Enhancing equity with research in oral health care for transgender patients

Hormone replacement therapy vector graphic

Everyday tasks that were once simple can sometimes become complicated and stressful for transgender people. Oral health care shouldn’t be one of them—and researchers across the School of Dentistry are doing their part to make sure that’s the case.

Identifying the issue

It started in 2019, with a dental hygiene project. Learners are required to complete a literature review, and are encouraged to choose something that interests them.

Anna Vo, BSDH ’19, approached instructor Michelle Arnett, MS, RDH,with the idea to explore the state of research on caring for transgender patients. “I thought it was a great topic,” Arnett recalled.

Vo was excited to take on the topic, citing her recognition of her own duty. “As a dental professional and just as a person, I am responsible for educating myself on the LGBTQ+ community and understanding the disparities related.” She focused on existing research into treating patients undergoing hormone replacement therapy.

Vo explored the existing literature alongside Arnett and Yvette Reibel, EdD, RDH.

They didn’t find much. “Much of the research we found was more about pronouns and training on communication, but there was very little on the oral manifestations as a result of hormone  treatment, or even things that might impact the community based on social determinants of health, other external factors or lifestyle behaviors,” Arnett recalled.

Vo focused her article on the research that exists, as well as gaps in existing coverage. “The article outlines how dental professionals, specifically dental hygienists, can reduce healthcare disparities for the transgender community by understanding the social determinants of health, oral-systemic conditions that may arise in those who undergo hormone replacement therapy and other commonly prescribed medications,” she explained. “It explores those topics and the dental hygiene care plan associated with the transgender community, in order to provide nonjudgmental patient-centered care.”

Reibel and Arnett were impressed by the Vo’s review of the literature  y, calling it a “very timely and under-researched topic.” Together with Vo, they revised and prepared the article for publication. The article was published in Dimensions of Dental Hygiene in September 2020.

“We thought that the audience of Dimensions of Dental Hygiene would benefit from the  information on this particular topic,” Arnett explained.

Vo hopes providers can learn from her discoveries and change the way they approach patient-centered care. “Providers need to recognize the social determinants of health: things like gender identity discriminiation, vulnerability in the community leading to adverse health outcomes, and increased barriers to oral and general healthcare,” she explained. “Another important thing a provider should be aware of is the increased risk factors in oral-systemic conditions associated with hormone replacement therapy. Dental hygienists should be competent and ethical providers who demonstrate respect and inclusive patient-centered care.”

Looking at care

Palak Bothra, BDS, MPH, dental data manager at the University of Minnesota, has always been interested in disparities in care. She began to notice the same lack of information on caring for transgender patients —especially when it comes to orthodontia.

Bothra recalled one particular case where an orthodontist did everything they thought they could in treatment, but wasn’t seeing results. The orthodontist finally discovered that the patient was on hormonal supplements that impacted the patient’s response to treatment. Bothra is working to explore what dental clinics do now—and what they can do better in the future—to support transgender patients undergoing hormone replacement therapy.

“I realized that there hasn’t been any research targeting transgender patients and their orthodontic treatment,” Bothra said. She was surprised to find that many clinics don’t ask their patients about preferred pronouns, the use of hormone replacement therapy or related issues.

Bothra’s research, currently in the result collection phase, surveys orthodontists at eleven dental schools about their experiences caring for transgender patients and the steps they have taken to improve those patients’ care. She hopes to gather better data about what happens when patients take hormones and guide the future of equitable care.

“I hope we can better understand how teeth move when a patient takes hormonal supplements so providers can recognize the need for different protocols and aid in those conversations from the moment a patient arrives in the office,” Bothra explained. “Even if a dentist is asking about medications, they need to know what kind of care methods to use based on that.”

Bothra also hopes her research leads to more compassionate care. “I want to recognize and identify any gaps that we have in making patients feel welcome and included,” she said.

Providing for practitioners

As Bothra works directly with orthodontic providers, a dental therapy student is gathering information on current students in the hopes of shaping the next generation of inclusive oral health care providers.

Callie Hanson, MDT ’22, focused her capstone project on students’ knowledge of hormone therapy medications and their impact on oral health, students’ comfort and attitudes discussing hormone therapy, and their perceptions of formal training to prepare them to provide oral health care for transgender individuals.

Hanson’s idea for this project came from her own experience caring for a transgender patient. “I found out that they had been delaying care due to fear of discrimination within the healthcare setting,” she said. “I also learned they were taking medications that can affect oral health. This made me want to study dental, dental therapy and dental hygiene students’ knowledge, comfort levels, attitudes and formal training on the impact of hormone therapy on oral health.”

Hanson surveyed School of Dentistry students, finding that while about 64% strongly agreed that they felt comfortable treating transgender patients, 41% strongly disagreed that they had the knowledge to provide education on oral manifestations of hormonal and non-hormonal treatments. They also didn’t feel they had learned about hormonal impacts in the School of Dentistry courses.

“I am hoping that the results of this study provide insightful information to guide future dental curricula,” Hanson said. “I also hope the study enhances diversity, equity and inclusion by preparing our students to properly care for transgender patients.”

Hanson is currently working post-graduation, with her faculty advisors Arnett, Reibel, and Christainson to modify her capstone project into a manuscript for publication in a peer-reviewed journal. 

Looking to a better future

Though recent research undertaken by dentistry professionals shows gaps in knowledge and understanding of oral health care for transgender patients, it also shows great room for growth and improvement—and the School of Dentistry community is eager to put those lessons into practice.

“Transgender patients often delay seeking healthcare due to fear of discrimination,” Hanson reflected. “Having better knowledge of the individual you are working with allows for better patient care and more trust from the patient.” She hopes her study, and others in the works, will prepare providers to feel “comfortable and competent when treating transgender individuals.”

And School of Dentistry educators agree.

“As oral health professionals, we are in the business of preventative care,” Reibel explained. “Identifying the treatments patients may undergo, and how those impact oral health, is important. And we want to create an environment for proper communication and trust with patients. Patients need to be heard and valued by their providers. We have to understand those implications as we try to foster relationships with our patients.