Bonding the Racial Gap in Oral Health and Care

The American healthcare system has long impacted people of color disproportionately, providing them with second-rate care that, in itself, is difficult to access. An area of healthcare that is often neglected where these disparities have existed for decades is dental care. This has contributed to prominent racial disparities in oral health that can begin early on in one’s life. Children of color from the ages of 3–5 suffer from untreated cavities at almost twice the rate of white children and triple the rate as they reach their teens. From the age of twenty, Black patients experience untreated tooth decay at twice the rate of white patients, and Black seniors will suffer from total tooth loss twice as often as white seniors.^[1] These disparities cannot be attributed to a single cause, but it is evident African American patients have faced a history of obstacles that contributed to this issue and continue to affect millions of people today.

A major factor in racial discrepancies in oral health can be attributed to the history of segregated dental clinics, which were standard until the 1960s. These facilities routinely refused to take care of minority patients in need, and in the rare case they did, they denied physician privileges to minority doctors.^[2] Many patients suffered devastating consequences to their oral and overall health due to these limitations. For some, severe cases of untreated oral infections even cost them their lives.

Needless to say, stories of mismanaged care, not uncommon among minority communities, greatly affected their trust in the healthcare system. One notable case occurred to a patient of color named Donald Lines in 1960. Lines suffered from a severe tooth abscess, which caused his whole jaw to swell and gave him a fever of 103. He required immediate hospitalization, but the Black hospital near his residence was full, and both white hospitals in the vicinity refused to treat him.^[3] Yet white hospitals received funding from the Hill-Burton Act, which funded projects that were supposed to provide equal healthcare regardless of race.^[4] Lines’s dentist, George Simkins, contacted the NAACP, and they filed Simkins v. Moses H. Cone Hospital in 1963, an instrumental case that desegregated hospitals in the South.^[5] This incident allowed many to understand the detrimental effects that segregated healthcare could have on patients and that dental care could not be equal while this separation existed. A year after this ruling, Congress passed the Civil Rights Act of 1964, formally prohibiting discrimination in public entities.

Efforts for reform in this field have been in place since 1895 with the formation of the National Dental Association (NDA), originally called the National Negro Medical Association of Physicians, Dentists and Pharmacists. This organization aimed to improve education for Black practitioners, combat racial discrimination in healthcare facilities, and eliminate inequities in healthcare services. In the late 1900s, a similar organization named the National Dental Association Foundation was created, distributing scholarships and grants to worthy students, dentists, and auxiliaries. While their achievements are notable, accessible and equal healthcare regardless of race has yet to be achieved, and this painful history affects the quality of care Black patients receive today.

Poor oral health is strongly tied to socioeconomic status, which is intertwined with race. Patients from a lower socioeconomic status live in areas without immediate access to affordable oral health resources because so few practitioners are willing to work in underserved communities.^[6] Additionally, time constraints due to employment prevent families from attending routine dental checkups or preparing healthy food options. These financial and temporal restrictions lead to higher rates of consumption of fast foods and sugary beverages, significantly affecting oral health. More so, familial factors contribute to these disparities. Having parents with higher levels of education (which in itself is part of a racial disparity) was shown to be a predictor of better oral health in preschool children, whose families showcased an increased likelihood of utilizing dental services, and a smaller rate of tooth decay.^[7] Poor oral health has also been linked to a loss of productivity in children, increasing their chances of performing poorly in school. Children of color are twice as likely to have their teeth categorized in poor or fair condition when compared to white children, further contributing to this educational disparity.^[8]

A de-emphasized, yet influential component, is the social norms, knowledge, and attitude that differ between different demographic populations. These sociocultural differences influence preferences in dental treatments, ultimately leading to differences in dental care and health. Notably, African American patients commonly prefer treatments that allow for more autonomy or a sense of control: for example, brushing with a fluoride toothpaste instead of receiving a fluoride treatment in their dental office. The value of autonomy in this community can prevent patients from seeking a wide variety of services, which can be crucial to their dental health.

It is no surprise, however, that autonomy is valued to such a great degree in this community. Implicit biases and unconscious stereotyping when diagnosing and treating African American patients are common.^[9] One study investigated how quickly medical practitioners resort to diagnoses that are stereotypical of a patient’s social group. Biases for conditions such as obesity and drug use were prominently apparent.^[10] Other than implicit biases, Black patients have also reported concerns due to explicit discrimination they have faced. A recent poll reported nearly a third of Black Americans experienced racial discrimination in healthcare settings, with nearly a quarter stating they actively avoid medical care out of concern they will be discriminated against.

Recent research has also suggested patients of color were significantly more likely to be dissatisfied with the oral care provided by their health practitioner when compared to white patients, likely due to discrimination and differentiation in treatment.^[11] As seen by a randomized clinical trial regarding recommendation for root canals, Black adults were far more likely to be recommended for tooth extraction, while white adults were recommended for root canal treatment, irrespective of their condition. The study suggested that assumptions regarding the financial ability of Black patients to cover the treatment expenses contributed to this disparity.^[12] Unfortunately, the execution of implicit biases as such has been established by current investigations.^[13] Another study found that Black patients are far less likely to receive surgery recommendations than white patients when consulting for oral cancer, irrespective of the cancer’s stage. When considering that Black men with oral pharyngeal cancers have an 82% higher rate of mortality than white men with the same condition, the imbalance of care is evident.^[14]

The concern of facing discrimination, among other factors, continues to contribute to the preference of many Black patients to be treated by a Black practitioner. This inclination emphasizes another disparity in dentistry, as there is prominent underrepresentation among dental practitioners. Even though African Americans make up 12.4% of the population, only 3.8% of dentists identify as African American.^[15] Dental schools did not accept Black dental students until almost thirty years after their inception. Even after this change in admissions, the vast majority of Black dental graduates attended Howard University’s dental college or Meharry Medical College, both predominantly Black schools.

Ultimately, stories like that of Donald Lines have set a precedent for the current reality of racial gaps in oral health. This painful history has rooted mistrust into this medical setting, leading to staggering statistics of differentiation in treatments. With more recent reports of continued discrimination, it is clear that radical changes are required in dental settings. These apparent disparities in oral health leave Black communities vulnerable to bigger problems in healthcare more broadly. While the effects of poor oral health are often trivialized, they are linked to major systemic diseases such as diabetes, heart failure, asthma, kidney diseases, the progression of certain cancers, and more. Recent research has even linked gum diseases to the stimulation of Alzheimer’s.^[16] Initiatives focused on education about proactive care have proven effective, leading to improvements in oral health.^[17] Education and further reformative measures must be taken to eliminate these racial discrepancies and better protect patients of color.

Danielle Ohana

Danielle Ohana is an undergraduate student at the Macaulay Honors College at the College of Staten Island majoring in bioinformatics and minoring in chemistry. She aspires to attend dental school to earn a DDS as well as a PhD in oral biology and pathology. Danielle is currently part of a research team developing an innovative treatment for periodontitis and has conducted experiments at Massachusetts General Hospital and Harvard Medical School.

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