The Hispanic and Latino dentist workforce in the United States

Identifying factors influencing orthodontic residency program selection

PURPOSE

The desirability of Orthodontic Residency remains high today relative to the past 30 years. This investigation seeks to re-assess factors influencing Orthodontic Residency program selection amidst contemporary challenges and changes, including increasing student debt, reduced residency stipends, and shifting practice models.

METHODS

This mixed-methods study consisted of interviews (qualitative) and surveys (quantitative). Fifteen final-year dental students and first-year orthodontic residents were interviewed one-on-one following a topic guide and then transcripts were analyzed using MAXQDA2022 to identify values, factors, and influences related to program selection and ranking. Qualitative findings and previous studies provided the basis for a survey distributed to residency applicants in 2020-22. Data were analyzed with bivariate and descriptive statistics with stratification by debt group.

RESULTS

Interviews (N = 15) elevated the importance of location, interview experience, program cost, and clinical education. Surveys (N = 239) identified the most desirable factors for program selection: satisfied residents, strong clinical training with multiple techniques, good interview impressions, low cost, high patient numbers, a strong reputation, and good clinical facilities with new technology. Less desirable factors include programs that are hospital-based, certificate-only, research-intensive, and require considerable after-hours work.

CONCLUSIONS

Clinical education and interview experiences are key for residency selection, consistent with prior studies, though program cost has grown in importance. Findings can help guide orthodontic programs in recruiting applicants and suggest a need to limit educational costs.

Applying a systems oriented ethical decision making framework to mitigating social and structural determinants of health

Objectives

Clinical ethical decision-making models are largely geared toward individual clinician choices and individual patient outcomes, not necessarily accounting for larger systemic issues that affect optimal patient outcomes. The purpose of this paper is to provide an ethical decision-making model, drawing upon systems orientation and ethical theory, specifically incorporating and aiding in the mitigation of social and structural determinants of health.

Methods

This paper presents a systems-oriented ethical decision-making framework derived from the analysis and critique of the Four-Box Method for Ethical Decision-Making by Jonsen, Siegler, and Winslade. Drawing upon both deontological and utilitarian ethical theory, the developed framework will assist providers, organizations, and health system leaders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations, who are largely impacted by social and structural determinants of health.

Results

The needs of underserved patients are inextricably linked to various social and structural determinants of health that, if left unaddressed, result in even poorer health outcomes, exacerbating existing health disparities. A systems-oriented ethical decision-making framework, centered on obligation, duty, and a utilitarian view of the optimal good, will aid providers, organizations, health system leaders, and community stakeholders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations.

Conclusion

Socioeconomic and political contexts have a significant impact on the way society is organized, how people are positioned in society, and how they will fare in terms of their health. Healthcare providers, including dentists, are largely unaware of and insensitive to the social issues that underlie the biological or psychological concerns that patients from socially disadvantaged backgrounds face. A systems-oriented ethical decision-making model will aid in mitigating social and structural determinants of health and the dental profession's obligations to the underserved.

Dentists Who Participate in Medicaid: Who They Are, Where They Locate, How They Practice

Low utilization of dental services among low-income individuals and racial minorities reflects pervasive inequities in U.S. health care. There is limited research determining common characteristics among dentists who participate in Medicaid or the Children's Health Insurance Program. Using detailed Medicaid claims data and a provider database, we estimate that among dentists with 100 or more pediatric Medicaid patients, 48% practice in high-poverty areas, 10% practice in rural areas, and 29% work in large practices (11 or more dentists). Among those with zero Medicaid patients, 18% practice in high-poverty areas, 4% practice in rural areas, and 11% work in large practices. We found that dentist race/ethnicity has an independent effect on Medicaid participation even when adjusting for community characteristics, meaning non-White dentists are more likely to treat Medicaid patients, regardless of the median income or racial/ethnic profile of the community.

Exploring the impact of household, personal, and employment characteristics on dentistry's income gap between men and women

BACKGROUND

This study provides an update on the income gap between men and women in dentistry, evaluating the impact of dentists' household, personal, and employment characteristics on income differences.

METHODS

This cross-sectional study used data from the US Census Bureau's 5-year American Community Survey (2014-2018). Data were analyzed using descriptive statistics and regression analysis (ordinary least squares regressions, Oaxaca-Blinder regression decomposition on logged personal income).

RESULTS

Female dentists were less likely to be White and born in the United States and more likely to be bilingual than male dentists. Adjusted estimates indicated that male dentists earned 22% more than female dentists (risk ratio, 1.22; 95% CI, 1.15 to 1.29). Black dentists earned 24% less (risk ratio, 0.76; 95% CI, 0.68 to 0.85) and other race non-Hispanic dentists earned 17% less (risk ratio, 0.83; 95% CI, 0.70 to 0.97) than non-Hispanic White dentists, after adjustment for covariates. Dentists with a nondentist partner or spouse earned more than those without a partner or spouse, and dentists with 3 or more children earned 19% more than those who were childless (P < .001; 95% CI, 1.09 to 1.31). The income gap between sexes was $51,784 (in 2018 dollars); 27.2% of this gap was explained by observable personal (that is, race and ethnicity, bilingualism), employment (for example, hours worked and employee or ownership status), and household (for example, partner or spouse occupation and education) characteristics.

CONCLUSIONS

The dental workforce is diversifying, but sex and racial disparities in income persist. The income gap between sexes, although reduced over time, is now less explainable than in the past.

PRACTICAL IMPLICATIONS

The diversification of the dental workforce is a promising sign for an increasingly diverse population's present and future oral health, but it is important that existing income gaps between men and women are addressed.

Dental diaspora: oral health care attitudes and experiences in culturally and linguistically diverse mothers in Australia

Background

Globally oral health care is unequally accessible or utilised within culturally and linguistically diverse (CALD) migrant communities. Yet much remains unknown about CALD mothers and their oral healthcare experiences in Australia. Hence, this paper explores the oral health care attitudes and experiences of CALD mothers within the Australian context with the broader objective to reduce oral health inequalities.

Methods

Qualitative semi-structured interviews were conducted from a social constructivism paradigm. Participants were foreign country born, spoke language/s other than English and have a child. Purposive snowball sampling and recruitment was conducted through CALD organisations and social media. Participants were interviewed for their attitudes and experiences to dental care and frequency of utilisation in Australia and the home country. Interviews were transcribed verbatim and grounded analysis (Strauss and Corbin) performed. Researcher bias was reduced through reflexivity and triangulation.

Results

The participants (n = 33) included 20 CALD mothers born in India and 13 from either China, Fiji, Nepal, Macedonia and Israel. The theme, experiences with health workforce personnel revealed positive attitudes toward CALD providers from similar cultural and/or linguistic backgrounds. We coin these CALD providers as the ‘dental diaspora’. The dental diaspora facilitated CALD mothers through culture and/or language factors, alleviating cost barriers and flexibility in appointments. Dental travel to the home country was affirmed, however family visitation was the foremost reason for travel.

Conclusion

The findings suggest that the dental diaspora plays a significant role in promoting oral health care utilisation for first generation CALD mothers in Australia. This paper brings to light the phenomenon of the ‘dental diaspora’ as an essential health workforce that contributes to addressing inequities in oral healthcare utilisation within CALD migrant communities. Universal health coverage in oral health is further affirmed, as aligned to the WHO policy context.

Oral health inequities: Recommended public policies to achieve health equity

In the United States (US), racial and ethnic minority populations experience poorer oral health than the general population. Social and commercial determinants of health embedded in structural and institutional racism and/or discrimination generate and exacerbate oral health inequities. We provide examples of oral health disparities (including oral health status and workforce issues) among selected racial and ethnic minority groups in the US. In addition, we compiled four priority areas based on research over the last two decades to guide actions to improve oral health equity. These four priority areas aim to improve health care models, interventions, and policies to help close gaps and reduce disparities in oral health and access to dental care.

Establishing an antiracism framework for dental education through critical assessment of accreditation standards

PURPOSE

The purpose of this manuscript is to establish an antiracism framework for dental education. Since the accreditation process is an influential driver of institutional culture and policy in dental education, the focus of the framework is the Commission on Dental Accreditation (CODA) standards for predoctoral education.

METHODS

The authors of this manuscript reviewed each CODA predoctoral standard for opportunities to incorporate antiracism strategies. Eight standards were identified under themes of diversity (Standards 1-3, 1-4, 4-4), curriculum development (Standards 2-17, 2-26), and faculty recruitment and promotion (Standards 3-1, 3-4, 3-5). Guided primarily by National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, a logic model approach was used to critically assess those standards for opportunities to establish antiracism strategies, with anticipated outcomes and impacts.

RESULTS

Strategies highlighted a need to improve recruitment, admissions, and accountability among dental schools to address the low numbers of historically underrepresented racial and ethnic (HURE) students and faculty. They emphasized the inclusion of racism in curricula geared toward training dental students to provide care to HURE populations. Finally, there are opportunities to improve accountability that dental schools are providing equitable opportunities for career advancement among HURE faculty, with consideration of conflicting demands for scholarship with HURE student mentoring, role modeling, teaching, and/or service.

CONCLUSIONS

The framework identifies gaps in CODA standards where racism may be allowed to fester, provides specific antiracism strategies to strengthen antiracism through the accreditation process, and offers dental education programs, a process for evaluating and establishing their own antiracism strategies.

Slipping through the cracks: Just how underrepresented are minorities within the dental specialties?

Objective

There is a lack of diversity in the dental workforce. Efforts to enhance underrepresented minority (URM) recruitment and retention within dental school exist, but little effort has been made to track URM providers through education and practice. This study assesses the status of workforce diversity in the dental specialties and the predictors of URM dentist specialization.

Methods

The primary data used were a 2012 national sample survey of Hispanic/Latino (H/L), Black, or American Indian/Alaska Native (AI/AN) dentists in the US, supplemented by publicly available workforce data. Descriptive and multivariate statistical analyses were performed to describe the demographic composition of URM clinical general and specialist dentists and analyze changes in proportions of URMs specializing among age cohorts, differences in specific type of specialization, and racial concordance between specialists and their patients.

Results

The pathway continues to winnow with fewer URM dentists in specialty practice. Among all URM clinical dentists being first in his/her family to obtain a college degree, having a strong desire to work in his/her own cultural community or joining a loan repayment program due to debt load independently predicted lower odds of specialization. Alternatively, being initially foreign trained as a dentist and valuing professional training were independently predictive of higher odds of specialization.

Conclusion

The lack of diversity within the dental specialties is a critical flaw in our education and care delivery systems demanding clear actions toward improving the pathway into residency programs for URM students.

American Indian/Alaska Native, Black, and Hispanic dentists' experiences of discrimination

OBJECTIVE

Little is known about the scope and role of discriminatory experiences in dentistry. The purpose of this study is to document the experiences that American Indian/Alaska Native (AI/AN), Black, and Hispanic dentists have had with discrimination.

METHODS

This study reports data from a 2012 nationally representative study of dentists documenting experiences with discrimination during their dental careers or during dental school by the setting of the discrimination, the providers' education, and geographic location. This study does not differentiate between levels of discrimination and focuses holisticly on the experience of any discrimination.

RESULTS

Seventy-two percent of surveyed dentists reported any experience with discrimination in a dental setting. The experiences varied by race/ethnicity, with 49% of AI/AN, 86% Black, and 59% of Hispanic dentists reporting any discriminatory experiences. Racial/ethnic discrimination was reported two times greater than any other type.

CONCLUSIONS

Experiences with racial/ethnic discrimination are prevalent among AI/AN, Black, and Hispanic dentists, suggesting that as a profession work is needed to end discrimination and foster belonging.

Addressing social determinants of oral health, structural racism and discrimination and intersectionality among immigrant and non-English speaking Hispanics in the United States

Background

The Hispanic population is the largest (18.5%) and fastest growing non‐majority ethnic group in the United States (US), about half of whom are non‐US born, and bears one of the highest oral disease burdens. Most current knowledge around oral health disparities in Hispanic populations examine the individual factors of culture, acculturation, and socioeconomic status. However, the root causes of this inequity; oral health literacy (OHL), social determinants of health (SDOH), structural racism and discrimination (SRD) and the intersectionality among the three, have not been well‐studied. Addressing this critical gap will be central to advancing health equity and reducing oral health‐related disparities in the Hispanic population, especially among immigrant and non‐English speaking Hispanics.

Results

Recommendations for future OHL/SDOH/SRD‐related research in oral health targeting Hispanic populations should include: (1) examining the direct and indirect effects of OHL/SDOH/SRD‐related factors and intersectionality, (2) assessing the impact of SRD on oral health using zip‐code level measures, (3) examining the role of OHL and SDOH as potential effect modifiers on the relationship between SRD and oral health outcomes, (4) conducting secondary data analysis to identify demographic, social and structural‐level variables and correlations between and among variables to predict oral health outcomes, and (5) obtaining a deeper understanding of how OHL/SDOH and SRD factors are experienced among Hispanic immigrant and migrant populations.

Conclusion

It is hoped these recommendations will lead to a better understanding of the mechanisms through which OHL, SDOH and SRD impact oral health outcomes among the largest minority population in the US so they can be addressed.

Racism and oral health equity in the United States: Identifying its effects and providing future directions

While racial/ethnic oral health inequities have been documented for many years in the United States, the potential role of racism has not been examined until recently. In fact, the common practice has been to attribute racial/ethnic disparities in oral health to low socioeconomic position and/or the lack of access to care. In contrast, racism is considered a fundamental cause of a broad range of adverse health outcomes for racial/ethnic minorities. Emerging evidence on oral health suggests that racism can affect access to oral health and clinical decision-making by acting as a social determinant of health (SDoH). Specifically, SDoHs may affect access to quality dental care due to the lack of dental insurance, low dentist-population ratio in racial/ethnic minority communities and the lack of diversity in the dental profession. We describe potential mechanisms through which racism can affect important SDoHs that are essential to oral health equity, outline recommendations to mitigate its existing negative effects and propose interventions to minimize pathogenic effects of racism on oral health outcomes in the population.

The 'leaky' BAME pipeline in UK dentistry

Introduction There are growing calls for dentistry to debate, critique and analyse the role and place of racism in the profession. This article supports this debate and considers whether people from Black, Asian and Minority Ethnic (BAME) backgrounds experience barriers to progressing in the profession.Aims To create a BAME 'pipeline' model illustrating how ethnicity shapes the composition of the dental profession in the UK.Material and methods Publicly available datasets from UK higher education agencies and professional dental associations were identified, examined and collated to create a BAME pipeline model.Results Registrants from the BAME category do not share similar experiences within the dental profession compared to white registrants. The experiences of British Asian people appear to be more favourable, vis-à-vis access to dental schools and progression to the General Dental Council register, compared to Black British people and other UK minority ethnic groups. Black British registrants experience blockages at all stages of their career progression, most notably when accessing dental schools, with only 2% commencing dental studies. All BAME groups 'leak' out of the dental pipeline at clinical academia. There are insufficient data to ascertain whether there are additional 'leaks' at the career specialisation stage.Discussion and conclusion The UK BAME dental pipeline is a leaky one and is in need of urgent action and repair.

Limited, uneven progress in increasing racial and ethnic diversity of dental school graduates

PURPOSE/OBJECTIVES

To assess racial and ethnic diversity of graduates of each dental school compared to the diversity of populations they draw from and to assess changes over time nationally and by school.

METHODS

We calculated diversity of graduates by school and nationally between 2010-2012 and 2017-2019 using the Integrated Post-secondary Education Data System (IPEDS) and compared the diversity of each state's college age population using data from the American Community Survey. We accounted for differences between in-state and out-of-state students attending public and private schools based on data from the American Dental Association's Survey of Dental Education Series. A diversity index (DI) was calculated for each school. A DI of 0.5 means that the representation of Black or Hispanic individuals among the graduates is half of their representation in the benchmark population.

RESULTS

Among the 63 dental schools analyzed, only seven had a DI of greater than 0.5 for Black graduates (two of which were Historically Black Colleges and Universities) in 2017-2019. For Hispanic graduates, 20 schools had a DI above 0.5. Nationally, while the number of Black graduates increased between 2010-2012 and 2017-2019, the percentage decreased from 5.8% to 5.1%. The percentage of Hispanic graduates increased from 6.4% to 8.7%.

CONCLUSIONS

Black and Hispanic individuals are underrepresented among dental school graduates. Increasing the diversity of the dental workforce could help address significant oral health disparities experienced by Black and Hispanic people. More needs to be done by the dental education community to increase racial and ethnic diversity of dental graduates.

Foreign-Trained Dentists in the United States: Challenges and Opportunities

The aim of the present study is to review the licensing process and challenges faced by foreign-trained dentists in United States (U.S.), and how incorporating foreign-trained dentists in the dental workforce in the U.S. impacts the population’s dental care. Foreign-trained dentists must complete additional training in a Commission of Dental Accreditation recognized program offered by a U.S. dental school in order to be eligible for licensing. Foreign-trained dentists interested in seeking employment in the U.S. face numerous challenges, including stringent admission processes, high tuition costs, immigration barriers and cultural differences. Opening the U.S. dental profession to foreign-trained dentists provides several advantages, such as increasing the diversity of dentists in the U.S., expanding access to underrepresented communities, and enhancing the expertise of the profession. Foreign-trained dentists are an important resource for a U.S. government seeking to build the human capital base and make the most of global trade opportunities through a “brain gain”. Increasing the diversity in the dental profession to match the general U.S. population might improve access to dental care for minorities and poor Americans, reducing disparities in dental care.

Underrepresented Minority Dentists: Quantifying Their Numbers And Characterizing The Communities They Serve

The underrepresentation of Blacks, Hispanics or Latinos, and American Indians or Alaska Natives among dentists raises concerns about the diversity of the dental workforce, disparities in access to dental care and in oral health status, and social justice. We quantified the shortage of underrepresented minority dentists and examined these dentists' practice patterns in relation to the characteristics of the communities they serve. The underrepresented minority dentist workforce is disproportionately smaller than, and unevenly distributed in relation to, minority populations in the United States. Members of minority groups represent larger shares of these dentists' patient panels than of the populations in the communities where the dentists are located. Compared to counties with no underrepresented minority dentists, counties with one or more such dentists are more racially diverse and affluent but also have greater economic and social inequality. Current policy approaches to improve the diversity of the dental workforce are a critical first step, but more must be done to improve equity in dental health.