New York, New York! What Can This Great, Diverse City Teach Us About Health Care?
Latinos and Access to Dental Care:
An Urgent Case for Diversity

Dr. Francisco J. Ramos-Gomez

What time is it? The collention of clocks at the Tourneau watch store in mid-town Manhattan reflects the city's global reach. NYU will soon have a campus in Abu Dhabi.

Radio City Music Hall was designed to be "a palace for the people."

By Francisco J. Ramos-Gomez, DDS, MS, MPH

Professor of Pediatric Dentistry;
Director, Graduate Program, Community Health University of California,
Los Angeles School of Dentistry;
President, Hispanic Dental Association

Latinos have a disproportionate oral health burden and less access to dental care than most other ethnic groups. A recent national survey1 of children's health indicated that only 65% of Latino children have "very good" health compared to 95% of white children.2 When rating the condition of Latino children's teeth, more than 50% showed a "suboptimal" condition.3 The 2006 Smile Survey in California,4 where 44% of US Mexican immigrants reside, indicated that 72% of Latino kindergarten and third-grade children had experienced dental caries, and 26% had rampant dental caries. Importantly, oral health disparities present an array of medical problems for Latinos since oral health and overall health are inextricably linked. The urgency of the situation is indicated by the fact that some very low-income Latino households cannot even afford individual toothbrushes for each household member.

The factors that contribute to unmet dental needs among Latinos include lack of dental insurance, lack of education and poor health literacy, lack of diversity and cultural competency among dental providers, lack of English language ability, lack of transportation and time, and a lack of providers willing to accept Medicaid reimbursement rates, and thus to serve low-income populations.

While the large number of the uninsured in the US has become a big news story in recent years, little has been made of how the lack of health coverage also affects dental care. Latinos are the most uninsured ethnic group in the United States.5They are more likely than other groups to have low-wage jobs without benefits,6 and unless these families have sufficient discretionary income, they cannot afford to buy private insurance, let alone pay for services out-of-pocket. Evidence also indicates that Latino parents are often unaware of their children's eligibility for dental safety-net programs; indeed, a survey found that an estimated 4.7 million children were eligible but not enrolled nationwide.7 Moreover, even when enrolled in these programs, families experience difficulties in finding participating dental providers. 8

The lack of parental education has rendered even the most widespread preventive interventions ineffective. For example, despite successful awareness campaigns to prevent baby bottle tooth decay, now called early childhood caries, interviews with parents conducted as part of the UCSF Center to Address Disparities in Children's Oral Health have found that Latino mothers sometimes knew about the risk for tooth decay from a baby bottle but attributed the problem to the bottle's nipple and not to the sugary liquid contents. Latino mothers don't understand the connection between diet and tooth decay and often confuse dental caries with tooth stains.9 Children in some communities are also denied the benefits of community water fluoridation - one of the most equitable and cost-effective means of preventing tooth decay - because Latinos from countries where tap water is often a source of pollutants and pesticides tend to avoid drinking household tap water. 10

The situation is further exacerbated by the fear many Latino parents have that they will be penalized for taking time off from work to accompany a child on multiple dental visits. Loss of income and fear of dismissal from employment often cause parents to delay seeking treatment. Families working in agriculture or other seasonal occupations may postpone their children's dental needs until "low season," when their incomes are reduced and they are more likely to qualify for subsidized or free dental coverage. Add to this the willingness of fewer and fewer providers to accept Medicaid patients, the difficulty that many people experience in having their claims accepted, and the limits on the frequency and types of preventive care covered by Medicaid, and it becomes clear that California and other states with large minority populations are heading into or have already arrived at a "perfect storm" dental health crisis.

Much can be done and should be done immediately to change Latinos' attitudes toward good oral health. On a state level, the myth of dangers in the public water supply needs to be debunked and fluoride varnishes should become standard and widely available. In order to ensure appropriate infant development during pregnancy, prenatal dental care during the first trimester is essential. Physicians and nurse-midwives should be promoting good oral hygiene practices during pregnancy and in the first years of life. Pregnant women tend to be more receptive to adopting health behaviors out of concern for their baby. All health professionals, not just dentists, should take advantage of this critical window by communicating the link between diet and oral health, and teaching expectant mothers how their own health directly affects the health of their baby.

Recent scientific investigations have demonstrated that dental caries (tooth decay) - the most prevalent chronic disease of childhood - is established before age two and linked to transmission of cavity-causing bacteria from mothers to infants. Consequently, meaningful preventive efforts must begin early and focus on children in the context of their families. Dental caries presents a particularly powerful example of how parents' knowledge, attitudes, and behaviors interact to affect not only their own oral health and use of dental services, but also that of their children.

In particular, mothers' oral health status, oral hygiene practices, diets and eating behaviors, attitudes toward dental care, and use of preventive modalities such as fluoride have substantial impact on children's oral health and attitudes about dental services. Because many of these factors are heavily influenced by culture, efforts to improve oral health and dental care must be culturally sensitive and appropriate to families' beliefs and circumstances.

The Relationship Between Diversity and Disparities

Of all the factors contributing to Latinos' problems in accessing dental care, the lack of diversity and cultural competency among dental providers is perhaps the biggest barrier to care.

Latino dentists in California make up 4.6% of the total state dental supply. This equates to one Latino dentist for every 9,446 Latino patients compared to one non-Latino dentist for every 950 non-Latino patients.11 In addition, while half of California's Latino adults report speaking English exclusively or "very well,"12 the other half report "difficulty in speaking English" or less than "very well." This language barrier is magnified by the fact that fewer than 2% of non-Latino dentists speak Spanish.13

In 2002, California's State Assembly introduced Assembly Bill 1045, which allows a limited number of Mexican-educated dentists and physicians to practice in extreme shortage areas in rural California. Although the bill was enacted into law, California's budget crisis prevented implementation.

One objective of Healthy People 2010 is to increase the national representation of Latinos in the health professions workforce to 12%. Nationally, and in California, this has been less than 5% for many decades. That goal is appropriate because Latinos comprise 12% of the US population.

The growing numbers of educated Latinos must be actively and aggressively cultivated by dental school recruiters in order to increase the number of Latinos who can help to fill future voids in dental provider diversity. But to meet the immediate needs of the Latino population, we need to start training our current dental students in cultural competency as well as in the correct protocols for handling young children under the age of six. Of the 56 US dental schools, 19 have adopted courses in cultural competency and mandate that students spend time in underserved communities; even fewer schools require hands-on training with pediatric patients.

One of the strengths of New York City is its immense cultural complexity, a complexity fostered by close physical proximity, which tends to promote cross-cultural accep-tance and increased cultural understanding, sensitivity, and competency. Increased cultural competency allows dental providers to draw out relevant patient information, makes patients more willing to follow a dentist's recommendations, and less likely to postpone necessary dental treatment.

In California, programs like the California Pipeline Project offer dental students opportunities to work with Latino populations by placing students in clinics, such as La Clinica de la Raza in Oakland, CA, and other Latino health centers, such as the San Ysidro Community Health Center at the US/Mexican border. These programs are a good start towards promoting cultural sensitivity and educating future doctors about the relationship between diversity and disparities, but the urgency of the situation demands more. It demands that we recognize that it is crucial both to make Latino enrollment in dental schools a national priority and to make cultural competency a requirement for graduation.

1 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Md: US Dept of Health and Human Services; 2005.

2 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Md: US Dept of Health and Human Services; 2005.

3 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Md: US Dept of Health and Human Services; 2005.

4 Dental Health Foundation. "Mommy, it hurts to chew": The California Smile Survey, an oral health assessment. February 2006.

5 Holtby S, Zahnd E, Chia YJ, Lordi N, Grant D, Rao M. Health of California's adults, adolescents, and children: findings from CHIS 2005 and 2003. September 2008.

6 US Census Bureau.

7 US General Office of Accounting. Survey of 50 State Medicaid and SCHIP Agencies and the District of Columbia. January 2000.

8 US General Office of Accounting. Dental Disease Is a Chronic Problem Among Low-Income Populations. April 2000.

9 Horton S, Barker JC. Rural Latino immigrant caregivers' conceptions of their children's oral disease. J Public Health Dent. 2008;68(1):22-29.

10 Barker JC, Horton SB. An ethnographic study of Latino preschool children's oral health in rural California: intersections among family, community, providers and regulatory sectors. BMC Oral Health. March 31, 2008;8:8.

11 Hayes-Bautista DE, Kahramanian MI, Richardson EG, Hsu P, Sosa L, Gamboa C, Stein RM. The rise and fall of the Latino dentist supply in California: implications for dental education. J Dent Edu. October 2006.

12 Ibid., 231.

13 Ibid.