Oral Health Matters

Richard Watt: Welcome to Oral
Health Matters, a podcast that

shines a spotlight on oral
health and calls for it to be

embraced as a key part of the
global public health agenda. I'm

Richard Watt, Professor of
Dental Public Health at

University College London, in
this second series of our

podcast, I've been in
conversation with leading

researchers and policy makers
from around the world who have

been working in fields of global
health and public health, and

who are interested in issues of
equity, Community Action and the

politics of health. In this
episode, we're focusing on a

fundamental question, the future
of oral health and the

profession of dentistry. Is that
future to be embedded as an

integral part of health and a
social contract, or is dentistry

essentially now a cosmetic
endeavor, and individual

responsibility left to the whims
of the private sector. I'm

pleased to be joined by two
leading figures in dentistry and

oral health research, Denise
Faulks based at the Centre for

Clinical Dental Research at the
University of Clermont Auvergne

in France, a very experienced
clinician, educator and

researcher with particular
expertise in special care

dentistry. My second guest is
Rob Whitten, Chief Executive and

Director of the Peninsula Dental
Social Enterprise and Deputy

Head of the Peninsula Dental
School at the University of

Plymouth. Rob is passionate
about making quality oral health

care affordable, accessible and
available to all. So thank you

very much, both of you to be my
guests on this episode, and what

I'd like to start off by doing
is is maybe starting at the very

fundamental level by considering
how we might define oral health.

Denise, do you want to start us
off with that? How do we define

oral health?

Denise Faulks: Good to be here
with you and Rob today. My sort

of favorite definition, if you
like, of oral health, has got to

be the WHO one contained within
the Global Strategy and Action

Plan, which starts that oral
health is the state of the

mouth, teeth and oral structures
that enables individuals to

perform essential functions. And
it's really that functions, oral

functions, being primordial
within this definition, it's

interesting. So we're talking
about functions such as eating,

breathing, speaking, but we're
also encompassing the

psychosocial dimensions within
this definition, such as self

confidence, wellbeing and the
ability to socialise and work.

So we're looking at oral
function, and we're looking at

social participation. And one
way to sort of pull out the

threads of that has been also to
look at another WHO tool, the

WHO International Classification
of functioning for which we've

just finished the oral health
four sets, and this tool

actually allows us, within that
definition to pull out the

anatomical, pathological, the
physiological domains of oral

health, but also, most
importantly, the social and

societal factors that influence
or influenced by oral health. So

for example, the environmental
contextual factors that included

in the ICF core sets include
health services systems and

policies, include social
security systems, and also the

support and attitudes of health
professionals. And I think it's

these last factors that are
really on the table today. How

oral health works within the
health system, Social Security

Systems, and in the hands of
individual professionals.

Richard Watt: Okay, well Denise,
a very wide, encompassing start,

you covered an awful lot to
think through defining oral

health. Rob firstly, do you have
anything you would disagree on,

or would you add any additional
elements when we consider a

definition of oral health?

Rob Whitten: No, I don't think
so, I think Denise has

encapsulated that very, very
well. I suppose the only point I

would make is that defining oral
health is quite complex, and it

means different things to
different people. I'm always

curious as to what non-dental
professionals consider to be

oral health, because I think
we're very good at defining oral

health from a dental
professional standpoint, but if

we really want to integrate oral
health into wider health care, I

think the views of others will
also be important.

Richard Watt: So that subjective
element, perhaps, is pretty

fundamental, and that's a very
important point, and I suppose

flipping it on its side a bit,
Rob for you, in terms of the

scientific data, in terms of the
impact of oral diseases, what

would you summarise as the main
impact of oral diseases that

adversely affect people's
quality of life?

Rob Whitten: Certainly from my
own perspective, I do lots of

community engagement, work with
undergraduate students, and what

I see is that oral health
impacting people in many

different ways. I think one of
the biggest impacts for me is

stigma, certainly with the
groups that I work with. So we

didn't really touch on the
appearance of teeth, but when

people's teeth don't look
attractive, it can really impact

their life and their functioning
position in society. I know of

many patients who you know will
not seek employment or be

embarrassed to appearance at
social events because of the

appearance of their teeth, and
that's because often they've got

very poor oral health and have
not been able to access dental

care.

Richard Watt: So that's, again,
a fundamental issue of social

stigma, marginalisation, etc,
linked to appearance and and

people's, you know, assumptions
made, perhaps, about people's

lives because of the quality and
state of the mouth. So that's

what oral health is, and what it
includes. What about dentistry

and clinical dentistry, all
three of us qualified as

clinical dentists across our
career. How would we summarise

this sort of global developments
in dentistry? Maybe Denise, how

would you try and and it's a
huge question, but looking for

this sort of big level picture,
high level picture, where's

dentistry going? Do you think,
as a profession globally,

Denise Faulks: We are leaving
what I think would have been

considered the traditional model
of primary health care. Primary

Healthcare is essential
healthcare based on

scientifically sound, socially
acceptable methods and

technology that's part of a
comprehensive, coordinated

national health system. Yeah,
you're recognising the WHO in

those words again, and this
healthcare should be provided at

a cost that the community can
afford, in a spirit of self

determination. And what we've
seen in the last number of years

is move away from dental care
being integrated into primary

health care and an appropriation
of dentistry by commercially

driven, environmental and
societal factors. So I think, I

think the one that really seems
the most important from where I

am in France is the commercial
priorities of dental

professionals. So most dentists
will work in practice. It can be

in France, over 90% of those are
public service dental practices.

So they're run as small
businesses for profit small

businesses, but they are in
contract with the public health

services. So in France, as in
many countries, dentists are

paid on a fee per item basis. So
the government will decide

what's essential care, what each
item of care is worth, for

example, a root treatment or an
extraction. But this caps the

fees for items of care
recognised by the Social

Security System, and it caps the
fees at a price that is

considered by many to be
inferior to the true cost of

provision. Okay, so within the
system, we think we're in a

primary health care system
because the state is intervening

to price cap, but perversely,
this actually pushes dentists to

preferentially propose or
provide more high tech items of

treatment that are not fee
capped or price regulated,

because for these types of
treatment, they can set their

own fees, and these fees are
invariably high because they're

associated with expensive
technology, laboratory costs and

additional training. So an
example of that would be a

patient that comes in that has
missing teeth, that needs those

teeth replaced, and the Social
Security System will provide a

removable denture for that, for
a very low cost, the dentist

says, "oh, I don't do removable
dentures, but I could provide

you with an implant", or several
implants and a bridge, and none

of that, or very little of that,
is then paid for by the state.

So I think that it's not to
blame the individual dentists,

it's it's a fact that's related
to the way in which dental care

is funded, certainly in France.

Richard Watt: Okay, so that's
quite a detailed sort of

critique of the of the French
system. Rob from, from your

perspective and we, and we
definitely don't want to go into

all the details of the NHS,
because that will bore everyone

senseless. I suppose that the
sort of global picture of

dentistry, the direction of
travel. Would you agree with

Denise that those commercial,
private, driven elements. Do you

think those are big drivers of
where dentistry is going?

Rob Whitten: Yes, I think so. I
mean, it's, it's quite an

interesting question, because I
was reflecting on this issue

just last week at a conference
in the US, and it just, it does

seem that the drive in dentistry
is towards very high tech

solutions for dental problems.
So the rise of digital

dentistry, digital enabled
technologies to enable the

placement of missing teeth, etc.
It does feel this is driving

dentistry down a particular
road, and I do worry that oral

health as a prime goal of dental
professionals is being lost

somewhat in this kind of
technological shift. It's a

little bit worrying really,
because I think culturally as

well, we have this juxtaposition
of like quick a quick fix

culture in healthcare, whereby
people want a quick fix to the

to the problems that they
experience, and obviously

digital dentistry and these
advanced techniques offer a

quick fix without really
addressing the underlying causes

of poor oral health, and that's
a real worry for the future I

think. We don't want a
profession of technicians who

can deliver often AI enabled
solutions without forgetting

there's a patient at the end of
these who has particular

lifestyle factors, behaviors,
needs, etc.

Richard Watt: That's a nice sort
of start into the maybe the

limitations of the sort of model
of 21st Century dentistry and

you know, we're looking at it
from a big level. And clearly

around the globe, there are
different challenges that are

apparent. But I think both of
you have said very nicely about

the this sort of high tech
treatment dominated approach,

which clearly has a long
history, but is perhaps moving

into that particularly
technological element and linked

to that, what do you think about
the issue of the sort of

cosmetic nature of dentistry,
and that the focus is on

appearance, esthetics, that I
mean, a term I absolutely love,

is this dental spa. Is that
where dentistry is heading? What

do you think Rob?

Rob Whitten: Yeah, I think so. I
mean, I often see dental spas

advertising certain treatments
such as composite bonding,

bleaching, veneers, implants,
those types of things. It was

quite interesting actually, I
mentioned earlier, I was at a

conference last week, and there
was an interesting poster that

was evaluating practice
websites. I won't name the

country, almost all of the
practice websites were dominated

by aggressive marketing of these
advanced and cosmetic

techniques. Very few of the
websites had any information on

oral health or prevention. So I
think that just gives you an

indication of where dentistry is
in the marketplace, certainly in

this country, very heavily
dominated by this, this kind of

marketing approach. And you
know, it didn't mention oral

health, didn't mention how to
look after your teeth, how to

maintain a healthy mouth. So
yeah, absolutely, heading in

that direction.

Richard Watt: And in Denise, in
France, do you have the

equivalent of of that dental
spa, cosmetic, esthetic movement

in dentistry?

Denise Faulks: There is, but I
think it's probably, it'll get

here. We're not at the same
stage, I don't think it's the

states or even the UK. The
problem we have here is more to

do with the fact that it's
difficult to find a dentist,

services are scarce, the demand
is is huge. In a way, patients

are being commodified within the
system, so where dental services

are scarce, if the only dentist
taking patients is a dentist

that can only propose, or will
only propose high tech

solutions, then that is
basically what the patient has

to accept. So I think here the
majority of patients want local,

affordable, effective dental
services providing pain relief

that help retain and prevent
disease, retain the natural

dentition, what they're being
offered when they actually

managed to find a dentist is not
necessarily, then what they

expected or they were hoping
for. So I think it's a question

of looking at how the services
are distributed, and we go back

to the equitable distribution of
services, looking at, you know,

accessibility, availability,
there is a notion of

appropriateness in what is being
proposed in dental surgeries.

Richard Watt: Well, maybe we'll
come back to the limitations a

bit more in just a minute, but
just to keep going with so this,

these commercial drivers of
dentistry, this sort of

marketisation of dentistry,
dentistry as a sort of, you

know, as a commodity that people
buy and spend their money on, et

cetera. I suppose the question
is, where does that come from?

What are the driving forces
behind that? Rob any insights

from your side about why do you
think dentistry has ended up in

this commercialised space, or
perhaps, has it always been

there?

Rob Whitten: Yeah, that's a
really good question. I mean, I

was trying to think on what it
was like when I was growing up

as a as a kid, my local dental
practice marketed itself as a

family dental practice somewhere
where families could attend, you

know, I attended my appointments
with my parents. We don't seem

to, we don't seem to have that
anymore, certainly in a UK

context, and I can only think
it's driven by culture, by

modern culture, by society, by
the need to look a certain way.

You know, we have the rise of
social media, which wasn't

really around when I was a kid,
visiting my dentist, and that, I

think plays a really significant
role in how people view their

teeth and oral health nowadays.
We know there are social media

influencers who even chart their
their journey through cosmetic

dentistry, and that can be quite
a powerful influence on on young

people.

Richard Watt: And as a old
person that doesn't really

understand social media
influencers, do those people get

paid for, if they're taking
their followers through a

journey, is there money
following that, do people pay

for that? How does that work?

Rob Whitten: Yeah, I think, I
think in many cases, the

treatment is provided free to
the to the social media

influencer as a marketing tool.
So I certainly know even where I

work in the Southwest, there's a
particular social influencer who

often promotes teeth whitening,
and of course, that that goes

viral. These influencers can
have many millions of followers.

Richard Watt: Right. So Denise,
in terms from your side, the

driving forces behind this
commercialization. How would you

summarize that?

Denise Faulks: Yeah, I would Rob
you were saying okay there's a

cultural influence. I think it's
very definitely a commercial

influence. Because even when
you're talking about social

media, it's commercial
priorities driving that and

driving the content that we're
seeing that driving these

unrealistic esthetic standards,
or peddling non-essential dental

interventions. But there's money
behind that, and I think,

Richard, your question was the
right question. That is a

commercial influence. It's not
just it's not just a cultural

influence, if it is at all. The
other massive commercial

influence is the hugely
profitable dental industry,

where technological, digital
solutions are evolving very,

very fast, much faster than
public systems can keep up with,

so if you're looking at the
multinational dental industry is

now valued at 38 billion US
dollars, and that is set to

double in the next 10 years.
That there's a massive

commercial pressure behind what
goes on in dental practice that

patients are certainly not aware
of, and that dentists are

probably not sufficiently harmed
to resist.

Richard Watt: Right, so that
commercial power, that

commercial influence, that the
money can buy, change that seems

an important one, and before we
sort of draw things to an end.

We've heard both of you describe
some of the limitations of this

approach in dentistry, but I'd
be interested Rob from you,

because of your public health
and clinical expertise in terms

of marginalised population
groups, this sort of commercial

model of dentistry doesn't
really have an inclusive nature,

does it? It doesn't really
support the the care of homeless

people or people in prisons or
people with complex medical

needs.

Rob Whitten: No, that's
absolutely right. I mean this,

this kind of shift in dentistry,
is excluding large proportions

of the population who really
need access to quite basic

dental care. So basic
periodontal care, extractions,

you know, restoration of teeth
to provide function. And I think

one of the challenges in the UK
market is that NHS and private

dentistry often delivered side
by side, which can create

conflict when delivering care to
patients. It's often not the

case in medicine. So private
practice in medicine is often

separate from the NHS, and I
think that does create a really

significant tension in UK
dentistry, particularly when

there's reduction in funding and
publicly available dental

services. It does naturally
create a shift within those

practices to these types of
treatments, but as we know, it

excludes the people with the
greatest needs. And I speak to a

lot of patients who are quite
vulnerable, and I don't think

that many of them would have the
confidence to walk into one of

these dental spa practices we're
talking about, it just doesn't

feel, they often feel it's not
for them.

Richard Watt: They don't feel
they're sort of othered. In

other words, they don't feel
welcome in such an

establishment. For you Denise,
the disadvantages of this sort

of global movement in dentistry,
what would you want to add,

again, maybe, thinking of your
clinical expertise in special

care dentistry, clearly, again,
many groups being excluded from

such a model.

Denise Faulks: Yeah, I think
that both Rob and I clinically

are involved with groups that
have traditionally been excluded

from dentistry, we're talking of
dentistry on a precipice today,

our patient groups have been
teetering on the edge of that

precipice for a long time. I
think what has changed is that

there are now this, marginalised
group is getting bigger and

bigger in France now it's very
difficult to find a dentist that

will treat children, for
example. Rob was saying about,

you know, the family dentist.
Now, children are starting to be

excluded, anybody who's a little
bit older, anybody who's had any

sort of chronic health
conditions, and with the

difficulty in accessing care, is
getting greater and greater for

a larger proportion of the
population, as services are

re-orientated, if you like,
towards a more cosmetic and more

high tech commercial practice.
And I think that has, these

things could be addressed if
there was a political will to do

so. It should be remembered that
despite system failure, all of

these people have the same
rights to dental care. You did a

lovely podcast, Richard with the
human rights groups. Oral health

is a basic human right, and all
of these populations have the

same rights to dental care. So
there is a lack of political

will, in fact, to address
inequities, and there's a lack

of political will to fund oral
health care, or even social care

in general, and address the
social determinants of ill

health. I mean, I think we
should be going higher, further

upstream, and looking at the
political will to intervene in

this model. I don't think it's a
fatality, I think it is

something that we should be able
to act upon as a society.

Richard Watt: Well, just just
before we consider what we can

do, because that's a useful
range of points to highlight

Denise. I suppose, a final
limitation, and I don't want to

be too highfaluting, but Ivan
Illich talks about iatrogenesis,

you know, the harm caused by
treatment. So we know there's

clinical iatrogenesis, and I
imagine, although it's a long

time ago since I feel competent
clinically, but you know, this

clinical high tech approach has
some risks at a clinical level

in terms of causing harm, but in
terms of social iatrogenesis,

does it create a population that
is dependent on professional

input, that sort of becomes
dependent on the professions

bleaching or placing implants,
etc? Does it, does it remove

their own autonomy, or Rob is
that going a bit too far?

Rob Whitten: I don't think it's
going too far, but I think I

think that's that's correct, and
it comes back to that point I

made earlier. We sort of operate
in a quick fix culture now,

where solutions, technical
solutions, can address any

problem. And I think if we're
not careful, we we lose that

focus on self care and self
empowerment and all of those

things that we know as dentists
help an individual to maintain a

healthy mouth. So yes, I mean, I
would agree with that. I mean,

we know you mentioned clinical
iatrogenic damage. We know that

some of these high end
technology enabled solutions are

incredibly destructive of dental
heart tissues, and there's

really no way back from that. So
you do ultimately enter this

professional circular ladder of
increasing intervention

required. And I suppose the
worry is, you know, a lot of

this dentistry is delivered to
quite young people. We've

mentioned social media, I do
worry what happens to these

individuals when they are in
older age? You know, how are we

going to support and address
their dental needs when they've

got quite complex dentistry that
needs to be replaced at some

point in the future.

Richard Watt: Do we have
scientific evidence if your

teeth have been bleached to bits
in your early life, what are

they going to be like when
you're 70? I wonder, I wonder

what the animal structure is
going to be like. But Denise,

anything to add on iatrogenesis?

Denise Faulks: Yeah, I think
that this is part of when we

talk about primary health
services, that we should be able

to define essential dental care
that is evidence based, and that

should be ingrained within
funding mechanisms. For example,

I know Richard, you're aware of
this project, but there's a the

European project prudent, that's
currently studying means to look

at funding mechanisms, to set
priorities, to set resource

allocation, and that includes
looking to define essential

treatment. But what we should be
trying to do is enforce a

practice that is guided by the
best interests of the population

rather than the financial
interests of the dentists or the

corporations behind them. And
that doesn't exclude high tech

treatment when it's
scientifically supported, for

example, putting in implants to
retain full removable dentures

and things that are definitely
evidence based. But there's got

to be some way to regulate
non-evidence based practice.

Richard Watt: Well, that that
leads very nicely. Let's now

think about, then we've talked a
lot about the problems of this

sort of high tech cosmetic
approach to dentistry. But let's

try and end with some solutions
or ways of regulating this

space, you know. So let's think,
how can we sort of reframe, or

indeed reclaim oral health and
dentistry? Rob, we could start

with you and think about from a
professional perspective from

our professional organisations
at global or national level,

what kind of role do you think
there is there in terms of

governance and training and sort
of professional ethics? Is this

a professionalism issue as well?

Rob Whitten: I think it can be.
I think the dental profession

needs to own this, there isn't
enough national leadership

around oral health and
prevention. I was looking at a

recent dental conference held in
the UK here, and over the three

days of the conference, there
were over 200 speakers, but

there were only two
presentations on oral health and

prevention. So it doesn't seem
that we have this balance quite

correct within the dental
profession itself, and I think

we need to do more to promote
oral health as a basic

fundamental right, as you and
Denise were just just chatting

about. Having said that, I think
it's quite challenging the

dental community, or the dental
profession, is often self

governing, And it's difficult to
see how external influence and

pressures can can alter that.
Certainly when we've we know

there are such commercial and
market forces at play in

dentistry, in both the UK and
globally.

Richard Watt: That's a
recognition of the sort of

limitations of what might
possible. But Denise, you

started talking about policy
makers, politicians, if people

begin to recognize oral health
as a fundamental human right,

governments are meant legally to
have an obligation then to

protect and fulfill their
citizens health, including their

oral health, what would that
mean for policymakers in

relation to sort of regulating
this commercialisation of the

mouth.

Denise Faulks: I think that
there has to be some kind of

regulation from outside of the
profession. I can't see how that

would work otherwise, not
necessarily from without inside

the health debate. But if oral
health were properly integrated

into general health, if we've
managed to really collaborate

within the NCD, the non
communicable disease agendas, if

we were able to gain funding to
plan and implement services,

prevention interventions,
particularly upstream health

promotion, lobbying and
legislating for changes in the

healthcare system, I think that
we could move this agenda. We're

never going to eliminate the
sort of practice where it's 100%

private, like ascetic or
cosmetic surgery in general.

You're not going to eliminate
it, but you can make it part of

a very private practice. And
come back to evidence based

primary health care for the vast
majority of the population. I

think that that is possible, but
I don't think that there's any

will within the dental
profession for that to happen

because of the commercial
determinants behind that. And

because the way things are
funded. People are, you know,

trying to make their businesses
work, and are trying to make

their businesses profitable, and
this is a very this is the way

to do that.

Richard Watt: Final question,
what about the role of civil

society, about community
organisations, about consumer

groups. Could they put pressure
on decision makers, policy

makers, professions, to to
basically de commercialise

dentistries, or is that being a
bit too naive. Rob, what's your

view on that?

Rob Whitten: I have seen some
local examples of that work,

actually in my area. So
community groups have campaigned

for access to dental care for
marginalised groups, and that

has led to action. I suppose the
challenge is, how you scale that

across a country? You know,
professional dental

associations, I think, have an
important role there, but they

often tend to advocate on behalf
of the dental profession and not

on behalf of the public or
patients who require care.

That's probably one of the
fundamental imbalances within

how dentistry is governed in
most countries.

Richard Watt: So the public
voice is quite limited, often

Denise anything to add on that
final point?

Denise Faulks: Yeah, I think
that the public needs to be

educated about commercial
influences on health care in

general, particularly perhaps in
oral health care in the context

of this discussion. But these
commercial influences are huge.

And we know that, we know that,
you know, Big Pharma, we know

that there's, there's a lot of
influence there, and I think

that it's a very gray area for
the majority of the public, and

that perhaps that would be
something that the civil society

could work on, is trying to get
some clear guidance for patients

on what are the commercial
influences, what are the

commercial determinants of
health? And perhaps in dental

terms at the appropriateness of
different treatment options.

Richard Watt: Well, that's a
good way to end. And I think

we've had a really interesting
discussion here about what oral

health is, if it is a
fundamental human right, what

does that mean? We've also
discussed these commercial

drivers of dentistry in this
global context, and both

understanding why that's
happening and the problems that

may occur, and then, you know
the solutions are, there's no

quick fixes here, but there's
different options in terms of

policy, professional, civil
society's role. So a really

interesting, really interesting
discussion, so thank you. And I

also want to just to to declare
for our listeners that your

host, ie me, has just had a bout
of severe toothache and a dental

abscess. And the place to be
when you've got acute infection

is, it's a horrible place to be.
And it really brings it home how

important oral diseases and oral
health is for everyone. Thanks

to our guests, Denise Faulks and
Rob Whitten and to you for

listening. That concludes series
two of Oral Health Matters, we

hope you enjoyed our
discussions. We hope to be back

with series three very soon, but
in the meantime, you can follow

the Dental Public Health Group
on LinkedIn, BlueSky and

Instagram. Oral Health Matters
is produced by the Dental Public

Health Group at UCL, with
production support from esearch

Podcasts, and funding from the
UK National Institute of Health

and Care Research. Thank you
very much.