ADEA CCI Liaison Ledger

Spring 2018: Social Determinants of Health

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In this issue of the ADEA CCI Liaison Ledger, we expand upon the concept of person-centered care by exploring the social determinants of health: those factors outside a person’s biological make-up or disease state that influence their health status.  

Recent research affirms what pioneering clinicians and public health advocates have long known: People’s income, address, diet, education level and a variety of other social factors have a powerful influence on their physical and mental well-being.

Kim Fenesy, D.M.D.

In next month’s Journal of Dental Education, the ADEA Commission on Change and Innovation in Dental Education 2.0 (ADEA CCI 2.0) will release a white paper exploring the integration of the social determinants of health into dental education. Two of the paper’s authors—Kim Fenesy, D.M.D., Vice Dean, and Emily Sabato, Ed.D., Assistant Dean for Academic Affairs, both at Rutgers, The State University of New Jersey, School of Dental Medicine—recently spoke with ADEA CCI Liaison Ledger about the ways in which social determinants impact oral health and how Rutgers faculty have woven this subject matter into the predoctoral curriculum at their institution.

We hope their remarks will inspire you to read the white paper and engage in dialogue with your ADEA CCI Liaisons. How might your school encourage students and faculty to develop an appreciation for the social determinants of health? Have you already found ways to integrate the consideration of social factors into patient assessments in your clinics? Join the
conversation—in the comment field below and with colleagues
at the upcoming 2018 ADEA Annual Session & Exhibition in Orlando.
We’re eager to hear your thoughts!

Emily Sabato, Ed.D.

Anthony Palatta, D.D.S., Ed.D., ADEA Chief Learning Officer

Liaison Ledger: Why do dental providers need to know about the social determinants of health?
Emily Sabato: The overall context of people’s lives has a big impact on their choices regarding dental care and what their treatment plans should look like. The social determinants impact so much. If people don’t have heat in their homes, their top priority is probably not teeth restoration but their utility bills. 

Kim Fenesy: They may just be focused on the basics—food, heating—and education about their oral health may take a back seat. People with low incomes may not have money to choose the best treatment. They may put treatment off. They may not be going in for any preventive care. When it comes to primary teeth, some people may feel that you’re going to lose them anyway so why even take care of them.

Liaison Ledger: How do the social determinants of health manifest themselves in the oral cavity?
Emily Sabato:
Pediatric caries is a good example. People who have limited access to healthy foods may be more likely to feed their children sugary sodas and fruit juices in sippy cups and baby bottles, a practice that can contribute to decay. Even foods like crackers and gummies get stuck in molars and can lead to decay.

Kim Fenesy: If people don’t have the background, education or routine of going for dental check-ups—either they’re not exposed to the practice or they don’t understand the necessity—then the unintentional neglect opens the door for chronic and acute life-threatening diseases. Smoking is obviously linked to all sorts of oral pathologies—from increased caries and periodontal disease all the way to life-threatening diseases like oral cancer.

Liaison Ledger: How do you operationalize the integration of the social determinants of health into dental education?
Emily Sabato: Learning about the social determinants of health needs to be woven through all four years. If the topic is brought up in a first-year culture course and never brought up again, students won’t grasp its importance. 

Kim Fenesy: Our paper includes a University of Colorado survey that assesses the social determinants of health. If this survey were incorporated into all our clinics, then students and faculty would be routinely exposed to this content. They would also understand that with every patient, we need to do not only a systems review, a medical history and a dental history, but also a social history. 

Emily Sabato: At Rutgers, we’re primarily introducing the social determinants of health through interprofessional case conferences. We have several cases where social determinants play a role. We have one case where the patient is drunk when she’s brought in, and the students tend to assume that she is an alcoholic. When they get the full history, it turns out she is using alcohol to numb the pain of the toothache. This scenario helps students get over their initial assumption, which equates homelessness with alcoholism.

Kim Fenesy: They fall into the trap almost yearly, and in a benevolent way. They think, “She’s an alcoholic. We need to help her. Let’s get her into a program for alcoholics.”

The case also exposes a bias in their treatment planning. We see every year with this case that the students immediately conclude they need to extract the tooth because they assume she probably can’t afford any other treatment. What about working with the social worker to see what resources might cover saving the tooth?

Emily Sabato: Everyone has biases, so a lot of our education focuses on teaching students to use neutral language and to make sure their biases don’t impact their care. We have a communication exercise in the second year focused on getting the patient’s full history. Our students tend to assume that everyone brushes and flosses twice a day, and may not ask patients about their oral hygiene habits. One of our standardized patient cases is designed to get past those assumptions and help students realize not everyone has this basic level of health literacy. 

Kim Fenesy: The literature talks about how health professions students and residents need to be educated in multiple settings and not always in sheltered settings like hospitals or dental school clinics. Even though people from the wider community come into these settings, the provider isn’t exposed to what the patients go through in their home communities. If students have exposure to community settings, they get a much better feeling for what patients are dealing with out there. 

Editor’s note: Integrating Social Determinants of Health Into Dental Education Curricula: An Interprofessional Approach is scheduled for publication in an upcoming edition of the Journal of Dental Education. The white paper will also be available on the ADEA CCI Resources page. 

In addition to Drs. Sabato and Fenesy, the following authors contributed to the white paper:

  • Jessica Owens, D.M.D., Predoctoral Director, Department of Periodontics, and Assistant Professor, Louisiana State University Health New Orleans School of Dentistry
  • Patricia Findley, Dr.PH., M.S.W., Special Assistant to the Dean for Interprofessional Health Initiatives and Associate Professor of Social Work, Rutgers University School of Social Work
  • Sangeeta Lamba, M.D., M.S., HP.Ed., Associate Dean of Education and Professor of Emergency Medicine, Rutgers New Jersey Medical School
  • Ann Marie Mauro, Ph.D., RN, CNL, CNE, Assistant Dean and Director, Center for Educational Research and Innovation, and Professor, Rutgers School of Nursing

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