Why Black People Stay Flossing
Black Americans disproportionately suffer from gum disease at a higher rate than any other racial group. What does early tooth loss mean for a community that already faces school and workplace discrimination because of their physical attributes?
A few years ago, a new patient presented at my office for his dental appointment holding in his palm — his lower front tooth. “I just can’t lose anymore teeth,” the African American early childhood educator explained, nervously covering his mouth to hide his smile. “I really don’t like dentists but I don’t want my students to see my mouth looking like this. They look up to me and I need to be a good example.”
Upon examination and discussion of his smile goals, I learned more about my patient’s past dental traumas that included long waiting periods in public health clinics for dentists who belittled his mother for not taking better care of his teeth. We also talked about his smoking habit, which had noticeably exacerbated his uncontrolled gum disease. Finally, he confessed that only since he had met his fiance the year prior, had he began regularly practicing oral hygiene and it was actually because of her encouragement that he was able to overcome his embarrassment and come in to the appointment.
Smile anxiety and particular concerns for its effect on one’s work environment is not out of the ordinary but for African Americans — who are more likely than any other racial group to suffer from periodontal disease — smile hopelessness is yet another hurdle for a group that already has their natural features weaponized against them.
In America, Black skin, hair texture, and even “Black sounding” names are under constant scrutiny. Most recently — at the start of the academic year, Darryl George a Black teenager in Texas was actually suspended from school due to his neatly tucked dreadlock hairstyle. This incident of racist intolerance prompted his family to file a federal civil rights lawsuit against the state in violation of the recently passed CROWN Act — legislation that demands protection against race-based hair discrimination in the workplace and in K-12 public and charter schools based on hair texture and natural hairstyles, like afros, braids, bantu knots, and locs. Black hair is an expression of identity and culture but in a society that devalues Blackness, it is so heavily policed that it had led to Black students being withheld from classroom instruction as well as school activities including prom and commencement ceremonies.
Beyond schools, Black employees often experience racial bias because of their hair at job interviews and racial unfairness in professional work interactions and promotions. Furthermore, Black women face health risks linked to hair straightening. According to Janice Gassam Asare, PhD, founder and CEO of BWG Business Solutions, a DEI consulting firm and author of the forthcoming book Decentering Whiteness in the Workplace:
“Black women are often aware of the harsh penalties they can face at work for wearing natural hairstyles, but the risks involved in adhering to societal norms is becoming greater and greater. One 2015 study found that certain hair products commonly used by Black women may increase the risk of breast cancer. The popular permanent hair straighteners, called relaxers, were also found to contain hazardous chemicals, and a 2022 study linked them to uterine cancer.”
Arguably, good oral health is connected to better overall health for the obvious benefits of mastication, digestion, and speech. Additionally, as part of our appearance, tooth loss greatly impacts self-esteem and dental problems pose a barrier to employment and self-sufficiency. A study in the Journal of Restorative Dentistry that examined welfare dental intervention and employment found that 79% of participants who pursued dental treatment plans exhibited improvement in their quality of life.
It is not unusual for patients to feel ashamed of their poor oral health status and unfortunately due to the inequitable structure of dental care in the United States, millions of patients do not have access to a dentist, which creates disparities. In addition to higher rates of gum disease, compared to White patient populations, African Americans are more likely to develop oral or pharyngeal cancer, are less likely to have it diagnosed at early stages, and will have lower five-year survival rates. Commonly, in the case of Black patients — past dental experiences are also connected to encounters of racial discrimination. Unwelcoming attitudes and bias from doctors and other dental personnel further limit access to care and contribute to the existing mistrust of African Americans towards the medical profession, particularly white doctors, from gruesome experiments on enslaved people to the forced sterilizations of Black women and the infamous Tuskegee syphilis study.
The Tuskegee Syphilis Study, which was sponsored by the United States Public Health Service from 1932 to 1972 intentionally withheld treatment from hundreds of Black men for decades to let doctors track the course of the disease.
A study in the International Journal of Environmental Research analyzed data from Social Ecological Models and Healthy People 2020 finding that even when education and income are considered — Black Americans still show increased oral health disparities compared to White Americans. This reality is a side effect of generations of racism in medicine and de facto discriminatory practices. Several structural, sociocultural, and familial factors impact African American’s ability to utilize oral care services, despite increased access to care. Evidence suggests that disparities may persist because a narrow focus on increasing access to care omits several other levels of influence that serve as barriers. As such, practitioners must exercise emotional intelligence in order to find ways to provide more holistic treatment.
As dental practitioners explore how to enhance the experiences of all patients, consideration should be given to typically unrecognized factors and utilize a holistic view to move beyond the mouth and concern oneself with the knowledge, attitudes, and beliefs of patients and their families.
Racial discrimination has always been pervasive in American society and continues to manifest in inequities that impact oral health. Furthermore, differences in population health outcomes are worsened by the “social determinants” of health, including poverty, limited access to care, unemployment, rurality, food insecurity, poor housing, and structural racism and discrimination that disproportionately affect Black people in the United States. Because racism and discrimination are weaved into the Black experience in America, approaches to care as well as policies and initiatives to combat anti-black practices must be mandated in order to advance equity in oral health as well as the greater society.
Dr. Brigitte White is a cosmetic dentist in the Washington, DC metro area and adjunct faculty at University of Pennsylvania School of Dental Medicine. Follow her on Instagram, Spotify, and Youtube.
