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Dr Ava Carter has done much to advance the cause of dental patients struggling with phobias. Now the multi- award-winning clinician has set her sights even higher. By Tracey Porter
When Dr Ava Carter commits to a cause, she goes all in. Whether working with patients on exposure response prevention or advocating for better mental health support for practitioners, she has made it her mission to ensure those on all sides of dentistry live happier lives.
More recently her work helping to drive system change in organisations within the healthcare sector has seen her recognised as a 2024 Churchill Fellowship award recipient. Coming on top of numerous other accolades—including the Calvary Healthcare Prize for Excellence and the Lived Experience Australia Award for best practice in consumer and carer inclusion—Dr Carter’s fellowship will see her head overseas on a fully funded trip to study innovative care models providing dental care for people suffering chronic mental illness in hospital. The end goal, she says, is to develop an Australian version.
Dr Carter argues such units are necessary because people suffering chronic mental illness are substantially less able to access dental care for cognitive and socioeconomic reasons. This leaves them 50 times more likely to suffer gum disease.
The dual-qualified dental surgeon and medical doctor argues the problem is exacerbated here because integrated dental services for hospitalised psychiatric patients do not currently exist.
Driving ambition
Dr Carter is a board director at the Royal Australian and New Zealand College of Psychiatrists and a board member on the Canberra Region Medical Education Council, as well as sits on several other panels in the healthcare sector.
Now based in Canberra, Dr Carter says she was drawn to this area because she grew up in a rural town where there was only one doctor and dentist. She was exposed to the effects of poor dental health from a young age as the nearest dental specialist was a three-hour drive away.
Originally planning to be an oral maxillofacial surgeon, she didn’t consider psychiatry until her internship year when she worked with patients who suffered severe mental illness.
To reach the level of expertise she enjoys today, Dr Carter spent five years in undergraduate dentistry at Griffith University, four years in post-graduate medicine at Canberra Australian National University and a further five years of subspeciality psychiatric training in Canberra with two internships, extensive CPD and years spent at the coalface in between.
Access issues
She believes anxiety and phobias prevent people from accessing care because they are fearful of needles, pain and the process.
However, the impact of poor mental health on oral health is not as simple as avoiding the dentist, she says. “It’s a challenging area. Poor mental health impacts home oral health care, which can impact kids and parents and can promote the unintentional development of anxiety and phobias, for example. From a consumer perspective, it is often access that is a barrier.”
There is a lot of positive work being done in the intellectual disability and physical disability space which [we] could learn more from as well… as the crossover between them and psychiatric is also immense.
Dr Ava Carter
Dr Carter argues neurodivergence and sensory and interceptive conditions also make it particularly difficult to access dental care because it’s a very “sensorially stimulating” surgical procedure.
“Even having one’s teeth cleaned involves all five of the senses, and if you add on pain, which many people experience from sensitive teeth then you’ve got a real challenge on your hands with a patient trying to overcome that.”
More training and specialised workshops to upskill all practitioners to assist their patients would help prevent some of the barriers to access. So too would having co-located and co-designed units where patients who have those additional specialist care needs can access dental care while in hospital.
Going forward
In terms of educating practitioners and the sector more generally about psychiatric care, Dr Carter believes dental and medical universities, CPD, and engagement with consumer and patient groups, all have a role to play.
The issue is nuanced because it’s not just those sitting in the chair who may have psychological hurdles to overcome, she claims.
Despite the old stereotype of people going into dentistry because they don’t want to talk to patients, the profession requires a high level of emotional intelligence and is itself quite emotive, Dr Carter says.
This is because dental practitioners are required to be experts at both verbal and non-verbal communication. They must quickly identify key issues for people who often are in pain and then manage them efficiently. They also have practice teams to manage, and leadership demands to navigate.
“And we’re not even at the operative part yet,” she says. “Here the physical nature of the job needs skill, patience, and concentration to perform but the practitioner must simultaneously keep a constant eye on the patient’s body language, facial expression and voice cues to identify if they’re in pain, worried or anxious.
“There’s lots of potential friction points that can contribute to that experience of struggling to cope.”
Thinking laterally
Compounding the issue is that there are few, if any, protocols that integrate psychiatric and dental care under the one roof, other than those set up by private clinics and those that exist within the ADA to help guide practitioners on techniques to manage patients with higher needs, Dr Carter says.
While the government has done a lot of work with the Child Dental Benefits Schedule, there is more opportunity to improve the health of the community in this space.
The key to assisting the public and private sectors when it comes to bridging the gap between mental and oral health is to embrace out-of-the-box thinking, she argues.
She believes Australia could piggyback off initiatives developed by the world leaders in this sector, such as the Center for Translational Oral Research run by Norway’s University of Bergen that integrates experimental, epidemiological and clinical research activities to facilitate translation into evidence-based innovative therapies.
King’s College Hospital, Broadmoor Hospital and The Maudsley Hospital in the UK also have specialist dental programs in special needs care that could be adapted to an Australian setting.
“There is a lot of positive work being done in the intellectual disability and physical disability space which [we] could learn more from as well… as the crossover between them and psychiatric is also immense.
“I also feel very strongly that we are missing the link for our Indigenous and First Nations peoples when it comes to the integration of mental and oral health. I have worked in very rural and remote areas, and it is heartbreaking to see the detrimental effects on people’s individual health.”
While there are some resources present that focus on the practitioner’s wellbeing, such as The Mindful Smiles Hub, which has been created with a focus on the mental health and wellbeing of Australian dental practitioners, there is more that could be done in that area too, she says.
“I don’t say all this to take away from that, but I believe there is more work to do to support each other as colleagues. I’d love to be a part of shaping that future where it’s okay for highly skilled dentists and specialists to be talking about the hidden difficulties in dentistry.
“I know there is so much potential here in Australia. We have so many wonderful clinicians, so many wonderful specialists in dentistry, medicine, and psychiatry and I truly believe that one day we can close this distance between the health people should and could have when combining all these multidisciplinary areas together, and the access to care people currently get.”
