The Sociology of Dentistry

Sociology as applied to dentistry is an essential part of training for dentists. The case for asking, even requiring, medical and other students of the health professions to engage with the multiple ways in which health-related phenomena, from individual behaviours through classifications of and strategies for coping with medically defined disease to the funding of healthcare systems, are embedded in the social world remains undeniable (Scambler 2008). “He or she needs it at the very least for protection against the very real hazard of frustration and unhappiness when it proves difficult to implement medical measures; but above all it is needed if the medical and other health-related professions are to make their greatest potential contribution to the welfare of the populations they are privileged to serve” (Margot Jefferys 1981, in Scambler 2008)

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Sociology is the study of how society is organized and how we experience life (British Sociological Association 2010). ‘It seeks to provide insights into the many forms of relationship, both formal and informal, between people. Such relationships are considered to be the ´fabric´ of society. Smaller scale relationships are connected to larger scale relationships and the totality of this is society itself’ (British Sociological Association 2010). It is a relatively new addition to the dental curriculum, having been initially introduced in the 1980s. An increasing recognition of the importance of ‘social’ factors associated with various illness states has ensured medical sociology a continuing place in teaching and research endeavours (Reid 1976). The General Dental Council’s learning outcomes for the first five years specifically states that as part of the undergraduate curriculum, students should be ‘be familiar with the social, cultural and environmental factors which contribute to health or illness’ (GDC 2008) and many of the other learning outcomes have a sociological approach at their heart.

The General Dental council highlight six key principles that dental professionals are expected to follow (GDC 2005). The first two of these principles regard a patient centred approach to dentistry. They specifically state that dentists should be ‘putting the patients interests first, acting to protect them’ and that as dentists we have to ‘respect a patients’ dignity and choices’. In order to fulfil these standards it is imperative that we understand that each individual will experience a number of different influences on their health, and how that individual will react to each influence will depend greatly on what has come before and what will come after. Without this basic understanding, dentists will fail to ever understand their patients or provide them with the best care.

How a patient will act in any given situation will very much depend on several factors that have influenced their life. What is accepted as ‘normal’ to one patient may be completely different to another patients view. With particular reference to health and illness, social and cultural variables have a significant part to play. Aukernecht showed this in 1947 when studying a South American tribe. The tribe had a skin condition that according to biomedical standards was a ‘disease’. But this ‘disease’ was considered ‘normal’ by the members of the tribe, so much so that if they did not have it they were not allowed to marry! (Aukernecht 1947). Although this might be regarded as an extreme example, if you consider some of the data from the most deprived areas of the UK, our view on what is regarded as ‘normal’ may be challenged. In the most recent children’s inspection, it was shown that 52.1% of primary seven children in the most deprived category showed obvious signs of decay experience (Scottish Dental 2010). Similarly if we look at the most recent adult dental health survey, it was shown that over half the people living in the most deprived areas (DEPCAT 6 & 7) were reliant on either full or partial dentures (ADHS 1998). It is ‘normal’ for people in deprived areas to experience dental decay. What the people in this group in society regard as ‘disease’ may be entirely different than our perception.

The world health organisation defines health as ‘the complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO 1948). It is important that dentists receive training in the sociological influences that determine what health means to different people in order that they understand that this definition is unattainable for the majority of the population. The medical model of disease causation as localisation of pathology is flawed. There should be a change away from our focus on disease. Shifting dentists perceptions away from a disease orientated view that dental diseases are the result of discrete pathology, to the view that health or illness occurs as a result of complex interactions between several factors including genetic, environmental, psychological and social factors is key (Tinetti & Fried 2004). Our focus should be shifted to a view of health that encompasses an individuals’ ability to be comfortable and function in a normal social role (Dolan 1993). It is essential that dentists are trained to have a holistic approach to the care of their patients, and are able to acknowledge the impacts that socio-environmental factors have on health. As described by Dahlgren and Whitehead in 1991, patterns of oral health and illness cannot be separated from the social context in which they occur (Figure 1).

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Figure 1. Main determinants of Health (Dahlgren & Whitehead 1991)

Even with this knowledge, dentists must be able to relate this to their patient. The world is not an equal place and dentists must be trained to acknowledge the effects that inequality can have on health.

As previously discussed, socio-economic status has a major influence on the health status of an individual. As early as 1842, Edwin Chadwick looked at life expectancy of those in different social classes (Chadwick 1842). This showed that the average age at death in Bethnal Green at that time was 35 for gentry and professionals but only 15 for labourers mechanics and servants. Although life expectancy has improved for all classes in Britain since this time, inequalities have remained.

The Black Report, published in 1980, showed that there had continued to be an improvement in health across all the classes (DHSS 1980). But there was still a co-relation between social class and infant mortality rates, life expectancy and inequalities in the use of medical services. In 1998 The Acheson Report again highlighted the growing gap between the richest and poorest in society in relation to health and life expectancy (Stationary Office 1998).

Regardless of whether you look at mortality, morbidity, life expectancy or self- rated health status, the gradients remain the same and the health of those at the bottom of the class system is worse than that of those at the top.

When looking at Oral Health a similar pattern emerges. Social inequality in oral health is a universal phenomenon (Peterson 2005). More deprived areas have higher levels of disease in the industrialized and non-industrialized world alike. The inequalities between groups are relatively stable and persist through the generations.

In the 1998 Adult Dental Health Survey, dental health was reported to be worse in the lower social classes and that there was a clear gradient between the rich and poor. Between 1978 and 1998, big improvements in the numbers of edentate adults were detected. However, the gap between those in the lower and upper classes was still apparent. By 1998, those in social class IV and V had only reached levels of oral health found in social classes I, II and IIIm in 1978.

In a more recent survey of children’s oral health in 2003 (Children’s Dental Health Survey 2003), similar patterns were found. Those in lower social classes were more likely to experience tooth decay, were more likely to have teeth extracted due to decay and were twice as likely to have unmet orthodontic need than their wealthier peers.

Access to dental services has also been shown to vary between social classes. The 1998 adult dental health survey showed that people from a higher social class were more likely to use dental services, and that middle class adults were more likely to attend for preventive treatment whereas working class adults were more likely to attend for relief of symptoms. Working class adults were also most likely to experience problems in paying for dental treatment, and more likely to attend irregularly.

Socio-economic inequality shows no signs of reversing, quite to the contrary. In the last 20 years the gap between rich and poor has widened. According to the office for national statistics, data shows that the top 1% of the population own 21% of the wealth. Perhaps more staggering is the fact that approximately half the population share only 7% of the total wealth (ONS 2003). This has a major impact on how we deliver dental services. Dentists have to be aware of the financial restraints that face a large portion of the population. With a limited budget to hand, dental treatment or indeed preventive measures such as toothpaste and floss may become a luxury that they cannot afford.

There is also a need for dentists to be trained to recognise the effects of other inequalities such as gender, ethnicity and age on health. There are key differences between men and women that not only determine their position within society, but also their position in the health spectrum. Women are less likely to hold a position of power and are paid less than their male counterparts (Scambler 2008 p134-140). They are also more likely to suffer ill health, although perhaps surprisingly they outlive their male counterparts, so much so that women from social class 5 live significantly longer than men from social class 1- ? this ref, in notes but can’t find elsewhere! (ONS 2000- ? 2004). There is debate about the effect that gender has on oral health, with some studies suggesting that gender does effect oral health, with women experiencing poorer dental health than their male counterparts (Todd & Lader 1991)(Downer 1994). Other studies suggest that the reverse is true (Scambler 2002). The issue appears to be related to the inability to draw a conclusion on whether it is gender alone that is causing the inequality, or if it is by virtue of the fact that women are in lower social classes than men and are currently living longer.

Age is the single biggest reason for the decrease in sound and untreated teeth across the population as a whole, with the next most important factor being region of the UK, the more deprived the area, the more disease. Older people are more likely to be living in poverty than any other sector of the population. In 2007/08, an estimated 2 million pensioners in the UK were living in poverty (ONS 2010). As seen in the discussion on social class, this will have obvious implications for their oral health.

Whilst life expectancy is increasing this does not necessarily mean that people are living longer in good health and there is some debate about the idea of healthy life expectancy (in notes). It can be surmised that perhaps an aging population will bring with it a catalogue of dental disease as they are not only more susceptible to disease by living longer, but by virtue of them falling down the social ladder. Older people currently experience higher levels of poor oral health than other groups and overall they make less use of dental services and receive poorer care than other groups (in notes). However, the older population is changing. More people are retaining natural teeth into their old age, and are more likely to make regular use of dental services. Dentists have to be aware of the changes that are going to happen with their patient demographic over the next few years. This group of patients will require more restorative and cosmetic treatments but will be further down the social ladder and less able to pay for such treatments.

Poor socioeconomic status is also thought to account for the differences that are seen in oral health of ethnic groups (Parliamentary Office of Science and Technology 2007). Programmes have been designed to improve dental students understanding of and attitudes to patients, such as Wagners cross-cultural patient instructor programme to improve dental students understanding of and attitudes towards ethnically diverse patients (Wagner et al 2008). But what this type of programme fails to address is that the biggest factor in determining the health of an individual is their socio-economic status (Watt and Sheiham 1999).

Not only do people in the lower socio-economic groups experience more ill-health, they also are more likely to perceive a lack of control over their health. Cornwell (1984) found that people in low socio-economic groups would go to great efforts to prove lack of responsibility if they became ill. In addition to this, Blaxter (1982) found that people in lower socio-economic groups tended to define health in a functional way. These two points are crucial for dentists to grasp. On the whole, dentists by nature of their profession fall into a traditional middle class status. Middle class people are more likely to take a moral responsibility for their health and to feel that they can do something about it (Scambler 2002). Given that the majority of the population in the UK view themselves as working class (BBC 2006), it is highly likely that the dentist and the patient will have very different views on not only how they define health but also on their personal ability to change their health status.

The differences between dentists and their patients do not stop there. Recent research suggests that the lower the socio-economic status the less likely that a patient will attend health services in the first place. Several ‘barriers’ have been suggested including fear (Todd and Lader 1995), availability of dentists (get ref), cost and dissatisfaction with care. It is worth noting that the presence of barriers increases the lower the socio-economic status of the individual. Even when people recognise that they are experiencing symptoms, they do not necessarily seek medical help (Zola 1973). Decisions about help-seeking are intricately bound-up with the social circumstances that people find themselves in. Evidence clearly demonstrates that there is a significant amount of unmet need in the community and that many people who experience symptoms do not seek help from medical or dental professionals. By far the most common illness behaviour is self treatment with over-the-counter medicines such as pain relief (Wadsworth 1971 in Scambler pg 49) Others have indicated the presence of a ‘lay referral system’, whereby “the whole process of seeking help involves a network of potential consultants from the intimate confines of the nuclear family through successively more select, distant and authoritative laymen until the ‘professional’ is reached” (Friedson 1970). “A situation in which the potential patient participates in a subculture which differs from that of doctors and in which there is an extended lay referral system would lead to the ‘lowest’ rate of utilisation of medical services” (Scambler 2008:48). This all adds fuel to the fire of the ‘inverse care law’ which states that those in need of the most healthcare have least access to it (Tudor-Hart).

Consulting behaviour has also been seen to not be solely related to the experiences of symptoms, with as many as 48% of those experiencing severe pain not consulting a dentist (Locker 1988- in notes). The type of symptom (i.e. pain) is only one factor and the effect that the symptom has on day-to-day life is also an important consideration.

It is essential that dentists are educated in sociology as applied to dentistry in order that they are able to treat their patients effectively. Without an insight into the bigger picture, dentists will effectively be tidying the deckchairs on a sinking ship. The society in which a person lives shapes the health, illness, life expectancy and quality of life of those within it. In order to make any change on an individual level, then changes have to occur on a societal level.

From work done by Wilkinson and Picket (2009) it would seem that the best way of reducing health inequalities would be to reduce the income inequalities that exist in the UK. Their work showed that “there is a very strong tendency for ill- health and social problems to occur less frequently in the more equal countries. With increasing inequality, the higher is the score on our index of health and social problems. Health and Social problems are indeed more common in countries with bigger income inequalities. The two are extraordinarily closely related- chance alone would almost never produce a scatter in which countries lined up like this.” Dentists have to be aware of this problem. There is a need for dentists to push for government to implement policies that will tackle these inequalities. Dentists (and other health professionals) need to work together to try to encourage government change. There has to be a move away from dentists accepting disease at face value, dentists have to be trained to realise that no amount of restoration placed within a patients mouth is going to bring about the change that is needed to help that individual have a healthy life. Every mouth we see is part of a person, which is part of a family, which is part of a society. Dentists should be taught to ‘think sociologically’ (Scambler 2008). By thinking sociologically we can start to realise that whilst we are all knitted together in the rich tapestry which is society, we are also co-creators of the blueprint for that tapestry. Dentists need to take a more active role in the creation of that blueprint, a role that is essential if we hope to achieve a more equal society.

Unit 1- Health, Disease and Society

Aim:

To introduce the relationship between health, disease and society and to define

and explore key models within health and oral health.

Objectives:

Define Disease, Illness, Health and Oral Health

Disease- a biomedically defined pathology within the human system which may or may not be apparent to the individual

Illness- the lay interpretation of bodily or mantal signs or symptoms as somehow abnormal

Illness and disease exist in a social framework and indices of disease and illness produced by dental and medical professionals do not always make sense to the lay population. Understandings of health and illness are constructed through the interplay between the symptom experience and the social and cultural framework within which this experience occurs.

Health is a multifaceted concept that can be experienced in different ways by different people at different times and in different places

Oral health- a comfortable and functional dentition that allows individuals to continue their social role.

Describe key historical variations in disease patterns- Knowledge about the body, about disease and about medicine, are products of their time; they are socially constructed by what is ‘known’ or thought to be ‘known’ at any point in time. Diseases themselves are socially constructed and can change over time.

Describe key theories of disease causation- monism and localisation of pathology

Monism- all disease in due to one underlying cause (usually one of balance) in the solid or fluid parts of the body. Balance distrupted, illness will occur. Restoration of balance, cure and illness irradicated

Localisation of pathology- Medical science developed this theory. Cases

Discuss the changing nature of dental disease patterns in adult populations

Unit 2- social structure and health- inequalities

Aim:

To introduce the nature of social structure and how this relates to patterns of oral

disease in the UK population

Objectives:

Introduce and discuss the meaning of social structure and social stratification

Describe ways of measuring inequalities

Discuss the relationship between social class and health

Discuss the relationship between social class and oral health

Discuss explanations for social class related differences in health/oral health

Unit 5: Social Structure and Health II – Gender;

Ethnicity; Ageing and Oral Health

Aims:

To describe social differences between the genders in relation to such factors as

equality, work, marital roles, and health behaviour.

To examine the health and oral health of ethnic minority groups in Britain today.

To look at the impact of ageing and the lifecourse on health experiences,

incorporating expectations of old age and differential treatment of older people.

Objectives:

Define gender, ethnicity and ageing.

Understand the mortality and morbidity differentials for men and women.

Understand gender differences in health behaviour.

Outline and discuss gender differences in oral health.

Be aware of the inequalities in the general health and oral health of ethnic

groups.

Have knowledge of some of the major dental health problems of older people.

Be aware of the social impact of ageing on dental health.

Unit 5: Health and Illness Behaviour and the Dentist-

Patient Relationship

Aim:

To introduce the concepts of health and illness behaviour and assess the range of factors which influence what happens when people become ill.

Objectives:

• To outline and discuss different perceptions of health and illness.

• To discuss the clinical iceberg in populations and its implications for dental health.

• To introduce and discuss the core variables Influencing illness behaviour.

• To discuss the concept of ‘triggers’ for seeking dental care and their implications for the dental treatment experience.

• To introduce the concept of access to health care.

• To discuss the nature of the dentist -patient relationship.

In order to begin to look at these inequalities, individuals can be stratified into different groups, according to specified criteria and resulting in a hierarchy with those at the lower end suffering in comparison with those at the top of the system. “Social stratification involves a hierarchy of social groups. Members of a particular stratum have common identity, similar interests and a similar lifestyle. They enjoy or suffer the unequal distribution of rewards in society as members of different social groups.” (Haralambos and Holburn 2000).

Webber devised a hierarchical model, in which class relates to occupational standing. Occupational type is considered along with social status and power. This model forms the basis for the two models of social class which are most often used within research in the UK: Registrar Generals Model of Social Class and National Statistics Socio-economic Classification.

Social Class has long been associated with levels of health.