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Dental Initiative Topic of Interest #3

Bureau of Health Professions
Division of Scholarships and Loan Repayment

According to the Surgeon General's report on Oral Health in America, though there have been major improvements over the past five decades for most Americans, disparities continue to exist for those individuals without the knowledge about and access to preventative and restorative oral health care. Despite the "dramatic improvements in oral health", as cited in the report, a disproportionate number of individuals from racially, ethnically, socially, economically and culturally diverse populations do not have access to dental services and oral health care. Children, including children and adolescents with special health care needs, the elderly, and individuals with disabilities are especially vulnerable. For more information see the Surgeon General Report on Oral Health in America.

Dental Care Utilization /Population Data

Recent census data reflect the continuous shift in the demographics of the United States. Over the past decade, the largest growth in the population has been individuals from racially and ethnically diverse groups. The elimination of health disparities and the achievement of the goals of Healthy People 2010 and Healthy People in Healthy Communities must address the challenge of good oral health for all Americans; oral health is essential to general health.

The literature (longitudinal studies, surveys and statistics) on the disparities of oral health care cites numerous areas of prevalence of tooth loss, periodontal diseases, dental service use, and life-threatening illness for individuals from ethnically and racially diverse populations:

  • Elderly African-Americans were at a heightened risk for poor health profiles; were significantly more likely to report a lower self-rating of dental care, had fewer teeth, and severe periodontal levels when compared to Whites (Schoenberg NE, Gilbert GH) creating nutritional vulnerability.
  • In a three-year study of 263 elderly African-Americans, 53% lost a tooth in a three-year period, 13 % lost their remaining teeth (Academy of General Dentistry).
  • The review and analysis of four data sources used to evaluate the periodontal disease status of Native Americans notes that "it appears that the prevalence of periodontal disease among Native Americans is increasing." The study also indicated in Native American population, Type II diabetes accounts for significant increases in periodontal disease and tooth loss (Skrepcinski FB, Niendorff WJ).
  • The prevalence of complete tooth loss for Native American elders is higher than in population surveys of elders based on random samples (Jones DB, Niendorff WJ, Broderick EB).
  • A survey of 12,349 American Indian and Native Alaska dental patient ages 18 and older results showed 11% complete tooth loss in individuals 35 and older; 42% for patients 65 and older. Tooth loss remains a substantial problem in American Indian and Alaska Native adults (Presson SM, Niendorff WJ, Martin RF).
  • The results from a study of 3,050 Mexican Americans ages 65 - 99 living in 5 southwestern states notes that: 27% were completely toothless, 22% reported visiting or speaking with dental care professional within the past year. The authors stated that the prevalence of tooth loss and use of dental services in this population of older Mexican Americans is lower than what was previously found among older people in the general population (Randolph WM, Ostir GV, Markides KS).
  • In a cross-sectional sample study of 105,781 individuals 25 years and older, a comparison of yearly dental visits of diabetic adults and non-diabetic adults was conducted. The study compared the frequency of the preceding year dental visit against the preceding year visits for diabetic care, dilated eye examinations, and foot examinations. The results were: diabetic individuals with some natural teeth were less likely than those without diabetes to have visited a dentist within the preceding 12 months; individuals with diabetes were less likely to have seen a dentist than a health care diabetes provider. The authors states that, " the disparity in dental visits among racial or ethnic groups and among socioeconomic groups was greater than that that for any other type of health care visit for subjects with diabetes (Tomer SL, Lester A).
  • Children from low-income families, children that are homeless, those with special health care needs and children of immigrant parents tend to have more oral problems and less access to dental services. A significant percentage of children from American Indian, Alaska Native, Hispanic and African American populations experience untreated dental decay. Children with special health care needs often require more extensive dental services as a result of their disability.

Statistics from 1997 and 1998 on the percentage of dental visits (in the past year) ages 2 to 65 and older revealed the following categorical data: The rates for female dental visits were higher than those for males until age 64 when the rates for males 65 and older surpassed the rates for females. Of the groups sampled, (White, Black, American-Indian or Alaska Native, Asian or Pacific Islander) the frequency of dental visits among Whites was the highest across the age span. Asian or Pacific Islanders had the second highest percentage. Blacks were third and, American Indian or Alaskan Natives had the overall lowest number of dental visits. White and Black non-Hispanic individuals dental visits rates were higher than the rates for Hispanics (Centers for Disease Control and Prevention, National Center for Health Statistics).

The literature and studies indicate that the percentage of dental visits decreases with age and increases with income and educational level.

Access to Oral Health Care

Individuals from racial and ethnic diverse populations are confronted with numerous barriers to oral health care. Those barriers include but are not limited to: geographic locations, race, cultural beliefs and values, language access, limited financial resources, and lack of adequate health insurance. These barriers prevent individuals from accessing preventative and restorative oral care.

  • Availability of the services - access is limited when providers and services do not exist within a community as is the case in both rural regions of the U.S. and poorer neighborhoods within urban areas.
  • Geographic location - access is limited if services are located too far from patients or in places that are not easily accessible. This is true for individuals that reside in both rural areas and in inner cities where transportation may be limited or lacking.
  • Times and logistics of services - access is limited when services are only offered during the normal business day or at other times when patients have work, family or other commitments.
  • Cultural competence - access is limited when services are provided in settings that are not welcoming and acceptable in terms of culture, race and/or ethnicity.
  • Linguistic competence - access is limited if patients cannot communicate in the language in which they are proficient (Monograph on Sharing a Legacy of Caring Partnerships between Health Care and Faith-Based Organizations).
  • Insurance - individuals often lack adequate health insurance and/or dental insurance. For individuals who are Medicaid eligible, there are a limited number of dentists who are willing to accept Medicaid as a payment source due to the low reimbursement provider rates.

With the advent of the Children's Health Insurance Program more children have access to dental coverage. All of the fifty states and the District of Columbia have approval from the Health Care Financing Administration for their Children's Health Insurance Program (CHIP). The majority of the plans includes at least basic dental services and is available for those who meet the eligibility criteria.

Dental services for adult Medicaid recipients is not as comprehensive as those for children and not as many states provide adult dental services. As a result of limited or non-existing dental services, adults often resort to hospital

Eliminating the Disparities

Eliminating health disparities and increasing access to oral health care for all individuals including ethnically and culturally diverse populations within the U.S. will require transformation in the way services are currently provided. Cultural competence is one tool that can be used to eliminate disparities through the infusion of culturally competent principles into the policies and practices of organizations providing dental services. The acquisition of knowledge, awareness and skills needed to provide culturally competent

At the Institutional Level

Increase recruitment and retention of culturally diverse faculty and students.

  1. On-going professional development activities to support faculty acquisition of cultural knowledge, awareness and skills needed to inform their teaching practice.
  2. Provide a vision and a commitment that will support the curriculum development committee in creating modifications to the dental school curriculum to include the oral health needs of children with disabilities and other health conditions.
  3. Provide a vision and a commitment that will support the curriculum development committee to create modifications to the dental school curriculum and teaching modalities to include content related to cultural and linguistic competence.
  4. Increase efforts to raise the level of public awareness about the importance of dental health including awareness and knowledge of signs and symptoms of oral cancers and the need for oral cancer examinations.
  5. Advocate for increased access to dental services for all.
  6. Advocate for increased Medicaid reimbursement rates.
  7. Develop policies and procedures that support a teaching/practice model which incorporates culture in the delivery of services to racially, ethnically, culturally and linguistically diverse groups.

At the Faculty Level

  1. Increase student awareness about the importance of dental health including awareness and knowledge of signs and symptoms of oral cancers and the need for oral cancer examinations.
  2. Provide demographic data on the oral health and preventive services needs of racially and ethnically diverse populations.
  3. Develop a teaching/training model which incorporates culture in the assessment and delivery of oral health services to racially, ethnically, culturally and linguistically diverse groups.
  4. Advocate for increased access to dental services for all.

At the student Level

  1. Take opportunities to learn more about the oral health needs for racially, ethnically, culturally and linguistically diverse groups.
  2. Advocate for increased access to dental services for all.
  3. Inquire about the cultural aspects of diagnosis, treatment, referral to other services in your various courses. Take a proactive stance to learning more about being a culturally competent provider.
  4. Engage in activities that will provide you with the opportunity to learn more about other cultures and understand the varying values, beliefs and practices around health.

References

Broderick, E.B., & Niendorff, W.J. (2000). Estimating dental treatment needs among American Indians and Alaska Natives. Journal of Public Health Dentistry Information, 60 (1), 250-5.

Jones, D.B., Niendorff, W.J., & Broderick, E.B. (2000). A review of oral health of American Indian and Alaska Native elders. Journal of Public Health Dentistry Information, Vol. 60.

Presson, S.M., Niendorff, W.J., & Martin, F. (2000). Tooth loss and need for extractions in American Indian and Alaska Native dental patients. Journal of Public Health Dentistry Information, Vol. 60.

Randolph, W.M., Ostir, G.V., & Markides, K.S. (2001). Prevalence of tooth loss and dental service use in older Mexican Americans. Journal of American Geriatric Sociology, Vol. 49.

Ronis, D.L., Lang, W.P., Antonakos, C.L., & Borgnakkle, W.S. (1998). Preventative oral health behaviors among African-Americans and whites in Detroit. Journal of Public Health Dentistry Information, Vol. 58.

Schoenberg, N.E., & Gilbert, G.H. (1998). Dietary implications of oral health decrements among African-American and white older adults. Ethnic Health, Vol. 3.

Skrepcinski, F.B., & Niendorff, W.J. (2000). Periodontal disease in American Indians and Alaska Natives. Journal of Public Health Dentistry Information, Vol. 60.

Tomar, S.L., & Lester, A. (2000). Dental and other health care visits among U.S. adults with diabetes. Diabetes Care, Vol. 23.

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