The Great British Smile: An institutional ethnography of power in cosmetic dentistry A thesis submitted in partial fulfilment of the requirement of the Degree of Doctor of Philosophy Rizwana Lala Academic Unit of Oral Health, Dentistry and Society School of Clinical Dentistry, The University of Sheffield May 2020 “Care about words” Imran Lala ii Abstract Background: Despite the expanding provision of cosmetic dentistry in the UK, there has been little critical research in this area. Aim: To describe the influence of dominant social norms in the provision of cosmetic dentistry in the UK. Method: Institutional ethnography (IE) was used to map the social relations in cosmetic dentistry. A multi-site qualitative method, IE explores beyond the boundaries of observed local activities; therefore, the social relations included actors’ activities and institutional texts. Data collection methods included participant observation at exclusive dental practices and events; contextual, in-depth, and diary interviews; and documentary analysis. Actors’ cosmetic dentistry activities were mapped schematically in relation to institutional texts to display how UK cosmetic dentistry is organised in terms of social relations. Attention was paid to discourses found within these social relations. The emergent forms of power in the mapped organisation were analysed by reference to Lukes’ (2005) theory. Results: The dominant institutional discourses found in the social relations were crime (beauticians undertaking teeth whitening), dentists’ professional standards and training, and safety. It was found that diverse actors with multiple interests have worked to create these discourses, which cultivate trust in cosmetic dentists and places them in a gatekeeper position in the provision of cosmetic dentistry. However, there were disjunctures between authorised accounts of dentists’ training, professional standards and safety, and what the public may expect. The discourse of happiness was used to link cosmetic dentistry to healthcare rather than beauty, and profit was kept distant from the public. These discourses were coordinated to mediate demand for treatments. Conclusion: Dentists increasingly play a gatekeeper role in the provision of cosmetic dentistry. The public trust cultivated in dentists facilitates the movement of beauty treatments into healthcare. However, the disjunctures and the disconnects between the fields of beauty and healthcare have consequences for public safety and people’s autonomy. iii Acknowledgments I would like to acknowledge the contribution of the following people, who over the years have enabled me to undertake this study. A special thanks to all the informants in this study. Without your willingness to share your time and experiences this study would not be possible. I hope the findings of this project work towards improving the cosmetic dentistry experiences of all those involved in its practice. My supervisors Professor Barry Gibson and Professor Peter G. Robinson who encouraged me and gave me the freedom to think outside the conventional dental public health paradigm. Your approach has led me to learn a great deal, for which I will always be grateful. Professor Zoe Marshman, who gave valuable advice about managing the competing commitments of clinical training, academic work, teaching and bringing up a young family. Professor Zoe Marshman and Ms Kate Jones were also instrumental in ensuring I had the space and flexibility to manage workloads. Dr Sarab El-Yousfi, who supported me immensely after I came back from maternity leave. Dr Jan Owens, who consistently gave up her time to answer the multiple ethics queries that emerged throughout the fieldwork. Dr Alison Patrick, Dr Tom Broomhead and Anisha Gupta who were there to bounce off silly questions and provide clarity. Professor Sarah Baker who, many years ago, encouraged me to pursue a doctorate. Professor Georgina Born, who gave a valuable tutorial on undertaking ethnographic work and effective interview techniques. Helen Owens, Sue Spriggs and Kathryn Hurrell-Gillingham, who gave invaluable support throughout the PhD process. The BDA Library, particularly Helen Nield, who was fabulous at sourcing historical documents. The lovely Lou, who helped with our home. All the people at Hamilton House, Sheffield Woodland Kindergarten and KDV De Kraai who have looked after my son so I could work. iv The immense love and support of my family. My beautiful boy, Faris Imran, whose arrival in the world gave me the much needed ‘break’ from my doctorate and continued to give me frustrating, but often needed, distractions. My parents, who have always encouraged my diverse projects. Their commitment as grandparents along with Bill and Anne let me have much-needed sleep catch ups. My sister, Roshan, and lovely niece, Khadija, for their play- based family fun. My partner, Christopher, and my brother, Ismail, for their encouragement and ‘academic’ conversations. A special thank you to my partner Christopher who took on the lion’s share of the domestic chores and did a fantastic job of caring for our son during the coronavirus lockdown so I could complete this thesis. And my little brother, Imran, you are with me every day. Funding I would like to thank Health Education East Midlands for funding an academic training post in dental public health that enabled me to undertake this PhD. I would also like to thank The University of Sheffield for awarding me the Women Academic Returners Programme (WARP) fund which was an immense help to be able to complete the thesis. v Table of Contents Abstract .......................................................................................... iii Acknowledgments ......................................................................... iv List of Figures .............................................................................. xiv List of Tables ............................................................................... xvi List of Abbreviations .................................................................. xvii Glossary ..................................................................................... xviii 1. Introduction ............................................................................. 1 1.1 Importance of the Research Topic .......................................................................... 1 1.2 Aim and Objectives ................................................................................................. 3 1.3 Methodology ........................................................................................................... 4 1.4 The Problematic ...................................................................................................... 4 1.5 Study Overview ....................................................................................................... 4 1.6 Results .................................................................................................................... 5 1.7 Policy Recommendations ....................................................................................... 8 1.8 Thesis Structure ...................................................................................................... 8 2. Background ........................................................................... 10 2.1 History of Cosmetic Dentistry ................................................................................ 10 2.1.1 Ancient Practices ............................................................................................ 10 2.1.2 Contemporary Teeth Beautifying Practices .................................................... 12 2.1.3 Meanings of Morality, Beauty and Class ........................................................ 13 2.1.4 The Straight, White Smile ............................................................................... 16 vi 2.2 The Professionalisation of Dentistry ..................................................................... 20 2.3 Cosmetic Dentistry ................................................................................................ 23 2.4 Cosmetic Market ................................................................................................... 24 2.5 Dentistry or Beauty? ............................................................................................. 28 2.5.1 Supplier-Induced Demand ............................................................................. 29 2.5.2 The Role of Dental Institutions ....................................................................... 29 2.6 Why Study Power and Cosmetic Dentistry? ......................................................... 30 2.7 Power .................................................................................................................... 30 2.7.1 Taxonomy of Power ....................................................................................... 31 2.7.2 Active and Passive ......................................................................................... 32 2.7.3 Theoretical Map of Power .............................................................................. 32 2.7.4 Dimensions of Power and Interests ............................................................... 33 2.7.5 Power and Freedom ....................................................................................... 34 2.7.6 Mechanisms of Power .................................................................................... 36 2.7.7 The Problem with Marxist