IQ6: What are the unique needs and risk factors of refugee oral health?

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Rick Harp: Welcome to Episode 6 of Infectious Questions, a public health podcast produced by the National Collaborating Centre for Infectious Diseases. At NCCID, we help those with infectious disease questions connect to those with answers. Hello, I’m Rick Harp.

Shivoan Balakumar: And I’m Shivoan Balakumar. This episode marks a shift in focus for our podcast, from a virus—Zika—to a population, namely, refugees. Refugee health remains a matter of concern to public health practitioners across Canada. Today, we’ll focus on their oral health, an aspect of wellbeing all too often overlooked.

Harp: Our guest expert on this topic is Dr. Carlos Quiñonez, an Associate Professor of Dental Public Health at the University of Toronto. The Director of its specialist training program, he’s a past president of the Canadian Association of Public Health Dentistry. Doctor, thank you for joining us on Infectious Questions.

Dr. Carlos Quiñonez: Thank you.

Harp: Now, generally speaking, how does the oral health status of refugees compare to that of other, foreign-born populations?

Quiñonez: So that’s actually a very nuanced question and I’m going to back up a little and talk about how the health of refugees compares to people born in Canada. We actually don’t have a lot of strong evidence in Canada with respect to the oral health of refugees, but a colleague of mine and a student and also a colleague in Montreal, recently did a scoping review or a review of the existing literature out there. And they found 32 relevant North American studies that spoke about the oral health of refugees. And they tended to find that refugee children, in particular, tend to have worse oral health across a variety of domains, whether it’s pain, whether it’s cavities, compared to, like I said, the domestic population.

What you’ve asked me though is how do you compare the oral health of refugees to other, foreign-born populations. And again, I have to tell you we don’t have a lot of really strong evidence to sort of make definitive claims, but we can say that, in general, whether you’re an immigrant, whether you’re a refugee, you tend to have poorer oral health than the domestic population. As to, you know, if I were to say, refugees have worse oral health than immigrants—again, I couldn’t say that just based on the lack of information. I will also tell you though, that if we go beyond North America and we look at other Western democracies, the evidence is actually a bit equivocal. Meaning, refugees or immigrants don’t always enter their respective new home countries with necessarily poor, poorer oral health. In fact, it really depends on where they’re coming from, the experiences they had in coming to Canada, so if we think about Syrian refugees, they clearly had significant, significant challenges before they were able to enter Canada. And all these things prior to the refugee entering clearly have an impact on their oral health.

I also want to stress this notion in the literature that we’ve also studied called, “The healthy immigrant effect.” There’s this sense that at least some immigrants—and I’m sure this applies to refugees—actually come in with better health than, in our case, the Canadian-born population, based on their experiences in home countries. So, you know, we in Western nations have a particular diet that tends to be… you know, increases the risk of oral diseases and other diseases. And refugees and immigrants may not come with that diet so they come with actually better health.

But then over time—and again, this has been well studied, at least for systemic health conditions, and we have a little bit of information for oral diseases—but over time, their oral health, or their health, deteriorates for a variety of reasons: the adoption of new diets, which I’ve mentioned, new behaviors, you know… whether it’s not having to do so much exercise… or whatever it might be, you end up having a worsening of health. And on top of that, of course, is the stress of coming to a new country and having to essentially build your life again.

So all these things result in the situation where people’s health can deteriorate over time. So that’s a very, I would say, complicated answer to what is essentially a very nuanced question because it depends on a lot of different things.

Balakumar: So what might that imply for day-to-day engagement with refugees on the part of public health practitioners?

Quiñonez: I think it really implies that there needs to be sort of a one-on-one assessment of individuals and individualized, I guess, assessment of families, but also where there refugees come from. You know, refugees from African nations are going to be different than from the Middle Eastern nations, than from Mexico or Central or South American nations. So these things have to be taken into consideration when primary health care professionals deal with these populations.

The first real step, though, is actually getting primary health professionals to look into people’s mouths and actually make an assessment of their oral health. We have to then… humorously, but unfortunately sadly, state that often, primary health care professionals ask people to say, “ahh,” and they just completely ignore everything and look immediately past all the structures that we as dental professionals are interested in, obviously.

Harp: So Doctor, are there any distinct risk factors practitioners might keep in mind in terms of refugees, as compared to other foreign-born populations, in the area of oral health?

Quiñonez: Yeah, most definitely. Really poor oral health, for the most part, is now a disease of social marginalization. Or to put it another way, a disease of poverty. So you would be looking at issues of income security, of food security. You know, we also know that consumption of high, high carbohydrate diets tends to promote the development of oral disease.

There are generally two major oral diseases, whether it’s caries or cavities, and periodontal and gum disease. We know that these diets tend to promote that level of disease. So it’s in looking at those things, the social marginalization: what are you able to eat? what can you afford? and so on. Oral health behaviours are also something that need to be looked at.

But I would say, at least it’s been my experience when I’ve treated refugees many moons ago, that many people come to Canada already knowing that they need to brush their teeth, you know, in the morning and before they go to bed and after they eat meals. They know they need to floss, you know. So this is now really, you know, this is a bit of an overstatement, but it’s a bit of a world standard now.

So I think another risk factor that people don’t often speak about is sort of psychological trauma. You know, when people come to this country, they can experience things like post-traumatic stress disorder. And generally, just the… probably, the overwhelming stress. I mean, I’m actually a child of a refugee family. I was very young, so I don’t really have the direct experience compared to my older siblings and my parents. But, you know, in speaking to them, I can tell you it’s an incredibly harrowing experience and it’s incredibly stressful.

And in those moments, as you’re trying to survive, certain things sort of get pushed: you know, as you’re trying to find housing, because you’re trying to figure out where your next meal is going to come from, and learning a new language, or figuring out how you’re going to sort of establish the life that you have left behind, for example. That’s not relevant for everybody, but it is in many cases. So much stress that, getting your kids to bed and making sure their teeth are brushed, finding ways to be able to go to the dentist; I mean, these are things that, in certain circumstances, are luxuries. So I think it’s important for people to understand that there’s a much broader dynamic going on here than just, you know, you need to brush your teeth and you need to eat healthy, because those things are determined by far greater issues, whether at the personal level or the family level, but really, what I’m pointing to, are issues at the structural level that we really, really need to pay attention to.

Harp: Dr. Carlos Quiñonez, thank you.

Quiñonez: Thank you.

Shivoan: That’s it for this episode of Infectious Questions. If you have public health questions about oral health of refugees, email them to nccid@umanitoba.ca. Or call us toll free at 1-844-847-9698, and record your question there.

Harp: Infectious Questions is a production of the National Collaborating Centre for Infectious Diseases. Production of this podcast has been made possible through a financial contribution from the Public Health Agency of Canada.

Balakumar: Note that the views expressed here do not necessarily represent those of the Agency. The host organization of the NCCID is the University of Manitoba. Learn more at nccid.ca.