Search

This paper is the third in a series of narrative reviews challenging core concepts in oral health research and practice. Our series started with a framework for Inclusion Oral Health. Our second review explored one component of this framework, looking at how intersectionality adds important complexity to oral public health. This current manuscript drills into a second component of Inclusion Oral Health, exploring how labels can lead to 'othering' thereby misrepresenting populations and (re)producing harms. Specifically, we address a common oral public health label: vulnerable populations. This term is commonly used descriptively: an adjective (vulnerable) is used to modify a noun (population). What this descriptor conceals is the 'how,' 'why,' and 'therefore' that leads to and from vulnerability: How and why is a population made vulnerable; to what are they vulnerable; what makes them 'at risk,' and to what are they 'at risk'? In concealing these questions, we argue our conventional approach unwittingly does harm. Vulnerability is a term that implies a population has inherent characteristics that make them vulnerable; further, it casts populations as discrete, homogenous entities, thereby misrepresenting the complexities that people live. In so doing, this label can eclipse the strengths, agency and power of individuals and populations to care for themselves and each other. Regarding oral public health, the convention of vulnerability averts our research gaze away from social processes that produce vulnerability to instead focus on the downstream product, the vulnerable population. This paper theorizes vulnerability for oral public health, critically engaging its production and reproduction. Drawing from critical public health literature and disability studies, we advance a critique of vulnerability to make explicit hidden assumptions and their harmful outcomes. We propose solutions for research and practice, including co-engagement and co-production with peoples who have been vulnerabilized. In so doing, this paper moves forward the potential for oral public health to advance research and practice that engages complexity in our work with vulnerabilized populations., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

This paper is the second of two reviews that seek to stimulate debate on new and neglected avenues in oral health research. The first commissioned narrative review, "Inclusion oral health: Advancing a theoretical framework for policy, research and practice", published in February 2020, explored social exclusion, othering and intersectionality. In it, we argued that people who experience social exclusion face a "triple threat": they are separated from mainstream society, stigmatized by the dental profession, and severed from wider health and social care systems because of the disconnection between oral health and general health. We proposed a definition of inclusion oral health and a theoretical framework to advance the policy, research and practice agenda. This second review delves further into the concept of intersectionality, arguing that individuals who are socially excluded experience multiple forms of discrimination, stigma and disadvantage that reflect intersecting social identities. We first provide a theoretical and historical overview of intersectionality, rooted in Black feminist ideologies in the United States. Our working definition of intersectionality, requiring the simultaneous appreciation of multiple social identities, an examination of power and inequality, and a recognition of changing social contexts, then sets the scene for examining existing applications of intersectionality in oral health research. A critique of the sparse application of intersectionality in oral health research highlights missed opportunities and shortcomings related to paradigmatic and epistemological differences, a lack of robust theoretically engaged quantitative and mixed methods research, and a failure to sufficiently consider power from an intersectionality perspective. The final section proposes a framework to guide future oral health research that embraces an intersectionality agenda consisting of descriptive research to deepen our understanding of intersectionality, and transformative research to tackle social injustice and inequities through participatory research and co-production., (© 2020 The Authors. Community Dentistry and Oral Epidemiology published by John Wiley & Sons Ltd.)

In response to headlines about the oral health of persons experiencing social exclusion resonating in high-income countries, and research demonstrating the need for urgent action, a symposium entitled 'International Perspectives on Socially Inclusive Dentistry: A Call to Action' was organized for the IADR International Meeting of 2018. The aim of the symposium was to initiate an international dialogue on barriers to care, multidisciplinary action and examples of best practice for service delivery for people experiencing social exclusion; in other words, to develop the idea of inclusion oral health. Through our international exchange, what emerged was an awareness of a lack of professional consensus: What exactly is inclusion oral health? A theoretical framework to push forward the policy, research and practice agenda was clearly needed. This paper advances such a framework. Over the decades, dentistry has forged an approach to service delivery mainly through a business, demand-led model. While oral health continues to improve globally, an important consequence of this approach is that it compounds the social exclusion that many people are already experiencing because of a constellation of economic, political, cultural and individual factors. Thus, many people are simply not getting the dental care they need. In contrast, drawing on the theoretical literature on social exclusion, intersectionality and othering, we suggest that dentistry could act as an agent for social inclusion as a more responsive, all-encompassing form of oral health care and delivery. This paper advances a theoretical framework for inclusion oral health, and an action plan to show how inclusion oral health may become one solution in an armamentarium to tackle the global phenomena of oral health inequities., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: This qualitative study explored how the foster family environment influenced children's oral health. It also aimed to better understand foster carers' oral health knowledge, attitudes and experiences of managing foster children's oral health behaviours and oral health care., Methods: An interpretative phenomenological analysis (IPA) study design was used to recruit a purposive sample of foster carers in Tower Hamlets, United Kingdom, from a range of backgrounds (maximum variation sampling). Participants were aged 21 years and older and provided full-time foster care for children for a minimum of 1 year. The foster carers took part in focus groups that were audio-recorded and transcribed verbatim. Data analysis followed a five-step IPA process, which included reading the transcripts, note taking, identifying emerging themes, connecting related themes and writing up the final themes. Iterative data gathering and analysis continued to reach thematic saturation., Results: Three focus groups were conducted, involving a total of 12 foster carers. Eight of the 12 participants had fostered children for more than 10 years and they were currently fostering 22 children aged five to 18 years old. Four themes emerged from within the context of the supportive and nurturing foster family environment that described how foster carers' responded to and managed the oral health of their foster children. Foster carers had adopted an oral health caregiving role, "in loco parentis" responding to the poor oral health of their vulnerable foster children. They were hypervigilant about establishing and monitoring children's oral health routines and taking their children to see a dentist; these were seen as an integral part of being good foster carers. They were knowledgeable about the causes of children's oral ill health, gained from their own dental experiences and from looking after their own children. Foster carers had experienced tensions while adopting this oral health caregiving role with dentists who had refused to see younger children. Foster carers had also experienced tensions with teenage foster children who questioned their parental authority and legitimate right to set rules about smoking and healthy eating., Conclusions: This is the first study to explore foster carers' oral health perspectives and the foster family environment within the oral health context. It highlights the unrecognized and important role that foster carers have in improving the oral health of vulnerable children. Further research is needed to explore the relationship between foster carers and dentists and to support the development of health and social care interventions to improve foster children's oral health., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: This study aimed to better understand low-income parents' child dental care decisions through a life course approach that captured parents' experiences within the social context of poverty., Methods: We conducted 43 qualitative life history interviews with 10 parents, who were long-term social assistance recipients living in Montreal, Canada. Thematic analysis involved interview debriefing, transcript coding, theme identification and data interpretation., Results: Our interviews identified two emergent themes: lay diagnosis and parental oral health management. Parents described a process of 'lay diagnosis' that consisted of examining their children's teeth and interpreting their children's oral signs and symptoms based on their observations. These lay diagnoses were also shaped by their own dental crises, care experiences and oral health knowledge gained across a life course of poverty and dental disadvantage. Parents' management strategies included monitoring and managing their children's oral health themselves or by seeking professional recourse. Parents' management strategies were influenced both by their lay diagnoses and their perceived ability to manage their children's oral health. Parents felt responsible for their children's dental care, empowered to manage their oral health and sometimes forgo dental visits for their children because of their own self-management life history., Conclusion: This original approach revealed insights that help to understand why low-income parents may underutilize free dental services. Further research should consider how dental programs can nurture parental empowerment and capitalize on parents' perceived ability to diagnose and manage their children's oral health.

Objectives: This study explored oral health disparities associated with food insecurity in working poor Canadians., Methods: We used a cross-sectional stratified study design and telephone survey methodology to obtain data from 1049 working poor persons aged between 18 and 64 years. The survey instrument contained sociodemographic items, self-reported oral health measures, access to dental care indicators (dental visiting behaviour and insurance coverage) and questions about competing financial demands. Food-insecure persons gave 'often' or 'sometimes' responses to any of the three food insecurity indicators used in the Canadian Community Health Survey (2003) assessing 'worry' about not having enough food, not eating enough food and not having the desired quality of food because of insufficient finances in the previous 12 months., Results: Food-insecure working poor persons had poor oral health compared with food-secure working poor persons indicated by a higher percentage of denture wearers (P < 0.001) and a higher prevalence of toothache, pain and functional impacts related to chewing, speaking, sleeping and work difficulties (P < 0.001). Fewer food-insecure persons rated their oral health as good or very good (P < 0.001). Logistic regression analyses showed that oral health disparities between food-insecure and food-secure persons related to denture wearing, having a toothache, reporting poor/very poor self-rated oral health or experiencing an oral health impact persisted after adjusting for sociodemographic factors and access to dental care factors (P < 0.05). Food-insecure working poor persons reported relinquishing goods or services in order to pay for necessary dental care., Conclusions: This study identified oral health disparities within an already marginalized group not alleviated by access to professional dental care. Working poor persons regarded professional dental care as a competing financial demand.

Aim: To investigate whether measures of school performance and socioeconomic circumstances could be used as indicators of caries experience in 5-year-old Wandsworth state primary schoolchildren., Design: An ecological study using aggregated caries data collected in the British Association for the Study of Community Dentistry (BASCD) Oral Health Survey of 5-year-old children (2001), Jarman scores generated from national census data and matched by school postcodes (1991), school performance results in English, mathematics and Linguistic Awareness of Reading Readiness test (LARR; literacy) and free school meals recipient data from the Local Education Authority, Research and Evaluation Unit (2001)., Setting: State primary schools in the London borough of Wandsworth, UK., Subjects: All 55 Wandsworth state primary schools including 1968 5-year-old pupils., Outcome Measure: The school mean dmft score., Results: Simple linear regression analysis demonstrated that school mean dmft was statistically significantly associated with all five explanatory variables: English (P = 0.001), mathematics (P = 0.002), LARR (P < 0.001), the percentage of children receiving free school meals (P < 0.001) and the school address Jarman score (P = 0.02). Stepwise multiple linear regression identified the LARR score and the percentage of children receiving free school meals as the strongest indicators of school mean dmft score explaining 41% of the variation in school mean dmft score., Conclusion: Early school performance results in English, mathematics and LARR, the percentage of children receiving free school meals and school address Jarman scores were good indicators of school mean dmft scores in 5-year-old children in the Wandsworth state primary schools.