Introduction

The social determinants of health have been described as the 'conditions in which people are born, grow, live, work, and age.'1 We know that they shape people's health and quality of life even more than health services. It is also well known that these conditions are not the same for everyone; the groups and individuals at the bottom of the social ladder, in particular, are disadvantaged and thus more vulnerable to sickness.2

In recent years, an increasing number of voices have called for health professionals to go beyond traditional medical care and tackle these social determinants of health.3,4,5 This movement is not surprising. Many professionals have observed that the services they provide to patients are often insufficient to improve their health in the long term; for that, they also need to address the conditions that make them sick.

Consequently, clinicians and professional health organisations from several countries have launched initiatives to expand the scope of medical care. Using different terms, such as 'social medicine,'6 social prescribing7,8 or 'social accountability,'9 they share a vision of 'structurally competent'10 clinicians; professionals able and willing to conduct upstream and midstream actions in addition to traditional downstream clinical interventions (Table 1).2,10,11,12,13,14

Table 1 Definition of key terms used in the article
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The field of dentistry needs to join this movement because the social structures shape people's oral health in the same ways they shape their general health. Alongside physicians and other professionals, dentists should thus address the conditions that not only lead to caries and periodontal diseases, but also cause asthma, cardiovascular diseases, or cancer.15

In doing so, dentistry would embrace the principles of social medicine of Rudolf Virchow, a German physician of the nineteenth century, famous for stating that health professionals are the natural advocates of the poor and should address the social conditions that made them sick.16 Dentistry would also renew with a tradition of public health that emerged at the end of the eighteenth century, when the profession's discourse recognised the importance of the social environment and emphasised the notion of prevention.17

During the twentieth century, however, dentistry has increasingly focused on biological processes and surgical procedures. This is why we still lack frameworks describing 'social dentistry', even though a small group of UK researchers has paved the way by encouraging the dental profession to tackle social determinants of health15 and proposing ways to do it.18,19,20 Social dentistry remains vague and abstract for dental professionals and educators in dental schools, so there is a need to propose models that could guide them.

The purpose of this article is to propose such a framework; we will explain how social dentistry could be practised and provide examples of 'social' or 'structural' competencies that dental professionals ought to have.

A framework of social dentistry

Dental professionals adhering to this framework, which mirrors approaches proposed in medicine,21,22,23 adopt a global perspective about health and conduct actions at three imbricated levels (Fig. 1). These actions address the needs of individual patients and their family (micro level), but also those of the local community in which they practise (meso level), and the society in which they live (macro level). We expect dentists to lead these actions, but the other members of the dental team – dental hygienists, dental assistants, and secretaries – could also be involved and share some of the tasks.

Figure 1
figure 1

Framework of actions conducted by socially engaged dental professionals

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Individual and family level (micro level)

At the individual level, socially engaged dental professionals mainly provide patient- and family-centred care (Fig. 1, arrow 1a), including diagnosing disease and exploring illness, identifying risk factors of oral disease and illness, making shared decisions with the patient about the choice and timing of interventions, providing clinical care as well as coaching to address oral diseases' risk factors, and referring patients to medical and dental specialists.24 In addition to this 'traditional' type of care, they try to conduct upstream actions to address their patients' risk factors and social determinants of health and disease (Fig. 1, arrow 1b). This additional 'layer' of interventions includes liaising and partnering with resources that are part of the healthcare system, like physicians, but also with resources beyond the healthcare system, such as local community or social services. Where social prescribing services exist, such as in some localities in the UK, dental professionals could partner with 'link workers'.7 Because they have good knowledge of a wide range of resources in the community, link workers act as 'community navigators' and help patients benefit from a 'panoply of social opportunities.'8

Table 2 provides several vignettes illustrating how socially engaged dental professionals might intervene.25,26,27,28,29,30,31,32,33 These vignettes first underline how the patients' oral health and illnesses are shaped by their social environment and living conditions. For Mr Johnson (vignette 1), for instance, dental caries is related to his diet and oral hygiene habits, of course, but these individual risk factors are influenced by his social situation. His recurrent experience of racial discrimination, in particular, generates feelings of devaluation and powerlessness that affect his ability to adopt a healthy lifestyle.

Table 2 Vignettes illustrating interventions by socially engaged dental professionals
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For Ms Da Silva (vignette 2), xerostomia, halitosis and oral candidiasis seem linked to her asthma medication, which was recently modified by her physician because of an aggravation of her condition. This coincides with the apparition of moulds in the apartment she rents, a situation she has little control over as her landlord refuses to tackle the issue of moulds. Ms Da Silva feels powerless because she does not know how to convince or force her landlord to make her apartment healthy; she also lacks the knowledge and resources to find a better place to rent.

Considering these complex situations and etiological pathways, what should dental professionals do? With a traditional approach, they would mainly provide symptomatic care and support their patients in addressing diseases' risk factors. For Mr Johnson, for instance (vignette 1), the dentist would probably suggest restoring his decayed teeth, providing fluoride topical applications, and helping him improve his diet and oral hygiene.

Socially engaged dental professionals, however, may adopt a more global approach. First they would be able to gather relevant information on their patients' social situation, and recognise how their environment shapes their health. In other words, they would identify the 'fundamental causes'34 of their patients' oral illnesses rather than simply recognise individual risk factors and biological processes. Second, they would try to intervene and address these fundamental causes at the level of the patient, but also, as we will explain in the next two sections, at the community and the societal levels.

With respect to Mr Johnson (vignette 1), a socially engaged professional may not only provide person-centred symptomatic treatment, but also try to address the causes of his unhealthy lifestyle, in particular his feelings of devaluation, discrimination, and isolation. One solution, among others, would be to liaise with existing local resources, such as local community organisations that provide various services to people who feel discriminated or stigmatised, and help them feel empowered. If a social prescribing scheme exists, the professional could refer Mr Johnson to a link worker that could identify appropriate community resources for him.

In the case of Ms Da Silva (vignette 2), the traditional approach would consist in alleviating the symptoms of xerostomia and candidiasis, whereas a socially engaged professional may also contact her physician to find an asthma medication with milder side effects. A more upstream action would consist in helping Ms Da Silva improve her deleterious environment, in particular the mould in her apartment. The dental professional or other members of the dental team could liaise with a legal clinic, for instance, or with a link worker when available, allowing Ms Da Silva to know more about her rights, determine the legal obligations of her landlord, and identify potential avenues for legal action. They could also examine Ms Da Silva's opportunities for subsidised and safe housing.

Community level (meso level)

As implied in the previous paragraphs, socially engaged dental professionals are involved in the community in which they work and learn its characteristics: Who lives in it? What are its most vulnerable groups? What are the conditions that make them sick? What are their specific needs? What are the local medical and social resources, including public health practitioners, link workers, social workers, and community organisations? In rural areas, dental professionals are de facto part of their community and can easily find answers to these questions; learning about the community may be a greater challenge in urban areas where clinicians are easily trapped into a 'dental silo'. In this perspective, Watt et al.18 suggest that dental professionals systematically record background social data of their patients and develop 'a profile of the practice population.' They also recommend that they search for epidemiological data related to the community, and if possible contact local consultants in public health in order to better understand the environment in which they practice.

Socially engaged dental professionals try to espouse the specific needs of the community, by making their clinic accessible to the most vulnerable groups, especially in terms of approachability, acceptability, and accommodation; a clinic is approachable when the population is well informed about the type and quality of its services; it is acceptable when it ensures tolerance and respect in regard of people's characteristics, such as their gender, sexual orientation, social status, and cultural as well as religious beliefs; it is accommodating when it 'can be reached both physically and in a timely manner', and adapts to the community, for instance with appropriate location, appointment system or opening hours.35 Socially engaged dental professionals also acquire clinical competencies adapted to the specificities of the community and offer services that respond to its particular needs.

For instance, if there is a climate of racial and social tensions in the neighbourhood, the dentist should be aware of and sensitive to the discriminations experienced by some groups, such as African American people. Being socially engaged first means understanding that these discriminations may impact the health and even the oral health of these people, as exemplified by Mr Johnson's story (vignette 1, Table 1). It also implies reflecting on how to make the dental clinic acceptable and even welcoming for people who have been racially and socially discriminated; for that, the dentist could consult and even partner with the African American community in order to develop appropriate solutions.

A similar collaborative approach could apply to other often-discriminated groups, such as people on social assistance, people with disabilities, and cultural or religious minorities. In Ontario (Canada), for instance, the Positive Spaces Initiative provides resources to organisations willing to create 'welcoming environments where LGBTQ newcomers are able to access culturally inclusive services with dignity and respect.'36 They offer useful tools, such as a Starter Kit with tips to better support people from this community; they also provide boards indicating that people are entering 'a space that is free from discrimination based on sexual orientation, gender identity, and gender expression.'37

In an aging community, a socially engaged professional would try to accommodate people with limited mobility and address their unmet needs. The clinician would first make the dental clinic accessible to this community and acquire, if necessary, additional competencies to better serve it. The dentist may also decide to acquire mobile dental equipment and, in complement to the care provided in the clinic, to deliver services within people's house or in nursing homes. The professional could also develop a partnership with local long-term care facilities to better plan, organise, and financially support the delivery of mobile dental services.

As health professionals, dentists hold a high degree of credibility in society. Their privileged position allows them to draw the attention of local authorities to health issues in the community, and advocate for healthy policies, like water fluoridation or school nutritional programs. Socially engaged dental professionals also advocate for more upstream actions targeting social determinants of health, including, as described in our vignettes, racial discrimination, access to safe housing, low literacy, or social isolation.

Societal level (macro level)

Socially engaged dental professionals may also intervene at the societal level by joining or creating organisations that promote healthy programs and policies, thus mirroring their advocacy activities at the community level. This type of organisation is more common in medicine where dynamic advocacy groups recurrently emerge. WhiteCoats4BlackLives, for instance, echoes the Black Lives Matters movement in the United States. With the mission 'to eliminate racial bias in the practice of medicine and recognise racism as a threat to the health and well-being of people of colour,' this medical student-run organisation has upstream goals, such as 'prepare future physicians to be advocates for racial justice' and 'raise awareness of racism as a public health concern.'38 Another example is the physicians who created Canadian Doctors for Refugee Care in 2012 when the government announced cuts in the federal health insurance program for refugees. Health professionals across Canada opposed these cuts for several years and successfully advocated for their reversal.39

Socially engaged dentists should also initiate actions within their professional organisations and encourage them to promote healthy policies. This is what the Canadian Medical Association recently did by launching a campaign calling on the government to develop a National Seniors Strategy; more than 40,000 supporters have sent approximately 100,000 letters to parliamentarians asking for better healthcare and more resources for this vulnerable social group.40 The Canadian Nurses Association, whose code of ethics emphasises the importance of social justice,41 has also been active by urging the federal government to implement a 'comprehensive, national poverty reduction strategy.' Relying on scientific evidence on social determinants of health, the Association asks, for instance, to 'implement strategies to generate good jobs that pay a living wage' and to 'increase access to affordable housing.'42

Considering the importance of social determinants of oral health, the participation of dental professionals in these movements is fully justified. Socially engaged dental professionals, and the organisations that represent them, should therefore advocate for eradicating poverty and social exclusion, improving job security and working conditions, reinforcing antidiscrimination laws and policies, and strengthening the social safety net, thus directly addressing determinants of oral health and access to dental care. They should also advocate for an improvement of the dental care systems, especially by lowering or removing the financial barriers that impede access to care for several social groups, such as the working poor and elderly people. They should engage with and for social groups that are often overlooked, disadvantaged, or stigmatised, such as elderly people, people with disabilities, aboriginal communities, people on social assistance, immigrants and refugees, or LGBTQ communities, for which oral health and access to dental care has been challenging.

Challenges for the development of social dentistry

Developing social dentistry in western countries will be a challenging endeavour, as dental professionals will need to widen their perspectives. In particular, they will have to identify the social determinants of their patients' oral health and imagine appropriate social interventions. This will require knowledge and skills that are often poorly taught or not even addressed in dental schools, such as communication, advocacy, partnership development, or social policies.18 In addition to that, the implementation of social dentistry will face several structural barriers: the payment systems for oral health services; the dominance of the biomedical model in dentistry; and the pre-eminence of the neoliberal ideology in our western societies.

With our framework, we suggested new tasks for dental professionals at the individual, community, and societal levels that may need to be financed. A capitation system seems to be more adapted to finance social dentistry than the current dominant fee-for-service system. With capitation, the professionals receive a salary to provide care to a defined group of patients. Thus it encourages them to keep their patients healthy and favours actions that prevent the occurrence of diseases. This system is rare in dentistry, but experiences in Sweden show that it leads to more preventive dental services than the fee-for-service system.43

The dominance of the biomedical model in our profession is the second challenge for social dentistry. Although dentistry's discourse originally emphasised prevention and public health, our profession, due in part to strong technological innovations,44 has narrowed its focus to biological processes, surgical procedures and new technologies. This model thus obliterates the social determinants of health and limits the potential for social interventions. The dominance of this biomedical model in dentistry may explain why our profession lags behind in the conceptualisation of patient-centredness and psychosocial models of healthcare.24

The hegemony of the neo-liberal ideology is another important challenge for social dentistry because it stresses individual responsibility.45 As Kirsh46 explains, 'within our neoliberal context, social issues are configured as individual problems and responsibilities, and independence and self-sufficiency are upheld as prime values.' By individualising what is socially determined, the neo-liberal ideology thus opposes the concept of social determinants of health and what Link and Phelan47 call the 'fundamental causes' of disease. It also supports the biomedical model as well as the privatisation of medical and dental care. Dentistry is embedded in this neoliberal ideology; it is often considered a business by professionals themselves and attracts students that, compared to their medical counterparts, value the attributes of entrepreneurial work, such as 'status and security' or 'high income.'48,49,50

Conclusion

We proposed an original framework of social dentistry that is based on the principle that if we want to improve the health of our patients, we need to address what makes them sick and tackle the social determinants of health. Our approach thus includes actions that socially engaged dental professionals should conduct at the individual, community, and societal levels. We hope that this article will open a debate on this subject in various countries and contexts, and lead to actions in terms of professional practice, dental education and research. Work is still necessary to develop undergraduate and graduate dental curricula teaching these skills and competencies, and to evaluate the impact of social dentistry on the social determinants of oral health.