Inclusion is an essential part of diversity, equity, and inclusion. Dentistry’s history has been such that the profession has experienced inclusion and exclusion, sometimes by choice and sometimes by the actions of others. This study reviews the concept of inclusion in the context of the current need to create inclusive environments for a workforce that is culturally and structurally sound to serve all patients, including the underrepresented or marginalized, in integrated health care. Additionally, this article serves as an introductory roadmap to the papers in this Dental Clinics of North America issue discussing components of inclusivity in dentistry.
Key points
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Inclusion is an essential part of diversity, equity, and inclusion as well as with the broader concepts captured with accessibility, belonging, and justice.
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Imagery for the population perspective in the United States for inclusion has moved from the melting pot where everyone was to adapt to be the same to the mixed salad or chili where separate contributions are recognizable but work together to make the best whole.
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The impact of inclusion ranges from the individual to the professional and population communities.
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Elements for dentistry need to be developed, to have the realization for optimal health care for all, so that other aspects of health care recognize the requirement of bidirectional inclusion of dentistry and oral health. Dentistry must be at the table and serve as a leader in inclusion among the health care professions.
Introduction
Inclusion as the last word listed in the context of diversity, equity, and inclusion (DEI) may be the word with the least attention paid to it. As solutions are sought for inequities and disparities, particularly related to health status and health care access in the United States, the importance of inclusion rises. Additionally, the importance of inclusion is magnified by seeing that it applies to everyone. A variety of definitions have arisen for inclusion or inclusivity (see Box 1 for examples). This study serves as an introduction to issues around inclusion for the dental profession and the discussions developed further in the accompanying articles in this issue of Dental Clinics of North America on Inclusivity in Dentistry: Environments of Belonging and Equity.
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American Dental Association
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Inclusion : Enables us to strive to have all people represented and included and make everyone feel a sense of belonging, not only for their abilities, but also for their unique qualities and perspectives.
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American Dental Education Association
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Inclusion : The practice of leveraging diversity to ensure individuals can fully participate and perform at their best. Inclusion is shared responsibility of everyone within the community. An inclusive environment values differences rather than suppressing them; promotes respect, success, and a sense of belonging; and fosters well-being through policies, programs, practices, learning, and dialogue.
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FDI World Dental Federation ,
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National Health Policy : The new definition of oral health adopted by the FDI World Dental Federation General Assembly in 2016 has laid the framework to allow the profession to reflect on what oral health encompasses and its implication for national oral health policies. Further, this definition, which was approved by consensus by FDI constituents, favors the inclusion of oral health in all health-related policies ….
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Our Values
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Culture of inclusiveness : We deliberately and meaningfully engage and seek representation from the diverse range of oral health professionals and the communities and individuals they serve. This is paramount to achieving our mission.
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International Association for Dental Research
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SCIENCE POLICY: Diversity, Equity, Inclusion, Accessibility, and Belonging Statement : Inclusion is the recognition, appreciation, and use of the talents and skills of all backgrounds by creating a welcoming environment through the proactive identification and removal of the barriers that impede the success of all.
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National Academies of Sciences, Engineering, and Medicine
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Ending Unequal Treatment: Strategies to Achieve Equitable Health care and Optimal Health for All.
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Inclusion : Efforts used to embrace differences; also used to describe how much each person feels welcomed, respected, supported, and valued in a given context.
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[White House] Executive Order (14035) on Diversity, Equity, Inclusion, and Accessibility in the Federal Workforce
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The term “inclusion” means the recognition, appreciation, and use of the talents and skills of employees of all backgrounds.
The diversity of the US population is increasing significantly. The projected trends are such that by 2034, adults over 65 years old will outnumber children under the age of 18 years, and as of 2045, non-Hispanic Whites will no longer be in the majority. Traditionally, the trajectory of health care providers was hoped to “mirror” the population demographics. However, the reflection has not been optimal. Risk predictors for health disparities have tipped the scale in terms of health care inequity as evidenced by increases in the lack of access to care, especially for historically underserved and marginalized groups who are susceptible to significant health conditions and risk of mortality. ,
The considerations and recognitions of the importance of DEI are complex and are not new as confirmed by decades of inequity and injustice. Some reflect on the civil rights movement in the 1960s as being the initiator of DEI. Yet orientation to this time as the starting point reinforces thoughts about just what are the definitions and contexts of DEI use, as it seems that the very premise of the founding of the United States was on equity.
Nevertheless, evolution is happening in the United States; dentistry is in it and needs to embrace the changes and engage to optimize the effectiveness of the profession. One question to ask is what fits best for the US population or the dental workforce as an analogy: a melting pot, a mixed salad, chili, or a boiling pot ?
The diversification of the US population is directly relevant to dentistry for addressing whether the dental workforce reflects the patient population. Contrasts of the components of dentistry viewed from first-year dental students to the dental workforce against the US population yield interesting and encouraging observations on the progress being made at the dental student entry level against the significant gaps from the perspectives of the workforce and dental school deans that are disproportionately non-Hispanic White male individuals ( Fig. 1 ).
A dynamic reflection on the desire to have a convenient term for seeking priorities and actions is that of the number of acronyms that have emerged. DEI has been expanded to consider other values, such as diversity, equity, inclusion and belonging (DEIB) with the addition of belonging, and justice, equity, diversity, inclusion (JEDI) or equity, diversity, justice, inclusion (EDIJ) when considering justice. The Federal Workforce adds another concept that of accessibility in its use of diversity, equity, inclusion, and accessibility in the June 25, 2021, Executive Order 14035. Interesting, in addition to government and academia, a consistent driver of trying to figure out what works best regarding the impact of inclusion and diversity is business and business is an important element of the dental profession.
The US Surgeon General (1982–1989) C. Everett Koop observed a strong tie between dentistry and medicine. “You are not healthy without good oral health” is widely cited in dentistry, while similar value does not always seem to be placed on its importance by medicine as the quote could not be found among Web sites with top quotes from and tributes to Surgeon General Koop. ,
Independence versus inclusion: a brief review of dental history and dental professionals
Dentistry as a profession has been reacting to inclusion in the context of whether the mouth belongs to the body for centuries. Splits are notable from the roles of the barber surgeons and establishment of the first dental college as measures of what medicine did not incorporate that became the features of the evolving profession dentistry, potentially using a collaborative practice model. The concept of collaborative, inclusive health care has taken a long time to manifest and has not yet been fully realized. See Box 2 for selected supplemental readings on broad societal perspectives on inclusion and belonging. The paradigm shift that has taken place in health care toward a more holistic and inclusive care model involving all systems of the body and the mouth is also required to address disparities that continue to produce inequities seen in oral health outcomes.
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2000 Paulo Freire. Pedagogy of the Oppressed: 50th Anniversary Edition. Bloomsbury Academic: New York.
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2017 No Health without Oral Health: How the dental community can leverage the NCD agenda to deliver on the 2030 Sustainable Development Goals. FDI World Dental Federation: Geneva-Cointrin, Switzerland.
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2019 Tomas Chamorro-Premuzic. Why Do So Many Incompetent Men Become Leaders? (and how to fix it). Harvard Business Review Press: Boston, Massachusetts.
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2020 Stefanie K. Johnson. Inclusify: The Power of Uniqueness and Belonging to Build Innovative Teams. Harper Business/Harper Collins Publishers: New York.
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2020 Isabel Wilkerson. Caste: The Origins of Our Discontents. Random House: New York.
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2024 National Academies of Sciences, Engineering, and Medicine. Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All. The National Academies Press: Washington, DC.
The profession of dentistry has some similarities to other health care professions but also has distinct differences. In the United States and Europe, dentistry has experienced exclusion from broader health system discussions and decisions. Such seems possibly attributable to the profession evolving from a trade and the solo expectation that dentistry takes care of teeth. The historic medical view of teeth has been that teeth are disposable, and it is inevitable to have them all lost, more of a nuisance than an essential contribution to overall function. The evolution of other components of health care circa other body parts, eyes and ears, or heart, for example, has gone differently. Perhaps dentistry’s history would be different if the original view of the body part in question was the mouth rather than the tooth. What if an early medical thought that has been attributed to Hippocrates of “all disease begins in the gut” had been more inclusive of the mouth being the portal to the gut? A recent review of the human microbiome is motivating for inclusive perspectives for health across the body. This suggested approach to an inclusive perspective has taken a long time to arrive and the story continues to be written. Dentistry has often been challenged by dynamics within the dental team, the medical system, and oral health disparities to name a few aspects. Working more diligently on achieving inclusivity at all levels will be instrumental in addressing the most glaring of the challenges that of improved oral health outcomes across the lifespan.
Dental professionals challenged with inclusion
Within dentistry, several notable challenges of inclusion persist within the profession across professional components. Several examples are provided here. The first explores the question of “Does oral surgery ‘belong’ to medicine or dentistry?” Oral surgeons walk on the border of these 2 professions, with many having both medical and dental doctoral degrees, albeit the pathway for oral maxillofacial surgery’s inclusion in surgery has been a bit of a circular path ( Box 3 ) for historic perspective from the training program at Harvard University, the first university-affiliated dental school. , The trade-offs might be easy to see from the desire not to spend the length of time involved in pursuing two degrees plus years in residency training. However, raised are additional questions of whether an oral surgeon without an MD degree will be welcomed equally compared to someone with both dental and MD doctorates, as it relates to obtaining hospital privileges, access to surgical time, and respect in the workforce and general community.
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In 1846, first public demonstration of ether anesthesia in surgery was conducted in Boston by dental surgeons William Morton and Nathan Colley Keep.
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In 1867, first university-affiliated dental school Harvard University established, with Keep as its first dean after his seeking establishment of dental education as part of medical education was denied: “My own predilection would favor a thorough and united dental and medical education.”
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In 1971, Harvard University Medical School approved awarding oral maxillofacial surgeons an MD degree with creation of a dual-degree program with Harvard School of Dental Medicine dental graduates as they had been in the same basic science training as the medical students.
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In 1985, Harvard Medical School approved acceptance of non-Harvard School of Dental Medicine dental students into the dual-doctoral program with an additional year of training and two years of medical school.
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In 1995, the Harvard Dual Doctoral program changed to all residents, regardless of where they attended dental school, in a 6- year program with 2 years of medical school.
The second example raises the question of “Where does dental hygiene fit?”. Interesting historic perspectives provided in Box 4 are from the 1926 paper presented by Fones. Barriers and attitudes toward women in the workforce, their promotion, progress, and respect have been consistent overtime. Many issues discussed today surrounding the relationship between the practice of dentistry and the role of the dental hygienist were discussed 100 years ago. Given the poor oral health status of many Americans, models for increasing prevention and access care continue to evolve with dental hygienists central to the role as preventive specialists. Box 5 displays data on the range of dental programs that fall under accreditation via the Commission on Dental Accreditation. Seeing the disproportionate number of programs located in two-year institutions versus dental schools provides insight into some of the difficulties around achieving inclusivity across the full field of dentistry. Traditionally, few areas of dentistry directly experience coeducation, such that much of the training would be in isolation from other components of dentistry and allied dental team members. Seen in the 2022 to 2023 data, only 24 dental schools have dental hygiene programs associated with their universities. , Only 7% of dental hygiene programs are in proximity to training within dental schools, leaving about a third (32%) of dental schools with dental hygiene programs. This dynamic has helped to create a co-educational gap that has been difficult to close even with implementation of programming to deliberately promote collaborative practices such as interprofessional education (IPE).
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In 1844, the American Journal of Dental Science Editorial “Dental Hygiene” calling for more attention to the hygiene of the teeth.
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1870 McLain A paper on “Prophylaxis or the Prevention of Dental Decay”
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1879 First record of “cleaning of the teeth as carried out by the dentist.”
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1884 Rhein ML article “Oral Hygiene” recommended dentists teach their patients to brush their teeth effectively.
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1884 Kingsley NW article “Women – Her position in dentistry” that advocated for women as assistants to the dentists and with experience “she will perform all operations required upon deciduous teeth, including fillings with any of the plastics ….”
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1902 Wright CM presentation at the Odontological Society in Cincinnati “A Plea for a Sub-specialty in Dentistry” to be “women of education and refinement”, provided education containing “special clinical training in prophylactic therapeutics,” for positions “just as physicians and surgeons recommend and insist upon the services of the trained nurse ….”
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1902 Low FW suggested the “Odontocure—a girl with an orange wood stick, some pumice, and possibly a flannel rag, who shall go from house to house … with polishing teeth every 2 weeks … possibly 50 cents would be the charge.”
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1903 Rhein ML proposed “The Dental Nurse” to the Section on Stomatology of the American Medical Association.
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1906 Dr Fones had his office assistant, Mrs Irene Newman begin “prophylactic work for the patients… as far as we know was the first lay woman to practice dental prophylaxis.”
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1907“The Connecticut dental law was amended to make it unlawful for dentists to employ unlicensed assistants for operative work in their offices” albeit further amended to allow for “so-called operation of cleaning teeth.”
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∼1911, “The name ‘dental hygienist’ generally accepted.”
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1915“Amendment of the Connecticut dental law … legally prescribed for the first time the field of operation of the dental hygienist.”
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1916“First university course [a full academic year in length] for dental hygienists … now conducted by the College of Dentistry of Columbia University.”
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In 1923, the American Dental Hygienists’ Association formed … sponsored by the American Dental Association
| Allied Dental Education Programs = 582 (All in the United States) | |
| Dental Assisting = 226 | Dental Hygiene = 340 |
| Dental Laboratory Technology = 13 | Dental Therapy = 3 |
| Predoctoral (DDS/DMD) Dental Education Programs = 75 | |
| United States = 73 |
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| Advanced Dental Education Programs = 776 (All in the United States) | |
| Advanced Education in General Dentistry = 95 | Dental Anesthesiology = 9 |
| Dental Public Health = 15 | Endodontics = 56 |
| General Practice Residency = 168 | Oral and Maxillofacial Pathology = 15 |
| Oral and Maxillofacial Radiology = 9 | Oral and Maxillofacial Surgery = 101 |
| Oral Medicine = 6 | Orofacial Pain = 13 |
| Orthodontics Total = 70 | Pediatric Dentistry = 87 |
| Periodontics = 57 | Prosthodontics Total = 57 |
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