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Service Delivery Innovation Profile

Oral Health Program Enhances Access to Culturally Sensitive Dental Care for Refugees and Asylum Seekers


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Snapshot

Summary

The Program for Refugee Oral Health aims to increase oral health literacy and access to dental services among refugees and asylum seekers in Massachusetts by providing free screenings, referrals for urgent and preventive care, culturally appropriate education, and training for medical practitioners on incorporating culturally sensitive oral health screening into medical examinations. Data suggest that the program is enhancing access to dental care and education.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on usage of the program and the need for dental services among those served, with the underlying assumption being that in the absence of the program these individuals would not have had access to the services offered.
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Developing Organizations

Boston Center for Refugee Health and Human Rights; Boston Medical Center; Boston University School of Dental Medicine; Massachusetts Department of Public Health, Refugee Health Assessment Program
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Date First Implemented

2001
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Patient Population

Vulnerable Populations > Immigrantsend pp

Problem Addressed

Refugees and asylum seekers who migrate to the United States often have unique health concerns, including a high prevalence of oral health problems that, if left untreated, can have long-term adverse effects.
  • Increased risk factors for poor oral health: Refugees have a high risk of poor oral health due to a number of factors, including poor diet and nutrition, lack of access to oral health prevention and treatment before and after their arrival in their new country, lack of water fluoridation, and torture-related injuries to the mouth and face.1 Many refugee children have never received dental care or been provided with access to common preventive measures such as a toothbrush or toothpaste.2
  • More untreated dental decay: A study comparing data on 224 newly arrived refugee children in Massachusetts to similar data on American children found that white refugee children were 9.4 times more likely to have untreated dental decay, while African refugee children were twice as likely to have untreated decay.2
  • Barriers to accessing dental care, leading to long-term adverse effects: Refugees in need of dental services are often hindered from seeking treatment by the cost of care, the social stigma attached to their minority status, limited English-language proficiency, and fear of unfamiliar medical procedures.3 Left untreated, dental disease can lead to pain, infection, nutrition problems, tooth loss, and sleep deprivation. Without proper treatment dental decay becomes irreversible and costly to treat.4

What They Did

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Description of the Innovative Activity

The Program for Refugee Oral Health aims to increase oral health literacy and access to dental services among refugees and asylum seekers resettled in Massachusetts regardless of their legal status. An initiative of the Boston Center for Refugee Health and Human Rights at Boston Medical Center, the program provides free screenings, referrals for urgent and preventive care, culturally appropriate oral health education, and training for medical practitioners on incorporating culturally sensitive oral health screening into medical examinations. Key program elements include:
  • Free dental sessions: The program provides free dental sessions to refugees and asylum seekers on a walk-in basis every Tuesday for 5 hours. Services are offered to individuals regardless of their legal status in the country. Patients are referred to the program when presenting with dental pain or problems during their overall health assessment at the Boston Center for Refugee Health and Human Rights. Each dental session lasts approximately 45 minutes and includes the following:
    • Culturally sensitive oral health history interview: Trained to understand common experiences that refugees endure, the program's staff dentist asks the patient (or the patient’s parent/guardian) questions regarding his or her cultural background, dental habits, and prior professional dental care experiences; the goal of this exercise is to build the patient’s comfort level and to identify any issues affecting the patient’s oral health. If a patient has been a victim of torture, the dentist takes steps to avoid retraumatizing the patient. For example, procedures and dental instruments are introduced and explained in advance and interrogation-like questioning is avoided. Sessions are conducted with the help of Boston Medical Center interpreters as needed to ensure cultural and linguistic appropriateness.
    • Dental screening: The dentist uses a penlight, disposable gloves, disposable mouth mirror, and sterile gauze to inspect all four quadrants of the patient’s mouth, looking for loose, missing, or broken teeth; fillings; signs of poor oral hygiene; and tooth pain and sensitivity. The dentist also performs an extra-oral exam, looking at the lips, neck, and jaw for any abnormalities. Using this information, the dentist triages the patient, determining the need for urgent or routine followup care.
    • Referrals for easy-to-access followup care: The program matches each patient with an appropriate dental service provider to receive additional care and treatment as needed. Program staff maintain an updated list of partner clinics and thus are able to connect each patient with a provider who meets his or her needs for interpreter services and transportation accessibility. Most partner sites either accept Medicaid (which many patients are covered by) or offer services free of charge. Before the session ends, the dentist also helps patients schedule the follow up appointment and provides contact information and directions to referred providers as needed.
    • One-on-one oral health education: Using visual aids (e.g., models, pictures, other props), the dentist provides each patient with personalized oral health education and a demonstration of how to care for his or her teeth. Patients also receive a description of their dental problems and needed treatments so that they can anticipate and feel comfortable with what will happen at the followup appointment. Patients are also given toothbrushes, toothpaste, and floss samples to take home.
  • Education and training for medical providers: The dentist periodically offers educational presentations and training sessions for providers and clinics that conduct health assessments or provide medical care for new refugees in Massachusetts. Training sessions are conducted on an as-needed basis and are designed to cover common oral health problems of refugees and principles of culturally sensitive care, thus helping providers avoid retraumatizing torture survivors via interrogation-like techniques, physical contact, or use of unfamiliar dental instruments. These trainings were offered frequently during the program's first years; however, low provider turnover at referring sites has resulted in a lack of demand over the past year. In addition to formal training sessions, the program offers an online tutorial and training video for conducting an oral health assessment of refugees and torture survivors.

Context of the Innovation

The Program for Refugee Oral Health is operated by the Boston Center for Refugee Health and Human Rights at Boston Medical Center, an outpatient clinic that provides refugees and asylum seekers with comprehensive medical, mental health, and dental care, along with coordinated legal and social services. Founded in 2001, the program was established to address the needs of refugees and asylum seekers, particularly torture survivors. There was a concern that many of the patients at the Boston Center for Refugee Health and Human Rights had not received dental services and were symptomatic. Some reports also suggested that some patients experienced direct trauma to the oral cavity as a result of torture. The program was established to address these concerns.

Did It Work?

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Results

While the oral health outcomes of patients served by the program have not yet been formally evaluated, post-implementation data on the oral health status of patients at the time of the initial screening and the use of clinic services suggest that the program is enhancing access to needed dental care and education in a population that has significant dental care needs and no other means of accessing services.
  • Demonstrated need within target population: An assessment of 216 adult patients receiving dental screenings between February 2002 and September 2006 found that 90 percent required immediate or near-immediate dental care, with 76 percent having untreated dental decay, 30 percent suffering from tooth or gum pain, and 18.8 percent having moderate or severe gingival inflammation. Only 20 percent of patients had seen a dentist within the past year, with 23 percent never having visited one.3
  • Facilitated access to services: To date, the program has provided dental care services and oral health education to approximately 360 refugees and asylum seekers. In the absence of the program, it is unlikely that these individuals would have had access to any of these services.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on usage of the program and the need for dental services among those served, with the underlying assumption being that in the absence of the program these individuals would not have had access to the services offered.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining initial funding: The Boston Center for Refugee Health and Human Rights partnered with the Boston University Goldman School of Dental Medicine to seek funding for the program. These organizations applied for and received a $225,000 grant from Delta Dental of Massachusetts to cover the first 3 years of program operation.
  • Recruiting and training staff: Two part-time dental hygienists were recruited and taught to conduct oral health screenings and lead training sessions with providers.
  • Developing tools: Program staff, with input from partner organizations, developed an in-house curriculum to be used when training medical providers on conducting culturally sensitive oral health screenings for refugees. Staff also adapted a Centers for Disease Control and Prevention oral health screening instrument to make it culturally appropriate for use with refugees.

Resources Used and Skills Needed

  • Staffing: Initially, the program was staffed by two part-time dental hygienists, each of whom allocated 10 percent of their time to the initiative. Currently, one dentist staffs the program on a part-time basis. Staffing decisions have been based largely on interest and availability.
  • Funding: On opening in 2001, the program operated with a budget of $75,000 per year, the vast majority ($67,000) of which covered staff salaries, with the remaining $6,500 being used for supplies. At present, annual operating expenses are $40,000 per year.
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Funding Sources

Office of Refugee Resettlement; Delta Dental of Massachusetts; Raymond J. and Mary C. Reisert Foundation
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Adoption Considerations

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Getting Started with This Innovation

  • Utilize partnerships to obtain funds: Partner with committed stakeholders to share resources and strengthen funding proposals.
  • Establish link to larger organization that can refer, follow up with patients: Large community agencies or clinics can serve as access points for future patients and often have systems in place for maintaining follow up contact with patients, a key point when serving transient populations such as refugees.

Sustaining This Innovation

  • Keep cultural sensitivity at the forefront: Patients will not feel comfortable or safe seeking care unless staff are prepared to offer dental care services catered to the unique concerns of refugees.
  • Maintain and regularly update list of referral sites: To ensure that patients receive the followup dental care and treatment they need, lists of referral sites must be kept up to date and accurate. Make sure in particular to maintain current information on which referral sites offer interpreter services and accept Medicaid or offer free services.
  • Consider colocating to ensure access to necessary equipment: Operating from within an established medical facility offering dental care may cut back on the need for outside referrals, because advanced services and equipment may be available on site.

More Information

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Contact the Innovator

Ana Zea, DDS
Boston Center for Refugee Health and Human Rights
Boston Medical Center
771 Albany Street
Dowling 7
Boston, MA 02118
Phone: (617) 638-4913
Fax: (617) 414-4796
E-mail: azea@bu.edu

Innovator Disclosures

Dr. Zea has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

For more information about the training video that was developed with the help of the United Nations, visit http://www.bcrhhr.org/.

Footnotes

1 NSW Refugee Health Service. The Oral Health of Refugees Web site. Available at: http://www.swslhd.nsw.gov.au/refugee/
2 Cote S, Geltman P, Nunn M, et al. Dental caries of refugee children compared with US children. Pediatrics. 2004;114(6):e733-40. [PubMed]
3 Singh HK, Scott TE, Henshaw MM, et al. Oral health status of refugee torture survivors seeking care in the United States. Am J Public Health. 2008;98(12):2181-2. [PubMed]
4 Fine J, Perkins A, Iton T, et al. More than just a toothache: untreated dental disease in our school children. 2006.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 28, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 19, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.