CDA Journal - October 2022: Looking to a Future of Equity and Excellence

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Editor/Connections, Redemption

Case of

features

DEIB: Looking to a Future of Equity and Excellence

An introduction to the issue.

Steven W. Friedrichsen, DDS, and Nader A. Nadershahi, DDS, MBA, EdD

Humanizing Oral Health: Race, Representation and Equity in Dental Education and Oral Health Care

This leadership brief offers The Integrated Humanizing Theoretical Framework for improving access of Black, Indigenous and people of color (BIPOC) to dental education and oral health care in order to treat diverse underrepresented populations and communities.

Mary J. Lomax-Ghirarduzzi, EdD

Improving Access to Care and Patient Experience Through Diversity, Equity, Inclusion and Belonging

This paper discusses the widely diverse population of California and how the frequency of multiple intersecting human characteristics offers significant challenges to providing equitable access and appropriate health care outcomes.

Elisa M. Chávez, DDS

The Importance of Diversity, Equity and Inclusion From the Clinician’s Perspective

This commentary features vignettes with clinical scenarios that create “teaching points” to illustrate how clinicians use strategies that integrate approaches to diversity, equity and inclusion (DEI) in their clinical encounters.

Pamela S. Arbuckle Alston, DDS, MPP; Jessica Baisley, DDS; Andrea Akabike, DDS; and Jack Luomanen, DDS, MPP

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Marisa Kawata Watanabe, DDS, MS Associate Editor

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Steven W. Friedrichsen, DDS, and Nader A. Nadershahi, DDS, MBA, EdD Guest Editors

Andrea LaMattina, CDE Publications Manager

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Editor Emeritus

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Volume 50 Number 10 October 2022

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Journal of the California Dental Association Editorial Board

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Steven W. Friedrichsen, DDS, professor and dean emeritus, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles

Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD, interim vice president research & biotechnology, associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry

Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco

Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

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Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry

Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Innovative Approaches for Fostering DEI Development in Preclinical and Clinical Training

This article describes ways in which dental education can play an integral role in shaping a better oral health tomorrow for individuals, families and communities from underrepresented minority backgrounds who continue to bear a disproportionate burden of oral disease.

Marisa K. Watanabe, DDS, MS; Lucian O’Connor, PhD; Keith R. Boyer, DDS; T. Jamie Parado, DDS; Paulina A. Saraza, DMD, MS; Edmond R. Hewlett, DDS; George Taylor, DMD, MPH, DrPH; and Bradley S. Henson, DDS, PhD

Connections, Redemption and Dentistry

Kerry K. Carney, DDS, CDE

Connections. We seem to be hardwired to look for connections. When I was studying in Canada, I was frequently quizzed on my knowledge of just which famous people were Canadian. (Lorne Greene, Neil Young, Wayne Gretzky, Shania Twain, Sandra Oh, Celine Dion, Justin Bieber, Dwayne Johnson, Ryan Gosling, Joni Mitchell, Michael J. Fox and K.D. Lang to name a few.) At the time, I thought this was meant as a reminder to me that not every star was American.

Years later, with a friend of Greek heritage, I would watch the credits at the end of a film and try to spot the Greek names. It was then that the real importance of these exercises became evident. It was all about the connections. It was the tribal connection that was being sought out and acknowledged. It is not unlike the connection we enjoy with sports teams and fans. We are connected by emotion and enthusiasm to the team and to the other fans. We feel a similar connection when we find out someone is from our school or neighborhood. We even recognize the pull of a tribal connection within our own profession.

On more than one occasion, I have found myself reminding someone else that some third person is a dentist, was a dentist or was married or somehow related to a dentist. This connection seeking may explain why I spent several hours one weekend looking up famous people in history who were dentists.

There were several individuals that California dental school graduates might recall: Doc Holliday (dentist, gunslinger and card player), Painless Parker (the man who turned dentistry into a traveling show) and Robert Semple (one of the early players in

Connections can help us understand how our profession can bring redemption.

California statehood and the co-founder of Benicia, California). But there were some interesting, though more obscure, connections between famous people and the practice of dentistry: Peter the Great of Russia (who was so fond of extracting teeth that members of his royal court would hide if they had a dental problem), Barney Clark (Seattle dentist and recipient of the first artificial heart) and Zane Gray (dentist and author of popular stories of the American West).

Amateur and professional sports produced a number of dentists. The most contemporary (and one of very few women recognized) was the 2022 curling Olympian Tara Peterson (dentist from Shoreview, Minnesota).

There was Gentleman Jim Lonborg of the Boston Red Sox, who won the Cy Young award in 1967 and went on to graduate from Tufts and had a successful “post season” practicing dentistry.

In basketball, I found “the owl without a vowel,” Bill Mlkvy. At Temple University, on March 3, 1951, he set a Division I record that still exists. It is the oldest extant individual record in the NCAA. That night Dr. Mlkvy scored 54 unanswered or interrupted points and a game total of 73 personal points in the 99-69 win. He played only one year for the Philadelphia Warriors because his dental school obligations necessitated missing games. Dr. Mlkvy explained, “I’d dress up for games having just extracted a tooth a few hours earlier.

My mind was on my patients.”1

Then I proceeded on to football. I found Les Horvath, who was one of two Heisman Trophy winners to go into dentistry after recognition in football. He played for Ohio State University and won the Heisman Trophy in 1944.

The second Heisman Trophy winner to go into dentistry was Billy Cannon. He won his Heisman playing for LSU in 1959, the same year he ran an amazing 89-yard return for a touchdown against Mississippi on Halloween night. That play would become known as “The Punt Return” and be replayed innumerable times. It is still accessible online. Though not as famous, Dr. Cannon’s tackle in the last few seconds of that game kept Mississippi from scoring what would have been a game-winning touchdown that night. LSU won that game and Dr. Cannon proceeded to play professional football for 11 years. In the off seasons, he earned degrees from University of Tennessee and Loyola University and became a successful orthodontist in Baton Rouge.

What happened to Dr. Cannon after that is even more important than our connection with him as a dental professional.

In 1983, Dr. Cannon was arrested. The “Secret Service … dug up $5 million in phony $100 bills on Dr. Cannon’s property, and he was charged with possession of counterfeit money and conspiracy. He earned an estimated $300,000 a year from

his dental practice but was reportedly in financial trouble from gambling debts and bad investments. He had been in dozens of lawsuits, most over unpaid bills. He pleaded guilty and was sentenced to federal prison. He was released in 1986, after serving almost three years of a five-year term.”2

Life went from bad to worse for Dr. Cannon. His practice was in ruins. He refused to answer the “why” that everyone wanted to ask. How could he fall so precipitously from his pedestal of fame?

“In 1997, after declaring bankruptcy, Dr. Cannon found work as the chief of dentistry at Louisiana State Penitentiary in Angola.”2 The prison dental service was in a shambles. Dr. Cannon cleaned up the operation of the Angola dental service so successfully that the head of the penitentiary asked him to do the same for the medical service as well.

When Dr. Cannon “talked about his work at the prison, you could hear the pride in his voice. The standard glory-days stories and aw-shucks one-liners disappeared when he discussed the ins and outs of treatment. He began to sound less like a former legend and more like a hardworking dentist.”3 “He scheduled all inmates for appointments, forcing them to decline if they didn’t want treatment.3 The warden said Dr. Cannon cared about the inmates and “ … the inmates love him, and because they love him, he

cares more and won’t dare let’em down.”3

Dr. Cannon did not offer much explanation about why everything went wrong and why he fell so far from the hero’s pedestal on which Louisiana had placed him. He said, “I did the crime and I did the time. I haven’t had a speeding ticket since.”3

He had a wild and rebellious adolescence, and perhaps his most insightful comment was: “There was times right when I got out of school when everybody was a friend and everybody was a good guy … After a while, you say, they’re not friends and they’re really not good guys. Now how much did it cost you to make that decision? Sometimes more than you want to talk about.”3

That statement brings it all home. Connections are important, but they are not always what they seem. Connections can get us in trouble, connections can facilitate our empathy for another’s predicament and pain. Connections can help us understand how our profession can bring redemption. Billy Cannon fell from grace. His profession, dentistry, helped him find his way back. n

REFERENCES

1. Walters J. This Future Dentist Once Dropped 54 Straight. Then He Was Lost to Time Sports Illustrated March 3, 2020.

2. Schudel M. Billy Cannon, 1959 Heisman Trophy winner later convicted of counterfeiting dies at 80 The Washington Post May 23 2018.

3. Thompson W. The Redemption of Billy Cannon. ESPN.

The Journal welcomes letters

We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

Anxiety, Depression Among Dental Health Care Workers on COVID-19 Frontlines

The first known U.S. study to evaluate the mental health of frontline dentists and dental hygienists during the pandemic found that dental health care workers report anxiety and depression symptoms during peaks of transmission among the public. The study was published jointly in the August issues of the Journal of the American Dental Association and the Journal of Dental Hygiene.

The one-year study conducted from June 2020 to June 2021 included 8,902 dental health care workers participating monthly in an anonymous longitudinal, web-based survey. The Patient Health Questionnaire-4 was used to estimate rates of anxiety and depression symptoms. Changes in mental health over time and differences by demographic and practice characteristics, COVID-19 community transmission level and COVID-19 vaccination status were tested using X2 tests and multilevel multivariable logistic regression.

Between June 2020 and June 2021, 17.7% of dental health care workers reported anxiety symptoms, 10.7% reported depression symptoms and 8.3% reported symptoms of both.

According to the findings, between June 2020 and June 2021, dental hygienists reported higher rates of depression symptoms than dentists at each surveyed time point, with depression symptom rates peaking in December 2020. Dental hygienists’ depression rates declined in 2021 as dentists’ rates of depression symptoms remained steady. At the end of the study period, both groups had relatively similar rates — 11.8% for dentists and 12.4% for hygienists.

Some participants’ anxiety symptoms decreased after receiving the COVID-19 vaccine. The study — also the first to examine the association between the COVID-19 vaccine and mental health — found that unvaccinated dental health care workers who intended to be vaccinated suffered significantly more anxiety symptoms (20.6%) compared to fully vaccinated dental health care workers (14.1%).

The study is part of ongoing collaborative research efforts between the American Dental Association (ADA) and the American Dental Hygienists’ Association (ADHA) to understand COVID-19’s impact on dental health care workers.

“As members of the dental profession, we are committed to improving the oral health of our patients and communities. Furthermore, as health care professionals, we must be committed to our own health and wellness to optimally care for others,” said study author Maria L. Geisinger, DDS, MS, professor and director of the advanced education program in periodontology at the University of Alabama at Birmingham School of Dentistry. “Creating professional environments that allow for open communication about mental health among members of the dental team can reduce the stigma around mental health diagnoses and treatment for dental health care workers.”

Interestingly, dental health care workers reported lower rates of anxiety and depression symptoms than the general public, despite being on the front lines and providing oral health care during the pandemic, the study authors said. n

An intraoral periapical radiograph of the lower right mandibular area revealed a fused third molar and supernumerary tooth with an irregular morphology and a wide mesiodistal width. Radiopacity seen in the furcation area appeared to be the enamel pearl. (Credit: Almutairi W et al. Licensed under Creative Commons CC BY-NC-ND 4.0.)

Case Report: Imaging Aids Treatment of Fused Third Molar

A report published in the American Journal of Case Reports confirms that successful treatment can be predicted when clinicians use a proper treatment plan and utilize all available diagnostic tools. Imaging assisted in the treatment of a man’s third molar that had fused with a supernumerary tooth, according to the report.

The man presented at the Qassim University of Saudi Arabia’s endodontics department after experiencing two days of severe spontaneous pain on the right side of his lower jaw. A dental exam revealed a large tilted, irregular third molar that was fused with the fourth molar. It was tender to the touch and caused pain when cold stimulus was applied. The exam suggested a diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis.

The patient underwent an intraoral X-ray that showed fused molars with an irregular morphology and a wide mesiodistal width. The 2D view offered by the X-ray made it difficult to identify the demarcation between the pulp chamber of the third molar and the supernumerary tooth. Also, clinicians could not ascertain the root canal configuration of the tooth. Therefore, he underwent a CBCT scan,

New Hydrogel Treatment Whitens Teeth Without Damage

Researchers at Nanchang University in China have developed a new hydrogel treatment that breaks apart cavity-forming biofilms and whitens teeth without damaging them. The study was published in the journal ACS Applied Materials & Interfaces

For better whitening, consumers often turn to over-the-counter or professional treatments that combine hydrogen peroxide-containing gels and blue light, producing a chemical reaction that removes stains. This combination removes most of the discoloration but generates reactive oxygen species that can break down enamel.

Previously, the researchers modified titanium dioxide nanoparticles for a less destructive tooth-whitening treatment. But this method still required high-intensity blue light, which can damage nearby skin and eyes. The team wanted to find a material that would be activated by green light — a safer alternative — to both whiten teeth and prevent cavities.

The researchers combined bismuth oxychloride nanoparticles, copper oxide nanoparticles and sodium alginate into a thick mixture and evenly coated the mixture onto the surface of teeth stuck to a slide and sprayed the concoction with a calcium chloride solution, forming a strongly adhering hydrogel. Next, the team tested the material on teeth that were stained with coffee, tea, blueberry juice and soy sauce and placed in a lab dish. Following treatment with the hydrogel and green light, the teeth got brighter over time and there was no damage to the enamel.

In another set of experiments, the team showed that the treatment killed 94% of bacteria in biofilms. To demonstrate that the treatment could work on teeth in vivo, they used the new method on mice whose mouths were inoculated with cavity-forming bacteria. The green-light activated hydrogel effectively prevented moderate and deep cavities from forming on the surface of the animals’ teeth.

Teeth treated with Control, the hydrogel’s base solution without nanoparticles, sodium alginate (SA) and hydrogel (BC-SA) immersed in colorant solution for zero, one, three and five days, respectively. (Credit: Li et al. ACS Applied Materials & Interfaces, 2022.)

which showed the pulp chamber was continuous and the tooth had five canals — two orifices on the mesial, two in the middle and one on the distal side.

The patient chose to undergo nonsurgical root canal treatment for the fused molar. Once the root canal was completed, an X-ray was taken and the tooth restored with a temporary filling.

Because fused teeth can have unusual anatomic variations, it is critical that clinicians use imaging to visualize the tooth before treatment, the authors wrote. X-rays are essential tools in endodontics, but they don’t consistently show the precise anatomy of the root canal system.

Cancer Patient Receives First 3D-Printed Titanium Jaw

After four years of intensive research by the Netherlands Cancer Institute and the Dutch company Mobius 3D Technology, a titanium lower jaw was implanted for the first time in a head and neck cancer patient. The jaw was completely reconstructed based on the patient’s 3D MRI and CT scans, and

Implications of Monkeypox for Dental Practices

the operation was successful.

Tumors in and around the lower jaw are often treated by removing part of the mandible. The mandible is reconstructed, if possible, with bone from elsewhere in the body (usually from the fibula, a small bone from the lower leg). The disadvantage of

The Netherlands Cancer Institute successfully carried out the first operation with a custom 3D-printed titanium lower jaw. (Image courtesy of Mobius 3D Technology.)

A study of literature gathered from World Health Organization and Centers for Disease Control and Prevention databases on the etiology, transmission modes, signs and symptoms, diagnosis and management of monkeypox (MPX), including the risk of its occupational transmission in dental settings, concluded that dental care workers should implement standard, contact and droplet infection control measures and patient isolation and referral, particularly during a local outbreak. The study by researchers at Qatar University was published in the International Dental Journal.

A negative stain, pseudo color, electron micrograph showing mature, oval, mulberry-shaped virus particles (pink) and the immature particles (blue) from a skin lesion of a patient with monkeypox. (Photo credit: Cynthia S. Goldsmith, Russell Regnery; Courtesy CDC Image library.)

these reconstruction methods is that they are complex and require vascular anastomosis and also cause morbidity at the donor site. When using only metal plates, these can break or extrude through mucosa or skin in about 40% of the cases and the screws with which the plate is attached can come loose, resulting in dramatic consequences for the patient. The new 3D-printed mandible exactly fits the defect, has the shape and weight of the original mandible and is much stronger than the currently used plates.

Of interest in the dental context is that the primary lesions originate in the oropharynx before manifesting on the skin, according to the study. Occasionally, oral ulcers can impair a patient’s ability to eat and drink, causing dehydration and malnutrition. Perioral papules that blister and ulcerate were reported initially in the current outbreak. In one study, it was reported that oral ulcers were present in almost one-quarter (23.5%) of participants with MPX.

The initial signs of MPX appear during the prodromal period, in the oral cavity as single or multiple macular lesions on the oral mucosa, accompanied by generalized lymphadenopathy. Subsequently, the characteristic rash appears on the skin and spreads centripetally from the trunk toward the palms and soles. MPX is a self-limiting disease with very low mortality and may last from two to four weeks. Although MPX is similar to chickenpox, there are a number of differentiating signs, the main element being lymphadenopathy. Strict adherence to infection control precautions, including wearing N95 masks, FFP3 respirators, fluid-resistant attire and eye protection, is necessary to prevent its spread, according to the study.

As of September 2022, more than 65,000 cases of MPX had been reported worldwide, including 25,000 in the U.S. and 4,800 in California, according to the CDC. For information, access updated resources and guidance on MPX at the California Department of Public Health website.

The implant is much stronger, partly because the forces are optimally distributed with an improved fastening technique. The implant also has a so-called “mesh structure” on the inside. In this way, the implant retains its strength, while the prosthesis still feels light for the patient (the comparable weight of bone is approximated). The implant can no longer break, and the innovative orientation of the fixation screws ensures that the implant stays in place. Because the implant is custom-made, the jaw retains its fit and pressure on the overlying mucosa or skin is distributed more evenly, therefore, functions such as talking, drinking and eating are preserved. The researchers hope this will diminish complications and improve functional and aesthetic outcome. Even the tools the surgeon uses in the operation are patient specific, and the operation is also simpler and shorter.

This application is expected to be more widely applicable in 2023 or 2024.

GUEST EDITORS

Steven W. Friedrichsen, DDS, is professor and dean emeritus of the College of Dental Medicine at Western University of Health Sciences in Pomona, California. With a lengthy history of engaging faculty and staff to build a more diverse and inclusive profession, he helped secure funding that included the Summer Select Program, Robert Wood Johnson Foundation awards at two dental schools, the Summer Health Professions Education Program at WesternU and several Health Resources and Service Administration grants. Dr. Friedrichsen has served his profession in numerous capacities for the Commission on Dental Accreditation, the American Dental Education Association, the California Dental Association and the Idaho State Dental Association.

Conflict of Interest Disclosure: None reported.

Nader A. Nadershahi, DDS, MBA, EdD, is dean of the University of the Pacific, Arthur A. Dugoni School of Dentistry and vice provost of the San Francisco campus. He is the first Iranian American dean of a dental school in the U.S. Dr. Nadershahi serves on the boards of the Bay Area Council, the San Francisco Chamber of Commerce and was appointed by the governor to the California Health Workforce Education and Training Council. He is the chair of the American Dental Education Association Board of Directors and has been a leader at the California Dental Association, American Dental Association and is a member of the Santa Fe Group. Conflict of Interest Disclosure: None reported.

DEIB: Looking to a Future of Equity and Excellence

Steven W. Friedrichsen, DDS, and Nader A. Nadershahi, DDS, MBA, EdD

It is a documented fact that the United States is becoming a more diverse nation.1 That statement does not represent breaking news but a population trend that has been developing for years. Nor should it be a novel concept that race, ethnicity, gender, religion, socioeconomic status and multiple other identifying factors can influence access to health care and health care outcomes — including oral health care.2

As a profession, we have the collective obligation to provide for everyone’s care and oral health. This issue of the Journal of the California Dental Association highlights several aspects of diversity, equity, inclusion and belonging (DEIB) with a focus on impacts to patient care. This issue also parallels the thoughtful conversations being held by our CDA boards, leadership and delegates to strengthen our profession and the critical service that we provide for our communities.

As will be established by multiple authors in this issue of the Journal, the influences can be described as “pervasive” (Chávez) and difficult to rectify. Although the challenges appear daunting, they also provide our profession with the opportunity to achieve greater success going forward.

We recognize that these issues may be personal, emotional and uncomfortable. However, to grow and strengthen our great profession, we must work together and push

beyond these issues that have held us back from achieving our true potential. The authors provide multiple perspectives that will give the reader an overview of the issues we face as a society and as a profession in assuring that all individuals can access quality care and attain optimal oral health. It will become apparent that there is no one solution or one certain pathway to achieve our shared goal. Achieving equitable access and outcome will be, as they say, “a journey.”

The starting point for our journey is a view of the profession from the outside. Dr. Mary Lomax-Ghirarduzzi is a national figure and scholar in the world of DEIB. She provides us with a candid view of dentistry, both historically and as it exists today. Her views provide a glimpse of how others see us. Although that view may be difficult to acknowledge, it is important that we recognize how others view dentistry and the oral health care system.

Next, Dr. Elisa Chávez provides a substantive overview of the literature outlining areas where we are as a profession. She provides evidence of our progress as well as where we have not made significant headway over the past two decades since the “Oral Health in America: A Report of the Surgeon General.”3 There are areas of laudable success and areas where we have many opportunities for improvement.4

The next stop on our journey takes us through a series of vignettes by

Dr. Pamela Alston and colleagues that help us understand the complex interplay of factors involved in the provision of care on a daily basis. Experienced oral health care practitioners understand that patients bring a level of complexity that is not easily replicated in a scientific study, cannot be addressed in a single-issue policy or solved without significant political will. In the world of DEIB, the concept that patients bring several identities that influence their ability to receive care is entitled intersectionality. As practitioners, we see this in virtually every patient. Each person we treat is a unique individual with all the complexity they bring to the health care process.

Looking to the future, Dr. Marisa Watanabe and colleagues look at how dental education is developing new approaches to education that help assure that the profession mirrors the face of a changing nation. They also preview examples of didactic and clinical curricula that help students understand the challenges their patients face. Additionally, dental education can and should provide the essential evaluation of the effectiveness of our efforts. Building the body of scientific knowledge beyond the challenges to assessing the outcomes from our policies, programs and practices is critical to our future as a profession.

Finally, in recognition of the still nascent nature of DEIB, we offer a glossary of terms5 to help us communicate with a common language. Even though it seems rudimentary, our professional and political discourses are often fueled by use of terms without a common definition. Using the same word or term with a different meaning can be a source of considerable friction and misunderstanding. Think for example of the first time we all began to learn the new language of tooth nomenclature and morphology — without commonly accepted terminology, it would

be impossible to communicate clearly

As we have progressed through the development of the submissions by multiple authors and considered their collective efforts, there are four observations we would like to share as guest editors of this issue of the Journal. Each of these observations provides the profession with an attendant opportunity for greater success in the future.

First, although the concepts of DEIB have been considerations for decades, there remains significant variability in the terms and language used. This is to be expected in an area of continuous

Just as patients present with multiple intersecting oral health care needs, they also face multiple structural and social determinants of health.

those without access to the more dominant practice models. As a profession, we have been strong advocates for care to underserved populations and opportunities for students seeking to become health care professionals. In a word, we need to let the world know more broadly of our efforts to become part of the solution.

movement and change. At the same time, our opportunity is to support development of a consistent lexicon that helps us communicate. An opening is available through the glossary on page 623 and in making this a part of how we craft our messaging to all communities of interest.

Second, being embedded in the profession of dentistry, we recognize and value the many efforts to address the issues of DEIB and assure equity of access and care for all. Unfortunately, those outside the profession may not see and perhaps don’t value what we have done to work toward equity, inclusion and belonging. This is an opportunity to communicate our efforts more robustly to those outside the profession of dentistry. We have multiple pathway programs with state and federal support and safety net care systems for

Third, most academic studies are of large numbers of patients or populations and, of necessity, are designed to isolate factors so that the findings can demonstrate suitable scientific validity. On the other hand, oral health care is provided to one person at a time and rarely does that patient have only one issue. Just as patients present with multiple intersecting oral health care needs, they also face multiple structural and social determinants of health. As a profession, we would benefit from building on the practitioner-based research network concept (PBRN) to evaluate the structural and social determinants of health (SSDH) as well as the aggregate effects of their intersectionality. These are complex problems, but we are a profession composed of highly intelligent and compassionate people who take care of other people — the solutions are not beyond us.

Fourth, the bulk of the literature cited by all of the authors elucidates and illuminates the challenges. At this point, we can say that we have a comprehensive understanding that race, gender, ethnicity, orientation, etc., influence care and access. The opportunity is to shift our scientific focus to understanding how those factors work in concert to magnify the challenge. We also can do a better job of elucidating the outcomes from our efforts. What aspects of pathway programs, outreach or collaboration agreements help reshape the profession and which don’t? How effective is an access program at increasing penetration among the populations the program was designed to serve? Those two and dozens of other questions regarding our efforts need

to be answered so that we may continue assessing the value of our work and modify those strategies that are suboptimal and look elsewhere when something simply doesn’t provide an acceptable outcome.

The inherent and advancing diversity of our state and country provides us with historical and ongoing challenges to equitable care and outcomes. As a profession, we have the responsibility to redirect those challenges into opportunities that demonstrate we are inclusive in every dimension, are supportive of equitable care and are working to create an environment

of belonging for all members of our society.

As Dr. Martin Luther King Jr. once said, “Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny … Whatever affects one directly, affects all indirectly.”

Our shared efforts to improve access and care for those historically underserved and underrepresented will make our profession stronger for everyone. We thank the authors for their important contributions and thank you for taking this journey with us and for your good work. n

REFERENCES

1. United States Census Bureau. Historical Population Change Data (1910-2020) . April 26, 2021. Washington, D.C.

Accessed September 2022.

2. CareQuest Institute for Oral Health. The Glaring Scope of Racial Disparities in Oral Health. Boston: June 2022.

3. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

4. National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, Md: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021.

5. McCleod J. Understanding Racial Terms and Differences National Institutes of Health, Office of Equity, Diversity and Inclusion. March 11, 2021.

BRENTWOOD: 4 Ops, professionally designed, Dentrix, Paperless, Laser, great location. 2019 GR $520K on 2.5 day week. #CA3008

CENTRAL VALLEY / MODESTO

AREA: New Listing! GP, 8 Ops, 20+ Yrs. Goodwill, Digital, 4 hyg days/wk. Hi-traffic area! 2021 GR $999K. #2721

ELK GROVE / S. SACRAMENTO

AREA: New Listing! 4 Op Ortho Practice, 21+ Yrs. Goodwill, Digital, Highly Desirable Area! 2021 GR $724K. #CA3250

DANVILLE: GP, 4 Ops+RE , Desirable location, 80 Yrs. Goodwill, Digital, with 5 ½ hyg days/wk. 2021 GR $1.3M. #3203

FAIRFIELD AREA: High traffic area, 7 Ops Digital, Pano/CB, 23+ NP/ mo. with 8+ Hyg. days/wk. Room to grow with specialties. 2019 GR $1.7M and 2021. #CA1824

FAIRFIELD/VALLEJO AREA: 7 Ops, Paperless practice in a high-traffic area. Digital, CEREC with 43 yrs. Goodwill. 2021 GR $1.5M. #3117

LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715

LAKE TAHOE AREA WITH LAKE VIEWS: Well-established practice in magical Lake Tahoe! 4 Ops, Paperless practice, Digital. 20 yrs. Goodwill, 2021 GR $1.4M. #3100

NORTHERN CALIFORNIA

PERIO: 4 Ops+RE, 33 yrs. Goodwill. 2021 GR $1.4M. #3118

PLEASANTON: Great neighborhood, paperless, digital, 6 Ops, 5 equipped. Don’t miss opportunity in this great community. #CA3023

RED BLUFF/CORNING/ORLAND

AREA: 6 Ops, 8 hyg days/wk w/ room to grow! 33+ yrs Goodwill, Paperless, Digital. 2021 GR $826K. RE for sale with practice. #CA3161

ROCKLIN/GRANITE BAY: Hi-end 4 Ops GP/Cosmetic practice in affluent area. Paperless, digital, iTero scanner, 8 + hyg days/wk. 2019 GR $1.6M+, 2021 Prod projected at $2M+. RE for sale with practice. #CA2793

ROSEVILLE/CITRUS HTS: 4 Ops with 18 Yrs Goodwill, Digital, Laser, Strong hyg., Specialties Referred, 2021 est GR $775K. #CA2897

S. SACRAMENTO METRO / ELK

GROVE / GALT AREA: 5 Ops, Open Bay Chair, Ortho Specialty Practice, 10+ yrs. Goodwill, Digital, Highly desirable area! 2021 GR $404K. #CA3149

SAN MATEO: 3 Ops, digital X-ray, great opportunity in this highly desirable area/busy retail strip center location. 2021 GR $381K with no advertising. #CA3044

SANTA CLARA COUNTY-WEST VALLEY: New Listing! 5 Op OMS Practice, Affluent Area with room to Grow! 2021 GR $579K. #CA3239

SONOMA COUNTY: Price Adjustment! Large GP, 2019 GR $2.3M +. Stand-alone 3,000 sf prime Real Estate, 72 NP/mo. & 10 Hyg Days. 6 Ops, Pano, Dexis, Cameras, Laser, Dentrix. Both Business & RE for sale or Lease. Doctor Retiring. #CA544

SONOMA COUNTY: 4 Ops in spacious layout in heart of the area off main highway. Est 22 yrs with 5-star Google reviews, Paperless with CEREC, Scope, Laser, Strong hyg. Retiring seller. 2019 GR $782K with good post-COVID recovery. #CA2594

SONOMA COUNTY: 4 Ops, FFS GP Practice, 27 yrs Goodwill, 8 hyg days/ wk, Digital, Paperless, Eco-Friendly and Energy Efficient Solar Panels. 2021 GR $1.6M. #CA3165

SONORA AREA: 5 Ops, Producing $825K in a renovated suite. RE for sale w/ practice. Strong hyg prog. Digital, Laser, and Digital Pano. #CA2850

S. SACRAMENTO/POCKET

ROAD/ELK GROVE AREA: 5 Ops, Paperless, Digital X-ray, Soft Tissue Lase, Pano X-ray, CEREC. 73 yrs. Goodwill. 2021 GR $803K. #CA3093

WOODLAND/DAVIS/W.

SACRAMENTO AREA: Endo Specialty practice! 2 full Ops (3rd Op plumbed), Paperless, Digital X-ray, Nitrous, Endo Microscope. 12 yrs. Goodwill. 2021 GR $623K. #CA3154

CENTRAL CALIFORNIA

GREATER MODESTO: 7 Ops, Desirable area, Dentrix, Digital, Laser, Digital Pano. RE for sale w/practice. Not a Delta Premier provider. 2020 GR $615K and 2021 should exceed it. #CA2795

SANTA CRUZ: 4 Ops, Minutes to beach! Digital, CEREC, Pano, CBCT. Bread and butter practice-room to grow with specialties. FFS and Delta PPO only. #CA2938

SOUTHERN CALIFORNIA

AGOURA HILLS/WESTLAKE

VILLAGE/THOUSAND OAKS:

4 Ops plus 1 plumbed not equipped. 18 yrs. Goodwill. 2021 GR $1.1M. #3085

BAKERSFIELD: 7 Ops, 38 yrs Goodwill, Digital, RE or sale, Fee for Service, PPO, Delta Premier. 2021 GR $732K. #CA2945

CENTRAL VALLEY: New Listing!

Pediatric Practice. 10 chairs, Ortho and Oral Surgery services in-house. Digital X-ray, Digital Pan/Ceph. 30+ yrs. Goodwill. Seller available to stay for transition. 2021 GR $2M. #2794

CENTRAL COAST: New Listing!

GP, 8 Ops, Digital, Paperless, 5 hyg days/wk. 2021 GR $2.4M. #3157

COASTAL ORANGE COUNTY: 5 Ops, 4 equipped, digital sensors & pano. Room to grow, in a wellestablished area. GR $735K. #CA2787

HESPERIA: Well-established GP practice, 5 Ops+RE, Digital, 22 Yrs. Goodwill. 2021 GR $500K. #1500

ORANGE: 4 Ops+RE, 2 hygiene days/ wk. with room to add more days. Seller refers out all specialties. 2021 GR $590K. #3143

NORTH ORANGE COUNTY: New Listing! GP, 4Ops, 30+ Yrs. Goodwill, Digital, Paperless, 3.25 hyg days/wk. 2021 GR $1M. #3262

PALMDALE/LANCASTER: 7 Op office in fast-growing community. Paperless with Dentrix, digital x-rays, 8 days of hyg./week and dedicated staff. Room to grow with specialties! #CA2612

RANCHO SANTA MARGARITA: 4 Ops, 30+ yrs Goodwill, Modern and Bright Designed Office! Digital Laser, Pano, Strong hyg. 2021 GR $665K. #CA3160

TORRANCE: 6 Ops, 40 yrs. Goodwill. Strong hygiene, in-house Perio and Endo specialists 2 days per month. Digital X-ray, Intraoral Camera and Laser. 2021 GR $1.5M #CA3113

WHITTIER: 4 Ops, 3 equipped, 30 yrs goodwill. Digital x-rays and pano, laser. 2021 GR $683K on 3 Dr. days/wk. Great visibility and signage in this wonderful community. #CA2788

WHITTIER: 4 plumbed Ops, 3 equipped, Paperless, Digital X-ray, Intraoral Camera and Laser. Longestablished FFS/PPO Practice. 2021 GR $497K. #3150

SAN DIEGO

ENCINITAS: GP practice. 6 Ops, Private parking lot. Great technology with a CBCT, 5 Microscopes, Scan X and SoftDent. 38 yrs. Goodwill. 2021 GR $960K. #CA3152

ESCONDIDO DENTAL REAL ESTATE: Stand-alone building with 5 fully equipped Ops, 2 with brand-new equipment. On corner lot with private parking and spacious floor plan. #CA3031

LA JOLLA: 5 Ops, Well-established GP Practice, 35 Yrs. Goodwill, 9 Hygiene days per week, Digital, Soft Tissue Laser. 2021 GR $816K. #CA3190

OCEANSIDE: GP practice blocks from the beach! 40 yrs Goodwill, 7 ops, 4 equipped. 2021 GR $691K. #3151

SAN DIEGO: 4 Op Open Bay w/3 private Ops, Emergency Sale Pediatric Practice, 19 + Yrs. Goodwill, Digital. 2021 GR $1M. #CA3140

SAN DIEGO: CHART ONLY SALE! Seller retiring, 30 yrs Goodwill, 400 patients seen in the last 18 months. 50% Cash, 50% PPO, No Delta Premier. #CA3188

SAN DIEGO: Rare opportunity, seller retiring, 4 Ops in desirable location with good cash flow. High quality work. Digital, Dentrix. #CA2851

SAN DIEGO: 6 Ops, 4 equipped, recently updated, Digital Pan, Microscopes, and Laser. Specialties referred, room for additional hours and dentistry. #CA3005

SAN DIEGO: Oral Surgery practice with 2 surgical rooms, 2 consult rooms in a standalone building. 46 yrs. Goodwill.

SCRIPPS RANCH: 5 Ops, 3 equipped, strip mall location, bright, spacious office. CEREC, CBCT, Dexis, Soft tissue Laser, Implant Motor, I/O Camera. Specialties referred. #CA3054

This is a sample of our listings.

Humanizing Oral Health: Race, Representation and Equity in Dental Education and Oral Health Care Mary J. Lomax-Ghirarduzzi, EdD

abstract

Background: Diversity, equity and inclusion (DEI) is an increasingly important issue in dental education and oral health care. Through illuminating exclusionary practices in the field and persistent health disparities among diverse communities, oral health educators and dental leaders are urged to confront the lack of diversity in dentistry, dental education and the oral health care professions.

Methods: To do so, this leadership brief offers The Integrated Humanizing Theoretical Framework for improving access of Black, Indigenous and people of color (BIPOC) to dental education and oral health care in order to treat diverse underrepresented populations and communities.

Results: Drawing from cultural humility theory, critical race theory and theory of restorative justice, this interdisciplinary multicritical framework sets out to analyze, disrupt and improve the care of diverse populations and communities by educating more Black, Hispanic/Latinx and Native American/ Indigenous oral health care providers who serve these minoritized communities.

Conclusions: This integrated humanizing theoretical framework is offered to remedy and eliminate racial disparities in dental education and oral health care through understanding the historical context of race as a structural and enduring form of exclusion and inequality in the health sciences and society.

Practical implications: Integrating this framework into dental school and continuing education curricula as an awareness and knowledge-building tool for both current and future professionals, educators and policymakers would promote the implementation of race conscious and equity advancing policy, procedure and practice in the field of oral health.

Keywords: Race, representation, racial equity, cultural humility, critical race theory, restorative justice, diversity, equity, inclusion

AUTHOR

Mary J. LomaxGhirarduzzi, EdD, is the inaugural vice president for diversity, equity and inclusion (DEI) and chief diversity officer at the University of the Pacific in Stockton, California. A professor and leader on race, leadership and faithinformed social justice, she is guiding the university through a transformative framework designed to integrate DEI into all aspects of campus life and operations. Prior to UOP, Dr. Lomax-Ghirarduzzi served as dean of students and vice provost of diversity and community engagement at the University of San Francisco, where she led diversity initiatives that resulted in one of the most ethnically diverse student bodies and faculty in the nation. Conflict of Interest Disclosure: None reported.

Exclusion and underrepresentation in any field of health sciences including oral health care poses a risk for the delivery of health care that is “just” and “without prejudice.”1

ADA Code of Ethics, PRINCIPLE: JUSTICE (“fairness”): The dentist has a duty to treat people fairly.

This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice. In its broadest sense, this principle expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all.

Information and research about the origins of racial disparities in dental education and oral health care provide insights about the past that can inform how to better confront inequality today. To prepare for a future of equity and racial inclusivity in oral health care, it is essential to contextualize why race and representation matter in dental education. This brief thus necessarily begins with the historical context of underrepresented minorities (URMs) in health sciences and medical education.

A History of Exclusion

A significant body of publicly available information recognizes the historic exclusionary policies and practices of educational institutions based solely on race.2

Data from the American Dental Association Policy Institute illustrates current underrepresentation (f IG ure 1 ).

The U.S. Hispanic/Latino population is the second largest racial ethnic group in the country3 and is expected to grow steadily over the next 20 years to become the largest population in the nation.

According to the National Institutes of Health, historically underrepresented racial and ethnic groups are the largest untapped talent pools for science, technology, engineering and mathematics in the U.S.4

This underrepresentation is not a statistical fluke. Historically underrepresented minorities are those whose racial or ethnic makeup is from one or more of the following groups: African American/ Black, Asian American, Pacific Islander, Hispanic/Latino, Native American/ Alaskan Native and two or more races when one or more are from the preceding racial and ethnic categories. The term “historically underrepresented minorities” helps to link past and present and refers to groups who were denied access and/or suffered past institutional discrimination in the United States (f IG ure 2 ).

A federal government report by S. Hill includes detailed documentation that the oral health care needs of Black and Native American/Indigenous people were not met by the dominant dental profession from the beginning of the oral health professions.5 African Americans who sought dental education were conscious that their professional pursuits directly responded to the needs of people who were experiencing exclusion in society broadly, including in oral health care. Refused equal opportunity for advancement in their field, Black dentists understood the needs of marginalized communities, both rural and urban. Many became essential health care educators in their communities and for other marginalized communities. Thus, community-focused health care has been a long tradition in the clinical practice of Black/African American dentists.

Institutional policy and decisionmaking is informed by historical racialized contexts. The exclusion of Black, Indigenous and other persons of color (BIPOC) in accessing dental education

and oral health care education persists nationally today. In the context of this collection of articles on this subject, there is an opportunity to view and analyze a persistent gap in professional representation through a specific framework: The Integrated Humanizing Theoretical Framework (defined below). This can help us to analyze how institutional policy and decision-making is informed by historical racialized contexts.

Increased Health and Oral Health Disparities by Race, Gender, Class

As with the historical racial disparities discussed in the previous section, current social forces are difficult to impossible to separate from the conditions they set forth.

As an example, COVID-19 provides a recent illumination of the health disparities and differentiated outcomes that existed well before the onset of the pandemic and of the implication of race, gender and class in these disparities.

The differences in health experiences and health disparities by gender, ethnicity and social class are well documented,6 including among Black, Hispanic/Latinx and Native American/ Indigenous populations.7 Nearly as soon as information about racialized outcomes was available, health professionals and researchers began to describe the disproportionate impact COVID-19 had on vulnerable and marginalized populations, specifically among people of color (Black/African American, Asian American/Pacific Islander and Hispanic).8

Analysis of the intersectional race and gender data reveals a disproportional impact. COVID-19 affected women of color by infecting them and affecting their communities at a higher rate than other populations.9

The type of employment a person engages directly affects their access to affordable, high-quality health care.

FIGURE 1. Data from the American Dental Association Policy Institute illustrates current underrepresentation.

Immigrant women of color in the U.S. are overrepresented as front-line and low-wage workers in the U.S. Their informal labor is invisible to most, as they labor behind the scenes within servicebased industries such as elder care, adult care, child care, janitorial work and food preparation. Immigrant women of color also are in consumer-facing industries such as fast-food restaurants and hotels, which puts them at greater risk of contracting the virus. Women of color who are employed on the frontlines of face-to-face labor services or informal labor environments like cleaning services and factories exist even further at the margins of society and away from reliable health care. Women of color, specifically immigrant women of color, are the lowest wage

earners in the nation,10 and they do not have equal access to oral health care.11 A lack of health care insurance prevents them from accessing oral health care.12

The rise of the gig economy is another window for critical examination of how informal or nonstandard employment diminishes access to oral health care for diverse populations by race, gender and class.

Understanding and acknowledging how factors such as race and social exclusion have an acute impact on diverse populations is a critical first step for dental educators and oral health clinicians to begin an informed response to better serve historically excluded populations, invisible workers and marginalized communities.

Interdisciplinary and Critical Theoretical Frameworks

The Integrated Humanizing Theoretical Framework uses cultural humility theory, critical race theory and restorative justice theory of change to provide a window into the realities of individuals and groups whose histories and experiences may otherwise remain largely invisible (f IG ure 3 ).

These three fundamental theories serve as a foundation for an equity-informed examination into how institutional policy and practice perpetuate racism that can be hidden within plain sight — visible and known to some, while invisible and unknown to others (f IG ure 2 ). Low numbers of BIPOC groups and BIPOC communities within dentistry and oral health professions prevent their equal engagement in this analysis.

A New Humanizing Approach for Diversity, Equity and Inclusion in the Fields of Oral Health Care

Informed by cultural humility theory, critical race theory and restorative justice theory of change,

the following interdisciplinary and multi-critical approach to diversity, equity and inclusion is offered for dental and oral health care educators, clinicians and policymakers to help solve BIPOC access to dental education and can also help improve the benefits of oral health care for marginalized BIPOC communities (f IG ure 4 ).

The purpose of The Integrated Humanizing Theoretical Framework is to help oral health care institutions become race conscious in their policy, decision-making, education and other governance processes to address the historic inequality embedded in access to dental education. Specifically, the following framework can be used by dental schools as an educational tool to fulfill the Commission on Dental Accreditation (CODA) standards requiring dental education programs to commit to a humanistic culture and learning environment (Standard 1-3) and advising that these schools “develop strategies to address the dimensions of diversity including, structure, curriculum and institutional climate (Standard 1-4).”18

This humanizing framework offers dental educators as well as oral health care policymakers and providers with a tool to learn about 1) intersectional prejudices from a 2) equity-focused and equityinformed perspective that recognizes 3) systemic inequalities and 4) social/racial forms of oppression. From this nuanced analysis, 5) integrative solutions can be developed to improve approaches to BIPOC access to dental education and improve the benefits of oral health care for these marginalized communities. In practical terms, the framework can be used as a guide or springboard for educators who wish to develop their own DEIfocused curriculum. Alternatively, dental educators and oral health professionals should collaborate with a DEI consultant or researcher to elaborate a quality curriculum that is critical, innovative and up to date on these issues. Though many dental schools in California and across the nation are beginning to work directly to address these concerns, they may benefit from a close examination of dental schools whose graduating classes are widely representative of BIPOC groups, academic

institutions with a proven commitment to diversity or nonprofit organizations that are at the forefront of DEI work and could create specific educational programs or general training models adaptable for dental school curriculum and continuing education opportunities in the field.

This analytical framework resists DEI being treated as an add-on — rather it is the focus of systemic change. In this sense, there is a real need for frameworks that humanize dentistry and oral health care and embody a spirit of change, hope and reconciliation.

Recommendations and Next Steps

Any investments to advance diversity, equity and inclusion by dental educators, oral health care providers or professional dental associations must pay close attention to the role of race, racial inequality and access in these professions and in improving access to care for all.1 Indeed, in following the principles that are fundamental to the work of oral health practitioners, racial equity in each of these realms — education, health care service and professional associations — is perhaps the most pressing need in dentistry and oral health today. Furthermore, identifying which groups are being underrepresented and recognizing the impacts of this exclusion on BIPOC students, BIPOC oral health care professionals and BIPOC communities is imperative.

The Integrated Humanizing Theoretical Framework guides dental educators and oral health care leaders through a deep inquiry into the oral health care profession. The framework offers a nuanced lens through which to examine and address how unequal and unfair historical precedents targeting certain groups engender persisting unequal and unfair repercussions in dentistry and oral health care professions.

Specific underrepresented minority

groups that would benefit from further data collection and analysis using the offered framework include immigrant women of color as well as those hidden under the umbrella of Asian American/ Pacific Islander (AAPI). This category includes the following historically underrepresented ethnic groups: Filipino, Hmong, Cambodian, Laotian and Vietnamese. Unfortunately, disaggregated data for these groups are not available and, without it, the percentages of underrepresented AAPI persons within dentistry remain undocumented.

Oral health care educators and providers can adopt what is already working in other fields and industries to expedite racial equity in their professions.

This brief examines the historical foundations of dental education and oral health care access and delivery through research, history and documentation that is publicly available. However, the issues, concerns and needs for URMs among immigrant women of color and within the AAPI community cannot be fully understood and addressed until data for these groups is disaggregated. Next steps:

n Weave DEI into dental education programs to ensure that oral health professionals are equipped with the information and awareness necessary for inclusivity and culturally competent care.

n Crystallize the concept of DEI within the field of oral health care by adopting it into the jargon: Incorporate DEI into the language

of the ADA’s Principles of Ethics and Code of Professional Conduct as well as CODA’s accreditation standards to perpetuate a “trickledown effect” across the profession.

n Encourage and develop continuing education programs, resources and opportunities based on DEI. The Accreditation Council for Continuing Medical Education (ACCME) has adopted a strategic approach to “reward practices that incorporate diversity, equity and inclusion (DEI) into all aspects of accredited education,”19 which offers an example of this action. Another way to implement this step could be to sponsor a DEI leadership certificate: Guided by an integrated humanizing approach, oral health care professionals can train leaders on how to address social disparities and disproportionalities within the communities and regions (whether at the local, state or national level) where they practice and serve.

n Learn more about how limited access to oral health care affects BIPOC communities today. Begin by collecting and disaggregating diversity data by race to understand the unique gaps and challenges for specific communities. In this vein, the lack of available data relating to immigrant women and disaggregated data concerning AAPI communities presents salient opportunities for future research.

n Commission environmental scans for DEI practices in dental education institutions and oral health professions in concert with other DEI-related research, training and initiatives to understand the need for racial equity in dental education programs and among oral health care providers.

n Offer DEI audits through professional dental associations and center the voices of BIPOC oral health professionals. Collect data and gather narratives about their experiences and perspectives as students, dentists, educators and clinical leaders.

The American Student Dental Association (ASDA), for instance, serves as a dynamic platform for such information gathering through its rich offering of “Diversity and Inclusion Resources” as well as its “Diversity and Outreach Blog Posts.”20 Document any themes, patterns and gaps that surface through this growing pool of information about BIPOC members of the oral health professions.

n Learn from and adopt policy and best practices in DEI approaches from the BIPOC community, other health care fields, public health agencies, business, education and government. For instance, racial equity approaches are at the forefront of inclusive public policy within governmental agencies including cities, counties and states. Oral health care educators and providers can adopt what is already working in other fields and industries to expedite racial equity in their professions.

n Ensure that all appointed and/or elected leaders have appropriate DEI education as part of the requirement for service to their profession. Develop leadership practices, approaches and mindsets committed to the principles of an integrated humanizing approach for racial equity from the top down. Policy bodies are critical stakeholders,

as they set the strategic direction and make decisions on matters of policy and practice at both the state and national levels. These bodies include boards of directors, delegates, standing committees, editorial boards and membership at large.

Anticipating Difficulty, Navigating Change

Change is difficult. Confronting how exclusionary practices in the profession limit BIPOC access to a dental education and BIPOC communities’ access to oral health care may be challenging for some leaders in the profession, while being cathartic, even liberatory for others. There may be consternation or concern about what racial equity work means on a personal level in terms of the role or position held within the field. Therefore, a critical component of racial equity work begins within a historical context, to encourage an understanding about how inequality becomes structural and embedded within the policies, practices and mindsets of the dentistry and oral health care professions. When race is no longer a predictor of outcomes, then it will be possible to move beyond addressing racial equity dental education and oral health care. Until that happens, it is vital to ensure that both dental education and oral health care are equally accessible to everyone. n

REFERENCES

1. American Dental Association. Principles of Ethics and Code of Professional Conduct. Accessed Aug. 5, 2022.

2. Daher Y, Austin ET, Munter BT, et al. The history of medical education: A commentary on race. J Osteopath Med 2021 Feb 1;121(2):163–170 doi: 10.1515/jom-2020-0212

3. Pew Research Center. Hispanics/Latinos. Accessed April 5, 2022.

4. U.S. Department of Health and Human Services, National Institutes of Health. Underrepresented Racial and Ethnic Groups. Accessed April 4, 2022.

5. Hill ST. The traditionally black institutions of higher

education: 1860 to 1982. National Center for Education Statistics; 1979. Accessed April 4, 2022.

6. Solana K. HPI publishes findings into racial disparities in oral health. American Dental Association; 2021. Accessed Apr. 3, 2022.

7. U.S. Department of Health and Human Services, National Institutes of Health. NCI study highlights pandemic’s disproportionate impact on Black, American Indian/Alaska Native and Latino adults. 2021. Accessed April 4, 2022.

8. Greenaway C, Hargreaves S, Barkati S, Coyle CM, Gobbi F, Veizis A, Douglas P. Covid-19: Exposing and addressing health disparities among ethnic minorities and migrants. J Travel Med 2020 Nov 9;27(7):taaa113. doi: 10.1093/jtm/taaa113. PMCID: PMC7454797. Accessed Apr. 4, 2022.

9. Damle M, Wurtz H, Samari G. Racism and health care: Experiences of Latinx immigrant women in NYC during COVID-19. SSM Qual Res Health 2022 Dec;2:100094 doi: 10.1016/j.ssmqr.2022.100094. Epub 2022 May 12. PMCID: PMC9095080

10. Panikkar B, Brugge D, Gute DM, Hyatt RR. They see us as machines: The experience of recent immigrant women in the low wage informal labor sector. PLoS One 2015 Nov 24;10(11):e0142686 doi: 10.1371/journal.pone.0142686. eCollection 2015. Accessed Apr. 4, 2022. PMCID: PMC4657936

11. Sim S, Asante-Muhammad D. Women of color, wealth and Covid-19. National Community Reinvestment Coalition; 2021. Accessed Apr. 4, 2022.

12. Suphanchaimat R, Kantamaturapoj K, Putthasri W, Prakongsai P. Challenges in the provision of healthcare services for migrants: A systematic review through providers’ lens. BMC Health Serv Res, 2015 Sep 17;15:390 doi: 10.1186/ s12913-015-1065-z PMCID: PMC4574510

13. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998 May;9(2):117–25 doi: 10.1353/ hpu.2010.0233

14. Yeager KA, Bauer-Wu S. Cultural humility: Essential foundation for clinical researchers. Appl Nurs Res 2013 Nov;26(4):251–6 doi: 10.1016/j.apnr.2013.06.008. Epub 2013 Aug 12. PMCID: PMC3834043

15. George J. A lesson on Critical Race Theory. American Bar Association. Jan. 11, 2021. Accessed Apr. 4, 2022.

16. International Institute for Restorative Practices. Reimagining Campus Community with Restorative Practices. Accessed Apr. 4, 2022.

17. Wardell-Ghirarduzzi MJ. Twice as Good: Leadership and Power for Women of Color. New York: Morgan James Publishing; 2020.

18. Commission on Dental Accreditation. Accreditation Standards For Dental Education Programs. Accessed Aug. 5, 2022.

19. Accreditation Council for Continuing Medical Education. Diversity, Equity and Inclusion Resources. Accessed Aug. 5, 2022.

20. American Student Dental Association. ASDA blog, category: Diversity. Accessed Aug. 5, 2022.

THE CORRESPONDING AUTHOR, Mary J. LomaxGhirarduzzi, EdD, can be reached at mlomax@pacific.edu.

Credit

Improving Access to Care and Patient Experience Through Diversity, Equity, Inclusion and Belonging

Elisa M. Chávez, DDS

abstract

Background: California is one of the most ethnically, racially, linguistically, geographically and economically diverse states in the country. Intersecting and unrelenting challenges of cost, location, language, literacy, marginalization, age and disability can result in mistrust, avoidance of care, challenges in diagnosis and poor adherence manifested in poor outcomes and disparities in care.

Studies reviewed: Data from the most recent National Institute of Dental and Craniofacial Research

“Report on Oral Health in America” as well as current information and, in some cases, lacking national or state information about disparities in oral health care are presented here to better understand the complex challenges that prevent individuals and populations from accessing even basic preventive care and information.

Results: Poverty, minority status, employment status, insurances status, educational attainment and dependence greatly impact the risk for oral disease, oral health status, the ability and resources to access care and outcomes of oral health care once received.

Practical implications: Proactive patient assessment and care, increased public awareness and new paradigms in practice, education and workforce that directly address persistent, systemic and systematic challenges experienced by patients seeking and needing oral health care are needed and possible.

Keywords: Diversity, equity, inclusion, belonging, disparities, poverty, oral health, disability, access

AUTHOR

Elisa M. Chávez, DDS, is a professor in the department of diagnostic sciences and the director of the Pacific Center for Equity in Oral Health Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. She graduated from the University of California, San Francisco, School of Dentistry and earned her certificate in geriatric dentistry from the University of Michigan, Ann Arbor. She has practiced in private practice, community health, long-term care and hospital settings. Dr. Chávez developed and directs extramural student rotations at On Lok Lifeways, a program for all-inclusive care for elders (PACE) in San Francisco. She is an advocate for the oral health needs of older adults nationwide. Conflict of Interest Disclosure: None reported.

California is the most populous state in the nation with almost 40 million people and one of the most ethnically, racially, linguistically, geographically and economically diverse states1–6 (TABLES 1 and 2) . As a result, social determinants of health, intersectionality, access to care and expectations for oral health vary greatly among individuals and populations across the state and even within counties and cities. Disparities in oral diseases have persisted for some individuals over entire lifetimes and within some populations for generations. The FDI World Dental Federation defines oral health as “multifaceted, including the ability to speak, smile, smell, taste, touch, chew, swallow and convey emotion through facial expressions with confidence and without pain, discomfort or disease; it is fundamental to physical and mental health and well-being; it exists along a continuum, influenced by the values and attitudes of people and communities; it reflects the physiological, social and psychological attributes that are essential to the quality of life; it is influenced by the person’s changing experiences, perceptions, expectations and ability to adapt to life circumstances.”7 Given the significance of oral health as represented here, it is clear that persistent disparities in care and unmet oral health needs have significant economic and health consequences for individuals and communities that can accumulate over lifetimes and generations.

The federal government classifies certain groups as being at higher risk of marginalization and concomitant health issues but these issues of marginalization and discrimination are rarely a one identity issue: age or gender or race or sexual orientation or ethnicity or socioeconomic status.8 People, like oral

health, are multifaceted and can describe and identify themselves in many ways. Society can also describe and define them in many ways, and their environments may support or suppress them.8 Societal norms will guide whether there is acceptance for the identities they carry; the local economy will determine their opportunities for education and work and adequate insurance and salary to afford dental care; geography will determine the density or scarcity of dental providers; and all of these will feed into not only their access to care but their health literacy and perceptions about the value of oral health. This intersectionality — the intersecting effects of discrimination and structural inequalities directed at the various identities someone may carry — can significantly impact health and well-being.8 An individual might experience this in many ways, impacting their ability to maintain good oral health over their lifetime. So as an example, a young girl who has been poor receives a marginal education and becomes a working poor adult woman who loses access to dental care she had as a child through the Affordable Care Act (ACA) or the Children’s Health Insurance Program (CHIP). And perhaps having faced some challenges in her work and limited upward mobility as a result of bias toward her as a woman with limited education, she finds herself with limited access to oral health care as an adult. Then as an old woman, with new biases fueled by ageism, she is possibly viewed as less in need or less deserving of oral health care at this time in her life. These examples are not to suggest that these barriers cannot be overcome, but that as practitioners we are challenged to see patients without the biases we may carry without even being aware, and as a profession we are tasked to identify and remove barriers to the benefit of all individuals and communities.9

This paper identifies issues of disparities in access to care and outcomes along racial, ethnic and socioeconomic lines across all ages in the general population. The paper then highlights specific populations that suffer disparities in access and care as discrete groups, which can be further exacerbated by issues of race and class and other social determinants of health with significant impact on the individuals who are reflected in the data. The most recent data from the National Institute of Dental and Craniofacial Research (NIDCR) report on “Oral Health in America: Advances and Challenges”10 and other national studies are presented in the absence of more recent state data. Current California data on oral health status across ages are limited, with the most current report being a 2017 report on oral health from the California Department of Public Health based largely on data from the prior decade.11 Other recent studies on oral health status, insurance access, workforce and utilization are also described.

Disparities in Oral Health: Where and for Whom Do They Occur?

Children and Adolescents

According to the NIDCR’s report, the greatest improvement in untreated tooth decay in primary teeth has occurred in children aged 2-5 years in the U.S., with caries experience decreasing from 19% to 10% conservatively.10 For children aged 6-11 years, caries in permanent teeth also has declined significantly from 25% to 18% since the 2000 “Oral Health in America: A Report of the Surgeon General.” Caries experience in children was significantly impacted by income with higher rates to start and much less decline for those with lower income — 28% to 24% for low income and 22% to 13% for high income over the last 20 years. This disparity has persisted despite efforts to achieve equitable access and

California Demographics Reflect a Diverse Patient Population1–6

Total population* ~ 40 million Age

< 18 22.5%

18–64 62.7%

≥ 65 14.8%

Median age 37.3 years

Gender**

Male 49.7%

Female 50.3%

Sexual orientation

LGBTQ 5.3%

Race

White alone 71.9%

Black or African American alone 6.5%

American Indian/Alaskan Native alone 1.5% Asian alone 15.5%

Native Hawaiian, other Pacific Islander 0.5%

Two or more races 4.0%

Ethnicity

Hispanic or Latino 39.4% White alone, not Hispanic or Latino 36.5%

Origin and languages

Foreign born (54% are citizens) 26.6%

Language other than English spoken at home 43.9%

English 58.8%

Spanish 28.5%

Mandarin or Cantonese 2.8%

Education

High school graduate or higher 83.9%

Bachelor’s degree or higher 34.7%

Insurance status

Under age 65 without health insurance 8.9%

Disability – not IDD

Under age 18-64 with a disability 8.2% 65 and older with a disability 36.0%

All Californians with a disability, 18+ years*** 24.0% Californians with IDD – see TABLE 2**** 1.0%

Income

Median household income $78,672

Per capita income in 12 months (2020) $38,576

Persons in poverty 11.5%

TABLE 1. *Population estimates from July 2021. **2020 Census did not collect data on gender other than male/female or sexual orientation. ***California Department of Developmental Services, regional center data for 2021.

**** California Department of Developmental Services, regional center data for 2021

California Department of Developmental Services Demographic Data, 2019 and

Intellectual and developmental disability diagnoses – 2019

Some consumers will have more than one disability

Intellectual disability only

Autism only

Epilepsy only

Cerebral palsy only

Fifth category only

Physical and intellectual impairments 2019

Vision

Hearing

Both hearing and vision

No intellectual disability

Only an intellectual disability

Gender 2019

Male

Age 2019 – average age of all consumers

0-2

and older

Ethnicity 2021

Hispanic

Non-Hispanic

Race 2021

White

Black/African American

Native American

Polynesian

Other

Primary language 2021

English

Spanish

Others

Living situation – adults 2019

In home: e.g.,

ILS/SLS:

SNF/ICF:

care:

State operated:

Other: e.g.,

operated

years old

outcomes for all children. There has been progress in the prevalence of at least one sealed permanent molar in children aged 6-8 years, which increased from 14% to 31% with Mexican American children. Children living in poverty achieved the largest gains of almost five times resulting in a near elimination of this health disparity in prevention among poor and Hispanic children. The prevalence of dental sealants among children aged 9-11 years also increased, from 29% to 53%.

Children with unmet oral health needs are at risk for nutritional deficiencies, missing school days and difficulty with school work as well as acute pain and infection that is largely preventable with measures such as sealants and routine dental care. Improvements for children have been attributed to improved access to care as a result of the ACA and CHIP.10

Improved oral health has not been observed in adolescents, those aged 12-19 years.10 In particular, there has been no significant change in dental caries, and the highest rates have been documented among Mexican American children at 69%. Disparities between Mexican American and non-Hispanic white adolescents as well as across those with lower income compared with higher income has increased. Disparity between non-Hispanic Black and nonHispanic white adolescents declined. Untreated tooth decay in this age group has declined overall about 3% but caries remains most prevalent among adolescents living in poverty. Almost a quarter of adolescents living in poverty have caries. Approximately 40% of American Indian/Alaska Native (AI/AN) teens aged 13-15 years have untreated tooth decay. Immigrants, LGBTQ+ (lesbian, gay, bisexual, transgender, queer and other sexual identities and orientations), homeless, those living

in health professions shortage areas (HPSA) and those in the juvenile justice or foster system are at greatest risk for poor oral health outcomes.10

There have been substantial gains for all adolescents who have received a sealant on at least one permanent molar during this developmental period.10 This has increased from 18% to 48% for all. This includes significant gains for non-Hispanic Blacks by nearly 30% and by 36% for Mexican Americans. For all of those living in poverty, this has increased more than 30% from 12% to 43%. Other gains in prevention have been made as well. In 2018, half of U.S. adolescents aged 13-17 years were fully vaccinated, with 68% having received at least one dose of the HPV vaccine, which is important in the prevention of oral cancers. Oregon recently became the first state to change its regulations to permit dentists to provide vaccines, including the HPV vaccine, representing one way in which dentists may improve outcomes of care for patients if more states allow this change in scope of practice. This could impact not only children, but older adults who receive regular series of vaccinations to prevent diseases such as pneumonia, shingles and COVID-19.10

New challenges for oral health have arisen for adolescents in last 20 years, with e-cigarettes presenting a significant risk for adolescents and young adults. Use increased from 1.5% to 27.5% between 2011 and 2018 among U.S. high school students and rose nearly 10% to 10.5% among middle school children.10 A 2013-2014 study found that 24.4% of California middle and high school students participating in the study had used e-cigarettes.12 This is compared with 15.6% who had ever used tobacco or smokeless tobacco. Further, Hispanic students who had never used tobacco products

were more likely to use e-cigarettes than non-Hispanic white students.12

Adults 18-64

The average number of teeth for adults in all economic groups has increased by 50% since the 2000 surgeon general’s report.10 However, 20% of adults aged 18-64 years living above the poverty level in the U.S. have untreated caries, which increases to 52% among those who are poor. Having dental insurance improves access to oral health care but recent data show that more than 25% nationally

While insurance is of help in access and utilization, it does not tell the whole story.

and 21% in California in this age group do not have any dental insurance.10,13 Nationally, approximately 50% of those with insurance, 20% of those with public dental insurance and 17% without insurance had a dental visit in the last year.5 Twenty percent of working-age adults reported that they needed dental care but could not afford it and were more likely to delay needed care due to cost compared with other types of health care including purchasing prescription drugs.10

When California’s Medi-Cal dental program eliminated adult dental benefits in 2009, there was a significant increase in the use of emergency rooms for nontraumatic dental emergencies.14 Emergency room care is expensive and rarely definitive. In the absence of

definitive care, patients may be forced to return to the emergency room multiple times without resolution. Palliative care could include repeated use of antibiotics and/or narcotic pain relievers in the absence of definitive care, contributing to risks for antibiotic resistance and substance dependence adding significant risks to lives already rife with risks to health.10 Young adults, minority groups and residents from urban areas were disproportionally represented in the estimated 1,800 additional emergency room visits per year across the state when this lapse occurred. A study of the California Emergency Department Database from 20052011 found that a third of those using emergency rooms for dental emergencies were uninsured and the percentage of patients enrolled in Medicaid who used those services increased to a third in 2011 as well.15 Other studies around the country and those looking broadly at national data showed time and again that these populations are most likely to seek care in hospital emergency rooms, although some studies reported increased use in rural rather than urban areas.16–18 A nationwide study looking at emergency room data from 2010-2017 found more visits by those aged 15-20 years, the uninsured, those with Medicaid and those from less affluent ZIP codes. This study did demonstrate that there was a reduction of ER visits by children following implementation of the ACA. However, poor children were taken to the ER for treatment more often than those who were not poor, indicating that while insurance is of help in access and utilization, it does not tell the whole story;19 there are many more barriers to care for marginalized groups that must be countered in order for people to receive appropriate care in appropriate settings with the appropriate provider.

Strategies for Improved Communication for Those With Hearing and Vision Loss and Altered Speech42

Hearing, vision and speech

• Review instructions one point at a time.

• Ask just one question at a time.

• Minimize distractions.

• Avoid physical barriers.

• Avoid shouting and intonation or rate of speech as if for a child.

Hearing and vision

• Speak slowly to aid in hearing or reading lips.

• Use gestures as needed and mutually understood.

• Explain procedures before the procedure, not during.

Hearing and speech

• Ask questions slowly with adequate response time.

• Provide a private space for discussion.

Hearing

• Make sure hearing aids are in place.

• Be able to assist patient with hearing aids.

• Turn off aids or turn down when using handpieces or cavitron.

• Speak in low tones.

• Use a pocket talker.

• Write down questions and information.

Vision

• Make sure patient brings and uses glasses.

• Reduce glare.

• Printed material should be in bold and contrasting colors and larger font.

Speech

• Plan additional time for discussion.

• Do not finish sentences or add words for the patient while they are speaking.

Adults 65 and Older

The fastest rates of growth among older adults in California will occur among Latinos (170%) and Asians (118%), and no ethnic group will be a majority of the senior population. Since 2020, the fastest growth among older adults in California has occurred among adults aged 75 and older. The over-85 group will have increased 61% since 2012 to 2030.

Approximately 1 million of California’s ~6 million adults aged 65 and older require assistance with one or more activities of daily living (ADLs) such as eating, bathing, dressing or doing chores, and the number of these older adults with disabilities is estimated to increase by 160% from 2015 to 2060.20 Projections show that by 2030, nearly 20% of older

adults will be childless and therefore more reliant on nonfamilial sources of care. In 2016, 16.9% of adults aged 65 and older in the U.S. required long-term care and 9.1% required some home health care.21 Those who live in long-term care are more reliant on others for self-care, have multiple concomitant chronic diseases and are at greater risk for oral diseases than most community dwelling older adults, except those who are bound at home or qualify for home health services.10

Older Californians are anticipated to live more years than the national expected average for those requiring assistance with two or more ADLs.20 As a result, there will likely be increased and prolonged risks to their oral health and challenges accessing oral health care compared with older

adults in other parts of the country. These issues can present significant challenges for patients seeking care. Whether these occur as a result of normal age-related changes like those in hearing, vision or as a result of disease, practices can be more accessible for those with these disabilities. While there are specific Americans with Disabilities Act (AwDA) requirements to make offices accessible, additional steps can be taken to be sure that spaces are well-lit and free of distraction and have clear and frequent signage, chairs that are more ergonomically friendly for those with mobility issues and available handrails (TABLE 322–25).

Edentulism has decreased from about 32% to 17% in the last 20 years, but those living in poverty are three times more likely to be edentulous. Edentulism rates differ greatly by state, ranging from 26% to just 6%.10 A 2016 report showed 19% edentulism overall in California, but when broken down by ethnicity, 15% of Hispanic, 17% of white and 29% of Black Californians had no teeth at all.26 A 2017 survey showed that a third of adults in long-term care in California were completely edentulous.27

Nationwide, just over half of older adults (51%) have retained at least a functional dentition (> 20 teeth). Once again, there are substantial differences for those in poverty compared with those who are not, 25% to 62% respectively. This was a 20% increase for nonpoor with a functional dentition but only 10% for poor in the last 20 years.10 Lack of a functional dentition can result in poor nutrition, selection of foods that are high in carbohydrates and highly cariogenic for the teeth that remain and potential embarrassment or loss of dignity for older adults who struggle to eat a meal or refrain from social engagement.28

Disparities in care are evident nationally with respect to caries and

periodontal disease in older adults as well. The prevalence of dental caries in older adults has declined only 1% since 2000 and untreated tooth decay declined by 6% to an estimated 22%. However, when comparing those living in poverty (43% untreated) with those who are more affluent (14% untreated), there is a significant difference in caries prevalence that becomes more pronounced for those aged 75 years and older. Disparities in periodontal disease also exist. Ten percent of older adults have severe periodontitis, but older men, Hispanic and African American individuals and those who are poor or who have fewer years of education are at increased risk for severe periodontitis.10 Among long-term care patients in California, half had untreated caries, 40% did not have opposing teeth to chew and those in rural settings had more decay and poorer oral health overall.27 Given our increased understanding of the role of periodontal inflammation in association with many chronic systemic diseases such as diabetes, cardiovascular disease, respiratory diseases and others, the persistence of these disparities places some individuals, such as those with disabilities or lack of insurance with fewer opportunities for oral health care, at greater risk than those with more access, resources and more frequent utilization.10

Oral diseases are largely preventable in older adults, but largely dependent upon regular access to oral health care as well as behaviors that support oral health. With increased retention of natural dentition among aging cohorts and higher expectations for oral health and cosmetic procedures than in prior generations, there is increasing interest in oral health among older adults themselves.29 However, almost half of all older adults lack dental coverage, which is a significant barrier to oral health care for this population and of all age groups,

the highest out-of- pocket expenditures are borne by older adults in America.10 In California, 39% of older adults do not have dental insurance. Although critical to access, insurance alone does not guarantee utilization, because those who receive comprehensive adult dental benefits through the Medi-Cal Dental Program were least likely to have seen the dentist in the last year.13 This could be in part due to the number who have one or more chronic diseases that may limit their ability to access care, as patients with more chronic diseases have greater functional

of integration with an interprofessional team can result in either under- or overtreatment of these populations32 that can also make patients reluctant to seek or follow through with care.

Intellectual and Developmental Disabilities (IDD)

Inadequate provider training and lack of integration with an interprofessional team can result in either underor overtreatment.

limitations.30 This is of particular concern for older adults who tend to have more chronic diseases than younger adults. A 2014 study found that 81% of adults aged 65 and older were diagnosed with two or more chronic diseases.30 Additional barriers have included low reimbursement rates and high administrative burden to participate in Medi-Cal Dental, which can limit the number of providers who will enroll as providers. While payment rates have increased and administrative burden has decreased for providers who accept Medi-Cal Dental in recent years, this remains a work in progress.31 These deterrents are also compounded by providers who may not feel prepared to manage patients with more complex combined medical and dental issues.10 Inadequate provider training and lack

The California Department of Developmental Services works through 21 regional centers, two stateoperated developmental centers and one state-operated community facility to serve 371,687 individuals who have a developmental disability.33 A developmental disability presents with substantial impairment in three or more areas of major life activity such as selfcare, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency. Developmental disabilities include intellectual disability, autism, epilepsy, cerebral palsy and disabling conditions closely related to or requiring treatment similar to that required by a person with an intellectual disability (referred to as fifth category).33 TABLE 2 provides demographic data from the California Department of Developmental Services.4,33,34 Studies have consistently shown higher rates of periodontal disease and untreated caries in those with IDD compared to those without. A 2012 study found a 32.2% prevalence for untreated caries, 80.3% for periodontitis and 10.9% for edentulism among their study population.33 Untreated disease is a particular risk for those who may be less able or unable to express a problem, such as a toothache, a broken tooth or bleeding gums. Individuals who are more independent and less reliant on others for self-care and ADLs will have less risk for oral diseases than those who require more assistance or who are less able to tolerate routine dental care due to

physical, intellectual or behavioral issues. Frequently, direct caregivers for adults with acquired developmental disabilities have low oral health literacy and little formal training in the provision of oral health care.35 Even for those living in skilled nursing facilities with more formal direct caregivers, these are often low-paying jobs that turn over quickly resulting in a lack of continuity and quality of care.36 Multiple aspects of socioeconomic status or race can intersect and potentially lessen an individual’s ability to access oral health care regularly if at all. Just as with older medically compromised adults who have difficulty finding providers who are trained and confident in their care, individuals with IDD have similar challenges, which increase with diminished ability to follow instructions and cooperate for care. And for those who require hospital-based dentistry for care, resources are scarce.37

LGBTQ+

Data from a 2017 Gallup poll showed that LGBT (lesbian, gay, bisexual, transgender) identification was higher in the Northeast and the West Coast. This is possibly because states such as California provide more legal protections, resulting in an increased willingness to identify in the surveys than in other parts of the country.38,40 Increases in LGBT identification between 2012 (5.8%) and 2017 (8.2%) was predominantly among millennials with other age cohorts unchanged over that time. The race and ethnicity of the respondents were similar to those of the general population. Collecting accurate demographics and other information such as oral health status specific to sexual and gender diverse (SGD) populations is needed to understand changing needs in our state, identify disparities in care compared to other populations and within the population itself and to

ensure that resources appropriate to the need are accessible for our patients.40 Studies based on the Behavioral Risk Factor Surveillance System Surveys have indicated that LGBTQ+ (lesbian, gay, bisexual, transgender, queer and other sexual identities and orientations) inequities in health care are related to poor economic and social circumstances.42 LGBTQ+ participants reported more behaviors-associated substance abuse and other risks to health, worse mental health and more disability. The data on oral health are limited and not included

Combating Disparities With Communication and Education

Access to health care is an opportunity to improve health outcomes through access to information.

in National Health and Nutrition Examination Survey (NHANES) data prior to 2009. The 2009-2014 data did not reveal clinical differences except that lesbian, gay and bisexual adults reported worse-perceived oral health than the heterosexual respondents. Perceived discrimination is also an increased risk for LGBTQ+ individuals that can inhibit them from seeking care, as well as overt discrimination, intimidation and even abuse in health care settings.10 An estimated 63% of older LGBTQ+ individuals do not have children, which may increase their reliance on nonfamilial caregivers to assist them in accessing dental care as needed with advanced age or disability.40

Low oral health literacy is a significant factor in disparities in care for low-income and marginalized populations with limited access to resources necessary to access health care and health information.10 The updated “Healthy People 2030” definition of health literacy addresses a dual element: An individual’s ability to “find, understand and use services to inform health-related decisions and action for themselves or another” plus the concept of an organizational health literacy in which “organizations equitably enable individuals” to exercise their health literacy.41 While public health campaigns can improve oral health literacy, those with limited access to direct care miss important opportunities for information that is relevant to them as individuals. Just as education is an important resource to combat poverty through knowledge, access to oral health care is an opportunity to improve health outcomes through access to information, and these are important opportunities for providers to raise their patients’ oral health literacy for the benefit of their overall health and well-being. Information can be shared not only about the patient’s oral condition but about the importance of good oral health to general health. And for those with chronic diseases or taking medications that impact disease, it is a critical opportunity to educate them about the specific risks to their oral health as a result of their diseases.10

A recent study conducted in California revealed that dental providers used some strategies to address and improve health literacy, such as using simple language and models or radiographs to enhance the information. However, the use of interpreters and translated materials or illustrations was limited, as was the use of motivational interviewing or the teach-back method.43 These

Resources To Improve Communication and Health Literacy

Oral Health Literacy in Practice: A Tool Kit. California Department of Public Health

“… resources for oral health providers offer an overview of what oral health literacy is and why it matters as well as practical tools and roadmaps for improving the health literacy of dental practices ….”

Health Equity Guiding Principles for Inclusive Communication. Centers for Disease Control and Prevention (CDC)

“… principles are intended to help public health professionals, particularly health communicators, within and outside of CDC ensure their communication products and strategies adapt to the specific cultural, linguistic, environmental and historical situation of each population or audience of focus ….”

Clear & Simple. National Institutes of Health

“Designed to assist health communicators in developing audience-appropriate information and communicating effectively with people with limited health literacy skills.”

Quick Guide to Health Literacy. Department of Health and Human Services, Office of Disease Prevention and Health Promotion

“ … provides information on key health literacy concepts; techniques for improving health literacy through communication, navigation, knowledge-building and advocacy; examples of health literacy best practices; and suggestions for addressing health literacy in your organization….”

Sign Language Interpreter Information for California

There are eight regional Deaf Access Program (DAP) service providers.

California Department of Managed Care, Language Assistance Services

Check with the patient’s dental plan to ask if they provide free interpreter services to their members. Ask about availability at the time of appointment upon request or if this must be scheduled in advance.

are missed opportunities and can result in misunderstandings, lack of adherence and poor outcomes.

Key barriers that providers in this study reported as interfering with effective communication included limited time, lack of oral health literacy training for themselves and staff and limited access to plain-language or translated materials. More than half of respondents reported that patients or caregivers would not follow instructions, no matter how well done, and that cultural beliefs are a barrier to understanding. Thirty-eight percent reported that their patients are not interested and 36% reported that they just do not understand the information. Sixtyfive percent of respondents reported more frequent challenges in communication with non-English speakers, 54% for patients with cognitive disabilities, 42% with elderly patients, 35% of those with low educational attainment and 31% who are hard of hearing or deaf41 (BOX 42 ) . Dentists could benefit from more opportunities to learn effective patient communication techniques and strategies

to develop a shame-free environment for those struggling with literacy and by securing interpretation services and materials in other languages for patients when needed. Use of interpreters improves satisfaction, reduces errors and malpractice and can also educate providers about potential cultural misunderstandings.43 Improved communication with all patients and caregivers is critical to avoid misunderstandings that result in delayed diagnosis, misdiagnosis and poor outcomes of care and avoidance of care.10

A recent study of 304 older adults in San Bernardino County found that poor oral health knowledge was significant for respondents aged 75 and older, those with an education of high school or less, those of a minority ethnicity, those with an income of less than $25,000 per year and those with less reading ability.43 Modeling for the variables revealed Hispanic participants were almost 25 times more likely to score as “poor” on oral health knowledge as compared to Caucasians. Then they looked at their Oral Health Impact Profile (OHIP, oral health-related

quality of life (OHRQoL) indicators). The strongest factor was an association with less than a high school education and a high (> 10) OHIP severity rating. And those with a poor oral health knowledge score were five times as likely as the other respondents to have a high severity OHIP rating.43

Several studies have demonstrated that poor social and socioeconomic conditions contribute to low health literacy, which can adversely impact health status, quality of life and outcomes of care plus reinforce behaviors that undermine health and limit use of preventive services.44 Health literacy can be improved as can modifiable social determinants of health — if individuals have access to someone who will educate them. Therefore, it is critical that the dental team is prepared to provide this opportunity for those who have access to care and that we have a public health initiative for those who do not have that access. Collaborative efforts from organized dentistry, public health and private organizations can ensure that providers in California have access to a wider variety of resources to facilitate effective and appropriate communication with their patients. Public campaigns targeted to increase knowledge and awareness among diverse populations and communities are also needed. This could include in-person support, telehealth support and print or digital communications that can be shared with patients and more broadly. The California Department of Public Health created an online toolkit called “Oral Health Literacy in Practice.”45 Other resources are available through the American Medical Association to describe and demonstrate strategies for clinicians to improve health literacy and outcomes of care (fIGure 3). Effective and appropriate communication and patient education is critical to achieve equity by making sure patients are heard and have a sense of belonging wherever they are seeking care,

whether in a community health clinic, dental school clinic or private practice.41

Workforce and Systems of Care Impact Individuals and Populations

Diversity of representation in the profession is critical.46 A recent report concluded that 8% of the state’s dentists are Black and Latino, yet the Black and Latino population comprises nearly 46% of the state’s population with nearly 40% being Latino.13 There is also evidence that historically underrepresented providers are more likely to care for the underserved populations as well as accept Medicaid or treat those who are uninsured.47 While it is not acceptable that these providers carry a disproportionate financial burden, it does demonstrate the potential for a more diverse workforce to practice in communities and with populations that have historically been underserved by our current workforce. Sustainable practice models, reimbursement structures and opportunities for loan repayment that allow providers to care for individuals and communities with fewer financial resources must go hand in hand with a diverse workforce because the current system of dental care remains inaccessible to many.

In addition to a greater ethnic, racial and geographic diversity of providers, a greater diversity in provider types and practice settings is critical to reaching populations that are reliant on others to access oral health care like those with a disability, children or those living in remote or underserved areas.10,48 There are 647 Dental Professional Shortage Areas (DHPSAs) in California.49 Making full use of our dental team to reach underserved communities that have few or no dentists is critical, through schools, adult day health centers, meal programs and better integration and collaboration with primary care.10 For individuals who may not feel safe leaving their neighborhood, are too far

from the nearest dentist, cannot afford or physically cannot use public transportation to reach a distant dentist or rely on others to get them to the dentist, taking care to them is one logical next step.10

Awareness of the barriers that prevent underserved populations and communities from seeking or following through with care is critical. Better collaboration with other health care providers who are already caring for these patients may result in increased referrals and better adherence; building networks of interprofessional teams and advocates

regular access to oral health care, but also require addressing social determinants of health and the marginalization of certain groups that prevent individuals and populations from getting the information and care they need to maintain good oral health over a lifetime.7,10

Almost half of all older adults lack dental coverage, which is a significant barrier to oral health care for this population; of all age groups, the older adults have the highest out-of-pocket expenses.10 The improved access to oral health care among previously uninsured children, subsequent to provisions for dental care through the ACA and CHIP, provides some evidence that inclusion of a dental benefit in Medicare could result in improved access to care for older adults.10

Diversity of representation in the profession is critical.

may encourage those who have been reluctant to seek care or even avoiding care.48,50 Making practices and clinics safe spaces for all who enter and seeking out places individuals already regard as safe may make the difference in increasing access to care and reducing disparities in oral health over the next 20 years.

Conclusion

The diverse population of California and intersecting human characteristics and conditions offer significant challenges to providing equitable access and good outcomes. Those challenges provide multiple opportunities to develop practices and policies that improve opportunities for efficient and effective person-centered oral health care. Oral diseases are largely preventable with good home care and

Many older individuals and those with a disability face financial barriers to care, but economics alone are not responsible for limited access to care.10,27 Whether disability results from normal, age-related changes like those in hearing or vision or as a result of disease, practices can be more accessible for those with disabilities.22–25,42 And providers need more education starting in predoctoral education and sustained through continuing education to manage the complex needs of those who are most vulnerable due to chronic disease or disability from the moment they come into the practice, through treatment, postoperative care, maintenance and prevention of future disease.25,32

Immigrants, LGBTQ+, homeless people, those living in HPSAs and those in the juvenile justice or foster system are at greatest risk for poor oral health outcomes.10 Collecting accurate demographics, oral health status and the discrete challenges in accessing care and perception of need among these populations is challenging but necessary to understand the full scope of need in our state.40 This knowledge is

important to both patients and providers to ensure that appropriate resources are accessible to those who need them in order to receive or provide care.

Active recruitment of historically underrepresented groups to the profession and diverse representation in dental education and organized dentistry are critical to improving access to care for underserved populations.46,47 Making full use of our dental team to reach into underserved communities with few or no dentists, through schools, adult day health centers, meal programs and better integration and collaboration with primary care is critical to improve access to preventive and basic care.10,48,50 Similarly, expanding the scope of practice for dentists to participate more fully in the primary health care network through the administration of vaccines is one example that demonstrates how utilizing dental providers to the fullest extent of their training and capability can improve access to important disease prevention and public health measures for all ages and across all socioeconomic lines.10

Public health campaigns and materials available through public health departments and organized dental organizations can increase knowledge and awareness among diverse populations and communities if they receive them.41,44 Collaborative efforts from organized dentistry, public health and private organizations can ensure that providers and patients in California have access to a wider variety of resources to facilitate effective and appropriate communication. Just as access to education is an important resource to combat poverty through knowledge, access to oral health care is an opportunity to improve outcomes in health care through access to information. These are important opportunities for providers to raise their patients’ oral health literacy and the importance of

good oral health to general health. The dental team would benefit from more opportunities to learn effective patient communication techniques and strategies to develop a shame-free environment for those struggling with literacy and to secure appropriate and affordable interpretation services and materials in other languages for patients across our multilingual state41,43,44 (fIGure 3).

Persistent challenges accessing oral health care due to cost, location, language, gender, race, ethnicity, age, illness and disability can result in a lack

achieving and maintaining good oral health that is faced by many Californians. n

REFERENCES

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6. ADA Participation Action Consortium. Percentage with a disability

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8. Seng JS, Lopez WD, Sperlich M, Hamama L, Reed Meldrum CD. Marginalized identities, discrimination burden and mental health: Empirical exploration of an interpersonal-level approach to modeling intersectionality. Soc Sci Med 2012 Dec;75(12):2437–45 doi: 10.1016/j. socscimed.2012.09.023. Epub 2012 Sep 26. PMID: 23089613. PMCID: PMC3962770

9. Gopal DP, Chetty U, O’Donnell P, Gajria C, BlackadderWeinstein J. Implicit bias in healthcare: Clinical practice, research and decision-making. Future Healthc J 2021 Mar;8(1):40–48 doi: 10.7861/fhj.2020-0233. PMID: 33791459. PMCID: PMC8004354

10. National Institute of Dental and Craniofacial Research. OralHealth in America: Advances and Challenges: Executive Summary. Bethesda Md:2021 Dec. Accessed April 4, 2022.

of trust, avoidance of care, challenges in communication, diagnostic errors and poor adherence that result in poor outcomes in medical and dental care. This can also result in diminished quality of life and financial strain on both patients and the health care system. While we aim to achieve diversity, equity, inclusion and belonging each of these is also a powerful strategy to improve access to care, patient experience and outcomes of care. The diversity of people in need of care, the need for more diversity in our profession and addressing the day-to-day challenges individuals and whole communities experience in obtaining oral health care requires new, equitable and inclusive strategies and paradigms in patient care and policy to appropriately address the significant and persistent challenges to

11. California Department of Public Health. Status of oral health in California: Oral disease burden and prevention 2017 Accessed April 4, 2022.

12) Bostean G, Trinidad DR, McCarthy WJ. E-cigarette use among never-smoking California students. Am J Public Health 2015 Dec;105(12):2423-5 doi: 10.2105/ AJPH.2015.302899. Epub 2015 Oct 15. PMID: 26469671 PMCID: PMC4638243

13) Pourat N, Ditter M. 2020. Despite Insurance, the Poorest Adults Have the Worst Access to Dental Care. Los Angeles: UCLA Center for Health Policy Research. Accessed April 5, 2022.

14. Singhal A, Caplan DJ, Jones MP, Momany ET, Kuthy RA, Buresh CT, Isman R, Damiano PC. Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs. Health Aff (Millwood) 2015 May;34(5):749–56 doi: 10.1377/hlthaff.2014.1358 PMID: 25941275.

15. Rampa S, Wilson FA, Allareddy V. Trends in dentalrelated emergency department visits in the state of California from 2005 to 2011. Oral Surg Oral Med Oral Pathol Oral Radiol 2016 Oct;122(4):426–33 doi: 10.1016/j. oooo.2016.05.003. Epub 2016 May 24. PMID: 27515432. Accessed April 5, 2022.

16. Claiborne DM, Kelekar U, Shepherd JG, Naavaal S. Emergency department use for nontraumatic dental conditions among children and adolescents: NEDS 2014-2015. Community Dent Oral Epidemiol 2021 Dec;49(6):594–601

Diversity, equity, inclusion and belonging are both strategy and goal.

doi: 10.1111/cdoe.12631. Epub 2021 Mar 23. PMID: 33755217.

17. Kelekar U, Naavaal S. Dental visits and associated emergency department-charges in the United States: Nationwide Emergency Department Sample, 2014. J Am Dent Assoc 2019 Apr;150(4):305–312.e1 doi: 10.1016/j. adaj.2018.11.021. PMID: 30922460.

18. Akinlotan MA, Ferdinand AO. Emergency department visits for nontraumatic dental conditions: A systematic literature review. J Public Health Dent 2020 Sep;80(4):313–326 doi: 10.1111/jphd.12386. Epub 2020 Oct 1. PMID: 33006151.

19. Morgan T, Samtani MT, Yeroshalmi F, Tranby E, Laniado N, Okunseri C, Badner V. National trends and characteristics in emergency department visits for nontraumatic dental conditions among pediatric patients. Pediatr Dent 2021 May 15;43(3):211–217. PMID: 34172115.

20. Legislative Analyst’s Office. Projections of seniors with disabilities in California from 2015 through 2060. Accessed April 3, 2022.

21. Public Policy Institute of California. Planning for California’s growing senior population. Accessed April 3, 2002.

22. The Independence Center. Creating disability-friendly dental practices. Accessed April 5, 2022.

23. Yuen HK, Wolf BJ, Bandyopadhyay D, Magruder KM, Selassie AW, Salinas CF. Factors that limit access to dental care for adults with spinal cord injury. Spec Care Dentist 2010 Jul–Aug;30(4):151–156 doi:10.1111/j.17544505.2010.00146.x. PMID: 20618781. PMCID: PMC2904989

24. Anåker A, Heylighen A, Nordin S, Elf M. Design Quality in the Context of Healthcare Environments: A Scoping Review. HERD 2017 Jul;10(4):136–150 doi:10.1177/1937586716679404. Epub 2016 Dec 18. PMID: 28643560. PMCID: PMC5484461

25. Fabisiak B, Jankowska A, Kłos R, Knudsen J, Merilampi S, Priedulena E. Comparative study on design and functionality requirements for senior-friendly furniture for sitting. BioResources 16(3):6244–6266

26. Justice in Aging. Oral health in California: What about older adults? Access April 5, 2022.

27. Center for Oral Health. A Healthy Smile Never Gets Old: A California Report on the Oral Health of Older Adults. Accessed April 5, 2022.

28. Gondivkar SM, Gadbail AR, Gondivkar RS, Sarode SC, Sarode GS, Patil S, Awan KH. Nutrition and oral health. Dis Mon 2019 Jun;65(6):147–154 doi: 10.1016/j. disamonth.2018.09.009. Epub 2018 Oct 4. PMID: 30293649.

29. Ettinger RL, Marchini L. Cohort differences among aging populations: An update. J Am Dent Assoc 2020 Jul;151(7):519–526 doi: 10.1016/j.adaj.2020.04.001 PMID: 32593354.

30. Buttorff C, Ruder T, Bauman M. Multiple chronic conditions in the United States. RAND Corporation, 2017.

31. Kent J. Reshaping the Medi-Cal Dental Program — evolving oral health care in California. J Calif Dent Assoc 50(7):401–405

32. Jiang CM, Chu CH, Duangthip D, Ettinger RL, Hugo FN, Kettratad-Pruksapong M, Liu J, Marchini L, McKenna G, Ono T, Rong W, Schimmel M, Shah N, Slack-Smith L, Yang SX, Lo ECM. Global Perspectives of Oral Health Policies and Oral Healthcare Schemes for Older Adult Populations. Front Oral Health 2021 Aug 16;2:703526 doi: 10.3389/froh.2021.703526. PMID: 35048040. PMCID: PMC8757822

33. California Department of Developmental Services. Fact Book: Fiscal year 2018-2019. Accessed April 5, 2022.

34. California Department of Developmental Services. Purchase of service report

35. Wilson NJ, Lin Z, Villarosa A, Lewis P, Philip P, Sumar B, George A. Countering the poor oral health of people with intellectual and developmental disability: A scoping literature review. BMC Public Health 2019 Nov 15;19(1):1530 doi: 10.1186/s12889-019-7863-1. PMID: 31729967. PMCID: PMC6858643

36. Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information. Health Aff (Millwood) 2021 Mar;40(3):384–391 doi: 10.1377/hlthaff.2020.00957. PMID: 33646872. PMCID: PMC7992115

37. Perlman SP, Wong A, Waldman HB, et. al. Dent Clin North Am 2022 Apr;66(2):261–275 doi: 10.1016/j. cden.2022.01.005

38. Movement Advancement Project. California’s equality profile. Accessed April 3, 2022.

39. UCLA School of Law Williams Institute. LGBT proportion of population : California. Accessed April 3, 2022.

40. National Academies of Sciences, Engineering and Medicine; Division of Behavioral and Social Sciences and Education; Committee on Population; Committee on Understanding the Well-Being of Sexual and Gender Diverse Populations; White J, Sepúlveda MJ, Patterson CJ, eds. Understanding the Well-Being of LGBTQI+ Populations Washington D.C.: National Academies Press; 2020 Oct 21. 3, Demography and Public Attitudes of Sexual and Gender Diverse Populations.

41. Tseng W, Pleasants E, Ivey SL, Sokal-Gutierrez K, Kumar

J, Hoeft KS, Horowitz AM, Ramos-Gomez F, Sodhi M, Liu J, Neuhauser L. Barriers and facilitators to promoting oral health literacy and patient communication among dental providers in California. Int J Environ Res Public Health 2020 Dec 30;18(1):216 doi: 10.3390/ijerph18010216. PMID: 33396682. PMCID: PMC7795206

42. Chávez EM, Ship JA. Sensory and motor deficits in the elderly: Impact on oral health in the elderly. J Public Health Dent 2000 Fall;60(4):297–303 doi: 10.1111/j.17527325.2000.tb03338.x

43. Kwon SR, Lee S, Oyoyo U, Wiafe S, De Guia S, Pedersen C, Martinez K, Rivas J, Chavez D, Rogers T. Oral health knowledge and oral health related quality of life of older adults. Clin Exp Dent Res 2021 Apr;7(2):211–218 doi: 10.1002/cre2.350. Epub 2020 Nov 17. PMID: 33200570. PMCID: PMC8019761

44. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promot Int 2019 Oct 1;34(5):e1–e17 doi: 10.1093/heapro/day062 PMID: 30107564.

45. California Department of Public Health. Oral health literacy in practice. Accessed April 3, 2022.

46. Wilbur K, Snyder C, Essary AC, Reddy S, Will KK, Saxon M. Developing workforce diversity in the health professions: A social justice perspective. Health Prof Educ 2020 Jun 6(2):222–229 doi.org/10.1016/j.hpe.2020.01.002

47. Wright JT, Vujicic M, Frazier-Bowers S. Elevating dentistry through diversity. J Am Dent Assoc 2021 Apr;152(4):253–255 doi: 10.1016/j.adaj.2021.02.003. PMID: 33775280.

48. Catalanotto F, Koppelman J, Haber J. Emerging models of dental practice aim at addressing needs of the aged. Compend Contin Educ Dent 2017 Oct;38(9):606–610; quiz 613 PMID: 28972385.

49. California Health & Human Services Agency. Health professional shortage areas in California

50. Mouradian WE, Lewis CW, Berg JH. Integration of dentistry and medicine and the dentist of the future: The need for the health care team. J Calif Dent Assoc 2014 Oct;42(10):687–96 PMID: 25345113

THE AUTHOR, Elisa M Chávez, DDS, can be reached at echavez@pacific.edu.

October 2022 CDA Continuing Education Worksheet

This worksheet provides readers an opportunity to review questions about the article “Improving Access to Care and Patient Experience Through Diversity, Equity, Inclusion and Belonging” before taking the C.E. test online. You must first be registered at cdapresents360.com

To take the test online, click here. Earn 1.0 of Core C.E. credit through this activity.

1. Which of the following apply to the FDI World Dental Federation’s definition of oral health? (mark all that apply)

a. The ability to speak, smile, smell, taste, touch, chew and swallow.

b. The ability to convey emotion through facial expressions with confidence and without pain, discomfort or disease.

c. It is fundamental to physical and mental health and well-being.

d. It is influenced by the person’s changing experiences, perceptions, expectations and ability to adapt to life circumstances.

e. All of the above.

2. According to the 2021 NIDCR report, “Oral Health in America: Advances and Challenges,” since the surgeon general’s 2000 report, all of the changes in oral health reported below have occurred except one. Mark the untrue statement.

a. In the U.S., the greatest improvement in untreated tooth decay in primary teeth occurred in children aged 2-5 years.

b. Untreated tooth decay in adolescents declined overall, with disparities between lower-income and higher-income families also decreasing.

c. Caries experience in children is significantly impacted by income with higher rates to start and less decline for those with lower incomes.

d. Mexican American children and children living in poverty achieved the largest gains in the placement of a sealant on at least one permanent molar, resulting in a near elimination of this health disparity in prevention among poor and Hispanic children.

3

. Which of these statements about older adults are true? (mark all that apply)

a. Projections show that by 2030 nearly 20% of older adults will be childless and will be more reliant on nonfamilial sources for their care.

b. Nationwide, nearly three-fourths of older adults (75%) have retained enough teeth to qualify as having a functional dentition.

c. Among long-term care patients in California, half had untreated caries, with those in rural settings experiencing more decay and poorer oral health overall.

d. As Californians have good access to dental care across the lifespan, over half are expected to keep their teeth and be able to maintain them in good health as they age.

4

. All but which one of the following statements about the LGBTQ population are true?

a. A 2017 Gallup poll survey showed increases in LGBT identification between 2012 and 2017 to be predominantly among millennials, with race and ethnicity of the respondents similar to those of the general population.

b. According to 2009-2014 NHANES data, LGBT respondents reported higher rates of untreated caries and periodontal disease.

c. Increased risk of overt discrimination, intimidation and abuse in health care settings, as well as concerns over perceived discrimination, may inhibit LGBTQ+ individuals from seeking care.

d. Many older LGBTQ+ individuals do not have children, which may increase their reliance on nonfamilial caregivers to assist them in accessing dental care as needed with advanced age or disability.

5. According to the NIDCR 2021 report, “Oral Health in America: Advances and Challenges,” which of the following populations are at greatest risk for poor oral health outcomes? (mark all that apply)

a. Immigrants.

b. LGBTQ+.

c. Homeless.

d. Those in the juvenile justice or foster system.

e. All of the above.

October 2022 CDA Continuing Education Worksheet Cont’d

6. True or False: An updated definition of health literacy (Healthy People 2030) includes both an individual’s ability to “find, understand and use services to inform health-related decisions and action for themselves or another” plus the concept of an organizational health literacy in which “organizations equitably enable individuals” to exercise their health literacy.

7. The author makes several points in her discussion on oral health literacy (OHL), including all but which one of the following?

a. To achieve equity, it is essential for patients to feel heard and have a sense of belonging wherever they seek care.

b. A wide variety of plain-language and translated oral health materials are readily available and frequently used as communication tools in dental offices.

c. Interpreter services improve patient satisfaction, reduce errors and can educate providers about potential cultural misunderstandings.

d. Poor social and socioeconomic conditions contribute to low health literacy, potentially reinforcing behaviors that undermine health, limiting use of preventive services and adversely impacting outcomes of care.

8. True or False: The California Department of Public Health has developed an oral health literacy toolkit for use in dental offices. The Oral Health Literacy in Practice Toolkit is free and available to download online.

9. True or False: The author suggests that if over the next five years dental schools successfully recruit and graduate 5% more students who are from racial or ethnic backgrounds that are currently underrepresented in the profession, this would be adequate to address the social determinants of health that result in disparities in oral health by 2030.

10. True or False: According to the author, making practices and clinics safe spaces for all who enter and making oral health care available to individuals in places they already regard as safe may make the difference in increasing access to care and reducing disparities in oral health over the next 20 years.

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CDA LIVE LEARNING EVENT

Fostering Diversity, Equity, Inclusion and Belonging in Dentistry

Every Californian deserves a healthy smile. Through a shared commitment to oral health equity, CDA members can forge change and reduce disparities.

Join our free, real-time events to better understand the association’s role in DEIB. Hear from engaging experts and gain actionable insights you can take right back to practice.

THREE-PART LEARNING SERIES

A Primer

October 27 | 5:30–7:00 p.m.

Learn from Dr. Brian Swann, Dr. Steffany Chamut and Dr. Tawana Feimster about the ways past and current governmental and organizational policies led to disparities in oral health.

Inclusive Healthcare: Fostering Belonging and Trust in Oral Health

November 3 | 12:00–1:00 p.m.

Gain insights from Dr. Eleanor Fleming on racism as a public health crisis and what oral health professionals can do.

Oral Health Disparities in California

November 10 | 5:30–6:30 p.m.

Hear Dr. Jennifer Perkins, Dr. Beth Mertz and Mary McCune explore California’s disparities at the patient population and dental team levels.

Register today at cda.org/DEIB

Sponsored by

The Importance of Diversity, Equity and Inclusion From the Clinician’s Perspective

Pamela S. Arbuckle Alston, DDS, MPP; Jessica Baisley, DDS; Andrea Akabike, DDS; and Jack Luomanen, DMD

abstract

Background: Clinical care contributes approximately 16% to health outcomes. Access to care and quality of care contribute to favorable health outcomes. Clinicians employing diversity, equity and inclusionary strategies in their patient encounters can improve access to care and quality care.

Methods: Vignettes are used to personify elements of diversity, equity and inclusion (DEI) during clinician encounters and how they impact their patient outcomes.

Results: Diversity in the oral health team composition is important to the clinician because it helps the clinician relate more effectively to a diverse patient population and offer more resources. Having difficult but necessary conversations can facilitate getting patients the resources they need to achieve their highest state of health. Inclusion is important to clinicians who leverage interprofessional collaborations for whole-person care and involve their team members to make their patients feel respected, understood and welcome. Embracing DEI helps the clinician to facilitate getting patients into treatment, promote continuity of care and adherence.

Conclusions: Providing oral care that is equitable and inclusive in a diverse environment helps safeguard patients from vulnerabilities that adversely affect health outcomes. Employing DEI in clinical encounters is important to clinicians because it helps them meet their obligation of service to patients.

Practical implications: Dental clinicians are in a position to play a key role in promoting health equity by embodying DEI principles. Working interprofessionally and creating a dental team with a diverse representation of social identities are some of the many ways clinicians can foster inclusion and equity within their practice.

Keywords: Health equity, diversity, inclusion, DEI, vignettes, empathy, whole-person care

AUTHORS

Pamela S. Arbuckle

Alston, DDS, MPP, served as president for the National Dental Association in 2021. She is a lead oral health specialist for the U.S. Department of Labor Job Corps Program health support contractor. Her clinical career spanned 37 years finishing as dental director at Alameda Health System. Dr. Arbuckle is a fellow of the American College of Dentists. Conflict of Interest Disclosure: None reported.

Jessica Baisley, DDS, is a member of the National Dental Association. She graduated from the pediatric dental residency program at the Herman Ostrow School of Dentistry of USC. She practices at a federally qualified health center in Richmond, California. Conflict of Interest Disclosure: None reported.

Andrea Akabike, DDS, is a member of the National Dental Association. She is a general dentist practicing at a federally qualified health center in the San Francisco Bay Area. Dr. Akabike currently serves as an associate director on the California Dental Association Foundation Board of Directors. Conflict of Interest Disclosure: None reported.

Jack Luomanen, DMD, is a member of the National Dental Association, National Network for Oral Health Access and National Coalition of Dentists for Health Equity. His clinical career spanned 46 years. Dr. Luomanen is the principal of JCL Consulting and has served as an oral health consultant, clinical consultant and peer reviewer expert advisor for a number of governmental agencies as well as dental director in four FQHC clinics. Conflict of Interest Disclosure: None reported.

Race and economic status are linked. The appalling truth is that they are social predictors of health. For example, the ADA Health Policy Institute reported oral health disparities by income, race and insurance status for seniors.1 A disproportionate number of low-income and minority adults seek oral care only for emergency needs compared to higher income and nonminority adults.2 Despite improvements in oral health and in oral disease prevention, oral health disparities persist.3 The Centers for Disease Control and Prevention (CDC) defines health disparities as “preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”4

Oral health disparities experienced by socially disadvantaged populations are unconscionable and unjust because they cause avoidable harm. Eliminating them is an ethical and moral imperative.

Oral health disparities are the result of inequities. Our nation depends upon public-private partnerships for structural change to overcome inequities and eliminate disparities in the living, working and economic conditions that influence health. There is also a pivotal role that clinicians are positioned to play. Clinicians have influence over a measure of access to care and quality of care, two components of clinical care that contribute to health outcomes. Clinicians have within their purview the ability to create spaces that are equitable and inclusive for patients during care. They have the opportunity to deliver productive patient encounters that contribute to favorable health outcomes and help to eliminate oral health disparities.

This commentary features vignettes with clinical scenarios that create “teaching points”5

to illustrate how clinicians use strategies that integrate approaches to diversity, equity and inclusion (DEI) in their clinical encounters.

Diversity is “involving the representation or composition of various social identity groups.”6 An oral health team composed of members with a diverse representation of social identities can relate to a diverse patient population. Equity is “providing resources according to the need to help diverse populations achieve their highest state of health and other functioning.”6 Inclusion is “an environment that offers affirmation, celebration and appreciation of different approaches, styles, perspectives and experiences. Inclusion allows all individuals to bring in their whole selves, i.e., all their social identities and to demonstrate their strengths and capacity.”6

The teaching points of the following vignettes are used to illustrate how DEI strategies eliminate inequities and oral health disparities.

Vignette One: Whole-Person Care

Toward the end of the clinic session, a teenager and her father presented to the dental clinic without an appointment. The teen complained of a toothache for which she specifically requested an opioid prescription. The dental receptionist notified the dentist who welcomed the teenager and father into an exam room. The dentist asked the teenager why she was specifically requesting the opioid. The teenager said she experienced a toothache previously at another dental office and received a prescription for the opioid. With the father’s consent, an X-ray was taken and the patient was examined. The dentist explained that the tooth was restorable.

The teenager and father requested the prescription instead. However, they agreed to listen to the dentist explain the

inevitable progression of decay without treatment. The dentist also spoke about opioids and their misuse. The father seemed disinterested until the dentist shared that people with opioid substance use disorders are successfully treated with buprenorphine medication-assisted treatment (MAT) as part of an opioid withdrawal and recovery program. The dentist praised the local hospital’s MAT program. At the end of the visit, the father reluctantly agreed to give his daughter ibuprofen instead for pain relief and to bring her back for treatment the following day. The patient returned the following day for a successful treatment.

Several months later, the dentist received a referral from the MAT program physician. The referral was for the father, now a patient in the MAT program. The patient was referred to the dentist for the buprenorphine side effects of dry mouth and dental decay. The patient agreed to the caries and xerostomia management plans. The dentist notified the physician of the clinical findings and treatment plan. The physician was relieved because the unmanaged side effects could have jeopardized the patient’s willing participation in the MAT program. The case manager, who was also part of the MAT team, reached out to the dentist to inform him that she was working with the father to keep his family sheltered because he was out of work.

Discussion of Vignette One

A dimension of diversity in the oral health team is the knowledge and skill set of the oral health team members. The clinician was familiar with treatment for opioid use disorders, knew how to treat the oral side effects of the treatment medication and had a referral relationship with the program clinicians. The clinician was skilled in treating extremely high-caries-risk patients according to the caries management by

risk assessment (CAMBRA) approach, thus increasing the patient’s retention prospects in the MAT program. Moreover, the clinician had a skill set that allowed him to converse comfortably with the patient about opioid use disorder. Conversations about substance use are often difficult, but those conversations are necessary in order to gain acceptance by patients for appropriate treatment.7

The initial information that the clinician provided with sensitivity and without judgment may have motivated the parent to obtain the help he needed

A dimension of diversity in the oral health team is the knowledge and skill set of the oral health team members.

the patient to achieve his highest state of health. The clinical environment was inclusive enough to be welcoming to this patient who had a history of opioid use disorder, was low-income and on the brink of homelessness without social support. The clinician did not stigmatize or marginalize the father for having an opioid use disorder. Ronni Brown, DDS, MPH, commented in her book “A State of Decay: Your Guide to Understanding and Treating ‘Meth Mouth:’” “How you understand addiction will determine whether your treatment of a patient who is addicted is appropriate or just plain silly.”7 Drug addiction is a chronic, relapsing brain disease.10 Just as the physician and behavioral health specialist partnered with the patient to overcome the opioid substance use disorder, the dentist partnered with the patient to manage his oral side effects. The wholeperson approach to the patient’s opioid addiction included the dentist as part of the treatment team. The whole-person approach promoted inclusion and enabled the patient to demonstrate his strength and capacity to overcome addiction.

to overcome his opioid use disorder. In providing oral care to the patient while he was in the MAT program, the clinician participated in a whole-person, interprofessional approach in collaboration with the physician, behavioral health specialist and case manager. The comprehensive case management that the father received was essential to his retention in treatment and the continuity of care across disciplines. He obtained linkages to needed housing to deter a downward spiral that could have led to relapse and missed oral health visits.8 Individuals with opioid use disorder often experience unstable employment with risks of being unhoused.9 The MAT while the patient was in opioid recovery, caries management and case management were health equity approaches available to

Vignette Two: Empathy

A 67-year-old Black woman presented to a local private dental practice for an emergency visit the day after her discharge from the emergency department (ED) for a swollen jaw. When she met with the dentist, who was also a Black female, the patient complained that the ED physician had given her the same prescriptions for an antibiotic and an analgesic that she said neither relieved the swelling nor pain. She said she overheard the physician tell the nurse, “Those people just want medication, and they don’t follow through.” The patient said she was offended. She believed the physician was referring to Black people as “those people,” because he was white and the waiting room was full of Black people. The dentist reassured the woman

that her appearance in the dental office was evidence that she did follow through. The patient apologized for missing previous dental appointments. She said the planned dental treatment was more than she could afford. She said that she was aware that neither her state Medicaid program nor her Medicare plan offered dental benefits. She said she could barely afford to pay for the office visit that day and certainly not for the treatment she needed.

The dentist explained that the tooth was a partially impacted third molar, and due to the complexity of removing it, the tooth would need to be extracted by a specialist. She referred the patient to the local federally qualified health center (FQHC) for follow-up treatment by the oral and maxillofacial surgeon on staff. The FQHC had a sliding scale payment system based on the individual’s income. The dentist also shared that she worked at the FQHC part time, which enabled her to continue to treat her patients of record who aged out of Medicaid dental benefits. She divulged that she had been a dental patient at that particular FQHC before attending dental school and did not have to pay for her oral care due to her low-income level. The dentist introduced the patient to the dental care coordinator who helped the patient schedule an appointment. The dentist also took time to explain the course of untreated oral infections and the importance of taking antibiotics as prescribed. The patient told the dentist she would fill the prescriptions and take them as prescribed. She also agreed to return to the dental office if the symptoms worsened and to keep her appointment at the FQHC. She thanked the dentist and said, “I trust you.”

Discussion of Vignette Two

The dimensions of diversity include race and other social identities. The clinician and patient were the same

race, and on that basis, the clinician related to the patient with empathy and understanding to build trust. Health outcomes are improved when there is racial concordance, that is, when the race is the same.11 The clinician easily established rapport with the patient when she divulged that she came from a low-income background. Her disclosure was an inclusionary strategy to make the patient feel welcome and comfortable sharing that her low-income status was a barrier to care. Even without racial concordance, genuine expressions of

a co-worker about the patient were racially biased. Cultural racism, which is negative racial and ethnic stereotypes, can affect health in various ways.13 Cultural stereotypes can lead to biases in health care delivery that perpetuate health inequities.14 Health care provider bias has been associated with lower levels of patient adherence to treatment plans and lower trust in health care providers.15

Vignette Three: Cultural Competency and Humility

Cultural stereotypes can lead to biases in health care delivery that perpetuate health inequities.

empathy, respectfulness and understanding by the clinician help to overcome patients’ feelings of marginalization and promote adherence to recommendations.

The patient indicated that she had financial barriers to treatment. Research shows that lack of income can cause health disparities.12 She resided in a state that did not offer adult dental benefits in its Medicaid program. The FQHC to which the patient was referred provided care to patients regardless of ability to pay. The sliding fee schedule that the FQHC offered is an equity measure. Assistance by the dental care coordinator to make the appointment was another equity measure. These factors help patients follow through with treatment to reach their highest state of oral health.

The ED physician’s remarks to

A 4-year-old Latino boy, accompanied by his mother, presented for an initial oral examination with the pediatric dentist. The dental assistant informed the dentist that the family was Spanish monolingual and that the patient would neither sit in the chair nor cooperate for radiographs. No medical or behavioral conditions were listed on the medical history. However, the mother reported that the patient was overdue for his annual visit with the pediatrician. When the dentist entered the exam room, she noticed the child was extremely anxious. Instead of sitting in the chair, he was huddled in the corner near his mother. The mother reported that her son was complaining of pain and having trouble eating on the right side.

The dental assistant interpreted for the dentist who was not fluent in Spanish. The dentist greeted the boy. The child acknowledged her, but he made no eye contact. The dentist asked if he would like to sit in the chair so she could count his teeth, and he began to cry, scream and cover his mouth with his hands. He did not move from the corner, but after much coaxing, the dentist got a quick look inside his mouth where she discovered multiple decayed teeth. The mother reported that the previous dentist was unable to perform an exam due to the patient’s behavior. She also reported that she could only manage to brush his teeth twice a week

and without toothpaste due to his oral aversion. The dentist informed her that the patient had multiple large cavities. She discussed the clinic’s treatment modalities including nitrous oxide sedation, oral conscious sedation and general anesthesia.

Due to the amount of restorative treatment the patient needed and the patient’s age and severe dental anxiety, the dentist recommended treatment under general anesthesia. The mother breathed a sigh of relief that there was an option for her son to finally be treated. The dentist then inquired about the patient’s behavior with the opening question, “What is it like to be his mama?” The mother shared the details of his behavior at home and during previous dental visits. As the dentist listened intently, the mother opened up to share her own concerns candidly about her son’s behavior. The dentist asked if she could share those concerns with the pediatrician and make a request for a behavioral and developmental evaluation when she requested an anesthesia clearance. The mother consented.

The dentist smiled at her reassuringly and gave the assistant instructions to help the mother schedule the appointment with the pediatrician. This patient interaction inspired the dentist to schedule a meeting with the clinic’s pediatricians to discuss correlations between behavioral disorders and dental fears in pediatric patients. The pediatric dentist and pediatricians collaborated to introduce a program to the clinic in which child-life specialists accompanied highly anxious children during dental visits.

Discussion of Vignette Three

An oral health team composed of members with a diverse representation of social identities can relate better to a diverse patient population. The clinician and patient neither shared the same ethnicity/race nor the same socioeconomic

background, but the dentist was still able to build trust and a therapeutic alliance — a collaboration and mutual agreement on treatment goals and tasks. The dentist utilized her Spanish-English bilingual dental assistant to interpret for her and communicated with cultural sensitivity, empathy and caring. The dental assistant conveyed those qualities to the patient and parent as she interpreted the dentist’s statements. It has been shown that when patients perceive similarities with physicians in terms of personal beliefs, values and communication, the patient-

Significant racial inequities exist in the diagnosis and treatment of Latino children with developmental disorders

diseases, oral health conditions and behavioral health conditions are better managed when medical, behavioral health and oral health clinicians work together. The pediatric dentist suspected that her patient may have a behavioral developmental disorder, so she referred the patient to his pediatrician for an evaluation. Interprofessional practice promotes health equity by encouraging providers across multiple disciplines (e.g., medical, dental, behavioral health, etc.) to collaborate to help patients achieve their best level of wellness.19 Significant racial inequities exist in the diagnosis and treatment of Latino children with developmental disorders such as autism when compared to their white counterparts.20 The delay in diagnosing these patients prevents them from taking advantage of early interventions during a crucial time during their development. Identifying a possible developmental disorder allowed the dentist to arrange for a referral to the pediatrician, thus improving the patient’s prognosis.

clinician relationship is strengthened.16 Effective communication is important. Research has shown that effective messaging along with strategies to improve patients’ ability to understand elementary health information enables them to navigate the health system more easily and adhere to regimens more readily.17 It is acknowledged that empathy in physician encounters has a positive impact on health outcomes18 and empathy contributes to the quality of the oral health encounter.

The bilingual dental assistant on staff added to the diversity of the dentist’s oral health team. The bilingual assistant gave the clinician a better understanding of the patient’s and mother’s needs. The dentist was resourceful in working interprofessionally to obtain the necessary help for the patient. Patients with chronic

The pediatric dentist and the bilingual dental assistant’s interaction with the patient’s mother displayed the importance of inclusion within the dental team. Because the clinician did not speak Spanish fluently, she managed to have a meaningful interaction with the mother by utilizing her assistant to interpret her concerns to the patient’s mother. Caregivers of Latino children have reported that clinician dismissal of health concerns and limited English proficiency are some of the reasons caregivers normalize their child’s behavior and lose trust in the health system.21 Including bilingual and bicultural staff is a strategy clinicians can utilize to help develop trust with their patients.21 Together with the clinician’s own cultural awareness, cultural competence and cultural humility utilized appropriately, a diverse oral health team enriches clinical encounters and creates an inclusive environment.

Cultural awareness is defined as the process of “developing knowledge about different cultures, including their beliefs, values, customs and language.”22 Cultural competence is defined as “the ability to work respectfully with people from diverse cultures, while recognizing one’s own cultural biases.”22 Cultural humility is defined as “the act of acknowledging one’s own biases and limitations in order to more deeply understand another culture.”22 All three are critical to maintaining a culture of respectful communication in the dental setting.

Summary

Empathy accompanied by a selfless concern for the well-being of others characterizes dentists. The dentists in the vignettes showed compassion and an empathetic understanding of their patients’ and patient families’ feelings.

Empathy and altruism are the motivation for clinicians to provide oral care that is equitable and inclusive in a diverse environment of care. The “American College of Dentists Ethics Handbook for Dentists” instructs, “The dentist’s primary obligation is service to the patient. Dentists have an obligation to use their knowledge, skills and experiences to improve the oral health of the public.”23 Dentists provide a valuable service to their patients when they find ways to incorporate diversity, equity and inclusionary values into their clinical encounters. Equity is important to clinicians who employ strategies in their clinician role to help patients overcome barriers to achieving their highest state of health. As the demographics change in the U.S., clinicians will continue to see an increasingly diverse patient population. A diverse oral health team equipped to address the needs of a diverse patient population along with other strategies can decrease health disparities.24 The

interprofessional partnerships illustrated in the vignettes are also key to improving health access, quality and outcomes.

The minimum ethical duty of the professional relationship into which the clinician enters with a patient is a therapeutic alliance in order to maintain or improve the patient’s health.25 Patients with diverse social identities who are welcomed into an inclusive clinical environment where they are heard and feel respected will be receptive to a therapeutic alliance with their clinicians. Employing diversity, equity and inclusion principles

inclusion framework. April 8, 2021.

7. Brown R. A State of Decay: Your Dental Guide to Understanding and Treating “Meth Mouth.” Rolling Hills Estates, Ca: Clarity Designworks; 2020.

8., U.S. Department of Health and Human Services. Opioid Crisis Statistics. Accessed March 4, 2022.

9. Alexander GC, Stoller KB, Haffajee RL, Saloner B. An epidemic in the midst of a pandemic: Opioid use disorder and COVID-19. Ann Intern Med 2020 Jul;173(1):57–58 doi:10.7326/M20-1141. PMID: 32240283; PMCID: PMC7138407

10. Heilig M, MacKillop J, Martinez D, Rehm J, Leggio L, Vanderschuren LJMJ. Addiction as a brain disease revised: Why it still matters, and the need for consilience. Neuropsychopharmacology 2021 Sep;46(10):1715–1723 doi: 10.1038/s41386-020-00950-y. Epub 2021 Feb 22. PMID: 33619327; PMCID: PMC8357831

11. Street RL, O’Malley KJ, et al. Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Ann Fam Med 2008 May–Jun;6(3):198–205 doi: 10.1370/afm.821. PMID: 18474881; PMCID: PMC2384992

12. Thornton RL, Glover CM, Cené CW, Glik DC, Henderson JA, Williams DR. Evaluating strategies for reducing health disparities by addressing the social determinants of health. Health Aff (Millwood) 2016 Aug 1;35(8):1416–23 doi: 10.1377/hlthaff.2015.1357. PMID: 27503966; PMCID: PMC5524193

13. Williams DR, Lawrence JA, Davis BA. Racism and health: Evidence and needed research. Annu Rev Public Health 2019 Apr 1;40:105–125 doi: 10.1146/annurevpublhealth-040218-043750 Epub 2019 Feb 2. PMID: 30601726; PMCID: PMC6532402

14. Bajaj SS, Stanford FC. Beyond Tuskegee – Vaccine Distrust and Everyday Racism. N Engl J Med 2021 Feb 4;384(5):e12 doi: 10.1056/NEJMpv2035827. Epub 2021 Jan 20. PMID: 33471971.

to the extent possible is an important aspect of providing the best service clinicians can to patients and achieving a beneficial therapeutic alliance. n

ACKNOWLEDGMENT

The authors express special thanks to National Dental Association Executive Director Keith Perry, JD.

REFERENCES

1. Yarbrough C, Vujicic M. Oral Health Trends for Older Americans, Oral Health in America: Advances and Challenges Washington, D.C.: National Institutes of Health; 2021.

2. Rozier RG, White BA, Slade GD. Trends in oral diseases in the U.S. population. J Dent Educ 2017 Aug;81(8):eS97–eS109 doi: 10.21815/JDE.017.016. PMID: 28765461.

3. Fellows JL, Atchison KA, et al. Oral Health in America: Implications for Dental Practice. J Am Dent Assoc 2022 Jul;153(7):601–609 doi: 10.1016/j.adaj.2022.04.002 Epub 2022 May 25.

4. Centers for Disease Control and Prevention. Health Disparities. Accessed on Aug. 26, 2022.

5. Burger A, Paesch M, Miller C. Clinical Vignettes 101 ENT Today March 2014. Accessed Aug. 26, 2022.

6. American Psychological Association. Equity, diversity and

15. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: Documenting racial bias in the electronic health record. Health Aff (Millwood) 2022 Feb;41(2):203–211 doi: 10.1377/hlthaff.2021.01423. Epub 2022 Jan 19. PMID: 35044842; PMCID: PMC8973827.

16. Edelstein BL, Perkins J, Vargas CM, et al. The role of law and policy in increasing the use of the oral health care system and services. Healthy People 2020, Office of Disease Prevention and Health Promotion, 2020.

17. Sisson Runyan A. What is intersectionality and why is it important? In: Academe vol. 104, no. 6. Washington, D.C.; American Association of University Professors; 2018. 18. Decety J. Empathy in medicine: What it is, and how much we really need it. Am J Med 2020 May;133(5):561–566 doi: 10.1016/j.amjmed.2019.12.012. Epub 2020 Jan 15. PMID: 31954114.

19. Fleming E, Frantsve-Hawley J, Minter-Jordan M. Health equity needs teeth. AMA J Ethics 2022 Jan 1;24(1):E48–56 doi: 10.1001/amajethics.2022.48

20. Zuckerman KE, Lindly OJ, Reyes NM, et al. Disparities in diagnosis and treatment of autism in Latino and non-Latino white families. Pediatrics 2017 May;139(5):e20163010 doi:10.1542/peds.2016-3010. PMID: 28557734; PMCID: PMC5404727

21. Aylward BS, Gal-Szabo DE, Taraman S. Racial, ethnic and sociodemographic disparities in diagnosis

Dentists have an obligation to use their knowledge, skills and experiences to improve the oral health of the public.

of children with autism spectrum disorder. J Dev Behav Pediatr 2021 Oct–Nov;42(8):682–689 doi:10.1097/ DBP.0000000000000996. PMID: 34510108; PMCID: PMC8500365

22. Sulaiman T. The Difference Between Cultural Competence and Cultural Humility. Black Men Heal, May 12, 2022. Accessed Aug. 30, 2022.

23. American College of Dentists. Ethics Handbook for Dentists: An Introduction to Ethics, Professionalism and Ethical DecisionMaking. Rockville; Md.; 2016.

24. Bouye KE, McCleary KJ, Williams KB. Increasing Diversity in the Health Professions: Reflections on Student Pipeline Programs. J Healthc Sci Humanit 2016 Spring;6(1):67–79 PMID: 29644118; PMCID: PMC5890504

25. Friedland B. Should dentists treat despite medical contraindications? AMA J Ethics 2022 Jan 1;24(1):E6–12 doi: 10.1001/amajethics.2022.6. PMID: 35133722.

THE CORRESPONDING AUTHOR, Pamela S. Arbuckle Alston, DDS, MPP, can be reached at pamsalston@gmail.com.

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Innovative Approaches for Fostering DEI Development in Preclinical and Clinical Training

Marisa K. Watanabe, DDS, MS; Lucian O’Connor, PhD; Keith R. Boyer, DDS; T. Jamie Parado, DDS; Paulina A. Saraza, DMD, MS; Edmond R. Hewlett, DDS; George Taylor, DMD, MPH, DrPH; and Bradley S. Henson, DDS, PhD

abstract

Background: Oral disease remains a significant health problem in the United States, and the burden of oral disease is greatest for the poor and those patients from underrepresented minority (URM) backgrounds. Tackling this problem in a comprehensive and enduring way requires a change in the way we train and support current and future dentists and staff. Lasting transformation also requires a systematic shift in the way we investigate and address minority health care gaps in practice. This article describes ways in which dental education can play an integral role in shaping a better oral health tomorrow for individuals, families and communities from underrepresented minority backgrounds who continue to bear a disproportionate burden of oral disease.

Types of studies reviewed: A summary of the literature related to diversity, equity and inclusion (DEI) curricula in dental education is presented along with illustrative examples from California dental schools.

Results: Systematic infrastructure changes in dental education to include DEI development further support a workforce capable of understanding economic and social factors and delivering patient, personcentered care.

Practical implications: DEI development goes beyond dental education; oral health providers from both private and public sectors who understand the dynamic changes in the growing, diverse population are imperative to attaining “optimal oral health for all.” DEI principles learned in a didactic setting can synergize with clinical training approaches to foster real and lasting change in dental medicine learners and the patients they serve.

Keywords: Diversity, inclusion, equity, DEI, dental students, dental education

AUTHORS

Marisa K. Watanabe, DDS, MS, is a professor and associate dean for community partnerships and access to care at the Western University of Health Sciences College of Dental Medicine. She oversees the entire community-based dental education curriculum for the college and focuses her research on modalities to address health inequities in oral and overall health.

Lucian O’Connor, PhD, is an associate professor at the Western University of Health Sciences College of Dental Medicine. His teaching and research expertise are in medical anthropology and history of science. He is the curriculum manager of diversity, equity and inclusion for the college.

Keith R. Boyer, DDS, is an associate professor at the Western University of Health Sciences College of Dental Medicine and a diplomate of the American Board of Endodontics.

T. Jamie Parado, DDS, is an assistant professor at the Western University of Health Sciences College of Dental Medicine and a diplomate of the American Board of Pediatric Dentistry. One of her key areas of interest is in interprofessional education and interprofessional collaborative practice, and she is the liaison for the WesternU CDM.

Paulina A. Saraza, DMD MS, is an assistant professor at the Western University of Health Sciences College of Dental Medicine. She is responsible for the servicelearning curriculum for the first-year predoctoral dental students as well as the public health elective in collaboration with the Los Angeles County, Department of Public Health, Oral Health Program.

Edmond R. Hewlett, DDS, is a professor and an associate dean for equity, diversity and inclusion at the University of California, Los Angeles School of Dentistry.

George Taylor, DMD, MPH, DrPH, is a professor and an associate dean for diversity and inclusion at the University of California, San Francisco School of Dentistry.

Bradley S. Henson, DDS, PhD, is an associate professor at the Western University College of Dental Medicine and interim senior vice president for research and biotechnology at WesternU. He is a head and neck cancer researcher and is also passionate about promoting oral and overall health in Indigenous communities.

Conflict of Interest Disclosure: None reported for any of the authors.

Oral disease remains a significant health problem in the U.S., and the burden of oral disease is greatest for the poor and for patients from historically marginalized communities. These identified populations have less access to oral and overall health care services.1,2 Specific to dentistry, studies have shown that individuals from historically marginalized communities experience disparities in access to dental care, including fewer dental visits, resulting in poorer oral health.2–4

Profound racial and ethnic disparities in health and overall well-being have persisted for many years in the U.S. Studies have shown that 10% of Latinx/ Hispanics,5 13.8% of African Americans6 and 17.4% of American Indians/Alaska Natives (AI/AN)7 reported having fair or poor health compared with 8.3% of nonHispanic whites. On average, Black and American Indian/Alaska Native people live fewer years than white people.8,9 These groups are also more likely to suffer from chronic health conditions, such as cardiovascular disease and diabetes, and to die from these treatable conditions.10,11 African American and AI/AN women are more likely to die or experience complications during and after pregnancy and are more likely to endure the loss of an infant child.12–15 Approximately 21.5% of Latinx/Hispanic adults over age 20 have been diagnosed with diabetes as compared to only 13% of their white counterparts,16 and approximately 25% of Latinx/Hispanic individuals have high blood pressure.17 The COVID-19 pandemic has contributed to the problem, with average life expectancies for Black, Latinx/Hispanic and, in all likelihood, AI/AN people falling more sharply compared to white people.18,19 Communities of color are also more likely to experience oral health inequities

and oral disease progression and are more likely to have unmet dental needs. Studies have found that African Americans and Latinx/Hispanic seniors are more likely to report self-rated poor oral health compared to non-Hispanic whites.20 Black seniors are more likely to report potential chewing difficulties and fewer teeth.20 Wu et al. reported that African Americans and Mexican Americans have more decayed teeth but fewer filled teeth than their white counterparts.21 Compared to the general U.S. population, AI/AN adult dental patients are more likely to report poor oral health, oral pain and food avoidance because of oral problems and are known to suffer disproportionately from untreated dental decay and severe periodontal disease.22

Tackling this problem in a comprehensive and enduring way requires a change in the way dental institutions train and support current and future oral health care providers and staff. Lasting transformation also requires a systematic shift in order to investigate and address minority health care gaps in practice.

Dental education has multiple intersecting roles that are integral to addressing the challenges of access to care and equitable outcomes as they relate to the issues of diversity, equity, inclusion and belonging (DEIB).

First, predoctoral dental education and other entry programs in dental hygiene, dental assisting and dental therapy form the sole pipeline for shaping the makeup of the profession for the future. Multiple efforts have yielded incremental progress. The efforts have often yielded uneven results based upon factors that are and are not under control of the dental education community.

Second, dental education should provide all students with a solid foundation of understanding related to the structural and social determinants of

health (SSDH) as identified by the World Health Organization.29 The historical and contemporary context of the environment of care can help dental professionals better understand and hopefully address the inequities that serve as impediments to optimal oral health care.

Third, dental education is increasingly providing learners with experiences in authentic care environments such as safety net clinics and interprofessional care environments. These environments are frequently based outside the primary training institution and allow the future members of the profession to grasp the challenges faced in the actual provision of care. These experiences not only supplement the amount of care provided, but also serve as a recruitment opportunity for future practitioners who will staff the clinics and systems.

Finally, health care educational institutions, including dental schools, are primary contributors to the scientific bodies of knowledge that fuel our progress as a profession. Their role in providing evaluation and interpretation of the progress that we are, or are not, making in creating equitable access and outcomes is invaluable.

The bulk of the scholarly work is focused on the historic and current inequities leaving significant room for additional study of the policy, programs, curricula and efforts to address the situation. Careful evaluation of the profession’s efforts can help guide their continuation, modification or redirection toward other approaches.

This article focuses on the need for a diverse workforce, the current and nascent didactic curricula at several California dental schools as well as the structure and value of the community-based dental educational models employed by the various institutions. The examples and outcomes describe ways in which dental

education is playing an integral role in shaping a better oral health tomorrow for individuals, families and communities from historically marginalized backgrounds who continue to bear a disproportionate burden of oral disease.

Need for a Diverse Dental Workforce

Nationally, the unbalanced distribution of dental providers leaves tens of millions of Americans without equitable access to oral health care.23 More than 5,800 Dental Health Professional Shortage Areas (DHPSAs) affect 58 million people

historically marginalized communities.23,24

Dentistry continues to have one of the least diverse practitioner populations of all health professions.

Since the release of the landmark “Oral Health in America: A Report of the Surgeon General” in 2000, significant gains have been made in the dental public health and oral health care delivery systems.25 Strategic support from federal and state public health programs, along with legislative and policy advancements, have led to increased access to critical oral health care services. During this time, many new dental schools have opened, and the number of dental providers across the nation has increased.23 Despite these gains, disparities in access to oral health care services continue to exist for many from cultural and ethnic minority backgrounds, according to a 2021 report published by the National Institute of Dental and Craniofacial Research.23

While many reasons exist for these inequities, three that contribute significantly to the challenges of meeting the health care needs of Americans are: 1) a rapidly expanding population; 2) a changing national demographic; and 3) a nonrepresentative dental workforce.2,24

in the U.S., reflecting rural areas and population groups such as those served by the Indian Health Service. California has more dentists than any other state, but an estimated 2.2 million of the state’s residents live in DHPSAs.24 The dental workforce historically lacks racial and ethnic diversity despite the growing numbers of racial and ethnic minorities comprising the national population.30 Hispanic/Latino, Black/African American and Indigenous dental providers remained underrepresented relative to their proportions in the national population.

Studies show that dentists from historically marginalized communities tend to serve minority communities, reside in counties with a partial HPSA, work in safety net or community health settings and accept a larger share of patients from

As of Jan. 1, 2020, more than 57 million persons across the nation reside in a DHPSA.26 With only 29.19% of the dental need met, more than 10,000 practitioners are needed to remove a DHPSA designation; however, the trend seen in the percentage of dental needs met has decreased over time, while the number of necessary practitioners to meet that need has continued to rise.27

Dentistry continues to have one of the least diverse practitioner populations of all health professions.27 One study argues that dentistry is in particular need of deepening the understanding of the role of race and ethnicity in the patientprovider relationship and increasing the number of students from historically marginalized communities in healthprofession schools in order to train

providers to treat minority populations and address disparities.28 According to a study by Tavernier et al., health professionals exposed to underserved populations during training are more likely to serve as health care providers for these same populations upon graduation.25 Therefore, it is imperative to address the need to improve the diversity in predoctoral dental programs, leading to an increase in the diversity makeup of the dental workforce population.

Diversity, Equity and Inclusion Development in Preclinical Training: Developing Structural Competency The Importance of Understanding Social Determinants of Health

A key strategy to prepare current and future oral health practitioners to identify and address health disparities and promote overall and oral health equity is to train them in understanding the impacts of the SSDH. Oral health disparities, like all health disparities, are outcomes of upstream social factors.

Many historical and contemporary contributors have led to these disparities: barriers to health care access, dental workforce shortages, a nonrepresentative dental workforce, lack of structural and cultural competency among health care personnel, racism’s wear and tear on individuals and communities, household income inequality, food insecurity and a lack of safe and affordable housing.24

It is important to distinguish social determinants of health from structural determinants of health. Social determinants represent the conditions under which individuals are born, raised, live, work and learn that affect a wide range of health risks and outcomes. Structural determinants of health refers to the social, political and economic mechanisms and structures that affect income, housing and working

conditions, educational and health care access and overall health and wellness. Structural determinants interface with and shape the social determinants of health experienced by individuals and communities. In its landmark report, “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health,” the World Health Organization (WHO) Commission on Social Determinants of Health described the need to address SSDHs as “a matter of life and death” and as an important part of social justice.29

to determine the extent to which professional training programs incorporate concepts of diversity, equity and inclusion (DEI) into their curricula.30–32 The literature supports that most U.S. dental schools have integrated some form of DEI or cultural competence into the dental curricula, but few describe a comprehensive and longitudinal DEI curriculum that is regarded with the same weight of importance applied to anatomy, physiology or any other important topic in the overarching dental curriculum. Even fewer curricula offer students a sufficiently deep exploration into the extent of oral and overall health disparities, their historical and contemporary contexts and their associated SSDHs.

The dental workforce and dental school educators are beginning to embrace these concepts, but significant efforts are still required. Dental health care providers are critical members of the overall health care workforce. Like other health professions, dental health professionals should be trained interprofessionally to understand SSDHs, demonstrate cultural competence and operationalize this knowledge to exact change in day-to-day clinical practice. In this way, dental health professionals can better understand their unique, front-line opportunity for working with others in providing more equitable patient care.

Where We Are and Where We Are Heading

A number of studies across the health professions have been conducted

Dental practice and educational settings should institute a policy that embraces DEIB for all aspects of the dental team and provide guidance to all stakeholders. Learning outcomes and takeaways gleaned from DEI curricula should drive an overall increase in cultural competence as well as an understanding of the root causes and impacts of systemic racism, homophobia, sexism, ageism, xenophobia and other barriers to achieving optimal oral health outcomes and maintaining an inclusive, diverse and equitable work/learning environment.

Dental DEI Curricula for the 21st Century

To illustrate, the authors present examples of California dental school curricular models that achieve the outcomes and objectives described previously. Several dental institutions have or are planning to integrate DEI into their overall curriculum. The new DEI curriculum at the Western University of Health Sciences College of Dental Medicine (WesternU CDM), “Social Differences and Health Disparities in Dentistry, Medicine and the Biomedical Sciences,” provides a longitudinal and

It is important to distinguish social determinants of health from structural determinants of health.

comprehensive framework that engages both preclinical and clinical experiences, with a firm grounding in the ways that race, gender, sexuality, disability and other socioeconomic factors affect health and access to health care. The one-year course is structured into four units.

Unit one begins with modules devoted to understanding forms of social difference, including race, indigeneity, gender, class and more. Students in week two, for instance, establish a common language about race via an accelerated review of how anthropology, sociology and biology define the category. Unit one culminates with modules on how scientists and clinicians incorporate categories of social difference into their research and clinical practice. Students review determinants, such as biological, social and cultural, and how to recognize when a disparity interfaces with social structures.

The DEI curriculum continues with two units that survey the formation of social structures and intersections of human difference as they relate to the history of science, medicine and dentistry. Critical case studies show why Institutional Review Board (IRB) protocols exist to protect racialized, gendered and other at-risk patients from exploitation. The fourth and final unit requires students to activate skills acquired in previous weeks by engaging with experts who present innovative research on contemporary topics. During this final unit, students begin actualizing what they learned in the design of a community improvement project by selecting a faculty advisor and drafting a project proposal. The goal is to teach future dentists how to be researchers who can make a difference, equipped with detailed knowledge about social determinants, cultural competence and structural competence, enabling them to identify a problem and develop a robust research program that provides solutions.

The University of California, Los Angeles, (UCLA) School of Dentistry’s overarching context for its predoctoral curriculum around DEI principles has evolved to one of racism in all of its forms as a social and structural determinant of health. As acknowledgement and discussion of evidence linking structural/ cultural racism, and individual-level discrimination to racial health inequities33 require explicit use of the “racism” term, overcoming reluctance to do is so essential. As such, foundational content for this framing added to the

has also embarked on a journey to enhance its predoctoral curriculum by planning to add a DEI component across the four-year predoctoral curriculum. In June 2020, the chancellor of UCSF announced the campus’s anti-racism initiative. One of the key elements of that initiative has been revising and updating the curricula in all of its professional and graduate school programs to ensure their curricula are anti-racist and anti-oppressive.

The goal is to teach future dentists how to be researchers who can make a difference, equipped with knowledge about social determinants.

UCSF’s initial focus for incorporating an anti-racism, anti-oppression component to its curriculum has been to enhance D1 students’ DEI foundational learning. To launch this transformation, UCSF engaged Denise Davis, MD, a leader in DEI instruction and professor in the UCSF School of Medicine, and Laura Cooley, PhD, senior director of external education and outreach of the Academy of Communication in Healthcare (ACH), to assist in developing a facilitated fourhour orientation session and revising a three-hour class session in the D1 students’ course on patient-centered care.

D1 curriculum in 2020 includes origins of the mythical “race” concept and its pervasive role in law, policy and social structure throughout U.S. history. Relevant examples appear in many courses, such as slave labor enabling the widespread availability of cheap sugar and triggering the so-called “caries epidemic” of the late 18th century. A student small-group facilitator training program was also launched in 2020 to increase engagement and conversation surrounding culture, race and health across the curriculum. Emphasis on personal and professional growth through cultural humility has supplanted that of cultural competence acquisition in the clinical and didactic curricula.

The University of California, San Francisco, (UCSF) School of Dentistry

The four-hour orientation session occurs in the fall quarter when students first arrive, and the three-hour class session occurs in the spring quarter. These sessions are interactive learning experiences that include brief didactics, skills training in team building and relationship-centered communication to facilitate understanding and effective dialogue about topics such as differences (especially racial differences), racism, equity, privilege, allyship, microaggressions, stereotype threat, implicit bias and cultural humility. Time is reserved in the sessions for facilitated small break-out groups to provide opportunities for skills practice. The first session in the fall quarter also includes a panel discussion consisting of near-peers and faculty who highlight diversity and

Dental Institutions Located In Health Professional Shortage Areas (HPSA) and Medical Underserved Areas/Populations (MUA/P)

Dental Institution

California Northstate University, College of Dental Medicine

Herman Ostrow School of Dentistry of USC

Dental Health HPSA Primary Care HPSA MUA/P

No No No

Yes Yes Yes

No No No University of California, Los Angeles, School of Dentistry

Loma Linda School of Dentistry

No No No University of California, San Francisco, School of Dentistry

No No No University of the Pacific, Arthur A. Dugoni School of Dentistry

Western University of Health Sciences College of Dental Medicine

HPSAs and MUA/P

No No Yes

No Yes Yes

Percentage Breakdown by Race/Ethnicity of Populations Served in Example Counties of WesternU CDM Clinical Experiential Training

Area American Indian/ Alaska Native Asian Black/African American Hispanic/Latino

Native Hawaiian/ Other Pacific Islander White

United States 1.30% 5.90% 13.40% 18.50% 0.20% 60.10%

California 1.60% 15.50% 6.50% 39.40% 0.50% 36.50%

Alameda 1.10% 32.40% 11.00% 22.30% 0.90% 30.60%

Kern 2.60% 5.40% 6.30% 54.60% 0.30% 32.80%

Los Angeles 0.20% 14.30% 8.50% 48.80% 0.20% 26.10%

Madera 4.40% 2.60% 4.20% 58.80% 0.30% 33.20%

Riverside 1.90% 7.20% 7.30% 50.00% 0.40% 30.60%

Sacramento 1.50% 17.00% 10.90% 23.60% 1.30% 43.80%

Santa Clara 1.20% 39% 2.80% 25.00% 0.50% 30.60%

Shasta 3.20% 3.10% 1.20% 10.50% 0.20% 79.20%

lived experience of the panel participants shaped by cultural forces as well as an overview of disparities/injustices in oral health. The next stage in UCSF School of Dentistry’s curriculum transformation regarding DEI will be to include antiracism and anti-oppression content in the D2 through D4 students’ curricula.

DEI Development in Clinical Training: A Community-Based Dental Education Model Clinical Experiences Supporting DEI Development

A study conducted in California

found that students who were educated in a diverse environment increased the probability of working and living in more racially and ethnically diverse areas postgraduation.34 This study also noted that students who learned and studied about racial and ethnic diversity throughout their doctoral curriculum were more prepared to live and interact in a diverse and multicultural community.27 The next section details how DEI principles learned in a didactic, preclinical setting can synergize with clinical training approaches to foster real

and lasting change in dental medicine learners and the patients they serve.

With more than 50% of the population predicted to consist of racial and ethnic minorities by 2050, the 2000 “Oral Health in America: A Report of the Surgeon General” called out the lack of diversity in the current workforce to address the needs of this future diverse population. To address the health disparities affecting these medically underserved communities, the U.S. Department of Health and Human Services (HHS) supports direct patient care in government

TABLE

Percentage of Persons From an Economic and Education Perspective in Example Counties of WesternU CDM Clinical Experiential Training

Area Persons in poverty Food insecurity

Eligible for free or reduced-price meal program

Highest level of education attained (among adults aged 25 years or more): Less than high school

Highest level of education attained (among adults aged 25 years or more): High school diploma

United States 11.2% 10.9% 41.2% 9.0% 27.6%

California 15.4% 10.2% 52.3% 14.0% 20.5%

Alameda 8.7% 8.4% 40.5% 11.0% 18.0%

Kern 18.0% 14.3% 71.6% 15.0% 24.0%

Los Angeles 13.2% 11.4% 68.7% 23.0% 21.0%

Madera 14.1% 13.2% 80.6% 15.0% 26.0%

Riverside 11.2% 9.0% 65.4% 10.8% 25.1%

Sacramento 12.5% 11.9% 56.8% 6.4% 22.3%

Santa Clara 6.6% 7.2% 32.4% 12.0% 15.0%

Shasta 13.9% 14.2% 53.6% 10.0% 25.5%

settings such as federally qualified health centers (FQHCs), Ryan White HIV/ AIDS Program-funded clinics, nonprofit clinics, the Indian Health Service (IHS), the Federal Bureau of Prisons (BOP) and the U.S. Department of Veterans Affairs.28 With more than 199,000 active dentists in the U.S. in 2018, only 0.9% (1,852/199,486) of the dentists practiced in federal services such as the Veterans Affairs, Public Health Service or FQHCs.28 Despite the increase in dentists who identify as women, from rural areas or from underrepresented racial and ethnic groups, there is still a growing need to promote diversity in the workforce.28

Through establishing immersive clinical experiences in medically underserved communities during predoctoral years, these experiential trainings serve as expanding the workforce to address the oral health needs of a growing diverse population. Many dental institutions have integrated communitybased rotations into the dental curriculum, providing exposure and potential pipeline employment opportunities for predoctoral dental students.

Of the seven dental institutions in California, three are located in medically underserved areas/populations, two are

Percentage/Ratio of Population To Be Served by WesternU CDM Clinical Experiential Training

Area Uninsured children Percentage of uninsured adults Primary care physician ratio Dentist ratio

National 5.6% 8.6% 1:2,169 1:1,644

California 3.6% 9.5% 1:1,389 1:1,285

Alameda 2.3% 6.0% 1:910 1:1,040

Kern 9.1% 12.0% 1:2,040 1:1,950

Los Angeles 7.0% 13.0% 1:1,360 1:1,120

Madera 7.0% 14.0% 1:2,220 1:2,310

Riverside 4.0% 12.0% 1:2,330 1:1,910

Sacramento 3.8% 8.0% 1:1,150 1:1,280

Santa Clara 3.0% 6.0% 1:960 1:840

Shasta 6.6% 9.0% 1:1,330 1:1,373

located in primary care HPSAs and only one is located in a dental health HPSA (TABLE 1 ). Dental institutions located in the HRSA-designated primary care HPSA and in a medically underserved area/populations (MUA/P) will inherently expose students to a diversity of patient populations including a wide array of underserved individuals. But beyond the four walls of the dental institution, clinical experiential training varies, with externship site rotations ranging from two-weeks in senior year to two seven-

week externship rotations spanning junior and senior year. These clinical rotations create three-fold benefits: 1) increased dental workforce in medically underserved communities (MUCs); 2) clinical, cultural and structural competency exposure; and 3) support of a pipeline of dental graduates as future safety net providers.

Impact of Clinical DEI Development

By addressing topics such as implicit bias, unconscious bias and systemic racism in predoctoral dental education,

Percentage of Population Served in Example Counties of WesternU CDM Clinical Experiential Training

Area Veteran Rural Persons with a disability Children with special health care needs

National 7.5% 19.3% 26% 18.8%

California 5.4% 0.02% 10.4% 14.1%

Alameda 3.9% 0.39% 5.6% 13.4%

Kern 5.9% 10.21% 8.7% 14.5%

Los Angeles 3.4% 0.61% 6.1% 13.7%

Madera 6.0% 32.92% 8.7% 15.3%

Riverside 7.0% 5.0% 7.5% 14.3%

Sacramento 7.0% 2.06% 7.8% 14.5%

Santa Clara 3.6% 1.08% 4.6% 12.3%

Shasta 10.2% 29.29% 12.4% 16.6%

dental students are able to increase their knowledge and understanding of providing care to an increased and diverse range of individuals. Equipped with the framework of cultural and structural humility, dental students are prepared for their externship and extramural clinical rotations. An example of clinical immersion is, specific to MUA/P, the two seven-week externship rotations (first as a junior and second as a senior) at WesternU CDM in FQHCs, Indian Health Service sites, nonprofit community clinics and the Veteran Affairs Hospital. TABLES 2-5 illustrate the diversity of populations in race/ ethnicity by education and economic and populations served by WesternU CDM as compared to the U.S. and California.35 Given the common nature of the community-based experiences, the data are likely representative of the community-based education populations served by all dental schools. TABLES 2-5 summarize the sociocultural determinants, health disparities and unmet health needs of the counties served.36 Among these underserved populations, 50% of dental needs remain unmet year after year.23 With the growing need to increase the dental workforce in MUCs, exposure and experiential learning as part of clinical immersion expand a student’s learning beyond clinical and also in cultural diversity, awareness and sensitivity.

The Herman Ostrow School of

Dentistry of USC has also integrated community-based clinical rotations into D3 and D4 curricula, offering rotations that are one to two weeks in community outreach/service learning geriatrics and individuals with intellectual/ developmental disabilities in medically underserved areas.37 To further student engagement with populations from diverse cultures and backgrounds, USC offers a free dental care mobile clinic, addressing the oral health inequity known to burden populations that are affected by social determinant factors such as racial/ethnic minority and low-income populations.23 Additionally, the University of the Pacific, Arthur A. Dugoni School of Dentistry has integrated multiple externship rotations to community health clinics, long-term care facilities, hospitals and mobile dentistry to prepare the dental students to care for patients with complex needs and limited access to care. This curriculum has also established telehealth appointments through the virtual dental home, and synchronous telehealth appointments have been utilized to expand access to care for vulnerable populations to address social determinant factors such as transportation.38

UCLA and UCSF have also established integration of student experiences in providing care to a diverse population outside the four walls of the institution. UCLA DEI in the

clinical curriculum is at the core of the community-based clinical education (CBCE) program. D4 students experience two three-week externships at CBCE partner sites, all of which deliver care to Medicaid beneficiaries or people who are uninsured and have difficulty affording needed care. The sites are located in a variety of underserved communities, both in state and out of state, exposing students to safety net delivery models and community demographics.33

UCSF has incorporated a community clinics externship course in D4 that follows the community-based learning lecture series in D3. These multiple community-based externships are completed at one of their 14 communitybased affiliated sites in California.39

In addition to externship rotations, dental institutions have created different programs and opportunities for dental students to better understand the social determinant factors that limit access to care for MUCs. The Loma Linda University School of Dentistry requires service-learning hours for all dental students. The dental students are expected to complete a minimum of 120 hours that may include at least one or more of the 20 international mission trips per academic year and other local community opportunities.40 With California Northstate University College of Dental Medicine entering its

first DMD class in 2022, its “community engagement mission” emphasizes community services and incorporating programs and partnerships to “prepare and inspire dental professionals to improve the health of their communities.”41

Within D1, the amount of oral health care provided in MUCs can increase by tens of thousands if every dental student in California has rotated at least once. The impact of these clinical experiential rotations has left lasting impressions that open opportunities in private and public practices. Dental students applying for postgraduate residency programs may opt to further their training at FQHCs, which will further support building a diverse dental workforce and better prepare them to serve patients of diverse backgrounds after their residency program. Additionally, new dentists electing to enter private practice are able to build better patient relationships due to knowledge and understanding of cultural and structural competency.

Therefore, to further develop greater numbers of graduates competent in serving patients from diverse backgrounds, dental institutions must constantly build upon their current extramural rotation sites.36 By integrating student exposure in community-based experiential training, students will be better compelled to meet the need for dental professionals comfortable in providing care to diverse and underserved populations upon graduation. Regardless of the dental care setting, employing well-rounded graduates who are multifaceted in providing services to diverse populations addresses the problem of oral health inequity head-on.

Conclusion

Based on the 2000 surgeon general’s report, “oral health as a comprehensive baseline for many oral conditions … has not improved significantly” for U.S.

adults, particularly affecting those from lower-income and specific race/ethnic minority groups due to social determinant barriers.23 The 2021 National Institute of Dental and Craniofacial Research report, “Oral Health in America: Advances and Challenges,” issued a call to action to support strengthening and diversifying the dental workforce trained and dedicated to improving oral health.23 Movement toward action in improving knowledge of social determinant factors that contribute to oral health inequities, particularly based on poverty status and

health providers from both private and public sectors who understand the dynamic changes in the growing, diverse population are imperative to attaining “optimal oral health for all.”23 n

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One of the key opportunities is collaboration among legislatures and insurance companies as well as dental professionals to establish an integrative oral health and overall health care system that improves access to care.42 As social determinants influence healthy behaviors, upstream factors such as policy and legislative action must be proposed and passed to reduce and lead to elimination of inequities that limit access to care.43,44 Such systematic infrastructure changes in dental education to include DEI development further supports a workforce capable of understanding economic and social factors and delivering patient, person-centered care. DEI development goes beyond dental education. Oral

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36. Reynolds PP. A legislative history of federal assistance for health professions training in primary care medicine and dentistry in the United States, 1963–2008. Acad Med 2008 Nov;83(11):1004–14 doi: 10.1097/ ACM.0b013e318189278c

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4: Oral Health Workforce, Education, Practice and Integration Rockville, Md: U.S. Department of Health Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2021.

43. U.S. Department of Health and Human Services. Fact Sheet Oral Health in America: Advances and Challenges. Key Summary of Full Report. Rockville, Md: U.S. Department of Health Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2021.

44. U.S. Department of Health and Human Services. Fact Sheet Oral Health in America: Advances and Challenges.

Section 1: Effect of Oral Health on the Community, Overall Well-Being, and the Economy. Rockville, Md.: U.S. Department of Health Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2021.

THE CORRESPONDING AUTHOR, Bradley S. Henson, DDS, PhD, can be reached at bhenson@westernu.edu.

Glossary of Terms

This glossary is from a blog post “Understanding Racial Terms and Differences” on the National Institutes of Health Office of Equity, Diversity and Inclusion. The author says that words commonly used in a discussion of race can be easily confused or misconstrued.

She compiled this list of terms to focus on the concepts and terminology used in minority, ethnic and racial groups studies.

GLOSSARY

Ally: Someone who makes the commitment and effort to recognize their privilege (based on gender, class, race, sexual identity, etc.) and work in solidarity with marginalized groups in the struggle for justice. Allies understand that it is in their interest to end all forms of oppression, even those from which they may benefit in concrete ways. Allies commit to reducing their complicity or collusion in oppression of those groups and invest in strengthening their knowledge and awareness of oppression.

Anti-Black: Resistant, antagonistic or oppositional to Black people.

Anti-Racist: Someone who supports policies and actions that express the idea that racial groups are equals and eliminate racial inequity.

Assimilation: The process whereby individuals or groups of differing ethnic heritage are absorbed into the dominant culture of a society. Assimilation does not denote “racial” or biological fusion, though such fusion may occur.

Bigot: A person who is utterly intolerant of any differing creed, belief or opinion.

Bigotry: Stubborn and complete intolerance of any creed, belief or opinion that differs from one’s own.

Black Lives Matter: A movement addressing the systemic violence against Black people serving as an affirmation of Black peoples’ humanity, their contributions to society and their resilience in the face of oppression.

Colonization: When one nation subjugates another, conquering its population and exploiting it, often while forcing its language and cultural values upon its people.

Critical Race Theory: Critical race theory refers to a broad social scientific approach to the study of race, racism and society. Popularized by Kimberlé Crenshaw and Derrick Bell with the notion of critical race theory within the subfield of critical legal studies in the 1980s. Unlike traditional civil rights, which embraces incrementalism and step by step progress, critical race theory questions the very foundations of the liberal order, including equality theory, legal reasoning, Enlightenment rationalism and principles of constitutional law.

Cultural Appropriation: Theft of cultural elements for one’s use, commodification or profit — including symbols, art, language, customs, etc. — often without understanding, acknowledgment or respect for its value in the original culture. Results from the assumption of a dominant (i.e., white) culture’s right to take other cultural elements.

Culture: A social system of meaning and custom that is developed by a group of people to assure its adaptation and survival. These groups are distinguished by a set of unspoken rules that shape values, beliefs, habits, patterns of thinking, behaviors and styles of communication, encompassing religion, food, clothing, language, marriage, music and behavior.

Diaspora: The definition of a diaspora is the dispersion of people from their homeland or a community formed by people who have exited or been removed from their ancestral homeland.

Discrimination: The unequal treatment of members of various groups based on race, gender, social class, sexual orientation, physical ability, religion and other categories. According to the Equal Employment Opportunity Commission, it is illegal to discriminate against someone based on race, color, religion, national origin or sex. The law also makes it illegal to retaliate against a person because the person complained about discrimination, filed a charge of discrimination or participated in an employment discrimination investigation or lawsuit.

Diversity: Diversity includes all the ways in which people differ, and it encompasses all the different characteristics that make one individual or group different from another.

Ethnicity: Large groups of people are classed according to common racial, national, tribal, religious, linguistic or cultural origin or background, a social construct used to categorize and characterize seemingly distinct populations.

Ethnicity: Also known as unconscious or hidden bias, implicit biases are negative associations that people unknowingly hold. They are expressed automatically, without conscious awareness.

Implicit Bias: Large groups of people are classed according to common racial, national, tribal, religious, linguistic or cultural origin or background, a social construct used to categorize and characterize seemingly distinct populations.

Inclusion: Involvement and empowerment, where the inherent worth and dignity of all people are recognized. An inclusive university promotes and sustains a sense of belonging; it values and practices respect for the talents, beliefs, backgrounds and ways of living of its members.

Institutional Racism: How institutional policies and practices create different outcomes for different racial groups. The institutional policies may never mention any racial group, but their effect is to create advantages for whites and oppression and disadvantage for people from groups classified as people of color.

Intersectionality: A framework for conceptualizing a person, group of people or social problem as affected by several discriminations and disadvantages. It considers people’s overlapping identities and experiences to understand the complexity of prejudices they face.

Microaggression: Everyday verbal, nonverbal and environmental slights, snubs or insults, whether intentional or unintentional, which communicate hostile, derogatory or negative messages to target persons based solely upon their marginalized group membership.

Nationality: The status of belonging to a particular nation by origin, birth or naturalization; people having common origins or traditions and often constituting a nation; existence as a politically autonomous entity; national independence.

Oppression: Oppression is the systemic and institutional abuse of power by one group at the expense of others and the use of force to maintain this dynamic. An oppressive system is built around the ideology of superiority of some groups and inferiority of others.

People (Persons) of Color (POC): A term primarily used in the United States and Canada to describe any person who is not white. It does not solely refer to African Americans; rather, it encompasses all non-white groups and emphasizes the common experiences of systemic racism.

Power: Power can be understood as the ability to influence others and impose one’s beliefs. All power is relational, and the different relationships either reinforce or disrupt one another. Power is unequally distributed globally and in U.S. society; some individuals or groups wield greater power than others, thereby allowing them greater access and control over resources. Wealth, whiteness, citizenship, patriarchy, heterosexism and education are a few key social mechanisms through which power operates.

Prejudice: A prejudgment or unjustifiable, and usually negative, attitude of one type of individual or group toward another group and its members. Such negative attitudes are typically based on unsupported generalizations (or stereotypes) that deny the right of individual members of certain groups to be recognized and treated as individuals with individual characteristics.

Race: A categorization of humans based on shared physical or social qualities into groups generally viewed as distinct within a given society. Race is a social construct and not biological.

Racial Justice: Systematic fair treatment of people of all races, resulting in equitable opportunities and outcomes for all. Racial Justice [is defined] as the proactive reinforcement of policies, practices, attitudes and actions that produce equitable power, access, opportunities, treatment, impacts and outcomes for all.

Racist: Someone who believes that other races are not as good as their own and therefore treats them unfairly.

Racism: A different from racial prejudice, hatred or discrimination. Racism involves one group having the power to carry out systematic discrimination through the institutional policies and practices of the society and by shaping the cultural beliefs and values that support those racist policies and practices.

Reparations: Something that one does or gives to correct a mistake or wrongdoing. Reparations are usually made by governments to make amends for wars, serious crimes and systemic abuse.

Systemic (Systematic, Structural, Institutional) Racism: Policies and practices entrenched in established institutions, which result in the exclusion or promotion of designated groups. It differs from overt discrimination in that no individual intent is necessary. Inequalities are rooted in the system-wide operation of a society that excludes substantial numbers of members of groups from significant participation in major social institutions.

White Fragility: Discomfort and defensiveness on the part of a white person when confronted by information about racial inequality and injustice.

White Privilege: The unquestioned and unearned set of advantages, entitlements, benefits and choices bestowed on people solely because they are white. Generally white people who experience such privilege do so without being conscious of it.

White Supremacy: A belief or set of beliefs to which one or more of the following key tenets exist: 1) whites should have dominance over people of other backgrounds, especially where they may co-exist; 2) whites should live by themselves in a whites-only society; 3) white people have their own “culture” that is superior to other cultures; 4) white people are genetically superior to other people. As a full-fledged ideology, white supremacy is far more encompassing than simple racism or bigotry.

Whiteness: White culture, norms and values in all these areas become normative. They become the standard against which all other cultures, groups and individuals are measured and usually found to be inferior.

Reprinted with permission from the National Institutes of Health Office of Equity, Diversity and Inclusion.

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CDA PRESENTS

In Case of Emergency, Preparedness Is Key

TDIC Risk Management Staff

Is your practice prepared for when the unthinkable occurs and a patient experiences an adverse occurrence during or after treatment? The Dentists Insurance Company’s Risk Management Advice Line takes calls from dentists facing these challenging situations. Their guidance offers insight into effective prevention, management and assistance with reporting of adverse events.

A Case Study in Adverse Occurrence

As reported in one Advice Line call, a 38-year-old patient with special needs presented with tooth pain. The patient had been previously treated by the dentist under general anesthesia without incident. Radiographs confirmed extensive decay involving the pulp in teeth Nos. 18 and 19. The dentist discussed treatment options with the patient’s legal guardian, who agreed that the best course would be extracting the teeth under general anesthesia at a local hospital.

The hospital physician ordered that the patient temporarily suspend some of her medications on the day of treatment, including a prescribed antiseizure medication. A certified nurse anesthesiologist administered general anesthesia during the outpatient procedure. The patient went into a pseudoseizure immediately after the administration of the general anesthesia, before the treatment could begin, and needed to be admitted to the hospital that day for observation.

Two days after her admission, the patient was discharged from the hospital. A few days following discharge, the dentist’s office received a phone call from

the county medical examiner’s office informing them that their patient had died. The medical examiner had questions about the medications that were administered, the vitals recorded and other procedural questions.

The dentist contacted TDIC’s Risk Management Advice Line for directions on how to handle the situation. The Risk Management analyst immediately forwarded the matter to the claims

department for a referral to an attorney. The attorney assigned to the case assisted the dentist in submitting the required regulatory report to the dental board detailing the event including the vital signs recorded, medications administered, the emergency procedures performed and their subsequent notification of the patient’s death. Even though the insured was not present or performing the treatment at the time of

Expert support to manage your risks.

death, the attorney guided the dentist with the level of detail necessary for the board report. After reviewing the required regulatory report, the board concluded that no further investigation was necessary and closed the case.

An Ounce of Prevention Is Worth a Pound of Cure

At best, preventable adverse events can result in time spent providing the required regulatory notification to the state dental board. At worst, the loss of life or livelihood is irrevocable. Dedicating time and resources to implementing robust safety protocols in your practice is an essential risk management tool. Documentation and communication are key. Make certain that your office and the patient’s records have documented evidence of the following:

n Establishing and maintaining formal safety protocols, which may include “time outs” to verify the patient and procedure and written checklists to make sure the team is fully prepared for emergencies. Follow these protocols for simple procedures as well as advanced procedures of sedation and anesthesia.

n Ensure staff members have adequate training. On a regular cadence, test familiarity with your practice’s established safety and emergency response protocols.

n Review and update each patient’s medical history.

n Review patients’ medications, including over-the-counter and herbal supplements.

n Check vitals prior to procedures. In most practices, this important step is handled by a dedicated staff member.

n Consult with the patient’s physician, particularly if the patient is medically compromised or has underlying health issues. TDIC policyholders

can log in to their online account to download a Consultation for Dental Treatment sample form.

n Conduct and document an informed consent discussion with the patient or the patient’s representative or legal guardian.

n When a procedure is being performed by a traveling specialist, confirm their license, training, current insurance and certification prior to the specialist working on patients.

team to quickly respond to a call for help. If an emergency is developing, do not wait to assemble your team. This includes designating a team member to immediately request assistance from local first responders. Also be certain to reassign roles if a team member leaves or is temporarily out of the office.

If one of your patients needs emergency care during treatment, your best risk management tool is a level head.

n Overcommunicate. By communicating clearly with all personnel on hand while handling a patient emergency, you can delegate tasks efficiently and reduce your own stress levels. Say aloud what you are doing and ask others if they have performed the tasks outlined in your safety protocols. “Have you called 911? Are we doing CPR?”

n Never raise your voice. Raising your voice is a sure way to spread panic among your staff members and nearby patients. This can lead to a poor caregiving environment. Maintaining a professional demeanor even in crisis is crucial.

How To Remain Calm During an Office Emergency

If one of your patients needs emergency care during treatment, your best risk management tool is a level head. Mistakes are often made when decisionmaking is influenced by emotions. Here are a few calm yet effective steps for responding to a crisis:

n Know where your gear is. Before beginning any procedure, know where your basic emergency response equipment is stored. You should be able to access it quickly. Assign a team member to regularly check and restock emergency response kits, including checking expiration dates of medications.

n Call for backup. Part of your safety protocols should be training your

n Debrief. After any emergency response, take time to discuss the incident with all responding team members. Talk about what went right and what could have been done better. Review documentation to make sure an accurate record of care is provided before and during the emergency. This is an opportunity for team members to provide emotional support to one another after a stressful experience.

The best way to foster calm is for the whole team to be prepared. Schedule regular crisis response training and drills to ensure everyone in your practice has experience working together efficiently to manage emergencies. TDIC experts recommend crisis training at least once per year or more often if you have changes to staff.

What To Expect After an Adverse Occurrence

According to TDIC’s Advice Line analysts, most state dental boards require licensees to report any adverse occurrences or events possibly related to dental treatment to their state licensing board. This includes the death of a patient following treatment. Failure to submit a report to the state licensing agency can result in discipline against a dentist’s license and potentially a finding of unprofessional conduct. Advice Line analysts suggest that if there is any question of whether an incident should be reported, it is best to file a report out of an abundance of caution.

Due to the profound consequences of failing to properly report adverse occurrences, TDIC strongly advises dentists to contact the Advice Line as soon as possible following an in-office emergency or death of a patient. (In some states, the period for reporting can be as soon as 48 hours after the event.) Knowledgeable analysts will guide you

through the appropriate steps of timely board reporting and will provide the necessary referral to an attorney versed in handling board matters.

When reporting the death of a patient, state dental boards generally require the following information:

n Dentist’s name and license number.

n Contact information (email, phone number and address).

n Date and time of the occurrence.

n Facility where occurrence took place.

n Name of patient, gender and medical history.

n Dental procedure involved and the duration of treatment prior to the incident.

n Type and dosage of all drugs and medications used in the procedure.

n A description of the occurrence and interventions.

n The condition of the patient preop and postop.

TDIC offers a helpful reference specifically for reporting adverse events, the Adverse Occurrence Guide.

Policyholders can log in to their TDIC online account to access this tool and other helpful resources to prepare for, prevent and respond to potential risks.

In dentistry, optimal patient safety exists when all members of the dental team actively work together to consistently apply measures and systems that ensure the well-being of each patient. When a crisis does arise, a prepared team is an effective team. Remain calm as you put into practice the emergency protocols you have established. As soon as possible following an adverse incident, contact TDIC’s Risk Management Advice Line for further guidance and resources.

The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 877.269.8844.

Keep up with regulatory compliance.

Get expert guidance from CDA Practice Support analysts on the latest regulations affecting your practice, plus new resources to make it easier to keep pace.

Benefit from dentistry-centered forms, required docs, checklists, a compliance calendar and more.

Explore your CDA member resources at cda.org/RegulatoryCompliance.

Dental Benefit Plans

Employment Practices

Regulatory Compliance

Management

Dr. Leslie Strommer Member since 1990

Don’t Get Phished

CDA Practice Support

The HIPAA Security Rule requires a covered entity, such as a dental practice or clinic, to have a security awareness and training program for its workforce.1 Phishing has been reported by the FBI as one of the top three most reported cybercrimes in 2021. Cybercrimes lead to losses of more than $6.9 billion nationally, the agency reported, with almost $13 million lost in California due to phishing. The agency’s annual “Internet Crime Report” also cites phishing as one of the top methods used to deploy ransomware:2,3

“Although cyber criminals use a variety of techniques to infect victims with ransomware, phishing emails, Remote Desktop Protocol (RDP) exploitation and exploitation of software vulnerabilities remained the top three initial infection vectors for ransomware incidents reported to the (Internet Crime Complaint Center) IC3.”

What Is Phishing?

Phishing is a type of social engineering tactic used to deliver malware to computer networks or to get a victim to provide log-in credentials or other sensitive information. It relies on human behavior; for example, many people are not attentive when they are in a hurry or are focused on something else. Email communication is often used for phishing. Phishing targets everyone with no regard to their job, industry or organization size, whereas “spear phishing” targets specific individuals or a group in an organization or industry, for example, senior vice presidents in a

corporation. Phishing websites spoof legitimate websites. Victims often are directed to these sites through phishing emails but can also come across them by browsing the internet.

Phishing emails create a sense of urgency for victims to act by clicking on a link or providing information. A threat may be implied. The emails can be convincing by appearing to be from a

legitimate organization, such as a bank, vendor or internet provider. If a link is clicked, the victim may unknowingly allow malware to download or provide information that can be used to access personal or business accounts.

The U.S. Department of Health and Human Services Office for Civil Rights (OCR) notes that “. . . most cyberattacks could be prevented or substantially

mitigated if HIPAA-covered entities and business associates (“regulated entities”) implemented HIPAA Security Rule requirements to address the most common types of attacks, such as phishing emails, exploitation of known vulnerabilities and weak authentication protocols. If an attack is successful, the attacker often will encrypt a regulated entity’s ePHI to hold it for ransom or exfiltrate the data for future purposes including identify theft or blackmail.”4

How To Prevent Getting Phished

A good first line of defense is to implement technology, such as a firewall and antivirus software, to filter out potentially harmful and malicious emails. Not all potentially harmful emails are caught by any one type of technology, so a multilayer security approach is best. Work with your IT adviser and your email service provider to determine the best solutions for your practice. You should consult with them periodically thereafter and keep these technologies up to date because cyberthreats, risks and technology continuously change.

Under the HIPAA Security Rule, a covered entity is required to provide its workforce with information security awareness training. Such training should not only review the security measures the dental practice has implemented, such as use of unique user IDs and regular system monitoring and auditing, but also inform the staff on how to do their part

in ensuring patient information remains secure. Doing their part means staff need to know how to recognize phishing emails and websites. There are different methods for delivering this training. Free training resources are available from:

n HHS Email Phishing Fact Sheet

n HHS Email Phishing Threat Slides

n NIST Phishing Guidance

n The Federal Trade Commission

n Cybersecurity & Infrastructure Security Agency, Avoiding Social Engineering and Phishing Attacks

n YouTube for videos on “how to avoid phishing” Enhanced phishing awareness training can include using a service that sends simulated phishing emails to employees. Employees should also be trained on what they need to do when they detect a phishing attempt. The dental practice’s security incident response plan must be documented, and training should be reinforced with periodic security reminders. Simple tips to help prevent phishing include:

n Don’t rush to click on a link.

n Carefully review the email sender’s address to ensure its legitimacy.

n Check for poor grammar, misspellings and other errors.

n To verify a link, place the cursor over it until the web address appears.

n If you remain uncertain about a web link or an email, contact the company or individual who may have sent the

email or link. Use the phone number found on the company’s website and not the one included in the email.

n Beware of suspicious attachments.

n Stay informed about current cybersecurity threats. Bad actors try to take advantage of situations. For example, phishing attempts in health care skyrocketed during the COVID-19 pandemic. Regularly check the Cybersecurity & Infrastructure Security Agency website for recent cybersecurity alerts or ensure your IT advisor is regularly checking the website.

The OCR states, “Combining an engaged, educated workforce with technical solutions gives regulated entities the best opportunity to reduce or prevent phishing attacks.”4 n

REFERENCES

1. Workforce includes nonemployees who work at the covered entity’s site.

2. Health IT Security. FBI IC3: Healthcare Sector Faced Most Ransomware Attacks Last Year. March 24, 2022.

3. Federal Bureau of Investigation. FBI Releases the Internet Crime Complaint Center 2021 Internet Crime Report. March 22, 2022.

4. U.S. Department of Health and Human Services. Defending Against Common Cyberattacks. OCR Quarter 1 2022 Cybersecurity Newsletter.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

A look into the latest dental and general technology on the market

DocuSign Administrative Rights

(Starts at $10/month, DocuSign)

Managing electronic documents is a complicated task made more difficult when multiple parties need to review, sign, send and/or store said documents. Since 2003, DocuSign has been providing companies with its electronic document management solution. From its humble beginnings as a purely digital signature application, DocuSign now boasts an entire suite of integrated document management capabilities allowing users to send whatever they want, whenever they want, from most devices. It even has specific services built for health care providers wherein the company is willing to enter into business associate agreements with practitioners. Is DocuSign viable for the private practitioner looking to modernize their operations and go entirely paperless?

DocuSign’s company is predicated on the recipient user’s optimal experience. Unfortunately, that means administrator-level users will be spending most of their time digitizing workflows and creating templates, which essentially are DocuSign-friendly versions of the documents in use. Administrators can upload existing forms in PDF or picture formats, add recipients and their roles, then customize as many fillable fields as necessary, a process similar to creating fillable forms on Adobe Acrobat. Afterward, these templates can be deployed to the recipients, who then follow the directions laid forth by the administrators. Recipient users all have seamless experiences. Nothing occurs without the administrator’s permission, viewing or signing documents is intuitive with mobile devices and desktops and steps are quickly completed. DocuSign’s pricing structure has changed over the years, and it now focuses on a per “envelope” business model, which means that most users are charged per document they need to send. Even in larger organizations, this can mean that users pay up to $6 per form for every form being signed and stored. Considering the multitude of documents ranging from intake forms to individual treatment consent forms, this can be a significant reoccurring cost. Ultimately, for private practitioners looking to securely digitize their forms, DocuSign is a viable, scalable, but pricey method to manage patient forms.

— Alexander Lee, DMD

Bitmoji (Free, Snap Inc.)

Many people have avatars, which are images that represent users, to personalize their online profiles. There are endless ways to create or select these icons of expression with users favoring more options for customization. Bitmoji is an extremely popular app for iOS and Android that helps users create personalized, expressive cartoon avatars more commonly known as emojis. Bitmoji users must be age 13 and older and have a Snapchat account or email to sign up. Users first select a default avatar that most closely resembles their likeness. To make it easier for users to customize their avatar, the app offers the option to take (and retake) a selfie, which it uses to generate options to choose from. Once an avatar is chosen, users can use the editor to fine-tune or completely change their selection. The editor has a wide array of customization options that include skin tone, hair, facial hair, eyes, eyebrows, nose, jaw, face shape, mouth, ears, cheek lines, forehead lines, eye lines, body type, earrings, piercings, eye shadow, blush, lipstick, glasses, headwear, outfits, tops, bottoms, dresses, footwear, socks and outerwear. Many options can be customized even further, such as eyes, which users can select from shape, lashes, size, spacing and color. Fashion options also include outfits from brand names such as Nike, Converse and others.

When a user finally completes creating their avatar, a large library of stickers, or images of enhanced personalized emojis, is available for search. Selected stickers can be shared through text messaging or any other app. Users can enable the Bitmoji keyboard for easy access to stickers from any app. Users logged in with their Snapchat account can also enable Friendmoji, which generates stickers that include themselves and their friends together. With so many customization options for avatars and searchable expressions for one-of-a-kind stickers, this app acknowledges and represents the diverse community of today. Whether in person or virtually, it is important for people to represent themselves in a unique way. Bitmoji allows people to make avatars that unmistakably resemble themselves and share personal emoji stickers that are both fun and expressive.

— Hubert Chan, DDS

Every Californian deserves a healthy smile.

You already know how dentistry relieves pain, restores dignity and instills hope. Join the CDA Foundation’s mission to improve the oral health of all Californians. Together with volunteers and donors, we support dentists’ efforts to give back to their communities and reduce barriers to care.

• Student Loan Repayment Grants to make careers in public health possible

• Dental Materials & Supplies Grant for non-profit dental care organizations

• Volunteer-led CDA Cares clinics that shine a light on underserved areas

• Support of RDA apprenticeship programs to fill dentistry’s staffing pipeline

• Peer-to-peer Wellness Program for dentists’ physical and mental well-being

See how you can contribute today at cdafoundation.org