Oral Health and Society

The Blog site for the Division of population and Patient Health KCL Dental Institute

Month: December 2017

The Mouth as a Visual Symbol of Inequality

teethBy Sasha Scambler


We know the statistics, those in poverty are more likely to experience tooth decay, gum disease, tooth loss and discoloured, crowded or misaligned teeth.  They are also less likely to engage in preventative behaviours either in the home or involving accessing dental care.  When care is accessed it is more likely to be symptomatic care and involve extractions and less likely to involve orthodontic treatment or cosmetic treatments.  Poverty has been associated with poor oral health on a global scale and poor oral health is becoming increasingly visible.

Or conversely, good oral health is becoming increasingly visible.  Dentists are no longer simply selling a healthy mouth and functional healthy teeth, they are now selling al ‘look’ or an ‘image’.  I recently joined a new dental surgery and in the process of registering I had to complete a questionnaire which asked me about pain, dental problems and previous treatment and then moved on to ask about aesthetics.  I was asked how I felt about my smile, to describe and rate the colour of my teeth, to describe any crowding or misaligned teeth and comment on any other features of my smile that I was unhappy with from an aesthetic perspective.  The questionnaire finished by asking whether I would be interested in any cosmetic treatments and if so which types.  The service that I was being offered was not solely a health service but was also an aesthetic service.  This made me wonder whether this is unique to dentistry or is a phenomenon that can be found in other medical specialisms.  Certainly cosmetic surgeons will perform medical procedures solely for the aesthetic results but these are separated from procedures which are carried out for health reasons and are usually done in different locations and very often by different professionals.  What is interesting about dentistry is the blurring of the line between aesthetics and health with procedures being separated neither by location nor by personnel.

The mouth has also entered our consciousness through the media as part of the package of technologies that can be utilised to enhance body image and the presentation of self.  Television programmes like the channel four ’10 Years Younger’ have normalised the idea of the mouth as a fashion accessory with the routine use of cosmetic dentistry to create the prefect smile to compliment the hair style and colour, skin care, makeup and clothes makeover.  This is not a new phenomenon in so far as the edge of the mouth through the lips has been part of conceptualisations of beauty for centuries.  Nor is it even the first time that the gaze has been turned on the inside of the mouth.  As recently as the 1950’s and 1960’s in the UK teeth were removed and full dentures fitted as wedding presents to ensure the aesthetics ad future functionality of the mouth, and gold teeth have been used throughout history as a symbol of wealth and attractiveness.  The difference between historical aesthetic treatments and more recent incarnations is the visibility of the treatment and the associated perception of health.  Modern cosmetic treatments are designed to blend in and the mark of good quality treatment is the inability to discern that treatment has occurred.  The trend now is towards teeth which are white, straight, well-spaced, healthy but not too perfect, not too white and not too even. This gives the perception that the healthy beautiful mouth is simply an extension of the healthy beautiful body and is organic rather than man made.

So where does this leave those who cannot afford basic dental care, let alone additional, and often prohibitively expensive, aesthetic treatments?  Visible, aesthetically good oral health is becoming mainstream.  The media promotes the image of an attractive person with straight, white, evenly spaced teeth and one of the by-products of this is that poverty becomes more visible.  It becomes harder for poorer people to reach that image of attractiveness when basic dental healthcare is perceived as being out of reach.  Research has identified one of the main barriers to oral healthcare as cost or fear of costs and the treatments that are needed to restore an unhealthy mouth to functional health at even the most basic level can be prohibitive.  Whilst an extraction or silver filling costs £49 as a band 2 NHS treatment, a crown or bridge, dentures or orthodontic treatment will come in at £214.  Whilst not excessive, this is beyond the pockets of many people when cost of living rises and falling income levels are factored in.  Teeth whitening can cost anywhere from £150 to £1000, and other treatments such as dental implants range from £300 (if you are willing to travel abroad for the treatment) to £3500 per tooth.  This suggests that the market for a beautiful, natural looking mouth may be beyond the pockets of many.  With all of the aesthetic treatments now available for those who can afford it, the gap between those who can and those who can’t, the rich and the poor, is growing, not just in terms of oral health and function but also potentially visibly.  In future decades the mouth may become the most obvious physical marker of poverty.

Reducing Free Sugar Intake – A simple process?

By Said Al-Rawahi


The World Health Organisation has made a strong recommendation that we all reduce the amount of free sugar that we consume, but how easy is it to achieve this goal? Free sugar intake is a complex behaviour that involves not only the decisions we make as individuals but decisions made by food producers, policy makers and politicians.  Sugar is added to food and drinks not only by us individually. So if we wish to reduce free sugar intake, a wide range of influential factors should be considered.

Free Sugar intake of more than 10% of the total energy intake per day can lead to many diseases including tooth decay and obesity. Therefore, the WHO suggests that a reduction to 5% during the lifespan of a person will prevent and reduce many diseases. Free sugar intake of 5% of the total energy consumed is equivalent to 7-8 teaspoons (35 g) of sugar for men and 5-6 teaspoons (25 g) for women.

Our study sought to explore peoples’ understanding of, and behaviour towards their sugar intake.  We conducted interviews with people to explore the factors that might help them to reduce their free sugar intake. Our study revealed that there are many factors within the individual that affect sugar intake and that these interact with the context in which the person lives. Examples of factors within the individuals include knowledge of foods and drinks that have more sugar than the recommendation and knowledge of food and drinks that contribute to tooth decay. For example, some people find the term ‘free sugar’ difficult to understand:

“I have no knowledge of what the term free sugar means…. Yeah I don’t have any educational about sugar”  (participant-W3)

Others understand the colour coding scheme in current use, but don’t know how to incorporate it into their everyday life:

“thinking  about now I don’t actually know what green means I just know that means good but I don’t know what  the cut off is for each one.” (Participant-WT14)

Contextual influences such as the cost of food and the availability of health options are important considerations:

” For example, they have a lot of vegetable which one I think its a 60 p value and then like right at the front of the store as soon as you go in my store anyway so that influence me to choose that vegetables.” (Participant-WT7).

“I think if I wasn’t too worry about the money at that time I would go for a healthier option.”(Participant-WT1)

“from what I have read it’s a complicated thing you know how they put it and then the  difference in  different  kind of sugars,  the truth  is even having read about it I don’t understand that much about so I would rarely  look at the labels.” (participant WT24).

“No I don’t think so because I, you could  end up with an awful lot of information on a page on the front in the base so and also  if it says the red and green  that doesn’t always help” (Participants-WT26)  

It is vitally important to reduce intake of free sugars however improving knowledge alone will not be successful unless the external environmental factors support the change. Reducing free sugar intake is a complex process which required understanding of the behaviour and then developing interventions that tackle reduce barriers and increase facilitators.