with PTSD can adversely affect treatment outcomes.6 17. van der Kolk BA. Clinical implications of neuroscience re- search in PTSD. Ann N Y Acad Sci. 2006 Jul;1071:277-93. 18. Wong M, Lytle WR. A comparison of anxiety levels associated References with root canal therapy and oral surgery treatment. J Endod 1991 1. Tanielian T, Jaycox LH. Invisible wounds of war: psycho- Sep;17(9):461-5. logical and cognitive injuries, their consequences, and services to assist recovery. RAND Corporation 2008. Lieutenant Colonel Dixon is a fellow and Captain Branch is staff in 2. Bryant RA. Posttraumatic stress disorder and traumatic the Orofacial Pain Department at the Naval Postgraduate Dental brain injury: can they co-exist? Clin Psychol Rev 2001 School. Aug;21(6):931-48. 3. Frewen PA, Lanius RA. Toward a psychobiology of post- The views expressed in this article are those of the authors and do traumatic self-dysregulation: reexperiencing, hyperarousal, not necessarily reflect the official policy or position of the Depart- dissociation, and emotional numbing. Ann N Y Acad Sci 2006 ment of the Navy, Department of Defense, nor the U.S. Govern- Jul;1071:110-24. ment.