Social Dentistry: addressing inequities Image source: [https://www.abc.net.au/news/2022-04-11/dental-care-reform-calls-for-older-people-federal-election-issue/100979420](url)   *Image source: https://www.abc.net.au/news/2022-04-11/dental-care-reform-calls-for-older-people-federal-election-issue/100979420* Clinical photo: A close-up view of an elderly man with a mustache inserting upper and lower partial dentures into his mouth. This figure illustrates the personal reality of dental care needs and the use of prosthetics, contextualizing the slide's topic of 'Social Dentistry' and calls for dental care reform. Film still: A close-up shot of actor Mark Wahlberg with a concerned or confused facial expression, set against a blurred outdoor background. Understanding social dentistry **Social medicine** It is the practice of medicine that integrates: 1. Understanding and applying the social determinants of health, social epidemiology, and social science approaches to patient care; 2. An advocacy and equity agenda that treats health as a human right; 3. An approach that is both interdisciplinary and multi-sectoral across the health system; 4. Deep understanding of local and global contexts; 5. Voice and vote of patient, families, and communities. **Social prescribing** It is a way of linking patients in primary care with sources of support within the community to help improve their health and well-being. A social prescribing scheme may include: i) a referral from a healthcare professional ii) a consultation with a link worker and iii) an agreed referral to a local voluntary, community and social enterprise organisation Source: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018) It is the practice of medicine that integrates: 1. Understanding and applying the social determinants of health, social epidemiology, and social science approaches to patient care 2. An advocacy and equity agenda that treats health as a human right 3. An approach that is both interdisciplinary and multi-sectoral across the health system 4. Deep understanding of local and global contexts 5. Voice and vote of patient, families, and communities #### Social Prescribing It is a way of linking patients in primary care with sources of support within the community to help improve their health and well-being. A social prescribing scheme may include: 1. A referral from a healthcare professional 2. A consultation with a link worker 3. An agreed referral to a local voluntary, community and social enterprise organisation *Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* > [!note] Lecturer — Clinical Social Dentistry > Social dentistry addresses oral health inequities both at the individual level and within dental practice. > > - Dentists should recognize social determinants contributing to oral disease and poor oral health. > - They should work with other professionals, organizations, and sectors. > - Social circumstances should be incorporated into clinical assessment and treatment planning. > - Person-centred care considers more than the mouth and can help explain why a person is experiencing a particular oral health condition. > [!note] Lecturer — Social Medicine > Social dentistry stems from social medicine, which applies social determinants in regular practice and recognizes that they can influence diagnosis. > > - Social medicine considers both medical and social history, including a person’s demographics and where they come from. > - It treats health as a human right, encourages interdisciplinary and multisectoral participation, and advocates for change. > - Dentists may need to identify injustices such as child abuse, know the reporting processes, and advise patients to seek non-dental support when non-dental problems contribute to dental problems. Societal level * Government * Health System * Professional bodies * Others Macro level: society * Advocacy for healthy public policies * Activism for inclusion and against discriminations Community level * Public health dentist * Medical resources * Social resources * Local authorities * Others Meso level: community * Adapting dental clinic’s organisation and equipment to the needs and characteristics of community * Partnering with community and advocating to improve local policies * Identifying and developing joint actions to improve oral health of community Micro level: individual patients and family * Providing person- and family-centered clinical care (1a) * Liaising and advocating to address patient’s risk factors and social determinants of oral health (through resources and partnerships at the community and societal levels) (1b)   #### Macro Level: Society **Stakeholders:** - Government - Health System - Professional bodies - Others **Actions:** - Advocacy for healthy public policies - Activism for inclusion and against discriminations #### Meso Level: Community **Stakeholders:** - Public health dentist - Medical resources - Social resources - Local authorities - Others **Actions:** - Adapting dental clinic’s organisation and equipment to the needs and characteristics of community - Partnering with community and advocating to improve local policies - Identifying and developing joint actions to improve oral health of community #### Micro Level: Individual Patients and Family **Actions:** - Providing person- and family-centered clinical care (1a) - Liaising and advocating to address patient’s risk factors and social determinants of oral health through resources and partnerships at the community and societal levels (1b) > [!note] Lecturer — Societal-Level Advocacy > The macro level concerns advocacy at a wider societal and policy level. > > - Dentists may engage with professional organizations such as the Australian Dental Association, raise concerns affecting oral health across the country, and bring them to governments and other higher authorities. > - Macro-level social dentistry aims to address structural determinants, contribute to societal change, and improve oral health. > [!note] Lecturer — Community-Level Practice > At the meso level, the dentist engages with the community rather than acting only for one specific patient. > > - Dentists can identify recurring problems affecting groups of patients, engage local authorities, and bring group-level concerns to the wider community. > - For example, dentists may identify common problems among refugee patients, such as insufficient resources, difficult living circumstances, and problems associated with being refugees, then raise these concerns with community organizations or local authorities. > [!note] Lecturer — Micro-Level Practice > The micro level includes the ordinary clinical obligations of assessing, diagnosing, and treating the patient, as well as engaging with the family where appropriate. > > - Social dentistry extends this care by identifying social determinants, advocating for the patient’s risks and determinants, and linking the patient with appropriate resources and partnerships. > - Clinical care is distinguished from additional social support, which involves liaising with organizations to improve the individual patient’s well-being. > - For example, where child abuse contributes to a child’s oral health, the dentist may link the patient with the Department of Communities or child protection organizations. Labelled diagram illustrating the interactions between a patient/family unit and a dental team, with arrows indicating flows of care and advocacy at different levels. The labels correspond to specific actions defined in the slide text: 1a = Providing person- and family-centered clinical care, 1b = Liaising and advocating to address patient’s risk factors and social determinants of oral health (through resources and partnerships at the community and societal levels). Labelled diagram illustrating the micro level of social dental practice, showing interactions between a patient/family and a dentist/dental team. 1a = Providing person- and family-centered clinical care; 1b = Liaising and advocating to address patient’s risk factors and social determinants of oral health (through resources and partnerships at the community and societal levels). A biomedical approach to a case.. **Patient situation** Ms Da Silva, aged 24, feels that her mouth is often dry and has a bad taste. She is also worried by white patches that appeared on her oral mucosa. She explains that her asthma has recently worsened and that she had to increase her use of asthma medication (B2-agonists and corticosteroids). Adapted from: Bedos, C., Apeljan, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018)  Ms Da Silva, aged 24, feels that her mouth is often dry and has a bad taste. She is also worried by white patches that appeared on her oral mucosa. She explains that her asthma has recently worsened and that she had to increase her use of asthma medication (B2-agonists and corticosteroids). *Adapted from: Bedos, C., Apeljan, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* - ==The beta-2 agonist was probably salbutamol.== Clinical photo: The image displays the oral mucosa of a patient, specifically showing white patches on the inner cheek and tongue. This visual evidence illustrates the symptoms described in the text, such as the 'white patches that appeared on her oral mucosa' associated with increased asthma medication use. A biomedical approach to a case.. **Potential aetiological explanation?** Ms Da Silva’s xerostomia, halitosis and oral candidiasis could be side effects of her asthma medication Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018)  Ms Da Silva’s xerostomia, halitosis and oral candidiasis could be side effects of her asthma medication. *Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* > [!note] Lecturer — Medication Mechanism > The clinician identifies extensive white patches and candidiasis during the clinical examination. > > - Corticosteroids are described as immunosuppressive and may therefore have contributed to the candidiasis. > - This biomedical explanation focuses on the direct medical and medication-related causes of the oral findings. > [!note] Lecturer — Biomedical Approach > The intervention is considered reasonable because it addresses the patient’s reported symptoms, the clinical findings, and the medication considered responsible for the oral condition. > However, the approach stops after considering the medical history and medication and does not investigate the patient’s wider social circumstances. > [!note] Lecturer — Patient Details > The lecturer describes additional oral symptoms associated with Ms. Da Silva’s worsening asthma. > > - Ms. Da Silva is 24 years old and reports a frequently dry mouth, a bad taste, and white patches on her oral mucosa. > - Her worsening asthma has led to increased use of beta-2 agonists, probably salbutamol, and corticosteroids. > [!note] Lecturer — Oral Aetiology > The clinician’s history and examination identify a direct medical and medication-related explanation for the oral findings. > > - The findings include xerostomia, halitosis, extensive white patches, and candidiasis. > - The candidiasis is considered potentially related to the corticosteroids used for asthma, which the lecturer describes as immunosuppressive. > [!note] Lecturer — Biomedical Intervention > The lecturer describes a reasonable biomedical approach that addresses the symptoms, clinical findings, and medication considered responsible for the oral condition. > > - The short-term treatment consists of oral hydration agents for dry mouth and antifungal ointment for candidiasis. > - The clinician proposes liaising with a physician to identify a less iatrogenic asthma treatment, potentially by replacing Ms. Da Silva’s current medications. > - This approach stops after considering the medical history and medication and does not investigate the patient’s wider social circumstances. Clinical photo: The image shows the buccal mucosa (inner cheek) and posterior teeth of a patient, revealing extensive white, patchy plaques adherent to the inflamed red tissue, consistent with oral candidiasis. A dental mirror is used to retract the cheek for examination. * *A biomedical approach to a case..* ## Proposed intervention The dentist suggests oral hydration agents and an antifungal ointment to alleviate Ms Da Silva's symptoms in the short term. He also proposes to liaise with her physician to find a less iatrogenic asthma treatment. Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018)  The dentist suggests oral hydration agents and an antifungal ointment to alleviate Ms Da Silva's symptoms in the short term. He also proposes to liaise with her physician to find a less iatrogenic asthma treatment. *Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* Clinical photo: An intraoral view of the buccal mucosa and tongue displaying white, curd-like plaques on an erythematous (red) background, illustrating the symptoms of oral candidiasis mentioned in the text. **A socially engaged approach to a case..** **Patient situation** Ms Da Silva says that her apartment is old and that moulds have appeared and grown in several rooms in the last year. Her landlord refuses to fix the problem, and she does not know how to negotiate with him nor where to find help. She stopped school at age 17 and acknowledges that she lacks skills to defend her rights. She does not consider moving as an option considering her low financial resources. Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018)  Ms Da Silva says that her apartment is old and that moulds have appeared and grown in several rooms in the last year. Her landlord refuses to fix the problem, and she does not know how to negotiate with him nor where to find help. She stopped school at age 17 and acknowledges that she lacks skills to defend her rights. She does not consider moving as an option considering her low financial resources. *Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* Clinical photo: An intraoral photograph showing the buccal mucosa with white, curd-like plaques on an erythematous background, characteristic of pseudomembranous candidiasis (thrush), being examined with a dental instrument. # **A socially engaged approach to a case..** ## **Potential aetiological explanation?** > In addition, Ms Da Silva's asthma has been aggravated by the apparition of moulds in her apartment, by her landlord's lack of actions to address this issue, and, more generally, by difficulties to find safe and affordable housing. --- Adapted from: *Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J **225**, 357–362 (2018)*  > In addition, Ms Da Silva's asthma has been aggravated by the apparition of moulds in her apartment, by her landlord's lack of actions to address this issue, and, more generally, by difficulties to find safe and affordable housing. *Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* Clinical photo: A close-up view of the buccal mucosa (inner cheek) showing diffuse white, patchy lesions on an erythematous background, consistent with oral candidiasis or a similar mucosal condition. The image includes visible teeth and dental instruments retracting the lip. A socially engaged approach to a case.. **Proposed intervention** To address the environmental factors of asthma, the dentist proposes to contact a 'free legal clinic' to clarify Ms Da Silva's rights as a tenant. The dentist also offers to liaise with a community social worker to identify possibilities of subsidised housing in the neighbourhood. At the meso and macro levels, the dentist advocates for safe and affordable housing programs. Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* **225**, 357–362 (2018)  To address the environmental factors of asthma, the dentist proposes to contact a 'free legal clinic' to clarify Ms Da Silva's rights as a tenant. The dentist also offers to liaise with a community social worker to identify possibilities of subsidised housing in the neighbourhood. At the meso and macro levels, the dentist advocates for safe and affordable housing programs. *Adapted from: Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018)* Clinical photo: An intraoral view of the buccal mucosa and mandibular teeth, showing white, patchy lesions on the inner cheek. A dental instrument is used to retract the lip for better visibility. Now I am Confused.. Image source: https://tenor.com/en-GB/search/jackie-chan-confused-gifs  Now I am Confused.. *Image source: https://tenor.com/en-GB/search/jackie-chan-confused-gifs* Line drawing illustration of a man holding his head with both hands, displaying a facial expression of confusion or frustration. ## Lets revise.. 1. What are inequalities vs inequities. 2. Determinants of oral health inequities. 3. Inequitable burden of oral diseases in Australia. 4. Understanding approaches to tackle oral health inequities - population level 5. Adopting practice of social dentistry – dental practice level    1. What are inequalities vs inequities. 2. Determinants of oral health inequities. 3. Inequitable burden of oral diseases in Australia. 4. Understanding approaches to tackle oral health inequities - population level 5. Adopting practice of social dentistry – dental practice level > [!note] Lecturer — Key Concepts > The lecturer distinguished inequalities from inequities and outlined the determinants and responses relevant to oral health. > > - Inequalities are differences in health, whereas inequities arise from injustice or unjust systems. > - Oral health is influenced by proximal, intermediate, structural, and commercial determinants. > - The inequitable burden of oral diseases in Australia includes priority population groups. > - Population-level responses involve upstream action, integrating health promotion with service delivery, and applying the Ottawa Charter framework. > - Dentists can practice social dentistry at the micro, meso, and macro levels. > - Social dentistry requires recognizing social determinants, avoiding victim blaming, understanding patients’ medical and social histories, providing person-centred care, and using social prescribing where appropriate. > - Dentists should advocate for patients and communities, work with other organizations and sectors, and identify and respond to injustice contributing to oral health problems. Clip art illustration of an open notebook with lined pages and a blue fountain pen resting on the right side, symbolizing note-taking or revision. Clip art illustration: A cartoon boy with a worried expression reading a blue book, serving as a visual metaphor for the 'Lets revise..' section of the presentation. Cartoon illustration of a yellow cat lying on an open book, serving as a decorative visual element for the 'Lets revise..' slide. # Recommended reading 1. Daly B, Batchelor P, Treasure ET, Watt RG, Essentials in Dental Public Health, Second Edition, Oxford university press 2. Watt, R., Sheiham, A. Inequalities in oral health: a review of the evidence and recommendations for action. *Br Dent J* 187, 6–12 (1999). 3. Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA’S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016. 4. Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. *Br Dent J* 225, 357–362 (2018)  1. *Daly B, Batchelor P, Treasure ET, Watt RG, Essentials in Dental Public Health, Second Edition, Oxford University Press.* 2. *Watt, R., Sheiham, A. Inequalities in oral health: a review of the evidence and recommendations for action. Br Dent J 187, 6–12 (1999).* 3. *Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA’S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.* 4. *Bedos, C., Apelian, N. & Vergnes, JN. Social dentistry: an old heritage for a new professional approach. Br Dent J 225, 357–362 (2018).* - ==The textbook is available through UWA OneSearch and online.== > [!note] Lecturer — Social Dentistry > Social dentistry connects oral health with the circumstances in which people live. > > - Dentists can understand social determinants and provide person-centred care. > - They can link patients with appropriate non-dental services and advocate for communities and policy change. > - What happens outside the mouth is directly connected to what happens in the mouth. Clip art illustration of a cartoon boy with brown hair reading a blue book at a desk. Thank you!!  Thank you! Clinical photo: A group photograph showing a class of young school-aged children wearing blue uniforms, sitting on a patterned rug in a classroom setting with an adult woman standing behind them. ## Case: 24-year-old woman with oral white patches and worsening asthma ### Question **Scenario:** A 24-year-old woman presents complaining of a dry mouth, bad taste, and white patches on her oral mucosa. She reports that her asthma has recently worsened, leading to an increased use of her asthma medications, which include beta-2 agonists and corticosteroids. **What's shown:** Clinical examination reveals extensive white patches on the oral mucosa. **Consider:** What is the likely biomedical diagnosis and immediate management for her oral symptoms, and what additional social history might you explore to address the root causes of her condition? ### Answer **Observations:** - The patient presents with xerostomia, halitosis, and oral candidiasis. - The candidiasis is a side effect of her increased use of corticosteroids, which act as an immunosuppressant. - Social history reveals she lives in an old, moldy apartment; her landlord refuses to fix it, and she is economically challenged and unaware of her tenant rights. - The mold in her home is the underlying trigger for her worsening asthma. **Reasoning:** A purely biomedical approach identifies the oral candidiasis as a side effect of her immunosuppressive asthma medication. The immediate management would be oral hydration agents and antifungal ointment for symptom relief, plus liaising with a physician to switch to a less iatrogenic asthma treatment. However, a social dentistry approach recognizes that changing the medication won't solve the problem if the environmental trigger remains. By exploring her social history, the dentist identifies that her housing conditions are driving her asthma. The holistic management therefore includes social prescribing—linking the patient to a free legal clinic to help her navigate her tenant rights and address the mold issue, which will ultimately improve her asthma and prevent future oral health complications. **Takeaway:** Practicing social dentistry means integrating social determinants of health into clinical practice by looking beyond the mouth to identify and address upstream social factors (like housing) that drive a patient's disease, often utilizing social prescribing to connect patients with community resources. ## Case: 24-year-old woman with oral white patches and worsening asthma ### Question **Scenario:** A 24-year-old woman presents complaining of a dry mouth, bad taste, and white patches on her oral mucosa. She reports that her asthma has recently worsened, leading to an increased use of her asthma medications, which include beta-2 agonists and corticosteroids. **What's shown:** Clinical examination reveals extensive white patches on the oral mucosa. **Consider:** What is the likely biomedical diagnosis and immediate management for her oral symptoms, and what additional social history might you explore to address the root causes of her condition?  ### Answer **Observations:** - The patient presents with xerostomia, halitosis, and oral candidiasis. - The candidiasis is a side effect of her increased use of corticosteroids, which act as an immunosuppressant. - Social history reveals she lives in an old, moldy apartment; her landlord refuses to fix it, and she is economically challenged and unaware of her tenant rights. - The mold in her home is the underlying trigger for her worsening asthma. **Reasoning:** A purely biomedical approach identifies the oral candidiasis as a side effect of her immunosuppressive asthma medication. The immediate management would be oral hydration agents and antifungal ointment for symptom relief, plus liaising with a physician to switch to a less iatrogenic asthma treatment. However, a social dentistry approach recognizes that changing the medication won't solve the problem if the environmental trigger remains. By exploring her social history, the dentist identifies that her housing conditions are driving her asthma. The holistic management therefore includes social prescribing—linking the patient to a free legal clinic to help her navigate her tenant rights and address the mold issue, which will ultimately improve her asthma and prevent future oral health complications. **Takeaway:** Practicing social dentistry means integrating social determinants of health into clinical practice by looking beyond the mouth to identify and address upstream social factors (like housing) that drive a patient's disease, often utilizing social prescribing to connect patients with community resources. Case: 24-year-old woman with oral white patches and worsening asthma Clinical photo: The image displays the oral mucosa of a patient, specifically showing white patches on the inner cheek and tongue. This visual evidence illustrates the symptoms described in the text, such as the 'white patches that appeared on her oral mucosa' associated with increased asthma medication use. 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