Many dentists would be happy not having to deal with either special needs patients, or those with intense dental phobia. Dr Avanti Karve has made a career out of dealing with both. By Andy Kollmorgen
Judging by her contributions to the profession so far, the first graduate of Sydney University’s Special Needs Dentistry program, Dr Avanti Karve, will be taking dentistry in a new direction between now and the time she retires. Fortunately for the patients she looks after these days, it will be a while before that happens. Dr Karve has an agenda, and her determination to make a difference is hard to miss when she talks about her work.
Dr Karve thinks it’s time for Australian dentistry to start moving away from its longstanding fixation on a strictly medical model of oral care and start embracing a more holistic approach—that is, to get on board with the evolving arc of healthcare as a whole. As with patients of all kinds, most dental patients would be better served, Dr Karve says, if practitioners looked beyond the immediate oral health issues at hand and concentrated more on what might be causing them. Then again, most dental practitioners in Australia (and many other countries) have had little time or opportunity to deliver this sort of multi-dimensional care. And here especially, holistic case management involving other medical and allied health professionals hasn’t been part of the culture. Dr Karve aims to change that, and she has started in a place where change is long overdue.
“We’ve had patients who’ve never had dental treatment in the past who are dentally phobic.” – Dr Avanti Karve
One lesson from the Sydney Uni program was particularly clear: Nowhere is a holistic view of the patient more crucial than when treating those who are relegated to the broadly defined category known as special needs. It’s a catch-all phrase that includes people with intellectual or physical disabilities, mental illnesses, neurodegenerative diseases like Parkinson’s and Huntington’s, various forms of dementia, and more. And it’s a patient pool whose numbers are growing.
For Dr Karve, this area of unmet need has sparked an enviable professional leap—she seems to have channelled her daily working life into an overarching career goal. The interest goes back to her graduation from the University of Adelaide’s School of Dentistry in 2003. “I was always interested in managing medically complex patients,” she says.
But it wasn’t until she undertook a residency in special needs dentistry at Westmead Hospital and signed up for the three-year Doctorate of Clinical Dentistry (SND) program at Sydney Uni that she understood how isolated special needs patients are from mainstream dentistry. “It’s a very challenging and unique area, and we have strong longstanding evidence that this group is being underserved.”
Special needs patients have been left out of the loop for a variety of reasons, from the practical to the discriminatory, Dr Karve points out. Practices may not be equipped to handle patients with a mental illness, a degenerative health condition, someone confined to a wheelchair, or someone in their 90s who finds dental treatment difficult. Or practices may simply not want to deal with such patients. “They are difficult to manage and challenging to treat, and this puts off a lot of general practitioners,” Dr Karve says. The statistics bear out the expected results: special needs patients have markedly poorer dental health.
The special needs category also includes phobic patients, a specialty of Dr Karve’s and an area, she says, that’s both ripe for further investigation and rife with misconceptions. While up to 40 per cent of patients in the western world suffer from dental anxiety to varying degrees, according to one recent survey, only 5 to 10 per cent are afflicted with debilitating fear—the kind that prevents would-be patients from visiting a dentist even in
the face of debilitating pain. The numbers are far from solid, however. “The statistics are quite difficult to interpret,” is how Dr Karve puts it.
Though the research-based science has moved on from the 1970s notion that dental phobia was rooted solely in painful dental experiences, the question of what causes such fear continues to elude a definitive answer. What is clear, though, is that an encounter with an inept practitioner is unlikely to engender a lifelong fear of dental care. In the US, researchers are also looking at a range of potential fear factors, with a focus on using the same tools to manage dental phobia as post-traumatic stress disorder. It’s a move away from earlier European studies that have attributed dental phobia to inherent personality traits, and a step in the right direction, Dr Karve says.
She hopes any legacy she leaves will include the understanding that dental phobia should be looked at separately from dental health and considered in the same light as other phobias, such as an overwhelming aversion to germs or needles or claustrophobia, agoraphobia and other tricks of the mind.
“We’ve had patients who’ve never had dental treatment in the past who are dentally phobic,” Dr Karve says. “You’re in a confined space in a vulnerable position and, obviously, the mouth is a very personal area. The fear may somehow be rooted in your sense of self, your sense of personal space.”
survey-based study published in the European Journal of Oral Science in 2009 compared the incidence of dental phobia to that of 10 other common fears among 1,959 Dutch adults aged 18 to 93. The prevalence of dental fear (another word for anxiety in this context) was 24.3 per cent, trailing behind fear of snakes, heights, and physical injuries (34.8 per cent, 30.8 per cent and 27.2 per cent, respectively). But when it came to full-fledged phobias, dental phobia was the most widespread (3.7 per cent), followed by heights (3.1 per cent) and spiders (2.7 per cent). The study found that dental fear is “a remarkably severe and stable condition with a long duration”, especially among females.
In a survey study published in the Australian Dental Journal in 2010, there was some common ground when it came to causation. Dental phobia across the social spectrum was “significantly associated” with concerns about injections, but the prospect of financial damage was even more scary. Cost of treatment was the most anxiety-producing worry of all in the study.
Trying to gain a clinical understanding of how best to treat special needs patients beyond survey exercise has built-in problems. Ideally, evidence that might make its way into treatment options would be drawn from randomised trials. But the patients needed to make such trials worthwhile are the least likely to take part. “We’re very much at the stage of case-control studies, and because there’s such a wide range of patients in each field, it’s a challenge to design studies, and to find participants,” Dr Karve says. “A callout for participants in a dental phobia trial is going to have a low response rate because the priority for these patients is to avoid dentists.”
One trial has gotten off the ground, however—one that Dr Karve coordinated through the Dental Phobia Clinic at the Westmead Centre for Oral Health. Dr Karve’s treatise came to the conclusion that women in their 40s are more likely than other age groups to suffer from dental anxiety as defined by Norman Corah’s Modified Dental Anxiety Scale (in use since the mid-20th century).
The study wasn’t designed to explore the full range of possible causes, but it did detect a link between previous head and neck trauma and fear of visiting the dentist. The emotional scar didn’t necessarily have anything to do with dentistry.
Despite the gaps in special needs care, Australian dentistry has been moving in the right direction in recent decades, Dr Karve acknowledges. Most dental school curriculums have included a special needs or behavioural component for the past 20 or 30 years, generally in the fourth year of study. But the training hasn’t been enough to keep pace with the complexities of the challenge. The Australian Society of Special Care in Dentistry (ASSCID), where Dr Karve currently serves as secretary, is an initiative to bring like-minded practitioners together in order to increase lobbying power as well as maximise other resources. In partnership with the Australia New Zealand Academy of
Special Needs Dentistry, ASSCID hosted the International Association for Disability and Oral Health Congress in Melbourne in October.
When it comes to hands-on help, Dr Karve divides her time these days between the Special Care Unit at Westmead Hospital and Norwest Special Needs Dentistry in the Sydney suburb of Bella Vista and The Dental Specialists practice in Sydney. Her special needs patients come from most points on the socioeconomic and demographic spectrum, but there is a link: It’s harder for them to get good treatment than the rest of the patient population. Dr Karve believes it’s a problem that can only get worse without a wider awareness of the obstacles they face and a strategy to deal with them. Such patients have longer life expectancy than ever, without a corresponding increase in dental services attuned to their needs. “We know we have an ageing population and increased retention of teeth,” Dr Karve says. “So we’re going to have to manage a new set of patients who have a long-term set of problems.”