Oral Health in America

In 2000, David Satcher, then US Surgeon General, issued the first-ever report on oral health in America. The intent of the Report was to “alert Americans to the full meaning of oral health and its importance to general health and well-being.”1 The Report detailed clinical, scientific, and psycho-social factors impacting the nation’s oral health and provided a framework to action to address deficits in these areas. Over 20 years later, the National Institutes of Health (NIH) took up the mantle and considered the progress made since the initial Report as well as shined a light on those challenges that persist in meeting America’s oral health needs.2

While both reports present robust discussions about and calls to action for scientific advances to address socioeconomic differences in care, and the need to for the consideration of clinical best practices neither specifically addresses the ethical challenges and opportunities related to the nation’s oral health. They do, however, allude to issues that are reflective of the foundational pillars of the American College of Dentists (excellence, ethics, professionalism and leadership)3 and reflect the guiding principles found in the American Dental Association Principles of Ethics and Code of Professional Conduct (autonomy, nonmaleficence, beneficence, justice and veracity).4 For example, the 2000 Report, recommended diversifying the dental workforce noting: a lack of racial and ethnic diversity in the oral health workforce. Efforts to recruit members of minority groups to positions in health education, research, and practice in numbers that at least match their representation in the general population not only would enrich the talent pool, but also might result in a more equitable geographic distribution of care providers. The effect of that change could well enhance access and utilization of oral health care by racial and ethnic minorities.1

Similarly, the 2021 Monograph addressed similar themes in its Call to Action:2

Nih Monograph Call To Action

• To significantly improve the nation’s oral health, policy changes are needed to reduce or eliminate social, economic, and other systemic inequities that affect oral health behaviors and access to care.

• To improve oral health for more people, dental and other health care professionals must work together to provide integrated oral, medical, and behavioral health care in schools, community health centers, nursing homes, and medical care settings, as well as dental clinics.

• To strengthen the oral health workforce, we need to diversify the composition of the nation’s oral health professionals, address the costs of education and training the next generation, and ensure a strong research enterprise dedicated to improving oral health.

Both reports speak to the issue of justice and beneficence. Additionally, they acknowledge the significance of social determinants of health, the need to improve ac- cess to care, the need to diversify and expand the dental workforce and the overarching importance of oral health to overall health and well being.

While both Reports were and are monumental, the ethical imperative they present is clear. To apply an ethics lens to the factors impacting the oral health of Americans, the American College of Dentists brought together a panel of experts at the 2022 Fellows Forum. The speakers gave voice to a theme that ran throughout both Reports focusing on social justice and the impact of health disparities and the social determinants of health on the past and current state of oral health in America from questions of access to care to the diversity of the dental workforce to the need for interprofessional education and practice, , the need for trauma informed care, and medical/dental integration.

This issue of the eJACD provides an edited transcript of the Fellows Forum as well as observations, opinions and opportunities for action from Drs. Smith, Ramos-Gomez, Tomar and Ray. The moderator and panelists came from varied backgrounds, different practice settings, and each with a unique perspective on the ethics of operationalizing the call to action set forth in the NIH Report. The moderator, Keisha Ray is an associate professor of bioethics at McGovern Medical School in Houston, Texas. She recently published a book with Oxford University Press entitled, Black Health: The Social, Political, and Cultural Determinants of Black People’s Health. Other panelists included Lisa Simon, a physician and dentist who is committed to improving access to care and developing medical-dental integration; Carlos Smith, the Associate Dean for Inclusive Excellence, Ethics and Community Engagement at Virgin- ia Commonwealth University; Scott Tomar, Associate Dean for Prevention and Public Health Sciences at University of Illinois at Chicago, College of Dentistry with expertise in Public Health Dentistry and Francisco Ramos-Gomez, Chair of the Division of Preventative and Restorative Sciences at UCLA with expertise in Pediatric Dentistry. Drs. Simon, Tomar, and Ramos-Gomez were actively involved in the development of the 2021 NIH Report.

The issue also includes an historical piece from a 1994 issue of the Journal of the American College of Dentists by Dr. Robert J. Collins entitled: “Celebrating the Year of Oral Health: Changing Public Expectation and Challenges for the Profession.” Additionally, in acknowledging how the profession is changing and how the public perception of the profession is influenced, an empirical study of dental influencers by Gravholt, Fleming, Montori, and Koka, entitled “Who Influences Dental and Oral Health Care in the United States?” is also included.

Together these pieces are intended to not only continue the important, and at times, difficult dialogue about access to care, social determinants of health, adaptation to new technology, but also to inspire and promote action including moving toward medical/dental integration, increasing interprofessional education and promoting interprofessional practice. “Oral health should be included in policy considerations, continued research, monitoring, surveillance, and other aspects of health. Advocacy is crucial to make permanent the temporary regulatory changes being implemented to address... ensure access to oral health care, address disparities and inequities, and improve population health.”5

References

1. Oral Health in America: A Report of the Surgeon General Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

2. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2021.

3. https://www.acd.org/?s=mission+stuatement. Visited May 29, 2023.

4. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to 2023. Available at https://www.ada.org/en/about-theada/principles-of-ethics-code-of-professional-conduct. Accessed on May 29, 2032.

5. Brian, Z., Weintraub, J.A. (2020). Oral health and COVID-19: Increasing the need for prevention and access. Preventing chronic disease. 17. https://www.cdc.gov/pcd/issues/2020/20_0266.htm