Oral Health Equity Research Articles

C.E. Credit. A Historical Overview of Language Access in Dentistry: The Impact of Language Access Protections on Oral Health Care

Background: More than 67 million Americans (22%) speak a language other than English at home, with more than 25 million (8.4%) speaking English “less than very well.” Language, culture and literacy are intimately related. However, the significance of language is often overshadowed in the larger conversation of oral health and health literacy.Methods: Studies have shown language-related barriers to be associated with medical errors, decreased patient satisfaction, poorer self-management and worsened clinical outcomes. Alternatively, use of professional interpreters and other quality language assistance services enhance language access, resulting in improved patient engagement and satisfaction, increased care quality and better clinical outcomes.Conclusions: Ensuring language access for our patients is a critical component in achieving oral health equity. This article provides a brief history of language access policy in this country, discusses the impact of language access protections on the dental profession and recommends actionable steps for dental providers to facilitate equitable, quality care for their patients and communities.Practical implications: Maintaining and prioritizing language access protections alongside other nondiscrimination practices mitigates significant barriers to care and helps to ensure all patients are able to receive the quality oral health care they need.

An approach to developing oral health knowledge for allied health students.

Oral health competency-based education approaches have been proposed as a mechanism to address oral health outcomes and equity issues. Recommendations for oral health education for allied health professional students include practices to increase team members' knowledge and skills in the integration of oral health and primary care practice (IOHPCP) initiative's oral health clinical competencies for primary care providers. This study aimed to examine changes in self-reported knowledge of occupational students in the topics of oral health, the dental profession, and dental healthcare systems following participation in a series of webinars and a community-engaged learning project. This study utilized an oral health education program through webinars and a community-engaged learning project for occupational therapy students. Program evaluation measures were utilized to assess the oral health education activities through self-reported knowledge in oral health topics aligned with IOHPCP domains along with topics identified by the community partner organization. Findings demonstrate that asynchronous webinars can increase self-reported knowledge in occupational therapy students. Recommendations for inclusion of oral health education for allied health students related to knowledge of oral health, the dental profession, and dental healthcare systems are shared. Asynchronous webinars have the potential to increase self-reported oral health knowledge for allied health professionals.

Dental Therapists in the United States: Health Equity, Advancing.

Dental therapists (DTs) are primary care dental providers, used globally, and were introduced in the United States (US) in 2005. DTs have now been adopted in 13 states and several Tribal nations. The objective of this study is to qualitatively examine the drivers and outcomes of the US dental therapy movement through a health equity lens, including community engagement, implementation and dissemination, and access to oral health care. The study compiled a comprehensive document library on the dental therapy movement including literature, grant documents, media and press, and gray literature. Key stakeholder interviews were conducted across the spectrum of engagement in the movement. Dedoose software was used for qualitative coding. Themes were assessed within a holistic model of oral health equity. Health equity is a driving force for dental therapy adoption. Community engagement has been evident in diverse statewide coalitions. National accreditation standards for education programs that can be deployed in 3 years without an advanced degree reduces educational barriers for improving workforce diversity. Safe, high-quality care, improvements in access, and patient acceptability have been well documented for DTs in practice. Having firmly taken root politically, the impact of the dental therapy movement in the US, and the long-term health impacts, will depend on the path of implementation and a sustained commitment to the health equity principle.

Promoting support for community water fluoridation: Testing message effects and the role of normative beliefs

BackgroundDespite evidence that community water fluoridation (CWF) protects oral health, improves health equity, is safe and cost-effective, and contributes to social well-being, little is known regarding which of these benefits should be highlighted to effectively influence support for CWF. MethodsThis within-participants study examines differences in CWF support in response to pro-CWF messages reflecting themes of oral health, health equity, CWF safety, cost-effectiveness, or social well-being among a sample of parents. Prior belief that CWF has health benefits, worry about potential health risks, and normative beliefs were also examined as independent predictors of support for each theme. ResultsOral health, health equity, and safety messages significantly increased support in comparison with social well-being messages (P < .05). Oral health messages also produced greater support than cost-savings messages. Belief that CWF has health benefits positively predicted support, as did normative beliefs that one’s family and physician approve of CWF. Worry about health risks and community and dentist norms were not significant predictors of support. There were no interaction effects of message themes and prior beliefs. ConclusionsMessaging focused on oral health, health equity, and the safety of CWF may be the most effective at influencing support for CWF. Preexisting personal beliefs about CWF benefits significantly predict support, but so do normative beliefs—family and physician norms in particular. Practical ImplicationsFindings suggest dental health educators should emphasize CWF's oral health benefits, such as preventing caries, over cost-saving and social well-being outcomes. They should also consider collaborating with family physicians to promote CWF and referencing other groups that may positively influence beliefs that CWF is beneficial.

Achieving Racial Equity in Oral Health Among Distressed Populations Amid COVID-19

This short communication frames an overview of racial equity gaps in oral health and describes how COVID-19 prevalence among distressed populations exacerbates disproportionate impacts that existed prior to the pandemic. Racialized oral health gaps compounded by COVID-19 affects their general and public health. Implications for policy and practice are highlighted.

Advancing racial equity in oral health (research): more of the same is not enough.

By critically appraising the literature on the oral health effects of race-based oppression, this focus article makes four recommendations that may both facilitate more nuanced research on the topic and mitigate racial/ethnic inequities in (oral) health. The first is recognizing that science itself may perpetuate racial/ethnic injustice, such that adopting a 'neutral' position must be replaced with actively fostering anti-racist narratives. The second is to not imply that racial oppression is bad because it harms oral health. Rather, studies should help build a fairer world, wherein oral health inequities would not abound. The third recommendation is encouraging initiatives that understand systems of oppression as conjointly operating to shape oral health. The fourth and final recommendation is taking race-based oppression as a multi-level system that operates on three inter-related conceptual levels - intra-personal, inter-personal, and structural. The extent to which scholars, practitioners, and policymakers are willing to follow these recommendations may determine how successful attempts to eradicate (oral) health inequities might be. Learning from, and avoiding mistakes made in, previous publications is one ethical pathway towards this end.

Health Literacy: A Path to Oral Health Equity

Health equity has been defined as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage.”1 The social determinants of health include literacy. Health literacy, including oral health literacy, is a driver of inequity of population health. Oral health professionals have an important role to improve structural systems and interpersonal communication, working toward health equity through focus on health literacy.

Advancing Oral Health Equity Through School-Based Oral Health Programs: An Ecological Model and Review.

In the United States and elsewhere, children are more likely to have poor oral health if they are homeless, poor, and/or members of racial/ethnic minority and immigrant populations who have suboptimal access to oral health care. As a result, poor oral health serves as the primary marker of social inequality. Here, the authors posit that school-based oral health programs that aim to purposefully address determinants of health care access, health and well-being, and skills-based health education across multiple levels of influence (individual/population, interpersonal, community, and societal/policy) may be more effective in achieving oral health equity than programs that solely target a single outcome (screening, education) or operate only on the individual level. An ecological model is derived from previously published multilevel frameworks and the World Health Organization (WHO) concept of a health-promoting school. The extant literature is then examined for examples of evaluated school-based oral health programs, their locations and outcomes(s)/determinant(s) of interest, the levels of influence they target, and their effectiveness and equity attributes. The authors view school-based oral health programs as vehicles for advancing oral health equity, since vulnerable children often lack access to any preventive or treatment services absent on-site care provision at schools. At the same time, they are incapable of achieving sustainable results without attention to multiple levels of influence. Policy solutions that improve the nutritional quality of children's diets in schools and neighborhoods and engage alternative providers at all levels of influence may be both effective and equitable.

Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream.

Vulnerable and socially excluded groups in society persistently experience significantly worse oral health and poorer access to dental services than the mainstream population. Action to tackle these unfair, unjust and avoidable inequalities in oral health needs to be informed by an understanding of the broad range of interacting factors that ultimately influence oral health across society and specifically the most vulnerable and marginalised. Failure to understand the underlying factors that create and perpetuate the oral health equity gap risks the development and implementation of ineffective interventions that do not achieve meaningful improvements in oral health for the most vulnerable. This paper presents a theoretical framework that combines a broad public health perspective on oral health inequalities, combined with more specific factors determining the oral health of vulnerable and marginalised groups. Actions to improve access to dental services and policies to combat oral health inequalities among vulnerable adult populations are then presented.

Impact of acculturation on oral health among immigrants and ethnic minorities: A systematic review.

ObjectiveCultural changes faced by immigrants and ethnic minorities after moving to a host country may have a detrimental or beneficial influence on their oral health and oral health-related behaviors. Therefore, this paper reviews the literature to see the impact of acculturation on immigrants and ethnic minorities’ oral health outcomes.MethodsWe searched seven electronic databases up to January 2018. All cross-sectional and longitudinal quantitative studies that examined associations between acculturation and oral health status and/or oral health behaviors among ethnic minority and immigrant population[s] were included. Study selection, data extraction, and risk of bias assessment were completed in duplicate. The Newcastle-Ottawa checklist was used to appraise the methodological quality of the quantitative studies. A meta-analytic approach was not feasible.ResultsA total of 42 quantitative studies were identified. The studies showed a positive association between acculturation and oral health status/behaviors. The most frequently used acculturation indicators were language spoken by immigrant and ethnic minorities and length of stay at the host country. High-acculturated immigrant and ethnic minority groups demonstrated better oral health outcomes, oral health behaviors, dental care utilization, and dental knowledge.ConclusionsAccording to existing evidence, a positive effect of acculturation on oral health status and behaviors was found.Practical implicationsDental practitioners should be culturally competent to provide the appropriate services and treatments to immigrant and ethnic minorities. Policymakers should also be sensitive to cultural diversities and properly address the unique needs of each group in order to maintain oral health equity.

In Defense of Dental Therapy: An Evidence-Based Workforce Approach to Improving Access to Care.

This article addresses new systems and practice models in community-based dentistry. Its purpose is twofold: to identify strategies and policies that support health equity and access to care; and to identify promising efforts that serve as new models for change in the dental workforce. Dental therapy meets both of these purposes and is the major focus of this article. The fundamental premises explored are threefold. First, the dental care system in the U.S. is broken for many people who then suffer the consequences of poor oral health; this is especially true for racial and ethnic minorities and lower income populations. Second, dental therapy is a proven, safe, high-quality, cost-effective, and ethical way to improve access to oral health care and oral health in general. Third, opposition to dental therapy comes only from the leadership of organized dentistry and is without an evidence base to support objections and criticism. This article reviews each of these three premises in detail. Based on this review, the article concludes that dental therapy is a safe, high-quality, effective, and ethical approach to improve the oral health workforce, increase access to dental care, and achieve oral health equity.

Using focus groups to design systems science models that promote oral health equity

BackgroundWhile the US population overall has experienced improvements in oral health over the past 60 years, oral diseases remain among the most common chronic conditions across the life course. Further, lack of access to oral health care contributes to profound and enduring oral health inequities worldwide. Vulnerable and underserved populations who commonly lack access to oral health care include racial/ethnic minority older adults living in urban environments. The aim of this study was to use a systematic approach to explicate cause and effect relationships in creating a causal map, a type of concept map in which the links between nodes represent causality or influence.MethodsTo improve our mental models of the real world and devise strategies to promote oral health equity, methods including system dynamics, agent-based modeling, geographic information science, and social network simulation have been leveraged by the research team. The practice of systems science modeling is situated amidst an ongoing modeling process of observing the real world, formulating mental models of how it works, setting decision rules to guide behavior, and from these heuristics, making decisions that in turn affect the state of the real world. Qualitative data were obtained from focus groups conducted with community-dwelling older adults who self-identify as African American, Dominican, or Puerto Rican to elicit their lived experiences in accessing oral health care in their northern Manhattan neighborhoods.ResultsThe findings of this study support the multi-dimensional and multi-level perspective of access to oral health care and affirm a theorized discrepancy in fit between available dental providers and patients. The lack of information about oral health at the community level may be compromising the use and quality of oral health care among racial/ethnic minority older adults.ConclusionsWell-informed community members may fill critical roles in oral health promotion, as they are viewed as highly credible sources of information and recommendations for dental providers. The next phase of this research will involve incorporating the knowledge gained from this study into simulation models that will be used to explore alternative paths toward improving oral health and health care for racial/ethnic minority older adults.

Elevating Oral Health Interprofessional Practice Among Pediatricians Through a Statewide Quality Improvement Learning Collaborative.

Because of persistent effects of early childhood caries and impacts of dental health professional shortages areas, the integration of oral health in primary care settings is a public health priority. In this study, we explored oral health interprofessional practice (OHIP) as an integrative pathway to reduce oral health disparities. OHIP can include performing oral health risk assessments, describing the importance of fluoride in the drinking water, implementing fluoride varnish application, and referring patients to a dental home. To conduct a formative evaluation of how 15 pediatric primary care practices implemented the adoption of OHIP in their clinical settings. Using an ecological framework, we conducted a qualitative process evaluation to measure the factors that inhibited and facilitated OHIP adoption into pediatric settings. Document review analysis and qualitative interviews were conducted with pediatric practices to contextualize challenges and facilitators to OHIP adoption. A total of 15 Children's Health Insurance Program Reauthorization Act pediatric practices located in 13 South Carolina counties participated in this study. Outcomes of interest were the facilitators and challenges of OHIP adoption into pediatric primary care practices. Thematic analysis revealed challenges for OHIP adoption including limited resources and capacity, role delineation for clinical and administrative staff, communication, and family receptiveness. OHIP training for clinical practitioners and staff and responsiveness from clinical staff and local dentists were facilitators of OHIP adoption. Twelve key recommendations emerged on the basis of participant experiences within OHIP, with developing an active dental referral network and encouraging buy-in from clinical staff for OHIP adoption as primary recommendations. We demonstrated the effectiveness of a learning collaborative meeting among pediatric primary care providers to adopt OHIPs. This work reveals an actionable pathway to support oral health equity advancement for children through an additional access point of preventive oral care, reinforcement of positive oral health behaviors, and interaction between parent and child for overall health and wellness of the family.

Advancing Oral Health Equity With Innovative Dental Approaches

Advancing Oral Health Equity With Innovative Dental Approaches

The Class Politics of Teeth

Mary Otto then delves into the disastrous condition of oral health in the United States. The state of our teeth reflects the inequities of our society, and in Otto's article, we meet disadvantaged individuals who suffer from the grave inadequacies of the American dental system. Achieving oral health equity will require a vision of universal healthcare that treats our teeth as an integral part of our bodies.

Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention.

Despite significant financial, training, and program investments, US children's caries experience and inequities continued to increase over the last 20 years. We posit that (1) dental insurance payment systems are not aligned with the current best evidence, exacerbating inequities, and (2) system redesign could meet health care's triple aim and reduce children's caries by 80%. On the basis of 2013 to 2016 Medicaid and private payment rates and the caries prevention literature, we find that effective preventive interventions are either (1) consistently compensated less than ineffective interventions or (2) not compensated at all. This economic and clinical misalignment may account for underuse of effective caries prevention and subsequent overuse of restorative care. We propose universal school-based comprehensive caries prevention to address this misalignment. Preliminary modeling suggests that universal caries prevention could eliminate 80% of children's caries and cost less than one fifth of current Medicaid children's oral health spending. If implemented with bundled payments based on cycle of care and measurable outcomes, there would be an alignment of incentives, best evidence, care, and outcomes. Such a program would meet the Healthy People Oral Health goals for children, as well as health care's triple aim.

Indian Country Leads National Movement to Knock Down Barriers to Oral Health Equity.

Tribal and other underserved communities are struggling under the weight of devastating oral health disparities. Tribes as sovereign nations are searching for innovative solutions to address their unique barriers to oral health care. Dental therapists are primary oral health providers who work as part of the dental team to provide a limited scope of services to patients. They were first brought to tribal communities by the Alaska Native Tribal Health Consortium. Despite strong opposition from the American Dental Association aimed at protecting its monopoly on oral health care, dental therapists are sweeping the nation. Evidence shows that they are effective and provide high-quality care, particularly in underserved communities. A community's ability to develop public health policy solutions tailored to its needs and priorities is essential in eliminating health disparities and achieving health equity. The Swinomish Indian Tribal Community is leading the way to more effective and efficient dental teams and working hard to lay the groundwork for the elimination of oral health disparities.

Achieving Equity in Oral Health: A Data-driven Approach for Informing Policy Changes

Due to the lack of access to affordable oral healthcare in outpatient settings, emergency departments (EDs) see unnecessary overuse in providing palliative care for mouth pain. Hospitals across the country are exhausting limited human and fiscal resources on patients seeking relief for non-traumatic oral conditions that could be better managed in nonhospital settings. Community dental clinics offer one strategy for easing the burden on EDs, while simultaneously reducing costs to the system, facilitating definitive care, and minimizing time away from work and home for patients. The expansion of government funding, including comprehensive adult Medicaid dental benefits, to facilitate preventive and restorative coverage for populations in need in outpatient settings would increase access to appropriate care and likely further reduce the tendency for patients to seek dental care in EDs. Targeting of specific high-risk groups (such as low-resourced or minority persons) also would help to remove barriers to care, lessen disparities in access and treatment, and improve equity in oral health in the U.S.

A Multi-level, Multi-Sector Oral Health Literacy Initiative to Reduce Oral Health Disparities and Achieve Health Equity: Early Lessons from the Maryland Model

The state of Maryland’s oral health literacy initiative experience serves as a case study. This experience was stimulated by the tragic death of Deamonte Driver in 2007 and highlights actions taken and lessons learned. It is a story of one state’s response, one that received strong support from state congressional and state legislative leaders, senior government leadership, multiple community and professional groups, foundations, and funding agencies. It is the hope that this experience can be used to inform other states that are working to enhance oral health promotion and disease prevention strategies, or other health conditions, for vulnerable populations.

Oral Health Provider Perceptions of Dental Therapists and Oral Health Equity in the Southeastern United States

Oral Health Provider Perceptions of Dental Therapists and Oral Health Equity in the Southeastern United States Purpose: A growing need for oral health care is challenged by the maldistribution of oral health providers and lack of opportunity to access oral health care in the current system among underserved populations. Emerging workforce models, such as dental therapists, is one option for improving oral health equity and promoting access across racial/ethnic and socio-demographic groups while addressing those who suffer from disparate lack of access. The purpose of this study is to investigate existing dental workforce perspectives in several southeastern states about emerging workforce models, specifically dental therapists, as a first step in moving toward workforce diversity and oral health equity. Procedures: Sixteen dental clinicians participated in focus group research. Findings: Open coding and the constant comparative method was used to analyze the data. Five themes emerged. Conclusions: The findings showed that participants held exclusionary and contradictory attitudes toward providing care to marginalized and underserved groups, questioned whether dental therapists had the training and skill to practice certain procedures and were most concerned about maintaining their own economic security. Findings were characterized by an absence of cultural competency and a resistance to intellectual inquisitiveness. Dialogue about how to address oral health inequity for the poor and underserved was given scant attention. These findings raise serious concerns as to whether dentists will become collaborative with other sectors of society to remedy the social policies that lead to oral health disparities and are willing to address the inequitable pain and suffering among those without access to oral health care.