Cultural Issues in Dental Education
- Populations are becoming increasingly heterogeneous, migrating longer distances, and bringing with them different cultural expectations and needs.
- The cultural heterogeneity impacts on the management of oro-dental diseases, including etiological risk factors (related to harmful lifestyle habits) through behavioral differences displayed by patients from different cultures.
- Training a dental workforce that is culturally and linguistically competent and that values the behavioral and psychosocial needs of multicultural populations is important.
- A dental workforce that will not only have the potential to reduce oral health inequalities, but also to deliver any communication, training, and clinical management with understanding, respect, and dignity needs to be developed.
Incorporating Culture into Dentistry
The word “culture” has several meanings. The two most relevant to dental education that can be considered is “development or improvement of the mind by education or training” and “the behaviors and beliefs characteristic of a particular social, ethnic, or age group” (Dictionary.com). These definitions of culture have direct implications in dentistry and are being incorporated into undergraduate curricula internationally. The American Dental Education Association (ADEA) has prompted the need to train culturally competent fgraduates to tackle widening oral health inequalities in the United States (Haden et al., 2003). Similarly in the UK, the General Dental Council (General Dental Council, UK, 2008) stipulates that UK graduates should
- have knowledge of managing patients from different social and ethnic backgrounds
- be familiar with the social, cultural, and environmental factors which contribute to health or illness
- be familiar with social and psychological issues relevant to the care of patients.
These are aspects of culture related to oral health and those directly relevant to patients. The General Dental Council and ADEA take this further and extends it into professional development, further stipulating that graduates should have “respect for patients and colleagues that encompasses, without prejudice, diversity of background and opportunity, language and culture” (Haden et al., 2003; General Dental Council, UK, 2008). Consequently, cultural issues in dentistry not only impact and include clinical care of patients, but also aspects of interaction between students and staff of different social and ethnicity backgrounds.
Given these requirements, dental institutions have a responsibility to introduce these elements into their training programs. Indeed, the word social responsibility has become de rigor in professional development. In its broadest sense, social responsibility is “the obligation of an organization’s management towards the welfare and interests of the society in which it operates” (Business Dictionary.com). The key objectives of this chapter will therefore be to focus on the impact and need of introducing culture and social responsibility into dental education using three main viewpoints related to the following.
- Impact of Culture on Patient Management: Impact of presence of dental institutions on the oral health of patients within migrating populations and multicultural communities.
- The Need for a Culturally Diverse Teaching Staff and Dental Training Courses: Ability of dental education to address the needs of culturally diverse dental student communities.
- The Need for a Culturally Balanced Academic Environment: Ability to impact on both clinical and societal teaching and learning and on recruitment and interview process for students.
Impact of Culture on Patient Management
Migration always carries serious risks for both human rights and health. As the global population becomes more mobile and more people travel greater distances, societies are becoming more culturally and socially complex. This in turn creates the requirement for new changes in public health, and consequently, for both clinical medical and dental delivery. The UN estimates that migrant populations total about 290 million (Carballo & Nerukar, 2001). However, it fails to account for rural–urban, irregular, circular, and seasonal migration, as well as trafficked women and children. The figure is probably closer to 1 billion (Carballo & Nerukar, 2001). Such populations carry with them the major challenge of integrating into new countries and communities, which has a major impact on their healthcare provision and access to services. They are known to have higher levels of communicable and noncommunicable diseases (including dental disease), given their exposure to behavioral, environmental, and occupational risk factors. It is these social determinants of health that are major causes of the observed inequalities associated with oral health that are prevalent among migrating populations (WHO Commission for Social Determinants of Health, 2008). Yet dental healthcare services do little to comprehend these complex factors that can influence compliance and adherence to both preventive and therapeutic programs for oral diseases. The current dental healthcare system needs to be alert to the fact that its populations are becoming increasingly heterogeneous, migrating longer distances and bringing with them different profiles and needs. These groups usually become increasingly marginalized and have poorer outcomes for oral health. This in turn has a broader impact on dental public health (WHO Commission for Social Determinants of Health, 2008). Current reports (Marmot, 2010; Fuller et al., 2011) suggest that although overall oral health of populations is improving, oral health inequalities are worsening. Despite this, training in dental schools tends to follow a very biomedical approach of “diagnose-treat-cure.” This tends to focus on the mouth or individuals’ teeth rather than the person as a whole. Many issues faced by migrants and those from ethnic minority backgrounds are psychosocial and need a deeper understanding of their social history and culture. A lack of understanding of these psychosocial and cultural behaviors can adversely affect clinical care of such patients. Dental anxiety and phobia is a strong predictor of postoperative pain following dental procedures rather than the procedure itself (Tickle et al., 2012). This is an indication of how psychosocial factors can influence postoperative pain, and an empathetic approach to patients is important prior to undertaking dental procedures. Awareness of the range of behaviors that are associated with cultural differences should be an important component of undergraduate dental education. Such awareness will also allow an understanding of how these complex behaviors can be targeted to alleviate dental anxiety and phobia. This will not only influence compliance and adherence to operative procedures, but also preventive and therapeutic programs for oral diseases.
It is also important for dental professionals to appreciate how psychosocial factors can themselves influence the onset and persistence of chronic dental diseases. The classical example of this includes chronic orofacial pain conditions like temporomandibular pain and persistent idiopathic orofacial pain. Such conditions are known to be associated with underlying psychosocial distress and maladaptive health-seeking behaviors (Aggarwal et al., 2010) and will be discussed in detail later in the book. They require early recognition to avoid invasive and irreversible treatments. Diagnosis of these conditions presents a huge challenge for most dental practitioners and will be even more challenging in patients from different cultural backgrounds. Similarly, procedures like the use of hypnosis and sedation that are highly sensitive to patient behaviors also need a deeper understanding of cultural differences if they are to be implemented successfully in migrant populations.
Other chronic dental diseases have their etiologies embedded in cultural habits; the classical example being oral cancer which has an increased risk in Asian populations particularly from the Indian subcontinent due to the high rate of paan consumption (a mixture of tobacco, slaked lime, and betel nut). Dental practitioners need to be aware of the increased risk and to be vigilant when screening the oral soft tissues in these populations (Vora, Yeoman, & Hayter, 2000). Incorporation of culturally dependent risk factors in history taking will allow appropriate preventive advice. The challenge is in getting patients to reverse harmful habits, and language can be a key barrier in communicating the risk of continuing with such harmful behaviors. Practitioners also need to be aware of increased prevalence, in some cultures, of systemic diseases that can affect dental management of patients, for example, type-2 diabetes that is prevalent in southeast Asians (Bhopal, 2012) and is discussed later in the book. Perhaps dental institutions need to do more to ensure that the pool of patients that their students treat during undergraduate training are culturally diverse so that they can gain appropriate experience in managing such patients, in particular gaining experience at reversing harmful lifestyle habits that lead to life-threatening diseases like oral cancer.
A third of the population of the United States belongs to cultural and ethnic diverse groups. They modify their diet by incorporating American food and portion size, adding this to their native eating and into their cultural habits, and diet. Their disease pattern shows increased diabetes, stroke, and cardiovascular disease. This configuration is similar to major morbidity patterns in ethnic groups in the UK. Diabetes on its own increases a patient’s chance of developing cardiovascular disease, kidney failure, blindness, and limb amputation. Dental healthcare workers are in a prime position to give health information to patients who may not seek medical care. Dentist/>