The Practices and Challenges of Indigenizing Dental and Dental Hygiene Education in Canada

ABSTRACT

Objectives

To explore the extent to which Indigenous content is taught in dental and dental hygiene curricula across Canada and to identify their objectives, delivery methods, barriers, and facilitators.

Methods

A descriptive cross‐sectional design was utilized via an anonymous survey developed using the Qualtrics platform. The survey was distributed to faculty members from all 10 accredited dental and 35 dental hygiene programs in Canada. The survey included 29 items focusing on demographic characteristics, Indigenous teaching, methods of delivery, assessment techniques, barriers, and facilitators. Descriptive analysis was conducted using SPSS software version 29.0.

Results

Responses were received from 34 programs; 90% (#9) of the undergraduate dental programs and 71% (#25) of the dental hygiene programs participated. Of the programs surveyed, 94.1% (n = 32) include Indigenous content. On average, 12.94 ± 7.44 h was dedicated to teaching such content. The most common delivery method was didactic format (88%), and the most frequently covered topics were history and Indigenous people's health, each covered in 79.4% of programs. Major barriers identified were overcrowded curricula (83.3%) and faculty shortages (58.3%), while key facilitators included supportive institutional policies (71.4%) and engagement with Indigenous experts (61.9%).

Conclusions

The study reveals that most Canadian dental and dental hygiene programs that responded included Indigenous content within their training. However, barriers such as overcrowded curricula and faculty shortages persist. Supportive institutional policies and the involvement of Indigenous professionals are vital for effective curriculum indigenization.

1. Introduction

The Indigenous Peoples in what is now Canada are defined as First Nations, Inuit, and Métis, and according to the 2021 Canadian census, they made up 6.1% of the Canadian population [1]. Oral health contributes to the well‐being of any individual. However, for Indigenous Peoples in Canada, the colonial policies, globalization, and transition to Western diets high in sugar and processed ingredients have resulted in a much higher burden of oral diseases compared to their nonindigenous counterparts [2, 3, 4]. Moreover, a significant number of Indigenous Peoples experience constant pain in their mouths and have a higher rate of tooth loss compared to the general Canadian population [5].

Mainstream health services continue to inadequately meet the needs of Indigenous Peoples. This inadequacy arises from their foundation in colonial and Westernized biomedical values, with an absence or limited appreciation for holistic understandings of well‐being [6]. The 2015 report by Canada's Truth and Reconciliation Commission (TRC)¹ called for improved healthcare for Indigenous Peoples. The Calls to Action #23 urges the government to increase the number of Indigenous healthcare providers, retain them in Indigenous communities, and provide culturally safe training for all healthcare professionals. The Call to Action #24 urges medical and nursing schools in Canada to offer courses on Indigenous health issues, including history, treaties, Indigenous teachings, and cultural competency training [7]. Other countries, including Australia [8] and New Zealand [9], have answered such calls for curricula indigenization.

In Canada, educational institutions have tried to address Indigenous health content through decolonizing care practices within the health system [10]. Still, most dental and dental hygiene curricula focus on oral and clinical science, with some emphasis on health promotion and prevention, motivational, and communication strategies [11]. While Canadian dental and dental hygiene training programs follow competency frameworks to guide their curricula [12, 13, 14], only the dental hygiene competency document explicitly mentions First Nations [14, 15]. Not surprisingly, more than half of the senior dental students from one Canadian dental school were not confident in treating patients from diverse cultural groups, including Indigenous Peoples, due to insufficient cultural competence training [13]. Similarly, a curriculum review in an Australian university emphasized the importance of increasing transcultural content in the dentistry curriculum [16], similar to a study from the University of Alberta [17]. Moreover, a recent scoping review explored the worldwide literature on Indigenous content within the oral health professions education curricula and only found 23 studies reporting teaching such content [18]. However, barriers still exist to promote such practices, including the limited number of Indigenous faculty [19], the need to train nonindigenous faculty, and the lack of proper framework regarding the implementation of Indigenous content [19, 20]. Additional challenges include competing priorities within the university, faculty and programs, and the notion that curricula are already crowded [21]. Nonetheless, it remains unknown as to whether or not dental and dental hygiene curricula in Canada have been Indigenized. Therefore, this study aimed to explore the extent to which Indigenous content and its objectives, delivery methods, and assessment are addressed within dental and dental hygiene curricula across Canada and to identify the barriers and facilitators to addressing such content. For this study, Indigenization was defined as any approach or philosophy of education characterized by delivering Indigenous content and cultural perspectives to oral health professionals, and Indigenous content refers to information, knowledge, and learning methods passed down through generations by Indigenous people.

2. Methods

2.1. Research Design

This study followed a descriptive cross‐sectional design via a national survey exploring the current pedagogies employed by all Canadian dental and dental hygiene programs to teach Indigenous content. While the study provides a national overview, it is not an in‐depth analysis but rather offers a broad understanding of how Indigenous content is currently addressed across programs. Ethics approval (H23‐01846) was obtained from the University of British Columbia. The respective Behavioral Research Ethics Board Office was consulted and advised that, given the nature of the study, it did not need to go through the Indigenous Research and Ethics Review Board.

A 29‐item survey was developed in English and French, using the Qualtrics platform (Provo, UT, USA), to address the proposed objectives as shown in the Supporting Information. The survey was pilot‐tested with two faculty members chosen based on their experience in curriculum design and with four oral health graduate students, all at the University of British Columbia, who provided insights used to refine the survey before the main data collection. The completion time for the survey was estimated to be approximately 10 min. The introductory page of the survey served as an invitation and consent form for participation, detailing the study's objectives, methods, and confidentiality assurances. The survey consisted of both closed‐ and open‐ended questions tailored to collect data on the following areas:

Demographic Information: Five questions identified the respondents' programs, the name of their institution, and whether participants had received Indigenous competency training themselves; no participants’ names or any other identifier was collected.

Indigenous Teaching: The remaining 24 questions focused on teaching objectives, content covered, number of instructional hours, pedagogies utilized, employed assessment techniques, as well as barriers and facilitators in incorporating Indigenous content within the curriculum.

Display logic was used so that different sets of questions appeared based on respondents’ answers. Although the name of the participating institution was requested to track responses, this information was not reported in the results, and respondents were informed accordingly.

2.2. Participants and Data Collection

Dentistry and dental hygiene educational institutions were identified through the official list provided by the Commission on Dental Accreditation of Canada (CDAC) website [22]. The total number of educational institutions at the time was 45, comprising 10 dental and 35 dental hygiene programs, and made up the purposefully targeted sample for the survey. Within each institution, faculty members (program or curriculum coordinators, instructors for Indigenous‐related courses) were identified per their academic duties and roles as described on their respective websites. One individual per program was then initially invited to participate in the survey. These individuals were asked to complete the survey themselves or forward it to a more informed colleague involved in teaching Indigenous content. While the findings may not be generalizable to all individuals involved in oral health education, this sampling approach ensured the representativeness of faculty members from the target educational institutions who would have the expertise to fulfill the study's objectives.

The survey was distributed via email between September and October 2023. The email included an invitation to participate in the study and a link to the electronic survey. Each completed survey represents a single respondent deemed most knowledgeable by either self‐identification or referral. Follow‐up emails were sent weekly for 4 weeks to nonrespondents to increase participation. Also, to encourage participation, respondents were offered the option to provide their email at the end of the survey to be entered into a random draw for one of five $50 gift cards. To maintain confidentiality, responses were collected through an anonymous link, and any identifiable data provided for the draw were anonymized prior to data analysis, as outlined in the informed consent.

2.3. Data Analysis

Following de‐identification, the survey data were imported from Qualtrics into SPSS software version 29.0 (SPSS Inc., IL, USA). The data were initially screened for missing values and outliers. Due to the survey design in Qualtrics, which required respondents to answer each question before proceeding, no missing values were found. Additionally, no outliers were detected.

Given that the survey included questions that allowed the respondents to select more than one answer option from a list of choices, each response option was dichotomized using “0 = no” and “1 = yes.” In cases where respondents selected more than one option for a question, each combination of selected options was assigned a unique code to ensure a comprehensive record of responses. Subsequently, descriptive analyses were conducted to determine the frequency and means of responses, as well as calculate general data trends. As nonparametric and parametric statistical tests lack statistical power with small samples and preclude achieving statistical significance, those tests were not conducted.

3. Results

Surveys were completed by 34 educational institutions: 9 undergraduate dental programs and 25 dental hygiene programs. Despite four institutions having both dental and dental hygiene programs, the primary unit of analysis was the program itself. Therefore, the survey achieved a response rate of 90% (n = 9) for undergraduate dental programs and 71% (n = 25) for dental hygiene programs.

3.1. Indigenous Teaching Programs

Out of the 34 surveyed institutions, 32 (94.1%) included Indigenous content in their curricula, encompassing all 9 (100%) dental programs and 23 (92%) dental hygiene programs participating in the study. More than half of the respondents (55.9%, n = 19) offered Indigenous content across multiple academic years, while 32.4% (n = 11) included it in a single academic year. Incorporating Indigenous content into one or more courses was most common, with 97% (n = 32) of the respondents reporting this approach. However, only 11.8% (one dental and three dental hygiene programs) had developed a separate course dedicated to Indigenous content. Indigenous content education was optional in one dental hygiene program, while four dental hygiene and one dentistry program included both mandatory and optional courses. The other 24 programs offered it as mandatory. On average, programs dedicated 12.94 ± 7.44 h (2–42 h) to teaching Indigenous content. The two most mentioned objectives of programs to include Indigenous content were to promote cultural awareness (82.4%, n = 28) and to improve the overall quality and relevance of the programs (64.7%, n = 22). The least cited reason was to comply with regulatory requirements or accreditation standards (26.5%, n = 9). According to Figure 1, lectures and seminars were the most employed delivery method in both dentistry and dental hygiene programs, either alone or in combination with other approaches, with 88% and 87% usage in each program, respectively. In dental hygiene programs, small group discussions were employed by 83% of the institutions. In dentistry programs, small group discussions and case studies/vignettes were equally common, each used in 55% of programs. Notably, one dental hygiene program reported using all the presented methods in the survey. Additionally, 16 programs (47.1%), including 5 dentistry and 11 dental hygiene programs, mentioned inviting guest speakers, including Indigenous representatives or elders.

FIGURE 1.

Employed delivery method by program type.

Among the programs incorporating Indigenous content, only 11.8% (n = 4) addressed all the listed topics in the survey (Figure 2 and Table 1). The most frequently covered topics in both dentistry and dental hygiene programs were “History” and “Indigenous People's Health,” with 27 programs (79.4%) addressing these areas. In dental hygiene programs, “Culture and Identity” was also commonly covered, with 20 respondents (87%) tackling this topic. In contrast, fewer than half of the dentistry programs (n = 4) addressed “Culture and Identity.” Additionally, one program mentioned covering “Indigenous Worldview in Oral Health Care Research.” The most employed assessment techniques were written exams (59.2%) and reflective journals (51.9%) by all the programs combined. While 76% (n = 19) of the dental hygiene programs utilized at least one form of assessment, 5 dental programs reported not using any form of assessment (Table 2).

FIGURE 2.

Addressed Indigenous topics based on the program type.

TABLE 1.

Description of the designated numbers according to Figure 2

Addressed Indigenous topics	Number	Addressed Indigenous topics	Number
History	1	Colonial policies and aboriginal rights	10
Culture and identity	2	Colonial histories	11
Indigenous diversity	3	Aboriginal health governance	12
Indigenous peoples' health	4	Healthcare system and Indigenous people	13
Racism and impacts on Indigenous health	5	Two‐eyed seeing and models of wellness	14
Stewardship, resistance, and activism	6	Research and health outcomes	15
Trauma‐ and violence‐informed care	7	Community engagement and transforming care	16
Determinants of Indigenous people's health	8	Effect of colonialism	17
Culture, language, and self‐determination	9

TABLE 2.

Employed methods of assessment by the program type

	Program type
Employed assessment techniques	Undergraduate dental programs (n = 7)	Dental hygiene programs (n = 20)	Total (n = 27)	Percentage
No assessment	5	1	6	22.2%
Written exams (multiple choice, pretest–posttest, etc.)	2	14	16	59.2%
Community feedback	0	8	8	29.6%
Objective structured clinical examination (OSCE)	0	2	2	7.4%
Reflection/reflective journal	0	14	14	51.9%
Report/essay	0	7	7	25.9%
Oral presentation	1	9	10	37%
Discussion	0	3	3	11.1%

A total of 12 programs (37.5%) reported experiencing barriers in teaching Indigenous content. Among these, the most prevalent barriers identified included “packed curriculum” (83.3%), “shortage of faculty members” (58.3%), and “lack of knowledge” (50%) (Table 3). Additionally, four programs cited other barriers not listed in the survey options, including “lack of Indigenous faculty in the institution,” “challenges in achieving consistent collaboration with Indigenous communities,” “competing priorities with other equity focuses and staff hesitancy/discomfort with Indigenous‐focused content,” and a “lack of support from the institution.”

TABLE 3.

Barriers to Indigenous education

Barriers	Program type		Total (n = 12)	Percentage
	Dentistry (n = 5)	Dental hygiene (n = 7)
Lack of knowledge	3	3	6	50%
Lack of interest	3	1	4	33.3%
Lack of budget	2	1	3	25%
Packed curriculum	4	6	10	83.3%
Shortage of faculty members	3	4	7	58.3%

A total of 21 programs (65.6%) reported having factors in their program that seemed to have facilitated the teaching of Indigenous content. Among these, the most mentioned facilitator was a “supportive institutional policy” (71.4%), followed by “engagement with Indigenous faculty or experts” and “access to relevant teaching materials and resources,” each mentioned in 13 programs (61.9%). The least cited factor was “student demand and interest” (19%, n = 4). Additionally, two programs cited other facilitators not listed in the survey options: One dental hygiene program mentioned “accreditation requirements,” while one dentistry program highlighted “having one Indigenous faculty member responsible for including Indigenous content; otherwise, administration is not supportive of Indigenous content or policies.”

4. Discussion

This study utilized a survey to explore the extent to which Indigenous content has been part of the dental and dental hygiene curricula across Canada. The survey also identified the objectives, delivery methods, and assessment techniques employed, as well as the barriers and facilitators to incorporating such content. To our knowledge, this is the first study of its kind to explore the extent of curriculum Indigenization within Canadian dental and dental hygiene programs on a national scale. The findings provide valuable insights into the current state of Indigenous education in these programs and highlight key areas for improvement.

The survey achieved a response rate of 90% for dental programs and 71% for dental hygiene programs, which is notably higher than the average response rate for electronic surveys [23]. The findings indicated that 94.1% of the programs surveyed cover Indigenous content, which may reflect a growing recognition of the importance of Indigenous‐related teaching in preparing healthcare professionals to provide culturally competent care in Canada [7, 24, 25].

The primary objectives for including Indigenous content in the participating programs were to promote cultural awareness and improve the overall quality and relevance of their programs. Similar objectives have been reported in other studies assessing cultural education in health sciences [26, 27, 28]. These findings also align with broader goals of enhancing cultural competence to ensure that healthcare professionals are equipped to address the unique needs of Indigenous Peoples, as emphasized by the TRC [7]. However, compliance with regulatory requirements or accreditation standards was the least cited objective, probably because only the dental hygiene competency document explicitly mentions Indigenous topics/First Nations [14, 15], which may suggest that intrinsic motivations related to improving care quality and cultural understanding are likely more influential for the dental programs. This is also evident in a study by Arcobelli [29] on physiotherapy curricula, who found that the primary drivers for curricular development related to Indigenous Peoples were internal to the university rather than regulatory requirements.

We found that Canadian dental programs varied widely in their curricular combinations of topics related to Indigenous content. The diversity in curricular content and the wide range in the number of hours dedicated to this content suggest that interpretations of what constitutes Indigenous‐related content, the amount of time needed to cover such content, and what should be included in oral health curricula may differ significantly between programs. These variations may also result from differences in terminology used for the topics covered [29, 30]. For example, what some programs teach under “Culture and Identity” may be referred to as “Culture, Language, and Self‐Determination” in other programs, given that both options were given in the survey. Incorporating diverse content may not only help students develop self‐awareness but also prompt them to critically assess their own beliefs, leading to an increase in cultural competence [31]. However, determining the adequacy of coverage for certain topics remains a challenge. While some may argue that limited coverage indicates insufficient inclusivity, others may consider that the current content is sufficient. This raises the important question: how much is enough? [32]. But it also reflects the inherent aspects of training a robust oral health care provider within the time constraints of a usually crowded curriculum, where more often than not, students ponder, “What I wished I'd learned at dental school” [33, 34]. Either way, there is a need for more thorough curriculum development that ensures that all relevant areas are covered sufficiently.

This study revealed a preference for traditional didactic formats, such as lectures and seminars, as the most common methods used to deliver Indigenous content, consistent with previous research on cultural competency education [26, 30]. However, the challenge with traditional educational approaches is that they often hinder critical questioning of content, purpose, and relationships [35]. But in addition to these conventional methods, many programs also used interactive approaches, including small group discussions, case studies, and vignettes, aiming to engage students through discussion and reflective‐based learning. Notably, 47.1% of the programs invited guest speakers, including Indigenous representatives or elders, along the lines of the community as the teacher pedagogy [36]. This practice enriches the educational experience by providing students with direct insights from Indigenous perspectives, fostering a deeper understanding and respect for Indigenous cultures and practices [26].

Regarding assessment, a notable disparity was observed between dental and dental hygiene programs. While most dental hygiene programs utilized at least one form of assessment, only two dental programs reported employing assessment methods. Despite the ongoing debate on whether assessment drives learning, it is argued that active and purposeful engagement with students and the thoughtful use of assessments and feedback can indeed enhance learning [37, 38]. Therefore, the disparity in assessment practices highlights a potential area for institutional support to ensure that all students are evaluated effectively and consistently.

In terms of barriers to teaching Indigenous content, a packed curriculum, a shortage of Indigenous faculty members, and lack of knowledge were prevalent. These challenges are consistent with findings from studies on other health programs [20, 21, 39]. For example, Doria et al. highlight that some non‐Indigenous educators fear perpetuating stereotypes and prefer to avoid delivering Indigenous content altogether rather than risk doing it poorly [21]. Moreover, faculty members' sense of readiness, in terms of knowledge and comfort in teaching Indigenous content, was noted as a challenge in many other studies as well [19, 29, 40–42]. Time constraints within already crowded curricula often result in the superficial inclusion of Indigenous‐related content, limiting meaningful engagement and depth [21]. In order to address these barriers, resources are available, including the Australian “Health Curriculum Framework” [43] and the CIPHER (Competencies for Indigenous Public Health, Evaluation, and Research) report [44], which is a collaborative effort by researchers from Canada, Australia, New Zealand, and the United States to provide an overview of Indigenous curricula and initiatives. These resources can offer valuable guidance and strategies for integrating Indigenous content effectively.

In fact, respondents identified several factors that facilitated the teaching of Indigenous content, including the availability of resources, supportive institutional policies, and active engagement with Indigenous faculty or subject matter experts. These facilitators underscore the importance of institutional commitment and collaboration with Indigenous People in enhancing the quality and delivery of Indigenous content that should be informed and directed by their voices and supported by allies ^{[ 2 ]} with the appropriate expertise [21, 45]. The importance of ensuring that Indigenous perspectives are at the heart of educational practices and curriculum development was also emphasized by participants. However, student demand and interest were the least cited facilitators. This may reveal a gap in valuing cultural competence compared to clinical proficiency by students [18, 31, 46–48]. This may also indicate a need for greater efforts to raise awareness and appreciation for the importance of Indigenous cultural practices among students. One suggested approach is providing real‐world experiences within Indigenous communities, which can increase students' acknowledgment of Indigenous knowledge and culture and expose them to Indigenous health issues [27, 49].

In turn, it becomes imperative to foster stronger partnerships with Indigenous Peoples, enhance training for educators, and advocate for supportive policies. By doing so, we can work towards creating a more inclusive and culturally respectful educational environment. This will better prepare oral healthcare professionals to meet the unique needs of Indigenous people, ultimately contributing to improved oral health outcomes and overall well‐being for Indigenous people in Canada. This endeavor is not only about fulfilling educational mandates but also about fostering a deeper understanding, respect, and collaboration that takes us one step closer to reconciliation. Such educational efforts should be ongoing and not just a “ticked box” on the school's and program's repertoires. Nonetheless, the challenges to incorporating Indigenous content into dental education we found herein might not be unique to Canada, as these issues might be inherent to educational institutions globally within the communities serving Indigenous populations.

4.1. Limitations

Despite the high response rate and potentially being the first study to explore the extent of curriculum Indigenization in all Canadian dental and dental hygiene programs, this study has limitations. One limitation is the reliance on participants' self‐assessment of the extent of Indigenization in their curricula. The accuracy of their responses may have been influenced by participants' perspectives, biases, or limited awareness of the full scope of Indigenization. Additionally, we could not ensure that the respondents were the instructors themselves knowledgeable about the Indigenous content in their programs; thus, caution should be exercised when generalizing these findings. Another limitation is the potential for socially desirable answers. Although respondents were assured that personal identification and institutional names would not be disclosed, there could have been a tendency for participants to overestimate the extent of Indigenization in their curricula. Furthermore, this study provides only a cross‐sectional snapshot and, therefore, does not capture dynamic changes or long‐term impacts associated with curriculum development. Finally, this research represents only one approach to understanding institutional positions and does not capture the perspectives of Indigenous communities themselves, including what they feel dental students should know, nor does it reflect what students themselves desire to learn to effectively care for Indigenous patients. These limitations necessitate future inquiries to address them accordingly.

5. Conclusion

This study has provided an overview of the current state of Indigenous content within Canadian dental and dental hygiene programs, with the majority of the participating programs poised to cover such important content, likely recognizing the value of Indigenous‐related teaching in preparing healthcare professionals. However, it also highlighted several persistent challenges, including the limited scope of such content, lack of assessment in many programs, the predominance of traditional didactic teaching methods, and barriers such as overcrowded curricula and faculty shortages. Despite these obstacles, supportive institutional policies and the engagement of Indigenous experts have emerged as vital facilitators for effective curriculum Indigenization and should be utilized for improving educational practices and health outcomes in Indigenous communities.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File: jdd13945‐sup‐0001‐SuppMat.docx

Shokouhi P., Donnelly L., Ardenghi D. M., Slack‐Smith L., and Brondani M., “The Practices and Challenges of Indigenizing Dental and Dental Hygiene Education in Canada.” Journal of Dental Education 90, no. 2 (2026): 166–173. 10.1002/jdd.13945