Oral health is an important yet often neglected component of overall health, linked to heart disease, stroke, and diabetic complications. Despite being integral to promoting overall health outcomes, oral health is a frequently forgotten component of overall health. Disparities exist for many groups, including racial and ethnic minorities such as African Americans. In the US, people are unable to afford regular preventive dental care, and many vulnerable communities lack access to transportation to appointments or lack fluoridated water. As a result, we see oral health disparities across the lifespan among racial/ethnic groups.
Dental care is one of the nation’s greatest unmet health needs. In particular, communities of color have much higher rates of tooth decay and tooth loss and fewer dental visits and preventive treatments than white populations. A communication brief from CareQuest Institute shines a light on these disparities, summarizing key findings from our 2021 and 2022 State of Oral Health Equity in America surveys and numerous other sources.
This article reviews the potential factors that perpetuate oral health care disparities in African American children in the United States in terms of structural, sociocultural, and/or familial factors. Promotion of health equity across the health care landscape requires elimination of disparities in access to care, as these disparities impact individuals’ abilities to receive affordable, comprehensive and quality care. Want to learn more? Health service access, affordability, and use varies for all Americans.
Addressing Oral Health Inequities that Promote Health Disparities
The Scope of the Problem
Health inequities persist in oral health care within racial/ethnic minority groups, which are also associated with lower socioeconomic status and high rates of poverty.
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- Children aged 2-5, 33% of Mexican American and 28% of Black children have had cavities in their primary teeth, compared to 18% of White children.
- Black adults were at least 2.5 times more likely than White, Hispanic, or Asian adults to have visited a hospital emergency department for dental care.
- Adults are twice as likely to have untreated caries than their White counterparts, and older non-Hispanic Black and Mexican American adults have 2 to 3 times the rate of untreated cavities as older White adults.
- Periodontal disease is most common among Black and Mexican American adults.
In Virginia, Black/African American adults aged 18-64 are more likely to have tooth loss (61%) than White adults of the same age (44%). Nearly 1 in 6 Black adults (16%) reported having lost at least six teeth due to tooth decay or gum disease.
Black/African American people use dental care less frequently than White people in America. This is true for children (42% vs. 55%), adults (29% vs. 48%) and seniors (29% vs. 55%).
Lower rates of dental visits and preventive care may contribute to the higher rates of untreated tooth decay among Hispanic and black children and adults. Preschool-age American Indian children in 2014 were four times as likely as white children to have untreated tooth decay-43 percent compared with 11 percent. In addition, 2 in 3 Native Americans ages 35 to 44 had untreated decay in 1999, the most recent year for which nationwide data are available.
Inadequate preventive care and untreated decay have consequences. Over time, teeth and gums become seriously diseased and can require costly treatment or extraction. Consistent with their higher rates of untreated decay, adults of color are more likely to lose teeth as a result of dental disease.
Oral Health Disparities (Source: CDC)
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Historical Context and Systemic Issues
Racism drives health inequities and is a public health emergency. Ongoing systemic racism and unequal impacts of the pandemic contribute to many health and health care disparities that adversely impact the overall health and well-being of Black people in America.
Racial inequity throughout the health care system is well-documented in the literature, and research shows how racial/ethnic minority groups are impacted by multiple social determinants of health. Individuals belonging to a racial/ethnic minority group are less likely to seek medical help and preventive care for serious chronic health problems - heart disease, diabetes, and cancer, to name a few - and are more likely to have poor health outcomes and higher mortality rates.
People of color, including Black and Indigenous populations, are 40% more likely to be served by water systems that violate the Safe Drinking Water Act.
Historic and ongoing policies of racism have created large racial/ethnic variations in income, education, employment and wealth that are strong predictors of access to health and dental insurance. To that end, racism can affect access to oral healthcare and/or appropriate clinical decision‐making by acting as a social determinant of health (SDoH) through reduced access to quality dental care via low dentist‐population ratio in minority communities, and poorer quality of care linked to the lack of diversity in the profession.
Access to Care
Implementation of the Affordable Care Act (ACA) in 2010 led to significant gains in health coverage over the past decade, yet substantial discrepancies remain for racial/ethnic minorities. As of 2018, 12% of Black adults, 19% of Hispanic adults, and 22% of American Indian and Alaskan Natives are uninsured, compared to only 8% of White adults.
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Dental care is not included as an essential benefit in many commercial health plans. The ACA does include oral health as an essential benefit for children only, not for adults and older adults. The CHIP program covers dental care in all 50 states for children insured by Medicaid, but only 35 states have an adult Medicaid dental benefit.
According to the ADA Health Policy Institute, the most common reason for delaying or not pursuing dental care is cost as many individuals and families cannot afford out-of-pocket care costs. Moreover, there are a limited number of dental practices that will accept Medicaid-insured patients, making access and availability a crucial issue.
COVID-19 has exacerbated the impact of the social determinants of health; financial strain, transportation limitations and general distrust of the health care system have prevented many Americans from visiting their dentists.
The Role of the Dental Workforce
One way to address oral health inequities, while also improving patient satisfaction and access to care, is supporting a racially and ethnically diverse oral health workforce. Practitioners from racial/ethnic minority backgrounds are best equipped to work in those communities that align with their background, as they can lend their own experiences to providing culturally-competent care and improve trust of health professions among racial/ethnic minority groups. Decades of racial bias and discrimination in health care settings, and resulting mistrust, are major factors contributing to low health care utilization and poor health outcomes in racial/ethnic minority populations.
A low dentist‐population ratio in minority communities contributes to reduced access to quality dental care. The dentist‐population ratio in the United States was 61 dentists per 100,000 population in 2020; a ratio that has remained nearly unchanged since 2012 (60 dentists per 100,000 population). Human Resources and Services Administration (HRSA) estimated in 2022 that the United States will need 11,181 additional dental professionals to meet the needs of shortage areas.
Prior research indicates that racial/ethnic minority dentists are more likely to practice in minority and underserved communities than White dentists. For example, Black (81%) and Hispanic (67%) dentists are more likely to work in underserved areas than White dentists (48%). Black (63%) and Hispanic (50%) dentists are also more likely to participate in Medicaid or public insurance than their White counterparts (39%).
Diversity of the Dental Profession (Source: Z Communications)
Addressing the Disparities
To reduce and/or avoid the ways in which racism can adversely affect oral health inequities, we need concerted efforts to acknowledge and remove the barriers affecting access to quality dental care in racial/ethnic minority communities. Specifically, we need a multi‐pronged approach to reduce and ultimately eliminate oral health inequities.
First, we need to identify factors that may bias admissions to dental schools for racial/ethnic minority applicants such as standardized tests, for example, Dental Admission Test, on which many racial/ethnic minority students do not do well. In tandem, we need to develop, fund and implement comprehensive plans to create sizeable cohorts of applicants from diverse racial/ethnic backgrounds that are prepared to successfully complete dental education. Moreover, increases in the racial/ethnic diversity of the student body should be one criterion considered in the accreditation of dental schools to highlight the vital importance of resolving the long‐standing racial/ethnic inequities in admission.
Second, dental schools must expand their curriculum to integrate factors affecting oral health beyond individual‐level factors, using a multidisciplinary approach. Specifically, the curriculum should be expanded to include SDoHs, racism/discrimination, health equity, and public health, and how these factors can affect oral health. Such curriculum change can promote interdisciplinary collaboration within and outside the biomedical sciences (medicine, nursing, social workers, public health, social scientists, etc.) to expand the focus of dentists from the mouth/head to also giving greater attention to the whole person and their individual's needs as well as their social milieu.
Third, there should be incentives in place to recruit and retain racial/ethnic minority dentists to work in underserved communities. For instance, current loan repayment programs should explicitly seek to recruit applicants during their senior year of dental schools from racial/ethnic diverse backgrounds, as well as others who would be interested in working in underserved areas. Moreover, future employers such as hospitals and local clinics, as well as federal agencies should create financial incentives for dentists, especially racial/ethnic minority dentists, to work in underserved and vulnerable communities.
Oral health curricula, simulation and clinical experiences should incorporate social determinants of health in patient interactions by addressing economic disadvantages, insurance complications, experiences of discrimination and environmental barriers to care among vulnerable populations. Interprofessional education experiences are crucial to promoting quality integrated health care that speaks to a wide spectrum of care interventions for racial/ethnic minority patients.
