Reframing Oral Health

Oral health is inextricably linked to overall health.

Unfortunately, the public does not understand this relationship; most people don’t understand how the mouth affects physical and mental health, or vice versa. Researchers found that, without prompting, Americans are unlikely to include oral health issues in their thinking about overall health. When researchers did introduce the topic, the public evinced a limited or narrow understanding of the connection between the mouth, the body, and the mind.

For this reason, FrameWorks urges advocates to emphasize the connection between oral and overall health. Messages like these cannot be repeated enough:

“Oral health and overall health are linked. When the body is healthy, the mouth is more likely to be healthy, too. And vice versa.”

“Healthier mouths mean healthier people. And healthier people mean stronger communities.”

“Oral health affects overall health. When we take care of our mouths, we’re taking care of our bodies, too.”

Avoid frames that narrow the scope of the issue to the teeth.

The good news: Oral health experts and advocates are emphasizing this theme in their messaging. A systematic review of advocacy materials revealed that organizational language consistently explains how problems in oral health relate to other health issues beyond the mouth, including behavioral and mental health issues. When the scope of this issue is narrowed to teeth, the potential for substantive reform also narrows.

However, while the field is saying one thing—the right thing—many organizations are showing another. Visuals are the one place where the field’s framing narrows the scope of oral health to teeth. These visual messages contradict—and undermine—the written and oral messages advocates make when communicating about this issue. Advocates should avoid language and images that narrow the scope of oral health to the teeth and select graphics/images that “widen the lens” and suggest a systemic perspective.

In other words: Beware the anthropomorphized cuspid. Watch out for the ubiquitous cartoon tooth with a toothbrush in one hand and a thumbs-up in the other. And remember: The image that telegraphs the topic easily or efficiently is not always, from a reframing perspective, the most effective. Be sure to support written communications with matching visual examples that help people understand the two-way connection between oral health and overall health.

As framing devices, values help people understand why an issue matters and whether it is of private or public concern.

Appealing to values in communications materials can have a measurable effect on people’s attitudes and policy preferences. They can deepen understanding of social issues and boost support for solutions to them.

Over the last two decades, FrameWorks has found that it’s impossible to guess which value or values will have a positive effect—and which will backfire. For this reason, FrameWorks researches the effects of values on attitudes about social issues and support for solutions. These findings inform decisions about which values work in service of advocates’ goals to help the public better understand oral health and reach decisions (as to what solutions are feasible and who is responsible for them) that align with experts.

Through a rigorous empirical process, FrameWorks found that the value of Targeted Justice is best able to build public agreement that society has a collective responsibility to address oral health inequities. (Read the research findings here). This value defines a just oral health care system as one that recognizes and accommodates different groups’ specific needs. It was more effective at building support than the value of Opportunity for All—the idea that a just system is one in which all people have the same basic conditions and services that support oral health. This sample text shows how to use Targeted Justice when communicating about disparities in access to oral health care:

When it comes to oral health, different people have different needs. Some people can make dental appointments during the weekday, but others can only go on nights or weekends. Some people can hop in the car and drive to the local clinic, while others rely on buses and trains to get to faraway offices. Some people know their dentist speaks their language, but others can’t make that assumption. A one-size-fits-all approach to oral health may sound like a good way to support equal access to oral health care—but it doesn’t work in practice. We need to make sure all people have the supports they need to access oral health care.

Avoid unframed data about oral health disparities.

When communicating about oral health inequities, it’s important to ensure your data are interpreted correctly. This is particularly true on issues relating to race and socioeconomic status. For example, stark statistics about regional or racial disparities can be taken as evidence of bad decisions, rather than systemic or societal barriers to care.

When oral health advocates highlight the economic consequences of our nation’s inadequate approach to prevention and care, they often frame their argument around workforce participation.

They point out that, because of the stigma attached to oral health problems, employers are less likely to hire people with visible dental decay. As a result, people with untreated oral health problems lose income and earning potential.

Sometimes advocates make a different economic case framed around the increased costs that result from the lack of access to affordable care. When making this argument, they highlight how the current system creates incentives for people to defer treatment, which leads to more serious problems that are ultimately more expensive to treat. Society bears the brunt of these avoidable costs in the form of higher spending on health care services.

Both make economic arguments, but which is more effective? To explore this question, FrameWorks researchers tested these frames head-to-head in a controlled experiment. The results show that it is more effective to frame the economic case around the value of Responsible Management, which explains how prevention programs reduce costs. (Read the full experiment). This text models how to do that.

We can reduce the cost of oral health by stopping problems before they start. Prevention programs help people avoid serious problems like gum disease that are expensive to treat. And they help people catch potentially serious problems like cancer before they progress. We need to use our resources wisely. We need to make sure that all communities have strong prevention programs in place so we can reduce the cost of health care and avoid unnecessary expenses.

Avoid leaving prevention undefined, undescribed, or individualized.

FrameWorks’ analysis of organizational communications found that advocates often assert the importance of prevention but do not explain how it works. This is unproductive.

People are more likely to assume that preventing oral health problems is equivalent to keeping one’s own teeth clean through self-care and periodic deep cleans from a professional. In fact, few Americans are aware that prevention in any other form even exists. From this perspective, it’s difficult to appreciate the role that public health efforts play in promoting oral health across society.

To build support for preventive approaches, oral health advocates should avoid appeals to prevention that lack explanations from a public health perspective. Communicators should also avoid reinforcing individualized understandings of prevention, such as brushing, flossing, and visiting the dentist. Instead, they should devote more communications space to descriptions of community- and policy-based prevention strategies. Advocates might, for example, describe how providing adult Medicaid recipients with dental benefits will prevent oral health problems across society and reduce the cost of care. Or they might point to a school program that brings dentists in to screen children for signs of decay.

Explanatory metaphors compare abstract or unfamiliar ideas to objects and processes that are concrete and familiar.

In so doing, they make information easier to understand. They help people think and talk about a complex concept in new ways—and often change the way ideas are understood.

FrameWorks designed the Keys to Oral Health metaphor to bring systemic barriers to the forefront of public thinking while also leading people to see that public solutions are reasonable and feasible. Read the experiment to see how this metaphor helps people think about the systemic and environmental influences on oral health. FrameWorks found that it shifts perspectives away from the idea that oral health is a purely individual pursuit and toward the social, economic, and political factors that shape oral health in America. This text models how to use it:

Accessing good oral health is like going through a series of locked doors. These doors open up to things like fluoridated water and nutritious food, insurance that covers dental benefits, and dentists who accept different kinds of health insurance. Some people have all the keys they need to unlock the doors to oral health, but others are missing some keys. Without a full set of keys, people won’t be able to get to good oral health—no matter how hard they try. When people have the keys they need to access good oral health, our communities are stronger.

Avoid zooming in on individual cases to illustrate systemic problems.

Advocates across social issues tell stories about individuals to build public awareness about social issues, deepen understanding of social problems, and drive social change. The oral health field is no exception. Advocates for oral health often highlight poignant cases like Deamonte Driver and Kyle Willis, both of whom experienced fatal brain infections caused by untreated tooth decay.

Advocates tell these stories to illustrate the potentially serious consequences of untreated oral health problems. Stories like these certainly garner attention, but do they also result in gains for policy reform? Some social science research suggests the answer is “no.” This research finds that stories that zoom in on individuals lead people to attribute responsibility for the problem and its solutions to the individuals themselves—not to society. On the other hand, other bodies of research point to the power of stories as memorable, compelling, and relatable, which reinforces that communicators need to ensure that their stories are doing everything that they can do to advance public understanding.

Advocates should look for opportunities to use language and images that help Americans visualize the different places where oral health care services are provided (e.g., primary care facilities, mobile care units, schools, etc.). Doing so will help move public thinking beyond the problematic belief that Dentists Are the System—the idea that the oral health care system comprises dentists and hygienists alone. One of the main problems with this way of thinking is that other important allies and actors in the system, such as primary care providers, insurance agents, school nurses, researchers, and advocates, are invisible.

Fortunately, the fix here is straightforward. Boosting public support for oral health policy reforms can be as simple as explicitly and consistently naming the many actors who are, or could be, part of an effective approach to oral health. These messages should involve people working in locations other than stand-alone dental practices, as they also give concrete examples of a variety of providers. This fairly simple framing tactic to expand thinking about the who and where of oral health care delivery systems is an important way to broaden public thinking about the efficacy and possibility for change. This text models how to accomplish this goal.

Lots of different people play a role in our oral health care system. School nurses and pediatricians are important team-players. And public health officials who monitor trends and information, like the number of dentists in a city or town, are important team-members, too. These professionals, along with dentists, hygienists, and others, work together so we all have access to good oral health.

Avoid leaving the solutions to the public’s imagination.

When people hear about social problems but don’t get information about solutions, it is difficult to build will for a collective response. People assume either that the problem is too big to solve or that it’s up to the people experiencing the problem to figure out the solution for themselves. To avoid these fatalistic ways of thinking, don’t leave solutions to the public’s imagination.

The oral health field has clearly already learned this important framing lesson. FrameWorks’ analysis of media and advocacy frames found that while news coverage rarely mentioned solutions, advocates almost always did. Indeed, discussions of solutions to oral health were present in almost 95 percent of advocacy materials in the sample.

However, advocates can deliver more effective solutions statements by including calls to action or clear statements about what should be done to address inequities at a systems or population-level. Remember that the public will likely think that the only solution to oral health problems is for individuals to do Three Simple Things: brush, floss, and visit the dentist. To broaden this understanding of solutions, communicators should use cues that focus on systems-level preventive actions and policies and at the same time, avoid language that might be interpreted as attributing responsibility to individuals for causing and addressing oral health issues.