Objectives: To explore the psychosocial impacts of dentistry as described by patients.
Methods: I conducted 6 qualitative interviews with people whose access to dental care had been limited because of financial barriers, but who had recently undergone significant treatment through a dental outreach program.
Results: In addition to physical benefits (including improved sleep and diet), participants discussed how dental treatment led to a greater level of confidence and an improved self-concept. They provided powerful examples of how this confidence boost improved their social interactions and relationships. They also felt more confident about their employability.
Conclusion: The benefits of adequate dental care extend well beyond its physical and medical aspects. Dental health is connected inextricably with people’s sense of self and social functioning. The far-reaching consequences of dentistry explored in this research raise questions about the inequalities in Canada’s current system and the need to address them.
Straight, white teeth have become a cultural ideal, and, as acquiring “perfect” teeth is often quite costly, crooked and decayed teeth have become a sign of social vulnerability.1 A large body of literature has already established the link between physical attractiveness and attribution of positive personality traits, showing that “what is beautiful is good” in the eyes of most social audiences.2
Researchers who have looked specifically at dental appearance have reached the same conclusion: people with straight, white teeth are appraised more positively in terms of their social competence, intellectual ability, psychological adjustment and relationship satisfaction.3,4 For example, Eli et al.5 presented their study participants with pictures of people with visibly decayed front teeth or the same people with intact dentition. Participants were then asked to assess candidates based on esthetic, professional, and social traits. In all three categories, the people with intact dentition were associated with more positive attributes compared with their decayed-dentition equivalents, suggesting that the esthetic appearance of teeth affects impression formation. Other studies have raised questions about a link between dental appearance and employment outcomes.6-8
My aim in this study was to expand on the existing literature by considering the perspective of people with poor oral health, who have had the benefit of dental treatment. This contrasts with most of the literature, which focuses on the reactions of others. More specifically, I was interested in how these people experienced the appearance issues their dental problems created for them and how they understood the effects of the dental treatment they received.
To determine the effects of dental care on lived experience, I interviewed 6 patients who had recently received dental care from an outreach program in Ontario. All were recruited through the dental outreach organization, which agreed to distribute information about the study to a sample of their patients so that those who wished to participate could contact me. Although I did not have specific participant criteria for the study, the nature of recruiting through the dental outreach program limited participants to adults demonstrating financial need. Three of the participants were male, and the other 3 were female. Each interview lasted approximately 25 minutes: 4 took place in person, another 2 over the telephone. Those interviewed in person signed consent forms, while those with phone interviews provided verbal consent after reading a copy of the consent form. Respondents did not receive compensation for their participation in the study.
I used a qualitative research method to gain an in-depth understanding of the issue. I approached this research using the symbolic interactionist perspective. Symbolic interactionism is a microsociological perspective rooted in the idea that people understand situations based on their social interactions with others and general society.9 Because of the concern with lived experience in symbolic interactionism, I aimed to get as close to the perspective of the participants as possible. To achieve this, I employed a naturalistic approach using conversational-style interviews based on an interview guide. I started by asking participants what encouraged them to apply for the dental program. From there, I asked open-ended questions, such as whether they had noticed any changes in their lives since the treatment. To end every interview, I asked participants if there was anything else that they thought was important to add to the discussion. This interview style allowed respondents to discuss their experiences in their own terms, while reflecting on the way they interacted with society before and after dental treatment.
With the consent of the participants, I audio-recorded the interviews, transcribed them verbatim and subjected them to a thematic analysis. Because of the exploratory nature of my interviews, my research followed an inductive method. Inductive theory involves drawing conclusions based on one’s findings rather than using research to test a theory.10 I reviewed the transcriptions to determine the overlapping themes that emerged in the interviews as a basis to reflect on the impact of dental care on individuals’ lived experience.
This project was reviewed and approved by the McMaster Research Ethics Board.
Most participants discussed the impact of the dental treatment they received in physical terms, including pain relief, general health improvements, the ability to eat a more nutritious diet and improved sleep patterns. However, the interviews were particularly striking in the emphasis that participants placed on how much more confident they felt as a consequence of the dental treatment. They discussed this confidence boost in relation to their self-concept, their interactions with others and their employability.
A predominant theme in participants’ reflections was the relation between the appearance of their teeth and their self-image. For example, after expressing embarrassment about his teeth, one man commented on the disconnect between his self-understanding and his appearance before the treatment, which had made it difficult for him even to see reflections of himself in a mirror. He explained, “I didn’t think that my appearance reflected the person that I felt inside, and now I’m able to look in the mirror.”
A female participant also mentioned a newfound excitement in looking at herself. “You start to feel better about yourself. You look in the mirror a little bit longer. Like I said, when I left the office and smiled, there is a mirror beside the door when you leave, and I looked in that again with a smile just to see it.”
Another respondent contrasted how he felt about himself before and after treatment by referring to a “snowball effect.” Once “down” on himself, he described the steadily growing sense of confidence he was experiencing as a result of having his teeth fixed: “If you feel better about yourself, keep thinking that way, you’re going to keep feeling better and better and better about yourself.” He predicted that this more positive view of himself and general outlook on life would continue to make things better for him.
The data highlight how the undesirable appearance of their teeth led participants to experience low-self-esteem. However, with treatment, their definition of themselves began to change. They began to feel more positive about themselves and experience higher levels of self-confidence.
Most participants were well aware of the link between self-concept and their social interactions. One participant described the importance of smiling in communication. She pointed out: “Smiles are a first impression when you see anybody. You want to smile or make eye contact, and if you don’t feel good about yourself, you can’t do that.”
She described how guarded she was before treatment: “You kind of always have a guard up and you think, ‘As I’m talking to you, she’s staring at that chip or can she see the stain?’” She also described the impact of treatment: “Now I can carry on a conversation longer and not worry about what they’re thinking.”
In response to the question, “Have you noticed any difference in how you feel like other people view you?” one man answered, “Yes. Yes. They’re not afraid anymore. When my teeth were very bad, I was not so friendly looking I guess, but now I’m in recovery. It’s a big difference.”
Another participant felt that his poor oral health caused others to assume that he was abusing drugs, leaving him experiencing shame and social isolation: “My teeth were in such a bad state just from having so many dental problems over the years. I was incredibly embarrassed about my appearance, and I had, you know, there was rumours that because my teeth were so bad, I must have been using methamphetamines or other drugs for many years, in my family and other people. And that certainly wasn’t the case!”
Participants made numerous references to shielding their teeth with their hands while engaging in conversation. For example, one participant mentioned how self-conscious he was while speaking and admitted that he even grew facial hair to try to deflect attention from his teeth and avoid negative judgements. Commenting on the difference that dental treatment had made, he added: “I’ve got a lot of confidence when I’m around people. I don’t cover my mouth when I’m talking or laughing in public.”
Several participants spoke specifically about how their interactions with family members had been affected. One man explained that the low self-esteem he experienced before treatment led him to distance himself from his family. Once his dental problems were addressed, he reached out to family members he had not seen in a while, including his mother. Commenting on the reconciliation with his estranged mother, he said, “She didn’t look down on me. She recognized some of the other achievements that I had made in my lifetime as well, and it made me feel extremely proud.”
One participant spoke about the difference he felt that his renewed confidence had on his romantic prospects: “I felt like I was able to smile again. It gave me a great deal of confidence to the point where I actually have a wonderful girlfriend today. Even though I never thought something like that would happen.”
In reflecting on their social interactions, participants gave expression at an intuitive and experiential level to the “what is beautiful is good” theme identified in the literature. They experienced first-hand the negative attributions, judgements, stigma and isolation that go along with violating societal appearance norms. However, they also had the opportunity to experience the difference that dental treatment can make. Once isolated and estranged from family and friends, they were now able to describe more positive interactions and the re-establishment of relationships they once thought were lost forever.
A final theme that emerged from the data was how participants experienced their improved confidence in the context of employability. Most felt that their job and career prospects had been enhanced as a result of the difference dental treatment had made in their self-esteem and confidence levels. Applying for a job or requesting a raise is difficult for most people under the best of circumstances, because it involves exposing oneself to vulnerability and rejection. For those with dental problems that affect their appearance, the stakes are even higher.
One participant identified an increased willingness to take this risk after his dental treatment. “Prior to having the dental work done, I would not have had any vested interest in sending out resumes or making appointments for job interviews. Now, I send out my resume. I don’t have a problem going to meet with anybody.”
Another participant admitted to limiting herself in terms of the kinds of jobs she was prepared to consider in light of the appearance of her teeth: “I probably wouldn’t have taken a front-desk position with my teeth the way they were before or worked in customer service direct one on one. I wouldn’t have because of how low my confidence was, and I couldn’t smile properly. So unless you can be free with your whole face, you can’t be true to the customer.”
A third participant spoke at length about the relation between his dental care and perceived employability. He explained that he had been away from the work force for 8 years because of a disability, but after recovering he was ready to work again. He described his time out of the labour force as a “big strike against” him and his odds of regaining employment as poor. He felt he was going to have to fight hard for a job. Before dental treatment, he doubted he would have had the confidence to do so. However, with treatment, he felt stronger and more confident. As he described it, it was easier for him to feel like “you are the right person for the job.” He concluded: “So yeah, I’m optimistic now — more than I would have been — to be able to interview properly and give it my best shot.”
Although the literature shows a relation between dental appearance and employment, there are still questions about its nature. The experiences of participants in this study highlight some of the complicating factors, including whether individuals with poor dental appearance pursue employment opportunities in the first place, the types of opportunities they seek out and their confidence in these pursuits.
Although limited in terms of number of participants, this study nevertheless yields valuable insights into the social impact of dental treatment that improves individuals’ appearance. The participants spoke eloquently and powerfully about the ways in which their treatment improved their lives. People who felt diminished and stigmatized by their poor oral health were able to overcome these feelings. They experienced a boost in confidence, which manifested itself in a more favourable self-concept, heightened willingness to interact with others, strengthened familial relationships and increased confidence in relation to employment.
Given the potential for dental treatment to have such overwhelmingly positive and life-altering effects on people’s lives, the study begs the question of access. This is a question that study participants themselves raised, without solicitation. For all of the participants interviewed, dental treatment was possible only because of a charitable organization that provides free dental care to adults with low incomes. In the absence of this assistance, and in the context of lives where people may be struggling even to house and feed themselves, dental treatment was viewed as “an unaffordable luxury.”
An estimated 6 million Canadians avoid dental treatment annually for financial reasons.11 Although the Canada Health Act has as its goal overcoming barriers that prevent equal access to health care, oral health is excluded from policy.11 The Canadian Academy of Health Sciences investigated the status of oral health and care in Canada, looking specifically at “vulnerable populations,” including people with low income, elderly people in institutions, refugees, immigrants and those with disabilities. These vulnerable groups tend to have poor oral health, including untreated dental decay, pain and gum diseases. However, because of cost barriers, these populations commonly seek dental care only in emergency cases.11 The current status of the Canadian oral health care system has been described as exemplifying “the inverse care law” because those who have the greatest need of dental care receive the least amount of treatment.11
The subjective nature of interview-based research puts inherent limitations on the conclusions that can be drawn from my findings. Because of the logistics of recruitment, the time frame of the research project and the narrow target population of people who have recently gained access to dental care, the sample size in this study is small. This introduces additional limitations to the generalizability of my findings.
However, the results of this study complement and reinforce the findings of large-scale, quantitative surveys. Although the self-reporting method does not result in objective findings, it does provide valuable insight into the patient perspective. My results provide a glimpse into how the lives of people whose appearance is affected by the lack of proper dental treatment are impacted in such a far-reaching way. They also show how extensive the benefits of receiving treatment can be and should prompt a more urgent conversation about access to dental health in this country.