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Innovative Approaches for Fostering DEI Development in Preclinical and Clinical Training
Marisa K. Watanabe, DDS, MS; Lucian O’Connor, PhD; Keith R. Boyer, DDS; T. Jamie Parado, DDS; Paulina A. Saraza, DMD, MS; Edmond R. Hewlett, DDS; George Taylor, DMD, MPH, DrPH; and Bradley S. Henson, DDS, PhD
ABSTRACT
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Background: Oral disease remains a significant health problem in the United States, and the burden of oral disease is greatest for the poor and those patients from underrepresented minority (URM) backgrounds. Tackling this problem in a comprehensive and enduring way requires a change in the way we train and support current and future dentists and staff. Lasting transformation also requires a systematic shift in the way we investigate and address minority health care gaps in practice. This article describes ways in which dental education can play an integral role in shaping a better oral health tomorrow for individuals, families and communities from underrepresented minority backgrounds who continue to bear a disproportionate burden of oral disease.
Types of studies reviewed: A summary of the literature related to diversity, equity and inclusion (DEI) curricula in dental education is presented along with illustrative examples from California dental schools.
Results: Systematic infrastructure changes in dental education to include DEI development further support a workforce capable of understanding economic and social factors and delivering patient, personcentered care.
Practical implications: DEI development goes beyond dental education; oral health providers from both private and public sectors who understand the dynamic changes in the growing, diverse population are imperative to attaining “optimal oral health for all.” DEI principles learned in a didactic setting can synergize with clinical training approaches to foster real and lasting change in dental medicine learners and the patients they serve.
Keywords: Diversity, inclusion, equity, DEI, dental students, dental education
AUTHORS
Marisa K. Watanabe, DDS, MS, is a professor and associate dean for community partnerships and access to care at the Western University of Health Sciences College of Dental Medicine. She oversees the entire community-based dental education curriculum for the college and focuses her research on modalities to address health inequities in oral and overall health.
Lucian O’Connor, PhD, is an associate professor at the Western University of Health Sciences College of Dental Medicine. His teaching and research expertise are in medical anthropology and history of science. He is the curriculum manager of diversity, equity and inclusion for the college.
Keith R. Boyer, DDS, is an associate professor at the Western University of Health Sciences College of Dental Medicine and a diplomate of the American Board of Endodontics.
T. Jamie Parado, DDS, is an assistant professor at the Western University of Health Sciences College of Dental Medicine and a diplomate of the American Board of Pediatric Dentistry. One of her key areas of interest is in interprofessional education and interprofessional collaborative practice, and she is the liaison for the WesternU CDM.
Edmond R. Hewlett, DDS, is a professor and an associate dean for equity, diversity and inclusion at the University of California, Los Angeles School of Dentistry.
George Taylor, DMD, MPH, DrPH, is a professor and an associate dean for diversity and inclusion at the University of California, San Francisco School of Dentistry.
Bradley S. Henson, DDS, PhD, is an associate professor at the Western University College of Dental Medicine and interim senior vice president for research and biotechnology at WesternU. He is a head and neck cancer researcher and is also passionate about promoting oral and overall health in Indigenous communities.
Conflict of Interest Disclosure: None reported for any of the authors.
Oral disease remains a significant health problem in the U.S., and the burden of oral disease is greatest for the poor and for patients from historically marginalized communities. These identified populations have less access to oral and overall health care services. Specific to dentistry, studies have shown that individuals from historically marginalized communities experience disparities in access to dental care, including fewer dental visits, resulting in poorer oral health.
Profound racial and ethnic disparities in health and overall well-being have persisted for many years in the U.S. Studies have shown that 10% of Latinx/ Hispanics, 5 13.8% of African Americans 6 and 17.4% of American Indians/Alaska Natives (AI/AN) 7 reported having fair or poor health compared with 8.3% of non- Hispanic whites. On average, Black and American Indian/Alaska Native people live fewer years than white people. 8,9 These groups are also more likely to suffer from chronic health conditions, such as cardiovascular disease and diabetes, and to die from these treatable conditions. African American and AI/AN women are more likely to die or experience complications during and after pregnancy and are more likely to endure the loss of an infant child. 12–15 Approximately 21.5% of Latinx/Hispanic adults over age 20 have been diagnosed with diabetes as compared to only 13% of their white counterparts, 16 and approximately 25% of Latinx/Hispanic individuals have high blood pressure. 17 The COVID-19 pandemic has contributed to the problem, with average life expectancies for Black, Latinx/Hispanic and, in all likelihood, AI/AN people falling more sharply compared to white people.
Communities of color are also more likely to experience oral health inequities and oral disease progression and are more likely to have unmet dental needs. Studies have found that African Americans and Latinx/Hispanic seniors are more likely to report self-rated poor oral health compared to non-Hispanic whites. Black seniors are more likely to report potential chewing difficulties and fewer teeth. Wu et al. reported that African Americans and Mexican Americans have more decayed teeth but fewer filled teeth than their white counterparts. Compared to the general U.S. population, AI/AN adult dental patients are more likely to report poor oral health, oral pain and food avoidance because of oral problems and are known to suffer disproportionately from untreated dental decay and severe periodontal disease.
Tackling this problem in a comprehensive and enduring way requires a change in the way dental institutions train and support current and future oral health care providers and staff. Lasting transformation also requires a systematic shift in order to investigate and address minority health care gaps in practice.
Dental education has multiple intersecting roles that are integral to addressing the challenges of access to care and equitable outcomes as they relate to the issues of diversity, equity, inclusion and belonging (DEIB).
First, predoctoral dental education and other entry programs in dental hygiene, dental assisting and dental therapy form the sole pipeline for shaping the makeup of the profession for the future. Multiple efforts have yielded incremental progress. The efforts have often yielded uneven results based upon factors that are and are not under control of the dental education community.
Second, dental education should provide all students with a solid foundation of understanding related to the structural and social determinants of health (SSDH) as identified by the World Health Organization. 29 The historical and contemporary context of the environment of care can help dental professionals better understand and hopefully address the inequities that serve as impediments to optimal oral health care.
Third, dental education is increasingly providing learners with experiences in authentic care environments such as safety net clinics and interprofessional care environments. These environments are frequently based outside the primary training institution and allow the future members of the profession to grasp the challenges faced in the actual provision of care. These experiences not only supplement the amount of care provided, but also serve as a recruitment opportunity for future practitioners who will staff the clinics and systems.
Finally, health care educational institutions, including dental schools, are primary contributors to the scientific bodies of knowledge that fuel our progress as a profession. Their role in providing evaluation and interpretation of the progress that we are, or are not, making in creating equitable access and outcomes is invaluable.
The bulk of the scholarly work is focused on the historic and current inequities leaving significant room for additional study of the policy, programs, curricula and efforts to address the situation. Careful evaluation of the profession’s efforts can help guide their continuation, modification or redirection toward other approaches.
This article focuses on the need for a diverse workforce, the current and nascent didactic curricula at several California dental schools as well as the structure and value of the community-based dental educational models employed by the various institutions. The examples and outcomes describe ways in which dental education is playing an integral role in shaping a better oral health tomorrow for individuals, families and communities from historically marginalized backgrounds who continue to bear a disproportionate burden of oral disease.
Need for a Diverse Dental Workforce
Dentistry continues to have one of the least diverse practitioner populations of all health professions. Nationally, the unbalanced distribution of dental providers leaves tens of millions of Americans without equitable access to oral health care. 23 More than 5,800 Dental Health Professional Shortage Areas (DHPSAs) affect 58 million people in the U.S., reflecting rural areas and population groups such as those served by the Indian Health Service. California has more dentists than any other state, but an estimated 2.2 million of the state’s residents live in DHPSAs. 24 The dental workforce historically lacks racial and ethnic diversity despite the growing numbers of racial and ethnic minorities comprising the national population. Hispanic/Latino, Black/African American and Indigenous dental providers remained underrepresented relative to their proportions in the national population.
Studies show that dentists from historically marginalized communities tend to serve minority communities, reside in counties with a partial HPSA, work in safety net or community health settings and accept a larger share of patients from historically marginalized communities. 23,24
Since the release of the landmark “Oral Health in America: A Report of the Surgeon General” in 2000, significant gains have been made in the dental public health and oral health care delivery systems. 25 Strategic support from federal and state public health programs, along with legislative and policy advancements, have led to increased access to critical oral health care services. During this time, many new dental schools have opened, and the number of dental providers across the nation has increased. 23 Despite these gains, disparities in access to oral health care services continue to exist for many from cultural and ethnic minority backgrounds, according to a 2021 report published by the National Institute of Dental and Craniofacial Research.
While many reasons exist for these inequities, three that contribute significantly to the challenges of meeting the health care needs of Americans are: 1) a rapidly expanding population; 2) a changing national demographic; and 3) a nonrepresentative dental workforce.
As of Jan. 1, 2020, more than 57 million persons across the nation reside in a DHPSA. With only 29.19% of the dental need met, more than 10,000 practitioners are needed to remove a DHPSA designation; however, the trend seen in the percentage of dental needs met has decreased over time, while the number of necessary practitioners to meet that need has continued to rise.
Dentistry continues to have one of the least diverse practitioner populations of all health professions. One study argues that dentistry is in particular need of deepening the understanding of the role of race and ethnicity in the patientprovider relationship and increasing the number of students from historically marginalized communities in healthprofession schools in order to train providers to treat minority populations and address disparities. According to a study by Tavernier et al., health professionals exposed to underserved populations during training are more likely to serve as health care providers for these same populations upon graduation. Therefore, it is imperative to address the need to improve the diversity in predoctoral dental programs, leading to an increase in the diversity makeup of the dental workforce population.
Diversity, Equity and Inclusion Development in Preclinical Training: Developing Structural Competency
The Importance of Understanding Social Determinants of Health
A key strategy to prepare current and future oral health practitioners to identify and address health disparities and promote overall and oral health equity is to train them in understanding the impacts of the SSDH. Oral health disparities, like all health disparities, are outcomes of upstream social factors.
Many historical and contemporary contributors have led to these disparities: barriers to health care access, dental workforce shortages, a nonrepresentative dental workforce, lack of structural and cultural competency among health care personnel, racism’s wear and tear on individuals and communities, household income inequality, food insecurity and a lack of safe and affordable housing.
It is important to distinguish social determinants of health from structural determinants of health. Social determinants represent the conditions under which individuals are born, raised, live, work and learn that affect a wide range of health risks and outcomes. Structural determinants of health refers to the social, political and economic mechanisms and structures that affect income, housing and working conditions, educational and health care access and overall health and wellness. Structural determinants interface with and shape the social determinants of health experienced by individuals and communities. In its landmark report, “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health,” the World Health Organization (WHO) Commission on Social Determinants of Health described the need to address SSDHs as “a matter of life and death” and as an important part of social justice.
The dental workforce and dental school educators are beginning to embrace these concepts, but significant efforts are still required. Dental health care providers are critical members of the overall health care workforce. Like other health professions, dental health professionals should be trained interprofessionally to understand SSDHs, demonstrate cultural competence and operationalize this knowledge to exact change in day-to-day clinical practice. In this way, dental health professionals can better understand their unique, front-line opportunity for working with others in providing more equitable patient care.
Where We Are and Where We Are Heading
A number of studies across the health professions have been conducted to determine the extent to which professional training programs incorporate concepts of diversity, equity and inclusion (DEI) into their curricula. 30–32 The literature supports that most U.S. dental schools have integrated some form of DEI or cultural competence into the dental curricula, but few describe a comprehensive and longitudinal DEI curriculum that is regarded with the same weight of importance applied to anatomy, physiology or any other important topic in the overarching dental curriculum. Even fewer curricula offer students a sufficiently deep exploration into the extent of oral and overall health disparities, their historical and contemporary contexts and their associated SSDHs.
Dental practice and educational settings should institute a policy that embraces DEIB for all aspects of the dental team and provide guidance to all stakeholders. Learning outcomes and takeaways gleaned from DEI curricula should drive an overall increase in cultural competence as well as an understanding of the root causes and impacts of systemic racism, homophobia, sexism, ageism, xenophobia and other barriers to achieving optimal oral health outcomes and maintaining an inclusive, diverse and equitable work/learning environment.
Dental DEI Curricula for the 21st Century
To illustrate, the authors present examples of California dental school curricular models that achieve the outcomes and objectives described previously. Several dental institutions have or are planning to integrate DEI into their overall curriculum. The new DEI curriculum at the Western University of Health Sciences College of Dental Medicine (WesternU CDM), “Social Differences and Health Disparities in Dentistry, Medicine and the Biomedical Sciences,” provides a longitudinal and comprehensive framework that engages both preclinical and clinical experiences, with a firm grounding in the ways that race, gender, sexuality, disability and other socioeconomic factors affect health and access to health care. The one-year course is structured into four units.
Unit one begins with modules devoted to understanding forms of social difference, including race, indigeneity, gender, class and more. Students in week two, for instance, establish a common language about race via an accelerated review of how anthropology, sociology and biology define the category. Unit one culminates with modules on how scientists and clinicians incorporate categories of social difference into their research and clinical practice. Students review determinants, such as biological, social and cultural, and how to recognize when a disparity interfaces with social structures.
The DEI curriculum continues with two units that survey the formation of social structures and intersections of human difference as they relate to the history of science, medicine and dentistry. Critical case studies show why Institutional Review Board (IRB) protocols exist to protect racialized, gendered and other at-risk patients from exploitation. The fourth and final unit requires students to activate skills acquired in previous weeks by engaging with experts who present innovative research on contemporary topics. During this final unit, students begin actualizing what they learned in the design of a community improvement project by selecting a faculty advisor and drafting a project proposal. The goal is to teach future dentists how to be researchers who can make a difference, equipped with detailed knowledge about social determinants, cultural competence and structural competence, enabling them to identify a problem and develop a robust research program that provides solutions.
The University of California, Los Angeles, (UCLA) School of Dentistry’s overarching context for its predoctoral curriculum around DEI principles has evolved to one of racism in all of its forms as a social and structural determinant of health. As acknowledgement and discussion of evidence linking structural/ cultural racism, and individual-level discrimination to racial health inequities 33 require explicit use of the “racism” term, overcoming reluctance to do is so essential. As such, foundational content for this framing added to the D1 curriculum in 2020 includes origins of the mythical “race” concept and its pervasive role in law, policy and social structure throughout U.S. history. Relevant examples appear in many courses, such as slave labor enabling the widespread availability of cheap sugar and triggering the so-called “caries epidemic” of the late 18th century. A student small-group facilitator training program was also launched in 2020 to increase engagement and conversation surrounding culture, race and health across the curriculum. Emphasis on personal and professional growth through cultural humility has supplanted that of cultural competence acquisition in the clinical and didactic curricula.
The University of California, San Francisco, (UCSF) School of Dentistry has also embarked on a journey to enhance its predoctoral curriculum by planning to add a DEI component across the four-year predoctoral curriculum. In June 2020, the chancellor of UCSF announced the campus’s anti-racism initiative. One of the key elements of that initiative has been revising and updating the curricula in all of its professional and graduate school programs to ensure their curricula are anti-racist and anti-oppressive.
UCSF’s initial focus for incorporating an anti-racism, anti-oppression component to its curriculum has been to enhance D1 students’ DEI foundational learning. To launch this transformation, UCSF engaged Denise Davis, MD, a leader in DEI instruction and professor in the UCSF School of Medicine, and Laura Cooley, PhD, senior director of external education and outreach of the Academy of Communication in Healthcare (ACH), to assist in developing a facilitated fourhour orientation session and revising a three-hour class session in the D1 students’ course on patient-centered care.
The four-hour orientation session occurs in the fall quarter when students first arrive, and the three-hour class session occurs in the spring quarter. These sessions are interactive learning experiences that include brief didactics, skills training in team building and relationship-centered communication to facilitate understanding and effective dialogue about topics such as differences (especially racial differences), racism, equity, privilege, allyship, microaggressions, stereotype threat, implicit bias and cultural humility. Time is reserved in the sessions for facilitated small break-out groups to provide opportunities for skills practice. The first session in the fall quarter also includes a panel discussion consisting of near-peers and faculty who highlight diversity and lived experience of the panel participants shaped by cultural forces as well as an overview of disparities/injustices in oral health. The next stage in UCSF School of Dentistry’s curriculum transformation regarding DEI will be to include antiracism and anti-oppression content in the D2 through D4 students’ curricula.
DEI Development in Clinical Training: A Community-Based Dental Education Model
Clinical Experiences Supporting DEI Development
A study conducted in California found that students who were educated in a diverse environment increased the probability of working and living in more racially and ethnically diverse areas postgraduation. 34 This study also noted that students who learned and studied about racial and ethnic diversity throughout their doctoral curriculum were more prepared to live and interact in a diverse and multicultural community. 27 The next section details how DEI principles learned in a didactic, preclinical setting can synergize with clinical training approaches to foster real and lasting change in dental medicine learners and the patients they serve.
With more than 50% of the population predicted to consist of racial and ethnic minorities by 2050, the 2000 “Oral Health in America: A Report of the Surgeon General” called out the lack of diversity in the current workforce to address the needs of this future diverse population. To address the health disparities affecting these medically underserved communities, the U.S. Department of Health and Human Services (HHS) supports direct patient care in government settings such as federally qualified health centers (FQHCs), Ryan White HIV/ AIDS Program-funded clinics, nonprofit clinics, the Indian Health Service (IHS), the Federal Bureau of Prisons (BOP) and the U.S. Department of Veterans Affairs. 28 With more than 199,000 active dentists in the U.S. in 2018, only 0.9% (1,852/199,486) of the dentists practiced in federal services such as the Veterans Affairs, Public Health Service or FQHCs. Despite the increase in dentists who identify as women, from rural areas or from underrepresented racial and ethnic groups, there is still a growing need to promote diversity in the workforce.
Through establishing immersive clinical experiences in medically underserved communities during predoctoral years, these experiential trainings serve as expanding the workforce to address the oral health needs of a growing diverse population. Many dental institutions have integrated communitybased rotations into the dental curriculum, providing exposure and potential pipeline employment opportunities for predoctoral dental students. Of the seven dental institutions in California, three are located in medically underserved areas/populations, two are located in primary care HPSAs and only one is located in a dental health HPSA Dental institutions located in the HRSA-designated primary care HPSA and in a medically underserved area/populations (MUA/P) will inherently expose students to a diversity of patient populations including a wide array of underserved individuals. But beyond the four walls of the dental institution, clinical experiential training varies, with externship site rotations ranging from two-weeks in senior year to two seven- week externship rotations spanning junior and senior year. These clinical rotations create three-fold benefits: 1) increased dental workforce in medically underserved communities (MUCs); 2) clinical, cultural and structural competency exposure; and 3) support of a pipeline of dental graduates as future safety net providers.
Impact of Clinical DEI Development
By addressing topics such as implicit bias, unconscious bias and systemic racism in predoctoral dental education, dental students are able to increase their knowledge and understanding of providing care to an increased and diverse range of individuals. Equipped with the framework of cultural and structural humility, dental students are prepared for their externship and extramural clinical rotations. An example of clinical immersion is, specific to MUA/P, the two seven-week externship rotations (first as a junior and second as a senior) at WesternU CDM in FQHCs, Indian Health Service sites, nonprofit community clinics and the Veteran Affairs Hospital. TABLES 2-5 illustrate the diversity of populations in race/ ethnicity by education and economic and populations served by WesternU CDM as compared to the U.S. and California. Given the common nature of the community-based experiences, the data are likely representative of the community-based education populations served by all dental schools. TABLES 2-5 summarize the sociocultural determinants, health disparities and unmet health needs of the counties served. Among these underserved populations, 50% of dental needs remain unmet year after year. With the growing need to increase the dental workforce in MUCs, exposure and experiential learning as part of clinical immersion expand a student’s learning beyond clinical and also in cultural diversity, awareness and sensitivity.
The Herman Ostrow School of Dentistry of USC has also integrated community-based clinical rotations into D3 and D4 curricula, offering rotations that are one to two weeks in community outreach/service learning geriatrics and individuals with intellectual/ developmental disabilities in medically underserved areas. 37 To further student engagement with populations from diverse cultures and backgrounds, USC offers a free dental care mobile clinic, addressing the oral health inequity known to burden populations that are affected by social determinant factors such as racial/ethnic minority and low-income populations. 23 Additionally, the University of the Pacific, Arthur A. Dugoni School of Dentistry has integrated multiple externship rotations to community health clinics, long-term care facilities, hospitals and mobile dentistry to prepare the dental students to care for patients with complex needs and limited access to care. This curriculum has also established telehealth appointments through the virtual dental home, and synchronous telehealth appointments have been utilized to expand access to care for vulnerable populations to address social determinant factors such as transportation.
UCLA and UCSF have also established integration of student experiences in providing care to a diverse population outside the four walls of the institution. UCLA DEI in the clinical curriculum is at the core of the community-based clinical education (CBCE) program. D4 students experience two three-week externships at CBCE partner sites, all of which deliver care to Medicaid beneficiaries or people who are uninsured and have difficulty affording needed care. The sites are located in a variety of underserved communities, both in state and out of state, exposing students to safety net delivery models and community demographics. 33 UCSF has incorporated a community clinics externship course in D4 that follows the community-based learning lecture series in D3. These multiple community-based externships are completed at one of their 14 communitybased affiliated sites in California.
In addition to externship rotations, dental institutions have created different programs and opportunities for dental students to better understand the social determinant factors that limit access to care for MUCs. The Loma Linda University School of Dentistry requires service-learning hours for all dental students. The dental students are expected to complete a minimum of 120 hours that may include at least one or more of the 20 international mission trips per academic year and other local community opportunities. With California Northstate University College of Dental Medicine entering its first DMD class in 2022, its “community engagement mission” emphasizes community services and incorporating programs and partnerships to “prepare and inspire dental professionals to improve the health of their communities.”
Within D1, the amount of oral health care provided in MUCs can increase by tens of thousands if every dental student in California has rotated at least once. The impact of these clinical experiential rotations has left lasting impressions that open opportunities in private and public practices. Dental students applying for postgraduate residency programs may opt to further their training at FQHCs, which will further support building a diverse dental workforce and better prepare them to serve patients of diverse backgrounds after their residency program. Additionally, new dentists electing to enter private practice are able to build better patient relationships due to knowledge and understanding of cultural and structural competency.
Therefore, to further develop greater numbers of graduates competent in serving patients from diverse backgrounds, dental institutions must constantly build upon their current extramural rotation sites. 36 By integrating student exposure in community-based experiential training, students will be better compelled to meet the need for dental professionals comfortable in providing care to diverse and underserved populations upon graduation. Regardless of the dental care setting, employing well-rounded graduates who are multifaceted in providing services to diverse populations addresses the problem of oral health inequity head-on.
Conclusion
Based on the 2000 surgeon general’s report, “oral health as a comprehensive baseline for many oral conditions … has not improved significantly” for U.S. adults, particularly affecting those from lower-income and specific race/ethnic minority groups due to social determinant barriers. 23 The 2021 National Institute of Dental and Craniofacial Research report, “Oral Health in America: Advances and Challenges,” issued a call to action to support strengthening and diversifying the dental workforce trained and dedicated to improving oral health. 23 Movement toward action in improving knowledge of social determinant factors that contribute to oral health inequities, particularly based on poverty status and ethnic/racial minority populations, is one essential area in the new report. 23
One of the key opportunities is collaboration among legislatures and insurance companies as well as dental professionals to establish an integrative oral health and overall health care system that improves access to care. As social determinants influence healthy behaviors, upstream factors such as policy and legislative action must be proposed and passed to reduce and lead to elimination of inequities that limit access to care. Such systematic infrastructure changes in dental education to include DEI development further supports a workforce capable of understanding economic and social factors and delivering patient, person-centered care. DEI development goes beyond dental education. Oral health providers from both private and public sectors who understand the dynamic changes in the growing, diverse population are imperative to attaining “optimal oral health for all.”
