Torture survivors who migrate to the United States often face numerous dental needs requiring immediate periodontal care. One study which assessed the oral health status of 216 refugee torture survivors living in the United States found that 90% of the survivors required immediate intervention and 76% had untreated cavities (Singh et al, 2008).  While treatment options may be available, very few dentists receive training to address the unique demands and challenges when providing care to a vulnerable population. Understanding the psychological and social challenges survivors face is crucial prior to delivering care as there are several considerations to take into account. As one student dentist explained, “If the patient doesn’t trust you, he’s not going to open his mouth. Or maybe he will the first visit, but he won’t be back.”(Keller et al, 2014).  The opportunity to improve the overall health status and confidence levels in survivors is immense, but the methods in which care is provided must be acknowledged and individualized.

Understand Trauma and Its Impact

Be mindful of the patient’s body language and make accommodations when necessary.Many survivors of torture risk retraumitization when exposed to bright examining room lights or common dentistry tools. The suction hose can trigger painful memories of waterboarding; dental masks may evoke fears of suffocation. Tools/machines which emit a burning smell can be especially traumatic as many have suffered the effects of scorching/burning as a form of torture. (Domino, 2010).

  • Offer to dim the overhead lights and/or use a pen light when applicable.
  • Allow the patient to hold the suction hose.
  • Avoid prolonged treatment; break a complex treatment into 2-3 less intensive sessions.

Promote a Safe, Welcoming Space

Establishing trust with a new patient may take time, so it is important for the provider to be patient and understanding in the process.

  • Provide an examining room with a window. If that is not possible, offer to keep the examining room door open. Paintings, photographs, and tapestries used to decorate the examining space can offer distraction and have a calming effect.
  • Thoroughly explain all procedures and tools prior to treatment. When the provider is required to touch the patient, communicate this with the patient/interpreter in advance.
  • Ensure the provider’s responses are predictable and consistent by delivering continuity of care. If the patient requires multiple visits, schedule the appointment with the original provider.

Ensure Cultural Competence

Be aware of the profound role culture plays in survivors of torture, from how one perceives traumatic events to the steps involved in the recovery process.

  • Create culturally-appropriate dental interventions. Oftentimes, a female survivor will feel uncomfortable receiving care from a male provider. If it is not possible to have care delivered by a female provider, allow the patient to have access to a female healthcare provider (nurse, receptionist) who will remain in the room throughout the procedure (Keller et al, 2014). 
  • Ask meaningful questions about their country of origin, but do not pry into specifics of their torture experience.

Support Patient Choice and Autonomy

Survivors of torture often feel powerless given their traumatic past.  Facilitating patient choice in regard to medical decisions can have a lasting impact and improve self-efficacy while also strengthening patient-provider communication.

  • Offer more than one option for the patient, while discussing the benefits and drawbacks of all available treatments and procedures.
  • Develop a specific plan tailored to the specific needs of the individual, and follow through with a promising end result. Oftentimes, a patient receiving dental care will be reluctant throughout the entire treatment process, but will be pleased once the final results are achieved.

*Adapted from the Trauma-Informed Organizational Toolkit

I’ve learned we aren’t only dentists. We cannot, nor should not, only deal with the teeth. We are caregivers and have to look at patients as a whole--even before we start the dental work.” ­-Dental student, NYU College of Dentistry