This course was published in the September 2022 issue and expires September 2025. The author has no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
AGD Subject Code: 558
After reading this course, the participant should be able to:
- Discuss oral health disparities faced by refugee populations.
- Identify the most significant influences on barriers to care experienced by refugee populations.
- List strategies to address barriers to care.
New refugees are a vulnerable population, with the majority being of low socioeconomic status (SES).1 Individuals of low SES experience more health disparities and poorer health outcomes than those of higher SES.2,3 This finding also holds true for oral health disparities and oral health outcomes.4 The increase in the number of new refugees across the globe requires an examination of oral healthcare access to ensure that dental needs can be met.5
Access to Care and Oral Health Disparities
Access to oral care is essential as preventive oral care and early treatment of oral disease improve overall oral health and systemic health status throughout the life course.5 During discussions regarding access to oral healthcare for new refugees, the high cost of care and the lack of, or limitations of, existing oral healthcare coverage are often the main focus.6 As such, public health and insurance policies need to be restructured in order to provide financial coverage for oral care.7 Research, however, has shown that the presence of dental insurance does not necessarily lead to increased utilization of oral healthcare services. This suggests a need to explore the impact of other social determinants of health—such as culture—to inform oral health public policy and practice.8–11 Language, customs, beliefs, and knowledge are all aspects of culture that may influence dental care, oral health status, and risk for oral health disparities.12–19
Language as a Barrier to Care
Health outcomes improve when patients receive care in their own language.20 In the United States, the Joint Commission mandates that all patients of low English proficiency have access to interpreter services when seeking medical care.21 However, dental care is less likely to be provided in settings accredited by the Joint Commission, resulting in a dramatic underutilization of interpretation services.22
Across Canada, interpretation services in healthcare settings are delivered by provincial agencies, regional health authorities, and individual healthcare organizations. While interpretation for American Sign Language and French are mandated by law, there is no equivalent for healthcare delivery in other languages. Interpretation services may be available for some languages in urban healthcare settings, but these services are sparse or nonexistent in rural settings.23 The exclusion of oral healthcare outside of universal health plans means the responsibility of arranging and financially compensating interpreters lies with individual oral healthcare providers, or the patient.24
The inability to access oral healthcare in their own language is a significant barrier for new refugees, the majority of whom do not speak English.13 New refugees often attempt to overcome this barrier by using family members as interpreters. This may result in misunderstandings and possible omission of key information.14 Refugees have also reported feeling misunderstood and humiliated, as well as prevented from receiving appropriate care due to the language barrier, resulting in unwillingness to seek out dental care in the future.25
Dentists and dental hygienists may be concerned with potential ethical implications when treating refugees who speak a language other than their own, as obtaining informed consent for proposed treatment prior to the initiation of services is required.26–29
Cultural Oral Beliefs
While the cultural beliefs and values of refugees are not homogenous, a scoping review by Keboa et al13 identified certain patterns of belief among refugees from various cultures that contribute to a lower likelihood of accessing oral healthcare. One such pattern is the value placed on natural teeth by older refugees. Many older refugees report feeling they have little control over the health of their teeth and, therefore, are less likely to attempt to access oral care. The value placed on natural teeth may be impacted by low oral health literacy and, as such, there may be a lack of knowledge surrounding the benefit and need for restorative treatments. This may contribute to the high rate of untreated oral disease in this population.12,13,30
Another pattern of belief is that preventive oral care is unnecessary. Some refugee populations may believe that oral healthcare visits are only required if an individual is experiencing pain.15,18 This assumption appears to be based on cultural norms in refugees’ countries of origin where access to oral care was limited.13,16 While 65.5% of adults in the US report visiting a dentist in the past 12 months for preventive care, a review by Batra et al15 indicates this percentage is significantly lower among refugee populations. When pain is the impetus for seeking dental care, the treatment is often extraction, resulting in a negative experience. Negative dental experiences are associated with a lack of willingness to seek future oral healthcare.18,31,32
A common belief among refugee parents is that primary teeth are not important and that tooth decay in primary teeth is inevitable.12,18,33–35 The current recommendation by the American and Canadian Dental Associations is that children are seen by a dentist by age 1 or within 6 months of the eruption of their first tooth.36,37 This recommendation stems from the desire to evaluate risk factors, such as diet and at-home oral hygiene practices, for developing caries, and to mitigate these risks through education of parents/caregivers. In addition to the pain caused by childhood caries, early loss of primary teeth can impact a child’s growth and development due to the effect on mastication. Caries can also affect the eruption pattern of permanent teeth, negatively impacting the permanent dentition.
Oral HealthCare Practices
Culturally influenced oral health behaviors vary between refugee populations. Methods for oral care may be considered unconventional when compared to North American standards such as the use of toothbrush, toothpaste, and floss for daily oral care. Many Horn of Africa, Middle Eastern, and South Asian populations use a miswak (also known as ade, adhei, adega, muswaki, and siwak)—a stick harvested from a tree—rather than a toothbrush, to remove plaque biofilm from their teeth (Figure 1). This is particularly common with refugees from Somalia and Sudan.17,38 The use of the miswak is most common in countries with large Muslim populations, where the use of the stick is intricately tied to religion and can be traced back to Islamic teachings.17
African refugees report using banana stems with carbon powder and plant leaves with ash accompanied by cotton, cloth, or fingers for oral cleaning.39 In a study of Sudanese refugees by Willis and Bothun,38 participants reported mixing ash from cow dung fires with water to make a paste to clean their teeth in addition to using reeds and grasses for interdental cleaning. While the efficacy of some of these unconventional methods for removing plaque biofilm is demonstrated in the literature, other research suggests they are ineffective.19,38 Regardless, refugee populations may not be able to access traditional oral hygiene aids in the country of resettlement, which negatively impacts their oral hygiene practices.25
Cultural Oral Customs
Among the Dinka and Nuer, two groups of Sudanese refugees, there is a cultural beautification custom of removing the lower front teeth. While not all refugees from these groups have taken part in this custom, at one time, it was mandatory for all boys and girls upon the eruption of the permanent teeth.38,40 Willis and Bothun38 discuss the implications of this custom when refugees who have taken part in this practice, settle in another country. The loss of the lower front teeth impacts the ability to chew as well as speech patterns. While the missing teeth may not pose a challenge when adhering to the traditional soft diets in the country of origin, their loss makes it more difficult to consume many foods that are part of the Western diet, increasing consumption of soft, processed foods high in sugar that elevate caries risk. Missing teeth are also regarded differently in Western culture where it is considered undesirable and viewed as indicative of lower SES.38
While most refugees understand the potential role of sugar in the formation of caries, a gap in the knowledge surrounds exactly which foods may be contributing factors.18 This is compounded by an unfamiliarity with foods available in countries of resettlement.17 In a study by Hunter et al,17 Somalian refugees reported learning that sugar would damage their teeth, but when asked what foods in particular could play a role in this process, they referred only to dates and homemade candies made from sesame seeds and honey. This gap in knowledge can negatively affect the ability of refugees to make sound dietary choices when many foods common in their countries of resettlement—such as crackers, cookies, juices, and sodas—contain refined sugars that contribute to caries risk.17–19,41
Chewing the khat plant, a known stimulant, also increases the risk for caries (Figure 2). This practice is common in refugee camps to ward off boredom and for celebratory occasions. The plant is very bitter, so to offset the bitterness, it is common to drink highly sweetened tea or soda, or to place a sugar cube between the lower lip and front teeth while chewing. This sugar provides a substrate for oral bacteria to produce acid, which demineralizes the tooth surface.17
Addressing the Cultural Barrier
Oral health professionals need to increase their cultural humility to minimize barriers to dental care for new refugees.10,15,18,25 Patrick et al10 stress the need for action at the government and community level to address the oral health disparities faced by refugees. At the government level, Patrick et al recommend policies that consider culture as a means to increasing access to oral healthcare and combat discriminatory practices by oral health professionals who may be reluctant to accept refugees as patients. At the community level, Patrick et al discuss the need to develop local oral health clinics staffed by community members who understand common cultural practices to help bridge cultural gaps between providers and patients.
Many factors contribute to oral health disparities faced by refugees, with barriers to care in their country of origin and in the country of resettlement serving as the most significant. While financial barriers are often discussed, access to care and oral health disparities need to be focused on from a cultural perspective. Cultural factors—such as language, beliefs, customs, and knowledge—impact the oral health status of new refugees upon their arrival in the country of resettlement but may also present barriers to accessing immediate and continued preventive oral care. While it is not possible to examine all the intricacies of the various cultures of the entire refugee population, common patterns exist and specific cultural practices of the more common refugee populations can be examined. More research is needed to advise oral health policy and practice for these vulnerable populations.
- Picot G, Lu Y. Chronic Low income among immigrants in Canada and its Communities.. Available at: 150.statcan.gc.ca/n1/pub/著f0019m/著f0019m2017397-eng.htm. Accessed August 17, 2022.
- Matthew P, Brodersen DM. Income inequality and health outcomes in the United States: An empirical analysis. Soc Sci J. 2018;55:432–442.
- McMaughan DJ, Oloruntoba O, Smith ML. Socioeconomic status and access to healthcare: interrelated drivers for healthy aging. Front Public Health. 2020;8:23.
- Northridge ME, Kumar A, Kaur R. Disparities in acess to oral health care. Annu Rev Public Health. 2020;41:513-535.
- Peres MA, Macpherson LMD, Weyant RJ, et al. Oral diseases: a global public health challenge. The Lancet. 2019;394:249–260.
- Hoang H, Feike S, Lynden T, Barnett T, Crocombe L. Oral health needs of older migrants with culturally and linguistically diverse backgrounds in developed countries: A systematic review. Australas J Ageing. 2020;39:193–208.
- Allin S, Farmer J, Quiñonez C, et al. Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions. Health Policy. 2020;124:998–1007.
- Lee JY, Divaris K. The ethical imperative of addressing oral health disparities: A unifying framework. J Dent Res. 2014;93:224–230.
- Butani Y, Weintraub JA, Barker J. Oral health related cultural beliefs for four racial/ethnic groups: assessment of the literature. BMC Oral Health. 2008;8:26.
- Patrick D, Yin Lee R, Nucci M, Grembowski D, Milgrom P. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006;6(Supp 1):S4.
- Hayes A, Azarpazhooh A, Dempster L, Ravaghi V, Quinonez C. Time loss due to dental problems and treatment in the Canadian population: analysis of a nationwide cross-sectional survey. BMC Oral Health. 2013;13:17.
- Goldsmith C, Slack-Smith L, Davies G. Dentist-patient communication in the multilingual dental setting. Aust Dent J. 2005;50:235–241.
- Keboa MT, Hiles N, Macdonald ME. The oral health of refugees and asylum seekers: A scoping review. Glob Health. 2016;12
- Woll A, Quick K, Mazzei C, Selameab T, Miller J. Working with interpreters as a team in health care (WITH Care) curriculum toolkit for oral health professionals. MedEdPortal. 2020;16:10894.
- Batra M, Gupta S, Erbas B. Oral health beliefs, attitudes, and practices of South Asian migrants: a systematic review. Int J Environ Res Public Health. 2019;16:1952.
- Garcia RI, Cadoret CA, Henshaw M. Multicultural issues in oral health. Dent Clin North Am. 2008;52:319.
- Hunter Adams J, Young S, Laird L, et al. The cultural basis for oral health practices among Somali refugees pre- and post- resettlement in Massachusetts. J Health Care Poor Underserved. 2013;24:1474–1485.
- Crespo E. The importance of oral health in immigrant and refugee children. Child Basel. 2019;6:102.
- Hoyvik A, Lie B, Grjibovski A, Willumsen T. Oral health challenges in refugees from the Middle East and Africa—a comparative study. J Immigr Minor Health. 2019;21:443–450.
- Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A systematic review of the Impact of patient–physician non-English language concordance on quality of care and outcomes. J Gen Intern Med. 2019;34:1591–1606.
- Joint Commission Resources Inc. Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, Illinois: 2016.
- Simon L, Hum L, Nalliah R. Training to care for limited English proficient patients and provision of interpreter services at US dental school clinics. J Dent Educ. 2017;81:169–177.
- Sultana A, Aery A, Kumar N, Laher N. Wellesley Institute Works in Research and Policy to Improve Health and Health Equity in the GTA through Action on the Social Determinants of Health. Available at: wellesleyinstitute.com. Accessed August 17, 2022.
- Amin M, Elyasi M, Schroth R, et al. Improving the oral health of young children of newcomer families: a forum for community members, researchers, and policy-makers. J Can Dent Assoc. 2014;80:e64.
- Keboa M, Hovey R, Nicolau B, Asfandiari S, Carnevale F, Macdonald ME. Oral healthcare experiences of humanitarian migrants in Montreal, Canada. Can J Public Health. 2019;110:453–461.
- Canadian Dental Association. CDA Principles of Ethics. Available at: cda-adc.ca/en/about/ethics. Accessed August 17, 2022.
- Canadian Dental Hygienists’ Association. Dental Hygienists’ Code of Ethics. Available at: files.cdha.ca/Profession/Resources/Code_of_Ethics_EN_web.pdf. Accessed August 17, 2022.
- American Dental Association. Principles of Ethics and Code of Professional Conduct. Available at: ada.org/-/media/project/ada-organization/ada/ada-org/files/about/ada_code_of_ethics.pdf?rev=86aeaa6fb0d0467f8a380a3de35e8301&hash=89BAA88FB9305B8F134414E337CAE55A. Accessed August 17, 2022.
- American Dental Hygienists’ Association. ADHA Bylaws and Code of Ethics. Available at: adha.org/resources-docs/쭫_Bylaws_and_Code_of_Ethics.pdf. Accessed August 17, 2022.
- Ghiabi E, Matthews DC, Brillant MS. The oral health status of recent immigrants and refugees in Nova Scotia, Canada. J Immigr Minor Healt. 2014;16:95—101.
- Cha AE, Cohen R. Urban differences in dental care use among adults aged 18-64. Available at: dx.doi.org/葖.15620/cdc:106856external icon. Accessed August 17, 2022.
- Appukuttan D. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35–50.
- Reza M, Amin M, Sgro A, et al. Oral health status of immigrant and refugee children in North America: a scoping review. J Can Dent Assoc. 2016;82:3.
- Riggs E, Gibbs L, Kilpatrick N, Gussy M, van Gemert C, Ali S. Breaking down the barriers: A qualitative study to understand child oral health in refugee and migrant communities in Australia. Ethn Health. 2015;20:241–257.
- Ng MW. Multicultural influences of childrearing practices: implications for today’s pediatric dentist. Pediatr Dent. 2003;25:19–22.
- Meyer F, Enax J. Early childhood caries: epidemiology, aetiology, and prevention. Int J Dent. 2018;2018:1415873,
- Segura A, Boulter S, Clark M, et al. Maintaining and improving the oral health of young children. Pediatrics. 2014;134:1224-1229.
- Willis M, Bothun R. Oral hygiene knowledge and practice among Dinka and Nuer from Sudan to the U.S. J Dent Hyg. 2011;85:306–315.
- Riatto S, Montero J, Perez D, Castano-Seiquer A, Dib A. Oral health status of Syrian children in the refugee centre of Melilla, Spain. Int J Dent. 2018;2018:2637508.
- Wolf M. Missing front teeth in exile Tamils- an unresolved phenomenon. Soc Sci Med. 1996;43:1057–1062.
- Geltman P, Hunter Adams J, Cochran J, et al. The impact of functional health literacy and acculturation on the oral health status of Somali refugees living in Massachusetts. Am J Public Health. 2013;108:1516–1523.
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From Dimensions of Dental Hygiene. September 2022; 20(9)28,31-33.