The Time for Oral Health Equity Is Now

The views the author expresses in this essay are his own and do not reflect the official viewpoints of any organizations he is associated with.

The World Health Organization defines equity as “the absence of avoidable, unfair, or remedial differences among groups of people, whether these groups are defined socially, economically, demographically, or by other means of stratification. ‘Health equity’ or ‘equity in health’ implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”¹ The COVID-19 pandemic has clearly exposed racial and ethnic disparities or inequities in overall health. The purpose of this commentary is to address racial and ethnic oral health disparities, their consequences on individual patients and society as a whole, and the role of dental therapists in addressing these problems.

RACIAL AND ETHNIC ORAL HEALTH DISPARITIES

Oral infections, such as dental caries and periodontal diseases, are preventable and manageable but they do not self-resolve. Consequently, access to quality dental care is a key and necessary aspect of achieving oral health equity. Significant data indicate that certain demographic groups suffer due to oral health disparities including rural populations, the elderly, low-income and even middle-income groups, those living in institutions, people of color, and children.

The United States Centers for Disease Control and Prevention recently released the 2019 Oral Health Surveillance Report showing the latest national data on oral health status changes between 1999 and 2004 and 2011 and 2016.² While overall oral health in children has improved, there are still large disparities by race/​ethnicity and poverty status for nearly every oral health indicator. Relative disparities have increased for many indicators. The relative disparities for Black and Mexican-American young children have increased by 76% and 43% respectively. Caries experience over the same time also increased by 10% for Black adolescents and 15% for Mexican-American adolescents, compared to their white peers.

Oral health disparities also appear in adults. Non-Hispanic Blacks, Hispanics, American Indians, and Alaska Natives generally have the poorest oral health of any racial and ethnic groups in the US. Blacks, non-Hispanics, and Mexican-Americans aged 35 to 44 experience untreated tooth decay nearly twice as much as white, non-Hispanics. The 5–year survival rate is lower for oral pharyngeal (throat) cancers among Black men than white men. Periodontal diseases are higher in men than in women, and greatest among Mexican-Americans, Non-Hispanic Blacks, and those with less than a high school education.³

These oral health disparities lead to problems in systemic health. Scientific literature on the effects of poor oral health—particularly periodontal diseases—on systemic health—including diabetes, atherosclerotic heart disease, and low birthweight premature births—is growing. A recent report from Blue Cross Blue Shield noted that Americans with serious oral health problems are 25% more likely to experience systemic disease and are at increased risk for autoimmune disorders, anemia, gastrointestinal disorders, and renal disease. The report also found that those with oral health diseases are twice as likely to seek care from an emergency department compared to those without oral health problems. And most seriously, Blue Cross Blue Shield determined that its members with oral health diseases live 2 years less than those without dental problems.⁴

SOCIAL DETERMINANTS OF ORAL HEALTH

Why are some people healthy and others unhealthy? What we have learned over the past few decades is that other factors besides healthcare determine an individual’s actual health. The social determinants of health are the conditions in which people are born, grow, live, work, and age. They are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.

Two key factors drive the lack of access to dental care and the resulting inequities in oral health. In virtually all recent studies and reports, affordability or cost is the major impediment to accessing dental care.⁵ Most interestingly, this cuts across several economic groups, but primarily affects the poor and middle class. The second factor is poor oral health literacy in individuals, communities, and policy makers. If you do not know the importance of good oral health and the consequences of poor oral health, you are not motivated to address access-to-care problems.

POTENTIAL APPROACHES TO IMPROVING ORAL HEALTH EQUITY

According to Marko Vujicic, PhD, executive director of the American Dental Association Health Policy Institute, the current model of dental care in the US is broken and unable to “drive significant, sustained improvements in oral health going forward care.”⁶ He goes on to make four recommendations to fix the dental care delivery system:

1. Address the dental coverage gap.
2. Define and systematically measure oral health.
3. Tie reimbursement, partly, to outcomes.
4. Reform the care delivery model.

While all of these recommendations can play some role in addressing oral health inequities, I think that reforming the care delivery model is an important factor as it supports the adoption of new categories of oral health professionals such as dental therapists. The data about the quality, safety, and cost-effectiveness of dental therapists in providing oral health care to all patients, but particularly underserved and vulnerable patients, are unequivocal.⁷

Dental therapists are integral to addressing oral health inequities and achieving oral health equity.

Thirteen states have now passed legislation authorizing dental therapy either to the general population or restricted to Native American tribal lands. Delegating basic primary care dental procedures to lower cost dental therapists leaves the more complex and expensive procedures to the higher cost dentists. This would be particularly valuable with patients enrolled in Medicaid where the reimbursements are usually quite low, sometimes equivalent to usual overhead costs. In addition, significant efforts are underway to recruit dental therapy students from underserved communities, thus increasing the potential for more culturally competent oral health providers.

CONCLUSIONS

The current dental care system in the US is splintered, leaving many people unable to access quality dental care. Clear evidence demonstrates that racial and ethnic minority groups suffer disproportionately from oral diseases. The primary impediments to quality oral health care are costs and oral health literacy. Dental therapists are integral to addressing oral health inequities and achieving oral health equity.

References

1. World Health Organization. Social Determinants of Health. Available at: who.i/​t/​topics/​heal_​h_​equity/​en. Accessed November 5, 2020.
2. United States Centers for Disease Control and Prevention. The 2019 Oral Health Surveillance Report. Available at: cdc.gov/​oralhealth/​publications/​OHSR-2019-index.html. Accessed November 5, 2020.
3. United States Centers for Disease Control and Prevention. Disparities in Oral Health. Available at: cdc.gov/​oralhealth/​oral_​health_​disparities/​index.htm. Accessed November 5, 2020.
4. Blue Cross Blue Shield. Brush Up on Dental Health. Available at: bcbs.com/​the-health-of-america/​infographics/​brush-dental-health. Accessed November 5, 2020.
5. American Dental Association Health Policy Institute. Main Barriers to Getting Needed Dental Care All Relate to Affordability. Available at: ada.org/​~/​media/​ADA/​Science%20and%20Research/​HPI/​Files/​HPIBrief_​0419_​1.pdf?la=en. Accessed November 5, 2020.
6. Vujicic M. Our dental care system is stuck and here is what to do about it.  J Am Dent Assoc. 2018;149:167–169.
7. Catalanotto FA. In defense of dental therapy: an evidence-based workforce approach to improving access to care. J Dent Educ. 2019;83(2 Suppl):S7–S15.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. November 2020(12):8-10.