Examining the Perceptions and Experiences of Dental Care Among Immigrant Free Clinic Patients

Abstract

Dental anxiety, the fear related to dental services, can be presented in diverse ways, hindering those in need of dental treatment. This anxiety often results in higher levels of untreated dental issues, affecting oral health-related quality of life primarily due to insufficient dental care or dental care avoidance. Identifying its causes is crucial for effective support and preventative care. This study explores dental care perceptions and experiences among patients at free clinics, offering valuable insights to improve dental support and care for uninsured and underserved individuals. Two hundred ninety-three immigrant patients, mainly Spanish speakers, participated from October 2023 to January 2024. Findings reveal that 14% experienced dental phobia, primarily linked to local anesthetic shots. The majority of patients reported unmet dental needs, highlighting dental care disparities. Understanding how dental phobia contributes to dental care needs is vital to understand, in order to improve oral health outcomes. Future research should address additional barriers like language, finances, and awareness of services. Additionally, exploring other anxiety factors beyond pain, noise, discomfort, and aesthetics is essential.

Key Points

1. A moderate number of participants (14%) expressed experiencing dental anxiety.

2. The majority of dental phobia experienced among the participants were linked to the anticipation of pain and anesthetic shots.

3. The majority of participants expressed an unmet need for dental treatment, highlighting disparities in dental care access among this population.

Introduction

Dental anxiety includes the fear or anxiety that individuals face regarding receiving or visiting dental services. ¹ Around 50% to 80% of adults in the United States have some degree of dental anxiety, ranging from mild to extreme. ¹ Dental anxiety also leads to a cycle of dental service avoidance, which includes missing appointments and poor attendance. ² Individuals tend to refrain from seeking dental care due to the apprehension of fear or anxiety, leading to a decline in their oral health and quality of life. ³ Individuals with dental anxiety have been found to have higher levels of untreated tooth surfaces, decayed teeth, and missing teeth. ⁴

Even with recent efforts to emphasize positive relationships between patients and dentists aimed at reducing dental anxiety, dental anxiety remains a challenge. ⁵ Dental anxiety can be caused by traumatic experiences, shame, distrust of the dentist, fear of loss of control, or a fear based on incidents of other individuals. People who express high levels of dental anxiety frequently connect their anxiety to past negative dental encounters. ⁶ Additionally, gender plays a role as a factor as women report higher levels of dental fear compared to men. ³ Socioeconomic factors such as lower income and lower education have also been linked with higher dental anxiety. ³ Despite efforts to reduce dental anxiety through awareness and improving relationships between a patient and dentist, dental anxiety still is one of the most common phobias globally. ⁷

Financial costs, lack of access to dental care, and language barriers can also add to the anxiety that individuals may face about receiving dental care. ⁸ Evidence suggests that Americans are facing financial barriers that prevent them from receiving dental care, which creates a larger amount of unmet dental needs. ⁸ Low-income individuals are more likely to get dental care only when dental problems become unbearable. ⁹ Additionally, uninsured individuals with lower incomes are 4 times more likely to avoid dental services because of financial burden while even the insured face challenges in accessing dental services because dental insurance has very restrictive or limited coverage. In lieu of higher costs, anxiety is also heightened which leads to an avoidance of dental care. ¹⁰ Overall, these barriers that uninsured and underserved populations face may hinder these individuals from receiving preventative care, which leads to more complicated and expensive treatments. Thus, it is crucial for providers to identify the causes of dental anxiety and dental avoidance. ¹¹ In doing so, healthcare providers can gain understanding into how to effectively support uninsured and underserved individuals experiencing dental anxiety.

Previous research has been done examining dental care and oral health behaviors in uninsured individuals. In a prior investigation conducted at a free clinic that offers free health care services to the uninsured in poverty, it was found that over 60% of patients at the free clinic expressed a need for dental services and treatment. ¹² Additionally, a significant proportion of these individuals practiced routine oral health habits, like brushing their teeth, consistently. ¹² There is a lack of studies and knowledge that help to develop effective oral and dental health promotion programs for free clinic patients. Additionally, further research should be done regarding understanding what other factors hinder free clinic patients from receiving dental services if a significant number of patients at free clinics recognize the need for dental treatment yet do not receive it

Poor oral health is a significant health concern for foreign-born individuals due to various barriers that may impact their access to dental care. Studies have shown that factors such as language proficiency, education, and health literacy are determinants of access to preventative dental care services among immigrants. ¹³ Language barriers remain a significant challenge, creating difficulty for foreign-born immigrants to communicate effectively with dental professionals and navigate the healthcare system. Low oral health literacy can also create challenges for immigrants to comprehend preventative dental care measures. The lack of proper communication and understanding of dental care measures can contribute to the development of oral health problems, such as cavities or gum diseases, which when untreated can worsen overtime. ¹³ Given the diversity of immigrant populations, studying and understanding immigrant experiences with dental care is crucial for understanding barriers that they may face, as well as improving oral health outcomes.

This study aims to better understand the factors that contribute to dental anxiety of foreign-born underserved and uninsured populations. By delving into the root causes and unique experiences that uninsured and underserved patients face, healthcare providers can gain a better understanding of their patient’s needs. This deeper understanding enables providers to create, and identify strategies aimed at alleviating dental anxiety or barriers to dental services. Understanding these experiences allows dental care providers to engage in preventative efforts to treat oral health issues before they escalate.

Methods

Setting

This study was conducted at the Maliheh Free Clinic in Salt Lake City, Utah. This clinic serves as a nonprofit organization providing medical care to uninsured patients who are 200% under the poverty line. Founded in 2005, the clinic operates with the motive to help members of the community who need medical care. More than half of the clinic's patients are Hispanic. Patients of the clinic are from more than 50 countries.

In 2022, the total number of patient visits since 2005 rounded up to around 245 000 visits. The clinic is funded privately, and without any public funding, the clinic turns to the valuable help of the individuals in their community who want to lend a hand and make a difference. In 2022, 910 volunteers have donated their time helping to run and provide care in the clinic. Services that the clinic provides include physical exams, laboratory tests, immunizations, appointments for urgent medical conditions, pediatric care, family medicine, x-rays and imaging, counseling, physical therapy, women's services, and patient education such as health living classes.

Participants

The study was approved by the University of Utah's institutional review board (approval number 00072275). Eligible participants were patients of the clinic, who were 18 or older, and who spoke English or Spanish. A consent cover letter was approved by the IRB. The consent cover letter stated that “Your data will be kept confidential” and “By returning this questionnaire, you are giving your consent to participate.” Furthermore, the consent cover letter stated that “Participation in this study is voluntary. You can choose not to take part. You can choose not to finish the questionnaire or omit any question you prefer not to answer without penalty or loss of benefits.” Consent was obtained in English or Spanish.

Data Collection

Research assistants distributed and collected the surveys in the waiting room of the free clinic. Potential participants were given 2 options—a paper version or an online version of the survey to take. Participants who preferred the online version were handed a QR code to scan on their devices in order to access the online survey or were sent an online version via text. The online version of the survey had a consent cover letter at the beginning. The consent cover letter was the same for the paper and online versions. All survey materials were available in English or Spanish. The survey was administered from October 2023 to February 2024. After completing the survey, the participants who completed a paper survey in the waiting room received a toothbrush as an incentive for participating in the study.

Survey Instrument

The survey instrument was developed based on the literature review and input from staff of the free clinic. Dental anxiety was measured using the Modified Dental Anxiety Scale. ²¹ The scale consists of 5 items (eg, “If you went to your Dentist for treatment tomorrow, how would you feel?” Each item was scored as follows: 1 = not anxious, 2 = slightly anxious, 3 = fairly anxious, 4 = very anxious, and 5 = extremely anxious. The sum of the 5 items was a total score ranging from 5 to 25. Participants who reported a total score of 18 or above were considered to be experiencing dental phobia. Additionally, participants were asked about any negative experiences they had during their past 3 dental visits. Participants were asked to choose from 7 potential negative experiences (multiple answers could be selected). The 7 items were developed from Cleveland Clinic's information about dental anxiety and fear of dentists. ¹⁴ The 7 items included: fear of getting anesthetic shots, fear of potential bleeding, fear of not being able to breathe, negative feelings with dentists, pain/discomfort, noise by dental instruments, and smells of the dentist's office. Furthermore, participants were asked 2 questions about the utilization of dental services: “Did you receive preventive dental care (cleaning and/or routine exam) in the past 6 months,” and “Do you currently have a need for dental treatment?” An additional question was asked about oral health behavior which was “How often do you brush your teeth a day?” To gauge the participants’ use of the free clinic, it was also asked; if it was the patient's first time at the clinic at the time of the survey, if the patients see the same provider for each visit, and if the participants have been patients of the clinic for 2 or more years. The sociodemographic characteristics required include age, gender, educational attainment, marital status, and employment status. The survey question sample is presented in Appedix 1.^14,21

Data Analysis

All data was entered on the online survey software Qualtrics. The data was analyzed with statistical software IBM SPSS Statistics software version 28. Descriptive statistics were performed to summarize the frequency, percentage, mean, and standard deviation for the data.

Results

Table 1 provides a comprehensive overview of the background and sociodemographic characteristics of the free clinic participants involved in the study. Due to the limited representation of US-born participants, only foreign-born participants were used in the analysis. After excluding both incomplete and US-born participants surveys, there were a total of 293 participants (38 English speakers and 255 Spanish speakers) involved in the study. Among these participants, 63% of the participants identified as female. Furthermore, less than half of the participants did not have a college education or higher. Approximately 80% of the participants have visited the free clinic more than once, with 37% of the participants having been visiting the clinic for more than 2 years. Additionally, the sociodemographic data analysis revealed that over half of the participants are married and are not currently employed. The mean age of the participants was 46.29 years (SD = 14.104). Focusing on immigrant-free clinic patients, the average duration of residency in the United States among participants was 10.4 years (SD = 10.798).

Table 1.

Characteristics of Participants.

Sociodemographic statistics	Frequency (n)	Percentage (%)
Sex/gender
Male	108	36.9
Female	185	63.1
College education or higher
Yes	133	45.4
No	160	54.6
First time visiting Maliheh Free Clinic
Yes	58	19.8
No	235	80.2
Patients seeing the same provider
Yes	150	48.8
No	143	51.2
Patient at clinic for 2 years or more
Yes	109	37.2
No	184	62.8
Married
Yes	156	53.2
No	137	46.8
Employed
Yes	137	46.8
No	156	53.2
Language
English	38	13
Spanish	255	87
Age
Average Age	46.29
Average years living in the United States	10.43
Race/ethnicity
Asian Pacific	16	5.5
Black	8	2.7
Hispanic	253	86.3
White	6	2
Other	2	0.7

Table 2 shows the results on dental anxiety, the use of dental care services, and oral health behavior. Notably, 14% of individuals within the study experienced dental phobia, as the average participant reported either slight anxiety or some anxiety while visiting the dentist. Over a third of the participants expressed anxiety regarding receiving an anesthetic shot for dental procedures, while a smaller portion of participants reported fears of potential bleeding (12.6%) and difficulty breathing (15%). Only 5.1% reported negative feelings towards dentists. A more significant portion of participants, around 33%, expressed fear of pain or discomfort during dental treatment, which suggests a widespread concern. Other sources of dental anxiety identified among participants include the noise of dental instruments (20.5%) and anxiety from the smells within the dental office or during treatment (6.8%).

Table 2.

Dental Health Related Anxiety and Behaviors.

Dental results	Frequency (n)	Percentage (%)
Dental phobic
Yes	41	14
No	252	86
Fear of getting an anesthetic shot
Yes	101	34.5
No	192	65.5
Fear of potential bleeding
Yes	37	12.6
No	256	87.4
Fear of not being able to breathe
Yes	44	15
No	249	85
Negative feelings with your dentist
Yes	15	5.1
No	278	94.9
Fear of pain or discomfort
Yes	98	33.4
No	195	66.6
Anxiety from noise of dental instruments
Yes	60	20.5
No	233	79.5
Anxiety from smells of the dental office or smells during dental treatment
Yes	20	6.8
No	273	93.2
Received preventative dental care in the past 6 months
Yes	185	63.1
No	102	34.8
I Is currently in need of dental treatment
Yes	222	75.8
No	66	22.5
Frequency of brushing teeth
More than once per day	241	82.3
3-6 times per week	37	12.6
< 3 times per week	7	2.4

The majority of participants, around 63%, had received dental care in the last 6 months. However, despite this recent utilization of dental care, 75.8% of the participants indicated a concern for unmet dental care needs. Additionally, results indicate a positive trend in oral hygiene within the participants, with 82% of the participants reported brushing their teeth more than once a day.

Discussion

This study produces a comprehensive overview of dental health perceptions and experiences among immigrant free clinic patients, offering insights into certain areas that need attention. This includes unmet dental care needs in immigrant-free clinic patients and the moderate presence of dental phobia. The demographic of the free clinic study participants are mostly Spanish speakers, indicating the importance of linguistic diversity within the healthcare system. Providing culturally and linguistically appropriate services are needed to cater to the diverse needs of immigrant and underserved communities.

The prevalence of dental anxiety varies, estimating around 50% of adults experience some degree of dental anxiety in the United States. ¹ Contrasting with free clinic patients included in this study, only 14% experienced dental anxiety based on the results, indicating dental anxiety is only a moderate problem within this population. Other studies showed a different trend, that poor economic status created more dental anxiety within lower socioeconomic populations. ³ Among Hispanics/Latinos living in the United States, dental anxiety is associated with acculturation. ¹⁵ These results may be due to the limited dental anxiety factors addressed in this current study, as the study failed to examine the cost of dental services as an influence on dental anxiety. Dental anxiety may be higher within this population primarily due to the cost of dental services, as it may be more of a privilege rather than a guarantee for individuals of lower socioeconomic status. ³

The study observed a high percentage of participants expressing a current need for dental treatment despite good oral health practices (brushing more than once a day), which is consistent with previous findings. ¹² Among Hispanic adults in the United States, financial barriers are the most significant factor associated with the unmet need for dental treatment. ¹⁶ A previous study shows that Haitian immigrants experienced high unmet needs for dental care due to a lack of access to preventive care. ¹⁷ This similarity suggests that while immigrant patients may receive some dental care, there are still unmet dental needs, which can have long-term effects on oral health.

Most of the anxiety is linked to the administration of anesthetic shots and the anticipation of pain. The finding of this study aligns with existing studies regarding the anticipation of pain contributing to dental anxiety. ¹⁸ The expectation of pain correlates to higher levels of anxiety for patients seeking dental care, which then leads to dental avoidance. ¹¹ Anxiety factors such as fear of pain, discomfort, aesthetic shorts, and dental instrument noise indicate that patient-centered approaches may be needed to address individual anxieties and preferences. These approaches may include communication or sedative approaches to address anxiety barriers and improve the overall dental care experience. By prioritizing patient comfortability, healthcare providers can facilitate better adherence to preventive dental care.

Most free clinic patients currently require dental treatment, emphasizing disparities in access to dental care. Recent immigrants who are uninsured reported a low utilization of dental services. ¹⁹ Beyond cost and insurance, which is a well-researched barrier for dental care, other factors such as availability, transportation, and lack of awareness of preventative measures may contribute to this disparity. ⁸ Many individuals may not fully understand the significance of dental care for maintaining good oral health, seeking dental care when the pain becomes severe. ⁹ In addition, diet among Hispanic immigrants is related to their dental problems because a higher intake of sugar-containing foods is related to dental problems. ²⁰ Furthermore, social networks and self-efficacy are important to seek or not to seek dental services among Mexican immigrants. ⁷ Transportation challenges and alternative responsibilities, common among economically unstable individuals, hinder the prioritization of dental care.

This study enhances understanding about dental phobia and anxiety among free clinic patients, aiding healthcare providers in adjusting practices to enhance patient satisfaction and access, aimed at improving oral health outcomes. Addressing barriers to healthcare services is important, as the correlation between lower education and disparities in oral health has been seen in underserved populations. This research sheds light on the challenges, like dental anxiety, that underserved and uninsured immigrant communities may face in accessing dental care.

Future research should prioritize several key areas to advance our knowledge and address the barriers posed by dental anxiety among immigrant-free clinic patients. First, a more comprehensive investigation into the triggers of dental anxiety, beyond the factors that were evaluated in this study (pain, discomfort, aesthetic shorts, and dental instrument noise) is needed. As Table 3 shows, the prevalence of anxiety among different populations is not necessarily consistent. It is very important to have a specific focus to measure anxiety. Exploring other factors such as acculturation, social network, diet, self-efficacy, past trauma cultural beliefs, or fear of specific actions/procedures that may contribute to unmet need and dental anxiety should be evaluated to understand why a high amount of this population needs dental care. Additionally, the exploration of the effectiveness of various interventions for reducing dental anxiety among immigrant-free clinic patients should be evaluated. For example, the evaluation of the effectiveness of dental anxiety management techniques, such as relaxation exercises or therapy, or even the impact of patient education programs targeted at improving dental care knowledge.

Table 3.

Anxiety Levels of Different Populations.

First author	Year published	Population	Results
Kamimura	2018	Uninsured mental health-free clinic patients (adults)	Prevalence of anxiety 23.6%
Notaro	2013	Homeless clients utilizing a free clinic (adults)	Prevalence of anxiety 13.8%
Szaflarski	2017	An adult sample from the National Epidemiological Survey on Alcohol and Related Conditions	Prevalence of anxiety disorders US-born 13.1% Foreign-born 8.6% Puerto Ricans 15.8% Asian/ Pacific Islanders 9.5%
National Alliance on Mental Illness	2017	US general public	Prevalence of anxiety disorders (adult) 19.1%

Kamimura, A., Gardner, N., Ahmed, F. et al. Health status and social characteristics among the uninsured using a mental health free clinic. J Behav Health Serv Res 45, 112-123 (2018). https://doi.org/10.1007/s11414-016-9533-8

Notaro, S.J., Khan, M., Kim, C. et al. Analysis of the health status of the homeless clients utilizing a free clinic. J Community Health 38, 172-177 (2013). https://doi.org/10.1007/s10900-012-9598-0

Szaflarski, M., Cubbins, L.A., and Meganathan, K. 2017. Anxiety disorders among US immigrants: the role of immigrant background and social-psychological factors. Issues in Mental Health Nursing, 38, 317-326.

National Alliance on Mental Health: (2017). Anxiety disorders. Available at: https://www.nami.org/about-mental-illness/mental-health-conditions/anxiety-disorders/ (Accessed 8 October 2024).

Although this study provides valuable insight into the experiences and perceptions that immigrant patients face, there are limitations. The percentage of the participants who reported dental anxiety was low. While there is a possibility that the population experiences a higher prevalence of dental anxiety, this study might not have captured it because of the timing of the survey (before or after an appointment) or participants in a waiting room (patients experiencing phobia may not come back). The study was conducted at a single free clinic in the Western United States, limiting the generalizability to free clinics across the nation. Though patients at this clinic come from various countries, the study focused only on English and Spanish speakers. The cross-section design limits establishing causality or assessing dental anxiety changes over time. Additional limitations include the study relying on self-reported data, which may be subjected to bias or influence the accuracy of the data.

Conclusions

This study has provided insight into the dental health perceptions and experiences immigrant-free clinic patients face. Most free clinic patients experience such anxiety in anticipation of pain as the primary cause, such as the administration of anesthetic shots. Although dental anxiety among the underserved population is not severe, it is important to note that a high percentage of free clinic patients are in need of dental care. Highlighting issues regarding obstacles to healthcare services is crucial, given the observed link between lower education and inequalities in oral health within underserved populations. Additionally, it is important to consider the possibility that dental anxiety may be influencing these numbers. Furthermore, this study suggests the importance of exploring the underlying factors contributing to dental anxiety. By understanding dental anxiety and phobias, healthcare providers may provide tailored interventions to better support uninsured and underserved populations and prevent dental avoidance to improve oral health outcomes. Since this study had only immigrant participants, future research should have both immigrant and US citizen participants to address comparative results in terms of dental anxiety, financial hardship, and insurability. Finally, it is important to emphasize the importance of access to preventive dental care services for all, including insured and uninsured individuals because dental insurance is very restrictive or limited.

Appendix

Appendix 1.

Survey Question Sample.

1. Can you tell us how anxious you get, if at all, with your dental visit? Scale: Not Anxious, Slightly Anxious, Fairly Anxious, Very Anxious, Extremely Anxious If you went to your Dentist for TREATMENT TOMORROW, how would you feel? If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel? If you were about to have a TOOTH DRILLED, how would you feel? If you were about to have your TEETH SCALED AND POLISHED, how would you feel? If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel? 2. Did you have the following negative experience at a dental office in the past three dental visits? Please check all that apply. fear of getting an anesthetic shot (numbing shot) (1) fear of (potential) bleeding (2) fear of not being breath (3) Negative feelings with your dentist (4) Pain/ discomfort (5) Noise by dental instruments used by the dentist or dental hygienist (6) Smells of the dentist’s office or smells during dental treatment 3. Did you receive preventive dental care (cleaning and/or routine exam) in the past 6 months? 1) Yes 2) No 4. Do you currently have a need for dental treatment 1) Yes 2) No 5. How often do you brush your teeth a day? More than once (1) 3 to 6 times a week (2) Less than 3 times a week (3)