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The screams of scared children at public dental clinics catapulted a Gqeberha clinical psychologist to embark on critical research about traumatic oral healthcare experiences in young, disadvantaged South Africans – and what we can do about it.

Nelson Mandela University psychology department lecturer Ashwin Navsaria graduated with his PhD in April this year, and hopes that his findings will make a difference in the government’s dental health space.

His study documented a high prevalence of negative dental experiences in a sample of paediatric patients in the public health sector.

With 60% of children in the study exhibiting a negative dental experience – contributing to the grim reality of poor oral health outcomes – the 39-year-old academic says that addressing fear and anxiety challenges is crucial for long-term oral health in public patients.

Dr Navsaria’s doctorate topic emerged from experiences while working for the Eastern Cape Department of Health, servicing various clinics in the Nelson Mandela Metro.

“The main clinic that I serviced had its department of psychiatry directly across (from) the department of dentistry.

“The screams of distressed children emanating (from the building) got my attention.

“I had also been requested by a dentist colleague in private practice to treat a young girl for severe dental anxiety, the origin of which was a negative dental experience at a public oral health facility.”

At around the same time, his wife, Dr Konesh Navsaria, also a psychologist, treated a patient who had avoided consulting any healthcare professional for 20 years, following a negative dental experience at a public oral health facility during childhood.

These events all provided the necessary impetus to get the ball rolling, he says.

Fear of dentists a global phenomenon

International research into dental anxiety and fear is nothing new, with the first scientific reports emerging over 60 years ago, says Dr Navsaria.

“It was therefore surprising that there were no South African studies which specifically focused on this topic. So little is known about the unique contextual factors surrounding these phenomena in a local public dental context.”

With scant information on the ground locally, he and his supervisors, Professors Christopher Hoelson and Greg Howcroft, decided to conduct an exploratory study in this area.   

“There are many factors that contribute to the development of clinically significant dental fear and anxiety.

“However, one common identified factor is a childhood negative dental experience.”

A patient-focused approach

The research was based on three objectives, all ultimately aimed at providing practical, contextually relevant solutions for young patients, their parents and dentists.

  • Determine the prevalence of childhood negative dental experiences in a typical, local public oral health facility
  • Gain a comprehensive understanding of the experience and perceptions of all parties: patients, parents and dentists
  • Map a terrain for future research in the area by providing a systemic perspective of the various implicated variables.
  • Additionally, Dr Navsaria sought to fully understand why children were experiencing this trauma in public dental facilities, and what clinical recommendations could be made to alleviate the problem.

How the study was conducted

Research was in two phases at a public oral health facility in Gqeberha, with the name kept anonymous to allow dentists to speak freely about their experiences.

In the first phase, dentists were trained to use a behavioural rating scale to record the behaviour of 50 children between the ages of six and 12 to identify any negative dental experiences.

A total of 60% of observed children exhibited a negative experience.

“This is an important finding, as childhood negative dental experiences are causally associated with the development of significant dental fear and anxiety, which in turn is associated with an avoidance of oral healthcare and poorer oral health outcomes.”

Phase two, a week later, involved interviewing children who had had a bad experience, as well as their parents.

A significant number of issues were uncovered following the study. Among others, these included:

  1. No preventative programmes or prophylactic measures provided to children or parents, increasing the probability of them arriving for dental treatment in pain and afraid
  2. Dentists being insufficiently trained to use proven psychological techniques to decrease their young patients’ distress
  3. Negative family attitudes towards dentistry, potentially influencing children before their dental visits.

The findings, though worrying, helped develop an overview of local negative dental experiences, providing a useful entry point for clinical recommendations to help minimise the probability of a traumatic event, says Dr Navsaria.

Where to now?

Doctoral supervisor Professor Hoelson says that the study, being the first to focus on identifying negative dental events among disadvantaged paediatric patients in a South African public health context, would help stakeholders to address issues and find solutions.

“The findings of his study have the potential, if they are addressed constructively by those in positions to bring about such change, to reduce the mental and physical suffering of these children,” he says.

Dr Navsaria has compiled a useful set of clinical and general recommendations that might help to reduce the probability of paediatric dental fear and anxiety.

It is vital, he says, to understand that negative dental experiences are causally associated with an increase in clinically significant dental anxiety and so, ultimately, poorer oral health: people tend to avoid what they fear.

“A summary of my study’s findings, together with these recommendations, will be provided to the national department of health via the National Health Research Database system.”

He will also develop training material for public oral health staff.

“I attended a recent online event by the Public Oral Health Forum, where one of the speakers, bemoaning the apparent sidelining of dentistry in broader South African healthcare, exclaimed, ‘We need to put the mouth back into the body!’

“Similarly, I hope that my study helps to put the mind back into the body.”

Dental drama – why we should care

So little importance is placed on psychological distress in public medical settings in general – and this has to change, says Dr Navsaria.

A key example was some parents reporting that their children had not had a bad dental experience, despite the children exhibiting “extremely high levels” of anxiety.

“This illustrates the underlying assumption that any distress experienced by the child is transient and of little consequence.

“While the immediate treatment needs of the patient must obviously take precedence, there is a large body of literature (about) the potential long-term effects of distressing medical encounters, particularly in childhood.” 

Why has SA lagged behind?

Much research into dental fear and anxiety has been generated in developed economies – but there is a large and growing body of literature from developing economies now, too, says Dr Navsaria.

The lack of adequate studies in South Africa could probably be explained by three points. Firstly, South Africa, with the legacy of Apartheid-era health inequities still firmly on its shoulders, has bigger fish to fry with respect to public oral healthcare.

However, it is important to recognise the contributory causal role that dental fear and anxiety have in poorer oral health outcomes, he says.   

Secondly, dentists in most countries are understandably more concerned with the acute treatment needs of the patient; and in South Africa, with its high burden of oral health disease, this is even more understandable, he says.

Lastly, there is also still a “silo” mentality in South African healthcare, with little interdisciplinary consideration. 

Contact information
Mrs Debbie Derry
Deputy Director: Communication
Tel: 041 504 3057