Should Dental Care Make a Transition?

Abstract

People identifying as transgender are those whose gender identity differs from their biological sex. It is estimated that there are at least 1.4 million transgender people in the United States1Flores A.R. Herman J.L. Gates G.J. Brown T.N.T. How many adults identify as transgender in the United States. The Williams Institute, Los Angeles, CA2016http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdfGoogle Scholar and at least 25 million worldwide.2Arcelus J. Bouman W.P. Van Den Noortgate W. Claes L. Witcomb G. Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism.Eur Psychiatry. 2015; 30: 807-815Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar, 3Conron K.J. Scott G. Stowell G.S. Landers S.J. Transgender health in Massachusetts: results from a household probability sample of adults.Am J Public Health. 2012; 102: 118-122Crossref PubMed Scopus (298) Google Scholar, 4Winter S. Diamond M. Green J. et al.Transgender people: health at the margins of society.Lancet. 2016; 388: 390-400Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar The number of people undergoing medical or surgical gender affirmation may rise, given the increasing social awareness and decreasing stigma surrounding transgender people.1Flores A.R. Herman J.L. Gates G.J. Brown T.N.T. How many adults identify as transgender in the United States. The Williams Institute, Los Angeles, CA2016http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdfGoogle Scholar More transgender people create a greater need for health care providers, including dental professionals, who are experienced in managing the care of transgender patients. Despite the growing need for multidisciplinary care, the social and institutional stigma against transgender people results in discrimination in the health care field.5Poteat T. German D. Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters.Socal Sci Med. 2013; 84: 22-29Crossref PubMed Scopus (388) Google ScholarMore transgender people create a greater need for health care providers, including dental professionals, who are experienced in managing the care of transgender patients. More transgender people create a greater need for health care providers, including dental professionals, who are experienced in managing the care of transgender patients. Dentists and dental specialists are uniquely qualified to perform procedures that involve the functional and esthetic aspects of the teeth, mouth, jaws, and face. The characteristics and size of ones’ teeth can be perceived on a spectrum ranging from feminine to masculine, but do we understand the importance of this when restoring dentition or performing esthetic procedures (that is, veneers) on transgender patients? Gingival tissue and alveolar bone provide an important component of smiles, but should we consider specific periodontal procedures such as gingival recontouring, grafting, or crown-lengthening procedures in a transgender patient? Lip esthetics are important to the masculinity or femininity of smiles, but do we use this understanding when managing the soft tissue of a transgender patient? The facial profile, including the brow, forehead, eyes, cheeks, nose, mandible, skin, and soft tissue, are important to a person's masculinity or femininity, but do we offer facial esthetic procedures, promote this skill, or take it into account when treating a transgender patient? The answer to each of these questions is likely we do not know. An answer that does no justice to the transgender population. In its Diversity and Inclusion Statement,6American Dental Association. ADA's Commitment to Diversity and Inclusion: ADA Diversity and Inclusion Statement. Available at: www.ada.org/en/about-the-ada/diversity-and-inclusion. Accessed November 19, 2017.Google Scholar the American Dental Association says it “strives to model diversity and inclusion in everything we do .… [It] allows us to further advance the dental profession, improve the oral health of the public, and promote equity and access to oral health.” The American Dental Association Commission on Dental Accreditation, in its Accreditation Standards for Dental Education Programs7Accreditation Standards for Dental Education Programs. Commission on Dental Accreditation; 2017. Available at: www.ada.org/∼/media/CODA/Files/pde.pdf?la=en. Accessed November 19, 2017.Google Scholar states that “programs must create an environment that ensures an in-depth exchange of ideas and beliefs across gender, racial, ethnic, cultural and socioeconomic lines” and that “graduates must be competent in managing a diverse patient population and have the interpersonal and communications skills to function successfully in a multicultural work environment.” Despite these statements, education about the care of sexual and gender minority patients has been found to be lacking in predoctoral dental education.8Feng X. Mugayar L. Perez E. Nagasawa P.R. Brown D.G. Behar-Horenstein L.S. Dental students' knowledge of resources for LGBT persons: findings from three dental schools.J Dent Educ. 2017; 81: 22-28PubMed Google Scholar, 9Hillenburg K.L. Murdoch-Kinch C.A. Kinney J.S. Temple H. Inglehart M.R. LGBT coverage in U.S. dental schools and dental hygiene programs: results of a national survey.J Dent Educ. 2016; 80: 1440-1449Crossref PubMed Google Scholar, 10Russell S. More F. Addressing health disparities via coordination of care and interprofessional education: lesbian, gay, bisexual, and transgender health and oral health care.Dent Clin North Am. 2016; 60: 891-906Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 11Behar-Horenstein L.S. Morris D.R. Dental school administrators’ attitudes toward providing support services for LGBT-identified students.J Dent Educ. 2015; 79: 965-970PubMed Google Scholar, 12Anderson J.I. Patterson A.N. Temple H.J. Inglehart M.R. Lesbian, gay, bisexual, and transgender (LGBT) issues in dental school environments: dental student leaders' perceptions.J Dent Educ. 2009; 73: 105-118Crossref PubMed Google Scholar The result is a profession of dental providers who may be uncomfortable with the delivery of care specific to transgender patients. The current literature on transgender populations in our field is lacking. For example, a simple search on PubMed with the word “transgender” and 1 term relating to our profession (for example, dentistry, dental, dentist, oral, teeth) yielded 14 citations. This included literature on dental fear among transgender patients13Heima M. Heaton L.J. Ng H.H. Roccoforte E.C. Dental fear among transgender individuals: a cross-sectional survey.Spec Care Dentist. 2017; 37: 212-222Crossref PubMed Scopus (22) Google Scholar; resources for lesbian, gay, bisexual, and transgender (LGBT) patients8Feng X. Mugayar L. Perez E. Nagasawa P.R. Brown D.G. Behar-Horenstein L.S. Dental students' knowledge of resources for LGBT persons: findings from three dental schools.J Dent Educ. 2017; 81: 22-28PubMed Google Scholar; support services for LGBT dental students11Behar-Horenstein L.S. Morris D.R. Dental school administrators’ attitudes toward providing support services for LGBT-identified students.J Dent Educ. 2015; 79: 965-970PubMed Google Scholar, 14More F.G. Whitehead A.W. Gonthier M. Strategies for student services for lesbian, gay, bisexual, and transgender students in dental schools.J Dent Educ. 2004; 68: 623-632PubMed Google Scholar; an overview of transgender dental patients15Madhan B. Krishnan B. Arunprasad G. Dental patients: transgender issues.Br Dent J. 2015; 218: 45Crossref PubMed Scopus (1) Google Scholar; a case report16Nishimura B.J. Treatment considerations for a full-mouth reconstruction of a transgender patient.Compend Contin Educ Dent. 2017; 38: 544-551PubMed Google Scholar; and dental and interprofessional education on LGBT topics.9Hillenburg K.L. Murdoch-Kinch C.A. Kinney J.S. Temple H. Inglehart M.R. LGBT coverage in U.S. dental schools and dental hygiene programs: results of a national survey.J Dent Educ. 2016; 80: 1440-1449Crossref PubMed Google Scholar, 10Russell S. More F. Addressing health disparities via coordination of care and interprofessional education: lesbian, gay, bisexual, and transgender health and oral health care.Dent Clin North Am. 2016; 60: 891-906Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 12Anderson J.I. Patterson A.N. Temple H.J. Inglehart M.R. Lesbian, gay, bisexual, and transgender (LGBT) issues in dental school environments: dental student leaders' perceptions.J Dent Educ. 2009; 73: 105-118Crossref PubMed Google Scholar, 17Taylor AK, Condry H, Cahill D. Implementation of teaching on LGBT health care [published online ahead of print April 12, 2017]. Clin Teach. https://doi.org/10.1111/tct.12647.Google Scholar, 18Madhan B. Gayathri H. Garhnayak L. Naik E.S. Dental students' regard for patients from often-stigmatized populations: findings from an Indian dental school.J Dent Educ. 2012; 76: 210-217PubMed Google Scholar, 19Brondani M.A. Paterson R. Teaching lesbian, gay, bisexual, and transgender issues in dental education: a multipurpose method.J Dent Educ. 2011; 75: 1354-1361PubMed Google Scholar, 20Aguilar E. Fried J. Enhancing dental and dental hygiene student awareness of the lesbian, gay, bisexual and transgender population.J Dent Hyg. 2015; 89: 11-16PubMed Google Scholar, 21Braun H.M. Ramirez D. Zahner G.J. Gillis-Buck E.M. Sheriff H. Ferrone M. The LGBTQI health forum: an innovative interprofessional initiative to support curriculum reform.Med Educ Online. 2017; 22: 1306419Crossref PubMed Scopus (30) Google Scholar We cannot provide evidence-based dental care to a subset of the population, if that population has yet to be studied. Patient-centered care is “respectful of and responsive to individual patient preferences, needs, and values”22Institute of MedicineCommittee on Quality of Health Care in AmericaCrossing the Quality Chasm: A New Health System for the 21st Century. The National Academies Press, Washington, DC2001www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-theGoogle Scholar and has been found to enhance patient satisfaction23Epstein R.M. Mauksch L. Carroll J. Jaén C.R. Have you really addressed your patient’s concerns?.Fam Pract Manag. 2008; 15: 35-40PubMed Google Scholar and improve outcomes.24Stewart M. Brown J.B. Donner A. et al.The impact of patient-centered care on outcomes.J Fam Pract. 2000; 49: 796-804PubMed Google Scholar, 25Bertakis K.D. Azari R. Determinants and outcomes of patient-centered care.Patient Educ Couns. 2011; 85: 46-52Crossref PubMed Scopus (68) Google Scholar Given the importance of patient-centered care in health care systems and the need for dental professionals to manage the care of transgender patients, it would be prudent for us as a profession to▪further evaluate the oral health statuses of transgender patients;▪understand the desire for dental and facial procedures among transgender patients;▪educate dental providers and students alike about managing the care of transgender patients;▪define the role of dental professionals in providing specialized services to transgender patients;▪identify procedures that we may offer to those pursuing gender-affirming surgery. As dentists and dental specialists, we should continually aim for progress in our field such that we can provide comprehensive and compassionate care to all, including those patients identifying as transgender. Dr. Ludwig is a resident, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA. Dr. Morrison is a resident, Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA.