How do you address dental neglect in underserved populations?

Addressing Dental Neglect in Underserved Populations

Expand the dental workforce by deploying midlevel providers such as dental therapists and dental health aide therapists who can deliver preventive and basic restorative services in underserved areas, while simultaneously engaging primary care providers to provide oral health screening, fluoride varnish application, and care coordination. 1, 2

Workforce Expansion as the Primary Solution

The fundamental barrier to addressing dental neglect in underserved populations is severe workforce shortage—the dentist-to-patient ratio in underserved communities is 1:2800 compared to the national average of 1:1500, resulting in 45% of children having untreated caries versus 19% nationally 1. The most effective strategy is training and deploying dental therapists and dental health aide therapists who work under dentist supervision to provide preventive services and basic restorative care. 1, 2

Specific Workforce Models to Implement:

• Deploy dental health aide therapists (DHATs) in remote and tribal communities, as Alaska's DHAT program has demonstrated improved oral health access and outcomes with strong community acceptance 1, 2
• Train dental hygienists with an additional year of education to provide expanded oral health services including preventive care and basic restorations 1
• Engage primary care providers (pediatricians, nurse practitioners, community health nurses, physician assistants) to provide oral health screening, fluoride varnish application every 3-6 months starting with first tooth eruption, and coordinate referrals to dental professionals 1, 2
• Recruit and retain Indigenous and minority dental professionals to increase workforce representation and cultural competency 1, 2

Community Engagement and Trust-Building

Dental neglect often reflects historical mistrust of healthcare systems, requiring direct community engagement rather than passive outreach 2. Build trust through face-to-face interactions at community centers, schools, and local events, and recruit community champions as peer educators who can promote oral health from within the community. 2

Specific Community Strategies:

• Involve community members as active participants in practice design and service delivery decisions, creating feedback opportunities and demonstrating willingness to modify approaches based on community input 2
• Provide educational sessions on topics chosen by the community, not just what providers consider important 2
• Use proactive recruitment with direct face-to-face contact at community events, fitness facilities, and schools where patients can ask questions and build trust 2
• Leverage trusted relationships through word-of-mouth referrals and collaboration with community leaders, as encouragement from family and friends reduces distrust 2

Clinical Prevention Protocols

Prevention is more cost-effective than operative repair and avoids the risks of general anesthesia in young children 1. Implement early intervention starting with first tooth eruption, as "two is too late" for preventive interventions in high-risk populations. 1

Specific Clinical Interventions:

• Establish a dental home by 12 months of age for all children, particularly those in underserved populations 1
• Apply fluoride varnish by dental or nondental healthcare providers starting with first tooth eruption, then every 3-6 months thereafter 1
• Promote supervised twice-daily use of fluoridated toothpaste beginning with first tooth eruption (rice grain-sized portion for children <36 months, pea-sized for ≥36 months) 1
• Incorporate silver diamine fluoride (SDF) into caries management protocols to arrest caries progression and reduce reliance on general anesthesia for operative repair 1
• Use sealants on primary molars to prevent caries and the need for operative repair 1
• Ensure community water fluoridation and verify that communities know their water supply's fluoridation level 1

Addressing Systemic and Financial Barriers

Accept Medicaid and public insurance while actively working to reduce barriers that limit acceptance of these patients, and provide nondiscriminatory care regardless of race, ethnicity, socioeconomic status, or insurance status. 2 The dental profession must accept that providing care to underserved populations is a professional responsibility, not an optional activity 3.

Specific System-Level Actions:

• Offer flexible scheduling including evening and weekend appointments to accommodate caregiving responsibilities and work schedules 2
• Consider the impact of practice changes that could make it more difficult for poorer patients to access care, and implement steps to mitigate such impacts 2
• Expand community health centers, health departments, and dental school clinics to provide comprehensive dental services for low-income residents 4
• Establish free dental clinics that bring volunteer dentists, hygienists, and dental assistants into contact with underserved populations, creating long-term professional commitment to access 3

Cultural Competency and Language Access

Train all dental staff to practice in culturally appropriate ways that demonstrate respect and awareness of cultural, generational, and linguistic barriers. 1, 2 This includes understanding that standard approaches may be less effective in certain populations 1.

Specific Cultural Adaptations:

• Translate all patient materials into appropriate languages with attention to maintaining tone, level, and cultural relevance 2
• Provide materials in multiple accessible formats including video, text, phone, in-person, and social media, using plain language that avoids scientific jargon 2
• Engage in implicit bias and cultural competency training to increase self-awareness, as 70% of physicians have implicit preferences that affect medical decision-making and communication 1, 2
• Provide preconception and prenatal oral health screening for women with anticipatory guidance and referral for dental care 1

Interdisciplinary Collaboration

Integrate dietitians into dental care teams to address sugar consumption as a shared risk factor for both dental caries and metabolic diseases like obesity and diabetes. 1, 5 This is particularly important in populations with high rates of both conditions 1, 5.

Specific Collaborative Actions:

• Implement community-based initiatives that reduce frequent consumption of sugar-containing drinks and sugary snacks through education and improved access to healthy foods 1, 5
• Coordinate dietary assessments for obesity or type 2 diabetes with dental caries risk counseling to simultaneously address both conditions 1, 5
• Promote collaboration between oral health and obesity/diabetes prevention efforts in high-risk communities 1

Common Pitfalls to Avoid

Do not rely solely on disseminating guidelines without implementation support—guideline awareness alone does not change practice behavior. 2 Additionally, avoid assuming that standard prevention strategies effective in the general population will work equally well in underserved populations, as these groups often experience earlier disease onset and more severe manifestations 1.

Additional Pitfalls:

• Do not wait until age 2 for preventive interventions in high-risk populations, as this is too late 1
• Do not focus solely on emergency care or operative repair without addressing prevention and early intervention 1
• Do not implement programs without understanding the specific barriers to care affecting the population being served 6
• Do not neglect the need for interdisciplinary cooperation within the public health system, as dental neglect requires more than just treatment of caries 7