A dentist with training wheels

By Nandini Sharma

In the United States the third year of dental school serves as the first clinical year of dental education. During this year we are expected to translate our first two years of didactic knowledge into full time patient care. By the end of my second year I was more than eager to get away from the constant barrage of examinations and start to treat patients. I expected the transition from treating a plastic tooth to a real patient to be difficult. What I didn’t expect was to learn was how social determinants of health can affect oral health.

Recently, I admitted a patient who exemplified how these factors influence oral health. She was a 24-year-old African American female who had braces placed at age 14 and has never had them removed. The patient complained of pain in her mouth and said she had recently been to the emergency room because of a dental abscess. The emergency room gave her amoxicillin to treat the infection and recommended finding care at the dental school. In 2014 the Journal of American Dental Association found emergency department visits for dental problems cost almost $3 billion from 2008-2010. The study also found that individuals who are uninsured and live in a low-income area are more likely to visit hospital-based settings for urgent dental care (1).

During her oral examination she presented with heavy calculus on her teeth, missing teeth, root tips, mobile teeth, generalized inflammation, and a chronic abscess on her maxillary palate. An endodontic resident was called in for a consult and used a palatal nerve block before draining the abscess (2). I realized she would need to have all her maxillary teeth extracted for immediate dentures. As a provider it was very difficult for me to tell a 24-year-old patient that she will need dentures. Although complete denture prosthodontics is a routine, inexpensive treatment option, it is a last resort.

As dental students we sink our teeth into clinical practice by treating a diverse, underserved population. This provides us with a unique insight on how social, physical, and behavioral barriers prevent our patients from attaining oral health care (3,4). My patient disclosed that her mother would take her for orthodontic check-ups when she was younger. But at the age of 19 she lost her mother and stopped visiting the dentist. Over time as the status of her oral health deteriorated she no longer felt the need to brush daily. For my patient one of her main deterrents of proper oral health care was psychosocial. Aside from treating dental disease we need to tailor our care based on which determinants are hindering our patients from having good oral health.



  1. Allareddy, V., Rampa, S., Lee, M. K., Allareddy, V., & Nalliah, R. P. (2014). Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. The Journal of the American Dental Association145(4), 331-337.
  1. Fitch, M. T., Manthey, D. E., McGinnis, H. D., Nicks, B. A., & Pariyadath, M. (2007). Abscess incision and drainage. New England Journal of Medicine357(19), e20.
  1. Scheerman, J. F., Loveren, C., Meijel, B., Dusseldorp, E., Wartewig, E., Verrips, G. H., … & Empelen, P. (2016). Psychosocial correlates of oral hygiene behaviour in people aged 9 to 19–a systematic review with meta‐analysis. Community dentistry and oral epidemiology.
  1. Strauss, R. P., Stein, M. B., Edwards, J., & Nies, K. C. (2010). The impact of community-based dental education on students. Journal of Dental Education74(10 suppl), S42-S55.
  1. Greenspan, J. S. (2013). Global health and dental education: a tipping point?. Journal of dental education77(10), 1243-1244.