Policy on Diversity, Equity, and Inclusion

Purpose

The American Academy of Pediatric Dentistry (AAPD) advocates for the health and well-being of all infants, children, and adolescents, regardless of their race, ethnicity, religion, sexual or gender identity, medical status, family structure, or financial circumstances¹ and supports efforts to increase health equity among youth. Diversity, equity, and inclusion (DEI) are critical to achieve the AAPD’S vision of optimal oral health for all children.² The intent of this policy is to review the published literature on how race, ethnicity, and other identifiers are related to children’s oral health and health inequities, to identify barriers to DEI within the dental profession, and to encourage clinicians, educators, researchers, and policy makers to advance DEI within the specialty of pediatric dentistry.

Methods

This policy was developed by the Council on Clinical Affairs. A review of current dental and medical literature and sources of recognized professional expertise related to DEI was completed. The literature search of the PubMed®/MEDLINE database was conducted using the terms: diversity, equity, inclusion; fields: all; limits: within the last 10 years, English. Papers for review were chosen from this list and from the references within selected articles. Expert and/or consensus opinion by experienced researchers and clinicians was also considered.

Definitions

Diversity: constitutes “a broad range of individual, population, and social characteristics, including but not limited to age; sex; race; ethnicity; sexual orientation; gender identity; family structures; geographic locations; national origin; immigrants and refugees; language; physical, functional, and learning abilities; religious beliefs; and socioeconomic status”.³ In addition, other characteristics of diversity include body/size image, veteran status, housing status, and mental health status.⁴

Equity: is defined as “the state, quality or ideal of being just, impartial and fair.”⁵ The concept of equity is synonymous with fairness and justice. To be achieved and sustained, equity needs to be thought of as a structural and systemic concept.⁵ Moreover, health equity is described as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities”.⁶

Inclusion: “is a dynamic state of operating in which diversity is leveraged to create a fair, healthy, and high-performing organization or community. An inclusive environment ensures equitable access to resources and opportunities for all. It also enables individuals and groups to feel safe, respected, engaged, motivated, and valued, for who they are and for their contributions toward organizational and societal goals.”⁷

Background

Marked oral health disparities exist by race and ethnicity for children and adolescents in the United States.^8-11 Children of American Indian and/or Alaska Native descent and Native Hawaiian children have the highest documented prevalence of early childhood caries, and a significantly higher percentage of non-Hispanic Black and Mexican American children have dental caries, compared to non-Hispanic White children.^12-15 Reasons such as consumption of more added sugars and less utilization of preventive dental care have been used to explain the higher caries risk assigned to racial and ethnic minorities.^16,17 While behavior modification strategies are important to improve oral health, the overarching role of social determinants of health must be addressed if oral heath disparities are to be reduced in a long-lasting and meaningful way.^18,19

Structural racism (i.e., processes that are embedded in laws, policies, and institutions^20,21) impacts social determinants of oral health.^22,23 Discriminatory policies such as unfair lending practices, employment standards, and workplace policies heavily influence factors such as income level, insurance coverage, quality of education, food security, housing, chronic stress, and neighborhood resources that lead to poorer oral health outcomes for marginalized populations.^{9,10,18,24,25} Access to dental services, nutritious food, and safe and fluoridated drinking water^10,25 are significantly hindered by barriers such as housing instability, food deserts, inflexible work schedules, lack of transportation, and high costs of care that disproportionately affect non-Caucasian families.^26-29 Recognition of the influence of discrimination on the social determinants of oral health is necessary to advocate for greater health equity.^25,30

Available literature has discussed more direct effects of bias on oral health. Racial minorities often receive lower quality health care than their White counterparts even when accounting for factors related to access, socioeconomic status, and education.^10,31 Negative effects on self-perceptions of oral health status^31,32, diminished oral health-related self-efficacy³³, and avoidance of dental appointments due to fear of maltreatment^10,34 have been reported. Caregivers of minority children have expressed unmet dental needs and inattentiveness from dental providers.¹⁰

Heightened awareness of oral health inequities and related social injustices have inspired professional efforts to enhance diversity and inclusion in the pediatric dental workforce and to combat discrimination that leads to oral health inequities. Dental schools and professional organizations have created strategies to increase diversity among their students, members, and leadership.^36,37 The increased presence of underrepresented populations among healthcare professionals is important for building trust between providers and marginalized families.^10,19 AAPD legislative priorities align with aims to increase professional diversity and health equity through the support of provider training programs, recommended Medicaid reform, and expansion of the dental workforce.^38,39

Both intentional and non-intentional provider biases affect the health care that children receive. The National Institutes of Health report Oral Health in America: Advances and Challenges calls for a new framework in dental education that emphasizes the social determinants of health, inequities, and population diversity.¹⁹ Improved cultural competency training in practices, residency programs, dental schools, universities, and other institutions relevant to the practice of dentistry is necessary to address discriminatory assumptions and behaviors among dental providers.^35,40-43 Relevant training may encourage providers to be mindful of the ways in which personal and professional biases influence practice settings, treatment decisions, office policies, and patient relationships²² and motivate them to create an inclusive and respectful environment for all children in their care. Barriers to implementation of DEI principles, including lack of social supports to help manage children’s needs, have been reported.^44,45

Policy statement

The AAPD acknowledges and celebrates the increasing diversity of children, including their racial and ethnic backgrounds, national origin and citizenship, languages spoken, religious beliefs, abilities, gender and sexual identities, and cultural norms. Additionally, the AAPD welcomes greater diversity within the profession and appreciates the personal experiences, skills, and knowledge possessed by each of its individual members. The AAPD supports broader inclusivity in leadership, membership, education, and practice and deeper engagement with communities to promote necessary collaboration, respect, and dignity for all children and families. Programs, initiatives, and policies that address and overcome social barriers, including racism and other forms of discrimination, are necessary to achieve greater health equity and the AAPD’s vision of optimal oral health for children.

Recognizing the importance of DEI to pediatric dentistry, the AAPD:

• supports social and economic policies, research, and initiatives to address social determinants of oral health that result in racial and ethnic oral inequities.
• encourages providers to implement DEI training within the dental office.
• urges dental educators to implement strategies to mitigate bias in applicant and trainee evaluation processes and to enhance institutional DEI curricula.