The future of diversity, equity, and inclusion in dentistry

By: Eleanor Fleming, PhD, DDS, MPH, Assistant Dean for Equity, Diversity, and Inclusion at the University of Maryland School of Dentistry.

For our latest Expert Voices Blog, the Delta Dental Institute engaged in a Q&A session with Eleanor Fleming, PhD, DDS, MPH, a political scientist, CDC-trained dental epidemiologist (disease detective) and board-certified public health dentist with both domestic and global experience in public health. Currently, Dr. Fleming serves as the Assistant Dean for Equity, Diversity, and Inclusion at the University of Maryland School of Dentistry (UMD-SOD). 

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    Q: What continues to inspire you today about your career in both dental care and public health?

My neighbors in West Baltimore are my current inspiration. Recently, my neighbors in Sandtown and Winchester did not have water because of contamination of the city water supplied to that area. This is the neighborhood where Freddie Gray lived, and it continues to be a place with lower life expectancy, fewer resources for good health, and greater barriers to opportunity. As I see the unhoused people in my neighborhood and witness just how hard life is for so many people, I remain inspired to use my voice and my work to advocate for social justice. I see water equity, health equity, and oral health equity through this same lens of justice. 

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    Q: What learnings have you applied in your new role as Assistant Dean of Equity, Diversity, and Inclusion at UMD-SOD based on your previous work as a dental epidemiologist on the National Health and Nutrition Examination Survey (NHANES) at the U.S.. Centers for Disease Control and Prevention (CDC)?

Regardless of the job position, I work as an epidemiologist: there is a problem, a crisis of some sort, needs that must be identified, evidence-based solutions to implement, and evaluation to measure impact. While there is nothing in my current position that falls under the umbrella of surveillance, my thought process and how I approach my work is very much as I did as a dental epidemiologist with NHANES and as a CDC disease detective. Because public health is context-based, much of my work at UMD-SOD has focused on understanding the context: the community of faculty, staff, and students; the community of University of Maryland Baltimore (UMB), and the larger community that we serve in West Baltimore and the state of Maryland. If nothing else, I bring a lot of curiosity to my work and intentionality to meet all of the stakeholders where they are to appreciate their needs and to find solutions where we can collaborate for a stronger community. This is what I bring to the position of Assistant Dean for EDI.

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    Q: Research shows that often, patients feel more trusting of health care providers who share their race or ethnicity, yet less than 10% of dentists are Black or Hispanic/Latino, though these groups make up more than 30% of the U.S. population. How can students from underrepresented communities who may be interested in dental careers be supported? 

Trust among health care providers is key. I can attest to having health care providers who sadly saw a Black person and not a patient in need of care and empathy. While the body of evidence documenting implicit bias and racism’s impact on oral health, we cannot think that our practice is immune to practices that are happening in health care where historically and contemporarily minoritized people receive care that leads to poor outcomes and for Black pregnant people death. Addressing this disparity in the dentist workforce — and let me also bring hygiene into this because I have yet to find demographic data on the hygiene workforce — is both a recruit and retention issue for those historically and contemporarily minoritized people to join the workforce and how are we training all providers to embrace a health equity lens in their work. Black, Hispanic, and American Indian/Alaska Native oral health providers alone cannot treat all of the Black, Hispanic, and American Indian/Alaska Native patients who often report experiences of discrimination in a dental clinic setting. To focus only on these providers as the solution distracts from the point that ending discrimination in health care is the responsibility of all providers, payers, and everyone in the health care system. Why aren’t more providers accepting Medicaid dental benefits? Why aren’t more clinical spaces safe space for patients? Why aren’t more providers building community trust?

In addition, creating pathways for students interested in dental careers is paramount. In a recent study, my colleagues and I explored student experiences with pathway programs. From our study participants, we identified that students face barriers in navigating the dental admissions process, and may not receive the support at their undergraduate institutions to have the best strategies for admissions. The Dental Admissions Teat (DAT) is a major barrier for students from underrepresented communities. Key opportunities for supporting these students with the DAT could come from providing assess to prep classes and study resources (students in the study reported sharing information and using outdated information because of costs) and vouchers to take the exam. Pathway programs for these students must be sustainable, meaning that there is continued investment in student mentoring, creating opportunities for students to shadow in offices, and that there are sufficient role models for students. There are many professional organizations involved in this work, but there is certainly space for more organizations and individuals to get involved in this critical work. 

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    Q: We know that oral health care can improve overall health outcomes, regardless of background. Why is it so important to focus on increasing access to dental care in underserved populations?

Oral health should be a right and not a privilege. All people should have a dental home and making access to care a reality for all people should be our collective goal. Oral health care should not be available only to those people who can afford it. Access to care must cover insurance benefits (especially comprehensive dental benefits in public insurance), workforce development, and the delivery of care in spaces where people can easily access preventive and restorative services. We need oral health care in schools, nursing homes, jails, prisons, and detention centers, and care integrated into hospitals and those spaces where people receive medical care. Improving access to care will require structural changes and policy initiatives that cannot be limited to provider reimbursement rates. Access to care is a “wicked problem,” and we need bold solutions to create an oral health system that works well in rural communities, in communities where English may not be the dominant language, in spaces where communities are centered in co-creating a delivery system that meets their needs and not what we as providers, payers, or decision makers think people want. Increasing access to dental care requires that we focus not just on those people whom we perceive to be underserved but to accept that care is out of reach for most people. Dental care should not be a luxury for people who can pay for it.

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    Q: How can the dental industry position itself as a leader in the equity, diversity, and inclusion space (EDI)?  

EDI is a team sport. Focusing solely on the providers places a disproportionate burden on what happens in a dental clinic ignoring that oral health practice includes industry and decision makers. I am hopeful that industry, especially payers, have entered into this space supporting research, pathway programs for students with scholarships, and advocating for better policies and programs to improve access, especially in public insurance programs. Best practices that I have observed have focused on addressing social determinants of health, whether through transportation and access to healthy foods initiatives to support people in making it to appointments and getting sufficient nutrition. Interprofessional health initiatives that focus on whole-person care connecting oral health to the rest of the body are also key. The ability of the industry to leverage its power and influence to elevate population-level health and EDI strikes me as a rich space for bold solutions. Given the state of the oral health workforce, I am curious to see how the industry will expand to include more diverse leaders in the C-suite and in the boardrooms with their Boards of Directors and other stakeholders. As much as historically and contemporarily minoritized people are needed in the oral health workforce as providers, they are desperately needed to have seats at the table where decisions are being made. 

To keep up with Dr. Fleming’s work, please follow her on LinkedIn