Racial/ethnic variations of practicing dentists

Oral Health Workforce and American Indian and Alaska Native Communities: a Systematic Review

OBJECTIVE

Understanding the oral health workforce representing and serving American Indian and Alaska Native (AI/AN) communities is vital to improving community dental health outcomes. No systematic review of recent published literature on the oral health workforce among this population has been completed.

METHODS

We conducted a systematic review of published literature examining the oral health workforce representing and serving AI/AN communities in the USA. We analyzed 12 articles according to the PRISMA Statement.

RESULTS

The studies suggested that AI/AN identity is an important aspect of routine and accessible oral healthcare. There are unique barriers and motivations that personnel in the oral health workforce face, let alone the distinctiveness of serving AI/AN communities.

CONCLUSIONS

This review provides evidence that expanded oral health positions aid in community members receiving more routine and preventative care and is an upstream public health approach that has diversified the dental workforce.

Perceived racial discrimination partially mediates racial-ethnic disparities in dental utilization and oral health

Objectives

Perceived racial discrimination has been associated with poor health outcomes, yet its impact on oral health disparities is not understood. We examine the role of perceived racial discrimination in healthcare settings in explaining racial‐ethnic disparities in dental visits and tooth loss.

Methods

We used behavioral risk factor surveillance system (BRFSS) data for 2014 from four diverse states (AZ, MN, MS and NM) that included “reactions to race” module. Using Poisson regression to estimate risk ratios, we employed inverse odds ratio(IOR)‐weighted estimation for mediation analyses to estimate the role of perceived discrimination, after equalizing other confounders and risk factors.

Results

We found that among those with similar risk factors, those who experienced racial discrimination were 15% less likely to visit a dentist, and 12% more likely to have tooth loss than those who were treated same as other races. Both Hispanics and non‐Hispanic Blacks were 26% less likely to visit a dentist (for Hispanics, RR = 0.74, 95%CI: 0.69–0.78; for non‐Hispanic Blacks, RR = 0.74, 95%CI: 0.70–0.79), and non‐Hispanic Blacks were 36% more likely to have tooth loss relative to non‐Hispanic Whites with similar risk factors (RR = 1.36, 95%CI: 1.28–1.45). Perceived discrimination appears to contribute to racial‐ethnic disparities in dental utilization among Hispanics, and disparities in tooth loss among non‐Hispanic Blacks, relative to non‐Hispanic Whites.

Conclusions

Perceived racial discrimination partially explains the racial‐ethnic disparities in dental utilization and tooth loss among those who otherwise share the same risk factors for these outcomes. Addressing discrimination and systemic racism can reduce the racial‐ethnic disparities in oral health.

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.

Assessing price sensitivity in dental education and implications on student diversity

Increasingly, the price of professional school is seen as a potential deterrent for interested students. Data collected by the American Dental Association (ADA) from the 66 U.S. dental schools showed the average 4-year nonresident tuition and fees totaled $321,575 in 2018-2019, 35% greater than in 2008-2009, after adjusting for inflation. The aim of this study was to assess whether dental education pricing has impacted applications, enrollments, and yield rates, particularly among students underrepresented in dentistry. Utilizing 7 years of ADA data across all 66 U.S. dental schools, OLS regression, fixed effects, and random effects models were used to examine the data in both cross-sectional and longitudinal analyses. OLS regression results show higher priced schools have higher rates of applications, admittances, and enrollment but lower yield rates. The inverse relationship between yield and tuition prices suggests, on average, students are sensitive to price when deciding whether to accept a spot at dental schools. Focusing on students underrepresented in dentistry, the results indicate that African American and Hispanic or Latino students are price sensitive: fewer of these students enroll in higher priced dental schools, and the relationship persists over time. In other words, fewer African American and Hispanic or Latino students enroll in U.S. dental schools as tuition increases over time. The salary potential is high for dental graduates, but social and cultural capital are significant factors in making students aware of a dental career. These findings suggest the breadth and scope of pipeline programs need to be enhanced to reach these potential students.

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.

The American Indian and Alaska Native dentist workforce in the United States

OBJECTIVES

The purpose of this article is to describe the American Indian/Alaska Native (AI/AN) dentist workforce, the general practice patterns of these providers, and their contributions to oral health care for AI/AN and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 34 percent response rate for self-reported AI/AN dentists. Data were weighted for selection and response bias to be nationally representative. Descriptive and multivariable statistics were computed to provide a workforce profile. Comparisons to Census data and published information on dental students and dentists were used to examine practice patterns.

RESULTS

The AI/AN dentist workforce (weighted n = 442) is very diverse with 55 reported individual tribal affiliations. Tribal heritage was provided by 95.7 percent of AI/AN dentists (n = 423), and of these, 93.9 percent (n = 400) reported an affiliation with only one tribe. The largest share of AI/AN dentists were born in the United States (98.2 percent, n = 434), married (75.6 percent, n = 333), and had dependent children under age 18 (52.0 percent, n = 222). Only 0.9 percent (n = 4) of AI/AN dentists spoke a traditional AI/AN language in patient care, while 10.6 percent (n = 46) were raised on tribal land or reservation. Initial practice in the Indian Health Service was reported by 15.8 percent of AI/AN dentists while 16.2 percent report currently practicing in a safety-net setting, and 42.0 percent report working in a practice that primarily serves underserved patients.

CONCLUSIONS

AI/AN dentists provide a disproportionate share of care for AI/AN populations, yet the number of AI/AN dentists would need to increase 7.4-fold in order to meet population parity.

The Hispanic and Latino dentist workforce in the United States

OBJECTIVES

The purpose of this paper is to describe the Hispanic/Latino (H/L) dentist workforce, their general practice patterns, and their contributions to oral health care for H/L and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 35.4 percent response rate for self-reported H/L dentists. Data were weighted for selection and response bias to be nationally representative. A workforce profile of H/L dentists was created using descriptive and multivariable statistics and published data.

RESULTS

Among all H/L dentists (weighted n = 5,748), 31.9 percent self-identify their origin as Mexican, 13.4 percent as Puerto Rican, 13.0 percent as Cuban, and 41.7 percent as another H/L group. The largest share of H/L dentists are male, married, and have children under age 18. Fifty percent of H/L dentists are foreign-born and 25 percent are foreign-trained. H/L dentists report higher than average educational debt, with those completing International Dentist Programs reporting the highest debt load. Sixty-nine percent of clinically active H/L dentists own their own practices, and 85 percent speak Spanish in their practice. Among clinical H/L dentists, 7 percent work in safety-net settings, 40 percent primarily treat underserved populations, and, on average, 42 percent of their patient population is H/L.

CONCLUSIONS

H/L dental providers are underrepresented in the dentist population, and those that are in practice shoulder a disproportionate share of dental care for minority and underserved communities. Improving the workforce diversity of dental providers is a critical part of strategy to address the high burden of dental disease in the H/L population.

The Black dentist workforce in the United States

OBJECTIVES

The purpose of this paper is to describe the Black dentist workforce, the practice patterns of providers, and their contributions to oral health care for minority and underserved patients.

METHODS

A national sample survey of underrepresented minority dentists was conducted in 2012 and received a 32.6 percent response rate for self-reported Black dentists. Data were weighted for selection and response bias to be nationally representative. Descriptive and multivariable statistics were computed to provide a workforce profile of Black dentists. National comparisons are provided from published data.

RESULTS

Among all Black dentists (weighted n = 6,254), 76.6 percent self-identify as African-American, 13.2 percent as African, and 10.3 percent as Afro-Caribbean. The largest share of Black dentists are male, married, heterosexual, born in the United States and raised in a medium to large city. One third of Black dentists were the first in their family to graduate from college. Black dentists report higher average educational debt than all dental students, with graduates from International Dentist Programs having the greatest debt. Traditional practices (i.e., private practices) dominate, with 67.1 percent of Black dentists starting out in this setting and 73.5 percent currently in the setting. Black dentists care for a disproportionate share of Black patients, with an average patient mix that is 44.9 percent Black. Two in five Black dentists reported their patient pool is made up of more than 50 percent Black patients.

CONCLUSIONS

The underrepresentation for Black dentists is extraordinary, and the Black dentists that are in practice are shouldering a disproportionate share of dental care for minority and underserved communities.

Factors Affecting Dental Job Satisfaction

In this cross-sectional study, a randomly selected group of dentists (n = 855) from nine provinces of Turkey were interviewed for their levels of intrinsic, extrinsic, and overall job satisfaction. The proportion of overall job satisfaction was computed as the proportion of dentists who had mean general satisfaction scores 4 on a 5-point, Likert-type scale and was found to be 40.8% for the sample as a whole. The significant factors that affected overall satisfaction were age, the type of social insurance possessed, income level, the presence of dental auxiliaries, and the number of patients examined per day. Multivariate analysis of the data revealed that the type of social insurance, the amount of monthly income, and the number of patients examined per day were the most common and statistically significant predictors of intrinsic, extrinsic, and overall satisfaction in Turkish dentists.

Tracking workforce diversity in dentistry: importance, methods, and challenges

OBJECTIVES

The objectives of this paper are to describe sources of data on underrepresented minority (URM) dental providers and to perform a structured critique of primary survey research on African American (AA), Hispanic/Latino (HL), and American Indian/Alaska Native (AI/AN) dentists.

METHODS

A national sample survey was conducted between October 2012 and March 2013, and secondary datasets were assessed for comparability. The survey used 21 sampling frames, with censuses of AI/AN and nonurban dentists, and assessed demographics, education, practice history, patient population, volunteerism, experiences with discrimination, and opinions on issues in dentistry. The survey was developed with constituent input, pilot-tested, and distributed online and through US mail with three reminder postcards, phone, and email follow-up. Continuing education credit and entry to a prize drawing were provided for participation.

RESULTS

Existing data sources cannot answer critical research questions about URM dentists. Using best practices, the survey received a 34 percent adjusted response rate. Selection likelihood and measurable response bias were adjusted for using base and poststratification weights.

CONCLUSIONS

The survey design was consistent with best practices, and our response analytics provide high confidence that the survey produced data representative of the URM dentist population. Enhanced study design, content, and response rates of existing survey efforts would be needed to provide a more robust body of knowledge on URM providers, perspectives, and practices.

Assessing the contribution of the dental care delivery system to oral health care disparities

OBJECTIVES

Existing studies of disparities in access to oral health care for underserved populations often focus on supply measures such as number of dentists. This approach overlooks the importance of other aspects of the dental care delivery system, such as personal and practice characteristics of dentists, that determine the capacity to provide care. This study aims to assess the role of such characteristics in access to care of underserved populations.

METHODS

We merged data from the 2003 California Health Interview Survey and a 2003 survey of California dentists in their Medical Study Service Areas (MSSAs). We examined the role of overall supply and other characteristics of dentists in income and racial/ethnic disparities in access, which was measured by annual dental visits and unmet need for dental care due to costs.

RESULTS

We found that some characteristics of MSSAs, including higher proportions of dentists who were older, white, busy or overworked, and did not accept public insurance or discounted fees, inhibited access for low-income and minority populations.

CONCLUSIONS

These findings highlight the importance of monitoring characteristics of dentists in addition to traditional measures of supply such as licensed-dentist-to-population ratios. The findings identify specific aspects of the delivery system such as dentists' participation in Medicaid, provision of discounted care, busyness, age, race/ethnicity, and gender that should be regularly monitored. These data will provide a better understanding of how the dental care delivery system is organized and how this knowledge can be used to develop more narrowly targeted policies to alleviate disparities.

How dental care can preserve and improve oral health

Oral health is associated with overall health, and lack of access to dental care has consequences that go far beyond aesthetics. Most oral diseases are preventable and are relatively easy and inexpensive to address at early stages. However, multiple barriers make dental care unreachable for a sizable portion of the United States population, who consequently has higher incidence and prevalence of disease. Achieving meaningful improvements in oral health status among these groups will require a revamping of the dental infrastructure, augmenting the productivity and skills of the dental workforce, and increasing the population's oral health literacy.

The impact of Title VII on general and pediatric dental education and training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Addressing health care disparities and increasing workforce diversity: the next step for the dental, medical, and public health professions

The racial/ethnic composition of our nation is projected to change drastically in the coming decades. It is therefore important that the health professions improve their efforts to provide culturally competent care to all patients. We reviewed literature concerning health care disparities and workforce diversity issues--particularly within the oral health field--and provide a synthesis of recommendations to address these issues. This review is highly relevant to both the medical and public health professions, because they are facing similar disparity and workforce issues. In addition, the recent establishment of relationships between oral health and certain systemic health conditions will elevate oral health promotion and disease prevention as important points of intervention in the quest to improve our nation's public health.

Tobacco attitudes, practices, and behaviors: A survey of dentists participating in managed care

Tobacco cessation knowledge, attitudes, and behaviors of dentists participating in a large national managed care dental plan were assessed using a mailed survey. The survey was administered to dentists recruited to participate in an evaluation of a CD-ROM and supportive electronic detailing to promote increased tobacco cessation activities. General dentists who met specific technological criteria, had an active E-mail account, and at least 200 adult patients were eligible to participate in this study. A total of 184 dentists, located in 29 states, agreed to participate. The survey instrument included questions that addressed (a) Ask, Advise, Assess, Assist, and Arrange behaviors, (b) self-efficacy including knowledge, confidence, and success regarding tobacco cessation, (c) success of various tobacco cessation strategies, (d) barriers to tobacco cessation, and (e) demographics including year of graduation, gender, and race/ethnicity. Self-reported baseline tobacco intervention-related behaviors were low, with 28% of dentists reporting that they asked their patients about tobacco or recorded tobacco use in their patients' charts at least 41% of the time. For Advise behavior, approximately half of the dentists advised tobacco-using patients to quit at least 41% of the time. Although self-reported lack of knowledge was high, 71% of respondents indicated that their lack of knowledge was either not a barrier or a slight barrier to incorporating tobacco cessation into their practices. The survey revealed that dentists do not routinely incorporate tobacco cessation into their practices. Newer information-transfer technologies may serve as vehicles for increased smoking cessation activities by dentists.