Abstract
Objectives:
Dental fear and anxiety are known determinants of delaying or avoiding dental care and vary considerably based on factors such as age and gender. However, little is known about dental fear and anxiety in racial/ethnic minority populations, which bear a disproportionate burden of poor oral health outcomes. Structural and social pathways responsible for producing these disparities are also understudied. Experiences of racism over the lifecourse may contribute to poor oral health outcomes through a pathway of dental fear and anxiety. This paper aimed to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services, in the Black Women’s Health Study (BWHS), a United States-based prospective cohort.
Methods:
Analysis of prospective data obtained from a geographic subset of participants in the BWHS was conducted. In 2014, BWHS participants residing in Massachusetts responded to a mailed oral health questionnaire that included the Index of Dental Anxiety and Fear (IDAF-4C+) instrument (N = 484; 69% response rate). Previously collected demographic and health information, along with reported experiences of everyday and lifetime racism, obtained from national BWHS questionnaires between 1995 and 2009, were merged with the Massachusetts-based sub-sample. Associations between high dental anxiety (HDA) (mean IDAF-4C+ score ≥2.5 on the dental fear and anxiety module) and oral health outcomes and perceived racism and HDA were explored via prevalence ratios (PR) calculated using log-binomial regression models, including adjustment for potential confounders.
Results
Reported exposures to everyday racism occurred weekly on average for the top 25% of the sample, while 13% of participants reported exposure to multiple (n = 3) experiences of unfair treatment due to their race over their lifetime. HDA was prevalent among 17.8% of the sample and was significantly associated with indicators of poor oral health status. High exposures to everyday and lifetime experiences of racism were positively associated with HDA (PR = 1.08; 95% CI: 0.90, 1.58 and PR = 1.72; 95% CI: 1.03, 2.88, respectively)
Conclusions:
Significant associations between racism and HDA, and between HDA and poor oral health and reduced utilization of dental care were observed. Dental anxiety may be a pathway through which perceived experiences with racism may impact oral health outcomes.
Keywords: dental anxiety, dental fears, healthcare utilization, minority health, oral health, racial discrimination, racism
1 |. INTRODUCTION
Unmet dental health care needs can lead to adverse oral and overall health outcomes and are disproportionately more prevalent among adult members of racial/ethnic minority groups in the United States (US).1 Studying potential barriers to dental services utilization by members of racial/ethnic minority groups may elucidate modifiable pathways that shape social disparities in population oral health. Existing research into the barriers associated with dental care utilization in the US has primarily focused on the role of socioeconomic factors, including lower income, racial and ethnic minority status, and lack of dental insurance.2–5 The role of psychopathologies, such as dental fear and anxiety, in delaying or preventing use of dental services is reported on to a lesser extent.
Prevalence estimates of dental fear and anxiety vary across populations worldwide, but they are generally estimated to affect 10%–20% of people and are more common among women compared with men.6–8 Dental fear and anxiety have also been found to be prevalent among younger adults relative to older adults, those less educated, and who are single or not cohabitating.9 Dental fear and anxiety are expected to be more prevalent among racial/ethnic minority populations in the US because of their strong associations with dental service utilization, in which there are documented disparities along racial and ethnic lines.5 Research on the topic is limited, however, likely due to a lack of available data. Dental fear and anxiety are key factors in the oft-described ‘vicious cycle of dental fear,’ in which fear-based avoidance of dental care reinforces and/or exacerbates the associated fear and anxiety by necessitating more extensive intervention.10,11 If sociodemographic characteristics are salient to the development of dental fear and anxiety, then this cycle may represent an important generative mechanism underlying the observed social disparities in population oral health. Thus, understanding predictors of dental fear and anxiety, particularly in populations experiencing a higher burden of oral disease, may reveal modifiable targets for interventions aimed at addressing oral health disparities.
There are well-documented disparities in oral health between racial groups in the US.12 The factors underlying these disparities are complex and multi-level, including societal features.13 Entrenched racism may play a role in the development and persistence of health disparities, but research into the potential mechanisms is sparse.14 Studies have reported that experiences of racism are associated with worse oral health outcomes, dental fear and deferred dental care in Indigenous women in Canada,15 an increased prevalence of toothache and reduced oral health quality of life among Aboriginal Australian women,16,17 and an increased prevalence of self-reported oral health problems in immigrants in Canada,18 though some studies report no association between discrimination and oral health outcomes.19–22 Experiences of racism have been associated with lower levels of trust and satisfaction with medical care, as well as delaying medical care.23 Racial bias and discrimination may additionally influence dentists’ treatment recommendations,24,25 pain management strategies26 and patient experiences with dentists and dental office staff.13 Additionally, existing research has evaluated the potential role of dental fear and anxieties in disparities along other sociocultural factors, showing a positive association between lower socioeconomic status and higher dental anxiety.27 Taken together, this research underscores the potential for interplay between experiences of racism, dental fear and anxiety, and oral health outcomes for members of racial/ethnic minority groups.
The aim of this paper was to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services in a population of Black women in the US under the working hypothesis that perceived racism may be linked to oral health outcomes via dental fear and anxiety. Detailed oral health information was obtained via questionnaires administered to a subsample of the Black Women’s Health Study (BWHS) who resided in the state of Massachusetts. This paper investigates the association of experiences with racism with high levels of dental anxiety.
2 |. METHODS
2.1 |. Black Women’s Health Study
The BWHS is an ongoing, prospective follow-up study of 59 000 women throughout the US who self-identify as Black. The study began in 1995 and recruited women by mailing questionnaires to subscribers of Essence magazine, members of Black professional organizations, and friends or relatives of early respondents. Respondents were aged 21–69 years (median 38 years) at study enrolment. Women are followed at 2-year intervals using mailed questionnaires.28 Follow-up on the baseline cohort has captured >80% of potential person-years. The study protocol was approved by the Institutional Review Board of Boston University Medical Campus. Participants indicate consent by completing and returning the questionnaires.
In 2014, oral health questionnaires were mailed to all active BWHS participants currently residing in Massachusetts (N = 699), the vast majority of whom resided in the Boston Metropolitan Area. The oral health questionnaire contained 23 items evaluating: (1) domains of dental care needs; (2) dental care utilization and insurance; (3) periodontal and gingival health; (4) oral health practices; (5) presence of fixed and removable replacements (e.g., dentures); (6) dental fear and anxiety; and (7) oral health-related quality of life. The response rate for the oral health questionnaire was 69% (N = 484). In 2015, questionnaire items related to oral health status were clinically validated among a subset of respondents.29 Data for this analysis were collected prospectively at different time points in the BWHS follow-up: age and US born were both assessed at or near the baseline (1995–1997), education level and household income were assessed in 2003, marital status in 2005, perceived experiences of racism, smoking status, diabetes, hypertension, body mass index (BMI) and parity in 2009, and oral health measures in 2014. Thus, the studied exposure (e.g., perceived experiences of racism) and covariates of interest were obtained at least 5 years prior to the assessment of the outcome of interest (e.g., high dental anxiety).
2.2 |. Measures
Perceived experiences of racism were assessed using an adaptation of an instrument developed by Williams et al.30 Perceived experiences of racism in daily life (everyday racism) were assessed by asking participants how frequently they had the following five experiences: (1) ‘you receive poorer service than other people in restaurants or stores’, (2) ‘people act as if they think you are not intelligent’, (3) ‘people act as if they are afraid of you’, (4) ‘people act as if they think you are dishonest’, and (5) ‘people act as if they are better than you’ because of their race. Response options were on a five-point scale and ranged from ‘never’, ‘a few times a year’, ‘once a month’, ‘once a week’, and ‘almost every day’, with 1 indicating ‘never’ and 5 indicating ‘almost every day’. An everyday racism score was calculated by taking the average response across the five questions (final score ranged from 0 to 5). The distribution of the everyday racism score in the sample was then divided into quartiles of the range. An additional three questions asked whether participants had ever in their life been ‘treated unfairly due to…race’ on the job, in housing, and by the police. Respondents could answer ‘yes’ or ‘no’ to each question. Responses were summed to create a summary score for lifetime racism, which ranged from 0 (no to all) to 3 (yes to all). There was minimal missing data for daily racism (N = 10, 2%) and lifetime racism (N = 14, 3%).
The oral health questionnaire administered in 2014 used the Index of Dental Anxiety and Fear (IDAF-4C+) to evaluate dental fear and anxiety. This index contains three modules covering dental fear and anxiety, dental phobia, and specific stimuli eliciting dental phobia.31 The fear and anxiety module contains eight questions related to dental fear. Participants respond on a Likert scale with responses ranging from ‘Disagree’ to ‘Strongly agree’, with ‘Disagree’ being scored as a 1 and ‘Strongly agree’ being scored as a 5.31 A mean score of ≥2.5 on the fear and anxiety module was considered ‘High dental anxiety’.32,33 For the module concerning specific fear-inducing stimuli, participants responded to 10 questions asking to what extent they are anxious about each specific stimuli on a 5-point scale ranging from ‘Not at all’ to ‘Very much’. These responses were evaluated individually via the percentage of respondents endorsing each response category for each specific stimuli.31 Two participants (<1%) were missing data on the IDAF-4C+.
Several self-reported measures of oral health were assessed and evaluated in relation to dental anxiety. Self-rated oral health was assessed using the question ‘Overall, how would you rate the health of your teeth and gums?’ with five categories of response options ranging from ‘Excellent’ to ‘Poor’. Responses were dichotomized for analyses to reflect ‘Excellent/Very good/Good’ vs. ‘Fair/Poor’. Dental visit attendance was assessed using the question ‘How long has it been since you last visited a dentist or a dental clinic for any reason?’ Response options were categorical and analyses compared use of dental services ‘Within the past year’ versus ‘Not within the past year’. Previously validated surveys and scales were used to assess periodontal health and oral health-related quality of life.34–36 Questions based on a set of validated items from the Centers for Disease Control and Prevention in collaboration with the American Academy of Periodontology were used to assess periodontal health and a history of periodontitis diagnosis or treatment.37
Demographic and health status variables included participant age (40–49 years, 50–59 years, ≥60 years), education (≤high school, some college, ≥college), annual household income (≤$50 000, >$50 000), marital status (married/cohabitating, single), US born (yes/no), parity (nulliparous, 1 birth, 2 births, 3+ births), body mass index (BMI, kg/m2), diabetic diagnosis (yes/no), hypertension diagnosis (yes/no) and cigarette smoking status (non-smoker, current smoker). Participants were also asked if they had seen a doctor in the past year. Most covariates had no missing values. Those missing values included parity (N = 3, <1%), US born (N = 4, <1%), smoking (N = 14, 3%), BMI (N = 16, 3%), income (N = 40, 8%) and marital status (N = 83, 17%). Participants missing data on a given variable were excluded from analyses that incorporated that variable but retained for all other analyses.
2.3 |. Statistical analyses
2.3.1 |. Demographic characteristics, high dental anxiety and exposure to racism
Sample characteristics were reported according to high dental anxiety status (defined as a mean score of ≥2.5 on the fears and anxiety module of the IDAF-4C+) and by both racism variables (e.g. everyday and lifetime). To assess patterns between participant characteristics and the exposure (e.g. racism) and outcome (e.g. high dental anxiety) of interest, log-binomial regression models were used to calculate prevalence ratios (PR) and 95% confidence intervals (95% CI) which compare the prevalence of characteristics between categories of the exposures and outcome. Unadjusted PRs were calculated separately for the association between participant characteristics and 4th versus 1st quartile of everyday racism score, ‘Yes to all’ versus ‘No to all’ for lifetime racism score, and high versus low dental anxiety.
2.3.2 |. High dental anxiety and oral health outcomes
Oral health outcomes were also reported according to high dental anxiety status. To evaluate the association between high dental anxiety and oral health measures, unadjusted PRs were calculated using high versus low dental anxiety as the predictor variable and dental and oral health variables as the outcome. For oral health outcomes that were continuous (tooth count and both versions of the oral health-related quality of life score), a linear regression was calculated. As a negative control, prevalence ratios were calculated for the association between high dental anxiety and visiting a doctor in the past year.
2.3.3 |. Exposure to racism and high dental anxiety
Crude prevalence ratios and 95% CIs were calculated to estimate the association between everyday racism and lifetime racism and high dental anxiety. Adjusted prevalence ratios and 95% CIs were calculated to estimate the association between racism and high dental anxiety using log-binomial regression models. A directed acyclic graph (DAG)38 was created to depict the underlying temporal nature of the hypothesized associations, based on existing literature and the theoretical framework of the analysis, as well as to specify the potential for confounding relationships between covariates and the association under study (see Figure 1). Potential confounders were identified as those known to be associated with both exposure to racism and poor oral health outcomes, owing to the paucity of known associations with high dental anxiety via other pathways. Additionally, poor oral health outcomes are believed to influence dental anxiety via a cycle in which poor oral health can necessitate symptom-driven treatment and intervention thereby exacerbating dental anxiety and future avoidance of care.10 To preserve sample size, and because the nature of confounding in this association remains incompletely characterized, the magnitude of change in the age-adjusted estimate was assessed after the individual introduction of each potential confounder. Smoking was also evaluated as a strong predictor of the outcome, though temporally it may be downstream of exposure to racism. This was done iteratively until no additional covariate resulted in a more than 5% change in the magnitude of the estimate. This analysis was designed to identify true confounders among those pre-specified by the DAG. The final variables included in the fully adjusted models were age (continuous), BMI, and marital status for both racism exposures. Both continuous and categorical versions of the racism exposure were assessed in relation to high dental anxiety.
FIGURE 1.
Directed acyclic graph depicting potential confounders of the association between racism and high dental anxiety. Figure depicts the hypothesized relationships believed to underlie the observed data. The relationship between oral health (OH), racism (R) and high dental anxiety (HDA) is believed to be cyclical over time. ‘t0’ represents an initial time point, ‘t1’ a subsequent time point, and so on. Grey shading enclose time points within these cyclical relationships at which the data used in this analysis may have been collected for OH, R, HDA and confounders (C). The vector C depicted at t0 represents potential confounding factors: age, education, annual household income, marital status, US born, parity, body mass index, diabetic diagnosis and hypertension diagnosis, all of which has prior observed associations with R and OH. Statistical control is depicted by boxing Ct0, preventing a ‘backdoor’ path from R to HDA.
2.3.4|. Dental fear-inducing stimuli
To evaluate the distributions of dental fear-inducing stimuli, response frequencies for each category of the five-point Likert scale ranging from ‘not at all’ to ‘very much’ in response to the question, ‘To what extent are you anxious about the following things when you go to the dentist?’ were generated both for the sample as a whole and then stratified by dental anxiety status.
3 |. RESULTS
The study population was on average 60 years of age, the majority of whom were college-educated and born in the US. The sample was actively engaged in healthcare, with 92% reporting having visited a doctor in the past year and 82% reporting having visited a dentist for any reason in the past year. Eighty percent of respondents reported having good, very good, or excellent oral health. The mean everyday racism score for the sample was 1.7 (standard deviation 0.9), with a minimum value of one, a maximum value of five, and a median of 1.3. Twenty-seven percent of participants scored 0 (no to all) on the lifetime racism scale, while 33% scored 1, 23% scored 2, and 13% scored 3 (yes to all). High dental anxiety was found among 17.8% of the study population.
Characteristics for the sample according to the exposures (e.g. everyday and lifetime racism) and outcome (e.g. high dental anxiety) of interest are presented in Tables 1 and 2, respectively. Compared with those women who were 60 years of age or older, younger women were more likely to be in the highest quartile of everyday racism, while they were less likely to respond ‘yes’ to all three lifetime racism questions. Lower education levels and less annual income were associated with lower prevalence estimates of both racism exposures. Health status indicators, such as high BMI, diabetes and hypertension, were associated with an increased prevalence of high exposure to lifetime racism but were associated to a lesser extent or not at all with everyday racism. With respect to the outcome of interest, those women who were single, less educated, and who had lower incomes were more likely to have high dental anxiety. Health status indicators, such as high BMI, hypertension and cigarette smoking, were also positively associated with high dental anxiety. As expected, there was no association between having visited a doctor in the past year and high dental anxiety (PR = 0.94, 95% CI: 0.47, 1.88).
TABLE 1.
Demographic and health status characteristics for a sample of participants (N = 484) in the Black Women’s Health Study residing in Massachusetts according to perceived experiences with racism
| Population characteristics | Everyday racism (quartiles)a |
Lifetime racism |
||||
|---|---|---|---|---|---|---|
| 4th Qrt (High; N = 104) | 1st Qrt (Low; N = 116) | Crude PR (95% CI) | Yes to all (N = 62) | No to all (N = 133) | Crude PR (95% CI) | |
| N (%) | N (%) | N (%) | N (%) | |||
| Age in years | ||||||
| 40–49 | 25 (24.0) | 17 (14.7) | 1.49 (1.06, 2.10) | 8 (12.9) | 32 (24.1) | 0.51 (0.26, 1.01) |
| 50–59 | 37 (35.6) | 36 (31.0) | 1.27 (0.91, 1.76) | 21 (33.9) | 49 (36.8) | 0.77 (0.49, 1.21) |
| 60+ | 42 (40.4) | 63 (54.3) | Ref | 33 (53.2) | 52 (39.1) | Ref |
| Education | ||||||
| High school or less | 9 (8.7) | 19 (16.4) | 0.62 (0.35, 1.09) | 2 (3.2) | 23 (17.3) | 0.22 (0.06, 0.84) |
| Some college | 25 (24.0) | 32 (27.6) | 0.85 (0.60, 1.18) | 15 (24.2) | 33 (24.8) | 0.85 (0.52, 1.37) |
| College or beyond | 70 (67.3) | 65 (56.0) | Ref | 45 (72.6) | 77 (57.9) | Ref |
| Annual household incomeb | ||||||
| ≤50000 | 41 (41.4) | 46 (43.8) | 0.90 (0.51, 1.61) | 18 (31.6) | 49 (39.8) | 0.61 (0.24, 1.55) |
| >50000 | 58 (58.6) | 59 (56.2) | Ref | 39 (68.4) | 74 (60.2) | Ref |
| Marital status | ||||||
| Married/cohabitating | 33 (38.8) | 45 (43.7) | Ref | 23 (41.8) | 53 (48.2) | Ref |
| Single | 52 (61.2) | 58 (56.3) | 1.12 (0.81, 1.55) | 32 (58.2) | 57 (51.8) | 1.19 (0.77, 1.84) |
| Born in the United States | ||||||
| Yes | 93 (90.3) | 103 (90.4) | 1.00 (0.62, 1.60) | 58 (93.6) | 114 (68.4) | 1.85 (0.75, 4.61) |
| No | 10 (9.7) | 11 (10.0) | Ref | 4 (6.4) | 18 (13.6) | Ref |
| Parity | ||||||
| Nulliparous | 25 (24.3) | 31 (26.7) | Ref | 15 (24.2) | 35 (26.3) | Ref |
| 1 birth | 31 (30.1) | 35 (30.2) | 1.05 (0.71, 1.55) | 17 (27.4) | 45 (33.8) | 0.91 (0.51, 1.64) |
| 2 births | 25 (24.3) | 25 (21.6) | 1.12 (0.75, 1.67) | 16 (25.8) | 28 (21.1) | 1.21 (0.68, 2.16) |
| 3+ births | 22 (21.4) | 25 (21.6) | 1.05 (0.69, 1.60) | 14 (22.6) | 25 (18.8) | 1.20 (0.66, 2.17) |
| Body Mass Index (kg/m2) | ||||||
| <25 | 20 (19.6) | 30 (27.0) | 1.04 (0.65, 1.66) | 8 (13.1) | 40 (30.8) | 0.52 (0.25, 1.07) |
| ≥25–<30 | 23 (22.6) | 37 (33.3) | Ref | 20 (32.8) | 42 (32.3) | Ref |
| ≥30 | 59 (57.8) | 44 (39.6) | 1.49 (1.04, 2.15) | 33 (54.1) | 48 (36.9) | 1.26 (0.81, 1.97) |
| Diabetes | ||||||
| Yes | 17 (16.4) | 19 (16.4) | 1.00 (0.68, 1.46) | 14 (22.6) | 20 (15.0) | 1.38 (0.87, 2.20) |
| No | 87 (83.6) | 97 (83.6) | Ref | 48 (77.4) | 113 (85.0) | Ref |
| Hypertension | ||||||
| Yes | 59 (56.7) | 59 (50.9) | 1.13 (0.85, 1.50) | 32 (51.6) | 56 (42.1) | 1.30 (0.86, 1.96) |
| No | 45 (43.3) | 57 (49.1) | Ref | 30 (48.4) | 77 (58.9) | Ref |
| Cigarette smoking | ||||||
| Non-smoker | 91 (91.0) | 101 (90.2) | 0.95 (0.57, 1.58) | 59 (96.7) | 121 (93.1) | 0.55 (0.16, 1.98) |
| Current smoker | 9 (9) | 11 (9.8) | Ref | 2 (3.3) | 9 (6.9) | Ref |
Abbreviations: CI, confidence interval; PR, prevalence ratio; Qrt, quartile.
The 4th quartile represents the highest exposure to everyday racism, and the 1st quartile the lowest.
Annual household income measured in USD/year in 2003.
TABLE 2.
Demographic and health status characteristics for a sample of participants (N = 484) in the Black Women’s Health Study residing in Massachusetts according to level of dental anxiety
| Population characteristics | Dental Anxiety |
||
|---|---|---|---|
| High (N = 86) | Low (N = 396) | Crude PR (95% CI) | |
| N (%) | N (%) | ||
| Age in years | |||
| 40–49 | 11 (12.8) | 75 (18.9) | 0.78 (0.42, 1.47) |
| 50–59 | 38 (44.2) | 131 (33.1) | 1.38 (0.92, 2.07) |
| 60+ | 37 (43.0) | 190 (48.0) | Ref |
| Education | |||
| High school or less | 11 (12.8) | 45 (11.4) | 1.19 (0.66, 2.14) |
| Some college | 24 (27.9) | 93 (23.5) | 1.24 (0.80, 1.92) |
| College or beyond | 51 (59.3) | 258 (65.1) | Ref |
| Annual household incomea | |||
| ≤50000 | 36 (45.6) | 140 (38.6) | 1.60 (0.72, 3.56) |
| >50000 | 43 (54.4) | 223 (61.4) | Ref |
| Marital status | |||
| Married/cohabitating | 24 (33.3) | 149 (45.6) | Ref |
| Single | 48 (66.7) | 178 (54.4) | 1.53 (0.98 2.40) |
| Born in the United States | |||
| Yes | 77 (90.6) | 349 (88.8) | 1.17 (0.60, 2.29) |
| No | 8 (9.4) | 44 (11.2) | Ref |
| Parity | |||
| Nulliparous | 21 (24.7) | 112 (28.4) | Ref |
| 1 birth | 25 (29.4) | 107 (27.2) | 1.20 (0.71, 2.03) |
| 2 births | 17 (20.0) | 96 (24.4) | 0.95 (0.53, 1.72) |
| 3+ births | 22 (25.9) | 79 (20.1) | 1.38 (0.80, 2.37) |
| Body Mass Index (kg/m2) | |||
| <25 | 13 (15.7) | 89 (23.2) | 0.93 (0.49, 1.77) |
| ≥25–<30 | 21 (25.3) | 132 (34.5) | Ref |
| ≥30 | 49 (59.0) | 162 (42.3) | 1.69 (1.06, 2.70) |
| Diabetes | |||
| Yes | 14 (16.3) | 75 (18.9) | 0.86 (0.51, 1.45) |
| No | 72 (83.7) | 321 (81.1) | Ref |
| Hypertension | |||
| Yes | 50 (58.1) | 199 (50.3) | 1.30 (0.88, 1.92) |
| No | 36 (41.9) | 197 (49.8) | Ref |
| Cigarette smoking | |||
| Non-smoker | 75 (89.3) | 355 (92.2) | 1.32 (0.72, 2.43) |
| Current smoker | 9 (10.7) | 30 (7.8) | Ref |
Abbreviations: CI, confidence interval; PR, prevalence ratio; Qrt, quartile.
Annual household income measured in USD/year in 2003.
Table 3 displays the associations between high dental anxiety and indicators of oral health status and dental services utilization. The average score on the IDAF-4C+ was 2.7 (SE = 0.0) for the sample, 4.4 (SE = 0.1) among those with high dental anxiety and 2.3 (SE = 0.0) among those with low dental anxiety. Self-reported tooth count was lower for those with high dental anxiety compared with low and the measured oral health-related quality of life scores indicated substantially worse oral health-related quality of life for those with high dental anxiety. Additionally, those with high dental anxiety were less likely to report excellent, very good, or good oral health (PR = 0.67, 95% CI: 0.55, 0.81) or a visit to the dentist in the past year (PR = 0.64, 95% CI: 0.53, 0.78). Relatedly, high dental anxiety was associated with a more than twofold increase in reports of current dental treatment needs (PR = 2.34, 95% CI: 1.89, 2.89) and the inability to afford needed care (PR = 2.63, 95% CI: 1.80, 3.86). In general, those with high dental anxiety were more likely to respond affirmatively to measures assessing the potential presence of periodontal disease, a chronic inflammatory condition of the gums.
TABLE 3.
Indicators of dental health status and dental care utilization according to level of dental anxiety in a sample (N = 484) of Black Women’s Health Study participants residing in Massachusetts
| Self-reported dental variables | Total population | Dental Anxiety |
||
|---|---|---|---|---|
| High (N = 86) | Low (N = 396) | Crude linear regression estimate (95% CI) | ||
| Dental anxiety & fears (IDAF-4C) (mean, SE) | 2.7 (0.0) | 4.4 (0.1) | 2.3 (0.0) | - |
| Tooth Count (mean, SE) | 23.4 (0.4) | 20.5 (1.0) | 24.0 (0.4) | −3.49 (−5.57, −1.52) |
| Oral Health-related quality of life, 6 item (mean, SE) | 14.4 (0.7) | 25.0 (2.1) | 12.0 (0.7) | 12.02 (9.40, 16.63) |
| Oral Health-related quality of life, 12 item (mean, SE) | 15.2 (0.7) | 25.9 (1.8) | 12.8 (0.7) | 13.13 (9.75, 16.50) |
| Self-rated Oral Health (N (%)) | Crude PR (95% CI) | |||
| Excellent/very good/good | 387 (80.1) | 49 (57.0) | 337 (85.3) | 0.67 (0.55, 0.81) |
| Fair/poor | 96 (19.9) | 37 (43.0) | 58 (14.7) | Ref |
| Partial or full dental insurance (N (%)) | ||||
| Yes | 392 (83.4) | 68 (79.1) | 324 (83.5) | 0.99 (089, 1.11) |
| No | 78 (16.6) | 14 (17.1) | 64 (16.5) | Ref |
| Last dental visit for any reason <12 months (N (%)) | ||||
| Yes | 393 (81.5) | 48 (55.8) | 343 (87.1) | 0.64 (0.53, 0.78) |
| No | 89 (18.5) | 38 (44.2) | 51 (12.9) | Ref |
| Currently in need of dental treatment (N (%)) | ||||
| Yes | 170 (36.3) | 58 (68.2) | 112 (29.2) | 2.34 (1.89, 2.89) |
| No | 299 (63.8) | 27 (31.8) | 272 (70.8) | Ref |
| Unable to afford needed care (N (%)) | ||||
| Yes | 82 (17.3) | 30 (35.3) | 52 (13.4) | 2.63 (1.80, 3.86) |
| No | 391 (82.7) | 55 (64.7) | 336 (86.6) | Ref |
| Self-reported periodontal health | ||||
| Do you think you might have gum disease? (N (%)) | ||||
| Yes | 361 (74.7) | 20 (23.5) | 65 (16.4) | 1.57 (1.02, 2.42) |
| No | 86 (17.8) | 53 (62.4) | 307 (77.5) | Ref |
| Don’t know | 36 (7.5) | |||
| Has a dentist/dental hygienist ever told you that you had gum disease? (N (%)) | ||||
| Yes | 304 (63.5) | 33 (39.8) | 130 (33.0) | 1.24 (0.93, 1.67) |
| No | 164 (34.2) | 46 (55.4) | 257 (65.2) | Ref |
| Don’t know | 11 (2.3) | |||
| Have you ever had treatment for gum disease? (N (%)) | ||||
| Yes | 252 (52.2) | 41 (48.2) | 178 (45.0) | 1.08 (0.84, 1.37) |
| No | 221 (45.8) | 42 (49.4) | 210 (53.0) | Ref |
| Don’t know | 10 (2.1) | |||
| Have you ever had any teeth become loose on their own, without injury? (N (%)) | ||||
| Yes | 415 (86.1) | 13 (15.1) | 49 (12.4) | 1.26 (0.71, 2.21) |
| No | 63 (13.1) | 70 (81.4) | 344 (87.3) | Ref |
| Don’t know | 4 (1.0) | |||
| Have you ever been told by a dental professional that you’d lost bone around your teeth? (N (%)) | ||||
| Yes | 135 (28.1) | 29 (33.7) | 106 (27.0) | 1.28 (0.92, 1.79) |
| No | 327 (68.0) | 52 (60.5) | 273 (69.5) | Ref |
| Don’t know | 19 (4.0) | |||
| Have you had a tooth that just does not look right in the past 3 months? (N (%)) | ||||
| Yes | 57 (12.0) | 19 (22.9) | 37 (9.5) | 2.44 (1.48, 4.01) |
| No | 416 (87.4) | 63 (75.9) | 352 (90.0) | Ref |
| Don’t know | 3 (0.6) | |||
Abbreviations: CI, confidence interval; IDAF-4C+, Index of Dental Anxiety and Fear (Armfield 2010); PR, prevalence ratio; SE, standard error.
Dental anxieties in this sample were focused on cost, use of injections or needles, and painful or uncomfortable procedures (the frequency of ‘very much’ anxiety in response to these stimuli was 20%, 16% and 14%, respectively; see Figure S1). However, relative to those with low dental anxiety, those with high dental anxiety were more likely to report ‘very much’ anxiety in response to the measured stimuli (Figure S2). The specific stimuli with the largest differences in the frequency of ‘very much’ anxiety between those with high anxiety compared with low dental anxiety were a perceived lack of control over what was happening (23.8% vs. 1%), painful or uncomfortable procedures (59% vs. 3.8%), and having an unsympathetic or unkind dentist (32.6% vs. 4.6%). Relative frequencies for ‘very much’ anxiety over the cost of dental treatment (40% vs. 15.3%) and needles or injections (42% vs. 10%) were lower by comparison.
The crude and adjusted associations between everyday and lifetime racism on high dental anxiety are presented in Table 4. A one unit increase in the everyday racism score in the fully adjusted model was associated with a nearly 20% increase in the prevalence of high dental anxiety (PR = 1.19; 95% CI: 0.90, 1.58). When scores were categorized into quartiles of the score distribution, a dose–response relationship with the prevalence of high dental anxiety was observed in crude and age-adjusted models. In fully adjusted models, the 4th and 3rd quartiles were associated with an 8% and 20% increase in the prevalence of high dental anxiety, respectively, when compared to the 1st quartile (e.g. the lowest exposure to everyday racism). However, these estimates have low precision due to the low prevalence of the outcome and the covariate distributions in these exposure categories. Lifetime racism was associated with a 17% increase in the prevalence of high dental anxiety for each additional affirmative response in the fully adjusted model (PR = 1.17; 95% CI: 0.94, 1.45). Women who responded ‘yes’ to all three questions related to lifetime racism were 72% more likely to have high dental anxiety (PR = 1.72; 95% CI: 1.03, 2.88) in the fully adjusted model. However, a similar direction and magnitude of effect was not observed for women reporting yes to fewer events relative to none (see Table 3).
TABLE 4.
Prevalence Ratios (PR) for the association between everyday racism, lifetime racism and high dental anxiety among a sample (N = 484) of participants in the Black Women’s Health Study residing in Massachusetts
| Crude PR | Age-adjusted PR | Fully-adjusted PRa | |||
|---|---|---|---|---|---|
| N | Mean Score (SE) | (95% CI) | (95% CI) | (95% CI) | |
| Everyday racism | |||||
| Mean score (continuous) | 2.0 (0.0) | 1.32 (1.04, 1.68) | 1.32 (1.04, 1.68) | 1.19 (0.90, 1.58) | |
| Quartilesb of mean score | |||||
| 4th quartile | 104 | 3.0 (0.1) | 1.51 (0.85, 2.66) | 1.5 (0.84, 2.66) | 1.08 (0.58, 2.00) |
| 3rd quartile | 130 | 2.1 (0.0) | 1.32 (0.75, 2.32) | 1.32 (0.75, 2.32) | 1.2 (0.66, 2.15) |
| 2nd quartile | 124 | 1.7 (0.0) | 1.1 (0.61, 2.00) | 1.09 (0.60, 1.99) | 0.96 (0.51, 1.83) |
| 1st quartile | 116 | 1.2 (0.0) | Ref | Ref | Ref |
| Lifetime racism | |||||
| Mean response count (continuous) | 470 | - | 1.21 1.00 (1.47) | 1.22 (1.00, 1.48) | 1.17 (0.94, 1.45) |
| Category of affirmative response | |||||
| Yes to all | 62 | - | 1.82 (1.12, 2.94) | 1.82 (1.12, 2.95) | 1.72 (1.03, 2.88) |
| Yes to two | 113 | - | 0.77 (0.44, 1.34) | 0.77 (0.44, 1.36) | 0.54 (0.26, 1.10) |
| Yes to one | 162 | - | 0.67 (0.39, 1.13) | 0.67 (0.39, 1.13) | 0.72 (0.41, 1.24) |
| No to all | 133 | - | Ref | Ref | Ref |
Abbreviations: CI, confidence interval; SE, standard error.
Adjusted for age (continuous), body mass index, and marital status based on a change-in-estimate approach.
The 4th quartile represents the highest exposure to everyday racism, and the 1st quartile the lowest.
4 |. DISCUSSION
This study of adult US Black women reports positive associations between perceived experiences of racism and high dental anxiety. Specifically, being in the highest quartile of the everyday racism score and having the highest lifetime racism scores were both associated with having high levels of dental anxiety. The overall prevalence of high dental anxiety was 17.8% in this sample, which is disproportionally higher than other, predominantly White, US-based samples,39–42 despite the population being highly educated, highly medically and dentally insured and engaged, and reportedly health conscious. High dental anxiety was also associated with poorer oral health. Taken together, these findings present an important possibility that racism and dental anxiety may play a role in observed racial disparities in oral health outcomes.
Our findings are similar to previous studies on the relationship between racism and dental fear and anxiety. Specifically, populations of Indigenous women in Canada15 and Australia17 have similarly reported positive associations between experiences of racism and dental fear and anxiety. This study is the first to report on it in a population of US Black women. Furthermore, given the particular demographics of this studied population that reflect higher socioeconomic position and engagement with health and dental health care relative to Black women across the US, it is quite likely that the observed estimate of the prevalence of high dental anxiety reflects an underestimation of what otherwise might be observed in a larger, more representative cohort. Additionally, reported experiences with perceived everyday and lifetime racism in this sample are much lower when compared to the distributions observed in the entire BWHS cohort. Finally, another study evaluated the potential role of dental anxiety in observed disparities in oral health by socioeconomic status and found that lower socioeconomic status was positively associated with higher dental anxiety,27 indicating that dental anxiety may be an important contributor to oral health disparities along multiple sociodemographic axes.
Understanding the mechanisms behind the development of dental fear and anxiety may facilitate intervention efforts to prevent delayed dental care, and thus, improve oral health outcomes. Many potential causal mechanisms between perceived experiences with racism and the presence of dental fear and anxiety exist. Scholars have long noted that racial disparities in health outcomes are likely to be primarily attributable to the effects of racism, which is a multi-level phenomenon and occurs at the level of the individual, institutions and society,43,44 and recent work has more directly begun to examine the role of racism in oral health specifically.45–47 In addition to societal manifestations of racism, personally mediated and internalized racism can impact how individuals engage with society and have been reported to impact use of and experiences with healthcare services in the US.48 Compounding this issue is the documented racial biases impacting the provision of equitable healthcare, particularly in the realm of pain management among Black adults.49 Unsurprisingly, similar associations have been observed with respect to oral health. Perceived experiences with racism have been associated with poor oral health outcomes15–18 and prior experiences with dental care, particularly around pain management and poor quality of care, and have been associated with the presence of dental fear and anxiety.50,51 Notably, the fear-inducing stimuli reported in this sample among those with high dental anxiety were primarily focused on painful procedures, needles and injections, having an unkind or unsympathetic dentist, and treatment cost, with about 60% of those with high dental anxiety reporting they had ‘very much’ anxiety about uncomfortable or painful procedures. Finally, relative to the healthcare workforce, the dental workforce in the US has historically had low participation by women and racial/ethnic minorities, the majority of whom practice paediatric dentistry.45–47,52 Therefore, the lack of gender and racial or ethnic representation among providers of adult dental care may contribute to the development of dental fear and anxiety among underrepresented minority populations. In sum, more research into the potential mechanisms underlying this association could potentially contribute important insights into racial/ethnic disparities in oral health.
There are several important limitations for consideration. First and foremost, this sample is not likely generalizable to US Black women as a whole, nor even participants of the BWHS generally. Participants in the BWHS tend to be more highly educated and health conscious than the general population of Black women in the US.53 This study sample included BWHS participants residing in the state of Massachusetts where sociocultural influences differ, education levels tend to be higher, and access to and engagement with healthcare tends to be greater. Thus, this sample may represent Black women who are generally more health and oral health conscious than even the entire BWHS cohort, let alone the US population of Black women generally. Indeed, the majority of this sample reported a higher prevalence of having seen both a doctor and a dentist in the past year and a lower prevalence of perceived experiences with racism compared with the full BWHS cohort. Additionally, although the measures of racism were obtained 5 years earlier in time relative to the measures of dental fear and anxiety, this does not necessitate a temporal relationship, highlighting one of the primary challenges faced in studying these associations. Specifically, both perceived experiences with everyday and lifetime racism and dental fear and anxiety develop and accumulate over time such that their respective measurements in this study capture only their prevalence and not their incidence, severity or duration. Therefore, while the primary focus of the study is in potential mechanisms underlying the development of dental fear and anxiety in this population, no inferences about the causal nature of their relationship can be made based solely on the temporality of their measurement and caution should be exercised in interpreting the results.
The results of this study should also be interpreted in the context of other potential sources of error. While potential confounders were pre-specified based on existing literature, adequate statistical control by these variables is limited both by a lack of causal knowledge due to the nascent nature of research on this topic and the fact that some of the variables available were likely proxies for other unmeasured confounders (e.g. BMI serving as a proxy for weight-related discrimination), which could result in residual confounding. Additionally, exposure to racism was assessed in this study using only two measures. This may limit the ability to observe the true magnitude of associations, as racism is a multifaceted phenomenon. Finally, because the study only included those participants residing in the state of Massachusetts, the size of the sample impacted the precision of the estimates.
Nonetheless, this study serves as an important call for a more in-depth investigation into the development of dental fear and anxiety, as well as their potential role in the persistent disparities in oral health across racial and ethnic lines. Dental fear and anxiety, and their risk factors, may represent feasible intervention targets to improve population oral health.
Supplementary Material
ACKNOWLEDGEMENTS
This work was supported by funding from the National Cancer Institute (NCI) (grant numbers R01 CA58420 and UM1 CA164974), the National Institute of Dental and Craniofacial Research (NIDCR) (grant numbers R03 DE026841 and K99/R00 DE025917), and the National Center for Advancing Translational Sciences at the National Institutes of Health (through BU-CTSI grant number U54TR001012).
Funding information
National Institutes of Health, Grant/Award Number: U54TR001012; National Institute of Dental and Craniofacial Research (NIDCR), Grant/Award Number: K99/R00 DE025917 and R03 DE026841; National Cancer Institute, Grant/Award Number: UM1 CA164974 and R01 CA58420
Footnotes
CONFLICT OF INTEREST
The authors report no conflict of interest.
PARTICIPANT CONSENT STATEMENT
Participants indicated consent by completing and returning the questionnaires.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.