Abstract
Purpose Social determinants of health (SDOH) significantly influence oral and systemic health outcomes yet are often unaddressed in dental hygiene clinical practice. The purpose of this study was to determine the feasibility of integrating SDOH screenings and referrals into a dental hygiene educational clinic and assess the impact on student learning.
Methods This two-part, survey-based study included adult patients (n=208) receiving care at a dental hygiene clinic who had completed a validated SDOH needs assessment. Patients with identified needs were referred to community resources using findhelp.org and 211.org, with follow-up conducted via phone calls. A second survey captured reflections from student dental hygienists (n=15) on their experience with the screening and referral process.
Results Findings showed that while most patients reported stable housing and food access, a modest number reported concerns related to personal safety, transportation, healthcare access, and emotional well-being. Only a small minority accessed resources post-referral, often due to barriers such as time constraints or that they were not given the website information. Student reflections indicated that the experience increased awareness of patient challenges beyond oral health and fostered empathy, although time limitations and patient discomfort were noted as barriers. Students expressed a variety of views on incorporating SDOH assessments into future practice.
Conclusion This study demonstrated that SDOH screening and referral is feasible within dental hygiene education and can enhance student understanding of the broader context of patient care. Further research is needed to determine the experiences of patients and students in other dental hygiene entry-level programs. Future curriculum integration and expansion to additional programs may further support efforts to address health disparities beyond the educational setting to clinical dental hygiene practice.
INTRODUCTION
Social determinants of health (SDOH) are nonmedical factors that affect the daily lives of people impacting health, health care and access, education, economics, neighborhoods, safety, and social support.1 Unmet SDOH needs negatively influence the health and well-being of individuals by reducing the opportunity to achieve optimal levels of overall health.2 Health-related social needs (HRSN) are related to SDOH and incorporate elements such as a lack of access to healthy foods, transportation, healthcare, and safe housing that diminish health outcomes in individuals as well as communities.3 Individuals with higher SDOH burden, such as those living with food insecurity or with limited use and access to dental care, are at greater risk for oral disease.4
Oral diseases continue to be a concern in the United States (US) with many oral conditions addressed as needs in Healthy People 2030.5 Obeidat et al. recognized the relationship between SDOH and oral health concluding that to improve oral health, SDOH needs must be addressed.6 Social determinants of health and HRSN burdens increase the risk for oral diseases such as dental caries, oral cancer, periodontal disease, and tooth loss.7-12 For example, children living in poverty experience a higher level of dental caries and untreated decay.11,13,14 Additionally, untreated decay rates are also higher for adults living at middle to high level poverty.14
Among individuals diagnosed with head and neck cancer, mortality rates increase with SDOH disparities.15 Additionally, complications in postoperative head and neck cancer surgeries were also higher.16 Patients with oral cavity cancer enrolled in Medicaid, versus other insurance plans, who also had unmet social needs had worse survival rates.7 Additional factors related to poorer outcomes included patients with SDOH needs who were less likely to participate in preventive health appointments, were diagnosed with later stage oral cancer, and were less likely to receive cancer surgery.7 In a systematic review, loerger et al. determined that SDOH influence the diagnosis for advanced stage head and neck cancer diagnosis due to factors such as low socioeconomic status and lack of insurance.17 Regarding periodontal diseases, SDOH burden increases the risk for periodontitis and more unmet social needs correspond with higher risk.8-9 Periodontal disease is multifactorial, but SDOH burden increases the prevalence particularly in disadvantaged populations with lower education and income levels.11 Improving oral health in the US will require addressing SDOH needs in individuals and communities.6
The impact of SDOH extends beyond oral health to chronic systemic diseases such as cardiovascular disease (CVD), obesity, and diabetes which are directly correlated with poorer periodontal disease outcomes.18-24 Hill-Briggs et al. conducted a comprehensive scientific review on the relationship between diabetes and SDOH and associated low social economic status, higher poverty neighborhoods, food insecurity, lack of healthcare insurance, and lack of social support, to be linked to poorer diabetes control outcomes.20 Javed et al. concluded there is a direct correlation between increased SDOH burden and obesity prevalence. Individuals with obesity reported lower education levels, problems with transportation and finances to pay medical bills, higher levels of unemployment, lower levels of medical insurance coverage and higher levels of food insecurity.22 In an umbrella review, Teshale et al. examined SDOH in regard to CVD and determined that many SDOH factors increase CVD risk and mortality including social isolation, loneliness, SES, neighborhood violence, and ethnicity.25
In a scoping review regarding dental curriculum and SDOH, Leadbeatter and Holden concluded that there is a lack of direction and experience addressing patient SDOH needs in dental education and that the SDOH should be taught at the foundational level.26 The American Academy of Pediatric Dentistry (AAPD) issued a policy statement encouraging oral health professionals to assess for SDOH and assist patients in finding necessary resources.27 Sabato et al. discussed how SDOH could be integrated into dental education and stressed the importance of addressing SDOH needs in the patient’s treatment plan.28 While some research exists on screening for SDOH in dentistry, none are specifically focused on dental hygienists.29-31
Dental hygienists in clinical practice and educational settings conduct assessments in many areas including systemic health, vital signs, head and neck cancer and risk, dental conditions, caries risk, periodontal disease conditions and risk factors, but SDOH screening has not universally been a part of this assessment process. The 2025 American Dental Hygienists’ Association Standards for Clinical Dental Hygiene Practice introduced a comprehensive evaluation for 15 different SDOH needs as part of the assessment process.32 As oral health care professionals and prevention care specialists, dental hygienists investigate the etiology of disease, formulate the dental hygiene diagnosis (DHDx) and care plan options, and communicate with patients the best evidence-based options to improve individual oral health. A SDOH diagnosis directs the care plan to include needed referrals.33 Educating health care professionals, including dental hygienists, on what the SDOH are and how unmet needs affect health outcomes, is necessary to help patients get the appropriate assistance.33
While there have been studies pertaining to SDOH in relationship to oral health, systemic health, screening and education over the past decade, there is limited knowledge on how to evaluate for SDOH needs and make referrals in clinical dental hygiene practice. Therefore, the purpose of this study was to determine the feasibility of conducting a patient assessment for SDOH and provide a resource referral process in a dental hygiene educational clinic setting and assess the impact of this process on student learning.
METHODS
This descriptive study was a two-part, survey-based project. The first part assessed Social Determinants of Health (SDOH) of patients presenting for dental hygiene care. The second part identified dental hygiene student perceptions of the feasibility of evaluating SDOH and impact on learning from participation in the SDOH screening and referral process. This research aligned with standards and practices for human participant research and was classified exempt by the Biomedical Research Alliance of New York (BRANY) (Part 1: BRANY File # 24-030-954) and (Part 2: Oregon Institute of Technology IRB File# 2025-01-07). In addition to the IRB approval, the research was assessed utilizing the Checklist for Reporting of Survey Studies (CROSS).34
Part One
Participants
All patients were invited to complete a paper-based survey during their dental hygiene clinic appointment. Inclusion criteria were all patients, 18 years and older, who were able to legally give consent to participate. Exclusion criteria were patients who were current dental hygiene students, faculty, or dental clinic staff members. Data collection was between May 1, 2024, and March 18, 2025.
Instrument
A 17-item, fixed-response survey was developed to determine the SDOH of patients presenting for dental hygiene care (Figures 1-3). The survey was derived from two sources, the American Academy of Family Physicians Social Needs Screening Tool35 and the National Association of Community Health Centers PRAPARE Assessment.36 Questions were based on the last 12 months and consisted of 11 SDOH sections (housing, utilities, food, childcare, medical or health care, understanding health information, education access and quality, employment, personal safety, transportation, and social and emotional health) followed by a section requesting participant demographic and contact information (for the purpose of follow-up referrals to community resources). Demographic information requested included gender, race/ethnicity, age, and education level (Figure 1). For those participants providing contact information, a follow-up phone call by a research team member was conducted to determine whether community resources were accessed and to help with the referral website, findhelp.org.37 The survey was determined relevant and valid through the use of a content validity index with all 17 questions receiving highly relevant scores ranging from 0.83 to 1.00.38
Demographic profile of SODH survey respondents (n=208)
Patient survey questions and responses to yes/no items (n=208)*
* Not all participants responded to every survey item
Patient survey questions and responses to SDOH items (n=208)*
Not all participants responded to every survey item
Procedures
Both junior and senior level student dental hygienists (n=40) were trained to conduct the SDOH screening and educated on the importance and relevance of the SDOH burden on patient health outcomes during two 30-minute PowerPoint lecture presentations presented by the principal investigator (PI), with interactive discussions during each session. While all students were trained to conduct the screening, they were provided the option to participate as screeners. Volunteer student dental hygienists were given a script to introduce the survey and facilitated its completion with consenting patients. The paper surveys were used during the dental hygiene clinic appointments in the educational clinic and participants took approximately 10 minutes to complete the survey. Dental hygiene students then evaluated the survey for SDOH needs with a key to identify the specific needs. The students then educated the patients on the referral resource, findhelp.org. Participants were given a referral card with a QR code and website link for the findhelp.org37 resource and the 211.org website link.39 A Spanish translation of the survey was also made available during the same time frame; however, no participants utilized this resource. The paper survey responses were entered into an online survey platform (QualtricsXM, Provo, UT, USA) by a member of the research team. Utilizing the phone contact information provided by the participant, a researcher attempted to contact all participants who reported SDOH needs within the survey.
Part Two: Dental Hygiene Student Reflection
Participants and Procedure
Junior and senior dental hygiene students (n=40) were invited to participate in a survey regarding the SDOH interventions. Inclusion criteria were student dental hygienists at least 18 years of age that had engaged in part one of the patient SDOH study. Participating student dental hygienists were invited to complete the survey through PI invitation accompanied by an email survey link and posted as a banner in the online learning management system. The survey was open between February 27 and March 13, 2025; participants took approximately 12 minutes to complete the survey.
Instrument
A novel 8-item follow-up survey was designed to identify dental hygiene student perceptions and impact on learning from participation in the SDOH patient screening and referral process and administered in QualtricsXM. The online survey consisted of two sections and combined both fixed and open response options. Section one asked participants about participation in the SDOH project, significance of learning, engagement with the referral process, barriers experienced, and anticipated use of SDOH learning in future practice as a clinical dental hygienist. Within the survey, participants were invited to share a photovoice40, reflecting the progress made regarding their understanding of SDOH. The photovoice response invited participants to write a free form prompt response accompanied by a photo/image that reflected the narrative. Participants also provided demographic information, including class level and age.
Data Analysis
Data analysis for both parts of the study was limited to descriptive statistics. All variables were summarized using counts (n) and corresponding percentages (%). No statistical comparisons or hypothesis testing were conducted, as the objective was to provide a descriptive overview of data.
RESULTS
A total of 208 individuals who sought care at the dental hygiene clinical facility responded to the SDOH survey (note: not all participants responded to every survey item). The majority identified as White/Caucasian (71.43%, n=145), gender distribution was nearly equal among participants. Participants ranged in age from 18 to 65 years or older, with half (49.5%, n=100, 49.50%) falling within the 18–24 age group. Regarding educational attainment, about one third (36.14%, n=73) reported having completed a high school diploma or GED, while 60.89% (n=123) indicated having education beyond high school, including college degrees. Demographic characteristics of the study population are shown in Figure 1.
Participants were asked about various aspects of SDOH based on the previous 12 months. Nearly all respondents (97.58%, n=202) reported having stable housing. However, 29.76% (n=61) indicated issues with their living conditions. Reported problems included the presence of bugs or rodents (11.47%, n=7), mold (13.11%, n=8), lead paint or pipes (4.91%, n=3), inadequate heat (11.47%, n=7), non-functional appliances (14.75%, n=9), missing or non-working smoke detectors (14.75%, n=9), water leaks (21.31%, n=13), or other problems (8.19%, n=5).
Regarding transportation, 21.18% (n=43) reported unmet transportation needs. In contrast, the majority (78.82%, n=160) indicated that their transportation needs were adequately met, including for attending medical or dental appointments, commuting to work, and managing daily living tasks. In terms of safety, 17.56% (n=36) reported feeling physically or emotionally unsafe in their current living environment, while the majority (82.44%, n=69) felt safe. Food security was not a major concern, most (84.47%, n=174) respondents reported they were not worried or rarely worried about running out of food before having money to buy more. However, some (15.53%, n=32) indicated they were sometimes, often, or always concerned about food availability. Utility insecurity was low, with nearly all (98.07%, n=203) stating they did not feel threatened by possible shut offs of electricity, gas, oil, or water. Childcare concerns were also limited. Most (94.67%, n=142) said they never experienced issues with childcare, while 27.31% (n=56) noted that they did not have children or dependents. Some (5.85%, n=12) expressed interest in receiving help with education or job training (e.g., completing a high school diploma or job certification), and wanted help finding or keeping a job.
About one-fifth of respondents (21.36%, n=44) reported that they sometimes, often, or always were unable to access medicine or medical care when needed. In terms of health literacy, the majority of participants (87.38%, n=180) reported that they often or always understood the health information provided to them. However, some (8.73%, n=18) indicated that they only sometimes or rarely understood the information, and a small proportion (3.88%, n=8) reported never understanding the health information they received. Regarding language spoken at home, the vast majority (89.32%, n=184) reported speaking English, while 10.68% (n=22) indicated they spoke either Spanish or Hmong at home.
When asked about feelings of loneliness or isolation, over one quarter (26.96%, n=55) reported experiencing these feelings sometimes, often, or always. Most (84.31%, n=172) reported that they often or always visited or communicated with people they care about and feel close to. However, 15.68% (n=32) either sometimes, rarely, or never talked to or visited family or friends. Responses to the SDOH survey items are shown in Figures 2 and 3.
Students provided participants identified with having one or more SDOH with information on accessing the findhelp.org website and made referrals for further support as needed. A member of the research team conducted follow-up phone calls to determine whether the participant was able to access support resources. Three contact attempts were made to each of the 22 participants who had reported an SDOH need and provided their name and phone number in the survey. Of those contacted, nearly half (48%, n=10) reported successfully accessing the website demonstrated by the student during their appointment, the remainder (52%, n=11) indicated they were unable to access the website. Gender and family role were not considered in this analysis.
Among the participants who were able to access the findhelp.org website, two individuals reported successfully obtaining assistance from a resource listed on the site. Others chose not to contact any resources, citing reasons such as not finding relevant services, lacking time to review the resources, or deciding not to follow through. Participants who were unable to access the website reported various barriers, including losing the referral card, not receiving the website information from the student, not having time to access the site, lacking access to a computer, or not feeling they needed assistance at the time although some noted they kept the referral card for future use.
Part two of the study consisted of a novel follow-up survey for dental hygiene students related to participating in screening patients for SDOH. Of the junior and senior dental hygiene students (n=40), 37.50% (n=15) completed the survey; 60.0% (n=9) were seniors and 40.0% were juniors (n=6). Fourteen (93.33%) of the students (n=15) indicated that they had participated in the SDOH patient screening and referral study.
Students were asked open-ended questions to reflect on their most impactful learning from participating in the research project, including experiences with referrals, perceived barriers, and how they might apply SDOH knowledge in future dental hygiene practice. Regarding impactful learning, students reported finding that most patients did not like to discuss the help they needed and that the conversation about SDOH was difficult to have. However, they appreciated the many resources that were available to those with SDOH needs. When asked if the patient’s needs were met by making the referral, students noted that it was rewarding to address additional needs besides oral health and to help create access to additional resources. Some students reported barriers to the screening and referral process in that it was difficult to start an appointment by immediately discussing a sensitive topic such as SDOH, there were time constraints involved in adding another component to their schedule, and patient comfort addressing SDOH was a concern. One student reported that they were surprised to see how many patients declined help even though it was clear they were struggling and needed assistance. Opinions were mixed regarding using a SDOH screening and referral process in future practice. Several students noted that they felt the front desk staff members should initiate the screening process and the dental hygienist could make referrals due to time constraints. Others reported that they would use this experience to identify patients having difficulty with SDOH and would use community resources for referral support. Another student stated that participating in this research project helped develop empathy, while one student indicated they would be more open-minded about the impact they could have as an oral health care provider as patients have more needs than just focusing on the mouth. Open ended responses are shown in Table I. A participant’s free-form response and accompanying image is shown in Figure 4.
Open ended student comments (n=15)
Example of a student photovoice entry
"Each step I took when actively participating in this survey made me understand the idea of SDOH and when certain conditions are not met, it leaves the paitent disregarding important aspects of their lives."
Credit: iStock.com/spukkato
DISCUSSION
This study provides a unique perspective on how one dental hygiene education program explored addressing the SDOH needs of their patient population as part of the dental hygiene student clinical experience. Although, as part of this study, dental hygiene students were educated on SDOH needs and their impact on oral and systemic health of individuals and screened patients for SDOH needs, results indicated that some students did not fully appreciate their importance. Dental hygiene accreditation standards require graduates to have competence in community-based oral health programming.41 These community health projects often expose students to the needs of underserved populations, but not specifically SDOH as a barrier to health outcomes. In a scoping review, Leadbeatter and Holden concluded that dental education on SDOH relies heavily on service experiences and needs to include activities interwoven within the curriculum such as student reflections and discussions for students to fully grasp the impact of SDOH barriers.26 Student participation in poverty simulations can also result in a deeper understanding of patient challenges.42
The dental hygiene curriculum must educate students not only on how to conduct (SDOH) assessments and make appropriate referrals, but also on why this process is critical to comprehensive patient care. This study revealed that individuals with unmet SDOH needs do exist within the patient population. Without assessment, these needs remain unidentified and unaddressed. Therefore, more in-depth instruction on SDOH should be integrated throughout the dental hygiene curriculum and not limited to community health courses or public health projects. Students should clearly understand that any patient seen in a clinical dental hygiene setting may have underlying social needs that could adversely affect both oral and systemic health outcomes.33 Similarly, dental students in general dentistry and residency programs often lack sufficient education on SDOH, highlighting a broader gap across dental education.43
Another challenging finding was regarding patient reluctance to answer the questions truthfully due to embarrassment or concerns over stigmatization.31 Communicating the benefits of the screening and referral process could encourage patients to be more forthcoming in their responses.31 Similarly, results from the second part of this study, student participants indicated that patients were at times uncomfortable discussing their needs. Students stated that they had no idea that a patient was struggling and how eye opening it was to see how many people had SDOH needs. Dental hygienists are generally excellent at building trust and rapport with patients, which can help tear down this barrier. One student felt it was hard to discuss this sensitive topic at the beginning of an appointment. Possibly incorporating the SDOH screening later in an appointment, after a relationship of trust has started to form, could help patients feel more comfortable being open about unmet SDOH needs.
Lastly, students’ responses in part two underscored the importance of the student “buy-in” for the screening and referral process. Some students felt other members of the dental practice team could conduct the assessments for SDOH due to time constraints within the dental hygiene appointment. If dental hygiene students do not believe in the importance of SDOH in patient care, educators need to develop an educational framework to account for the student clinic time devoted to addressing SDOH. Students may be setting priorities on the patient care that is evaluated and graded, such as instrumentation, over addressing SDOH. Addressing SDOH in clinical practice is similar to helping patients with tobacco cessation counseling. Both areas can negatively impact oral and systemic health and require some type of student evaluation as part of the delivery of comprehensive oral health care. Students need time in clinical sessions to practice discussing what can be sensitive topics with patients under the guidance of experienced faculty members. Guided practice and constructive feedback can help ensure students are competent and confident in addressing these patient needs after graduation. Although dental hygienists might consider time limits as a barrier in adding SDOH assessment to an already full schedule, involving other members of the dental care team in part of the process might relieve this barrier and still facilitate patients getting the referral resources that are so important.44
Use of one entry-level dental hygiene program limits generalizability of the study and may not accurately reflect the broader population of dental hygiene students and patients. Without data from multiple programs, comparisons and contrasts of different approaches cannot be assessed. However, this was a program designed to capture SDOH needs and student learning. Another limitation was that student participation was voluntary, which may have affected their level of commitment to asking patients to complete the survey or taking the time to educate patients on using the findhelp.org website.37 Incorporating the evaluation of SDOH into all patient assessments and integrating identified needs into the dental hygiene diagnosis and care plan may increase student engagement, accountability and consistency in completing the process.
Directions for further research could include adding a SDOH assessment and dental hygiene diagnosis as a component of the standard patient care protocol and evaluating the effectiveness of the intervention. Another research option could involve creating and implementing dental hygiene curriculum specifically on SDOH and person-centered care and evaluating the outcomes. A further consideration is training students utilizing multiple approaches and through an assortment of activities, such as role-playing, and then assessing perceptions regarding SDOH and patient care through a reflection or qualitative survey on the process. Consideration should be given to incorporating SDOH education and assessment into the Commission on Dental Accreditation Standards for dental hygiene education programs and the revised American Dental Education Association Dental Hygiene Curriculum Standards.
CONCLUSION
This study demonstrated that integrating a SDOH screening and referral process into dental hygiene education is feasible and impactful for both patients and students. Patients presenting for care in the educational clinic exhibited a range of unmet social needs, and student dental hygienists gained valuable insights into the importance of addressing these factors as part of comprehensive oral health care. While barriers such as time constraints and patient unease were identified, the study highlighted opportunities for improving communication strategies and curriculum development. Expanding SDOH education and assessment in dental hygiene programs can better prepare future professionals to recognize and respond to the broader health-related challenges patients face, ultimately advancing equity and improving health outcomes. Future research should explore additional didactic and clinical student experiences to further refine best practices in addressing SDOH within dental hygiene clinical practice.
IMPLICATIONS FOR DENTAL HYGIENE PRACTICE
Incorporating SDOH assessments into routine dental hygiene care enables providers to identify and address non-clinical factors that significantly affect oral and systemic health, supporting person-centered care and alignment with the 2025 ADHA Standards for Clinical Dental Hygiene Practice.
Introducing SDOH screening and referral training in dental hygiene education promotes critical thinking, deepens understanding of health disparities, and cultivates empathy in future oral health care professionals.
Dental hygienists can implement streamlined processes for addressing the SDOH to ensure patients are referred to community resources and reinforcing the dental hygienist’s role in addressing broader determinants of health.
ACKNOWLEDGEMENTS
The authors would like to thank Holly G. Nereson, BS, data and visualization consultant for the creation of the manuscript tables; Taylor Watt, student dental hygienist for data entry and patient follow-up; and Diana Escamilla, BS, for data entry.
Footnotes
NDHRA priority area, Population level: Access to care (vulnerable populations).
DISCLOSURES
The authors have no conflicts of interest to disclose.
- Received July 29, 2025.
- Accepted September 17, 2025.
- Copyright © 2025 The American Dental Hygienists’ Association
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