Dentistry has faced, and continues to face, challenges in expanding its ranks to include diverse, especially minoritized, people. American Indian/Alaska Native, Hispanic, and Black representation, for example, has not grown significantly in dentistry. Although dental schools have an accreditation standard to be humanistic environments, it is not clear that dental schools have climates that are functionally inclusive of minoritized people—whether for patients, the student body, staff members, faculty members or leadership. For the profession to advance oral health equity, intentional efforts are needed in education and across the full dental workforce.
Key points
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Diversifying dentistry is key to realizing oral health equity.
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Support of inclusive climates at dental schools and within professional dental organizations is crucial to the recruitment and retention of diverse people.
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Inclusive communication and the use of person-centered language should be leveraged for advancing population-level health and promoting optimal clinical outcomes in working with patients and communities.
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Sentiments such as “I don’t see color” do not support inclusive environments and result in the “othering” of people, which fails to create belonging.
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Dentistry requires building inclusive leadership capacity to support belonging and diversity.
Introduction
Dentistry faces challenges in expanding its ranks to include diverse people (specifically, minoritized people). , For groups like American Indian/Alaska Native, Black, Hispanic, Native Hawaiian and Pacific Islanders, their presence in dentistry has not grown significantly over the decades. , Although dental schools have an accreditation standard that values diversity and inclusion as core values to foster humanistic environments, it is not clear that dental schools have climates that are inclusive of minoritized people, whether they are patients, students, staff members or faculty members. , For the profession to advance oral health equity, intentional efforts for diverse people are essential.
Historical Perspective
The issue of inclusion in dentistry is not a new concern. In 1866, the American Dental Association (ADA) adopted the first Code of Ethics, which emphasized the importance of prioritizing patients’ needs while upholding ethical conduct in dentists’ professional responsibilities. Since then, the ADA Principles of Ethics and Code of Conduct have evolved over the years. Although some words such as diversity, equity, inclusion, and belonging (DEIB) are not explicitly presented, they are part of these principles. The relationship between the dental code of ethics and inclusion is one that, at its core, outlines the professional responsibilities and moral obligations of dental practitioners toward their patients, colleagues, and society at large. Inclusion, within the context of dentistry, can be defined as one that creates an environment where all individuals, regardless of their background, identity, or ability, feel valued, respected, and provided with equitable access to dental care. To highlight inclusivity in this important document, the principle of justice fosters and encourages dentists to be fair in their dealings and practice of dentistry for the benefit of all, while improving access to care to the community at large. Overall, the principles of the code of ethics intertwine with inclusivity, which promotes patient-centered care and upholds the values of respect, equity, and dignity within the dental profession. By embracing the principles of inclusion, dental professionals can ensure that their practices are not only ethically sound but also truly welcoming and accessible to all individuals in need of dental care.
In 1926, Dr. William J. Gies, who is considered the founder of modern dental education, published Dental Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching . In the report, Dr. Gies identified three fundamental areas that are essential for improving oral health: practice, education, and research. While not a direct theme in Gies’ writing, these areas are inclusive components currently. Gies indicated that the right dental education should include a cultural background for the dentist as for the physician (See two quotes selected from the Gies Report in Box 1 ).
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Education
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The proper training of the practitioner is a matter of prime importance. That he should be an educated man, with a background of culture and refinement, is quite as essential for the dentist as for the physician. That his professional training should give him a true medical comprehension of his duties, as well as mechanical facility and esthetic felicity in the execution of his procedures, is equally obvious. In educational quality and influence, dental schools should equal medical schools, for their responsibilities are similar and their tasks are analogous. The dental graduate should be the peer of the medical graduate in all important personal attributes, and in professional capability . (Page 237)
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Need for Additional Dental Schools for Negroes
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Economic, social, and educational conditions long conspired to prevent Negroes from entering the professions of health service. With improvement in the economic status of the colored group, however, the ability of Negroes to meet the expenses of a professional education is steadily growing. Inasmuch as prevailing sentiment for segregation prevents admission of more than a few colored students to the existing medical and dental schools attended by white students, there is evident need not only for improvement and support of such schools as are devoted exclusively to the training of Negroes, but also for an increase in their number. The creation of departments or schools for the training of Negroes in health service, in state universities or in universities having adequate endowments, should appeal strongly to the citizens of states containing large colored populations . (Page 93)
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Looking back at this report, the exploration of dentistry from a historic lens allows for contemporary oral health professionals to better understand challenges to enhance diversity and inclusion in the profession of dentistry. Gies identified the need for a more significant number and more effective distribution of Black practitioners in the dental and medical professions. Furthermore, Gies advocated for Black practitioners to participate and be integrated in the community for the welfare of the underrepresented population (see Box 1 ).
Gies effectively argues for greater diversity in the oral health workforce to support the delivery of care to underserved populations, which is a cornerstone of health equity. Moreover, in naming the “economic, social, and educational conditions” (see Box 1 ) that have been barriers to Black people for entering the profession, contemporary oral health professionals can glean from Gies that the profession has not lived up to being a humanistic environment inclusive of all people who want to be a part of the oral health team and, by extension, patients who may need care. Now is the time to explore how dentistry can become inclusive and embrace inclusion in its clinical practice and the recruitment and recruitment of the workforce that the 21st century requires.
Is 21st Century Dentistry Inclusive?
The U.S. is an increasingly diverse country. At the 2020, Census the three most prevalent racial/ethnic groups in the United States are non-Hispanic White, Hispanic or Latino, and non-Hispanic Black. The demographics of the United States are projected to continue to evolve with the country becoming minority White in 2045. Given these changes in the country, questions arise as to how inclusive and diverse is the health care workforce for insuring health equity. Fig. 1 provides percentage contrasts of recent demographic data from the US populations to NIDCR grant applicants showing inconsistencies in representation.
Is Dentistry a Humanistic Environment?
Minoritized populations in the United States, such as Black, Hispanic, American Indian/Alaska Native, Native Hawaiian and other Pacific Islanders, are underrepresented across various facets of the oral health workforce in corresponding proportions of these populations in the US population. While not expecting perfect parity in the workforce reflecting the population, it is telling that the disparities in the representation of minoritized population are so stark. Given a variety of reasons for the low level of diversity in dentistry, the question arises about whether dentistry is a humanistic environment.
The Commission on Dental Accreditation (CODA) emphasizes that inclusion should be evaluated as part of institutional climate in the accreditation process. Institutional climate includes programs and initiatives established by the institution to actively support diversity as a fundamental value, creating an inclusive, engaging environment conducive to learning and professional growth for all. Recognizing diversity as crucial for academic excellence, CODA underscores the importance of dental schools creating environments that facilitate the exchange of ideas and beliefs across gender, racial, ethnic, cultural, and socio-economic backgrounds. Hence, all dental schools are expected to support a humanistic, inclusive culture.
The climate of dental schools
In 2022, the American Dental Education Association (ADEA) launched the first-ever climate study among dental schools and dental education programs in the United States and Canada. Preliminary by-variate findings were reported in November 2022. Participants from 66 dental schools (88% of the dental schools) participated in the survey with an estimated overall response rate for participants from US Dental Schools of about 24%. Assessments included five composite scores for well-being, sense of belong, inclusive environment, inclusive culture, and welcomeness. See Fig. 2 for US Dental Schools mean scores by Race/Ethnicity and Public versus Private Dental Schools. Variations across these domains appear evident for different perceptions by respondents by the race/ethnicity groups. Nevertheless, the highest composite scores in the areas assessed were for welcomeness and the lowest were for inclusive environment. The mean scores for Private Dental Schools appear higher than those for Public Dental Schools or for all race/ethnicity groups, raising questions about the intersectionality issues that might be contained.
Student experiences with discrimination
Few studies assess student experiences with discrimination in dentistry. As individual assessments were made regarding equitable policies and practices, cultural “competence”, and harassment and discrimination in the 2022 ADEA Climate Survey. (For a little insight, see Box 2 ) . A qualitative study, using focus groups at a UK dental school in December 2020, found students in dental schools experience a range of racist encounters from stereotyping and microaggression to racial mocking. In another qualitative study, using focus groups of minoritized dental students at a US school in spring 2021, students described experiences of discrimination trackable from their pre-dental training across applying to dental school and exploring career opportunities with post-graduate training. Several studies at dental schools in the US surveyed students. , In the fall of 2011, one school’s assessment, where 95% of the respondents were Hispanic or Black, 22% of students reported having experienced discrimination. Another school survey using a discrimination questionnaire found Black/African Americans students scored the highest, and that all the non-White racial/ethnic groups had a higher mean score of perceived discrimination compared to the non-Hispanic White group of students.
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Equitable Policies and Practices
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Experiences of Bias of Inequities
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With dress code, personal appearance, and attire: 26%
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With code of conduct or discipline policy: 26%
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Agree their dental school has effective strategic diversity goals and plans: 61%
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Agree their dental school has effective admissions practices and policies that increase student diversity: 63%
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Agree their dental school has effective hiring practices that increase faculty diversity: 55%
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Agree their dental school has effective hiring practices that increase staff diversity: 55%
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Cultural Competence
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Agreed that since dental school, my understanding of the social determinants of health and how they impact oral health treatment has improved: 87% of US dental students
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Harassment and Discrimination
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Experienced harassment in US Dental Schools: 13%
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Witnessed harassment in US Dental Schools: 20%
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Experienced discrimination in US Dental Schools: 17%
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Witnessed discrimination in US Dental Schools: 27%
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Experience harassment or discrimination in US Dental Schools: 34%
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Dentists experiences with discrimination
A limited scholarship on the prevalence of discrimination in the dental workforce exists, particularly when focusing on race/ethnicity. Two studies provide context for questioning the degree to which dentistry embraces inclusion. , In an undated national assessment published in 2017, using 41 Black Oral and Maxillofacial Surgeons respondents to a survey distributed from the mailing list of the National Society of Oral and Maxillofacial Surgeons, 24% reported experiencing race-related harassment in their residencies, 54% perceived bias against African Americans in Oral and Maxillofacial Surgery residencies and 46% reported race-related harassment in their workplace. In a 2012 national survey of underrepresented minority dentists, 72% of surveyed dentists reported any experience with discrimination in a dental setting, with the rates of experiences highest among Black dentists (86%) compared to 59% of Hispanic dentists and 49% American Indian/Alaska Native dentists.
Patient experiences with discrimination
The first national study of discrimination experiences in oral care visits was conducted in 2022. The existing Everyday Discrimination Scale was adapted to the oral care setting (EDSOC). Minoritized survey respondents, specifically non-Hispanic Asian, non-Hispanic Black and Hispanic groups had higher mean scores on the discrimination scale than had the non-Hispanic White group of respondents. Moreover, respondents with experiences of discrimination were associated with reporting fair/poor oral health, not having visited a dentist in Two years, and not planning a future oral care visit. The study suggests that patient experiences with discrimination (ie, the lack of inclusivity in dentistry) may exacerbate oral health inequities.
A recent dissertation explored psychosocial and behavioral factors related to experiences with discrimination in oral health care settings for 751 Black adults’ (ages 21–64 years) in Baltimore. A concerning level of discrimination in oral health care settings is shown, with approximately half of the study participants indicating experiences of discrimination, which appears intensified if using emergency room serices.
Challenges to Humanism and Inclusion
Debunking the myth of inclusion: “I don’t see color”
“I don’t see color” is a phrase that has been used for thinking that it deescalates tensions circa equity, diversity, and inclusion efforts. However, the underlying notion in the phase “I don’t see color” is colorblindness. Scholars argue that colorblindness becomes either a form of color evasion (“not seeing color”) or power evasion (denying racism). While colorblindness sounds harmless and inviting of a notion of “post-racial America”, the phrase “I don’t see color” actually serves as an affront to inclusion and efforts to advance justice.
For minoritized, people of color who are told “I don’t see color” may take the message as they are not seen: “I don’t see color” can be understood as “You don’t see me”. The impact of these words can foster a sense of “othering” (the act of treating someone as though they are not part of a group and are different in some way ) and potentially cultivate imposter syndrome in minoritized people. Further, the process of “othering”, students being particularly vulnerable, therefore poses a threat to the sense of inclusion and belonging that every dental school aspires to foster as a humanistic environment. For students who feel othered and forced to “blend in”, they may experience imposter syndrome (UK “impostor”). Imposter syndrome “describes high-achieving individuals who, despite their objective successes, fail to internalize their accomplishments and have persistent self-doubt and fear of being exposed as a fraud or impostor.” , For people experiencing imposter syndrome, they may “attribute successes to external factors such as luck or receiving help from others and attribute setbacks as evidence of their professional inadequacy”. , In a systematic review, imposter syndrome was found “common among African American, Asian American, and Latino/a American college students and that imposter feelings are significantly negatively correlated with psychological well-being and positively correlated with depression and anxiety”. While no studies assessed the prevalence or impact of imposter syndrome among minoritized dental students, it is worth considering that the negative correlations with well-being among college students would be similar in professional students. Moreover, the feelings of imposter syndrome and othering can be imagined to be additive to negatively impact one’s sense of belonging and inclusion at a dental school.
In the clinical setting, “othering” is a threat to trust and the delivery of optimal care. “Othering” spotlights the “social gulf,” a term used by Otto to express differences between the oral health provider and patients. Furthermore, the “social gulf” exacerbates power imbalances that can exist between the oral health provider and patients. The lived experiences and social identities of the providers and patients creates an imbalance of power where the providers having specialized knowledge about oral health and clinical practice and perhaps lacking the knowledge and information about communities, social histories, and lived experiences may perceive patient behavior as “undesirable” or “deviant”. These negative perceptions and othering create a tension where the patient’s ability to be heard and to trust the providers are threated.
“Inclusion Health”: Re-Imagining Dentistry as an Inclusive Profession to Advance Health Equity
Inclusion is especially key in the health care professions as practitioners and leaders grapple with improving access to health care and improving health outcomes. A growing science and literature from the United Kingdom support the notion of “inclusion health”. “Inclusion health” centers social exclusion and populations made vulnerable by their social conditions, inviting health care provider, researchers, policy advocates, and other leaders to explore social exclusion as a driver of health outcomes. , The term “Inclusion Oral Health” emerged with the aim of the profession of dentistry to act as an agent of social inclusion as a solution to address oral health inequities globally ( Box 3 ). An application to dentistry focused on “inclusion health” can be seen in a recent paper by Bradley and colleagues on models of dental care for people experiencing homelessness.
