Deamonte Driver was a 12-year-old African American child from Maryland who died from a tooth infection on Feb. 25, 2007. Ever since his mom was unable to find a Medicaid dental provider in his low socioeconomic status (SES) neighborhood, he has stood as an example for how severe oral health disparities can be for disadvantaged children in the United States, specifically those from a non-white race or ethnicity.
The effects of systemic racism have impacted communities of color for generations, in areas such as home ownership and education to the ability to earn an equitable income. It is impossible to discuss health disparities in the United States without looking at the influence of poverty and limited resources in our most vulnerable communities. For instance, data from the 2014 U.S. Census Bureau reports that, on average, Hispanic and Black populations earn 70 and 59 cents, respectively, for every dollar that white populations earn. When accounting for wealth, or a household’s net worth, Hispanic and Black populations have 7 and 6 cents, respectively, for every dollar of wealth that white populations have. According to 2018 census data, of those Americans living below the poverty line, 25.4% are Native American, 20.8% are Black and 17.6% are Hispanic, while white and Asian populations each make up 10.1%. An April 2020 Annual Review of Public Health study points out that people are more likely to have poor oral health if they are “low-income, uninsured, and/or members of racial/ethnic minority.”
Dental caries is the most common chronic disease in children, more than four times more prevalent than asthma, the Federal Interagency Forum on Child and Family Statistics says. Hispanic, Black and Native American children are two times more likely to have unmet dental needs compared to white children. Unmet dental needs such as untreated cavities can lead to extreme pain, increased emergency room visits, and lost hours at school and work. A UCLA Health Policy Research Brief showed that non-white children have more frequent school absences than their white peers due to dental problems. Notably, 80% of dental cavities are localized among 25% of children, with the majority of these being of low SES, according to a March-April 2002 Ambulatory Pediatrics study.
Barriers to care
Most oral health disparities stem from barriers to care, which are the obstacles that prevent patients from receiving medically necessary care. Access is one barrier. Children of low-income families are generally on public-based insurance, also known as Medicaid or CHIP. Unfortunately, there are not enough dentists accepting Medicaid insurances, with only 39% of dentists accepting Medicaid as of 2015, according to the Health Policy Institute. Public-based insurance reimbursements to dentists are only 49.4% of what the dental treatment would normally cost. To increase access to care for children who rely on Medicaid, there must be more dental offices who can take Medicaid insurances and continue to sustain their office operations. Numerous studies have shown a statistically significant positive relationship between Medicaid reimbursement rates (above the average 49.4%) and dentist participation in Medicaid. Therefore, if government-issued Medicaid reimbursements are closer to the national average dental fees, more dentists will be able to accept Medicaid and treat underserved communities.
Another barrier to care is that there are not enough dentists in low-income areas. One reason for this is the burden of student loan debt ($292,600 on average). The Public Service Loan Forgiveness Program, a publically funded program that encourages dentists to work in low-income areas or federally qualified health clinics by offering loan forgiveness, intends to combat this, yet according to an article in Forbes, the program has had its challenges. The article explains that 99% of students applying for loan forgiveness have been rejected because of a complicated application procedure that often renders recent graduates ineligible even after 10 years of service to underserved communities. A restructuring of this program to ensure an accepted application would encourage dentists to take advantage of this opportunity at a lower risk and provide underserved communities with the care they need.
An additional barrier that is more difficult to quantify is inherent racial/ethnic bias among providers. A January 2019 JDR Clinical & Translational Research article defines bias as “an inclination for or against a person or a group, as it allows for ones’ personal opinions to influence judgement.” In 1999, a Kaiser Family Foundation survey showed that Americans generally believe Black and white people receive the same level of health care, yet studies have shown that implicit bias negatively impacts Black and Hispanic patient care.
How can you help?
Many barriers to care for families of low SES are due to poor government aid, so one of the best things we can do is educate ourselves on the legislative process and vote. For example, funding for Medicaid is controlled by local and state governments, so it is important to research your local and state officials to put people in office who support an increase in Medicaid funding. In addition, as a dental provider, you can consider working in low-income areas or federally qualified health clinics.
One of the most effective public health measures to combat unmet dental care needs is public water supply fluoridation, which can directly prevent cavity development in children. According to a fall 2002 Journal of Public Health Dentistry article, studies show that water fluoridation also could decrease the disparities between SES populations. If a local government makes the decision to not provide water fluoridation, there will be little impact on wealthier populations that already have a lower incidence of dental decay. Low-income households, though, would gain the greatest benefit, as it would decrease their incidence of dental caries. Advocating for water fluoridation in these communities is another action we can take.
In addition, all health care providers should work to identify and combat implicit bias. According to the Institute for Healthcare Improvement, providers can do this by seeing their patients as individuals (not stereotyping them), understanding cultural differences on a foundational level, increasing opportunities to interact with diverse populations, and practicing empathy with their patients.
Recognizing the oral health disparities for people of color, especially those of a low SES, is a difficult topic to discuss. Yet it is important for dental providers to continuously be aware of these disparities and work each day to improve the care for their communities.
~ Alec Robin, DMD, Chief Pediatric Dental Resident, University of Pennsylvania/Children’s Hospital of Philadelphia, Pennsylvania ‘21