On The Mouth-Body Split 1

The mouth-body split is something that policy makers and commentators talk about when they decry the state of either oral health related inequalities or dental services world-wide. The ideas underpinning this problem have their origins in the sociology of health and illness, the history of bio-medicine and in particular in thinking around the bio-medical model. The basic premise of this argument is that as the emergence of the bio-medical model resulted in the separation of the mind from the body. The implication, for colleagues working in oral health care, is that this also led to the separation of the mouth from the body. Consequently the result was the separation of dental services from health services and this has had negative consequences for oral health. What, if anything, would a sociology of the mouth-body split have to say about this? The answer to this question is not easy. It will require a bit more depth than a few blog posts can answer. But let us start with what dentistry has been thinking on this topic.

This idea is a prominent feature of Mary Otto’s book on the state of oral and dental services in the United States (Otto, 2017). Otto makes several compelling arguments about the state of oral care, she traces the consequences of the current system, charting stark inequalities in oral and dental health alongside narratives of the opulence and deprivation of the system.

Otto's (2017) book is filled with examples of how inequalities play out. She explains how a 12 year old child in Maryland, Deamonte Driver, died from a dental infection that had gone untreated. A completely unnecessary death and a waste of a young life. Otto argues that just as the mind became separated from the body through the deployment of the biomedical model. The same model led to the separation of the mouth from the body. Sociology, along with other disciplines (history, epidemiology and social policy), has a lot to say about this. From phenomenology and the early sociology of oral health and medicine, through to the work of Foucault there has been a thorough and long standing analysis of this split. In dentistry there has been some debate either through empirical research or in some of the conceptual debates around the topic.

Empirical research

One way to assess this division might be to ask what people themselves think. This is precisely what Corrigan et al (2001) did when they looked into the concepts of health employed by various ethnic minority groups in the United Kingdom (UK). Groups included in this study were White British, Black Caribbean, Black African, Pakistani, Indian, Bangladeshi and Chinese amongst other groups. Participants were interviewed in an unstructured way and a topic list was used in case prompts were needed. The data were analysed using Interpretative Phenomenological Analysis (IPA) into key themes, including member checking (Corrigan, Newton, Gibbons, & Locker, 2001). The findings showed that members of the public conceived of oral health in two ways. They saw oral health in terms of the traditional model of health (oral health as the absence of disease) and also as a form of psycho-social well being. This means that when we speak to people we will often find that oral health can either be assessed independently of general health, or it can be assessed as an integral part of general health. This leaves us with a bit of a puzzle – why do the public reflect these different ways of speaking about oral health? More importantly what resources are they drawing on when they speak in these ways?

The answers to these questions are not obvious they involve charting a path away from such everyday accounts. In fact this problem goes to the heart of the structure/agency debate in sociology. A sociology of oral health and dentistry has to be able to provide some answer to this problem. Put in simple terms, the problem that we have is what were people actually doing in Corrigan et al’s (2012) work when they were asked “what is oral health?” In order to answer this question participants will have had to draw on a language about oral health, this language has been made readily available to them. It clearly contained traditional models of oral health as well as holistic ideas about oral health. There are several solutions to this problem. On the one hand we can follow symbolic interactionism and argue that people access social resources in such responses, such resources include a ‘pool of meaning’ that people draw down when they need to speak about oral health (Bury, 2001). Another response is to argue that this pool of meaning is in fact more than simply freely floating words but are in fact systematically organised for us by the oral health system. We have covered this challenge in similar work on dentine hypersensitivity where we mapped the distinctions people used to discuss dentine hypersensitivity (B. Gibson & Boiko, 2012) and subsequently went on to trace the conceptual history of these terms (BJ. Gibson & Paul, 2014). But we are getting ahead of ourselves here, there has also been some conceptual discussion in the dental literature that points towards an even more fundamental problem with this distinction.

Conceptual debate in the dental literature

There has been considerable debate about this split in the dental literature - for example Locker (1997) once stated that:

“The point being made here is that we do not conventionally attach the concept of health to any body part other than the oral cavity and, indeed, it seems faintly ludicrous to do so. According to the definitions presented earlier, oral cavities as anatomical structures cannot be healthy or unhealthy only people can. Consequently, the distinction that is often made or implied between general health and oral health is unwarranted; it has no underlying biological or theoretical logic. Rather, it should be seen as nothing more than an organisational distinction that arose through historical accident. Although this is frequently recognised in the literature, and implied by the use of generic conceptual frameworks and measures, it is often the case that the use of language and concepts and the questions we ask about oral and general health frequently implies the opposite; that is, they constitute separate and distinct domains. This is another source of confusion and ambiguity in current discussions of what we mean by oral health” (Locker 1997 p. 17).

Locker (1997) went on to conclude that when we speak of oral health we are talking about how oral conditions affect the individual. It is when these conditions are linked to other conditions they can threaten overall health, well-being and the quality of life. In this respect oral disorders are no different to other disorders (Locker, 1997). This all points to the importance of definitions of health and their consequences.

Why we should pay attention to definitions of health?

Definitions of health are important because they can have implications for how healthcare is organized (Seedhouse, 2005). The significance of the biomedical model, we are told, is that this conception of disease results in ways of working that are primarily focused on treating disease. As Nicky Hart (1985) once said that “the medical profession has successfully persuaded us that our personal health depends on high standards of medical care. As a result, the National Health Service (NHS), has been designed as a national medical service” (Hart, 1985; p. 1). The implication being that the underlying conception of disease has had profound consequences for the way our health care system works. The biomedical model sees health as a commodity and the solution is to attend services and have disease removed and any damage ‘fixed’ (Seedhouse, 2005). The problem with this definition is that it risks mysticism. How can we even be sure the treatment is what people actually ‘need’?

This type of thinking is quite popular and has a number of policy implications it drives ideas around integrated care and person centred medicine. Otto (2017) follows these ideas when arguing for a more holistic health system that will bridge the gap between oral health and overall health. A system where care is integrated.

But is this really the answer? Can we be sure that the underlying problem has been adequately diagnosed?

References

Bury, M. (2001). Illness narratives: fact or fiction? Sociology of Health & Illness, 23(3), 263-285.

Corrigan, M., Newton, J. T., Gibbons, D. E., & Locker, D. (2001). The mouth-body split: conceptual models of oral health and their relationship to general health among ethnic minorities in South Thames Health Region. Community Dental Health, 18(1), 42-46. <Go to ISI>://000169519100009.

Gibson, B., & Boiko, O. (2012). The experience of health and illness: polycontextural meaning and accounts of illness. Social Theory and Health, 10, 156–187. https://doi.org/10.1057/sth.2011.22.

Gibson, B., & Paul, N. (2014). Differentiation and displacement: unpicking the relationship between accounts of illness and social structure. Social Theory and Health, submitted.

Hart, N. (1985). The Sociology of Health and Medicine. Lancashire: Causeway Press.

Locker, D. (1997). Concepts of oral health. Disease and the quality of life. In G. Slade (Ed.), Measuring oral health and quality of life. Chapel Hill: University of North Carolina.

Otto, M. (2017). Teeth: The Story of Beauty, Inequality, and the struggle for Oral Health in America. New York: The New Press.

Seedhouse, D. (2005). Health: The Foundations for Achievement. London: John Wiley and Sons Ltd.