We all know that toothache can often involve unbearable pain for the sufferer. From Shakespeare to Shaw writers have remarked on how the agony of dental pain can lead to total distraction from all else. Robert Burns even wrote an ‘Address to the Toothache’, in which he demonises and curses the affliction. At a time when thousands of people still struggle to access NHS dentists it would seem that prevention rather than cure is the best strategy. Official advice on avoiding toothache recommends that we brush our teeth at least twice a day using toothpaste that contains fluoride. Most of us stick to this advice and go through this daily ritual with little self-awareness. While tooth brushing may be mundane it is also a curious activity that straddles the boundary between health and cosmetic maintenance. It is also big business, with UK sales alone totalling over £1 billion – a market that blurs the line between marketing, advertising, health education and public health. The scale of these profits suggest we should pay greater scrutiny to the worth and value of these dental technologies.
Supermarkets and pharmacies carry an ever growing array of toothpastes, tooth-gels, mouthwashes, flosses and dental brushing devices. Between 1961 and 1998 over 3000 patents were filed for toothbrush designs. This growth in dental products has occurred alongside significant shifts in understanding of oral health over the last two decades. A far greater proportion of children become adults with healthy teeth than have ever done before. There has been a move away from dentists repairing damage towards preventative self-management of dental disease through the application of technologies in the home. In an extension of new markets many of these technologies, such as tooth whitening kits, are more concerned with cosmetic appearance than any purported health gain.
Such cosmetic effects are not trivial; in a culture where ‘good teeth’ have become a symbol of middle class adequacy ‘rotten’ and uneven teeth have become a marker of low status. Taking care of ones teeth is an activity where it is difficult to separate ‘health’ from ‘consumer culture’. Like many other health behaviours today consumers are facing ever more complex decisions and have to draw on an increasing array of information in order to make choices about what and how to consume. This is not only to prevent disease, but also to display valued social identities. Dental professionals spend an increasing proportion of their time on cosmetic procedures rather than fixing rotten teeth. Indeed in a strange reversal, there is now a move, in Japan and America, away from a ‘too perfect’ set of straight, ‘picket fence’ teeth towards orthodontics being used to actually introduce gaps and crooked teeth into mouths.
The increasing commodification of the toothbrush means that when buying something as simple as a brush to put in the mouth, consumers are confronted with a bewildering range of brands, textures and sizes. All this before they even have to consider different brushing techniques. And the mouth, maintained on a daily basis by the toothbrush, itself has a peculiarly symbolic position in our culture. The mouth is the space through which things pass both into and out of bodies. It is the boundary between the self and society. As such it is surrounded by a whole series of conventions and taboos concerning what we will and will not allow to enter it. How many of us are comfortable sharing a toothbrush?
A relatively recent addition to the technologies available for oral care is the electric toothbrush. Of course the electric toothbrush has been around for decades but early innovations were bulky, inefficient and unreliable with few people using them. They are now in widespread use and there is an increasing availability of the electric toothbrush in supermarkets and pharmacies.
Our own qualitative research found that whilst the uptake and use of the electric toothbrush (ETB) was relatively common, the ETB presented users with a number of problems. Some thought that the ETB was unnecessary ‘over kill’ – a solution in search of a problem. But others, often after a negative encounter with a dental professional, were keen to adopt or at least try an ETB, as a means of ensuring reduced contact with dentists (i.e. as a technique of dental self-management). But even after deciding to acquire an ETB the purchase itself was not simple and was compared to the confusion of buying a mobile phone.
Once people started using the ETB problems continued with many complained that the technology was not suited to the British home. Many houses do not have electrical outlets in the bathroom and yet this is where people brush their teeth. Most felt uncomfortable brushing their teeth elsewhere in the house. This meant that ETBs frequently ran out of power and were then abandoned. The ETB also often caused mild domestic conflicts. This happened in two ways: where a base unit was shared users became disgusted when other users failed to clean up the debris and gunk; or where the device had a built in timer there were often disputes between parents and children over the length of time spent brushing. There was also a generalised feeling that the ETB user was in some way more ridiculous than a manual toothbrush user: few were prepared to use in front of others, even when in their own home. In short, the ETB appeared to be an ‘unstable’ object in the home.
The ETB is now widely used in many households and there is often a feeling, (sometimes as a result of negative encounters with dental professionals) that they are superior for oral health care. However, our research has shown that there is nothing inevitable about this process and the ETB often becomes an ‘unstable’ object within the domestic environment. Be this as it may, most people had at some point bought an electric toothbrush and attempted to incorporate the device into their routines. Indeed many people had attempted this more than once so perhaps the instability of ETB is not so important when we are all willing to continue buying them. As a domestic health technology that blurs the boundary between public health, marketing and consumption it is no wonder the market for oral health care is growing so rapidly.
A more extended version of this post appears as a paper in Social Theory and Health
About the Authors: Judy Green is based at the London School of Hygiene and Tropical Medicine and has researched and published on methodology, risk and the sociology of health. Nicki Thorogood is based at the London School of Hygiene and Tropical Medicine and has research interests in the sociology of health promotion and of mental health.