Integrating Social Determinants of Health into Dental

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Integrating Social Determinants of Health
into Dental Curricula: An Interprofessional
Emily Sabato, EdD; Jessica Owens, DMD; Ann Marie Mauro, PhD, RN; Patricia Findley, DrPH, MSW; Sangeeta Lamba, MD; Kim Fenesy, DMD
Abstract: Approaching patient care from a holistic perspective, incorporating not only the patient’s medical and dental history but also psychosocial history, improves patient outcomes. Practitioners should be trained to provide this style of care through inclusive education, including training working on interprofessional teams. A component of this education must incorporate social determinants of health into the treatment plan. Social determinants of health include income, race/ethnicity, education level, work opportunities, living conditions, and access to health care. Education regarding social determinants of health should be woven throughout dental curricula, including hands-on application opportunities. This education must extend to patient care situations rather than be limited to didactic settings. This article explains the need to incorporate social determinants of health into dental education and illustrates how social determinants education is being addressed in two U.S. dental schools’ curricula, including how to weave social determinants of health into interprofessional education. These descriptions may serve as a model for curricular innovation and faculty development across the dental education community.
Dr. Sabato is Assistant Dean for Academic Affairs and Instructor, Rutgers School of Dental Medicine; Dr. Owens is Predoctoral Director, Department of Periodontics and Assistant Professor, Louisiana State University School of Dentistry; Dr. Mauro is Assistant Dean for Educational Research and Innovation and Professor, Rutgers School of Nursing; Dr. Findley is Special Assistant to the Dean for Interprofessional Health Initiatives and Associate Professor, Rutgers School of Social Work; Dr. Lamba is Associate Dean for Education and Associate Professor, Rutgers New Jersey Medical School; and Dr. Fenesy is Vice Dean and Associate Professor, Rutgers School of Dental Medicine. Direct correspondence to Dr. Emily Sabato, Rutgers School of Dental Medicine, 110 Bergen Street, Newark, NJ 07101; 973-972-4440; [email protected]
Keywords: dental education, person-centered care, social determinants of health, patient-provider relationship, interprofessional education
doi: 10.21815/JDE.018.022

Consider this scenario: Taylor Carter is a 61year-old homeless woman who was found passed out on the curb in a snowstorm without a coat. Emergency responders found her smelling of alcohol, incoherent, holding her hand to her left jaw, and moaning with dental pain. An interprofessional team meets her at the emergency room. What does the team need to consider for her assessment and care?
In this age of swift change in technology, research, and the human environment, the American Dental Education Association (ADEA) has recognized that dental education must evolve to remain current and best serve patients.1,2 The ADEA Commission on Change and Innovation in Dental Education (ADEA CCI) has recently been transformed into ADEA CCI 2.0, with a focus on

fostering developments in dental education to enhance delivery of health care and health outcomes centered on person-centered health care provided by future-ready graduates educated in a transformative learning environment.2 ADEA CCI 2.0 has identified five domains as topics of interest to focus transformation: technology, education, demographics, health care, and environment. Taken together, the last three describe social factors that greatly impact patients’ health, income, and overall quality of life (e.g., rising income inequality, changes in health care access and insurance, climate change). This article explains the need to incorporate social determinants of health into dental education and illustrates how social determinants education is being addressed in two U.S. dental schools’ curricula, including the weaving of social determinants of health into interprofessional education.

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Concept of Social
Determinants of Health
It has long been accepted that social factors contribute greatly to health inequality. This inequality persists both globally and nationally and can lead to disparities in many areas, including overall health, life expectancy, and access to health care.3-5 In 2005, the World Health Organization (WHO) formed a Commission on Social Determinants of Health to identify conditions contributing to this inequality and to formulate recommendations for combatting these conditions.4,6 In 2008, this group concluded that, to reduce existing health disparities, both global and national leadership and advocacy would need to improve overall living conditions, address financial disparities as well as access to care, and focus more research on evaluating both the underlying causes and the outcomes of interventions.6 In 2012, the U.S. Department of Health and Human Services published an Environmental Justice Strategy and Implementation Plan, which examined the relationship between the physical and social environments in which people are born, grow, live, work, and play and how that relationship can impact human health.7 Factors that can adversely affect mental and physical health include lack of income or education, low-paying jobs, limited social support, inadequate nutrition, limitations in transportation, and a lack of available health services.8
In 2016, the FDI (Federation Dentaire Internationale) World Dental Federation adopted a new definition of oral health, encompassing the dynamics of genetic and biological factors, social environment, physical environment, health behaviors and access to care, and elements that modify oral health including age, culture, income, experience, expectations, and adaptability.9 The federation framed these factors into a context that supports overall health and well-being. Structural determinants and conditions including income, race/ethnicity, education level, work opportunities, living in an urban or rural environment, social policy, and access to health care are recognized for their contribution to health inequities and are collectively known as social determinants of health (SDH).3,4 These determinants “contextualize the systemic and structural challenges that patients may face in addressing their health goals” (p. 13).8 The FDI’s broader definition of oral health incorporates SDH and supports the understanding that oral diseases can be socially patterned. Oral health is an important indicator of overall health: “the mouth is

both a cause and reflection of individual and population health and well-being” (p. 1).5
While a person-centered approach is critical,10 the most positive health outcomes may not be realized without considering SDH.8 Untreated caries, periodontal disease, and tooth loss continue to be pervasive problems in the U.S. population,11,12 and research now links income inequality, lower socioeconomic status, and lack of routine home care to these health concerns.13-20 In addition, dental caries in children continues to be a problem, with factors such as low family income, limited education, and poor maternal mental health found to be predictive of poor oral health.21
Despite the evidence that SDH is integral to optimizing health care outcomes, targeted collection of information on social determinants is not routine. Data regarding insurance status and similar data points are piecemeal throughout electronic health records (EHRs), and the majority of EHRs do not allow providers to cohesively collect or review SDH data.22 Tools exist for the collection of information on SDH. For example, the Colorado Community Health Network uses the Social Determinants Needs Assessment Survey (Table 1).23 This survey not only informs the provider; it also gauges the patient’s understanding and knowledge of how SDH may be affecting his or her health and health care. Historically, dental students have been taught to take social histories, but have not been well trained to act on patients’ social needs to improve health outcomes.8 Including the SDH in the systems and dental history review can highlight specific concerns that would affect compliance and proper follow up for oral health care treatment. Using a tool like this in dental school clinics would consistently reinforce the importance of SDH in clinical decision making and future dental practice.
The Advisory Committee on Training in Primary Care Medicine and Dentistry recommended that health professions education incorporate learning that enhances access to care as well as integrates care across disciplines.8 Utilizing the framework proposed by the Institute of Medicine (IOM) for SDH, dental schools should seek to make their curricula integrated and collaborative and provide experiential learning across each curriculum.24 In the IOM framework, the learning model requires student engagement through applied learning, interprofessional education (IPE) experiences, and collaborative learning opportunities. SDH can be woven through the coursework and across the four years of the curriculum.


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Table 1. Selected items from a social determinants of health survey

HEALTHY COMMUNITY: SUCCESSES AND CHALLENGES On a scale from 1 to 5, please rank your level of confidence for each of the following areas as they exist in your community. 1 No confidence 2 Rarely confident 3 Confident 4 Somewhat confident 5 Extremely confident

 Education  Employment/job skills  Health care  Healthy eating  Parks/green space  Community safety  Workplace safety

 Community activities  Police  Personal space  Legal issues  Insurance  Transportation

 Language  Family  Substance abuse  Mental health  Physical activity  Housing

The biggest challenge I see in this community is: ___________________________________

What are the greatest strengths of your community? (Check boxes for all that apply.)



 Mental health treatment access


 Personal space

 Substance abuse treatment access

 Health care


 Affordable housing options

 Healthy eating



 Workplace safety

 Community safety


 Community activity


Other: ________________________________________

What are the greatest weaknesses of your community? (Check boxes for all that apply.)


 Lack of community activities

 Poor access to health care

 Job skills




 Lack of personal space

 Limited transportation

 Substance abuse

 Lack of affordable housing

 Workplace safety

 Mental health

 Legal issues

 Language skills

 Lack of healthy food


 Minimal recreation and green spaces

 Community safety

Other: _________________________________________

AREAS OF NEED On a scale from 1 to 4, please rank the level of need in the following areas as they exist in your community. 1 High 2 Low 3 No need 4 Don’t know

Health Care: what is the greatest health care need?  Primary care  Specialty care  Dental care  Eye care

 Substance abuse  Mental health  Transportation to health care  Appointment

Nutrition: what is the greatest nutritional need?  Access to affordable healthy foods  Access to healthy food in school

 Access to healthy food in stores  Cooking classes

Stress: what is a source of stress in your daily life?  Relationships  Fear of domestic violence  Access to health care service  Access to food

 Access to transportation  Access to safe housing  Access to education  Community violence


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Table 1. Selected items from a social determinants of health survey (continued )

Transportation: what is the greatest transportation need?  Transportation to health care  Transportation to work  Transportation to grocery stores

 Affordable transportation  Transportation to community activities  Reliable, scheduled transportation

Language: what language barriers do you experience in your community?  Access to multi-lingual services  Access to language skill education  Access to employment in your first language

Substance abuse: what is the greatest substance abuse need?

 Prevention programs

 Reduction of alcohol use

 Reduction of drug use

 Drug specific treatment

 Reduction of prescription drug use

 Access to treatment-outpatient

 Access to treatment-residential

Mental health: what is the greatest mental health need?  Residential mental health treatment  Mental health professionals

 Prevention  Access to treatment

Quality of life: what would improve the quality of life for you in your community?

 Educational opportunities

 Community activities


 After school programs

 Recreational opportunities

 Partnership with local police department

 Community safety

 Connections to resources/community agencies

 Health care access

 Access to local parks and community classes

 Dental care access

 Trails and paths

 Public transportation

 Substance abuse support

 Mental health services

 Employment opportunities

Housing: what is the greatest housing need?  Resident advocacy  Senior housing  Affordable housing

 Access to loans  Financial literacy

Employment: what is the greatest employment need?  Job search and placement assistance  Income-generating skills  Internships, paid, leadership, or volunteer work opportunities

Education: what is the greatest education need?  Childhood development  Youth development  Access to the outdoors  Nutrition and physical exercise  Life skills training

 Parenting classes  Health education  Adult education  Day care  Quality of available education

Note: The survey is used with permission from the Colorado Community Health Network ( Demographic items are not included here. The full survey is available from the corresponding author.

Given the strong relationship between psychosocial stressors (e.g., employment status, unsafe neighborhoods, financial stress) and oral health status,25 it is important that dental curricula address SDH broadly and in an integrated manner, rather than in isolation. For example, the link between car-

ies risk factors in children and family income, race, and maternal education21 should be discussed in a pediatric dentistry course. In this context, SDH could be addressed from a targeted intervention and disease prevention standpoint6 (e.g., educating patients on how changes in diet can reduce pediatric caries


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including assistance on access to affordable and healthier foods with consideration of patient culture). Furthermore, SDH education would simultaneously increase students’ awareness of the impact of their own biases and preconceived notions on patient beliefs (e.g., what is affordable, preferable, compliance level for treatment) and teach them techniques to recognize and manage these issues through effective communication8 and self-awareness.
SDH in Dental Curricula
In addition to inclusion in didactic coursework, experiential learning experiences are considered an effective teaching methodology for increasing awareness of SDH.8,25 However, one study found that medical students became callous to SDH across their education and suggested that an effective curriculum include multiple SDH experiences, community engagement, and student reflection to be effective.25 Examples at Rutgers School of Dental Medicine (RSDM) and Louisiana State University School of Dentistry (LSUSD) may help other schools see how SDH can be incorporated into dental curricula (Table 2). In these programs, for example, students complete rotations in rural, underserved areas as well as assisted living facilities, where patients may have significant limitations with respect to oral health care.
A goal of this education is for future practitioners to gain the skillset needed to obtain SDH

information from patients in an unbiased manner. At RSDM, dental students are trained in recognizing cultural differences and are educated on tools for communicating with diverse populations in the Culture and Communication course in the second year of the dental curriculum. This course addresses traditional communications issues such as use of an interpreter and also teaches students to integrate SDH into practice by learning about culturally relevant perspectives on the receipt of dental care, being aware of financial issues, and acknowledging health literacy levels. Students have the opportunity to practice their communication skills in a simulated patient experience. Fellow students and a faculty member observe this interaction, which is followed by group discussion to debrief after each simulation. Cases include a patient with a physical job and schedule affecting his physical health; another who holds cultural beliefs about her diet and health that are inconsistent with medical recommendations; and a patient who is inconsistent in relaying information to the provider. This exercise exposes students early in the second year to SDH they may learn in a patient history interview. The experience precedes the students’ experiences in the treatment planning clinic and emphasizes the importance of patients’ social history, which provides context for their health-related behaviors.8
In a slightly different educational approach, dental students at LSUSD have SDH integrated throughout their curriculum. In addition to courses

Table 2. Examples of social determinants of health education for students at Louisiana State University School of Dentistry and/or Rutgers School of Dental Medicine

General Topic

Content Type


Geriatrics/aging population
Oral diagnosis Pediatric dentistry Periodontics Community experiences

Experiential learning Lecture/exams Collaborative learning Experiential learning Experiential learning
Experiential learning

Biomedical considerations of aging Managing chronic disease Long-term care policies Cognitive changes/behavioral management of patients with
cognitive concerns Rotation in assisted living facility
Differential diagnosis (e.g., pathology, oral diagnosis, radiology, treatment planning)
Dental grand rounds
Rotation in special needs clinic Performance of caries risk assessment on a pediatric patient
Periodontics diagnosis, including assessment of condition, identifying etiologic factors, and formulating and communicating a home care plan to address the condition
Rural practice rotation experience Community dental clinic rotation experience in student-run
federally qualified health center and other community health centers

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focused on aspects of SDH, such as Caring for an Aging Population, students are also enrolled in a four-year Professional Development Continuum, in which cross-cultural experiences are introduced in the first year then expanded during the second year. Examples of SDH highlighted in this course are the impact of education level in the patient population as well as health literacy. Students are given information concerning basic literacy skills of Louisiana residents broken down by regions and the ways that can influence how information should be disseminated to patients. Case scenarios are introduced, ranging from misreading prescription information to misinterpreting biopsy results. Training modeled after the U.S. Department of Health and Human Services segment on culture competence is given.26 Small student group discussions include scenarios involving verbal and nonverbal communication miscues that often occur due to language barriers or cultural differences and how that relates to all aspects of patient care in a dental setting.
Regardless of the approach, in our health care landscape and in the spirit of enhancing personcentered care, dental school curricula should be designed to specifically address SDH topics. One of the best avenues to address these topics is through IPE, which is used by both RSDM and LSUSD. At LSUSD, students are enrolled in a formal IPE curriculum titled Team Up, which emphasizes compassion, communication, and collaboration in health education. This two-year longitudinal course involves all first- and second-year students in the LSU Health Sciences Center Schools of Allied Health, Dentistry, Medicine, Nursing, and Public Health, with Graduate Studies joining in 2018. Students meet monthly in 65 teams to learn “about, from, and with each other” (p. 196)27 with the help of a faculty facilitator. Students in the first year of study participate in team building, motivational interviewing, and communication. Additionally, these interprofessional teams develop their observations skills through a Health Partner program, connecting with members of the community to learn about their health care goals, access to resources, and experience of receiving care. In the second year, these same team members analyze a series of cases with various health components such as physical and/or cognitive disabilities, substance use disorder, oral cancer, and obesity. Each team member applies his or her discipline-specific knowledge in a collaborative effort to analyze and manage the cases.
At RSDM, key interprofessional competencies are mapped across all four years of the curriculum

with the other schools of Rutgers Biomedical and Health Sciences and the Rutgers School of Social Work. The IPE curriculum uses hybrid teaching modalities to promote interprofessional experiential and collaborative learning, including in-person large and small group sessions, patient care experiences at Rutgers and community sites, online learning, and simulation activities. Dental students work in teams with medical, social work, nursing, dental hygiene, and pharmacy students in varied activities. Table 3 outlines IPE activities incorporating SDH.
An illustration of a dedicated SDH IPE experience is a case used in the second year of the RSDM curriculum. The case is presented as a hybrid experience, combining an online pre-assignment with an in-class, interprofessional team-based learning format. The experience addresses such IPE competencies as team communication, roles and responsibilities, ethics, and values.28 The case (from which an excerpt appeared at the beginning of this article) focuses on social determinants of urban health and the challenges this environment may present for patient care: “Taylor Carter, a 61-year-old homeless female patient was transported to the hospital after being found unconscious and without a coat in the middle of winter in a dense, urban area. Upon gaining consciousness, the patient is determined to be intoxicated, has dental pain on the left side of her face, and says she has pre-diabetes. It is learned that the patient was widowed, has been unemployed for several years, and is living in shelters following depletion of her assets. She reports prolonged dental pain and has attempted self-medicating with alcohol and aspirin to reduce the pain. It is also noted that she is unaware of available health and social services.”
Over 300 medical, dental, nursing, and social work students complete this exercise annually. The SDH IPE session consists of four components: 1. Pre-assessment using the Interprofessional Social-
ization and Valuing Scale (ISVS), which measures the degree to which individuals have the affinity to work together and may be used to evaluate the efficacy of IPE.29 2. Pre-assignments that include completion of Institute of Healthcare Improvement (IHI) modules on teamwork, communication, and the culture of safety and the viewing of a videotaped, simulated interprofessional team encounter with Taylor Carter in the emergency department. Through the IHI case studies, students learn essential communication tools that foster a culture of safety by learning to speak up to prevent medical errors and address patient concerns.


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Table 3. Rutgers School of Dental Medicine interprofessional education (IPE) incorporating social determinants of health (SDH)


Professions Involved

Event Summary

Year 1: Orientation

Dental, medicine, physical therapy*

Presentation by vice chancellor for interprofessional programs

Year 1: Online course Dental, medicine, nursing

Discussion regarding care of young pregnant woman; focus on value of teams and understanding roles and responsibilities of health professions in providing optional patient care

Year 2: SDH case

Dental, medicine, nursing, social work

Small-group case discussion focused on SDH and effective communication among team members

Year 3: IPE case conferences

Dental, medicine, nursing, social work, pharmacy, nutrition, physical therapy, occupational therapy assistant, physician assistant, clinical laboratory sciences

Group case discussion (students attend one of three: stroke case, veteran case, oncology/hospice case)

Years 3 and 4: Clinic experiences

Dental, medicine

Patient care experiences in dental school clinic

Year 4: IPE case conferences

Dental, medicine, nursing, social work, pharmacy, dental hygiene, nutrition

Case conferences of 10-12 students focused on patients with special needs and medically complex patients (dental students attend both)

Year 4: Community rotations

Dental, nursing, medicine, nutrition

Community rotations in student-run clinics

*Professions involved in 2017; different schools are scheduled annually for the session with dental and medical students as schedules permit.

3. A team-based learning session that begins with an in-class discussion of the videotaped patient encounter to analyze team dynamics and collaborative care. An interprofessional faculty-led panel debriefing and reflection follow the student team discussion, highlighting how SDH affected assessment, treatment planning, and patient outcomes.
4. Post-exercise assessments including the Assessment of Interprofessional Team Collaboration Scale to measure four elements key to collaborative practice: partnership, shared decision making, cooperation, and coordination.30 An ISVS posttest and student evaluation are also completed to assess students’ perceived attainment of interprofessional competencies and ability to successfully integrate SDH in care.29
Health professions trainees need to learn to assess and manage the SDH of their patients to ensure they provide holistic care and promote the highest levels of health outcomes.28 In this SDH IPE experience, the team-based learning session allows students to consider the patient’s care in the context of her SDH. For example, one student suggested her tooth be extracted because she was homeless and could not afford treatment. Similarly, students often assume the patient is an alcoholic due to her homeless status and the fact that she was found passed out on the curb. However, the subsequent patient interview

reveals otherwise. Faculty members guide students to view patient care more holistically, considering the patient’s SDH from a collaborative care perspective to identify alternatives and other treatment options. Students then begin to see how their assumptions about the patient’s homelessness may prevent a more balanced assessment of her needs. The patient reveals that she tried to self-medicate by holding an aspirin on her gum, which students usually view as ineffective and an “old wives’ tale.” While the treatment may not be recommended, it can be seen as a strength representing a patient’s attempt at self-care using a culturally relevant treatment method. Acknowledging this attempt, the team could build on this strength and provide more evidence-based patient education.31
This IPE scenario shows that developing a plan of action that includes SDH with focused interventions may improve health outcomes, increase health equity, and enhance patient satisfaction.32 Furthermore, focusing solely on technical aspects of care (biological factors) without considering social needs (non-biological factors) can worsen outcomes.8 For example, some students—prior to considering the patient’s SDH—suggested extracting the abscessed tooth without considering other treatments because she was found unconscious on the curb. This rash decision could leave the patient open to a future of oral health complications.

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To focus on the collaborative care aspects of the case and how SDH was incorporated into the discussion of furthering patient care, the ISVS pre- and posttests were used to assess students’ appreciation and understanding of including the patient as part of the team. Preliminary data analysis from an exempt, retrospective study (Rutgers IRB Pro2017000006) showed the ISVS for interprofessional students increased from pretest to posttest overall, indicating an increase in their perceived value of interprofessional patient care. All initial average scores were “to a moderate” or “to a great” extent, as were final average scores on question responses, indicating the students valued interprofessional health care before and after the learning activity. Most ISVS items showed statistically significant increases for the overall student population in reported value of interprofessional teamwork; however, this effect was much more limited for the dental student population. However, the dental students showed a significant increase in positive response to leadership of a team, debating within a team, and working within a team.
Although the ISVS largely focuses on interprofessional teamwork, several questions are strongly related to practitioner competence to successfully integrate SDH into care, including themes of the importance of the patient and his or her family as a part of the team and shared decision making. The students’ understanding of these elements was reflective of their ability to engage with patients with respect to SDH, as evidenced by increased overall ISVS scores following the interprofessional learning activity.
The Commission on Dental Accreditation (CODA) is explicit about the importance of educating future dentists to include SDH in facilitating accurate diagnosis and effective treatment as well as compliance in patients, and all U.S. dental schools must show development of a robust faculty development process.33 Faculty members should be encouraged to educate students about current standards of patient care reflecting state-of-the-art practice, such as inclusion of SDH, which in turn informs best practices in dental education as defined in accreditation Standard 3-2. Furthermore, Standard 2-16 discusses the importance of education regarding disparities in health status in an environment that supports diversity and inclusion, incorporating the development of solutions. This standard lends itself to innovative curricular changes by supporting collaborative didactic and clinical efforts by dental school and social work faculty, such as including a social worker as part of

the dental faculty. This creative approach could improve patient access to community services to address SDH as well as reinforcing, through observation for both student and faculty member, how directly intervening on SDH can change patient health outcomes in real time. These changes in how providers approach integration of patient history into care will help patients like Taylor Carter in the future.
Health care is shifting to a more integrated, person-centered approach, and as a result, the dental community needs to change to remain current. Social determinants of health will continue to present a challenge in our society and deserve explicit focus in dental school curricula. Awareness of the psychosocial factors influencing patients’ oral and overall health will not only enhance their diagnosis, preventive care, and dental treatment but, with the proper training and tools, will facilitate dentists’ playing an integral role in health care teams.
The RSDM IPE curriculum is supported in part by Grant Number D85HP28497 from the Health Resources and Services Administration, an operating division of the U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.
This article is one in a series of invited contributions by members of the dental and dental education community as commissioned by the ADEA Commission on Change and Innovation in Dental Education 2.0 (ADEA CCI 2.0) to focus on how changes and trends in several domains of interest external to dentistry are having a global impact on the content and delivery of health care, health professions education and research, and, ultimately, how health care can benefit patients. This article is by invited authors who are members of the ADEA CCI 2.0, but it does not necessarily reflect the views of ADEA, individual members of the ADEA CCI 2.0, or the Journal of Dental Education. The manuscript was reviewed by the ADEA CCI 2.0 directors and Steering Committee.


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Integrating Social Determinants of Health into Dental