Meeting Patients Where They Are: Dr. Donald Chi on Improving Oral Health Equity

For Dr. Donald Chi, the Lloyd and Kay Chapman Endowed Chair for Oral Health at the University of Washington and incoming dean of Griffith University's Gold Coast campus in Australia, the path to becoming one of the nation's leading oral health equity researchers began with a frustration he encountered early in his clinical training.

As a pediatric dentistry resident, Chi repeatedly treated children whose cavities returned despite regular dental visits. The experience prompted him to look beyond the dental chair. Many patients received regular care yet continued to develop disease because the factors driving that disease existed outside the clinic.

“We would have a check-up, we'd find cavities, we'd fix them, and then six months later they'd come back with more cavities,” Chi said. “What I realized was that the fillings and crowns we were doing were important, but they weren't long-term solutions. Things like poverty and diet, and what was happening in patients' neighborhoods and homes, were important factors that contributed to dental disease.”

Rather than focusing solely on how patients access care, Chi became increasingly interested in what happens after they enter the healthcare system, leading him to focus on the social and behavioral drivers of health.

As part of the Dean's Distinguished Lecture Series, Building Bridges for Oral Health Research, Chi delivered a lecture titled “Harnessing the Power of Sociobehavioral Interventions to Improve Oral Health Equity,” arguing that lasting improvements in oral health require bridging the gap between clinical care, community realities, behavioral science, and public policy.

While access to dental care, diet, and use of fluoride are well-established drivers of oral health, Chi emphasized that improving them is often more complicated than it appears. A parent may understand the importance of limiting sugar or brushing a child's teeth twice a day, but factors such as food availability, household stress, and economic circumstances can make those habits difficult to maintain.

While policy changes can have broad public health impact, meaningful opportunities are often infrequent and can take years to materialize.

“Policies also require unique circumstances to align,” he said. “If you are waiting for a policy opportunity, you may be waiting a long time. So in the meantime, we're working on behaviors.”

Dr. Rena D'Souza, leader of the Dean's Distinguished Lecture Series and visiting professor at Columbia University College of Dental Medicine, said Chi's work offers “a model approach for the prevention and arrest of dental caries, the most common chronic disease in children.”

D'Souza noted that Chi's research highlights the importance of tailoring behavior change strategies to the environments in which families live.

“His research underscores the need for the conditioning of behaviors in both children and parents that must be tailored to specific environmental influences that drive the socioeconomic determinants of health,” she said.

To illustrate those principles, Chi highlighted a long-running research program in Alaska Native communities, where childhood tooth decay rates remain among the highest in the nation. Although the national prevalence of untreated decay among children ages three to five is approximately 20 percent, some Alaska Native communities experience rates approaching 75 percent.

Chi first began traveling to Alaska as a clinician, providing care in communities across the Yukon-Kuskokwim Delta. The severity of the disparities he encountered led him to investigate one of the factors driving disease: sugar consumption. Working with researchers at the University of Alaska Fairbanks, his team used a novel hair-based biomarker to estimate how much added sugar children consumed over time.

“What we found was that kids were consuming, on average, about 50 teaspoons of sugar per day,” Chi said. “That's the amount of sugar in five regular cans of Coke per day.”

Rather than simply telling families to stop serving sugary drinks, Chi and his colleagues investigated why beverages such as Kool-Aid and Tang were so common. Researchers found that the drinks were familiar to parents who had grown up drinking them, inexpensive to purchase, easy to store in remote communities, and often preferred by children themselves.

During one home visit, Chi recalled watching a young child effortlessly pour multiple glasses of Kool-Aid from a large pitcher stored in the refrigerator.

“It gave me insight into the backstory,” Chi said. “I did not show up with my laptop, wanting to collect data. I was doing fillings. And I was getting to know the families.”

Those experiences shaped the intervention that followed. Rather than designing a solution and bringing it into the community, Chi and his colleagues worked with families to develop the intervention together.

“Every little piece was developed with input from communities,” Chi said. “You really have to understand the why. If you don't understand why, your intervention may be based on the wrong assumptions.”

Instead of asking families to stop drinking sweetened beverages altogether, the team worked with community members to identify acceptable alternatives, including sugar-free beverage flavorings that children preferred in taste tests.

The approach reflected a broader philosophy that Chi has adopted in both research and clinical care: helping families identify realistic changes that fit within the realities of their daily lives.

When the team evaluated the intervention, however, the results were not what researchers had hoped. Children were consuming approximately 35 teaspoons of added sugar per day at baseline, and after six months there was no statistically significant difference in added sugar intake between the intervention and control communities.

“A null finding is a finding,” Chi said. “And I think it’s important.”

Sugar consumption increased in all three communities during the study period, but the increase appeared smaller in the communities that received the intervention.

Follow-up interviews offered a possible explanation. While many families embraced the sugar-free alternatives, access proved inconsistent.

"So many families said, 'Hey, we really like these sugar-free drinks. We just couldn't get any at the store, so then we switched back to the sugar,'" Chi said.

The findings reinforced a central lesson of his lecture: healthy behaviors depend not only on individual choices but also on the environments in which those choices are made.

Rather than closing the book on the Alaska project, Chi said the findings opened the door to a new set of questions. Researchers are now examining why the intervention appeared to work for some children but not others.

“We know that the intervention did work for a subset of groups,” Chi said. “What we're doing now is we're looking at the data to try to analyze subgroups of kids for whom the intervention did work. We want to understand why.”

For Chi, those questions reflect a broader shift in how researchers and clinicians approach oral health. Rather than approaching patients and communities with predetermined solutions or assuming providers always know best, he believes patients and families should play an active role in identifying strategies that fit their needs and circumstances.

“I think patients are now demanding a seat at the table where decisions are made together,” Chi said.

Whether developing community-based interventions or caring for patients in the clinic, Chi argued that lasting improvements in oral health depend on listening to patients, understanding their lived experiences, and working with them to identify solutions that are both practical and sustainable.

D'Souza said the implications of Chi’s work extend beyond oral health.

"This topic is gaining far more attention nationwide, especially for addiction research where treatment success has been shown to depend heavily on behavior, environment and social factors and not medications alone," she said.