BMC Oral Health

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BMC Oral Health

  1. 1. BMC Oral Health BioMed CentralProceedings Open AccessReducing Oral Health Disparities: A Focus on Social and CulturalDeterminantsDonald L Patrick*1,2, Rosanna Shuk Yin Lee2, Michele Nucci3,David Grembowski1,2,3, Carol Zane Jolles4 and Peter Milgrom3Address: 1Department of Health Services, University of Washington, Seattle, WA, USA, 2Deparment of Sociology, University of Washington,Seattle, WA, USA, 3Northwest/Alaska Center to Reduce Oral Health Disparities and School of Dentistry, University of Washington, Seattle, WA,USA and 4Department of Anthropology, University of Washington, Seattle, WA, USAEmail: Donald L Patrick* - donald@u.washington.edu; Rosanna Shuk Yin Lee - rsyl@u.washington.edu;Michele Nucci - mnucci@u.washington.edu; David Grembowski - grem@u.washington.edu; Carol Zane Jolles - cjolles@u.washington.edu;Peter Milgrom - dfrc@u.washington.edu* Corresponding authorfrom Biotechnology and Biomaterials to Reduce the Caries EpidemicSeattle, USA. 13–15 June 2005Published: 10 July 2006 <supplement> <title> <p>Biotechnology and Biomaterials to Reduce the Caries Epidemic</p> </title> <editor>Rebecca L Slayton, James D Bryers, Peter Milgrom</editor> <note>Proceedings</note> <url>http://www.biomedcentral.com/content/pdf/1472-6831-6-S1-info.pdf</url> </supplement>BMC Oral Health 2006, 6(Suppl 1):S4 doi:10.1186/1472-6831-6-S1-S4© 2006 Patrick et al; licensee BioMed Central Ltd.This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Oral health is essential to the general health and well-being of individuals and the population. Yet significant oral health disparities persist in the U.S. population because of a web of influences that include complex cultural and social processes that affect both oral health and access to effective dental health care. This paper introduces an organizing framework for addressing oral health disparities. We present and discuss how the multiple influences on oral health and oral health disparities operate using this framework. Interventions targeted at different causal pathways bring new directions and implications for research and policy in reducing oral health disparities.Introduction ulation health. What these disparities are, what causesReducing health disparities is a major goal for public and them, and how to ameliorate and prevent them requiresprivate health agencies in the United States [1] for health awareness, research, knowledge accumulation, and trans-professionals and for the public at large. In 2000, the Sur- lation of this knowledge into action. Finally, reducing oralgeon General highlighted oral health as a major compo- health disparities requires the will to act. Changes arenent of general health and well-being [2]. Oral health needed in resource allocation, in social and public healthimplies much more than healthy teeth. The mouth is both policy, in community organization, in the provision ofa cause and a reflection of individual and population effective dental health care, and in professional and indi-health and well-being. vidual behavior.Persistent and consequential oral health disparities exist Processes and mechanisms that may be called "determi-within the U.S. population, and reducing these oral health nants" operate at all levels of our society. Determinants ofdisparities is central to the overall goal of improving pop- oral health disparities represent a complex mix of the bio- Page 1 of 17 (page number not for citation purposes)
  2. 2. BMC Oral Health 2006, 6:S4logical, the behavioral, the cultural, the social, the eco- and dental care. Thus, low-income groups, racial minori-nomic, and the political. ties, and people with disabilities are often found to have higher hospitalization rates and more emergency roomWe present a conceptual framework for investigating oral visits than people of higher income, often due to thehealth disparities, with a focus on social and cultural unhealthy and unsafe environments in which they livedeterminants. Why a conceptual framework? This frame- [3].work recognizes that inequality is produced throughdynamic sociocultural processes. To reduce disparities, a Health disparities is a term that describes a disproportion-cumulative science is needed that places knowledge ate burden or risk of death, disease, disability, and illgained from research, practice, and expert deliberation health on a particular population or group. Healthy Peo-into a framework that identifies the modifiable mecha- ple 2010, a national health promotion and disease pre-nisms by which we can act to narrow inequalities. This vention initiative, placed primary concern on gender, racepaper focuses on dental caries (or tooth decay), because it or ethnicity, education or income, disability, geographicis the major oral challenge U.S. society faces. The model, location, and sexual orientation. Oral health disparitieshowever, also applies to other oral health disparities, are often poorly understood. Women report more dentalincluding periodontal diseases, oral pharyngeal cancer, visits than men, yet few women receive dental care duringand congenital and acquired facial differences. pregnancy, a critical period [2]. Older individuals go to the dentist less frequently than the general population, areDefinition: How Oral Health Disparities Work in poorer oral health, and have a lower quality of life as aThree key concepts are social determinants of health, result [4].health disparities, and population health. Understandinghow these concepts apply to oral health requires defini- Population health is a term that focuses on the interrelatedtion and examples. conditions and factors that influence the health of popu- lations over their life course, identifies systematic varia-Social determinants of health refer to both specific features tions in their patterns of occurrence, and applies theof and pathways by which societal (including cultural) resulting knowledge to develop and implement policiesconditions affect health and well-being. Perhaps a misno- and actions to improve health and well-being. The goalsmer but currently in widespread use, the notion of deter- of a population health approach to oral health are tominants suggests clear causal pathways that are often maintain and improve the oral health of a given popula-anything but clear. We concentrate on social and cultural tion and to reduce inequities in oral health. Methods forconditions that might be altered by programs and poli- addressing disparities are emerging through social epide-cies. Examples are income, education, social capital, occu- miologic research and public health applications [5].pation, community structure, social support, availabilityof health services, and larger forces such as structural ine- Health insurance inequalities contribute to oral healthquality, cultural beliefs and attitudes, and legal channels. disparities [2]. In the U.S., access to oral health care isSocial determinants interact with biological and personal mediated through the availability of private dental insur-determinants at a collective level to shape individual biol- ance or poorly funded public oral care. Private dentalogy, individual risk behaviors, environmental exposures, insurance facilitates use of preventive oral care and miti-and access to resources that promote health. A graded rela- gates negative effects of oral diseases. Public oral healthtionship between social position and health status affects care funds preventive care but few eligible persons actu-all persons in the social hierarchy [3]. ally receive it [2].Through the process of social stratification, individuals The RAND Health Insurance experiment provided evi-are divided into subgroups. They are differentiated based dence that providing free dental care can improve oralon attributes that are considered important by society, health in low-income preschool children [6]. Access tosuch as income, race, sex, and education. Once the process dental insurance, however, does not always guaranteeof differentiation has occurred, individuals are evaluated reduction in oral health disparities [7]. In many Americanbased on their attributes. Individuals with more favorable Indian and Alaska Native communities, oral health dis-attributes are sorted into a higher social status in the hier- parities exist even though dental care is theoretically avail-archy, which subsequently determines the provision of able without cost as a function of tribal status. For tribalrewards. This social hierarchy provides differential bene- communities, the primary influences include a combina-fits to individuals who occupy different positions. Hence, tion of factors, such as: geographic isolation, ethnic differ-stratification functions as a process that formalizes ine- ences in social and cultural values, cultural and socio-quality in the form of unequal access to valuable economic changes that have strongly affected diet, lack ofresources, such as quality housing, education, health care, education as a consequence of social, political and cul- Page 2 of 17 (page number not for citation purposes)
  3. 3. BMC Oral Health 2006, 6:S4tural peripheralization at the hands of the dominant cul- multinational companies based in the U.S. invest littleture, and overall low levels of income that affect all of money in developing new preventive technologies to helpthese factors. ameliorate oral health disparities. So-called new technol- ogies, such as fluoride varnish or Atraumatic RestorativeThe gap between available preventive oral technologies Technique using glass ionomer, are either imported fromand their full dissemination and application also widens Europe or created for use in developing countries. Federaloral health disparities among different social and ethnic device and drug regulations, administered by the U.S.populations. Enormous growth in scientific technologies Food and Drug Administration (FDA), are stringent inhas led to remarkable public health advances in nutrition, protecting the safety of the population and in evaluatingimmunization, personal hygiene, sanitation, and water efficacy. These regulations and the "market place" createand air safety. Yet, as a society, we continue to struggle economic disincentives to private enterprise for newwith the challenge to allocate human and financial research and development for preventive care. Little pub-resources effectively to reduce social disparities in oral lic subsidy exists for development of new preventive den-health. The "inverse care law" operates here. That is, those tal technology. Most promising devices, such as slow-who most need care do not get it [8,9]. release fluoride vehicles or better antimicrobials, sit unused on the lab shelf.Tooth decay, which occurs chiefly during childhood andadolescence, is a transmissible bacterial infection. The The complexity in addressing oral health through dentalmajor reservoir from which infants acquire tooth decay is care can be illustrated by the experience in Head Start.through transmission of mutans streptococci from mothers Tooth decay attacks largely before children are enrolled inand between infected and uninfected children [10]. Head Start, and damage to the teeth is already done. At theAmong some groups a childs extended family may very same time, the children are too young to benefit from tar-likely be responsible for significant transmission from geted approaches to prevention of dental caries in firstadults to children. Efforts to prevent the transmission of permanent molars because the teeth have not yet erupted.bacterial agents begin with prenatal care and continue School systems do not follow up on attempts during thethroughout the early childhood. Suppression of maternal Head Start years to arrest tooth decay, and children inbacterial reservoirs through preventive and curative treat- these populations often go on to experience uncheckedment can prevent or delay the infection of young infants tooth decay in their permanent teeth.among certain affected groups [11,12]. A Snapshot of Oral Health Care Disparities inDental caries can be prevented or its impact lessened the U.Sthrough lower consumption of sugar-rich foods and According to Oral Health in America: A Report of the Surgeonthrough water fluoridation, school- or home-based topi- General, dental caries is the single most common chroniccal fluoride programs, supervised toothbrushing with childhood disease in the United States [2]. Children livingfluoridated toothpaste at school, and toothpaste distribu- in poverty [16], including those with disabilities, are mosttion schemes. For populations that are more severely likely to be affected by dental disease. Dental caries inimpacted by tooth decay, additional measures, such as young children is five times more common than asthma,dental treatment or antimicrobial therapy, are required to and seven times more common than hay fever [1]. Dispar-control the disease [11,13]. ities are also unequally distributed among adults. Low socioeconomic status, minority status, and unemploy-Unfortunately, newly developed dental treatments and ment are associated with patterns of infrequent preventivetechnological advancements that enhance prevention of dental care and high rates of dental disease [17].tooth decay are unevenly distributed across segments ofthe population [14,15]. Differing values may deter the Lowering the cost of dental insurance has yielded little sig-adoption of efficacious preventive behaviors. Poor teeth nificant progress. Although the U.S. has made strides inand poor oral health have different meanings to different lowering the cost of medical insurance via federal pro-segments of society, and values coupled with perceived grams such as Medicaid and Medicare, low-incomeavailable choices may influence what persons are willing patients have reduced access to dental care because soto do to prevent oral problems. For example, some per- many dentists refuse to participate in Medicaid and Medi-sons may believe that tooth loss is inevitable regardless of care does not include dental coverage [18]. Gortmakerswhat they do. Others may adopt habits conducive to tooth (1981) examination of Medicaid utilization betweenpreservation. 1973 and 1977 found that Medicaid increased utilization of dental service among children only during the earlyResearch and development in the relatively small dental years of the research study [19]. Mueller (1984) examinedindustrial sector worldwide is very limited. Even major utilization patterns of dental care among children with Page 3 of 17 (page number not for citation purposes)
  4. 4. BMC Oral Health 2006, 6:S4and without Medicaid and found that in 1977 the rate of Another major component in the underuse of availableutilization by children with Medicaid was 35 percent – dental services is the culture gap between dentists andonly 10 percent higher than those without Medicaid – and patients from varying social and ethnic classes [24]. Den-still well below the national average of visits for children tists and their patients differ in educational level, commit-with private dental insurance [20]. ment to oral health values, and in the "culture" of dental practice [6]. Dentists respond to patients in different waysAmong older adults, dental health problems are cumula- based on the patients characteristics [25-29]. This culturaltive and just as prevalent as in childhood. According to the divide sometimes leads to discrimination. TreatmentU.S. Census Bureau, nearly 35 million Americans were 65 selection and quality of care also depend on the character-years or older in 2003. Oral diseases in this group affect istics of the dentist-patient relationship [30].older adults who are economically disadvantaged, lackdental health insurance, and are members of racial and Receptionists – the gatekeepers of the dental office – areethnic minorities. Having a disability, being in an institu- also implicated in such discrimination. For example, Lam,tion, or not being able to leave the house also increase the Riedy, and Milgrom [31] found that staff members per-risk of poor oral health [2]. According to the 2003 Oral sonal connection to Medicaid-insured patients; staffHealth in America Report, "A State of Decay: The Oral members attitudes about Medicaid-insured patients; andHealth of Older Americans," about 30 percent of adults 65 staff members perceptions of Medicaid-insured patientsyears or older no longer have any natural teeth, which is a barriers to care affect Medicaid patients willingness tocondition that affects food intake and nutrition. seek dental care. An additional problem contributing to inequalities is the lack of preparation of dentists to treatDental benefit levels often increase only when state offi- children. Few dentists leave their training with as muchcials are sued by advocates for poor people. Head Start has skill and knowledge in treating children as they acquire inattempted to increase access but, lacking the ability to pro- treating adults. The majority of dentists refuse to see pre-vide direct services, is stymied in this effort by needing to schoolers.use Medicaid as its payment system. As for older adults,Medicaid provides limited dental insurance coverage for The nations dental schools largely have failed to recog-maintenance of oral health for persons with very low nize their own role in reinforcing disparities. Increasinglyincomes, but these programs inadequately address the the dental schools themselves reject Medicaid- coveredneeds of older adults with a disability, living without a patients, further institutionalizing this discrimination.primary caregiver, or in a nursing home. Programs such as the widely cited ABCD Program in Washington State have attempted to remedy this compo-Currently national statistics are not available to compare nent (that is, the problem with dental schools, or thethe utilization rates of dental care between children with underutilization problem?) of the disparity problem [32].and without Medicaid, or between older adults withMedicare and those without. Yet a recent cohort study that In addition to the difficulty of finding a dentist willing toinvestigates the effects of WIC participation on childrens take payment from Medicaid, patients with limited socio-use of oral health services in North Carolina showed that economic resources have to evaluate a whole web of fac-53,591 of all 81,518 live births were enrolled in Medicaid, tors associated with visiting a dentist; for example, theand about 12 percent stayed continuously enrolled during amount of time and money associated with one dentalthe first five years [21]. Children whose mothers partici- visit, the difficulty of finding reliable transportation, andpated in WIC for a full year were about 1.7 times more the problem of taking time off work [33]. Therefore, eligi-likely to have two or more dental visits per year than those bility for Medicaid insurance does not necessarily result inchildren who never participated in WIC [21]. patients enrollment, and enrollment does not ensure the availability, accessibility, and obtainment of needed den-Numerous explanations have addressed the under-use of tal care.dental services offered through Medicaid, including expla-nations that involve the rejection of patients with Medic- Patterns of under-use of dental care also emerge from cog-aid by dentists because of low and inconsistent nitive stereotypes and discriminative practices of provid-reimbursement rates, frequently failed appointments, and ers, patients, and the health-care system in whicha possible reluctance to treat patients whose dental prob- decisions about treatment are made [34]. Patient charac-lems may be complex and time consuming [22]. Related teristics (e.g., race, ethnicity, age, income, gender, maritalto this is the problem of recruiting dentists willing to serve status, amount and type of health insurance, educationpopulations living in remote rural areas or in urban areas level, cultural values associated with oral health, level ofthat are considered undesirable [23]. perceived disease burden, and disease severity) influence dental treatment and treatment decisions. Simultane- Page 4 of 17 (page number not for citation purposes)
  5. 5. BMC Oral Health 2006, 6:S4ously, provider characteristics, such as practice specialty, tive care, agreement among members of the joint house-practice style, attitudes, or bias about a patients race, eth- hold with respect to altering market opportunities, andnicity, gender, class, and social background, may influ- the amount of income forgone due to seeking treatment,ence the type and quality of service provided [35,36]. in conjunction with the expected expenses of dental treat- ment.A comprehensive review of empirical evidence hasrevealed that dental care, particularly care for patients Second, the individual must perceive the preventive meas-from vulnerable groups, is a complex process. A whole ure/medical service as feasible and efficacious such that itrange of factors contribute to under-use of Medicaid serv- would reduce the perceived severity of the dental condi-ices. On the patient side, cultural values, education, prior tion and would outweigh the gains from the associatedexperience with dentists, perceived value of dental care, psychological, physiological, monetary, time, and/orand access issues influence care seeking. On the dental other types of costs [40,49-52]. Alternatively,professional side, practitioners peception of poor Antonovskys salutogenic model emphasizes individualpatients, financial costs, time, and reimbursement issues sense of coherence (comprehensibility) as the primarycan influence delivery of oral care. mobilizing resource through which patients utilize their ability to deal with stressful events (manageability), andExisting Models of Oral Health Behavior and to possess the motivation, desire, and commitment toService Use cope (meaningfulness) [53].Although an extensive body of theoretical and empiricalliterature on oral health has been published, a compre- Third, the probability of a dental-care episode depends onhensive dynamic model explaining social disparities in the social interactional exchange nature of the patient-oral health has yet to emerge [25,37-41]. A thorough dentist relationship. As a variant of the behavioral model,review of all models goes beyond the scope of this paper. the social interaction model emphasizes the powerTherefore we discuss basic models of the use of dental dynamics among individual characteristics of the patient,health services. These models concentrate on dental serv- the provider, and structural characteristics of the health-ices rather than oral health disparities. care provider. During an episode of dental care, the den- tist occupies an authority position – the "gatekeeper,"Currently, our knowledge of dental care use is frag- who controls the flow of information exchange (e.g., con-mented. The most commonly applied behavioral and cern for the patients general health) and the extent tosocial interaction models include Andersons predispos- which the patient is informed of her/his dental needs anding, enabling, need model of health services use [42]; treatment options [25,54].Rosenstocks (1966) health belief model; Mechanics(1978) factors of sociocultural/psychosocial model [43]; Conversely, a patient may demand information regardingAntonovsky and Kats (1970) preventive dental behavio- treatment options and remedies from a dentist andral model [44]; Fishbein and Ajzens (1975) model of threaten to withdraw visits to that dentist. Similarly, den-belief, attitude, and intention [45]; Manning and Phelps tal health insurance providers, including government,(1979) model of the demand for dental care [46]; and the may withdraw options for various dental treatments,social exchange model by Grembowski et al. [25]. based on the imbalance of economic costs and potential rewards for the insurance provider or because of perceivedReviews of these models reveal several common themes short-term savings to government. A very good example of[25,46-48]. this phenomenon was reduction of adult Medicaid dental benefits in Maryland, resulting in higher utilization of theFirst, most behavioral models assert that an individuals hospital emergency room [55]. Hence, a dental visit,use of health services is a function of the perceived threat according to the social interactionist perspective, involvesof disease, past use of medical services, and perceived a reciprocal, dynamic flow of power among the dentist,value of action. In particular, the individual has to be psy- patient, and health insurance provider, based on costs,chologically ready to become aware of a symptom as a rewards, and level of compliance of the patient with theproblem and must then choose to visit a health-care pro- dentist and the health insurance provider.fessional as the appropriate action. A variant of the maintheme of the behavioral models is Manning and Phelps These basic psychosocial and social interactional modelsdemand model of dental care, which casts the demand of are useful in examining how individuals make decisionsdental care in economic terms of "demand" and "supply." in regard to visiting a dentist, and they have made impor-Within the context of household, dental care is a weighted tant contributions in clarifying the utilization of healthoutcome determined by income, price of treatment, time services. However, these traditional health belief modelscost, variables affecting tastes and preferences for preven- have notable limitations. First, they are biased in their Page 5 of 17 (page number not for citation purposes)
  6. 6. BMC Oral Health 2006, 6:S4emphasis on "rationality" – that is, patients are assumed nic minorities may come to rely mainly on their inheritedto act as rational agents capable of conceiving a symptom social referral system to avoid contacts with dentists lack-as a threat, and medical professionals are assumed to have ing the cultural competency to understand and appreciatethe ability to reduce this threat. Empirical studies have their distinct habitual and dietary practices. Similarly, eth-revealed only weak relationships between psychological nic minorities with language barriers may rely primarilyconcepts such as motivations, beliefs, attitudes, and opin- on their inherited community social networks when seek-ions with preventive dental health behaviors, particularly ing dental care to avoid cultural and language barriers.among vulnerable populations such as minority patientsand children in poverty [56,57]. Fifth, the social interaction models have responded to cri- tiques of the health belief model by placing more empha-Moreover, the health behavior models employ a very nar- sis on the reciprocal and interactional nature of therow focus on individual psychological states and ignore dentist-patient relationship. Empirical support for thisthe pivotal role of macro level influences – political econ- model, however, is sparse. Few empirical attempts haveomy, wealth distribution, and the unequal distribution incorporated both the health belief and social interac-and dissemination of new technology – along with the tional models in researching oral health disparities, par-possible interaction of macro and micro level factors. Oral ticularly in studying the underlying dimension of socialhealth is clearly situated within the larger framework of distance in relation to the cause of under-use among vul-political, economic, and cultural forces. Empirical quests nerable minority populations.to discover the connection among biological processes,social structure, and oral health disparities have generally Finally, most of the published models concentrate onfocused on measurable individual attributes (e.g., socioe- dental care as the major determinant of oral health andconomic background, past experience with dentists, and oral health disparities. Hay and colleagues, in an applica-the perceived ability of the patient to recognize his or her tion of the Grossman model described above, reportedown ill health conditions) and have ignored the larger analyses showing that number of dental visits had a nega-social and cultural contexts in which individual character- tive effect on the number of decayed teeth, demonstratingistics are defined. a beneficial effect of dental care [61]. Number of visits was related positively to oral hygiene but was not significantFor example, in epidemiological studies, socioeconomic statistically. These results must be regarded as tentative,status, or social class, is almost universally transmuted however, because of the studys small sample size. New-methodologically into attributes of individuals (e.g., house and Friedlander found no association between theincome, occupational status, educational attainment). prevalence of periodontal disease and an areas dentalSocioeconomic status is a multifaceted and historical phe- resources, measured by the dentist-population ratio, in 39nomenon defined and reproduced via social processes areas of the U.S. [62]. Weinstein and colleagues found noand power relations structuring materialistic conditions relationship between time spent with dental hygienistsand life changes over time. Few empirical oral health and levels of oral plaque and inflammation [63]. Moreo-models have made visible the contextual qualities in ver, education efforts toward patients were inverselywhich structural/political forces constrain and perpetuate related to the level of the problems presented. That is,processes of social differentiation in society, which subse- healthier patients received more attention, and patientsquently contribute to oral health disparities. with more problems received less attention [64].Fourth, these models fail to incorporate social capital fac- Dental care, particularly preventive dental care, is antors, such as a "lay-referral" system, in which individuals extremely important determinant of oral health inequal-share experiences and seek advice on their symptoms ity. Less is known about the broader social and culturalfrom family, friends, or relatives. In vulnerable popula- determinants that influence oral health practices, the val-tions, which often lack direct access to health-care profes- ues and beliefs about teeth, mouth, and face, and howsionals, social networks may have a strong influence that these values, beliefs, and practices vary across differenthelps individuals seek needed health care [58-60]. For social and cultural groups. Dental care and dental insur-example, a substantial proportion of ethnic minorities ance are not the major determinants of oral health dispar-live in enclave communities in which a distinct "collective ities [65]. Concentrating only on providing access tolifestyle" shapes local customs, values, norms, percep- dental care may detract from the more powerful effects oftions, and habitual practices (e.g., culturally specific food social stratification, power differentials, and the under-and personal hygiene practices), and few ethnic dentists standing of different cultures and their beliefs and prac-are available to provide adequate dental care. As cultural tices that contribute to oral health. Broadening the scopeperceptions are intimately tied to perceptions of the of the conceptual framework is intended to open the doordynamic power relations between dentist and patient, eth- to new and different channels for intervening, while rec- Page 6 of 17 (page number not for citation purposes)
  7. 7. BMC Oral Health 2006, 6:S4 INFLUENCES ON ORAL HEALTH AND ORAL HEALTH DISPARITIES Individual Status-Ascribed: Genetic, Ethnicity, Age, Gender Achieved:Education, Income, Occupation DISTAL INTERMEDIATE IMMEDIATE PROXIMAL HEALTH & WELL- BEING Macro Community Interpersonal Individual Individual & Population Status Natural Environment Physical Environment Stressors Biological Processes •Natural fluoride in water •Location of dental services •Dentist-Patient interaction •Host defense •Geography / Climate •Artificial water fluoridation •Homeless persons, persons •Streptococcus mutans •Sugar in environment cognitive impairment, HIV Health Outcomes e.g. Schools •Oral health Macrosocial Factors vending machines •Dentistry in health services soda and candy and public health •Political support for dentistry •Support for sugar and corn syrup Social Environment •Advertising Sugar Laden •School curricula Health Behaviors Products •Community education Social Integration and •Sugar consumption •Legal system and legislation •Community Practices Support •Alcohol and smoking Well-Being and •Social stigma •Community •Oral hygiene practice •Family and school Influences •Delay in seeking dental care Quality of Life Inequalities on oral health practice •Oral-related quality of life •Dental caries disparities Type and Use of •Oral Health Disparities •Disparities in opportunity Cultural Environment Services related to oral and craniofacial •Motivational interviewing •Importance of oral health conditions •Beliefs about oral health Infection transmission •Caries infection transmission Organization & •Periodontal Infection Individual Psychology Delivery of Services •Taste preference for sugar Access to Oral Health •Fear of dentists and dental •Supply of dentists •Number and distribution of Care treatment minority dentists •Access to dental care •Dental insurance •Preventive dental (flurodated •Reimbursement for caries toothpaste) treatment •School based services, e.g. •Technological diffusion screening and parent among dentists notification •Dental practice regulation Birth LIFE COURSE Death Based on Patrick and Erickson, 1993 and Schulz and Northridge, 2004Figure 1Influences on Oral Health and Oral Health DisparitiesInfluences on Oral Health and Oral Health Disparities.ognizing that professional care is necessary throughout These forces are arrayed according to the approximatelife to maintain good oral health and to benefit from evi- time sequence in producing oral health disparities:dence-based technological advances. • distal/macro level factors (e.g., natural environment,Toward a Conceptual Framework for Oral macro-social factors, social inequalities, organizationalHealth Disparities practices, and delivery of oral health services);Utilizing models from epidemiology and sociology [66-69], we identified a series of causal mechanisms through • intermediate/community factors (e.g., environmentalwhich institutional, political, community, and social forces, social/cultural context, access/utilization of oralinteraction factors contribute differential impacts on indi- health care);vidual oral health and overall quality of life. In Figure 1,titled "Influences on Health and Oral Health Disparities," • immediate/interpersonal factors (e.g., negative stressors,we propose a comprehensive conceptual framework that social integration, infection transmission);encompasses oral health as a dynamic process in which avariety of forces operate both to perpetuate and to reduce • proximal/individual factors (e.g., biological processes,social disparities in oral health. personal oral health hygiene practices, psychological state). Page 7 of 17 (page number not for citation purposes)
  8. 8. BMC Oral Health 2006, 6:S4At the bottom of the figure, the arrow indicates that the Intermediate/community factorsrelative contribution of these determinants varies across These factors include the physical, social, economic andthe life course from birth to death. Underneath the col- cultural environment of a particular community. Decisionumn headings (for example, DISTAL/Macro), the boxes makers wield power over services, such as transportationcontain selected examples in italics (Natural fluoride in and health care, land use, and access to a healthy environ-water) of different influences. These examples can be ment. At this level, public input can influence city andadded to by readers and researchers to customize the fig- county councils, school boards, zoning committees, andure to different influences and different disparities. medical boards. This level becomes important as citizens try to negotiate access to health care, education, transpor-Our framework outlines the multiple and dynamic path- tation, jobs, and social services. In wealthy communities,ways through which underlying political, social, cultural, individuals will likely have political and economic powerand economic forces influence oral health. Here is a brief to influence allocation of resources. Communities withdescription of each. fewer resources may experience greater social, environ- mental, and psychosocial stressors [74].Distal/macro factorsAt this broadest level, disparities are produced and repro- Immediate/interpersonal factorsduced by political, economic, social, and cultural forces. Immediate/interpersonal factors are the "mediating path-For example, in the United States, national policies, legal ways" within a community. Families, support groups, orframeworks, and social ideologies have created and per- other formal or informal networks may intervene to offsetpetuated unequal distribution of wealth, spatial segrega- distal/macro or intermediate/community factors. Fortion, and concentrations of poverty. Vulnerable example, a group of parents may ask a school board to setpopulations, including African Americans, Latinos and aside a primary grade toothbrushing time after lunch. Annew immigrant groups experience limited access to environmental group might organize an annual beachopportunities (e.g., jobs with medical/dental insurance, cleanup. Influences can be harmful as well. For example,which affect access to dental care). gang violence may cause a community to close a play- ground or a park. An antifluoridation lobby might workFor our purposes, macro factors include the allocation of to halt fluoridation plans for a communitys water supply.resources to organizations that perpetuate preferentialdelivery of oral health education and technologies. Private Proximal/individual factorsdentists are more likely to practice in urban metropolitan The focus at this level is the actions and beliefs of individ-areas with a high proportion of middle- and higher- uals who make up a community. Personality traits, moti-income residents than in rural areas. Currently, there are vations, values, and personal preferences come into play,no national statistics that describe the distribution of den- along with health needs. Genetic-environmental interac-tists by income areas. Instead, estimates are obtained per tion and organ function, use of community services, andstate. For example, Krause, Mosca, and Livingston (2003) individual psychology are considered. These individualfound that in Mississippi, with a high proportion of rural factors influence all other levels. For example, an individ-residents, approximately 40 percent of the licensed den- ual concerned about lack of affordable dental care mighttists practice in only two metropolitan areas – Jackson and encourage neighbors (immediate/interpersonal), his/herthe Gulf Coast [70]. As a result, 38 of the 82 counties in city (intermediate/community), and federal agencies (dis-Mississippi have 4,000 or more persons per dentist. Mertz tal/macro) to lobby for local low-cost community dentaland Grumbach (2001) investigated distribution of den- care or water fluoridation.tists by geographic areas with low socioeconomic levels inCalifornia [71]. Results showed that about 20 percent of Any or all of these levels of social organization can influ-California communities had a shortage of dentists. In par- ence dental health and dental care. At the proximal/indi-ticular, two-thirds of dentalshortage communities were vidual level, a child may become infected with dentalrural with high percentages of minorities, children, and caries. Bacterial infection is necessary but not sufficient forlow-income persons. developing dental cavities if proper care is available [75]. The child may be deemed eligible for Medicaid (distal/Dental insurance is often considered one of the primary macro factor) and receive care at a local clinic (intermedi-links to maintaining oral health. Empirical studies have ate/community factor). Health conscious caregivers mightrepeatedly documented lack of access to dental insurance schedule the child for regular checkups (immediate/inter-as a factor for widespread dental caries in young children personal factor), and parents might encourage daily tooth[72,73]. cleaning (proximal/individual factor). Page 8 of 17 (page number not for citation purposes)
  9. 9. BMC Oral Health 2006, 6:S4In summary, the emphasis in our proposed conceptual As early as the beginning of the 20th century, Alaskaframework is on the implications of broad social and eco- Natives traded furs and other goods for imports of tea,nomic disparities (macro/distal factors) for the social, flour, sugar, tobacco, ammunition, and other productsenvironmental, and cultural contexts (intermediate/com- that would eventually change levels of self-sufficiency andmunity factors) that influence interpersonal relationships transform local domestic economies. For the most part,(immediate/interpersonal factors), and ultimately affect communities provided adequate diets for families withindividual quality of oral health and oral-related quality foods taken directly from the local environment, eitherof life (proximal/individual factors). from the land or the sea. Following World War II, how- ever, the flow of goods, imported first via barge and boatThe varying plausible pathways in our proposed frame- and eventually by airplane, began to affect the relativework (distal/macro, intermediate/community, immedi- independence of rural villages.ate/interpersonal, and proximal/individual) may exertboth uni-directional and bi-directional "push" and "pull" By the 1970s and 1980s, dramatic increases in the con-forces on oral health. That is, negative factors at one level sumption of non-native foods had occurred. Such con-may "push off" or "pull in" other levels of factors. Though sumption depended on a shift from subsistence-orientedour graphic presentation may not capture all the interac- domestic economies to a wage-earning, mixed market-tions within and across varying levels of factors, we hope subsistence economy common to the rest of the Unitedit will offer an explicit picture to illustrate the complex States. This shift was accompanied by increased depend-inter-linkages among macro, meso, and micro phenom- ence on subsidies, and with these linked dependenciesena that affect individual oral health. came an increased flow of material goods into the local communities – especially such items as commercially pre-Applying the Conceptual Framework: Two Case pared and packaged foods, coupled with an already prev-Studies alent use of the imported foods mentioned above, and anTo illustrate the utility of our conceptual framework, we increased dependence on imported fuel. Diets onceuse two case studies involving minority populations to devoid of all but locally available meats, fish, eggs, greens,trace pathways through which social disparities intersect and berries suddenly were rich in carbohydrates and sug-with social, cultural, and political contexts to affect oral ars, which exposed children to a higher susceptibility tohealth and overall well-being. Each illustrates the interre- tooth decay [78]. Practices designed to deal with mainte-lated, overlapping process in which changes at one level nance of oral health as the result of this major diet shiftinduce counter-forces that may mediate/intervene, or per- simply did not exist. Traditionally, the occasional "badpetuate disparities in oral health [76,77]. tooth" was treated by a local person adept at pulling teeth. Dentistry as practiced elsewhere was unknown.Case Study of Oral Health in AlaskaAlaska Natives, particularly children, are disproportion- The problems persist today, compounded by the relativeately affected by oral disease. According to the Oral Health geographical isolation of tribal populations in AlaskaSurvey of American Indian and Alaska Native Dental (distal/macro factors). It is difficult to attract dentists toPatients (1999), tooth decay is five times more frequent remote areas on more than a peripatetic basis and evenamong Alaska Native children than among the U.S. aver- more difficult in extremely remote rural areas of Alaska toage population of children 2–4 years of age [77]. Seventy- establish sufficient tribal health facilities to provide regu-nine percent of Alaska Native children aged 2–5 years larly available treatment (intermediate/community fac-have tooth decay; 60 percent have severe early childhood tors). This is true despite intense recruitment efforts andcaries. Further, the prevalence of tooth decay increases offers of significant financial incentives to attract dentistswith a childs age. Approximately 99 percent of Alaska to Alaskas rural areas. According to a survey in 1999,Native youth 15–19 years old have at least one decayed Alaska tribal facilities have approximately a 25-percenttooth. vacancy rate of dentists and a 30 -percent average annual turnover rate [79]. The ratio of dentists to population is 1The most frequently cited significant factors for dental car- to 2,800, compared to 1 to 1,500 individuals in the gen-ies in Alaska are linked to distal/macro levels – economic eral population of Alaska [79,80]. The ratios understatechange, social disparities, and environmental isolation – the problem, because many communities are geographi-that impact the intermediate/community factor of access cally isolated, and dentists are concentrated in regionalto professional dental care. Distal/macro factors also centers, such as Nome, Bethel, Fairbanks, and Kotzebue,include the natural environment, geographic isolation, often hundreds of miles away from the rural communitiesand an unprecedented economic conversion to a market they serve.economy (which directly impacts dietary and culturalpractices). Page 9 of 17 (page number not for citation purposes)
  10. 10. BMC Oral Health 2006, 6:S4The Native Health Service has worked hard to overcome ers, the UW research team determined that some of thethe limitations of episodic and symptomatic care and to problems experienced may have been caused by research-institute preventive measures, such as fluoridation. Unfor- ers unfamiliarity with local cultural traditions regardingtunately, attempts to fluoridate rural water systems are concerns about chewing gum during pregnancy. One par-fraught with problems, and capable engineering and con- ticular cultural barrier appears to have been a fear thattrol staff are rarely available. In May 1992, an outbreak of chewing gum might harm unborn infants, and several vil-acute fluoride poisoning that resulted from inadequate lages declined to allow the researchers to distribute xylitolinspection of a water system affected almost 300 people gum to their pregnant women. Also, the women them-[80]. Thus, fluoridation of central water systems became selves often felt they could not make the decision to par-impossible. Topical fluoride programs have been insti- ticipate without discussion with other family members.tuted but are limited by the absence of trained staff in When they were approached at a regional center wheremany locales and the relative ineffectiveness of fluoride they went for delivery, the extended family was not avail-alone as a preventive strategy in the face of rampant tooth able for consultation, so researchers were once again sty-decay, carbohydrate-rich diets, and lack of oral hygiene. mied.Even the cost of fluoridated toothpaste, if it is available invillage stores, is double the price in the lower 48. Although the researchers made a concerted effort to pro- vide education and health care to potential participants,To address the disproportionately high rate of dental car- problems of communication manifested in an inability toies in young children in Alaska, the Northwest/Alaska establish trust in the villages. A more general lack ofCenter to Reduce Oral Health Disparities of the University understanding of cultural differences by both researchersof Washington launched the Caries Transmission Prevention and potential recruits brought a final halt to the study. Asin Alaska Native Infants Study (CTP) to investigate difficul- a result, it was not possible to determine whether the chlo-ties tied to previous studies of high prevalence of dental rhexidine/xylitol gum would have contributed to a reduc-caries in most communities [81]. The study goal was to tion in the high level of dental caries that afflicts Alaskadetermine if serial use of chlorhexidine mouth rinse and Native infants [81]. Dental caries among young infantsxylitol chewing gum would reduce the vertical transmis- remains a primary health problem of Alaskan children.sion of caries between 250 Alaska Native mothers andtheir infants. To reduce oral health disparities in Alaska Native popula- tions, oral health promotion programs will need toThe study protocol involved giving chlorhexidine rinses address cultural differences and collaborate more closely(alcohol free and previously shown to have an acceptable with communities to initiate acceptable education andtaste to Native Alaskans) and chewing gum containing intervention programs. Programs will need to movexylitol to pregnant female participants in conjunction beyond cultural and social barriers to implement cultur-with a program that would determine participant satisfac- ally sensitive care at the immediate/interpersonal leveltion with and efficacy of xylitol/chlorhexidine use. Oral and to eliminate the current gap between dental care pro-chlorhexidine is a widely available antimicrobial. Xylitol fessionals and patients. These efforts assume thatis a naturally occurring sugar available in the United States researchers can learn culturally-aware listening behaviors,and elsewhere in chewing gum and foods for diabetics openness to culturally inclusive ways to introduce possi-[82]. It is used widely as a sweetening substitute for ble oral health promotion and intervention programs tosucrose and fructose in Northern Europe because of its vulnerable communities, and culturally appropriatepreventive effect on dental caries[83]. Yet even with strong methods for alleviating community-level reservationsempirical evidence of xylitols preventive benefits, this about seeking dental care.technology is just beginning to be incorporated in den-tistry in the U.S. Participants were interviewed throughout High on the list of appropriate behavioral changes is thevarious monitoring time points regarding their percep- necessity for researchers to resist attempting to imposetions of xylitol use, dental caries, and preventive strategies "western ideas" on local communities. For example,to fight dental caries in young infants. researchers must set aside the habit of speaking quickly and without regard for those whose habits of conversingEarly into the study, however, significant problems of sub- may include lengthy pauses before answering questions.ject recruitment and attrition affected the collection of To gain long-lasting, trusting relationships, researchersdata, and ultimately the study was abandoned [81]. The will need to establish rapport both with local tribal lead-study also had been plagued by persistent problems in ers and with community members in face-to-face encoun-recruiting and maintaining local staff in the remote areas. ters, at the immediate/interpersonal and proximal/In spite of their previous experience in Alaska and the individual levels. A long-term horizon is needed.enthusiastic acceptance of the program by health provid- Page 10 of 17 (page number not for citation purposes)
  11. 11. BMC Oral Health 2006, 6:S4A new study is underway to investigate difficulties associ- particular, Hispanic children of all ages are twice as likelyated with the earlier project, to identify and explore to have untreated dental caries in their permanent teeth asunderlying causes of the difficulties, and to generate non-Hispanic white children [88].hypotheses for an alternative and more culturally sensitivemodel [84]. The primary goal is to use ethnographic The most frequently cited barriers to oral health care[qualitative] methods and approaches common to socio- among Latinos are related to distal/macro and intermedi-cultural research to reinvestigate the Alaska Native com- ate/community factors. Disadvantaged economic posi-munity perceptions of oral health, the priority placed on tions and immigration contribute to differential access toinfant/child oral health, and the fear levels associated oral health. Latino families experience substantial barrierswith oral health in general, and with the participation of to receiving dental care, including lack of dental insurancerecruited subjects in medical/dental research interven- (distal/macro factor), under-representation of Latinos intions in particular. Clearly, rapport, trust, and tribal coop- the U.S. dental work force (distal/macro level factor), anderation/collaboration and endorsement are necessary to cultural and linguistic obstacles (intermediate/commu-address community oral health issues. nity factors). For example, studies of the effects of accul- turation on oral health among Latino populationsUsing the conceptual framework as applied to this case consistently show that acculturation is a predictor of bet-study, social integration and cultural in-competency, in ter oral health, increased utilization of oral health serv-combination with distal/macro and intermediate/com- ices, and more positive self-rated oral health [89-91]. Inmunity level factors, "pull-in" increasingly negative effects studies, Latinos frequently cited language barriers as aof social and economic disparities in oral health. That is, deterrent to effective interaction between themselves andwhile the Alaska Native population faces the on-going health care providers. Latinos who speak primarily Eng-negative effects of economic and social changes, geo- lish at home were more likely to use dental health servicesgraphic isolation continues to contribute to lack of access than those who speak primarily Spanish at home [92].to oral health professionals (distal/macro factors→interme- Poor English skills create substantial difficulties and fearsdiate/community factors), and at the same time, social for Latinos, making them less willing and trusting towardopposition against the study (intermediate/community fac- dental care professionals. In short, due to unequal distri-tor) contributes to its failure. Social opposition was par- bution of wealth, lack of access to health-care insurancetially related to a lack of cultural competency of the (distal/macro factor), cultural barriers (intermediate/researchers, who were unfamiliar with the local circum- community factor), and a language barrier (proximal/stances of each participant community and unable to individual factor), Latinos are less likely to make regularaddress concerns over traditional tribal beliefs about gum visits to dentists, or to attend to tooth decay. Some Latinoschewing during pregnancy and other concerns growing may also fear that using public health programs couldout of the traditional cultures (immediate/interpersonal expose them to harassment by immigration authoritiesfactor). Until an effective health intervention program (distal/macro factor). One of our researchers (PM) con-addresses the distal/macro and immediate/interpersonal ducted a preventive dental screening and topical fluoridebarriers, economic, social, and environmental disparities program in a church in rural Washington State only to bewill continue to negatively impact the population. told afterward that the federal governments Immigration and Naturalization Service swooped down on the popula-Oral Health Among the Latino Population tion served as they left the church hall.Latinos, the nations largest minority group, have thehighest rate of untreated tooth decay and the lowest level To reduce oral health disparities among Latinos, oralof dental visits of all racial and ethnic groups in the United health intervention programs will need to develop cul-States [85]. According to 1988–1991 data from the Third tural and language intervention programs at the interme-National Health and Nutrition Examination (NHANES diate/community level. At that level, oral healthIII), Latino children receive few preventive services; for interventionists can begin to build culturally competentexample, only 10 percent of 8-year-old Mexican-American dental homes, which offer culturally relevant, specificchildren received sealants, compared to 29 percent of dental health information for new immigrants and youngnon-Hispanic white children [86]. Mexican-American children. Latino patients, with a low level of English lan-adults experience tooth decay disproportionately as well. guage skills and high level of fear, need to interact withThe percent of untreated oral disease for Mexican-Ameri- Spanish-speaking, culturally competent health care pro-can adults was 40 percent in 1991, compared to only 24 fessionals. Dental outreach clinics may coordinate effortspercent for non-Hispanic whites [87]. According to the with local community centers to deliver services to newNational Health Interview Survey (1999), Mexican Amer- immigrants who lack access to dental insurance. In partic-icans, Cuban-Americans, and Puerto Ricans visited the ular, oral health information in Spanish is needed todentist less frequently than did non-Hispanic whites. In reach recent immigrants who fear dentists and health care Page 11 of 17 (page number not for citation purposes)
  12. 12. BMC Oral Health 2006, 6:S4professionals. Emphasis should be on oral communica- Both studies lead us to conclude that oral health interven-tion (in Spanish) instead of written health information. tions must begin to permeate all levels – distal/macro, intermediate/community, immediate/interpersonal, andImplications for a New Direction proximal/individual – in order to induce effective strate-The structure of our conceptual model has explicated the gies for the elimination of disparities in oral health. Theprocess in which environment, economy, social context, following section proposes interventions at each level.cultural practices, social integration, individual factors,and biological factors influence oral health. Our model Interventions at Each Levelhas incorporated aspects of the traditional health belief Distal/Macro levelmodel and the social interaction model. Within the con- Current inequalities in oral health (for example, differen-text of the traditional health belief model, we recognize tial access to oral health care and discriminative practicesthat ones health beliefs reflect a process of rational deci- of the health care service providers) must be redressed atsion making, based on the severity of the oral illness, past the distal/macro level if the U.S. is to move toward equal-experience with dentists, and the potential costs and ity in oral health care.rewards of a dental visit. In relation to the social interac-tion model, we acknowledge that an episode of dental Nationally, political parties and lobbying efforts dictatecare is an on-going interactional process in which dentist, distribution of resources. Social groups with morepatient, and oral health service payer all influence the resources are better equipped to negotiate and bargain fornature of the social exchange. goods and services than social groups with fewer resources. Minorities or recent immigrants are less able toWe have responded to critiques of both the traditional use their political rights to activate structural and politicalhealth belief model and the social interaction model by support to fight violent crime, ensure medical and dentalcombining both models and incorporating a new aspect services, and ensure human rights. Moreover, socialin which we emphasize the interrelated dynamic nature in groups with fewer resources may be less likely to questionwhich social processes both influence and are influenced the unequal distribution of wealth and power, therebyby various aspects of factors embedded in our model. Cul- increasing their vulnerability to discrimination and une-tural and social processes may directly influence commu- qual treatment.nity norms and individual behaviours. In terms of dentalcare, a dental visit requires not only a patients self recog- In our opinion, to combat disparities in oral health andnition of a dental illness, but also social exchange between other health and social disparities, we need a "structuraldentist and patient. The main contribution of our concep- readjustment" in the political process that allows alltual model is that we emphasize both the "pull" and members, regardless of social status, equitable access to"push" forces of each of the social processes in which political power to achieve equal access.social inequalities are produced and reproduced. Oral health is intimately tied to national (distal/macro)Our case study of the Alaska Native population has eluci- policies. Policies that promote opportunities for the lowerdated how previous experience and ones health beliefs class may also reduce health risks and financial barriers toare conditioned by ones immediate relations to family, dental care [25]. We cannot adjust for equitable access tocommunity, and to the overall structural forces of society. dental care without addressing the political and economicIn addition, we have discussed structural factors as a sig- processes that cause poverty and disparities in oral health.nificant influence on oral health. For example, the most Financing for better education and installation of familycrucial problems in the Alaska Native population are wage policies are fundamental to improving opportuni-related to the geographic isolation of communities and ties for all.their cultural practices. Thus, given that this geographicisolation is unlikely to be altered in the near future, oral Programs that reduce discriminative practices andhealth workers will need to redouble their efforts to increase multicultural awareness are crucial to a stableunderstand Alaska Native cultures and to develop cultur- economy in which all social groups may benefit. Discrim-ally sensitive and appropriate efforts to target the dispro- inative practices that permeate the dental setting willportional spread of oral health disease among young require effort from medical and dental associations inchildren. Similarly, our case study on Latinos pointed to order to bring forth effective measures. For example: Elim-structural and immediate factors – limited access to dental inate discriminative practices of dental professionals: Dentistryhealth insurance, cultural and language barriers, and fear literature has consistently indicated negative attitudes– as the primary forces leading to high rates of oral health towards poor people. Oral health intervention effortsdisease. must address this cultural gap by improving dentists awareness of minority cultural values and practices. Mul- Page 12 of 17 (page number not for citation purposes)
  13. 13. BMC Oral Health 2006, 6:S4ticultural studies could be incorporated into the dental countries for dental therapists, and the limited independ-school curriculum and students could begin to work with ent practice of hygiene lacks integration into a coherentskilled medical interpreters before graduation. The Amer- system. Nevertheless, with proper training, a new focus,ican Dental Association could organize conferences to and deployment to underserved areas, dental hygienistsaddress multicultural issues in order to narrow the cul- might play a role in reducing inequities. The organizedtural gap between dentists and patients. dental profession opposes such practices because the cur- rent system of deployment of dental hygienists asImprove financing for Medicaid patients and dentists employed production workers in affluent private practicesOne of the most important causes of under-use of Medic- is highly profitable.aid has been its rejection by dentists because of low feesand inefficient reimbursement systems. Yet, often the pro- The bottom line for reducing oral health disparitiesfessional associations themselves have failed to place bet- through dental care is likely to be no different from theter funding for Medicaid at the top of their political challenge for health disparities in general. Many Europeanagendas instead claiming their political action commit- nations have incorporated health care as a centralizedtees are impotent to change state-based policies. The net national policy, in which all members receive equal accessresult is that low-income patients, even with Medicaid, are to care, including dental care. As one of the wealthiestunable to find dental care. These structural barriers can be countries in the world, why cannot the U.S. also afford toreduced by increasing Medicaid reimbursement fees, adopt a centralized system of health care?improving the efficiency of payment schedules, expand-ing the types of dental treatment options, and encourag- Intermediate/Community Leveling dentists to participate in Medicaid programs. The will At the intermediate/community level, health insurance isto find the opportunity for these structural changes is generally delivered as part of employment benefits. How-required. ever, many low wage earners are unable to receive dental or medical insurance due to low number of work hours.Expand Public Health programs The distribution of health care is intimately tied to the dis-Public health programs are an important vehicle for tribution of employment opportunities. In the public sec-improving oral health among the poor. These may tor, employment decisions are based on bureaucraticinclude expanding fluoridation programs in poor neigh- procedures that account only for applicants skills andborhoods and expanding the use of dental health care qualifications, irrespective of gender and race. However,teams. Fluoridation benefits everyone who drinks from in the private sector, hiring practices may include reliancethe water supply irrespective of their own resources or on lay referral systems, such as internal networks. Dis-behavior, which means that socioeconomic gradients in criminative practices may include use of referral systemsoral disease are blocked and everyone benefits equally that exclude members of certain social groups based on[93,94]. In New Zealand and many other countries, dental stereotypes. To reduce oral health disparities at the inter-therapists have been trained to provide comprehensive mediate/community level, we need to first examine theprimary care to school children [72]. The training curricu- differences in hiring practices and evaluate how theselum for New Zealand dental therapists consists of two aca- processes may be altered.demic years, both of which are 32 weeks long. Thesetherapists provide a full range of care for children in Alternative delivery systemsschool-based clinics. The Alaska Native Tribal Health The current oral health delivery system is bifurcated.Consortium, under the provisions of Native sovereignty, Patients with medical and dental insurance seek treatmenthas deployed an initial group of New Zealand-trained at private clinics; patients with Medicaid attend publictherapists in rural villages. The American and Alaska Den- health clinics. (Most are turned away from private dentaltal Associations are vigorously opposing this move. Efforts offices.) To adjust the bifurcated system to a moreto establish a training program and further deployment in dynamic system, dentistry must allow for alternativethe U.S. also have incurred strong resistance, including delivery systems, such as retail dentistry, mobile dentistry,lawsuits and attempts to get Congress to ban the practice, independent practice of dentist hygienists, and deploy-even though the therapists are trained to work in collabo- ment of dental therapists.ration with dentists, and the integrated system in whichthey all work allows for referral of problems to dentists Expand current systemsand specialists in regional centers or to the Alaska Native Access to dental care for the poor can also be in increasedMedical Center in Anchorage. by expanding the number of public dental clinics and pri- mary care programs in the community [69]. At commu-Training programs for dental hygienists in the United nity dental clinics or community dental homes, childrenStates also lag far behind the types of programs in other and low-income parents can request and receive informa- Page 13 of 17 (page number not for citation purposes)
  14. 14. BMC Oral Health 2006, 6:S4tion and education about the importance of oral health, Proximal/Individual Levelwhich in turn can help instill good oral health hygiene Health disparity interventions at the proximal/individualhabits. Furthermore, community health clinics are staffed level, when carefully applied, can reduce stressors and oralby local community members, who are equipped to health disparities. Individual intervention efforts mayunderstand and comprehend distinct cultural practices in include the following:the community and to aid in reducing the cultural gapbetween dentists and patients. In ethnic enclave commu- -Learning to practice oral health hygiene to help fight bac-nity clinics, new immigrants may also rely on translators teria and maintain good oral health.for help in communicating with dentists and other healthcare professionals. -Visiting dental offices or dental clinics and then transfer- ring newly-learned knowledge to family and friends.Community collaboration and mobilizationCommunity-organized efforts are intimately tied to how -Introducing fresh produce and nutritional supplementsresources are allocated in society. Citizens can influence into the family diet and limiting sugar intake.zoning policies and can tap into resources to build goodschools, recreational facilities, parks, and community Action at All Levelscenters. That is, community-organized efforts can "push The underlying themes for interventions at all levels areback" forces that contribute to unequal access and subse- financial support, structural change, conscious effort, andquently induce change at the proximal/individual level. education. All involve conscious effort. That is, successfulFor example, a community may demand changes to zon- interventions and policy efforts must incorporate a fun-ing policies in order to promote financial investments demental-social-cause approach with contextually popu-such as a business district, supermarkets, and banks. lation based health interventions that automaticallyAccess to a healthy neighborhood can decrease residents benefit everyone, irrespective of their socio-economic sta-personal stress levels by providing such amenities as fresh tus, resources, or behaviors. In the United States, interven-produce, safety, and good schools. tions must be organized and priortize to people at all socioeconomic levels, with a specific target to address theCommunity efforts can begin to improve oral health via special needs of resource poor groups who may face obsta-coordination with already existing school and community cles and barriers in implementing health interventions.programs, such as Parent Teacher Student Associations Hence, we need to promote policies that promote the elu-and local community centers. Promotional and preven- cidation and elimination of SES gradient across popula-tion efforts may be incorporated into school curricula, tion groups – via increases of the socioeconomic resourcesconcentrating on good oral hygiene via school- and com- available to resource poor groups [93]. The following rec-munity-based programs. These programs can improve ommendations recommend action at all levels:social integration and encourage parents, teachers, nurses,and community leaders to facilitate, educate, and share Financial supporthealth information. Dentistry needs financial resources to expand delivery services, improve Medicaid reimbursement, increase edu-Community information campaigns that stress health lit- cation, and reduce poverty at the societal level. Theseeracy can bring attention to the problems of untreated interventions all require efforts by federal and state gov-tooth decay among the poor. Low-income wage earners, ernments to launch new social policies and allocate fundswho lack access to dental insurance, need to receive infor- to reduce social disparities (which contribute to oralmation regarding the benefits of Medicaid and of attend- health disparities).ing to their health care needs. Patients fromdisadvantaged social groups often want to have informa- Structural changestion regarding their health status [95]. They often need to Only when structural problems, such as the political proc-know how to recognize signs of tooth decay in young chil- ess in which social groups coordinate efforts with interestdren. This important oral health information may come and lobbying groups, are fundamentally altered, can pov-from community health care professionals who already erty be mitigated. It is unlikely that such structural read-have a close relationship with local residents, and who justment will be realized in the near future. Interventionsmay also be able to eliminate language barriers. In areas may yet develop to improve the Medicaid insurance pro-that lack community health care professionals, new pro- gram. Expansion of dental health facilities and Medicaidgrams must be developed to address the problem of lack insurance for vulnerable populations, are important com-of access to oral health information. ponents of oral health. Patients from disadvantaged back- grounds may need to be able to find dentists willing to accept Medicaid insurance and treat their dental disease. Page 14 of 17 (page number not for citation purposes)
  15. 15. BMC Oral Health 2006, 6:S4Interventions to increase dentists participation in Medic- dental professionals will have a chance to carefully eluci-aid are basic to increasing and improving care to its cov- date and effectively eliminate underlying factors thatered population. Programs to motivate dentists to treat cause and drive social disparities in oral health.Medicaid patients, such as the ABCD program in Wash-ington State, have demonstrated success at increasing the Competing interestsnumber of Medicaid providers. The author(s) declare that they have no competing inter- ests.Children living in poverty are likely to have limited accessto dental care. Improvement of Medicaid insurance pro- Authors contributionsgrams with acceptable reimbursement rates may encour- All of the authors contributed to this review.age more dentists to accept patients with Medicaidinsurance. Studies have shown that increased reimburse- Acknowledgementsments increase the number of patients per dentist, but We acknowledge the assistance of Jackie Stein and Justin Coyne of thethese increases can also bring new dentists into the Med- Northwest/Alaska Center to Reduce Oral Health Disparities. We areicaid field [10]. Educational programs designed to grateful to Dr. Clemencia Vargas for reviewing the case example on Latino dental health disparities. We appreciate advice on the project by Dr. Shirleyincrease the skills of dentists to effectively treat children Beresford and Dr. Colleen Huebner. The work was supported in part byare needed. Grants No. R13DE015798 and U54 DE14254 from the National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD.New TechnologiesDental professionals are important agents who directly Referencesinfluence the prevalence of dental caries. They are also the 1. 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