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Racial inequality in dental care and oral health is not a new issue. Nor is it something that can be attributed to a single cause. More and more research is demonstrating how, for decades, people of color have been at a significant disadvantage when it comes to accessing and receiving dental care.
The Impact of Inequality of Care
The results of this disparity generally become evident in childhood, with African American children’s rate of untreated dental cavities almost triple that of their white peers by the time they reach their teens. With age comes even greater dental issues that can further jeopardize overall health. African American adults (aged 20-64) experience untreated tooth decay nearly twice as often as white Americans, which leads to black seniors suffering total tooth loss at almost double the rate of white individuals over age 65. This imbalance of care is also evident regarding even more serious oral health matters. Most notably, the fact that African American men historically have a lower 5-year survival rate of oral pharyngeal cancers, with one study citing an 82% higher rate of mortality for the group.
A History of Obstacles for African American Patients
Up until the 1960s, one very real obstacle to receiving care for black Americans was segregated healthcare facilities. Holdovers from the era of Jim Crow, these hospitals not only refused to care for minority patients but also denied physician privileges to minority doctors.
This issue was brought to the forefront by a black patient, Donald Lines. His dentist, George Simkins, Jr., a black dentist in Greensboro, NC recognized that because of a severe tooth abscess, Lines required immediate hospitalization. Dr. Simkins attempted to admit Lines into two white-only hospitals when the facility for black patients was full. Both white hospitals denied the patient care, leading Dr. Simkins to file (and eventually win) a lawsuit claiming that federal support for the white-only hospitals was unconstitutional. The case, Simkins v. Moses H. Cone Hospital, would become instrumental in the desegregation of hospitals throughout the South.
Factors in Racially Biased Dentistry
Today’s barriers to equitable dental care are far subtler than mandated segregation, but still pack potential for severe outcomes.
Socioeconomic
While measures such as those included in the Affordable Care Act (ACA) have increased the number of African American children visiting the dentist, financial concerns (taking time off of work for dental visits, costly out-of-pocket expenses, etc.) are still relevant. However, even when income is removed from the equation, African Americans still show increased oral health disparities compared to Caucasians. The social determinants of this imbalance range from lack of awareness regarding the importance of oral health, to undependable transportation, and even poor food choices.
Lack of Black Dentists
African Americans tend to mistrust the healthcare industry in general, and demonstrate a preference for black practitioners specifically. However, finding a black dentist can be difficult. According to a report produced by the American Dental Association, African Americans comprise 12.4% of the population but only 3.8% of dentists identify as African American. This disproportionate number of black dentists, may also be evidence of even larger, more systemic barriers facing people of color as they try to study dentistry and participate fully in the industry. The results: underrepresented dental practitioners (and underserved communities) of color.
Discrimination from Dental Professionals
According to a recent poll from National Public Radio (NPR), roughly one-third of black Americans have personally experienced racial discrimination when seeking healthcare, with nearly a quarter (22%) saying that they have avoided medical care for themselves or a family member out of concern they would be discriminated based on their race.
Similarly, individuals who have experienced racism are 25 percent less likely to visit the dentist, than those who have not. This is evidenced in a study — focusing on caregivers’ experience in accessing dental care for their children — where African American participants explicitly pointed to racial discrimination as a “major barrier” in seeking care. They reported “overhearing dental receptionists making negative comments about black people,” and white receptionists helping white patients before black patients. In this same study, one participant noted the “stares of people upon entering a private office in a predominantly white neighborhood” and receiving rushed service so that he would not create “problems in the office.”
Differentiations in Treatment
In addition to anecdotal evidence of racial discrimination, research has also brought to light numerous examples of how actual dental care and treatment can differ between black and white patients. One such example involves a randomized clinical trial regarding recommendation for root canal treatment. Overall, participating dentists were significantly more likely to recommend a root canal for white patients, and tooth extraction for black patients, irrespective of the patient’s condition.
Another study, exploring the impact of race regarding surgery recommendations after oral cancer diagnosis, found that black patients were less likely than white patients to receive a surgery referral from their oral healthcare provider — again, irrespective of their cancer stage. The study’s conclusion includes this statement: “This evidence provides support for the hypothesis that health and human service providers contribute to institutional racism in the current healthcare system.”
Mounting Evidence and Need for Action
There is a tremendous amount of evidence demonstrating the very real existence of racial inequality in the area of dental care that is incongruous with the amount of attention the issue receives. That being said, this information has led to some progress in reducing obstacles to care — reaching as far back as ending segregation, as well as (more recently) positively affecting dental insurance coverage and patient education. Additionally, many broad efforts that employ community partnerships have also helped to narrow the gap of care. School-based dental sealant programs, for example, have been proven to be a cost-effective way to improve dental outcomes for many children who would have otherwise not received care. And several individual endeavors are also making inroads, especially in the area of mentoring aspiring African American dentists.
Yet, experts agree that before this imbalance of care can be corrected, its multitude of causes must be met with a multitude of solutions. One examination of the issue suggests the solution lies in intervention at all levels: financial support, structural change, conscious effort, and education; and must incorporate a ‘fundamental-social-cause approach’ that benefits all patients.
Rachel Hardeman is an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health who has been studying racial disparities in health care. Here is what she has said regarding eradicating systemic racism in healthcare: “We all can play a role. Because eventually that collective is what’s going to start to dismantle a lot of these structures that we’re seeing that are creating unequal opportunities.”
Renee Hense is a staff writer at Dentistry.com, the online consumer source for dental education and individuals seeking the information they need to be empowered to become true advocates of better dental health.
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