As the world wages battle against the new coronavirus, a much older war has yet to be won.
More white Americans and citizens of the world are awakened to the reality that racism—covert and overt—exists and needs to be confronted. It exists in every facet of our lives and is overwhelming in medicine and dentistry.
In this article, we take a look at the reality of racial inequality when it comes to oral health. We enlist the help of two experts and members of the American Dental Association: Jane Grover, D.D.S., M.P.H., Director of the Council on Advocacy for Access and Prevention for the A.D.A. and Cheryl D. Watson-Lowry, D.D.S., a general dentist in Chicago, IL.
With their industry knowledge, we aim to figure out what we need to do going forward to ensure that everyone has equal access to quality dental care.
“When the oral health of the community improves, the overall health of the community improves.”
Access to care
There are various barriers that non-white patients come up against when looking for quality oral health care. Some of these are a result of a combination of gender, sex, race and socioeconomic status; some have cultural aspects, some are language-related.
The solution won't be one size fits all, but nuanced and always mindful of the intersectionality of race, class, culture, geography, gender and other factors. In this article, we examine race as it intersects with class, geography, and language as a significant factor in disparities in oral health care.
“If you can't communicate with a patient, you can't provide care.”
It may seem obvious, but understanding your dentist clearly, and vice versa, is essential for proper care. The failure to provide adequate interpreting services has many adverse outcomes. It can result in severe health complications; it can mean that a patient can't communicate what hurts to their dentist; it means patients can't disclose any existing conditions or allergies to drugs. It can also mean the patient doesn't understand care instructions from their dentist.
In fact, according to Mara Youdelman, who is an attorney at the National Health Law Program in Washington D.C., in an interview with NPR, “If you can't communicate with a patient, you can't provide care.”
Patients who have limited fluency in English might not understand their diagnoses, and they are likely to experience more pain and anxiety. If you have any kind of anxiety when it comes to going to the dentist, imagine how much it would amplify if you couldn't tell your dentist about your medical history, pain, or even the anxiety itself.
Approximately 25.9 million people in the United States speak or understand English with limited proficiency. Most oral health care providers are likely to treat some patients whose first language isn't English. Title VI of the Civil Rights Act decrees that healthcare centers that offer federal financial assistance like Medicaid must provide interpreters for patients with limited English proficiency (LEP). Research provides evidence that the use of professional interpreters reduces disparities and improves clinical outcomes among LEP patients.
However, despite the laws that are in place, physicians are often unfamiliar with the legal requirements for having an interpreter, or they simply lack the funding to provide one, especially in facilities that accept Medicaid. In a survey conducted by the American Hospital Association, only 56% of hospitals offered linguistic and translation services. There's a lack of enforcement, and a lack of funding, even though a study from 2017 showed that if hospitals provided consistent access to interpreters, they would have fewer readmissions and save around $160,000 per month on patient care.
According to the American Student Dental Association, geography is one of the most common barriers to accessing dental care. There are huge disparities when it comes to levels of oral health care for rural populations compared with urban populations. And ruralhealthweb.org reports that rural communities have fewer dentists and more cavities and permanent tooth loss than urban communities.
According to the professional community, the reasons for this lack of care are geographic isolation; a more significant percentage of elderly, low-income and uninsured; provider shortages; and providers that don't accept Medicaid.
This is a big deal because 16% of rural residents have Medicaid, versus 13% of urban residents, and 35% of rural children are on Medicaid, versus 28% of urban children. The lack of access to oral health care isn't just devastating for patients. It also has a significant financial impact on rural health care systems, because patients have to rely more on emergency rooms for dental issues that a dentist could resolve.
Additionally, the inadequate care provided by the emergency department staff, through no fault of their own since they aren't dental specialists, could lead to repeat visits to the ER.
All in all, around 43% of rural Americans lack access to dental care. One of the solutions offered is to have more dentists in rural areas. The National Health Service Corps program provides loan assistance to doctors and dentists who are willing to work for two years in an area where there is a shortage of providers.
Lack of funding
However, just bringing in more dentists is unlikely to solve the problem. That's because if those providers don't offer sliding scale fees, or coverage for Medicaid, people still won't be able to afford the dentist.
To paraphrase an interview with a dentist from West Virginia in the Washington Post, it's a vicious cycle. Many dentists have hundreds of thousands of dollars in school debt, so they are reluctant to work in rural areas where people don't have money to pay. Thus, rural residents suffer from deteriorating oral health which will require even more money and expertise to fix.
Poverty isn't just a problem in rural areas. It's ubiquitous in cities as well, and although there are poor whites and Asians, poverty disproportionately affects Black, Hispanic, and American Indian/Alaska Native households in America. In 2018, according to a survey by the Kaiser Family Foundation, 9% of the white population lived below the poverty line, 22% of the black population, 19% of the Hispanic population, 11% of the Asian population and 24% of the American Indian and Alaska Native population.
According to Dr. Watson-Lowry, for people living in underserved communities, accessible locations for dental care are limited. When care is offered, it's usually just the bare minimum. She attributes part of the problem to inadequately funded Medicaid plans in many states.
Not all discrimination is conscious. In a survey in the J.D.R. Clinical & Translational Research, 57 dentists were given a clinical scenario, with either a black or white patient with a decayed tooth and symptoms of irreversible pulpitis. The survey measured explicit bias in terms of the course of treatment that the dentists recommended to their patients, and perception of patient dental cooperativeness.
The results were that dentists recommended root canal treatment, a tooth-saving procedure, for their white patients more than for their black patients. This led to a higher likelihood of extractions for black patients, while white people were able to get root canals and keep their natural teeth. We discuss the consequences of poor oral health in more detail below, but they are real and life-changing, both socially and professionally.
Another example from Harvard Medical School's blog talks about a patient who experienced inferior treatment because she was black. When she went to the emergency room with a terrible toothache, the emergency room staff thought she was just seeking pain medication for a drug habit, and she had to go elsewhere to get the help she needed.
White readers may think this the exception, that this particular ER staff had biases when most don't, while many non-white readers may know this as their own personal reality.
Most of the time, this is unconscious bias on the part of dentists, most of whom would probably shudder at the idea of having such prejudices. But even so, they operate in an inherently racist system, and excuses for allowing unconscious biases to dictate how doctors deliver care have way past expired.
One of the solutions to this problem could be to make sure there are more black oral health care providers. But inequality exists among dental professionals as well. The black dentists that are practicing have higher educational debt than all other dental students, and they also are responsible for a disproportionate share of black patients.
In fact, 2 out of 5 black dentists report that their patient pool consists of more than 50% black patients. If black and minority patients are less likely to have the resources to pay full price for their dental care, and black dentists are disproportionately caring for black patients, the black dentists themselves have a more difficult time getting out of debt and climbing the socioeconomic ladder.
Dr. Watson-Lowry also says that often, quality care isn't provided to people of color in more impoverished communities because some practitioners think that their patients won't understand their condition, or won't be able to afford quality care.
She says that to reduce inequities, there must be more health care providers from these communities, who will work as a provider there and provide oral health education and dental care. But for this to happen, there must be a system in place that ensures they get paid, even if their patients can't afford the care.
When people don't have access to dental care, the consequences are wide-ranging. Periodontal disease is one of the main risks and in turn, increases the risk of cancer and cardiovascular diseases. Bacteria in oral infections can also circulate to other parts of the body, contributing to strokes and heart disease. And then there are the more obvious consequences, like loss of teeth and excruciating pain, which can lead to an unhealthy diet, because a crispy, firm apple or carrot doesn't exactly sound appealing when you've got painful teeth.
People with poor oral health are stigmatized, whether it comes to social or professional life. Unfortunately and unjustly, physical appearance is an important factor in social interaction. But we also make judgments about the intelligence of others based on their dental appearance. And 1/3 of adults below 138% of the poverty level say that the esthetics of their teeth affects their ability to interview for a job. In contrast, only 15% of adults above 400% of the federal poverty level said the same.
Additionally, 23% of adults are embarrassed about the condition of their mouth and teeth, so they aren't as socially active as they would otherwise be. 1 in 4 adults avoid smiling because of their teeth, and 1 in 5 adults experience anxiety because of their teeth. There's a strong correlation of mental health concerns and oral health.
What we can do about it
In terms of access to dental care financially, Dr. Watson-Lowry says that to improve care, adequate reimbursement levels need to be instituted and that this reimbursement should cover the overhead required to provide care, at least.
Reimbursement should also cover preventive care and patient education, about diet, oral hygiene, and restorative options. Along with this, there need to be fewer extractions, because these are a temporary solution to a more significant problem, and ultimately negatively impact the patient's overall health.
What can dental professionals do?
Dr. Watson-Lowry says that dental professionals need to educate their medical colleagues on good oral health and maintenance. If pediatricians could add basic oral care to their practice, with regular dental visits and diet tips, that would go a long way toward preventing cavities in childhood and future health problems. Primary care practitioners can ask patients when their last dental visit was and provide their patients with resources to find care near them.
Dr. Jane Grover agrees with her colleague; medical students should get basic oral health training, specifically during years 1 and 2, with continuing online education accompanied by in-person lectures. Additionally, there should be a joint medical-dental provider meeting every year to discuss bidirectional referrals, ensuring patients who see a dentist also see their primary care physician and vice versa.
What can members of the public do?
Dr. Watson-Lowry says there are several ways the public can help, mostly at the legislative level.
Funding for Medicaid
- We must expand funding for Medicaid-covered dental services to include preventive, restorative, and periodontal care.
- Medicaid dental funding must at least cover the average overhead costs of providing the services.
Oral health education
- Follow the example of a program in Massachusetts schools run by the Massachusetts Coalition for Oral Health. This program teaches good oral health habits in school. It began in response to the death of Deamonte Driver, a 12-year-old boy who died from an untreated abscessed tooth.
- Additionally, in this program, teachers are made aware that the leading cause for absences of students from school is pain from tooth decay. This pain also makes it difficult for students to focus while they are in school. Trouble in school early on has lifelong effects on success.
- Teachers can incorporate information about healthy oral habits as part of reading assignments, integrating it into the curriculum, instead of creating additional work.
Community Dental Health Coordinators (CDHCs)
- Hire a sufficient amount of CDHCs who will be working in their own communities, to help patients navigate when and where to receive care.
- Because of their familiarity with the community in which they work, they can offer reliable advice and help find appropriate solutions.
“Speak up and make your voices heard to state legislators, state agencies, and the media.”
Dr. Jane Grover says that congress won't make policy changes to help their constituents if they don't hear that change is needed. Everyone should vote for candidates that keep their best interests in mind, and who commit to funding programs that will benefit their communities.
NPR.org: With Scarce Access To Interpreters, Immigrants Struggle To Understand Doctors' Orders. Consulted 9th July 2020.
Journal of Health Care for the Poor and Underserved: From Admission to Discharge: Patterns of Interpreter Use among Resident Physicians Caring for Hospitalized Patients with Limited English Proficiency. Consulted 9th July 2020.
NCBI: Interpreting at the End of Life: A Systematic Review of the Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients With Limited English Proficiency. Consulted 9th July 2020.
American Hospital Association: AHA Hospital Statistics, 2018 Edition. Consulted 9th July 2020.
NCBI: Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients with Limited English Proficiency. Consulted 9th July 2020.
Rural Health Information Hub: Oral Health in Rural Communities. Consulted 9th July 2020.
Ruralhealthweb.org: Rural America's Oral Health Care Needs. Consulted 9th July 2020.
Nhsc.hrsa.gov: National Health Service Corps Loan Repayment Program. Consulted 9th July 2020.
Washingtonpost.com: Cavity Country. Consulted 9th July 2020.
Kff.org: Poverty Rate by Race/Ethnicity. Consulted 9th July 2020.
JDR Clinical & Translational Research: Unconscious Racial Bias May Affect Dentists' Clinical Decisions on Tooth Restorability: A Randomized Clinical Trial. Consulted 9th July 2020.
Health.harvard.edu: Racism and discrimination in health care: Providers and patients. Consulted 9th July 2020.
Researchgate.net: Black dentist workforce in the United States. Consulted 9th July 2020.
NCBI: Periodontal Disease, Tooth Loss, and Cancer Risk in Male Health Professionals: A Prospective Cohort Study. Consulted 9th July 2020.
NIDCR: 2000 Surgeon General's Report on Oral Health in America. Consulted 9th July 2020.
The International Journal of Prosthodontics: The Impact of Dental Appearance on the Appraisal of Personal Characteristics. Consulted 9th July 2020.
NCBI: Integrating Oral, Physical, and Mental Health Via Public Health Literacy. Consulted 23rd February 2022.