The Smile Gap: A History of Oral Health and Social Inequality

Catherine Carstairs’s new history, The Smile Gap: A History of Oral Health and Social Inequality, explores the changes in oral healthcare in Canada from the beginning of the 20th century to the present. Drawing on a wide range of sources, including patient voices, Carstairs considers oral health history from a number of angles. Given how little has been written on oral health in Canada, or indeed in other parts of the world, Carstairs’ work is a very welcome addition to the history of oral healthcare as well as the history of health systems and health equity. In addition to these themes, the work considers scientific and technological developments in oral health, including its connections to beauty and cosmetic cultures, the professional and educational history of dentistry and associated roles, as well as the cultural history of personal oral healthcare and the significance of smiling. Many of the themes covered in this history are almost certainly reflective of changes that occurred in other high-income countries during the 20th century, making this book of interest to a wide audience.

At the beginning of the 20th century most Canadians did not regularly visit a dentist, and those that did sought help for tooth pain rather than visiting for preventive care. Moreover, most Canadians did not even own their own toothbrush; families usually shared a toothbrush and daily brushing was unusual. This, coupled with a diet that was high in sugar and other refined carbohydrates, meant that most people had poor oral health and hygiene. The majority of people did not anticipate keeping their teeth into later life, but rather expected at some point to have their teeth removed and replaced with dentures. During the next hundred years personal hygiene practices changed this situation markedly, with the growth in commercial toothbrush and toothpaste production and associated advertising in the interwar years. There was also a marked change in habits around consulting a dentist—it became much more common to go for regular check-ups with a dentist and later with a hygienist as well (presumably, at some point, denturists will become obsolete). This improvement in oral health means that most people now expect to keep the majority of, if not all, their teeth for life. In turn, this means that they have become more willing to invest in cosmetic dentistry. At the same time, not everyone has benefited equally from improvements in oral health and this 20th century story of improvement is marked by widening disparities.

Carstairs begins her history with a brief account of why people’s teeth were in such poor condition in the early 20th century—her explanation is that it was a result of a high sugar diet combined with a fear of very rudimentary and expensive dental treatment, with many dental practitioners in Canada having no formal qualifications at the time. Inspired by advances in the science of dentistry, a growing movement towards professionalisation began in the 1910s and 1920s, which recognised that the prevention of tooth decay was as critical as the need to treat tooth pain and loss. Good oral health was increasingly understood to be important in and of itself, but also because of a perceived connection between poor oral health and diseases such as goiter, hypertension, and genito-urinary tract infections.

The development of dentistry as a profession was supported by the formation of several professional organisations at a federal and provincial level. Among other activities, these organisations were focused on oral health promotion that targeted children and encouraged them to eat healthy foods and to brush their teeth four times a day (common dental advice until the 1970s). From the 1920s toothbrushes and toothpastes were marketed and sold in increasing numbers and pharmaceutical companies drew on the growing body of dental research to sell these items. Not surprisingly, the inter-war advertisements for oral hygiene products were highly gendered and many warned young women of the detrimental effect bad breath could have on their eligibility when dating. By mid-century, however, clean, glistening teeth were marketed as being good for one’s employment and marriage prospects as well as one’s health, regardless of gender. Carstairs highlights the irony that, by the 1950s, when most people were engaging in daily toothbrushing, some dentists were beginning to suggest that diet, rather than brushing, was key to good oral health. During the second half of the century, as newer toothpastes were developed and dental technology improved, Canadians were advised to engage in good oral hygiene habits at home, visit the dentist regularly, and follow a healthy diet for optimal oral health.

Perhaps the most contentious public health issue in relation to oral health in Canada, as in many countries, was fluoridisation of drinking water. By the 1950s, research from the United States was showing that fluoride could reduce tooth decay and, while fluoride could be applied directly to teeth at the dentist’s office, fluoridisation of water was considered the cheapest and most efficient method to ensure that everyone benefitted from the advantages of fluoride. However, this was a much-debated issue in Canada in the 1950s and 1960s (as well as elsewhere) and by the early 1970s only about a third of Canadians were drinking fluoridated water on a regular basis. Proponents and opponents of water fluoridisation made a number of arguments in support of their cause. Carstairs discusses these arguments, as well as drawing attention to the generational nature of the debate—fluoridisation was considered an intervention which primarily supported children’s health, so it was not surprising that it was a major public health issue during the 1950s and 1960s post-war baby boom. It was often older people, who had concerns about the possibility of increased bladder and kidney problems, that opposed the measure.

Another important theme covered in this book is how Canadians paid for their dental care and how the provision of dental care was included (or excluded) from the wider medical system. While a national programme of free medical care was introduced in Canada in 1968, this programme excluded dentistry. From the 1930s there had been growing support in Canada for the public provision of healthcare. Dentists were not, in general, supportive of publicly provided dental care as they believed that it would have an adverse effect on their incomes and that it would be highly bureaucratic and time-consuming to navigate. They were also concerned about losing their independence—a recurring argument across high-income countries that have considered, or indeed implemented, some form of state-funded healthcare. Canadian dentists were aware of the changes that the introduction of the NHS had brought to Britain and believed that their income, status, and independence could only be maintained through continued private practice. There was also a moralistic element to this position, with dentists arguing that Canadians could afford private dentistry if they budgeted properly and prioritised their teeth over other frivolous items such as confectionary, radios, and jewellery.

Dental care for children received particular attention in post-war Canada, again a likely result of the baby boom. Access and approaches to dental care for children did, however, vary across the provinces. Saskatchewan adopted the New Zealand approach of school dental nurses (or therapists)—mostly women who worked in clinics set up on school grounds. At a time when there was a shortage of dentists in Canada, this approach was seen as a cost-effective solution, although critics complained that dental nurses were not properly trained or supervised. Ultimately, this programme was short-lived, lasting only 13 years. The shortage of dentists was a problem in many Canadian provinces, reducing the effectiveness of subsidised care for children. This shortage also increased inequities, with those in urban areas having better access to dental care than their rural counterparts, and those from higher-income households accessing better care than those from lower-income households. This was further exacerbated in the 1980s and 1990s, with the rise of neoliberalism resulting in the reduction and abolition of children’s dental programmes.

The inequity of access to dental care and the consequent impacts this had on oral health was not limited to children. An important theme in this history is the complexity of health inequities and the variety of forms on these inequities take. Not surprisingly, indigenous Canadians had much poorer oral health than other Canadians, although this is not discussed in detail in this book—Carstairs has addressed this important topic elsewhere with Ian Mosby(1). The most obvious form of oral health inequity is that between high-income households and low-income households. This would seem self-explanatory for private care but, interestingly, health economists looking at existing insurance plans in the late 1970s found that the wealthy were more likely to use dentists than those on lower incomes even when no out-of-pocket payments were required.

At the same time, it was those in higher-paid, more secure jobs who benefited most from the increase in employer-funded dental insurance in the 1970s. Programmes to cover the dental costs of those on social assistance, and the disabled were often ineffective as these groups found it hard to find dentists willing to negotiate the associated bureaucracy to obtain reimbursement for treatment provided. Additionally, few dentists were adequately trained to treat people with disabilities, and their surgeries were rarely suitably designed. Once dental insurance became a part of employment packages, the elderly were also disadvantaged when they left paid employment. There also continued a significant difference in access to dentists between urban and rural populations, with dentists being reluctant to set up practices in small towns. Immigrants are another group that have often struggled to access high-quality dental care, and Carstairs draws attention to a particular type of medical tourism which developed, whereby immigrants to Canada have sought dental care on return visits to their home countries, where treatment is more affordable.

From the 1970s there was a significant growth in cosmetic dentistry. This was a result of technological developments, cultural ideas about the importance of having a perfect smile, and Hollywood normalisation of this ideal. When considering these changes, the theme of equity continues to resonate as the expense involved in cosmetic dentistry often excludes the groups highlighted in the previous paragraph. Carstairs also, however, draws attention to other factors which have contributed to the growth in cosmetic dentistry. As people’s oral health has improved more generally and more people keep their teeth for life, they are more willing to invest in the appearance of their teeth, which usually discolour as they age. Additionally, cosmetic dentistry provided the perfect opportunity for dentists to increase their incomes, which was important as improved home oral care had reduced work for dentists.

The first major innovation in cosmetic dentistry was orthodontic treatment. Initially children and teenagers were the main recipients of this treatment (there was a gendered element to this, with parents being more likely to pay for their daughters’ teeth to be straightened than their sons’), but as early as the 1980s it was estimated that a quarter of people seeking treatment were adults. The growth in adult orthodontics, coupled with the growth in teeth whitening and dental implants more recently, speaks to the cultural importance of having a perfect smile and what such a smile conveys. Canadians increasingly believed that good teeth could improve confidence and success in the workplace, as well as socially. Carstairs predicts that Canadians’ desire to improve the appearance of their teeth will continue to increase and asks what this means for those who cannot afford cosmetic treatment and for the place cosmetic treatments might have in any state-funded denticare scheme.

Addressing such diverse themes as collective versus individual responsibility for health, and debates on good parenting, Carstairs has taken the broad topic of oral health in Canada and produced a highly readable and thorough history. As well as addressing the themes already highlighted, she considers trans-national connections in the development of Canadian oral health policy, and the book speaks to a wider history of oral health in high income countries, particularly Anglo-Settler societies. At the same time as considering international connections, Carstairs has successfully navigated the challenge of writing a national history, where much of the policy has been determined at a provincial (and sometimes a municipal) level. Readers are given a good sense of general changes across time as well as having their attention drawn to particular developments or innovations at the local level. This work provides a wonderful model, or at least a starting point, for those considering researching the history of oral health care in other high-income countries.

Notes

1. Catherine Carstairs and Ian Mosby. ‘Colonial Extractions: Oral Health Care and Indigenous Peoples in Canada, 1945-79.’ Canadian Historical Review, 101:2 (2020), pp.192-216.Back to (1)