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Lee JY, Divaris K. J Dent Res 2014; 93: 224–230

In this challenging paper, question are asked, conventional wisdom shaped, and solutions offered for narrowing the oral health divide. At the centre of such discussions are the seminal contributions of Marmot (for an example, see Lancet 2005; 365: 1099–1104) who identified the reductionist slant, 'causes of the causes'.

The authors of this paper concede that although major advances have been made in the underpinning science and the practice of dentistry, this has 'not led to notable reductions in oral health disparities.' However, such approaches are not dismissed, but there is a plea that 'omics' should be translated into relevant and actionable public health strategies.

Not surprisingly, it is argued that such disparities can be most effectively addressed if efforts are focused on distal/upstream factors including 'political, economic, social, and community characteristics'. But not only should distal factors be embraced, but also 'intermediate' determinants, 'such as health beliefs and cognitions, knowledge and understanding, health literacy, resilience, and self-efficacy'. The demands of requiring individuals to navigate health systems should be neutralised. All information should be accessible and culturally acceptable. It is stated that high-risk group strategies targeting individual behaviour do not address the root causes of health disparities, and have not narrowed the gap between the disadvantaged and more affluent.

The authors propose a holistic approach adopting a multi-level method based on a modified Andersen's behavioural model. They place particular emphasis on distal determinants. Yet almost paradoxically, Andersen's behavioural model focuses on individual factors, but interfacing with those within the community. Both models place particular emphasis on a feedback loop. For example, health outcomes affect health beliefs. Common risk-factors are described such as smoking, alcohol and diet.

Tensions in addressing racial/ethnic health disparities are identified in that 'racialization may perpetuate aspects of discrimination'. The authors also touch on epigenetics ('changes in gene activity that are not caused by changes in the DNA sequence'). In the context of this paper, 'imprinting' of social disadvantage influences disease occurrence with a possible possibly bi-directional relationship. The authors assert 'social environments 'get under the skin' to cause disease'.