Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults.

Racism, an oppressive and fallacious sociopolitical hierarchy, is a fundamental cause of oral health inequities worldwide. Everyday discrimination is associated with worse self-rated oral health, toothache and adult tooth loss, and lower oral care utilization. Few studies examine discrimination or microaggressions within oral care settings or their effects on oral health outcomes. We adapted the seven-item Everyday Discrimination Scale to the oral care setting (EDSOC); developed a four-item Dignity in Oral Care Scale (DOCS); fielded them to a probability-based nationally representative sample of US households as part of the 2022 State of Oral Health Equity in America survey (SOHEA, n = 5682); and examined associations between EDSOC and DOCS scores and three outcomes: self-rated oral health, duration since last oral care visit, and planning for future preventive/routine oral care. Nearly, all EDSCOC and DOCS measures were significantly associated with oral health outcomes. Discrimination experience in dental settings had an additive effect on reporting fair/poor oral health and a suppressive effect on planning a future dental visit. Indignity experience doubled-to-quadrupled the likelihood of reporting fair/poor oral health, not having visited a dentist in 2 years, and not planning a future oral care visit. Racio-ethnically minoritized patients may experience the unjust double bind of resolving urgent dental or completing preventive services needs amidst being treated in a discriminatory manner or without dignity. Oral health stakeholders should invest more effort to understand relationships between racism and oral health outcomes and introduce evidence-based interventions to ultimately abolish this societal harm.

Heightened vigilance and perceived discrimination in dental trainees' readiness for clinical practice.

PURPOSE/OBJECTIVE: The aims of this study were to examine associations between heightened vigilance and perceived discrimination on readiness for clinical practice and to examine the mediating effects of social support and resilience. METHODS: A survey was distributed to dental trainees (dental and dental hygiene students) enrolled at a US dental school located in the mid-Atlantic region. The survey assessed readiness for clinical practice and included measures of perceived discrimination, heightened vigilance, and the following wellness measures: perceived stress, resilience, anxiety, social support, and coping. Adjusted for gender, and race/ethnicity, we regressed heightened vigilance and perceived discrimination independently on students' readiness for clinical practice. To assess mediation, we computed the direct effects of heightened vigilance and perceived discrimination and potential indirect effects mediated through social support and resilience. RESULTS: A total of 250 students who completed the survey had complete data on all variables. Five percent identified as Black or African Americans, 34% as Asians, and 8% as Hispanic/Latino. Sixty-two percent were female and 91% were dental students. The overall mean (SD) heightened vigilance and perceived discrimination scores were 18.9 (4.9) and 10.5 (7.6), respectively. Only the mean score for heightened vigilance differed significantly by race/ethnicity (p = 0.02). Higher heightened vigilance (odds ratio [OR] = 0.75 95% confidence interval [CI]: 0.25, 2.23), and perceived discrimination (OR = 0.52, 95% CI: 0.33, 0.88) scores were independently associated with lower adjusted odds of reporting high confidence in readiness for clinical practice even after adjusting for the mediating effects of social support and resilience, although the association for heightened vigilance was not statistically significant. CONCLUSIONS: Heightened vigilance and perceived discrimination appear to negatively impact dental trainees' career readiness. Intentional efforts to prioritize an anti-racism approach within dental education programs and patient care across the nation are warranted.

Calibrating a Transformer-Based Model's Confidence on Community-Engaged Research Studies: Decision Support Evaluation Study.

BACKGROUND: Deep learning offers great benefits in classification tasks such as medical imaging diagnostics or stock trading, especially when compared with human-level performances, and can be a viable option for classifying distinct levels within community-engaged research (CEnR). CEnR is a collaborative approach between academics and community partners with the aim of conducting research that is relevant to community needs while incorporating diverse forms of expertise. In the field of deep learning and artificial intelligence (AI), training multiple models to obtain the highest validation accuracy is common practice; however, it can overfit toward that specific data set and not generalize well to a real-world population, which creates issues of bias and potentially dangerous algorithmic decisions. Consequently, if we plan on automating human decision-making, there is a need for creating techniques and exhaustive evaluative processes for these powerful unexplainable models to ensure that we do not incorporate and blindly trust poor AI models to make real-world decisions. OBJECTIVE: We aimed to conduct an evaluation study to see whether our most accurate transformer-based models derived from previous studies could emulate our own classification spectrum for tracking CEnR studies as well as whether the use of calibrated confidence scores was meaningful. METHODS: We compared the results from 3 domain experts, who classified a sample of 45 studies derived from our university's institutional review board database, with those from 3 previously trained transformer-based models, as well as investigated whether calibrated confidence scores can be a viable technique for using AI in a support role for complex decision-making systems. RESULTS: Our findings reveal that certain models exhibit an overestimation of their performance through high confidence scores, despite not achieving the highest validation accuracy. CONCLUSIONS: Future studies should be conducted with larger sample sizes to generalize the results more effectively. Although our study addresses the concerns of bias and overfitting in deep learning models, there is a need to further explore methods that allow domain experts to trust our models more. The use of a calibrated confidence score can be a misleading metric when determining our AI model's level of competency.

Conceptualizing inequities and oppression in oral health research.

Major sociohistorical processes have profound effects on oral health, with impacts experienced through structural oppression manifested in policies and practices across the lifespan. Structural oppression drives oral health inequities and impacts population-level oral health. In this global perspective paper, we challenge old assumptions about oral health inequities, address misleading conceptualizations in their description and operation and reframe oral health through the lens of intersecting systems of oppression. Furthermore, we emphasize the need for oral health researchers to explore causal pathways through which oppression harms oral health and engage in social science concepts to understand the root causes of oral health inequities fully. Finally, we call on policymakers, dental scholars and decision makers to consider health equity in all policies and to take a systems-oriented approach to effectively address oral health inequities.

"Like pouring salt in a wound": A qualitative exploration of the consequences of unmet housing needs for cancer patients and survivors in New York City.

OBJECTIVE: To identify consequences of unmet housing needs in the period following cancer diagnosis. DESIGN: Qualitative descriptive design. PARTICIPANTS: New York City-based cancer patients and survivors (n = 21) who reported experience of unmet housing needs while receiving cancer treatment. Key informants (n = 9) with relevant expertise (e.g. oncology social workers). METHODS: One-time semi-structured telephone or in-person interviews were conducted with all participants. Inductive thematic coding was conducted using a pragmatic paradigm. FINDINGS: Four categories of consequences emerged: 1) cancer management and health (rest and recovery, illness/injury risk, medical care); 2) psychological (stress and anxiety, lack of control and independence, self-esteem/pride, sadness/depression, cancer coping); 3) social (relationships, consequences for others, isolation); and 4) standard of functional living. CONCLUSION: The simultaneous experience of cancer and unmet housing needs is broadly burdensome. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Screening and resources for addressing unmet housing needs must be prioritized to holistically care for patients.

Refining the process: Safety net dental professionals' experiences with teledentistry implementation during the first year of COVID-19.

OBJECTIVES: Teledentistry helped dentistry adapt to pandemic-era challenges; little is known about dental professionals' teledentistry experiences during this time. This analysis sought to understand professionals' pandemic teledentistry experiences and expectations for the modality's future. METHODS: We conducted virtual individual interviews (n = 21) via Zoom to understand how federally qualified health centers (FQHCs) delivered oral care during the first year of the pandemic, including but not limited to the use of teledentistry. We independently coded each transcript, then identified themes and sub-themes. RESULTS: We identified three major themes: (1) Logistical and equity considerations shaped teledentistry's adoption; (2) Team-based factors influenced implementation; and (3) Teledentistry's future is as-yet undetermined. CONCLUSIONS: Experiences with teledentistry during the first year of COVID-19 varied substantially. Future directions should be more deliberate to counter the urgency of pandemic-style implementation and must address appropriate use, reimbursement guidance, patient and provider challenges, and customizability to each clinic's context.

Building sustainable approaches to recruit, retain, and professionalize Black, Latinx, and American Indian students interested in dental careers.

BACKGROUND: Only twelve percent of dentists in 2020 self-identified as being Black, Latinx, or "Other," which includes American Indian. Moreover, the proportion of dentists from these groups profoundly fails to reflect the demographic composition of the U.S. overall. Evidence-based, ethically-grounded approaches are needed to successfully and continuously recruit and retain Black, Latinx, and American Indian dental students. We explored the barriers and opportunities to sustainable pathways to the dental profession. METHODS: We conducted focus groups in 2021 with current Black, Latinx, and American Indian dental students and key informant interviews with dental school administrators using elicitation guides developed for this project. We completed a thematic analysis of data to identify and check findings to strengthen validity. RESULTS: We identified the following successes, challenges, and opportunities for recruiting Black, Latinx, and American Indian dental students. Successes include institutional investment to build and sustain pathways, yet many of these practices are institution- or administrator-specific and may defy replication. Challenges are more widespread, and include weak accreditation standards; systemic bias and failure to consider candidates holistically in admissions decisions; costs associated with admissions test preparation and volunteer shadowing; transportation, geography, school culture and language/citizenship status. Opportunities include mentoring, scholarships, removing bias from admissions, institutional financial investment in pathway programs, and peer norming among programs. CONCLUSION: Building sustainable pathways involve early support of students, removing systemic biases, and institutional commitments to equity to create a workforce to meet population needs.

Attention-Based Models for Classifying Small Data Sets Using Community-Engaged Research Protocols: Classification System Development and Validation Pilot Study.

BACKGROUND: Community-engaged research (CEnR) is a research approach in which scholars partner with community organizations or individuals with whom they share an interest in the study topic, typically with the goal of supporting that community's well-being. CEnR is well-established in numerous disciplines including the clinical and social sciences. However, universities experience challenges reporting comprehensive CEnR metrics, limiting the development of appropriate CEnR infrastructure and the advancement of relationships with communities, funders, and stakeholders. OBJECTIVE: We propose a novel approach to identifying and categorizing community-engaged studies by applying attention-based deep learning models to human participants protocols that have been submitted to the university's institutional review board (IRB). METHODS: We manually classified a sample of 280 protocols submitted to the IRB using a 3- and 6-level CEnR heuristic. We then trained an attention-based bidirectional long short-term memory unit (Bi-LSTM) on the classified protocols and compared it to transformer models such as Bidirectional Encoder Representations From Transformers (BERT), Bio + Clinical BERT, and Cross-lingual Language Model-Robustly Optimized BERT Pre-training Approach (XLM-RoBERTa). We applied the best-performing models to the full sample of unlabeled IRB protocols submitted in the years 2013-2019 (n>6000). RESULTS: Although transfer learning is superior, receiving a 0.9952 evaluation F1 score for all transformer models implemented compared to the attention-based Bi-LSTM (between 48%-80%), there were key issues with overfitting. This finding is consistent across several methodological adjustments: an augmented data set with and without cross-validation, an unaugmented data set with and without cross-validation, a 6-class CEnR spectrum, and a 3-class one. CONCLUSIONS: Transfer learning is a more viable method than the attention-based bidirectional-LSTM for differentiating small data sets characterized by the idiosyncrasies and variability of CEnR descriptions used by principal investigators in research protocols. Despite these issues involving overfitting, BERT and the other transformer models remarkably showed an understanding of our data unlike the attention-based Bi-LSTM model, promising a more realistic path toward solving this real-world application.

From describing disparities to understanding why disparities exist: Anti-racist methods to support dental public health research.

Racism is understudied in the oral health literature at the same time that race is overutilized as an explanatory factor in study design. Social and behavioral methodologies offer conceptual models that can be used to include racism in dental public health questions. In addition, interdisciplinary and mixed methods approaches allow for understanding racism as an underlying cause of social and health disparities and exploring solutions that address historical, institutional, social, political, and economic drivers of oral health inequity, while recognizing the limits of measuring racism quantitatively. In a collective acknowledgement of the limitations of conventional methods, there are new opportunities to explore how qualitative and mixed methods research can serve as drivers for both social justice and health equity, while building and sustaining a diverse research workforce that can better close these disparities and offer antiracist solutions to oral health inequities.

Dental safety net providers' experiences with service delivery during the first year of COVID-19 should inform dental pandemic preparedness.

BACKGROUND: COVID-19 disrupted oral health care delivery and revealed gaps in dental public health emergency preparedness and response (PHEPR). Emerging dental PHEPR frameworks can be strengthened by means of understanding the experiences of the discipline's frontline workers-dental safety net providers-during the initial phase of the COVID-19 pandemic. METHODS: Experienced qualitative researchers interviewed dental safety net directors and clinicians (n = 21) in 6 states to understand their experiences delivering care from March 2020 through February 2021. Interview transcriptions were analyzed using iterative codes to identify major and minor themes. Conventional qualitative validity checks were used continuously to ensure impartiality and rigor. RESULTS: Three major themes were identified: unpredictability caused concerns among staff members and patients, while also deepening fulfilling collaborations; care delivery was guided by means of various resources that balanced safety, flexibility, and respect for autonomy; and pandemic-driven changes to oral health care delivery are timely, long-lasting, and can be somewhat fraught. CONCLUSIONS: The human, material, and policy resources that providers used to control infections, serve vulnerable patients, maintain clinic solvency, and address provider burnout during the first year of the COVID-19 pandemic can improve dental PHEPR. PRACTICAL IMPLICATIONS: Dental PHEPR should address concerns beyond infection control within and between practice models, governmental agencies, and professional organizations. Examples of such concerns include, but are not limited to, guideline synchronization, materials exigencies, task shifting, and provider resilience.

Developing a classification system and algorithm to track community-engaged research using IRB protocols at a large research university.

Community-engaged research (CEnR) is now an established research approach. The current research seeks to pilot the systematic and automated identification and categorization of CEnR to facilitate longitudinal tracking using administrative data. We inductively analyzed and manually coded a sample of Institutional Review Board (IRB) protocols. Comparing the variety of partnered relationships in practice with established conceptual classification systems, we developed five categories of partnership: Non-CEnR, Instrumental, Academic-led, Cooperative, and Reciprocal. The coded protocols were used to train a deep-learning algorithm using natural language processing to categorize research. We compared the results to data from three questions added to the IRB application to identify whether studies had a community partner and the type of engagement planned. The preliminary results show that the algorithm is potentially more likely to categorize studies as CEnR compared to investigator-recorded data and to categorize studies at a higher level of engagement. With this approach, universities could use administrative data to inform strategic planning, address progress in meeting community needs, and coordinate efforts across programs and departments. As scholars and technical experts improve the algorithm's accuracy, universities and research institutions could implement standardized reporting features to track broader trends and accomplishments.

Oral Health, Health Service Utilization, and Age at Arrival to the U.S. among Safety Net Patients.

BACKGROUND: Immigrants' oral health disparities have not been adequately investigated using a lifecourse approach, which investigates the cumulative effects of risk and protective exposures among other considerations. METHODS: We examined self-reported oral health outcomes and health care appointment outcomes among a sample of patients enrolled at a federally qualified health center in Richmond Virginia (N = 327) who were categorized into three groups by approximate age at arrival to the U.S. RESULTS: Study participants who arrived to the U.S. prior to age 18 had better retention of natural dentition, better oral health related quality of life, and a lower proportion of dental appointments to address pain than those who arrived after age 18 or were born in the U.S. CONCLUSIONS: Im/migrants' differentiated oral health outcomes by age at arrival to the U.S. suggest the relevance of lifecourse factors, for example the cumulative effects of risk and protective exposures, and confirm the merits of lifecourse studies of im/migrants' oral health.

Oral Health Knowledge, Barriers to Dental Care, and Awareness of a Medicaid Pregnancy Dental Coverage Among Reproductive-Age Women.

Objectives: Oral health is an integral part of women's health, yet many women face barriers and go without necessary dental care. The objectives of this study were to (1) examine and compare pregnancy-related oral health knowledge and barriers to dental care access during pregnancy among women with private and public insurance and (2) estimate awareness of available Medicaid pregnancy dental benefit among Medicaid-enrolled women and explore associated factors. Methods: A cross-sectional survey was administered to a convenience sample of 21- to 45-year-old women (n = 187) visiting a large urban academic health center in Virginia. Data on pregnancy-related oral health knowledge, barriers to dental care access, Medicaid dental benefit awareness, health insurance, socio-demographics, health information source, and last dental visit were collected. Chi-square tests, t-tests, and multivariable regression were used to examine associations at p ≤ 0.05. Results: More than half of the women reported private insurance (52.4%), 40.3% reported Medicaid, and 8.3% reported being uninsured. Medicaid-enrolled women reported a lower prevalence of a routine dental checkup in the past year (44% vs. 71%, p = 0.002), lower knowledge scores (2.9 vs. 3.6, p < 0.001), and more barriers to accessing dental care during pregnancy compared with privately insured women. One in every three Medicaid-enrolled women (34%) was unaware of the Medicaid pregnancy dental benefit. Benefit awareness was associated with the receipt of health information from a health care source (p = 0.030) and a high oral health knowledge score (p = 0.018). Conclusions: There was a significant gap in dental care use and knowledge between Medicaid-enrolled and private-insured women in our study sample. Targeted programs should be developed to educate women about the importance of oral health and share information about available Medicaid dental coverage to reduce barriers to dental care during pregnancy.

Advancing health equity through a theoretically critical implementation science.

While implementation science is driven by theory, most implementation science theories, models, and frameworks (TMF) do not address issues of power, inequality, and reflexivity that are pivotal to achieving health equity. Theories used in anthropology address these issues effectively and could complement prevailing implementation science theories and constructs. We propose three broad areas of theory that complement and extend existing TMF in implementation science to advance health equity. First, theories of postcoloniality and reflexivity foreground attention to the role of power in knowledge production and to the ways that researchers and interventionists may perpetuate the inequalities shaping health. Second, theories of structural violence and intersectionality can help us to better understand the unequal burden of health disparities in the population, thereby encouraging researchers to think beyond single interventions to initiate partnerships that can impact overlapping health vulnerabilities and influence the upstream causes of vulnerability. Finally, theories of policy and governance encourage us to examine the social-political forces of the "outer context" crucial for implementation and sustainability. The incorporation of critical theories could enhance implementation science and foster necessary reflexivity among implementation scientists. We contend that a theoretically critical implementation science will promote better science and, more importantly, support progress toward health equity.

Survival of silver diamine fluoride among patients treated in community dental clinics: a naturalistic study.

BACKGROUND: Silver diamine fluoride (SDF) is a minimally-invasive preventive service used in the U.S. to avert and arrest caries since 2014. No studies document survival outcomes based in real world delivery. We analyzed 12-month survival outcomes of SDF applied independently or concurrently with other restorative procedures among a population receiving community dental care. METHODS: We analyzed data on SDF applications from de-identified dental claims on Oregon Health Plan patients served by Advantage Dental in 2016, who had been seen in 2015 (patient n = 2269; teeth n = 7787). We compared survival rates of SDF alone, SDF applied with a sedative filling, and SDF with a same-day restoration. Failure was defined as a restoration or extraction of the tooth 7 to 365 days after initial application. Survival was defined as a patient returning 180 or more days after application whose tooth did not have a restoration or extraction. Differences were assessed through Wilcoxon equality of survivor function tests and log-rank equality of survivor tests to compare failure rates, Cox Proportional Hazards models to assess factors associated with survival of SDF, and Kaplan-Meier survival estimate to calculate the probability of survival over time. RESULTS: SDF alone had an overall survival rate of 76%. SDF placed with sedative filling and with a same-day restoration had survival rates of 50% and 84% respectively, likely reflecting treatment intent. SDF alone survived exceptionally well on primary cuspids, permanent molars, and permanent bicuspids and among patients aged 10 to 20 years, with modest variation across caries risk assessment categories. A single annual application of SDF was successful in 75% of cases. Among SDF failures on permanent dentition, more than two-thirds of teeth received a minor restoration. CONCLUSION: SDF is a minimally invasive non-aerosolizing option that prevented non-cavitated lesions and arrested early decay among community dentistry patients when applied independently or concurrently with restorative procedures. Professional organizations, policy makers, providers, and payors should broaden optional SDF use by informing clinical guidelines, reimbursement policies, and treatment decisions. Future research should address clinical, social, service delivery, workforce, and economic outcomes using diverse population-based samples, and the mechanisms underlying single application success and caries prevention potential.

MORE Care: an evaluation of an interprofessional oral health quality improvement initiative.

OBJECTIVE: This evaluation assesses the Medical Oral Expanded Care (MORE Care) initiative in four states that focused on oral health integration into primary care practices located in dental shortage areas. METHODS: This analysis is conducted using self-reported primary data collected from each of the participating MORE Care clinics in South Carolina, Pennsylvania, Colorado and Oregon. Three measures: the percentage of pediatric patients with a) fluoride varnish applied, b) self-management goals reviewed, and c) risk assessed, were evaluated to compare the impact and timing of change tactics on participating teams. An engagement dashboard tool was also hand coded with inductive codes using an adapted grounded theory approach common in applied health services research, to iteratively identify themes that could illuminate or explain quantitative findings. RESULTS: The average proportion of pediatric patients receiving fluoride varnish increased from 25 percent after the first collaborative learning session to 40 percent after the third collaborative learning session. The proportion of pediatric patients with self-management goals reviewed also improved, increasing from 25 percent to 62 percent. There was more variation in the proportion of pediatric patients with oral health risk assessments completed increasing from 47 percent to 77 percent. Qualitative analysis of MORE Care open text data produced three themes related to facilitators and barriers of project implementation and criteria for project success. CONCLUSIONS: The results of this analysis demonstrated that MORE Care is effective in creating an operational structure for integrating oral health care into primary care practices and most successful when participating clinics meet success criteria.

"You Have to Keep a Roof Over Your Head": A Qualitative Study of Housing Needs Among Patients With Cancer in New York City.

PURPOSE: Housing status can become compromised in the wake of financial hardship for some patients with cancer and become a source of disparity. This qualitative study describes the types of housing issues experienced by patients with cancer and survivors of cancer in New York City. METHODS: Semistructured interviews were conducted with a volunteer sample of 21 patients with cancer or survivors of cancer treated in New York City who reported housing needs in the period after diagnosis through survivorship. Nine supplemental interviews were conducted with cancer and housing key informants. Conventional content analysis was conducted on transcripts to create a codebook describing types of housing needs. RESULTS: Patients and survivors most commonly had breast (n = 9) and blood (n = 4) cancers and ranged from recently diagnosed to many years posttreatment. Twenty-nine distinct housing-related issues were identified, which were grouped into the following six major categories: housing costs (eg, rent, mortgage), home loss, doubled up or unstable housing, housing conditions, accessibility (eg, stairs, proximity to amenities), and safety. Issues were often interrelated. Housing needs sometimes predated cancer diagnosis. Other issues newly emerged in the wake of cancer-related physical limitations and disruption to finances. Needs ranged in severity and caused patients and survivors considerable burden during a difficult period of poor health and financial strain. CONCLUSION: This study contributes depth to current understandings of housing needs among patients with cancer and survivors by providing detailed disaggregated descriptions. We recommend increasing availability of services responsive to these needs and exploring promising options such as patient navigation and legal services. Findings also highlight the importance of creative solutions addressing ecologic-level factors such as housing affordability.