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

Mary J. Lomax-Ghirarduzzi, EdD

ABSTRACT

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

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

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

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

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

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

AUTHOR

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

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

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

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

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

A History of Exclusion

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

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

The U.S. Hispanic/Latino population is the second largest racial ethnic group in the country 3 and is expected to grow steadily over the next 20 years to become the largest population in the nation.

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

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

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

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

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

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

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

The differences in health experiences and health disparities by gender, ethnicity and social class are well documented, including among Black, Hispanic/Latinx and Native American/ Indigenous populations. 7 Nearly as soon as information about racialized outcomes was available, health professionals and researchers began to describe the disproportionate impact COVID-19 had on vulnerable and marginalized populations, specifically among people of color (Black/African American, Asian American/Pacific Islander and Hispanic). Analysis of the intersectional race and gender data reveals a disproportional impact. COVID-19 affected women of color by infecting them and affecting their communities at a higher rate than other populations.

The type of employment a person engages directly affects their access to affordable, high-quality health care. Immigrant women of color in the U.S. are overrepresented as front-line and low-wage workers in the U.S. Their informal labor is invisible to most, as they labor behind the scenes within servicebased industries such as elder care, adult care, child care, janitorial work and food preparation. Immigrant women of color also are in consumer-facing industries such as fast-food restaurants and hotels, which puts them at greater risk of contracting the virus. Women of color who are employed on the frontlines of face-to-face labor services or informal labor environments like cleaning services and factories exist even further at the margins of society and away from reliable health care. Women of color, specifically immigrant women of color, are the lowest wage earners in the nation, 10 and they do not have equal access to oral health care. A lack of health care insurance prevents them from accessing oral health care.

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

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

Interdisciplinary and Critical Theoretical Frameworks

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

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

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

Informed by cultural humility theory, critical race theory and restorative justice theory of change, the following interdisciplinary and multi-critical approach to diversity, equity and inclusion is offered for dental and oral health care educators, clinicians and policymakers to help solve BIPOC access to dental education and can also help improve the benefits of oral health care for marginalized BIPOC communities.

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

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

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

Recommendations and Next Steps

Any investments to advance diversity, equity and inclusion by dental educators, oral health care providers or professional dental associations must pay close attention to the role of race, racial inequality and access in these professions and in improving access to care for all. 1 Indeed, in following the principles that are fundamental to the work of oral health practitioners, racial equity in each of these realms — education, health care service and professional associations — is perhaps the most pressing need in dentistry and oral health today. Furthermore, identifying which groups are being underrepresented and recognizing the impacts of this exclusion on BIPOC students, BIPOC oral health care professionals and BIPOC communities is imperative. The Integrated Humanizing Theoretical Framework guides dental educators and oral health care leaders through a deep inquiry into the oral health care profession. The framework offers a nuanced lens through which to examine and address how unequal and unfair historical precedents targeting certain groups engender persisting unequal and unfair repercussions in dentistry and oral health care professions.

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

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

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

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

■ Crystallize the concept of DEI within the field of oral health care by adopting it into the jargon: Incorporate DEI into the language of the ADA’s Principles of Ethics and Code of Professional Conduct as well as CODA’s accreditation standards to perpetuate a “trickledown effect” across the profession.

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

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

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

■ Offer DEI audits through professional dental associations and center the voices of BIPOC oral health professionals. Collect data and gather narratives about their experiences and perspectives as students, dentists, educators and clinical leaders. The American Student Dental Association (ASDA), for instance, serves as a dynamic platform for such information gathering through its rich offering of “Diversity and Inclusion Resources” as well as its “Diversity and Outreach Blog Posts.” 20 Document any themes, patterns and gaps that surface through this growing pool of information about BIPOC members of the oral health professions.

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

■ Ensure that all appointed and/or elected leaders have appropriate DEI education as part of the requirement for service to their profession. Develop leadership practices, approaches and mindsets committed to the principles of an integrated humanizing approach for racial equity from the top down. Policy bodies are critical stakeholders, as they set the strategic direction and make decisions on matters of policy and practice at both the state and national levels. These bodies include boards of directors, delegates, standing committees, editorial boards and membership at large.

Anticipating Difficulty, Navigating Change

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