31 minute read
Improving Access to Care and Patient Experience Through Diversity, Equity, Inclusion and Belonging
Elisa M. Chávez, DDS
ABSTRACT
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Background: California is one of the most ethnically, racially, linguistically, geographically and economically diverse states in the country. Intersecting and unrelenting challenges of cost, location, language, literacy, marginalization, age and disability can result in mistrust, avoidance of care, challenges in diagnosis and poor adherence manifested in poor outcomes and disparities in care.
Studies reviewed: Data from the most recent National Institute of Dental and Craniofacial Research “Report on Oral Health in America” as well as current information and, in some cases, lacking national or state information about disparities in oral health care are presented here to better understand the complex challenges that prevent individuals and populations from accessing even basic preventive care and information.
Results: Poverty, minority status, employment status, insurances status, educational attainment and dependence greatly impact the risk for oral disease, oral health status, the ability and resources to access care and outcomes of oral health care once received.
Practical implications: Proactive patient assessment and care, increased public awareness and new paradigms in practice, education and workforce that directly address persistent, systemic and systematic challenges experienced by patients seeking and needing oral health care are needed and possible.
Keywords: Diversity, equity, inclusion, belonging, disparities, poverty, oral health, disability, access
AUTHOR
Elisa M. Chávez, DDS, is a professor in the department of diagnostic sciences and the director of the Pacific Center for Equity in Oral Health Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. She graduated from the University of California, San Francisco, School of Dentistry and earned her certificate in geriatric dentistry from the University of Michigan, Ann Arbor. She has practiced in private practice, community health, long-term care and hospital settings. Dr. Chávez developed and directs extramural student rotations at On Lok Lifeways, a program for all-inclusive care for elders (PACE) in San Francisco. She is an advocate for the oral health needs of older adults nationwide. Conflict of Interest Disclosure: None reported.
California is the most populous state in the nation with almost 40 million people and one of the most ethnically, racially, linguistically, geographically and economically diverse states 1–6 (TABLES 1 and 2). As a result, social determinants of health, intersectionality, access to care and expectations for oral health vary greatly among individuals and populations across the state and even within counties and cities. Disparities in oral diseases have persisted for some individuals over entire lifetimes and within some populations for generations. The FDI World Dental Federation defines oral health as “multifaceted, including the ability to speak, smile, smell, taste, touch, chew, swallow and convey emotion through facial expressions with confidence and without pain, discomfort or disease; it is fundamental to physical and mental health and well-being; it exists along a continuum, influenced by the values and attitudes of people and communities; it reflects the physiological, social and psychological attributes that are essential to the quality of life; it is influenced by the person’s changing experiences, perceptions, expectations and ability to adapt to life circumstances.” 7 Given the significance of oral health as represented here, it is clear that persistent disparities in care and unmet oral health needs have significant economic and health consequences for individuals and communities that can accumulate over lifetimes and generations.
The federal government classifies certain groups as being at higher risk of marginalization and concomitant health issues but these issues of marginalization and discrimination are rarely a one identity issue: age or gender or race or sexual orientation or ethnicity or socioeconomic status. 8 People, like oral health, are multifaceted and can describe and identify themselves in many ways. Society can also describe and define them in many ways, and their environments may support or suppress them. 8 Societal norms will guide whether there is acceptance for the identities they carry; the local economy will determine their opportunities for education and work and adequate insurance and salary to afford dental care; geography will determine the density or scarcity of dental providers; and all of these will feed into not only their access to care but their health literacy and perceptions about the value of oral health. This intersectionality — the intersecting effects of discrimination and structural inequalities directed at the various identities someone may carry — can significantly impact health and well-being. 8 An individual might experience this in many ways, impacting their ability to maintain good oral health over their lifetime. So as an example, a young girl who has been poor receives a marginal education and becomes a working poor adult woman who loses access to dental care she had as a child through the Affordable Care Act (ACA) or the Children’s Health Insurance Program (CHIP). And perhaps having faced some challenges in her work and limited upward mobility as a result of bias toward her as a woman with limited education, she finds herself with limited access to oral health care as an adult. Then as an old woman, with new biases fueled by ageism, she is possibly viewed as less in need or less deserving of oral health care at this time in her life. These examples are not to suggest that these barriers cannot be overcome, but that as practitioners we are challenged to see patients without the biases we may carry without even being aware, and as a profession we are tasked to identify and remove barriers to the benefit of all individuals and communities.
This paper identifies issues of disparities in access to care and outcomes along racial, ethnic and socioeconomic lines across all ages in the general population. The paper then highlights specific populations that suffer disparities in access and care as discrete groups, which can be further exacerbated by issues of race and class and other social determinants of health with significant impact on the individuals who are reflected in the data. The most recent data from the National Institute of Dental and Craniofacial Research (NIDCR) report on “Oral Health in America: Advances and Challenges” and other national studies are presented in the absence of more recent state data. Current California data on oral health status across ages are limited, with the most current report being a 2017 report on oral health from the California Department of Public Health based largely on data from the prior decade. 11 Other recent studies on oral health status, insurance access, workforce and utilization are also described.
Disparities in Oral Health: Where and for Whom Do They Occur?
Children and Adolescents
According to the NIDCR’s report, the greatest improvement in untreated tooth decay in primary teeth has occurred in children aged 2-5 years in the U.S., with caries experience decreasing from 19% to 10% conservatively. For children aged 6-11 years, caries in permanent teeth also has declined significantly from 25% to 18% since the 2000 “Oral Health in America: A Report of the Surgeon General.” Caries experience in children was significantly impacted by income with higher rates to start and much less decline for those with lower income — 28% to 24% for low income and 22% to 13% for high income over the last 20 years. This disparity has persisted despite efforts to achieve equitable access and outcomes for all children. There has been progress in the prevalence of at least one sealed permanent molar in children aged 6-8 years, which increased from 14% to 31% with Mexican American children. Children living in poverty achieved the largest gains of almost five times resulting in a near elimination of this health disparity in prevention among poor and Hispanic children. The prevalence of dental sealants among children aged 9-11 years also increased, from 29% to 53%. Children with unmet oral health needs are at risk for nutritional deficiencies, missing school days and difficulty with school work as well as acute pain and infection that is largely preventable with measures such as sealants and routine dental care. Improvements for children have been attributed to improved access to care as a result of the ACA and CHIP.
Improved oral health has not been observed in adolescents, those aged 12-19 years. In particular, there has been no significant change in dental caries, and the highest rates have been documented among Mexican American children at 69%. Disparities between Mexican American and non-Hispanic white adolescents as well as across those with lower income compared with higher income has increased. Disparity between non-Hispanic Black and non- Hispanic white adolescents declined. Untreated tooth decay in this age group has declined overall about 3% but caries remains most prevalent among adolescents living in poverty. Almost a quarter of adolescents living in poverty have caries. Approximately 40% of American Indian/Alaska Native (AI/AN) teens aged 13-15 years have untreated tooth decay. Immigrants, LGBTQ+ (lesbian, gay, bisexual, transgender, queer and other sexual identities and orientations), homeless, those living in health professions shortage areas (HPSA) and those in the juvenile justice or foster system are at greatest risk for poor oral health outcomes.
There have been substantial gains for all adolescents who have received a sealant on at least one permanent molar during this developmental period. This has increased from 18% to 48% for all. This includes significant gains for non-Hispanic Blacks by nearly 30% and by 36% for Mexican Americans. For all of those living in poverty, this has increased more than 30% from 12% to 43%. Other gains in prevention have been made as well. In 2018, half of U.S. adolescents aged 13-17 years were fully vaccinated, with 68% having received at least one dose of the HPV vaccine, which is important in the prevention of oral cancers. Oregon recently became the first state to change its regulations to permit dentists to provide vaccines, including the HPV vaccine, representing one way in which dentists may improve outcomes of care for patients if more states allow this change in scope of practice. This could impact not only children, but older adults who receive regular series of vaccinations to prevent diseases such as pneumonia, shingles and COVID-19.
New challenges for oral health have arisen for adolescents in last 20 years, with e-cigarettes presenting a significant risk for adolescents and young adults. Use increased from 1.5% to 27.5% between 2011 and 2018 among U.S. high school students and rose nearly 10% to 10.5% among middle school children. 10 A 2013-2014 study found that 24.4% of California middle and high school students participating in the study had used e-cigarettes. 12 This is compared with 15.6% who had ever used tobacco or smokeless tobacco. Further, Hispanic students who had never used tobacco products were more likely to use e-cigarettes than non-Hispanic white students.
Adults 18-64
The average number of teeth for adults in all economic groups has increased by 50% since the 2000 surgeon general’s report. 10 However, 20% of adults aged 18-64 years living above the poverty level in the U.S. have untreated caries, which increases to 52% among those who are poor. Having dental insurance improves access to oral health care but recent data show that more than 25% nationally and 21% in California in this age group do not have any dental insurance. Nationally, approximately 50% of those with insurance, 20% of those with public dental insurance and 17% without insurance had a dental visit in the last year. Twenty percent of working-age adults reported that they needed dental care but could not afford it and were more likely to delay needed care due to cost compared with other types of health care including purchasing prescription drugs.
When California’s Medi-Cal dental program eliminated adult dental benefits in 2009, there was a significant increase in the use of emergency rooms for nontraumatic dental emergencies. Emergency room care is expensive and rarely definitive. In the absence of definitive care, patients may be forced to return to the emergency room multiple times without resolution. Palliative care could include repeated use of antibiotics and/or narcotic pain relievers in the absence of definitive care, contributing to risks for antibiotic resistance and substance dependence adding significant risks to lives already rife with risks to health. 10 Young adults, minority groups and residents from urban areas were disproportionally represented in the estimated 1,800 additional emergency room visits per year across the state when this lapse occurred. A study of the California Emergency Department Database from 2005- 2011 found that a third of those using emergency rooms for dental emergencies were uninsured and the percentage of patients enrolled in Medicaid who used those services increased to a third in 2011 as well. 15 Other studies around the country and those looking broadly at national data showed time and again that these populations are most likely to seek care in hospital emergency rooms, although some studies reported increased use in rural rather than urban areas. 16–18 A nationwide study looking at emergency room data from 2010-2017 found more visits by those aged 15-20 years, the uninsured, those with Medicaid and those from less affluent ZIP codes. This study did demonstrate that there was a reduction of ER visits by children following implementation of the ACA. However, poor children were taken to the ER for treatment more often than those who were not poor, indicating that while insurance is of help in access and utilization, it does not tell the whole story; 19 there are many more barriers to care for marginalized groups that must be countered in order for people to receive appropriate care in appropriate settings with the appropriate provider.
Adults 65 and Older
The fastest rates of growth among older adults in California will occur among Latinos (170%) and Asians (118%), and no ethnic group will be a majority of the senior population. Since 2020, the fastest growth among older adults in California has occurred among adults aged 75 and older. The over-85 group will have increased 61% since 2012 to 2030. Approximately 1 million of California’s ~6 million adults aged 65 and older require assistance with one or more activities of daily living (ADLs) such as eating, bathing, dressing or doing chores, and the number of these older adults with disabilities is estimated to increase by 160% from 2015 to 2060. 20 Projections show that by 2030, nearly 20% of older adults will be childless and therefore more reliant on nonfamilial sources of care. In 2016, 16.9% of adults aged 65 and older in the U.S. required long-term care and 9.1% required some home health care. Those who live in long-term care are more reliant on others for self-care, have multiple concomitant chronic diseases and are at greater risk for oral diseases than most community dwelling older adults, except those who are bound at home or qualify for home health services.
Older Californians are anticipated to live more years than the national expected average for those requiring assistance with two or more ADLs. As a result, there will likely be increased and prolonged risks to their oral health and challenges accessing oral health care compared with older adults in other parts of the country. These issues can present significant challenges for patients seeking care. Whether these occur as a result of normal age-related changes like those in hearing, vision or as a result of disease, practices can be more accessible for those with these disabilities. While there are specific Americans with Disabilities Act (AwDA) requirements to make offices accessible, additional steps can be taken to be sure that spaces are well-lit and free of distraction and have clear and frequent signage, chairs that are more ergonomically friendly for those with mobility issues and available handrails.
Edentulism has decreased from about 32% to 17% in the last 20 years, but those living in poverty are three times more likely to be edentulous. Edentulism rates differ greatly by state, ranging from 26% to just 6%. 10 A 2016 report showed 19% edentulism overall in California, but when broken down by ethnicity, 15% of Hispanic, 17% of white and 29% of Black Californians had no teeth at all. 26 A 2017 survey showed that a third of adults in long-term care in California were completely edentulous.
Nationwide, just over half of older adults (51%) have retained at least a functional dentition (> 20 teeth). Once again, there are substantial differences for those in poverty compared with those who are not, 25% to 62% respectively. This was a 20% increase for nonpoor with a functional dentition but only 10% for poor in the last 20 years. 10 Lack of a functional dentition can result in poor nutrition, selection of foods that are high in carbohydrates and highly cariogenic for the teeth that remain and potential embarrassment or loss of dignity for older adults who struggle to eat a meal or refrain from social engagement.
Disparities in care are evident nationally with respect to caries and periodontal disease in older adults as well. The prevalence of dental caries in older adults has declined only 1% since 2000 and untreated tooth decay declined by 6% to an estimated 22%. However, when comparing those living in poverty (43% untreated) with those who are more affluent (14% untreated), there is a significant difference in caries prevalence that becomes more pronounced for those aged 75 years and older. Disparities in periodontal disease also exist. Ten percent of older adults have severe periodontitis, but older men, Hispanic and African American individuals and those who are poor or who have fewer years of education are at increased risk for severe periodontitis. Among long-term care patients in California, half had untreated caries, 40% did not have opposing teeth to chew and those in rural settings had more decay and poorer oral health overall. 27 Given our increased understanding of the role of periodontal inflammation in association with many chronic systemic diseases such as diabetes, cardiovascular disease, respiratory diseases and others, the persistence of these disparities places some individuals, such as those with disabilities or lack of insurance with fewer opportunities for oral health care, at greater risk than those with more access, resources and more frequent utilization.
Oral diseases are largely preventable in older adults, but largely dependent upon regular access to oral health care as well as behaviors that support oral health. With increased retention of natural dentition among aging cohorts and higher expectations for oral health and cosmetic procedures than in prior generations, there is increasing interest in oral health among older adults themselves. However, almost half of all older adults lack dental coverage, which is a significant barrier to oral health care for this population and of all age groups, the highest out-of- pocket expenditures are borne by older adults in America. In California, 39% of older adults do not have dental insurance. Although critical to access, insurance alone does not guarantee utilization, because those who receive comprehensive adult dental benefits through the Medi-Cal Dental Program were least likely to have seen the dentist in the last year. This could be in part due to the number who have one or more chronic diseases that may limit their ability to access care, as patients with more chronic diseases have greater functional limitations. This is of particular concern for older adults who tend to have more chronic diseases than younger adults. A 2014 study found that 81% of adults aged 65 and older were diagnosed with two or more chronic diseases. 30 Additional barriers have included low reimbursement rates and high administrative burden to participate in Medi-Cal Dental, which can limit the number of providers who will enroll as providers. While payment rates have increased and administrative burden has decreased for providers who accept Medi-Cal Dental in recent years, this remains a work in progress. These deterrents are also compounded by providers who may not feel prepared to manage patients with more complex combined medical and dental issues. Inadequate provider training and lack of integration with an interprofessional team can result in either under- or overtreatment of these populations 32 that can also make patients reluctant to seek or follow through with care.
Intellectual and Developmental Disabilities (IDD)
The California Department of Developmental Services works through 21 regional centers, two stateoperated developmental centers and one state-operated community facility to serve 371,687 individuals who have a developmental disability. 33 A developmental disability presents with substantial impairment in three or more areas of major life activity such as selfcare, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency. Developmental disabilities include intellectual disability, autism, epilepsy, cerebral palsy and disabling conditions closely related to or requiring treatment similar to that required by a person with an intellectual disability (referred to as fifth category). 33 TABLE 2 provides demographic data from the California Department of Developmental Services. 4,33,34 Studies have consistently shown higher rates of periodontal disease and untreated caries in those with IDD compared to those without. A 2012 study found a 32.2% prevalence for untreated caries, 80.3% for periodontitis and 10.9% for edentulism among their study population. 33 Untreated disease is a particular risk for those who may be less able or unable to express a problem, such as a toothache, a broken tooth or bleeding gums. Individuals who are more independent and less reliant on others for self-care and ADLs will have less risk for oral diseases than those who require more assistance or who are less able to tolerate routine dental care due to physical, intellectual or behavioral issues. Frequently, direct caregivers for adults with acquired developmental disabilities have low oral health literacy and little formal training in the provision of oral health care. 35 Even for those living in skilled nursing facilities with more formal direct caregivers, these are often low-paying jobs that turn over quickly resulting in a lack of continuity and quality of care. Multiple aspects of socioeconomic status or race can intersect and potentially lessen an individual’s ability to access oral health care regularly if at all. Just as with older medically compromised adults who have difficulty finding providers who are trained and confident in their care, individuals with IDD have similar challenges, which increase with diminished ability to follow instructions and cooperate for care. And for those who require hospital-based dentistry for care, resources are scarce.
LGBTQ+
Data from a 2017 Gallup poll showed that LGBT (lesbian, gay, bisexual, transgender) identification was higher in the Northeast and the West Coast. This is possibly because states such as California provide more legal protections, resulting in an increased willingness to identify in the surveys than in other parts of the country. 38,40 Increases in LGBT identification between 2012 (5.8%) and 2017 (8.2%) was predominantly among millennials with other age cohorts unchanged over that time. The race and ethnicity of the respondents were similar to those of the general population. Collecting accurate demographics and other information such as oral health status specific to sexual and gender diverse (SGD) populations is needed to understand changing needs in our state, identify disparities in care compared to other populations and within the population itself and to ensure that resources appropriate to the need are accessible for our patients.
Studies based on the Behavioral Risk Factor Surveillance System Surveys have indicated that LGBTQ+ (lesbian, gay, bisexual, transgender, queer and other sexual identities and orientations) inequities in health care are related to poor economic and social circumstances. 42 LGBTQ+ participants reported more behaviors-associated substance abuse and other risks to health, worse mental health and more disability. The data on oral health are limited and not included in National Health and Nutrition Examination Survey (NHANES) data prior to 2009. The 2009-2014 data did not reveal clinical differences except that lesbian, gay and bisexual adults reported worse-perceived oral health than the heterosexual respondents. Perceived discrimination is also an increased risk for LGBTQ+ individuals that can inhibit them from seeking care, as well as overt discrimination, intimidation and even abuse in health care settings. 10 An estimated 63% of older LGBTQ+ individuals do not have children, which may increase their reliance on nonfamilial caregivers to assist them in accessing dental care as needed with advanced age or disability. 40
Combating Disparities With Communication and Education
Low oral health literacy is a significant factor in disparities in care for low-income and marginalized populations with limited access to resources necessary to access health care and health information. 10 The updated “Healthy People 2030” definition of health literacy addresses a dual element: An individual’s ability to “find, understand and use services to inform health-related decisions and action for themselves or another” plus the concept of an organizational health literacy in which “organizations equitably enable individuals” to exercise their health literacy. While public health campaigns can improve oral health literacy, those with limited access to direct care miss important opportunities for information that is relevant to them as individuals. Just as education is an important resource to combat poverty through knowledge, access to oral health care is an opportunity to improve health outcomes through access to information, and these are important opportunities for providers to raise their patients’ oral health literacy for the benefit of their overall health and well-being. Information can be shared not only about the patient’s oral condition but about the importance of good oral health to general health. And for those with chronic diseases or taking medications that impact disease, it is a critical opportunity to educate them about the specific risks to their oral health as a result of their diseases.
A recent study conducted in California revealed that dental providers used some strategies to address and improve health literacy, such as using simple language and models or radiographs to enhance the information. However, the use of interpreters and translated materials or illustrations was limited, as was the use of motivational interviewing or the teach-back method. These are missed opportunities and can result in misunderstandings, lack of adherence and poor outcomes.
Key barriers that providers in this study reported as interfering with effective communication included limited time, lack of oral health literacy training for themselves and staff and limited access to plain-language or translated materials. More than half of respondents reported that patients or caregivers would not follow instructions, no matter how well done, and that cultural beliefs are a barrier to understanding. Thirty-eight percent reported that their patients are not interested and 36% reported that they just do not understand the information. Sixtyfive percent of respondents reported more frequent challenges in communication with non-English speakers, 54% for patients with cognitive disabilities, 42% with elderly patients, 35% of those with low educational attainment and 31% who are hard of hearing or deaf. Dentists could benefit from more opportunities to learn effective patient communication techniques and strategies to develop a shame-free environment for those struggling with literacy and by securing interpretation services and materials in other languages for patients when needed. Use of interpreters improves satisfaction, reduces errors and malpractice and can also educate providers about potential cultural misunderstandings. Improved communication with all patients and caregivers is critical to avoid misunderstandings that result in delayed diagnosis, misdiagnosis and poor outcomes of care and avoidance of care.
A recent study of 304 older adults in San Bernardino County found that poor oral health knowledge was significant for respondents aged 75 and older, those with an education of high school or less, those of a minority ethnicity, those with an income of less than $25,000 per year and those with less reading ability. 43 Modeling for the variables revealed Hispanic participants were almost 25 times more likely to score as “poor” on oral health knowledge as compared to Caucasians. Then they looked at their Oral Health Impact Profile (OHIP, oral health-related quality of life (OHRQoL) indicators). The strongest factor was an association with less than a high school education and a high (> 10) OHIP severity rating. And those with a poor oral health knowledge score were five times as likely as the other respondents to have a high severity OHIP rating.
Several studies have demonstrated that poor social and socioeconomic conditions contribute to low health literacy, which can adversely impact health status, quality of life and outcomes of care plus reinforce behaviors that undermine health and limit use of preventive services. 44 Health literacy can be improved as can modifiable social determinants of health — if individuals have access to someone who will educate them. Therefore, it is critical that the dental team is prepared to provide this opportunity for those who have access to care and that we have a public health initiative for those who do not have that access. Collaborative efforts from organized dentistry, public health and private organizations can ensure that providers in California have access to a wider variety of resources to facilitate effective and appropriate communication with their patients. Public campaigns targeted to increase knowledge and awareness among diverse populations and communities are also needed. This could include in-person support, telehealth support and print or digital communications that can be shared with patients and more broadly. The California Department of Public Health created an online toolkit called “Oral Health Literacy in Practice.” Other resources are available through the American Medical Association to describe and demonstrate strategies for clinicians to improve health literacy and outcomes of care (FIGURE 3). Effective and appropriate communication and patient education is critical to achieve equity by making sure patients are heard and have a sense of belonging wherever they are seeking care, whether in a community health clinic, dental school clinic or private practice.
Workforce and Systems of Care Impact Individuals and Populations
Diversity of representation in the profession is critical. 46 A recent report concluded that 8% of the state’s dentists are Black and Latino, yet the Black and Latino population comprises nearly 46% of the state’s population with nearly 40% being Latino. 13 There is also evidence that historically underrepresented providers are more likely to care for the underserved populations as well as accept Medicaid or treat those who are uninsured. 47 While it is not acceptable that these providers carry a disproportionate financial burden, it does demonstrate the potential for a more diverse workforce to practice in communities and with populations that have historically been underserved by our current workforce. Sustainable practice models, reimbursement structures and opportunities for loan repayment that allow providers to care for individuals and communities with fewer financial resources must go hand in hand with a diverse workforce because the current system of dental care remains inaccessible to many.
In addition to a greater ethnic, racial and geographic diversity of providers, a greater diversity in provider types and practice settings is critical to reaching populations that are reliant on others to access oral health care like those with a disability, children or those living in remote or underserved areas. 10,48 There are 647 Dental Professional Shortage Areas (DHPSAs) in California. 49 Making full use of our dental team to reach underserved communities that have few or no dentists is critical, through schools, adult day health centers, meal programs and better integration and collaboration with primary care. 10 For individuals who may not feel safe leaving their neighborhood, are too far from the nearest dentist, cannot afford or physically cannot use public transportation to reach a distant dentist or rely on others to get them to the dentist, taking care to them is one logical next step.
Awareness of the barriers that prevent underserved populations and communities from seeking or following through with care is critical. Better collaboration with other health care providers who are already caring for these patients may result in increased referrals and better adherence; building networks of interprofessional teams and advocates may encourage those who have been reluctant to seek care or even avoiding care. Making practices and clinics safe spaces for all who enter and seeking out places individuals already regard as safe may make the difference in increasing access to care and reducing disparities in oral health over the next 20 years.
Conclusion
The diverse population of California and intersecting human characteristics and conditions offer significant challenges to providing equitable access and good outcomes. Those challenges provide multiple opportunities to develop practices and policies that improve opportunities for efficient and effective person-centered oral health care. Oral diseases are largely preventable with good home care and regular access to oral health care, but also require addressing social determinants of health and the marginalization of certain groups that prevent individuals and populations from getting the information and care they need to maintain good oral health over a lifetime.
Almost half of all older adults lack dental coverage, which is a significant barrier to oral health care for this population; of all age groups, the older adults have the highest out-of-pocket expenses. The improved access to oral health care among previously uninsured children, subsequent to provisions for dental care through the ACA and CHIP, provides some evidence that inclusion of a dental benefit in Medicare could result in improved access to care for older adults.
Many older individuals and those with a disability face financial barriers to care, but economics alone are not responsible for limited access to care. Whether disability results from normal, age-related changes like those in hearing or vision or as a result of disease, practices can be more accessible for those with disabilities. And providers need more education starting in predoctoral education and sustained through continuing education to manage the complex needs of those who are most vulnerable due to chronic disease or disability from the moment they come into the practice, through treatment, postoperative care, maintenance and prevention of future disease.
Immigrants, LGBTQ+, homeless people, those living in HPSAs and those in the juvenile justice or foster system are at greatest risk for poor oral health outcomes. 10 Collecting accurate demographics, oral health status and the discrete challenges in accessing care and perception of need among these populations is challenging but necessary to understand the full scope of need in our state. This knowledge is important to both patients and providers to ensure that appropriate resources are accessible to those who need them in order to receive or provide care.
Active recruitment of historically underrepresented groups to the profession and diverse representation in dental education and organized dentistry are critical to improving access to care for underserved populations. Making full use of our dental team to reach into underserved communities with few or no dentists, through schools, adult day health centers, meal programs and better integration and collaboration with primary care is critical to improve access to preventive and basic care. Similarly, expanding the scope of practice for dentists to participate more fully in the primary health care network through the administration of vaccines is one example that demonstrates how utilizing dental providers to the fullest extent of their training and capability can improve access to important disease prevention and public health measures for all ages and across all socioeconomic lines.
Public health campaigns and materials available through public health departments and organized dental organizations can increase knowledge and awareness among diverse populations and communities if they receive them. Collaborative efforts from organized dentistry, public health and private organizations can ensure that providers and patients in California have access to a wider variety of resources to facilitate effective and appropriate communication. Just as access to education is an important resource to combat poverty through knowledge, access to oral health care is an opportunity to improve outcomes in health care through access to information. These are important opportunities for providers to raise their patients’ oral health literacy and the importance of good oral health to general health. The dental team would benefit from more opportunities to learn effective patient communication techniques and strategies to develop a shame-free environment for those struggling with literacy and to secure appropriate and affordable interpretation services and materials in other languages for patients across our multilingual state.
Persistent challenges accessing oral health care due to cost, location, language, gender, race, ethnicity, age, illness and disability can result in a lack of trust, avoidance of care, challenges in communication, diagnostic errors and poor adherence that result in poor outcomes in medical and dental care. This can also result in diminished quality of life and financial strain on both patients and the health care system. While we aim to achieve diversity, equity, inclusion and belonging each of these is also a powerful strategy to improve access to care, patient experience and outcomes of care. The diversity of people in need of care, the need for more diversity in our profession and addressing the day-to-day challenges individuals and whole communities experience in obtaining oral health care requires new, equitable and inclusive strategies and paradigms in patient care and policy to appropriately address the significant and persistent challenges to achieving and maintaining good oral health that is faced by many Californians.
