Sociology in the Oral and Dental 'Nexus'

The reason for starting this blog was to start the very serious process of working on a sociology of oral health and dentistry. The focus of this sociology will be on oral health and disease as well as oral and dental care as the social response to disease. The problems that need to be examined include: Why oral disease exists? Why it is patterned in the way it is and why our responses are the way they are? There is of course room for many 'sociologies' in this field but these are just some brief notes on one way we might start to build a systematic sociology of oral health and dentistry.

So where do we start?

There is nothing inevitable about dental disease, it is very much the product of how our society is organised. Yet dental disease persists, despite the billions that are spent each year on personal oral care as well as attending dental services. A sociology of oral health and dentistry has to be able to tackle the continued persistence of dental disease. It also has to be able to explain why we have such marked inequalities in dental disease in different our societies world wide.

If the persistence of dental disease is a challenge to be explained we also have to explain why there are marked and sustained inequalities in oral health. Figure 1.1 taken from Thomas et al. (2009) shows how breadline poverty can be mapped onto neighbourhoods in Sheffield. You can see that in some parts of Sheffield almost 50% of families are living on or below the breadline. These inequalities had deepened by 2001. If we map dental disease in the same way we see a similar picture (Figure 3, Source Public Health England, 2012). In Figure 3 below we can see that dental disease is present in between 50-60% of children and that it is concentrated in the same parts of Sheffield that breadline poverty is. None of this is new. Even if you believe that the sole determinants of oral disease are biological in nature you have to explain these inequalities.

Over the last 40 years sociologists, epidemiologists and dental public health colleagues have long recognised that the key determinants of inequalities in oral disease are social. More recently public health colleagues have recognised that our response to these diseases must also focus on these 'social determinants' through various 'upstream' policies (Watt 2005, 2012). This has led to a new and growing collaboration between sociology and public health. It is clear that the role of sociology is to examine very closely what is 'social' about these 'social' determinants. Sociology can enrich our understanding of why such patterns persist. In doing so it can therefore help to open up new possibilities for public health colleagues and dentists to think about when it comes to disease prevention and the reduction of inequalities. But how can this be achieved?

The answer is deceptively simple - we have to adopt a theoretical framework that will provide us with the conceptual and methodological tools to enable the systematic study of the underlying phenomena. The challenge that we face is being able to bring together disparate phenomena into a thoroughly social account of oral diseases and the resulting social responses to that disease. This means being able to explain how the 'drug-food-complex' (Mintz, 1979-1980) results in varied levels of disease, it includes examining how the various responses to such disease (consumerism, personal dental services and public health policy) are organised and why they have varied success when it comes to disease prevention. We have to be able to explain dental practice, to examine how the work of dentists is organised and shaped and why it is this way. In short, we have to adopt a theoretical framework that can enable a flexible and wide ranging study of the oral and dental 'nexus'.

The term 'nexus' strikes me as the most appropriate term through which to describe how oral health and dentistry works. This term is derived from the 'practice turn' in social theory (Hui et al, 2017; Shove et al. 2012). A 'nexus' refers to a very wide constellation of practices embedded within an array of various social and material contexts. What this means, for those of us working in oral health and dentistry, is that rather than just studying dentistry as a complex system, or indeed as a profession, we need to understand it more as a conglomeration of various 'practices' all linked together in very complex patterns. Our task as a community is to unpick just how chains of practices become interdependent and tied together. But what are practices?

There are a wide range of theorists working on the theory of social practices. The approach has a long history (1) in social theory from Marx, Heidegger and Wittgenstein through to Bourdieu, Giddens and eventually to Theodore Schatzki. Basically put, all of these authors have one thing in common they argue in various different ways that if we are going to understand the social world we have to focus on ongoing complexes of practical activity. A social practice is defined as "doing, but not just doing in and of itself. It is doing in historical and social context that gives structure and meaning to what people do. In this sense, practice is always social practice" (Wenger 1998, p. 47). Schatzki defines a social practice famously as 'doings and sayings' or 'bodily, doings and sayings' (Schatzki, 1996). So, for example, tooth brushing involves bodily sensations, movements and ways of talking about oral health. We brush our teeth drawing on a range of techniques and using technologies that have developed over a long history, experimenting with different shapes of brush, different materials and including different techniques. You just need to go to the British Dental Association's Exhibition "The yardstick by which civilisation is measured : 200 years of the toothbrush" to begin to see that not only is this a practice with a rich history of doings and sayings but that history is very much ongoing today.

Once we start to get the idea that the social nature of oral health and dentistry is a sociology of all of the practical activity associated with the social production of disease as well as the social activity around personal oral health care as well as dental practice. We start to open up a whole plethora of places to collect data and start our analysis. We can begin to study the social arrangements and practices that result in increased sugar consumption. Such work can unpack why the associations our epidemiological and dental public health colleagues are seeing exist. But we can do more than this. We can start to see where upstream action might be targeted and suggest which elements of a practices pre-dispose to disease and how these might be challenged. This approach may enable the development of innovations in social practices to enable the reduction of disease. In short, having waited for some time for a sociology up to the task of dealing with the social complexity of oral health and disease we may now have the right approach to begin this task.

Footnote

1. For a brilliant introduction see Nicolini (2012) or Shove et al (2012).

References

Hui, A., Schatzki, T., & Shove, E. (2017). The Nexus of Practices: Connections, constellations, practitioners. London: Routledge.

Mintz, S. (1979-1980). Time, Sugar and Sweetness. Marxist Perspectives, 2(4), 56-73.

Nicolini, D. (2012). Practice theory, work & organisation. Oxford: Oxford University Press.

Public Health England. (2012). National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2012). London.

Schatzki, T. (1996). Social Practices: A Wittgensteinian Approach to Human Activity and the Social. Cambridge UK: Cambridge University Press.

Shove E., Pantzar, M., & Watson M. (2012). The Dynamics of Social Practice: Everyday life and how it changes. . London: Sage.

Thomas, B., Pritchard, J., Ballas, D., Vickers, D., & Dorling, D. (2009). A Tale of Two Cities: The Sheffield Project. Sheffield: Social and Spatial Inequalities (SASI), University of Sheffield.

Watt, R. (2007). From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dentistry and Oral Epidemiology, 35(1), 1-11.

Watt, R. (2012). Social determinants of oral health inequalities: implications for action. Community Dentistry and Oral Epidemiology, 40, 44-48.

Wenger, E. (1998) Communities of practice: learning, meaning, and identity. Cambridge: Cambridge University Press.