Racism Is Linked to Dental Anxiety and Fear among Black Women

It’s not uncommon for people to feel apprehensive about going to the dentist, but growing evidence suggests that dental anxiety may be higher among certain populations—and not just because of the needles and drilling that often accompany these appointments.

Experiences of racism appear to heighten dental fear and anxiety among Black women, according to a study led by School of Public Health researchers.

Published in the journal Community Dentistry and Oral Epidemiology, the study found that encounters with everyday or lifetime racial discrimination—from poor experiences in a store or restaurant, to unfair treatment at work, in housing, or by police—contributed to elevated dental fear and anxiety among nearly 1 in 5 Black women, more than double the prevalence of dental fear among White women. The findings also linked these heightened fears to a delay or avoidance of dental services and poorer oral health outcomes among a population that is already burdened by inequities in oral health and access to quality and affordable dental healthcare services.

The paper, written by lead author Brenda Heaton (SPH’05, ’12), jointly appointed as associate professor of epidemiology at SPH and adjunct associate professor of health policy and health services research at BU’s Henry M. Goldman School of Dental Medicine; senior author Yvette Cozier (SPH’94, ’04), associate professor of epidemiology; and coauthors Julia Bond, a PhD student studying epidemiology, and Jaeyoung Bae, an MS student studying biostatistics, also recently earned the prestigious Judith Albino Award for Outstanding Research in Health Equity by the International Association for Dental, Oral, and Craniofacial Research (IADR). The organization recognizes a single paper each year that addresses inequities in oral healthcare. Heaton, who is a member of IADR, accepted the award during the organization’s virtual business meeting in June.

“The drivers of oral health inequities in the US are complex and rooted in our history,” says Heaton. “Documenting the disproportionately high frequency of dental care-related fear and anxiety among Black women is a key step in piecing together our understanding of what’s driving oral health inequities. Linking that outcome to their lifetime experiences with racism starts to tell a story that encourages further exploration.”

For the study, the researchers utilized data from 484 participants in the Black Women’s Health Study, an ongoing study of 59,000 Black women in the US, based at BU’s Slone Epidemiology Center. The participants lived in Massachusetts and responded to mailed surveys about dental anxiety and experiences with racism.

More than 13 percent of participants reported that they experienced unfair treatment due to their race over the course of their lifetime. More than 70 percent of the people who reported experiencing this mistreatment in the three scenarios of housing, employment, and policing were more likely to encounter high dental anxiety. Black women with higher levels of dental fear and anxiety said these fears were fueled by a perceived lack of control during dental exams or procedures, painful or uncomfortable procedures, and unsympathetic or unkind dentists—all stressful experiences that only worsen in instances of perceived discrimination during a healthcare visit. Documented research has already shown how racial biases in healthcare lead to poorer pain management among Black people.

Increasing awareness about racial biases in healthcare and training on how dental staff can reduce these biases are important steps to reduce poor treatment and health outcomes based on race, Cozier says.

“How dental staff communicate with patients is important not only during the exam or procedure, but from the time they arrive at the check-in desk,” says Cozier, a co-leader of BWHS. “These can be the first negative encounters that a patient experiences, which can affect the entire examination.” Judgment or lack of compassion from dental staff for poor dental healthcare maintenance, especially when tinged around race, can also make patients feel uncomfortable during visits or lead them to avoid the dentist altogether, creating a vicious cycle of poor health, she says. “We need engagement and advocacy from dental professionals to make sure that everyone who needs oral healthcare has access to getting oral healthcare, without being in the most extreme pain or feeling like they are being judged.”

The broader separation of dental care from medical care in the US is also driving racial inequities in oral health outcomes, the researchers say. Despite the well-documented connection between oral health and overall health, most health insurance plans do not cover dental services.

But poor oral health can lead to cardiovascular disease, diabetes, pregnancy complications, and even mortality. Two previous studies by Bond and Heaton linked periodontal disease and edentulism (losing all teeth) to increased risks of mortality, particularly among racial and ethnic groups that already lack access to care. Extracting a tooth is cheaper than restoring a tooth, Heaton says, so patients who cannot afford certain services—or those who receive inadequate care as a result of mistreatment—are at risk of multiple consequences.

“There are many historical reasons as to why dental care is still not considered part of health care, but a likely consequence of this separation is the persisting perspective that oral health care is a luxury, not a necessity,” she says.

Of the Albino Award, Heaton says the honor “amplifies the collective interest in furthering discovery related to oral health inequities, particularly as it relates to dental care utilization and any fear and/or anxiety associated with that experience.”