Oral Health Equity for Minority Populations in the United States
- LAST MODIFIED: 11 January 2018
- DOI: 10.1093/obo/9780199756797-0172
- LAST MODIFIED: 11 January 2018
- DOI: 10.1093/obo/9780199756797-0172
Along with the Oxford Bibliographies in Public Health article “Dental Public Health,” this article hopes to achieve the objective of reconnecting the mouth to the rest of the body of public health on this platform. Other commissioned bibliographies on evidence-based pediatric dentistry and global oral disease will follow, so this guide will focus primarily, but not exclusively, on adult populations in the United States. While improved nutrition and living standards after World War II have enabled certain population groups to enjoy far better oral health than their forbearers did a century ago, not all Americans have achieved the same level of oral health and well-being. Indeed, people are much more likely to have poor oral health if they are low-income, uninsured, and/or members of minority populations or other high-risk groups who do not have access to oral health care. Oral health equity for minority populations is a social justice issue, and it rightly belongs in the purview of public health. To achieve this goal, it is necessary to address the root causes of current inequities. These include poverty and the increasing gap between the “haves” and “have nots”; maldistribution of resources within society, including oral health care services; racism and other forms of discrimination; weak laws or lack of enforcement of laws protecting human rights; and disenfranchisement of groups from the political process. While evidence-based strategies to prevent dental caries (including fluoride use and dental sealants) have been known for decades, dental caries remains a prevalent chronic disease across the lifespan in the United States and around the world. This situation is both infuriating and tragic, since dental caries is a highly, if not entirely, preventable disease. As a step forward, it is essential for public health to reclaim oral health as part of its mandate. The division between oral health and health writ large is reinforced by the fact that dentists, dental hygienists, and dental assistants are separated from other health care professionals in virtually every way: where they are trained, how their services are reimbursed, and where they provide oral health care. If and when US society is able to ensure respectful and accessible health care that includes comprehensive oral health care to everyone regardless of race/ethnicity, socioeconomic position, age, gender, sexuality, immigration status, or geographic location, it will move closer to achieving oral health equity for minority populations. Partial support for M. E. Northridge was provided by a grant from the National Institute of Dental and Craniofacial Research and the Office of Behavioral and Social Sciences Research of the National Institutes of Health (Integrating Social and Systems Science Approaches to Promote Oral Health Equity, award R01DE023072).
This section provides the rationale for using a public health approach to understand and address oral health equity for minority populations. The authors of Allukian and Horowitz 2006 have training in dentistry and dental hygiene, and are leading advocates of a preventive approach to oral disease. Treadwell and Northridge 2007 provides the basis for considering oral health as a social justice issue. The classic report on water fluoridation as one of the ten greatest public health achievements of the 20th century is also key to understanding evidence-based population-level interventions to improve oral health (Centers for Disease Control and Prevention 1999). Two reports, Sullivan Commission 2004 and Mertz, et al. 2016, target increasing diversity in the health care workforce, including dentistry. Sullivan Commission 2004 makes the case that racial/ethnic diversity in medicine, nursing, and dentistry will not only improve health care access and quality for minority populations, but also assure a sound health care system for everyone. Mertz, et al. 2016 documents through quantitative analysis how inadequate the cumulative impact of policy efforts to increase workforce diversity have been to date. The accessible text Benzian and Williams 2015 is a call to action on the unacceptable global burden of oral disease. A collection of papers centered on this text was recently published as an issue of the Journal of the Academy of Distinguished Educators, with an emphasis on the impact of global oral health on dental education; it includes an insightful contribution, Cunha-Cruz and Senturia 2017, on the need for systematic evaluative evidence on the benefits of international service-learning initiatives. Watt 2007 argues for upstream action to tackle the social determinants of oral health inequalities, noting that a downstream approach narrowly focused on changing the behaviors of high-risk individuals has failed to effectively reduce the oral health equity gap.
Allukian, M., and A. M. Horowitz. 2006. Oral health. In Social injustice and public health. Edited by B. S. Levy and V. W. Sidel, 359–378. New York: Oxford Univ. Press.
This chapter describes the impact of social injustice on oral health. The authors first define oral health and describe the oral disease epidemic. They then discuss US national priorities, local and state priorities, school programs, dental public health infrastructure, the dental workforce, and practices of the food and tobacco industries. They end by advocating for strategies to improve oral health and reduce the impact of social injustice on oral health.
Benzian, H., and D. Williams, eds. 2015. The challenge of oral disease: A call for global action. Brighton, UK: Myriad Editions.
This text views the state of global oral health through a public health and population-focused lens and is explicitly directed at policymakers and opinion leaders. The stated purpose is to act as an advocacy resource for oral health care professionals and those concerned about the unacceptable global burden of oral disease. The book brings together information, data, and facts on a broad range of topics related to oral health. Published by Myriad for the FDI World Dental Federation.
Centers for Disease Control and Prevention. 1999. Achievements in public health 1900–1999: Fluoridation of drinking water to prevent dental caries. Morbidity and Mortality Weekly Report 48.41: 933–940.
This report recognizes community water fluoridation as one of the ten great public health achievements of the 20th century, provides a brief history of water fluoridation, and describes the decline in dental caries. The overall conclusion is that while other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.
Cunha-Cruz, J., and K. D. Senturia. 2017. Moving beyond charitable dental missions: The pursuit of equitable partnerships to reduce oral health disparities. In Special issue: Global oral health: Its impact on dental education. Edited by Elyse Bloom. Journal of the Academy of Distinguished Educators 5.1: 15–17.
Part of a collection of papers is centered on the text The challenge of oral disease: A call for global action (Benzian and Williams 2015). The contribution by Cunha-Cruz and Senturia on moving beyond charitable dental missions is of special interest. They argue that systematic evaluative evidence is lacking that international service-learning benefits dental students, universities, the US health care system, the host countries, or the communities being served.
Mertz, E. A., C. D. Wides, A. M. Kottek, J. M. Calvo, and P. E. Gates. 2016. Underrepresented minority dentists: Quantifying their numbers and characterizing the communities they serve. Health Affairs 35.12: 2190–2199.
This article quantifies the shortage of underrepresented minority dentists. The cumulative impact of policy efforts to increase workforce diversity is inadequate. Dentists who want to serve high-need communities may be unable to do so, given the current economics of the dental practice environment. Improving the diversity of the dental workforce would involve investing in a longer, deeper, and sustained pipeline; robust systems of care; and a genuine culture of inclusion.
Sullivan Commission. 2004. Missing persons: Minorities in the health professions; A report of the Sullivan Commission on diversity in the healthcare workforce.
This report makes the case that racial/ethnic diversity in medicine, nursing, and dentistry will improve health care access and quality for minority patients and assure a sound health care system for everyone. Further, it will strengthen health care delivery systems at multiple levels, enhance educational experiences for all health professions students, promote relevant research and needed changes in health policy, and serve the cause of social justice.
Treadwell, H. M., and M. E. Northridge. 2007. Oral health is the measure of a just society. Journal of Health Care for the Poor and Underserved 18.1: 12–20.
When entire communities suffer from poor oral health, it becomes a social justice issue that merits concerted attention. If and when US society is able to ensure respectful and accessible health care that includes comprehensive oral health care to everyone regardless of race/ethnicity, socioeconomic position, age, gender, sexuality, or immigration status, then the United States will have achieved the measure of a just society: oral health for all.
Watt, R. G. 2007. From victim blaming to upstream action: Tackling the social determinants of oral health inequalities. Community Dentistry and Oral Epidemiology 35.1: 1–11.
This influential paper argues that the dominant preventive approach in dentistry—narrowly focusing on changing the behaviors of high-risk individuals—has failed to effectively reduce oral health inequalities, and may indeed have increased the oral health equity gap. Instead, a conceptual shift is needed away from this biomedical and behavioral (also known as downstream) approach, to one that addresses the social determinants of population oral health (upstream approach).
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