Children's Oral Health: A Matter of Social Justice, Health Equity and Human Rights

Francisco Ramos-Gomez, DDS, MSc, MPH UCLA Professor/ Chair Division of Preventive and Restorative Oral Health Sciences

Early Childhood Caries (ECC) affects 600 million children worldwide and is entirely preventable,1 yet oral health inequalities persist and are prevalent and universal.2 In the United States, 23% of children from 2 to 5 years of age have ECC, and 80% percent of dental disease (including ECC) is concentrated in just 20-25% of the country’s children who are primarily from low socioeconomic and minority backgrounds.3-4 A review of studies from North America, Europe, Asia, Africa, and the Middle East showed the prevalence of ECC in socio-economically disadvantaged groups was as high as 70%.5 Therefore, positioning oral health as a matter of social justice, health equity and human rights to ensure all children receive basic care is critical to reducing oral health disparities among children worldwide.

Societal systemic and structural factors affecting oral health equity, social justice and human rights

Societal systemic factors affecting oral health equity, social justice, and human rights include government policies and social and structural influences that foster the continuation of privilege for some and discrimination for others based on such characteristics as race and ethnicity, economic status, gender, age, and physical disabilities or behavioral and emotional difficulties.6 More specifically, at the structural level, structural racism and discrimination (SRD) can impact oral health through macrolevel conditions, such as residential segregation and institutional policies that limit opportunities, resources, power and well-being of individuals and populations based on race/ethnicity or other characteristics.7 Studies in the United States have found that states with high levels of SRD have poorer oral health outcomes for Blacks compared to non-Hispanic whites.8 In Hispanic populations, studies on the direct association of SRD with oral health treatments and outcomes (e.g., restoration, sedation, extraction) are lacking;8-9 however, some community-level factors associated with poor oral health could be suggestive of the effects of structural racism. For example, studies have shown that living in a monolingual community and a school district with a high proportion of limited English proficiency (LEP), a form of residential segregation, heightens the impact on access to and utilization of care for Hispanic families.10-11 Addressing these societal systemic and SRD-related factors can have a positive impact on an individual’s oral health in addition to overall health.12

How providers can help address oral health disparities among children and underserved populations

Viewing ECC through a lens of social justice, health equity, human rights and SRD awareness will help oral health providers, public health practitioners, and policy makers develop targeted actions consistent with the infrastructure capacity and current oral health situation of the populations they serve to ensure basic oral health prevention and care for all children.13-15 Below are 5 recommendations oral health professionals can use to promote ECC prevention to help eliminate oral health disparities among children and underserved populations worldwide.

1. Encourage oral health and medical care providers to promote and advocate for mandatory age 1 health visits for all children, as this is a crucial first step in the prevention of ECC.6,16-17 The American Academy of Pediatric Dentistry (AAPD) and World Health Organization (WHO) recommend a child see a dental provider by age 1 or within six months after the first tooth erupts.18-19 Additionally, oral health providers can promote and advocate for other population-based policies such as fluoridation of public water supplies (considered by the American Dental Association to be the single most effective public health measure to help prevent tooth decay),20 and a tax on sugary drinks to help reduce sugar consumption.21

2. Promote oral health education and increase oral health literacy. Oral health literacy is defined as the capacity to acquire, process, comprehend and act upon basic oral health information. Most oral health literacy research comes out of the United States. These studies have shown an association between low levels of oral health literacy and decreased utilization of preventive dental services and poor oral health outcomes.22-23 There are substantial dental public health implications surrounding oral health literacy that must be taken into consideration. For example, populations unable to access dental care should be able to easily obtain educational materials regarding preventive dental care that are easy to understand and use. The information should focus on the risk factors and preventive strategies for oral disease and be culturally and linguistically competent.23 Dental and pediatric primary care providers and community health care workers should be encouraged by residency programs, hospitals and clinics, and non-governmental organizations (NGOs) to disseminate culturally and linguistically appropriate oral health information to schools as well as civil, religious and social service organizations outside of their dental practices.

3. Establish a collaborative partnership between oral health care providers and communitybased oral health workers (COHW) which could help improve oral health outcomes and reduce socioeconomic and culture-based disparities in a range of ways including, helping to coordinate care and educating about such things as brushing and flossing. The community health worker model has been used worldwide to help increase access to health care services, especially among hard-to-reach populations. Community health workers are selected based on community membership and knowledge of the community’s culture and languages spoken. Their established membership in the community encourages trust and respect.24 Thus, community health workers are an important link between the community and use of health care services.24 Several countries (including the US, New Zealand, Canada, Great Britain, Netherlands, Switzerland, Malaysia, Thailand, Hong Kong, Singapore, Brunei, Cameroon, Cambodia and Azerbaijan) have established community and school-based dental service programs using COHWs and dental nurses/dental therapists to help expand the reach of oral health care, reduce dental caries and treat dental disease in children.25-28

Viewing ECC through a lens of social justice, health equity, human rights and SRD awareness will help oral health providers, public health practitioners, and policy makers develop targeted actions consistent with the infrastructure capacity and current oral health situation of the populations they serve to ensure basic oral health prevention and care for all children.

4. Support interprofessional education (IPE) and encourage collaborative practice between oral health, medical and other pediatric primary care providers to help increase access to and use of oral health care services for children in both developed and developing countries.29-30 Several dental schools in the US, Canada and Europe have incorporated IPE programs into their existing dental curricula.31-32 Research results from these programs report positive findings regarding the benefit of IPE on teamwork and have shown improvements in primary care providers’ oral health knowledge and increased confidence for providing oral health care services to children.30,32-36

5. The use of dental homes and teledentistry patient-provider relationships that build trust, cultural competency and continuity of care across the patient’s lifetime are needed to increase access to oral health care, especially in underserved areas.37 Dental homes refer to a community-based oral health delivery system in which people receive preventive and simple therapeutic dental services (such as prophylaxis and education about brushing, flossing and nutrition) in community settings where they live or receive educational, social, or general health services. In countries lacking dental offices at a nearby location, dental home community providers can refer patients who require more complex treatment that only a dentist can provide to mobile dental clinics or other communitybased/neighborhood dental centers (if available) where advanced restorative procedures are done.6

CONCLUSION

Developing practical and innovative strategies and health policy suggestions for systems-and SRD-level change approaches to improving oral health among children and underserved populations is of utmost importance, as access to basic oral health care is a matter of equity, social justice and continues to be an urgent human rights issue in both developed and developing countries.6,38 We need to advocate and have some specific policy recommendations for UNICEF and the United Nations to spell out, that “without good Oral Health there is no Total Health for the child.” All children have the right to health, in line with international human rights law, we need to add “oral health” to this UN mandate.

All experts agreed that the best Equity Policy includes the adoption of “Age One Dental Visit.” While more research is needed to better understand Oral Health Literacy and the direct association between SRD and oral health outcomes,8 it is hoped the recommendations in this paper will provide a platform for further discussion on how action can be taken to implement the strategies and policies needed to overcome oral health inequalities and bring social justice, health equity and human rights to children worldwide.

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