Oral Health Inequities: An AJPH Supplement to Help Close the Gap

While health disparities have been stressed since the late 1970s (http://bit.ly/2r3lWfQ) and early 1980s (http://bit.ly/1Q5LUaX), it was not until the publication of the Oral Health in America: A Report of the Surgeon General (http://bit.ly/2r3pO0H) in 2000 that oral health inequities were brought to attention. Since then, efforts have been made to close the gap between and among different groups of the population.

33 ORAL HEALTH OBJECTIVES

The midcourse review of the Healthy People 2020 published early this year suggested that 16 of the 33 oral health objectives had met or exceeded their targets (http://bit.ly/2r9NXqa), but oral health inequities have persisted despite the progress achieved since the Oral Health in America report in 2000. For example, the target for all children experiencing dental caries in their primary dentition was set at 30%. The midcourse review showed a decrease of 3.6 percentage points (29.7%; 2013–2014) from the baseline burden of dental caries (33.3%; 1999–2004), with female (31.2%), Mexican American (41.5%), and African American (30.3%) children carrying a disproportionate burden of dental caries in their primary dentitions. However, a challenge is the lack of a uniform and inclusive data collection that could be used to monitor oral health within and between groups representing the population.

MONITORING ORAL HEALTH INEQUITIES

Documenting and monitoring inequities in the oral health status in the US population between and within groups as well as over time requires routine data collection using uniform definitions and measurements, group and subgroup comparisons, as well as comparison and reference groups or targets used. Consider periodontal diseases as an example: at baseline, periodontal diseases were determined using a partial recording (i.e., two random quadrants), whereas for the midcourse they were assessed using a full-mouth recording examination. There is evidence that the former may lead to a 50% underestimation of the true prevalence in the population.¹ Similarly, the age groups and targets have been changed between Healthy People 2010 and 2020. To reduce the proportion of children experiencing dental caries in the primary teeth, children aged two to four years were selected for Healthy People 2010 with a target of 11%, whereas children aged three to five years were selected for Healthy People 2020 with a target of 30%. Consistencies in these criteria and over time are crucial if we are serious about health disparities and inequities in the United States.

A COLLECTION OF 30 ARTICLES

Over the years, the central focus of oral health inequities has been around individual characteristics such as age, sex, race/ethnicity and socioeconomic indicators. However, little attention has been paid to the role of the workforce, access to care, and population with the greatest oral health needs.² In line with our record of publication,^3–5 this supplemental issue of AJPH comprises a collection of 30 articles including editorials, analytic essays, public health practice, commentaries, briefs, and research articles on diversification of the health profession to address oral health inequities and attend the needs of vulnerable populations. These articles are aggregated under three broad categories: inequities, vulnerable populations, and professional diversification.

ORAL HEALTH INEQUITIES

The first set of articles (n = 12) underscores the persistency of oral health inequities in the United States. The editorials start by revisiting the Oral Health in America Report (Satcher and Nottingham, p. S32), underscoring the oral health inequities in Asian and Pacific islanders (Le et al., p. S34), presenting the National Institute of Dental and Craniofacial Research’s perspective in oral health disparities (Fischer et al., p. S36), and making a case for the importance of oral health for a productive life (Sullivan, p. S39). The remaining articles call attention to the issues contributing to these inequities: reimbursements and Medicaid for children and older adults, oral health as part of health insurance coverage, and lack of access to care among Hispanic and Asian American adults (pages S61–S111).

VULNERABLE POPULATIONS

The second set focuses on vulnerable populations (n = 7). These articles stress the need to provide access for uninsured and underserved populations through a private, nonprofit health care system that could improve the health status of rural low-income children (Harrell et al., p. S48), the importance and need for dental home for older Americans (Chávez et al., p. S41; Raphael, p. S44) and incarcerated populations (Makrides and Shulman, p. S46), the delivery of care in a correctional facility clinic (Simon et al., p. S85), the use of an effective and efficient dental team to eliminate oral health disparities among tribal and other underserved communities (Cladoosby, p. S81), and oral health intervention in a vulnerable and neglected population such as African American men (Hoffman et al., p. S104).

DENTAL PROFESSION

The third and final set of articles (n = 11) raises an important issue: the shortage of dental professionals and how the diversification of the profession could be enhanced to help reduce oral health inequities. These articles start by addressing the need for partnership and expansion of the traditional dentist-centered system approach to address oral health inequities equity (Harper et al., p. S10), and the most needed inclusion of dental therapists and registered dental hygienists to expand dental care to those carrying the higher burden of oral health diseases (pages S8–S31).

A STARTING POINT

Together, these articles emphasize oral health as an important part of an individual’s overall health and provide a starting point for a much needed and timely discourse on oral health inequities, and on the limitations of the current dental care delivery system to address such inequities. In addition to the workforce, these articles raise issues around the diversity of the US population and the need to identify the challenges and policy strategies that could reduce or close the gap in oral health, such as recognizing proximal and distal causes to approach oral health and health care delivery systems, designing integrated prevention and treatment programs for chronic diseases including oral health, integrating precision medicine principles in oral health treatment and delivery of care, and last but most importantly, considering oral health as an essential component of health insurance coverage.