The Oral Health in America Report: Pulling the Ethics Thread in Practice and Education

Carlos S. Smith, DDS, MDiv, FACD Associate Dean, Inclusive Excellence, Ethics, and Community Engagement, and Associate Professor, Department of Dental Public Health and Policy, VCU School of Dentistry

Understanding ethics and the process of ethical decision making are daily undertakings for oral health professionals. Whether one finds themselves carrying out the daily tasks of a clinician, molding the next generation as an academician, or even simply being a friend of oral health care from various vocations, ethics and our ethical commitments ought to ground the essence of our every interaction. The 2022 Convocation Fellows Forum had, at its purpose, the unpacking of the relatively recently released Oral Health in America: Advances and Challenges, 1 a report from the National Institutes of Health’s National Institute of Dental and Craniofacial Research, published in December 2021, which was the follow-up to the historic and groundbreaking Oral Health in America: A Report of the Surgeon General from the year 2000.2

With the ACD’s mission of advancing excellence, ethics, professionalism, and leadership in dentistry, the Report’s timing, significance with our cultural climate and how and why it matters to dental education is essential. The Report laid out interdisciplinary approaches that direct, conduct, and apply research and implement policies to promote oral health. Detailed were preventive measures as well as obstacles to their implementation and distribution. Also presented was a call for systems change and policy reform, combined with scientific advancements across the research spectrum, greater population-level data and analysis, and community participatory involvement, all to prevent disease and promote population oral and general health. The Fellows Forum presented an unprecedented opportunity for the American College of Dentists, the conscience of dentistry, to engage with many of the Report’s themes and scopes.

The multiple determinants of health and how dentistry and dental education choose to engage or ignore the social and societal components leading to optimal health outcomes are of paramount importance. Social determinants of health (SDOH), as defined by the World Health Organization, are those conditions in which people are born, grow, work, live, and age, and the broader set of forces and systems shaping the conditions of daily life.3 The necessity to be able to characterize those influences on health outside of the realm of healthcare itself led to the development of the SDOH idea. Often, these SDOH play a significant role in who becomes sick, is riddled with disease, or lacks the opportunity to be the healthiest they can be. SDOH are estimated to account for more than 50-60% of health outcomes,4 with some studies indicating that social determinants account for up to 80% of health outcomes.5

Perhaps most intriguing is that the Report gives attention to SDOH, most notably in the section on pediatric dentistry. With the large percentage of patients, particularly those from populations experiencing access to care issues, it seems curious that issues around social and societal needs that go unmet are not linked throughout the report. Why do you think this is? Is this troubling, ethically? Is dentistry too focused on “personal responsibility” to refuse to see how larger systemic issues may result in circumstances beyond the public’s and/or patient’s specific control?

Oral disease is among the most significant unmet health needs in the world, and populations most prone to these diseases are also the most vulnerable: the poor, the very young, the elderly, those with disabilities, and those with comorbidities.6-8

Perhaps most intriguing is that the Report gives attention to

SDOH, most notably in the section on pediatric dentistry. With the large percentage of patients, particularly those from populations experiencing access to care issues, it seems curious that issues around social and societal needs that go unmet are not linked throughout the report. Why do you think this is? Is this troubling, ethically? Is dentistry too focused on “personal responsibility” to refuse to see how larger systemic issues may result in circumstances beyond the public’s and/or patient’s specific control? While general notions around access to care are threaded throughout the report, larger system views and lenses seem to be lacking. To be clear, the issue of racism is only lightly mentioned when a vast number of health and healthcare organizations, such as the American Medical Association, the Amer-