SOCIOLOGY AND ORAL HEALTH

Sociology is derived from the Latin socio, meaning society and the Greek logos, meaning science. The word society is derived from the root words socius, meaning individual and societa, meaning group. "Sociology is the study of human social life, groups and societies. It is a dazzling and compelling enterprise, having as its subject matter our own behaviour as social beings. The scope of sociology is extremely wide, ranging from the analysis of passing encounters between individuals in the street up to the investigation of world-wide social processes". Anthony Giddens ("Sociology", 1989).

Sociology deals with the study of human relationships and of human behavior for a better understanding of the pattern of human life. It is also concerned with the effects on the individual of the ways in which others individuals think and act. Sociology can be viewed from two angles: a) Study of relationships between human beings
b) Study of human behaviour. Sociological interest in health may be recent, but attempts to understand the cultural and social aspects of diseases and health were done much before the emergence of sociology as a discipline. With the development of modern medicine and newer theories of health and disease had made socio cultural aspects not very important. But as a result of industrialization, urbanisation, technological advancement and more recently economic policies like globalisation, liberalisation and privatisation of social life has become stressful giving rise various diseases depending upon the life styles of persons. Oral diseases have seen dramatic changes at global level with decrease in dental caries in developed countries. Modern dentistry has to reach beyond the conventional clinical disciplines. The future challenges to dentistry and public health care planning are confined to areas of expertise that relate to the non clinical dimensions of dental practice health promotion, community based preventive care and outreach activities. A proper understanding of the social context of oral health and illness is a prerequisite to the provision of such care by dental profession and its participation in public health action programmes.

Structural aspects of society:

Social Institutions: o It is a social structure and machinery through which human society organizes, directs and executes the multifarious activities required to satisfy human needs. o E.g. School, Hospital etc., Family is a social institution.

Community: o It is defined as the group, small or large, living together in such a way that the members share not one or more specific interests but rather the basic conditions of common life.

Associations: o They are groups of people united for a specific purpose or a limited number of purposes and are based on utilitarian interest. o E.g. Indian Dental Association.

Functional aspects of society:

a. Social Norms:

Every living organism has some basic requirements and tries its best to satisfy them. In man, biological factors trigger the desires but, contrary to animals, there are also social standards which guide man. The resultant of these two forces is the actual behaviour which we perform in the society. The specified rules of conduct to be followed by the members of a society are technically known as social norms. They are: 1. Folkways: They refer to customary ways of behaviour. People conform to these ways not out of fear of being penalized, but because it is obligatory in the proper situation. E.g. Ways of eating, dressing. Etc., They are necessary for the group solidarity. Vitality of a group is indicated by the extent to which people follow or abide by folkways. 2. Mores: They are socially accepted ways of behaviour that involve moral standards. Each more is believed to be essential for social welfare. There is a greater unwillingness to

see them violated. Folkways are the protoplasm of the cell, the bulky part, while the mores form the nucleus, the essential part. 3. Laws: Some important mores are converted into laws in order to ensure implementation.

b. Customs and Habits:

Custom is a broad term embracing all the norms classified as folkways or norms. It refers to practices that have been repeated by a number of generations, practices that tend to be followed simply because they have been followed in the past. Customs have a traditional, automatic, mass character. A habit is purely personal affair, not entailing any obligation. Eg., Brushing daily.

c. Etiquettes and Conventions:

Etiquettes are concerned with choice of the proper form for doing something in relation to other people. Convention is merely an agreed upon procedure.

d. Social Values:

They constitute an important part of the selective behaviour of man. Values refer to those standards of judgement by which things and actions are evaluated as good or bad. Thus values are directive principles of human action and serve as criteria for selection. Norms are said to be the enactment of social values. E.g. It is a norm that no man should be differentiated in terms of sex, caste, colour or creed while practising the art of medicine. The value behind it is that all men are born free and equal

Sociology in Health: The Indian Scenario Indian society had its own way of dealing with the illnesses according to the practices of the local culture which had shown that social factors are very important in determining the health of the community in general and individual in particular. Traditional Indian medicine had always taken serious and genuine considerations for cultural aspects of the disease and treatment pattern was also logical and culture/ region specific. Ancient healing practices in India were heavily dependent on the lifestyle of the person. Charaka Samitha quotes that the essence of healing is integration. Faith, love, the sense of unity and sacred nature of life and humanity is very essential for persons to be healthy. Sushrutha sutra says Only whose body, mind, self, senses, with her or his social relationships are intact, that we can call a person healthy.

KEY CONCEPTS IN SOCIOLOGY Several key concepts in sociology relate to its role in public health. Foremost is the emphasis on society rather than the individual. The individual is viewed as an actor within larger social processes. This distinguishes the field from psychology. The emphasis is on units of analysis at the collective level, such as the family, the group, the neighbourhood, the city, the organization, the state, and the world. Of key importance is how the social fabric, or social structure, is maintained, and how social processes, such as conflict and resolution, relate to the maintenance and change of social structures. A sociologist studies processes that create, maintain, and sustain a social system, such as a health care system in a particular country. The scientific component of this study would be the concern with the processes regulating and shaping the health care system. Sociology assumes that social structure and social processes are very complex. Therefore its methodology is appropriately complex and often, particularly in American sociology, dominated by multivariate statistical methods of

analysis. The advent of the computer in the second half of the twentieth century presented the field with the opportunity to work with very large bodies of data and complex variables.

SOCIAL DETERMINANTS OF HEALTH The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

Reducing Oral Health Disparities: A Focus on Social and Cultural Determinants

Reducing health disparities is a major goal for public and private health agencies, for health professionals and for the public at large. Oral health implies much more than healthy teeth. The mouth is both a cause and a reflection of individual and population health and well-being. Persistent and consequential oral health disparities exist within population, and reducing these oral health disparities is central to the overall goal of improving population health. What these disparities are, what causes them, and how to ameliorate and prevent them requires awareness, research, knowledge accumulation, and translation of this knowledge into action. Finally, reducing oral health disparities requires the will to act. Changes are needed in resource allocation, in social and public health policy, in community organization, in the provision of effective dental health care, and in professional and individual behaviour.

Processes and mechanisms that may be called "determinants" operate at all levels of our society. Determinants of oral health disparities represent a complex mix of the biological, the behavioural, the cultural, the social, the economic, and the political.

Towards a Conceptual Framework for Oral Health Disparities

Utilizing models from epidemiology and sociology, we identified a series of causal mechanisms through which institutional, political, community, and social interaction factors contribute differential impacts on individual oral health and overall quality of life. In "Influences on Health and Oral Health Disparities," we propose a comprehensive conceptual framework that encompasses oral health as a dynamic process in which a variety of forces operate both to perpetuate and to reduce social disparities in oral health. These forces are arrayed according to the approximate time sequence in producing oral health disparities distal/macro level factors (e.g., natural environment, macro-social factors, social inequalities, organizational practices, and delivery of oral health services); intermediate/community factors (e.g., environmental forces, social/cultural context, access/utilization of oral health care); immediate/interpersonal factors (e.g., negative stressors, social integration, infection transmission);

Proximal / individual factors (e.g., biological processes, personal oral health hygiene practices, psychological state).

At the bottom of the figure, the arrow indicates that the relative contribution of these determinants vary across the life course from birth to death. Underneath the column headings (for example, DISTAL/Macro), the boxes contain selected examples in italics (Natural fluoride in water) of different influences. These examples can be added to by readers and researchers to customize the figure to different influences and different disparities. This framework outlines the multiple and dynamic pathways through which underlying political, social, cultural, and economic forces influence oral health. Here is a brief description of each.

Distal/macro factors At this broadest level, disparities are produced and reproduced by political, economic, social, and cultural forces. For example, in the United States, national policies, legal frameworks, and social ideologies have created and perpetuated unequal distribution of wealth, spatial segregation, and concentrations of poverty. Vulnerable populations, including African Americans, Latinos and new immigrant groups experience limited access to opportunities (e.g., jobs with medical/dental insurance, which affect access to dental care). For our purposes, macro factors include the allocation of resources to organizations that

perpetuate preferential delivery of oral health education and technologies. Private dentists are more likely to practice in urban metropolitan areas with a high proportion of middle and higher income residents than in rural areas. In particular, two-thirds of dental shortage communities were rural with high percentages of minorities, children, and low-income persons. Dental insurance is often considered one of the primary links to maintaining oral health. Empirical studies have repeatedly documented lack of access to dental insurance as a factor for widespread dental caries in young children

Intermediate/community factors These factors include the physical, social, economic and cultural environment of a particular community. Decision makers wield power over services, such as transportation and health care, land use, and access to a healthy environment. At this level, public input can influence city and county councils, school boards, zoning committees, and medical boards. This level becomes important as citizens try to negotiate access to health care, education, transportation, jobs, and social services. In wealthy communities, individuals will likely have political and economic power to influence allocation of resources. Communities with fewer resources may experience greater social, environ-mental, and psychosocial stressors.

Immediate/interpersonal factors Immediate/interpersonal factors are the "mediating path-ways" within a community. Families, support groups, or other formal or informal networks may intervene to offset distal/macro or intermediate/community factors. For example, a group of parents may ask a school board to set aside a primary grade tooth brushing time after lunch. An environmental group might organize an annual beach clean-up. Influences can be harmful as well. For example, gang violence may cause a community to close a play-ground or a park. An antifluoridation lobby might work to halt fluoridation plans for a community's water supply.

Proximal/individual factors The focus at this level is the actions and beliefs of individuals who make up a community. Personality traits, motivations, values, and personal preferences come into play, along with health needs. Genetic-environmental interaction and organ function, use of community services, and individual psychology are considered. These individual factors influence all other levels. For example, an individual concerned about lack of affordable dental care might encourage neighbours (immediate/interpersonal), his/her city

(intermediate/community), and federal agencies (distal/macro) to lobby for local low-cost community dental care or water fluoridation. Any or all of these levels of social organization can influence dental health and dental care. At the proximal/individual level, a child may become infected with dental caries. Bacterial infection is necessary but not sufficient for developing dental cavities if proper care is available. The child may be deemed eligible for Medicaid (distal/ macro factor) and receive care at a local clinic (intermediate/community factor). Health conscious caregivers might schedule the child for regular check-ups (immediate/inter-personal factor), and parents might encourage daily tooth cleaning (proximal/individual factor). In summary, the emphasis of the framework is on the implications of broad social and economic disparities (macro/distal factors) for the social, environmental, and cultural contexts (intermediate/com-munity factors) that influence interpersonal relationships (immediate/interpersonal factors), and ultimately affect individual quality of oral health and oral-related quality of life (proximal/individual factors). The varying plausible pathways in the given frame-work (distal/macro, intermediate/community, immediate/interpersonal, and proximal/individual) may exert both unidirectional and bi-directional "push" and "pull" forces on oral health. That is, negative factors at one level may "push off" or "pull in" other levels of factors. Though the presentation may not capture all the interactions within and across varying levels of factors, it offers an explicit picture to illustrate the complex interlinkages among macro, meso, and micro phenomena that affect individual oral health.

Interventions at Each Level

Distal/Macro level Current inequalities in oral health (for example, differential access to oral health care and discriminative practices of the health care service providers) must be redressed at the distal/macro level if the society is to move toward equality in oral health care. Nationally, political parties and lobbying efforts dictate distribution of resources. Social groups with more resources are better equipped to negotiate and bargain for goods and services than social groups with fewer resources. Minorities or recent immigrants are less able to use their political rights to activate structural and political support to fight violent crime, ensure medical and dental services, and ensure human rights. Moreover, social groups with fewer resources may be less likely to question the unequal distribution of wealth and power, thereby increasing their vulnerability to discrimination and unequal treatment.

To combat disparities in oral health and other health and social disparities, we need a "structural readjustment" in the political process that allows all members, regardless of social status, equitable access to political power to achieve equal access. Oral health is intimately tied to national (distal/macro) policies. Policies that promote opportunities for the lower class may also reduce health risks and financial barriers to dental care. We cannot adjust for equitable access to dental care without addressing the political and economic processes that cause poverty and disparities in oral health. Financing for better education and installation of family wage policies are fundamental to improving opportunities for all. Programs that reduce discriminative practices and increase multicultural awareness are crucial to a stable economy in which all social groups may benefit. Discriminative practices that permeate the dental setting will require effort from medical and dental associations in order to bring forth effective measures. For example: Eliminate discriminative practices of dental professionals: Dentistry literature has consistently indicated negative attitudes towards poor people. Oral health intervention efforts must address this cultural gap by improving dentists' awareness of minority cultural values and practices. Multicultural studies could be incorporated into the dental school curriculum and students could begin to work with skilled medical interpreters before graduation.

Improve financing for Medicaid patients and dentists One of the most important causes of under-use of Medic-aid has been its rejection by dentists because of low fees and inefficient reimbursement systems. Yet, often the professional associations themselves have failed to place better funding for Medicaid at the top of their political agendas instead claiming their political action commit-tees are impotent to change state-based policies. The net result is that low-income patients, even with Medicaid, are unable to find dental care. These structural barriers can be reduced by increasing Medicaid reimbursement fees, improving the efficiency of payment schedules, expanding the types of dental treatment options, and encouraging dentists to participate in Medicaid programs. The will to find the opportunity for these structural changes is required.

Expand Public Health programs Public health programs are an important vehicle for improving oral health among the poor. These may include expanding fluoridation programs in poor neighbourhoods and expanding the use of dental health care teams. Fluoridation benefits everyone who drinks from the water supply irrespective of their own resources or behaviour, which means that socioeconomic gradients in oral disease are blocked and everyone benefits equally. In New

Zealand and many other countries, dental therapists have been trained to provide comprehensive primary care to school children. These therapists provide a full range of care for children in school-based clinics. The bottom line for reducing oral health disparities through dental care is likely to be no different from the challenge for health disparities in general.

Intermediate/Community Level At the intermediate/community level, health insurance is generally delivered as part of employment benefits. However, many low wage earners are unable to receive dental or medical insurance due to low number of work hours. The distribution of health care is intimately tied to the distribution of employment opportunities. In the public sec-tor, employment decisions are based on bureaucratic procedures that account only for applicants' skills and qualifications, irrespective of gender and race. However, in the private sector, hiring practices may include reliance on lay referral systems, such as internal networks. Discriminative practices may include use of referral systems that exclude members of certain social groups based on stereotypes. To reduce oral health disparities at the intermediate/community level, we need to first examine the differences in hiring practices and evaluate how these processes may be altered.

Alternative delivery systems The current oral health delivery system is bifurcated. Patients with medical and dental insurance seek treatment at private clinics; patients with Medicaid attend public health clinics. (Most are turned away from private dental offices.) To adjust the bifurcated system to a more dynamic system, dentistry must allow for alternative delivery systems, such as retail dentistry, mobile dentistry, independent practice of dentist hygienists, and deployment of dental therapists.

Expand current systems Access to dental care for the poor can also be in increased by expanding the number of public dental clinics and primary care programs in the community. At community dental clinics or community dental homes, children and low-income parents can request and receive information and education about the importance of oral health, which in turn can help instil good oral health hygiene habits. Furthermore, community health clinics are staffed by local community members, who are equipped to understand and comprehend distinct cultural

practices in the community and to aid in reducing the cultural gap between dentists and patients. In ethnic enclave community clinics, new immigrants may also rely on translators for help in communicating with dentists and other health care professionals.

Community collaboration and mobilization Community-organized efforts are intimately tied to how resources are allocated in society. Citizens can influence zoning policies and can tap into resources to build good schools, recreational facilities, parks, and community centres. That is, community-organized efforts can "push back" forces that contribute to unequal access and subsequently induce change at the proximal/individual level. For example, a community may demand changes to zoning policies in order to promote financial investments such as a business district, supermarkets, and banks. Access to a healthy neighbourhood can decrease residents' personal stress levels by providing such amenities as fresh produce, safety, and good schools. Community efforts can begin to improve oral health via coordination with already existing school and community programs, such as Parent Teacher Student Associations and local community centres. Promotional and prevention efforts may be incorporated into school curricula, concentrating on good oral hygiene via school- and community based programs. These programs can improve social integration and encourage parents, teachers, nurses, and community leaders to facilitate, educate, and share health information. Community information campaigns that stress health literacy can bring attention to the problems of untreated tooth decay among the poor. Low-income wage earners, who lack access to dental insurance, need to receive information regarding the benefits of Medicaid and of attending to their health care needs. Patients from disadvantaged social groups often want to have information regarding their health status. They often need to know how to recognize signs of tooth decay in young children. This important oral health information may come from community health care professionals who already have a close relationship with local residents, and who may also be able to eliminate language barriers. In areas that lack community health care professionals, new programs must be developed to address the problem of lack of access to oral health information.

Proximal/Individual Level Health disparity interventions at the proximal/individual level, when carefully applied, can reduce stressors and oral health disparities. Individual intervention efforts may include the following: Learning to practice oral health hygiene to help fight bacteria and maintain good oral health. Visiting dental offices or dental clinics and then transfer-ring newly-learned knowledge to family and friends. Introducing fresh produce and nutritional supplements into the family diet and limiting sugar intake. Action at All Levels The underlying themes for interventions at all levels are financial support, structural change, conscious effort, and education. All involve conscious effort. That is, successful interventions and policy efforts must incorporate a 'fundamental social cause approach' with contextually population based health interventions that automatically benefit everyone, irrespective of their socio-economic status, resources, or behaviours. In the United States, interventions must be organized and prioritize to people at all socioeconomic levels, with a specific target to address the special needs of resource poor groups who may face obstacles and barriers in implementing health interventions. Hence, we need to promote policies that promote the elucidation and elimination of SES gradient across population groups via increases of the socioeconomic resources available to resource poor groups. The following recommendations recommend action at all levels:

Financial support Dentistry needs financial resources to expand delivery services, improve Medicaid reimbursement, increase education, and reduce poverty at the societal level. These interventions all require efforts by federal and state governments to launch new social policies and allocate funds to reduce social disparities (which contribute to oral health disparities).

Structural changes Only when structural problems, such as the political process in which social groups coordinate efforts with interest and lobbying groups, are fundamentally altered, can poverty be mitigated. It is unlikely that such structural readjustment will be realized in the near future.

Interventions may yet develop to improve the Medicaid insurance program. Expansion of dental health facilities and Medicaid insurance for vulnerable populations, are important components of oral health. Patients from disadvantaged back-grounds may need to be able to find dentists willing to accept Medicaid insurance and treat their dental disease. Children living in poverty are likely to have limited access to dental care. Educational programs designed to increase the skills of dentists to effectively treat children are needed.

New Technologies Dental professionals are important agents who directly influence the prevalence of dental caries. They are also the crucial link between newly invented technology and its distribution to patients who need it. New technologies such as fluoride varnish and xylitol toothpaste are low-cost, effective preventive agents against dental caries. Yet, despite their documented effectiveness, they remain underused in clinical practice. In a recent study among general dentists on the use of fluoride varnish in adults, only 44 % were found to use fluoride varnish regularly on their adult patients. Many dentists cited the lack of awareness, lack of convincing evidence of favourable benefit to cost, patients' lack of knowledge regarding fluoride varnish, and lack of acceptance among patients as reasons for the low rate of use. Clearly, evidence supports expansion of the dentist's role to include educating patients and disseminating proven and effective technologies for preventing dental caries.

Turning resistance into cooperation Efforts to address social disparities in children's oral care must anticipate resistance from political interest groups, the private sector, and organized medical professional societies. For example, distribution of fluoride varnish and xylitol gum or candies by school nurses may be opposed by professional societies as interfering with the rights of dental professionals, who currently are the only legal recourse for treatment of dental caries. Meanwhile, local communities, concerned medical professionals, non-profit social policy groups, and individuals may organize to combat the opposition by increasing awareness of oral health in society. By involving themselves in distribution of societal and political resources, including community planning, school curricula and improved access to health care, concerned individuals and dental professionals will have a chance to carefully elucidate and effectively eliminate underlying factors that cause and drive social disparities in oral health.

SOCIOLOGY IN PUBLIC HEALTH Public health has been and remains a very applied field. It is also characterized by a population-based approach to health, and statistical methods are deemed the appropriate underlying method for the field. It is viewed as a science that seeks to intervene, control, and prevent large-scale processes that negatively affect the public's health. By these criteria, there is a strong logical fit of sociological principles and practices within public health. Nonetheless, sociology has not been the key social science discipline in public health. That position has gone to psychology, where the emphasis on individual behaviour resonates more with a biomedical model. Despite this, many of the primary concerns of present-day public health, with large-scale variables such as social capital, social inequality, social status, and health care organization and financing, remain topics best suited to the sociological perspective and methodology. The emphasis in public health is thus shifting toward a sociological perspective. MEDICAL SOCIOLOGY Earlier social theorists, such as those noted above, did write on subjects of concern to medicine, health, and illness, but medical sociology, as a sub discipline of sociology, developed in the post-World War II period. Early debates in medical sociology were concerned with the role of sociology as it relates to medicine: Should the field be critical and analytical, concerning itself with the sociology of medicine (i.e., examining how medicine works); or should it be largely applied, focusing on sociology as a handmaiden for medicine? Like many such formative debates, there could be no conclusive answer. However, the field has developed into two groups: those (largely within academic settings) which focus on the sociology of medicine; and those (primarily in schools of public health and governmental institutions) which focus on the application of sociology to medicine. Later debates related to whether the focus should be on health sociology or medical sociology. This debate has moved the field to a broader, more ecological, view of medicine and health. SOCIOLOGICAL CONCEPTS IN PUBLIC HEALTH Sociology in public health is reflected in the myriad of sociological concepts that pervade the practice of public health. More than any other social science, sociology has the discussion of socioeconomic status at its very core. Social-class variation within society is the key explanatory variable in sociologyfor everything from variation in social structure to differential life experiences of health and illness. Indeed, there appears to be overwhelming

evidence that Western industrialized societies that have little variation in social class experience have far better health outcomes than societies characterized by wide social-class dispersion. In short, inequalities in health are directly related to social and economic inequalities. Much of later-twentieth-century public health is devoted to the reduction of these inequalities. SOCIOLOGICAL METHODS IN PUBLIC HEALTH Methodological concerns are critical to sociological research. The great debate in sociology has been on the relative merits and role of quantitative versus qualitative approaches. Both approaches are widely used and play a critical role for public health. Sociology has long recognized that the social world comprises both an objective and a subjective reality. For example, the objective reality of having cancer is accompanied by the subjective reality of the experience of cancer by the patient, and the patient's family and friends. Both realities are relevant to the sociological approach. The subjective, qualitative approach is generally discussed in the theory and methods concerned with illness behavior, but qualitative approaches are equally applicable to the understanding of social policy, world systems, and areas of sociology where statistical measurement is difficult or less relevant. Within public health, surveillance is seen as a key approach to describing the distribution and dynamics of disease. In sociological approaches to public health, the role of social and behavioural factors in health and illness is central. Survey methodology has occupied a central place in sociological research since the middle of the twentieth century. The concern has been with the collection, management, analysis, interpretation, and use of large quantities of data obtained by direct interview with respondents. Social surveys are characterized by large random samples, complicated questionnaires, and the use of multivariate statistics for analysis. By their very nature, most sociological variables are complex to measure and to analyse. For example, the assessment of socioeconomic status of an individual requires the accurate measurement of several variables that sit within a larger social context. Socioeconomic status (SES) is regarded as a product of several components, including income, residence, education, and occupation. Determining the relative weight of each of these components is a major analytical problem. Thus, when considering the role of socioeconomic status on health care outcomes, there is no easy answer to what mechanism actually works to determine the observed relationship between SES and health.

SOCIOLOGY AND EVALUATION IN PUBLIC HEALTH Because many sociological variables are at the so called macro level, there is limited opportunity to intervene rapidly, directly, or simply. For example, the SES of a group is affected by complex components, such as education and occupation, that are part of the total life course of individuals within the group. Thus, to change the SES of a group would require significant redistribution of resources of the larger social structure. A significant period of time and concerted effort is needed to change such macro variables. This is, however, not dissimilar to many other challenges in public health, such as the long-term and timeconsuming effort to change lifestyles and reduce behavioural risk factors related to chronic diseases. The chief role of sociology in public health remains its evaluation of those macro components of society that affect public health at the population level. Such evaluations provide an understanding of why inequalities in health exist, and they help elaborate upon the mechanisms and processes that sustain these inequalities. This relates to the long-standing theoretical concern with social structure among sociologists. Further, sociology reveals the mechanisms for long-term changes that may lead to a reduction in health inequalities. The product of sociological thinking in public health is not immediate or easily understood by those who seek quick and easy solutions to the suffering of humanity. Nonetheless, the longterm role of sociology in public health is to change and improve the public health.

Epidemiology of oral health worldwide Oral health means being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity. The sequelae of poor oral health affect the individual and the state. People compromised by poor oral health have a reduced quality of life. The Federation Dentaire Internationale (FDI) cites budget limitations, lack of infrastructure, resources and knowledge, lack of capacity, different priorities or even unwillingness to act, as the key elements preventing global improvements in oral health. Lack of funding as well as overt poverty strongly influences peoples access to oral healthcare although factors other than funding are influential: age, frequency of visiting when dental care is available and dental status is predictors of oral health perceptions. Access is still a major determinant when comparisons are made between urban and rural populations. In the USA, children living in poverty, or whose parents had little formal education, were at greater risk of disability. Education provides knowledge and skills that a person needs to better their life and play a role in building a peaceful and equitable society. SubSaharan Africa is characterized by massive educational deprivation. In the developed world, dental schools have traditionally attracted students from socio-economically advantaged groups within the population.

Oral healthcare delivery

In 1981, in Pursuit of Health for All by the Year 2000, the WHO stated that All people in all countries should have at least such a level of health that they are capable of working productively and of participating actively in the social life of the community in which they live . As part of this, the primary healthcare approach, based as it is on accessibility, affordability, acceptability, appropriateness and availability, should allow for the equitable distribution of services and would provide a basis for oral healthcare that is appropriate, i.e. with community involvement. However, for disadvantaged groups, there are more barriers than prospects: Lack of government engagement and unhelpful legislation in relation to disadvantage. Poor healthcare education. Symptomatic consultations.

 Inequitable distribution of healthcare workers. Cultural barriers. Lack of professional commitment to excluded groups. Lack of under- and postgraduate education in the field of special care to motivate young colleagues to make a commitment to this field of dentistry. Uneconomic patients, from the dentists perspective.

Economic inaccessibility, from the patients perspective.

Recommendations

Promotion of equitable access to education and healthcare is the responsibility of the whole profession: the school philosophy should encompass a community-based approach to its education and healthcare delivery.

Regular collection of epidemiological data, including attitudinal and behavioral data, to design and deliver culturally competent and appropriate services (community development approach), is vital. The skills mix of the oral health team should be responsive to the disease prevalence and the needs of the population.

The oral healthcare team should be preventively orientated in terms of care delivery and integrated with the primary healthcare team. More advanced care can be offered when resources permit.

The incorporation into undergraduate education, including all those members of the team delivering oral healthcare, of exposure to, and teaching on, disadvantaged populations serves to foster a more inclusive attitude in dental graduates. Dental students should provide care for patients from all segments of society, especially those with a disability.

Dental students should be drawn from all segments of society irrespective of economics, race, disability, gender or ethnicity; financial resources should be available to make this possible. Intra and inter-governmental policies and incentives should encourage students to return to their home communities.

Academic staff should include those from minority populations to act as role models. All faculty members need to be encouraged to act as mentors and support students from disadvantaged backgrounds.

To prepare adequately the workforce to deliver care to disadvantaged populations, dental undergraduate programmes should have in depth educational components in dental public health as well as a significant clinical outreach experience.

Governments need to provide legislation and with non-governmental organizations and the private / corporate sector, facilitate access to education, together they should provide the finance, for the necessary service infrastructure to deliver care to those with greatest need.

There needs to be encouragement of research and development strategies that devise appropriate technologies, which reflect the needs of all populations and not just those who are economically advantaged.

THEORIES IN SOCIOLOGY
Sociologists develop theories to explain social phenomena. A theory is a proposed relationship between two or more concepts. In other words, a theory is explanation for why a phenomenon occurs. Sociological theory is developed at multiple levels, ranging from grand theory to highly contextualized and specific micro-range theories. Some of the more wellknown and most commonly used grand and middle-range theories in sociology applicable in general and dental health is discussed below.

Structural-Functionalism
Structural-Functionalism is a sociological theory that originally attempted to explain social Institutions as collective means to meet individual biological needs (originally just functionalism). Later it came to focus on the ways social institutions meet social needs (structural-functionalism). Structural-functionalism draws its inspiration primarily from the ideas of Emile Durkheim. Durkheim was concerned with the question of how societies maintain internal stability and survive over time. He sought to explain social cohesion and stability through the concept of solidarity. In more "primitive" societies it was mechanical solidarity, everyone performing similar tasks that held society together. Durkheim proposed that such societies tend to be segmentary, being composed of equivalent parts that are held together by shared values, common symbols, or systems of exchanges. In modern, complex societies members perform very different tasks, resulting in a strong interdependence between individuals. Based on the metaphor of an organism in which many parts function together to sustain the whole, Durkheim argued that modern complex societies are held together by organic solidarity (think interdependent organs). The central concern of structural-functionalism is a continuation of the Durkheimian task of explaining the apparent stability and internal cohesion of societies that are necessary to ensure their continued existence over time. The parts of a society are organized into an integrated whole. Consequently change in one part of the society (e.g. economy) leads to changes in other parts (e.g. family, health care system). Consensus on the value of health and oral health, goal setting and priorities. And organization of work by health professionals and health workers provides for cooperation and

ultimately for improved oral health of the population.

Conflict theory
Conflict theory argues that society is not best understood as a complex system striving for equilibrium but rather as a competition. Society is made up of individuals competing for limited resources (e.g., money, leisure, sexual partners, etc.). Broader social structures and organizations (e.g. Religions, government, etc.) reflect the competition for resources in their inherent inequalities; some people and organizations have more resources (i.e., power and influence) and use those resources to maintain their positions of power in society. The structural-functionalist approach argued that society tends toward equilibrium, focusing on stability at the expense of social change. This is contrasted with the conflict approach, which argues that society is constantly in conflict over resources. One of the primary contributions conflict theory presents over the structural-functional approach is that it is ideally suited for explaining social change, a significant problem in the structuralfunctional approach. The following are three primary assumptions of modern conflict theory: Competition over scarce resources is at the heart of all social relationships. Competition rather than consensus is characteristic of human relationships. Inequalities in power and reward are built into all social structures. Individuals and groups that benefit from any particular structure strive to see it maintained. Change occurs as a result of conflict between competing interests rather than through adaptation. Change is often abrupt and revolutionary rather than evolutionary. Conflict theorists focus on the inevitable disagreements among people in groups, and individuals and groups compete (conflict) with one another as they attempt to preserve and promote their own special values and interests. Such conflicts also are often seen among health professionals or between health professionals and health politicians or administrators.

Symbolic Interactionism
Symbolic Interactionism is a theoretical approach to understanding the relationship between humans and society. The basic notion of symbolic interactionism is that human action and interaction are understandable only through the exchange of meaningful communication or symbols. In this approach, humans are portrayed as acting as opposed to

being acted upon. The main principles of symbolic interactionism are: 1. Human beings act toward things on the basis of the meanings that things have for them 2. These meanings arise of out of social interaction 3. Social action results from a fitting together of individual lines of action Interactionism attempts to understand social life from the viewpoint of the individuals involved. Accordingly, groups can only exist because their members influence one anothers behaviour. Three basic assumptions are outlined. I) II) III) We act according to our interpretation of the reality. Subjective interpretations are based on the meanings we learn from others and We are constantly interpreting our own behaviour as well as the behaviour of others in terms of the symbols and meanings we have learned.

ORAL HEALTH AND POVERTY

The WHO report of 2003 underscored the fact that changing chronic disease patterns are closely related to socio environmental determinants and changing lifestyles. Oral diseases are part and parcel of this common risk factor representation but, on the other hand, also are related to the protective capacities of exposure to fluoride and ample oral hygiene. The greatest burden of oral diseases is on disadvantaged countries and socially marginalized communities within countries.

Dental Caries: Dental caries is related to lifestyle and self controlled behavioural factors, including poor oral hygiene, poor diet and inappropriate feeding habits for infants. Other factors that increase dental caries are poverty, deprivation, education. WHO report 2003 claims that the prevalence of dental caries was more in many Asian and Latin American countries. Also caries is low in developing regions in Africa and south East Asia. As societies and countries develop and adopt an urbanized, industrialized and westernized culture, sugar consumption increases with increase in dental caries.

Periodontal disease: Periodontal disease is strongly associated with oral hygiene practices and habits like smoking. Developing countries with poor access to oral hygiene aids have prevalence of periodontal disease that is found to be higher than the developed countries. Periodontal disease is found to be high in smokers in developing countries compared to the developed countries due to limited access to oral health care.

Oral Cancer: Oral cancer is more prevalent in developing countries compared to developed countries owing to the fact that tobacco usage especially spit tobacco usage was found to be higher in these countries. In Southeast Asia, oral cancer ranks as one of the three more prevalent types of cancer, oral cancer incidence levels among developing countries is generally twice as high as in developed countries.

Tooth loss: Prevalence of tooth loss was twice more higher in people under poverty line than those above poverty line.

CONTENTS

INTRODUCTION CONCEPTS IN SOCIOLOGY THEORIES IN SOCIOLOGY SOCIAL ORGANIZATION HOSPITAL SOCIOLOGY SOCIOLOGY IN PUBLIC HEALTH SOCIOLOGY AND ORAL HEALTH o ORAL HEALTH AND POVERTY o SOCIAL SRATIFICATION AND ORAL HEALTH o SOCIAL IMPACTS OF ORAL CONDITIONS AND TRATMENT o REDUCING ORAL HEALTH DISPRITIES: A FOCUS ON SOCIAL AND CULTURAL DETERMINANTS

CONCLUSION REFERENCES

Conclusion Besides biological factors Oral Health status is influenced by various factors like Culture, Socio economic factors, psychological factors of the patient etc.,. There exist disparities which are due to the above mentioned social factors. Dentists around the world should not only treat patients on biological context rather they should understand the sociological factors that contribute to the oral health status of the patient and treat them.