Oral Health Disparities Persist Among Racial & Ethnic Minorities
Jessamin E. Cipollina, M.A.
Health service access, affordability, and use varies for all Americans. Promotion of health equity across the health care landscape requires elimination of disparities in access to care, as these disparities impact individuals’ abilities to receive affordable, comprehensive and quality care. Regular primary care visits and preventive care are under-utilized by racial/ethnic minority groups, due to a long history of discrimination. Racial inequity throughout the health care system is well-documented in the literature, and research shows how racial/ethnic minority groups are impacted by multiple social determinants of health. Despite being integral to promoting overall health outcomes, oral health is a frequently forgotten component of overall health. Due to access barriers, such as lack of dental insurance or low socioeconomic status, there are significant oral health disparities among U.S. racial/ethnic minority populations.
Studies have found that people from racial/ethnic minority groups are less likely to have health insurance than their White counterparts. Implementation of the Affordable Care Act (ACA) in 2010 led to significant gains in health coverage over the past decade, yet substantial discrepancies remain for racial/ethnic minorities. As of 2018, 12% of Black adults, 19% of Hispanic adults, and 22% of American Indian and Alaskan Natives are uninsured, compared to only 8% of White adults.1 Individuals belonging to a racial/ethnic minority group are less likely to seek medical help and preventive care for serious chronic health problems – heart disease, diabetes, and cancer, to name a few – and are more likely to have poor health outcomes and higher mortality rates.2-4 The high costs of health care, combined with an extensive history of racial stereotyping, coupled with experiences that have built mistrust, prevent racial/ethnic minority individuals from achieving better health outcomes within their communities.
Dental care is not included as an essential benefit in many commercial health plans. The ACA does include oral health as an essential benefit for children only, not for adults and older adults. The CHIP program covers dental care in all 50 states for children insured by Medicaid, but only 35 states have an adult Medicaid dental benefit.5 According to the ADA Health Policy Institute, the most common reason for delaying or not pursuing dental care is cost as many individuals and families cannot afford out-of-pocket care costs.6 Moreover, there are a limited number of dental practices that will accept Medicaid-insured patients, making access and availability a crucial issue.6 Finally, a high proportion of racial/ethnic minority individuals live in communities without fluoridated water and schools that have fluoride varnish and sealants programs, which are shown to be highly effective in preventing oral health problems.7
Prominent health inequities persist in oral health care within racial/ethnic minority groups, which are also associated with lower socioeconomic status and high rates of poverty. In the US, people are unable to afford regular preventive dental care, and many vulnerable communities lack access to transportation to appointments or lack fluoridated water.3,8 As a result, we see oral health disparities across the lifespan among racial/ethnic groups. In U.S. children aged 2-5, 33% of Mexican American and 28% of Black children have had cavities in their primary teeth, compared to 18% of White children.8 Black and Mexican American U.S. adults are twice as likely to have untreated caries than their White counterparts, and older non-Hispanic Black and Mexican American adults have 2 to 3 times the rate of untreated cavities as older White adults.8 Periodontal disease is most common among Black and Mexican American adults; a study using data from the 2009-2014 National Health and Nutrition Examination Survey and found that the highest rates of moderate-severe periodontitis were in Black (42%) and Mexican American (46.4%) adults, while white adults had the lowest rate at 31%.9 Oral cancer, which affects about 54,000 Americans every year,10 shows a 41% survival rate for Black men, more than 20% lower than White men.9
Despite strong evidence that oral care and overall care are connected, dental care continues to be treated as a silo component of health care, separate from other health care professions. Interprofessional health education may be the answer to solving this dilemma! Think about how we can expand current interprofessional initiatives that bring dental, nursing, medical and other health professions together for classroom, simulation, and “live” clinical experiences to learn from, with, and about each other while learning about oral health and its links to overall health, as well as the related social determinants of health. Think about the oral health contributions that can be made by clinicians in primary care settings; think about the contributions the dental team can make to improving overall health. This perspective is particularly important when providing primary care or dental care for racially and culturally diverse patients especially those with disabilities, without dental insurance, or difficulty accessing affordable dental care.
Expanding a diverse health professions workforce is crucial to promoting oral health and primary care utilization among racial/ethnic minority Americans. Presently, approximately 20% of the nursing workforce (RNs, NPs, and MWs),11 20% of physicians,12 10% of dentists are from racial/ethnic minority backgrounds.13 Practitioners from racial/ethnic minority backgrounds are best equipped to work in those communities that align with their background, as they can lend their own experiences to providing culturally-competent care and improve trust of health professions among racial/ethnic minority groups. Decades of racial bias and discrimination in health care settings, and resulting mistrust, are major factors contributing to low health care utilization and poor health outcomes in racial/ethnic minority populations.2-4,14 Increasing the number of racially/culturally diverse health care professions students and clinicians can contribute greatly to expanding health care access and satisfying health care experiences for individuals and families from underserved communities and improve health care perceptions and trust among Americans from racial/ethnic minority communities.
The COVID-19 pandemic has underscored the physical, financial and sociopolitical barriers that disadvantaged populations face in accessing regular oral care and treatment. COVID-19 has exacerbated the impact of the social determinants of health; financial strain, transportation limitations and general distrust of the health care system have prevented many Americans from visiting their dentists. Oral care education, practice and policy initiatives need to incorporate the social determinants of health in understanding how to best treat vulnerable patients. Racial/ethnic minority identity often overlaps with several social determinants that impact health outcomes, namely low socioeconomic status.2,3,14 Oral health curricula, simulation and clinical experiences should incorporate social determinants of health in patient interactions by addressing economic disadvantages, insurance complications, experiences of discrimination and environmental barriers to care among vulnerable populations. Interprofessional education experiences are crucial to promoting quality integrated health care that speaks to a wide spectrum of care interventions for racial/ethnic minority patients. Oral health literacy products that address common oral-systemic complications can be disseminated to minority and disadvantaged communities to improve oral health and overall health outcomes. The responsibility falls on health care teams that include oral care professionals to engage with their communities and encourage health care utilization to reduce oral health and overall health disparities and to build a better health future for racial/ethnic minority Americans across the lifespan.
- Artiga S, Orgera K, Damico A. Changes in health coverage by race and ethnicity since the ACA, 2010-2018. Kaiser Family Foundation. Published March 5, 2020. Accessed February 23, 2021. At: https://www.kff.org/racial-equity-and-health-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/
- Manuel JI. Racial/ethnic and gender disparities in health care use and access. Health Serv Res, 2017;53(3):1407-1429. doi: 10.1111/1475-6773.12705.
- Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med, 2006;21(6):667-669. doi: 10.1111/j.1525-1497.2006.0512.x.
- Frakt, A. Bad medicine: the harm that comes from racism. The New York Times. Published January 13, 2020. Updated July 8, 2020. Accessed February 23, 2021. At: https://www.nytimes.com/2020/01/13/upshot/bad-medicine-the-harm-that-comes-from-racism.html
- American Dental Association, Health Policy Institute. Dental benefits and Medicaid. Accessed February 23, 2021. At: https://www.ada.org/en/science-research/health-policy-institute/dental-statistics/dental-benefits-and-medicaid
- Yarbrough C, Nasseh K. Vujicic M. Why adults forgo dental care: evidence from a new national survey. American Dental Association Health Policy Insitute. Published November 2014. Accessed February 23, 2021. At: https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx
- Griffin S, Naavaal S, Scherrer C, et al. School-based dental sealant programs prevent cavities and are cost-effective. Health Affairs, 2016;35(12). doi: 10.1377/hlthaff.2016.0839.
- Centers for Disease Control and Prevention. Disparities in oral health. Updated February 5, 2021. Accessed February 23, 2021. At: https://www.cdc.gov/oralhealth/oral_health_disparities/index.htm
- Eke PI, Thornton-Evans GO, Wei L, et al. Periodontitis in US adults: national health and nutrition examination survey 2009-2014. J Am Dent Assoc, 2018;149(7):576-588. doi: 10.1016/j.adaj.2018.04.023.
- The Oral Cancer Foundation. Oral cancer facts. Accessed February 23, 2021. At: https://oralcancerfoundation.org/facts/
- Rosseter R. Enhancing diversity in the workforce. American Association of Colleges of Nursing. Updated April 1, 2019. Accessed February 23, 2021. At: https://www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity
- Association of American Medical Colleges. Diversity in medicine: facts and figures 2019. Accessed February 23, 2021. At: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
- Peterson, B. How diversity in the dental profession could mean better care for minorities. Chicago Crusader. Published June 3, 2019. Accessed February 23, 2021. At: https://chicagocrusader.com/how-diversity-in-the-dental-profession-could-mean-better-care-for-minorities/
- Healthy People 2030. Discrimination. Accessed February 23, 2021. At: https://health.gov/healthypeople/objectives-and-data/social-determinants-health/literature-summaries/discrimination