Patient and public involvement in research is designed to put the patient front and centre in research direction and design. I am in the midst of developing a study proposal around oral-hormonal health and my research is being designed with and by women.

Of the 17 women I spoke with, only two were already aware of the links between hormones and their mouths. Many women spoke of oral symptoms during pregnancy, at particular times during their menstrual cycle and during perimenopause - but most hadn't connected the dots to hormonal health.

Only two women had been advised about oral health and pregnancy by their dentist, but the information they were given was only related to the risks of having x-rays taken - not the effect of hormones on the mouth. The women highlighted that the gap in knowledge and communication around oral-hormonal health is real and they felt it should be studied.

I gave a short presentation for the women to give them a deeper understanding of the impact of hormones across the life-course. Once the women had learned about the links between hormones and oral health they wanted dentists to be talking about more it… and they also felt that dental nurses could play a really important part in any study communicating oral-hormonal health.

While most women over 35 had a regular dentist, most women we spoke to under 35 did not. This highlighted that focusing the study on peri-menopause had the potential to reach the right age group of women in dental practice.

All women felt that it was important to have more knowledge about oral-hormonal health and felt that the topic of the study was an important part of the revolution happening around women's health in general. Pregnancy was identified as a key point of access due to free NHS dental care and a time when women could be provided with information about oral-hormonal health for the future.

In order to understand how to reach women with oral-hormonal health information, I wanted to understand how women find out about health issues. In women 35+ NHS resources, healthcare professionals and Google were commonly referenced. Women under 35 mostly used chatGPT for health information.

I asked the women how they'd feel being asked about menopause and if they'd take offence at being asked (see my previous blog about dental professionals resistance to asking about taboo topics). All women agreed they wouldn't feel offended and thought it was a great idea for the study to add questions about hormonal health and oral-hormonal symptoms into the general questionnaire.

Most women explained that if they had mouth or general health issues their first point of access for care would be their GP, the dentist was used for routine check ups and cleans. This demonstrated how routine check ups, versus symptoms driven visits, could be the most appropriate time for an oral-hormonal health intervention to be delivered in dental practice and women opportunistically asked about symptoms.

In summary:

Awareness is incredibly low despite lived experience being common
• Communication is lacking only two women had ever been advised about oral health in pregnancy, and this focused solely on X-rays
• Once informed, women want these conversations to happen in dental settings
• Dental nurses were seen as highly acceptable in communicating this information
• Many women under 35 didn't attend a regular dentist
• Pregnancy presents a unique opportunity for education via free NHS dental access
• Routine check-ups, not symptom-driven visits, may be the best moment for intervention
Perhaps most importantly: none of the women felt uncomfortable being asked about menopause or hormonal health. In fact, they welcomed it.

There is a clear gap around oral-hormonal health knowledge, communication, and care pathways. Oral-hormonal health feels like an important piece of the wider shift happening in women’s health right now.

If you’re working in dentistry, healthcare, or research, I’d love to hear your thoughts.

If you're passionate about womens health and want to keep up to date with oral-hormonal health issues. Follow the Feminist Dentist for more typo-riddled mouth-musings that you never knew you needed in your life.

The podcast covers all manner of women's health issues in an accessible and informal way. As I delved through the podcast back catalogues, I couldn't see any mention of oral-hormonal health - yet! That was a green flag for me to create some new connections and highlight the impact of women's sex hormones on oral health.

After my initial email, but before our planning meeting, I got the feeling that oral health + women's health seemed a bit of a weird and not immediately relevent combination - the team joked that it would be OK if the episode only lasted 20 minutes.

Quite to the contrary, our podcast session lasted more than an hour. We discussed life-course oral-hormonal health, gendered oral health tips, myth busting and FAQs. I loved the podcast experience and some of the Instagram clips have from the session have been viewed almost 3000 times.

You can access the episode here if you'd like to learn more: https://open.spotify.com/episode/5G235dFt7YRowyn6i48IUp?si=mvrRBnUAS6uhiIQK5b99Xg&context=spotify%3Ashow%3A2UswE043FcRqw8ci362ftm

The podcast was just the start of bringing oral and hormonal health closer together at the University of Liverpool. Since then Dr Tempest and I have begun working with medical students and trainees to design a study exploring obs and gynae health care professionals’ knowledge of life course oral-hormonal health. Alongside that, my own research interest in oral-hormonal health has blossomed.

This week I am collaborating with the Between2Ovaries team again. The team also lead the Liverpool Women's Hospital patient and public involvement group. On Tuesday, we will be hosting two online sessions with more than 20 women from diverse age groups and ethnicities to gain an insight into womens’ experiences and understanding of oral-hormonal health and the acceptability of dental professionals being more engaged with this topic in real-world practice.

During the sessions, the women will have the opportunity to take centre stage to highlight their priorities and preferences around oral-hormonal health research. In my studies, I try to centre lived experience and patient involvement at each stage: rationale, objectives, design, recruitment, analysis, interpretation and dissemination.

This weeks sessions will certainly be eye opening and insightful. The women's contributions will help to shape the topic, aims and methods for a grant proposal for oral-hormonal health right from the outset. And that's the beauty of it.

Out of the other side of this process the proposal will be richer, more relevant to women, more acceptable, and represents the views of the people the study is designed to target.

A huge thank you to the Between2Ovaries team for their continued support and engagement with oral-hormonal health.

If you want to read more about how this weeks’ patient and public involvement sessions shape my oral-hormonal health research, you know what to do - click subscribe for more typo-riddled, organic, female-focused content from The Feminist Dentist.

A different city. A different setting.

It was a rocky start to our interview day, I was delayed in M6 gridlock, panicking as I watched the destination time creeping up. And our art facilitator was getting train updates about terminations somewhere south of Stoke on Trent and all trains in and out of Manchester being cancelled.

All turned out OK though: traffic started moving for me and Ella (coming up from Kent) came into Stockport and taxied over to central Manchester. Phew. Crisis averted.

When we arrived, there was nothing much to reveal that we were in the right place. Shutters down over the windows. A buzzer at the door.

Once inside, the space was bright, modern, cosy and welcoming. A dedicated space for women who sex work to socialise, have some food and a cuppa, and take part in activities. Our team of four female researchers unpacked the goodies we'd brought for lunch and set about preparing the interview and art workshop spaces.

It was our first visit to this support space for female sex workers - including trans women. I'd been speaking to our gatekeeper contact for a few months in the lead up to the project. To access the space we went through a formal application process, sent through all study documents and met with the gatekeeper to discuss the project.

The women had been anticipating our visit. Our posters were displayed around the building. Apparently we had been the topic of conversation for most of the week. The women were curious to understand more about the project, who could be involved and how their stories might impact dental care for sex workers.

Manchester <> Liverpool: contrast and commonality

Most of the women we'd spoken with in Liverpool were unstably housed, living in hostels, using heroin +/- crack or alcohol or spice or weed and were engaging primarily in on-street survival based sex. In contrast, in Manchester most of the women we spoke with had permanent housing, were not actively using drugs (though some previously had a a history of drug and alcohol use). While a few of the women were involved in street based sex work, others were involved in escorting, erotic dancing, online sex work and pornography.

Our experiences of the service and interview logistics were also very different. In Liverpool our window of opportunity was often very short as the women came and quickly went - needing to score, fielding calls from controlling partners, or attending legal or medical appointments. In Liverpool, assessing capacity to consent was a constant iterative process as many of the women came in intoxicated or drinking alcohol.

In contrast, in the Manchester space women came for an entire afternoon, taking their time to socialise, create detailed artworks and to speak to us at length about their oral health. The conversations we had were wide ranging and diverse.

Similar to our findings in Liverpool, the women who street sex worked and had used drugs had the poorest oral health and least frequent contact with dental services. Some mentioned prison services as a way to obtain comprehensive dental care, especially to replace missing teeth.

What was strikingly different about some of the interviews, were those with escorts or who were involved with pornography or online sex working. This line of sex work gives higher income compared to street sex working, meaning women were able to access dental treatment including cosmetic dental treatment.

We learned how in the escorting and online sex work industry, having nice teeth was just as crucial as boobs and butt. And how full mouth cosmetic dental care abroad was an online sex work industry standard. None of the women had, and most said they never would, disclose that they were a “working girl” to their dentist. They couldn't see that it was relevant. They also thought that if they did, they would be treated differently - concerned they might be denied appointments and access to dental care.

As the “If my mouth had a voice…” sex worker oral health project moves from a local to national focus, we are gaining important and novel understanding of sex workers’ oral health, the diversity of their lived experiences, and ways to address their oral health needs.

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Across these diverse areas, one concern from dental professionals arises with remarkable consistency: “What if the patient gets offended?”

This concern often emerges when considering interventions and topics that intersect with, but sit just beyond, traditional dental boundaries. For example, when I first proposed the introduction of finger-prick HIV testing in dental practices in high-prevalence areas of London, the idea was frequently met with hesitation (1). At the heart of this hesitation was a fear of misinterpretation. Offering an HIV test might be perceived as making assumptions about a patient’s sexual behaviour, ethnicity, or perceived “risk.” In short, the offer itself was seen as potentially offensive.

A similar pattern appeared in research exploring dental professionals’ role in identifying and referring cases of domestic abuse (2). Even after training, many clinicians reported significant discomfort asking patients whether injuries might be non-accidental. This reluctance isn’t isolated. Studies on HPV and oral cancer prevention described similar avoidance of sensitive discussions (3). In my own interviews, dental students spoke about discomfort asking about drug use or discussing sex work.

Highlighting a stark contrast are conversations about oral-hormonal health; while dental professionals report feeling comfortable discussing pregnancy, they “never ask the question… are you in menopause?” (4). This is despite the fact that menopause is directly associated with a range of oral symptoms, including xerostomia, periodontal disease, and orofacial pain. These are missed opportunities to open conversations about menopausal oral health that could act as a gateway to earlier diagnosis, access to care, and improved quality of life (5).

Taboo, stigma, and the fear of offence.

Taboo and stigma are tightly interwoven. Taboo defines what is socially restricted or unspeakable. Stigma assigns shame or negative judgement to those associated with it. Together, they create a powerful silencing force.

For dental professionals, raising a taboo topic carries a perceived risk: that initiating the conversation may unintentionally attach a stigmatising label to the patient. The fear of causing offence is real. But it is often overestimated.

Overestimating offence

Evidence consistently challenges this assumption. In studies with women with experience of domestic abuse, the women reported that they wanted to be asked about abuse in healthcare settings (5). In my own HIV testing study, of over 400 patients offered testing, only two individuals (0.5%) expressed offence. The overwhelming majority supported the integration of HIV testing into dental care.

Once dental professionals had repeated exposure to offering testing without negative reactions, their confidence and willingness to test increased significantly. However, the inverse was also true: a single negative comment could have a disproportionately negative impact, leading to hesitation to test or even total disengagement.

This imbalance reveals something important. The fear of offence is not purely evidence-based. It is emotionally weighted and exaccerbated by rare but memorable negative encounters.

A two-way taboo

While clinicians may fear offending patients, patients themselves navigate a parallel concern: the risk of being stigmatised if they disclose. In my interviews with sex workers, most participants stated they would not disclose their work to dental professionals. Similarly, when I interviewed people with HIV, they often reported choosing not to disclose their status in dental settings. Yet many still felt it was acceptable to be asked about these topics.

Their reluctance to disclose wasn’t driven by discomfort with the question itself, but by concern about how they might be treated afterwards: with less compassion or with subtle judgment.

The overlooked parallel: oral health as a daily taboo

There is an important paradox here. While dental professionals hesitate to raise “taboo” topics such as HIV or domestic abuse, they routinely engage in another highly sensitive and potentially stigmatising domain: oral health itself. Oral health carries its own moral undertones. Plaque, decay, and periodontal disease are often interpreted, implicitly or explicitly, as failures of personal responsibility for oral hygiene and health.

Dental practices can unintentionally amplify this. Disclosing solution staining plaque vivid purple. High-resolution intraoral images displayed on large screens. Language that inadvertantly centres neglect and blame.

Patients are acutely aware of this. In the EXIST oral health stigma study, many participants described feeling judged, shamed, or blamed by their dentists for their oral health. Avoidance of dental care is not driven by anxiety alone, but also by the anticipation of being met with stigma from the dentist. The above raises an important question. If the goal is to avoid offending patients and preserve trust, why doesn’t this principle consistently extend to discussions of oral health?

Stigma silences and silence harms

Sitting underneath all of this is not just taboo and stigma. It’s the interpersonal negotiation happening on both sides of the chair. The clinician wondering: ‘Will this offend them?’ The patient wondering: ‘Will this change how you see me?’.

I’ve written this blog to highlight the potential harm that arises from stigma-silence. The person with undiagnosed HIV doesn’t receive timely antiretroviral therapy. The person experiencing domestic abuse goes unheard and unsupported. The sex worker does not disclose how broken and sharp teeth are increasing her risk of violence from clients when performing oral sex. The person taking drugs is not managed for dry mouth or grinding. The person at risk of HPV-related cancer is never given the information they need. And closer to home, the patient, already ashamed of their mouth before their dental visit, decides not to come back.

So the issue is not whether taboo topics should be discussed in dental practice, but how they are approached. When conversations are shame-aware and grounded in compassion, taboo subjects can shift from moments of risk to opportunities for real human connection and relationship strengthening (6).

I hope you’ve enjoyed this organic, home-cooked slice of The Feminist Dentist pie. It took me friggin’ forever to write, which hardly seems an economical use of time in the era of AI. That said, taking the time to write is about more than churning out content. It’s one of my greatest pleasures and delights. So, you know what to do: subscribe if you want to read more left-field mouth-musings from The Feminist Dentist.

References

(1) Yazdi-Doughty J, Santella AJ, Porter S, Watt RG, Burns F. Exploring the Acceptability of HIV Testing in the UK Dental Setting: A Qualitative Study. Dent J (Basel). 2024 Aug 2;12(8):246. doi: 10.3390/dj12080246. PMID: 39195090; PMCID: PMC11352954.

(2) Femi-Ajao O, Doughty J, Evans MA, Johnson M, Howell A, Robinson PG, Armitage CJ, Feder G, Coulthard P. Dentistry responding in domestic violence and abuse (DRiDVA) feasibility study: a qualitative evaluation of the implementation experiences of dental professionals. BMC Oral Health. 2023 Jul 12;23(1):475. doi: 10.1186/s12903-023-03059-y. PMID: 37438748; PMCID: PMC10337062.

(3) Griner SB, Thompson EL, Vamos CA, Chaturvedi AK, Vazquez-Otero C, Merrell LK, Kline NS, Daley EM. Dental opinion leaders’ perspectives on barriers and facilitators to HPV-related prevention. Hum Vaccin Immunother. 2019;15(7-8):1856-1862. doi: 10.1080/21645515.2019.1565261. Epub 2019 Feb 20. PMID: 30735476; PMCID: PMC6746486.

(4) Williamson, Zelda & Reed, Debbie. (2023). Barriers and enablers to patient conversations about menopause in the dental surgery.

(5) Femi-Ajao O. Perception of Women with Lived Experience of Domestic Violence and Abuse on the Involvement of the Dental Team in Supporting Adult Patients with Lived Experience of Domestic Abuse in England: A Pilot Study. Int J Environ Res Public Health. 2021 Feb 19;18(4):2024. doi: 10.3390/ijerph18042024. PMID: 33669680; PMCID: PMC7922980.

(6) Dolezal L, Gibson M. Beyond a trauma-informed approach and towards shame-sensitive practice. Humanit Soc Sci Commun. 2022 Jun 24;9:214. doi: 10.1057/s41599-022-01227-z. PMID: 35791341; PMCID: PMC7612965.

Ok. I'll admit it. As well as being a researcher, I am a dentist. My husband is also a dentist (he happens to be my dentist, for his sins). And I have pretty perfect teeth nowadays.

The Ubiquitous: White. Straight. Teeth.

Natural looking. Milky white. Pretty evenly spaced and shaped. Instagrammable. Teeth.

Which is great for me in that I don’t hide my mouth away from photos or cover my smile with my hand any more.

But on the flip side, I'm a qualitative researcher leading a national study (funded by the Academy of Medical Sciences) on the topic of stigma and shame about oral health. Spoiler alert, being a dentist and having straight white teeth doesn’t always make participants feel comfortable talking about their own dental issues…

Positionality: the researcher is not neutral and doesn’t exist in a vacuum

Part of the process of being a qualitative researcher involves being cognisant of what we personally bring into the interview space. Know as our positionality. Who we are and how that might impact the interview process. The direction of flow of the conversation. Determining what is disclosed and what is self-censored. Affecting the comfort or unease of the participant.

Awareness and transparency of positionality is necessary. It exposes inherent power imbalances built into the researcher and participant dynamic. It acknowledges who holds the power in what way and considers the effect this might have. I bring my whole self to the table, recognising both the strengths and limitations of my characteristics, beliefs, values, and lived experience.

Where am I going with this and what has qualitative interviewing got to do with having perfect teeth anyways?

When I do an interview face to face or on a video call there are many things that quickly become apparent (in no particular order of importance):

I am a woman. I am white. I have long blonde hair. I am slightly built. I'm wearing a wedding ring. I have a big smile with Straight. White. Teeth. I have an unplaceable well-spoken accent (a mix of South Africa, Bristol, Nottingham, London and Cheshire I imagine) and I have an infectious enthusiasm for my topic.

How does my whole self affect the interview process?

None of the above characteristics are neutral. They mean something. Each aspect of myself, immediately evident from first sight and “how do you do's”, elicits a host of stereotypes and assumptions.

Simply being the interviewer (the expert or professional) as opposed to the interviewee creates an instant power imbalance that subtly alters the texture of the conversation.

My accent might elevate the power dynamic in my direction even further.

Perhaps being female and having blonde hair might affect my credibility as I've experienced in the past; that’s a whole other post in itself!

Noticing a self-consciousness pattern

After interviewing literally hundreds of people across multiple studies and patient and public involvement groups, I started noticing a pattern.

When I spoke to people in person or on video calls, even if the topic wasn’t about oral health directly - for example when talking about HIV testing at the dentist - simply being visible in the presence of someone who identified themselves as a dentist made many people feel self-conscious about and sometimes even apologise for the appearance of their teeth.

It's always seemed odd to me that people apologise to me, perhaps in that moment outside of the dental clinic environment I am experienced as an embodied representation of the dental profession as a whole. Perceived as rating and ranking people on their dental health / appearance and being deeply unhappy if observed as less than perfect. I digress.

Alongside this, people frequently commented on my teeth. Recently when facilitating interviews with sex workers, almost all the women attending one of the evening sessions commented on my teeth.

“Hasn't she got lovely teeth. I wish I had teeth like yours”

These experiences led me to change my approach to qualitative interviewing for the oral health stigma study.

Going old school: Can I give you a call?

I am not willing to change how I look or alter my teeth in a fundamental way.

After careful thought about how I position my role/occupation I felt that it wasnt appropriate to omit that I was a dentist.

I also found in many instances, letting people know I’m a dentist enables them to let off some steam about the struggles they've had with dentists and their teeth, knowing that it will be understood and fed back to the profession through research outputs.

But I wanted to find a way to restore balance in the interviews, especially because these were people who were experiencing oral health stigma.

The participants in this study suffered immense distress because of their oral health conditions. Avoiding mirrors. Isolating themselves. Using filters on photos. Not smiling or laughing. Evading intimacy.

I decided to try asking participants for a straightforward phone call. After viewing their survey responses, I give them a quick ring to see if they fancy doing an interview with me. I send the information sheet and consent by email. And arrange a date to give them a call on the phone.

While this may not sound ground breaking to anyone born before 1985, in this day and age people are so used to video calls via Teams or WhatsApp that it can feel quite alien to do a “traditional” phone call.

What I noticed was really profound. Using a phone call instead of video calls lead to some of the most rich and engaging interviews of my career. Some lasting more than 90 minutes.

The participants, one of whom I met face to face at a later date, said she felt truly listened to and heard after our conversation.

I felt the difference myself too. A whole layer of concern had evaporated - how do I look? How am I being perceived visually? What assumptions are being made about who I am based on how I look?

Poof. Vanished.

I could listen more closely. Remain more focused. And stay present with their words and my scribbled notes.

After the interview some participants voluntarily sent me photos of their teeth, sometimes to show their issues visually to help me to better understand and other times to show how their teeth had changed with dental treatment.

Using the old dog and bone (phone) was a new and beautiful freedom that gave me a more authentic and powerful interview experience and I believe also a more comfortable and less self-conscious experience for the participants. We didnt have to see one another in order for a meaningful interview process to happen. In fact, quite the opposite.

So why not consider adopting this method yourself in the future if you are researching topics around attractiveness and appearance.

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“Oral health is multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.”

Whilst I appreciate those roles of the mouth are certainly important, I also believe that mouth-intimacy such as kissing and oral sex are also a crucial aspect of the role of our mouth and the way we connect with others sexually.

Whether related to appearance, pain or other factors such as bad breath, oral health can affect self-esteem and the permissions we grant ourselves to feel sexy and to be intimate. Oral health issues can also provoke disgust, that can prevents others from being close to us, whether romantically or platonically.

What I'm wondering is whether intimacy was considered during the development of this definition of oral health. Or whether, indeed, intimacy and sex were too taboo to mention in a professional quotable definition?

At a time when couples’ sexual activity is at an all-time low and birth rates are declining, oral health, as a fundamental part of intimacy and sexual health, should not be sidelined or overlooked.

Sex and intimacy are intertwined with ideas around morality. Talking about sex and intimacy can feel embarrassing and exposing. Silenced. Shameful. And in this definition of oral health - entirely absented from the conversation.

I'm thinking about the mouth and intimacy because earlier this year I found myself sat next to a sex therapist at a local women's networking event. As we got to know one another more over the course of the event talk turned to sex and oral health - of course.

We talked about my oral health stigma study, I explained how people's intimacy had been seriously affected by their oral health in a variety of different ways.

For example, avoiding kissing because of bad breath or being self-conscious about decayed teeth. I've been told about dentures being dislodged during oral sex, an event so mortifying it was relationship ending. Sharp teeth also cause problems during oral sex for sex workers whose clients accused them of biting them.

But this conversation is not only about pleasure. The mouth can represent a site of sexual trauma too. Having something in the mouth such as a denture or having someone close to and inserting dental tools in a supine position that can feel powerless can be deeply triggering for survivors.

Professionally, its time to admit that tiptoeing around uncomfortable and taboo topics is preventing dentists from having important and open conversations about their patients oral health. It's preventing us from addressing important topics like oral sex and HPV - one of the leading causes of oral cancer in men. It means we also do not take full account of the harms oral health causes to relationships and quality of life.

It's long overdue for more advanced communications to be embedded in dental education. Skills to eqip dentists with shame-aware, trauma informed approaches to topics beyond gum disease and dental decay. Topics such as sex yes, but other uncomfortable topics such as domestic abuse, poverty, hormones (menopause!), HIV, HPV, alcohol and drug use and many others.

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Women involved in the University of Liverpool project “if my mouth had a voice” shared experiences of teeth crumbling and literally falling out in their hands, using drugs to self-medicate dental pain and even DIY dentistry to file down sharp teeth. Sharp broken teeth even risked the women's physical safety as some clients accused them of biting them during oral sex.

The women talked at length about how their life circumstances, often stemming from childhood poverty, neglect and intergenerational drug use, alongside homelessness, disordered eating and intimate partner violence led to visibly damaged teeth in adulthood. They shared how the combination of crack and heroin use alongside high sugar diets, lack of dental access and unpredictable oral hygiene completely destroyed their teeth, sometimes within a year or two.

When able to access a service, being met by kind, respectful and experienced dentists was core to the women feeling confident and comfortable to receive care. Dentists who looked down on them or treated them differently created negative memories and led to the women avoiding future care.

The women's art work repesented two stories running parallel to one another. The first depicting how the deconstructed mouth brings shame, stigma, loss of sense of self, a representation of lived violence, injustice, sexual assault, low self esteem and a misrepresented identity.

And the other story depicted across the images was one of hope, colour, rainbows, sparkles, glitter, femininity, beauty, motherhood, healing, pleasure, freedom, dreams and wishes for a better future.

Working with co-created illustrations and art workshops enabled the women to overcome barriers of literacy, short windows of attention and self-censoring that showed up during interviews.

The images created by the women were a powerful way of expressing their suffering and also their resilience and determination for a better future for their mouth. More than that, their future mouth was a source of hope, a means to reconnect with loved ones, to reclaim their sense of self and a fundamental part of coming to love themselves again.

All of the study qualitative findings, illustrations and artworks are being presented in Liverpool on the evening of the 4th June. Please leave a comment or DM if you would like to attend.

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For each of us four researchers, its the first time doing a project like this, a project involving on-street sex workers who are unstably housed and who use drugs.

We want to do research with and for, not on and to, women who sex work. Our aim is Participatory engagement. This day is the first step of what will become a national project a few months down the line. But we dont know that yet.

The day is laid out just as with all my previous interview sessions with other demographics of participants. But today is different: I am worrying. I dont know how we'll be received or whether any one will talk to us at all.

We've worn tracksuits. Dressed down. Hair in a pony. Little make up. We're an all female team of dental researchers. We don't want to seem like we're pouncing. We don't want to seem too clinical. We are here to talk and to listen non-judgementally as much or as little as the women want.

The Dental Bus is visiting; outside in the car park providing treatments for the women. Everyone is thinking about teeth today. The service gatekeeper (who has been fundamental in making this day happen) has been to the hostel to give the women a nudge to come in for food and teeth.

Slowly, slowly, they start coming in to chat. They sit down with a plate of the food we've brought with us for their lunch. A hot drink in hand. 4 sugars please. We try to establish whether the women want to and are able to be part of the research.

Sometimes we have just a few minutes, 5 or 10 before the women need to go. Get back to a controlling partner. Score. Get high. A legal appointment. Simply be somewhere other than talking to us about oral health.

Some can read. Others cant. We support. Some can write. Others cant. We support.

The consent process is a dance. Gently checking and double checking, understanding, retention, capacity, avoiding coercion and all the while conscious we have a short window of attention and want some in reserve for the interview.

Underlying all this is the deep desire to share the women's unheard stories about oral health, to advocate for better care and access. And at the same time we want to be sure not to exploit the women in any way. On our first day we interview seven women.

The interviews range from 5 minutes to 35 minutes. All interviews are generous, informative and also heartbreaking. We learn a lot. We try to make sense of what we've heard. We debrief afterwards. We go home thinking we are all OK. But we're not.

The interviews with the women have left us dissociated, reeling. Cognisant of our privelege, safety and the rights we expect and take for granted daily. When we come back together 2 days later for round 2 of interviews, its obvious that we as researchers have vicarious absorbed trauma during the interview process.

The women's stories. Their shared lived trauma. Have been deeply felt by us all. We debrief again before the start of the day.

Something unexpected is emerging. What began as a project about oral health has morphed into a new personal level of compassion, of understanding and has lit a fire in our bellies to do what we can to advocate with the women and services that work with them.

We are, all of us, aflame with the injustice of the inequalities and harms experienced by the women.

We realise after our first day of interviews: we cannot even begin to consider oral health as separate to the lived reality of the women's daily and lifetime experience of survival and threat.

Dental appearance. Stereotypes. Sense of self and identity. These are so tightly enmeshed as to be inseparable. The women felt they could not reclaim their lives without reclaiming their oral health first. And in the midst of a dental access crisis this felt like an impossibility.

In later articles I'll share more about our Participatory and arts-based methods with women who sex work.

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A term I hadnt some across before two days ago.

It was a chilly Wednesday evening huddled in the pre-fab community shed space outside the back of our local football club. A group of around 20 people living with - predominantly type 2 - diabetes were meeting to support one another and on this evening had come to hear me and my colleague Rob talk about the links between oral health and diabetes.

We shared insights about the inflammatory and microbiome links between oral and general health conditions and answered the usual FAQs on oral hygiene, whitening toothpastes, fluoridated water and water flossers came and went.

But what really intrigued me was afterwards when the conversation turned to the topic of diabetes distress.

Diabetes distress, as I understand it, is a term encapsulating the ongoing cognitive and emotional load of navigating diabetes management, lifestyle changes, health systems navigation, shame, blame, guilt and near constant self-monitoring and policing around diet, medication, and continuous blood glucose monitoring.

As people spoke about their lived experience of diabetes distress I realised that before this moment I had never truly put myself in the shoes of someone with diabetes. I had, had my first real glimpse into their daily lives. The pursuit of stable blood sugar levels sounded relentless and all consuming.

It also got me to thinking about how this same process is mirrored in dentistry. I will coin it here as 'dental distress’: The cognitive and emotional load of dealing with stereotypes, shame and stigma around dental health and appearance, the burden of impossibility of accessing NHS dental care and the logistical nightmare of trying to secure an NHS appointment, the mental drain of oral hygiene regimes, tooth-healthy diets and the expectation of being met with blame from the dentist.

Diabetes distress is something that can be measured and quantified, which helps to identify who it affects and to what extent as well as whether it is getting better or worse over time.

At time of writing there is no dental distress measure. From my research with more than 300 people experiencing oral health stigma its clear that the phenomenon goes beyond stigma and is deeply intertwined with identity, social interaction, dental treatment access and morality around hygiene and beauty.

Just like with diabetes distress people experiencing dental distress self monitor, police disclosure through concealing their mouths, isolating themselves and avoiding photos, videos or mirrors and even avoid dental services when they need them.

What do you think? Is dental distress something you've experienced? Let me know.

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My name is Dr Janine Doughty, I am a dentist and a participatory health researcher focusing on shame, stigma and gendered oral health. This substack is my small way of sharing my ideas with the world to raise awareness and advocate for gender and stigma/shame-aware dentistry.

In this short article, I share how oral health is distinctly gendered and uniquely harms women and girls both because of physiology and societal norms.

Physiologically, the Oral-Hormonal axes affects women throughout their life course. Adolescence. Menstruation. Pregnancy. Menopause. Contraception. HRT. The undulating chorus of oestrogen fluctuations specifically and significantly impact oral health.

For example, during adolescence, girls uniquely experience puberty gingivitis. An angry red characteristic swelling of their gums related to pikes in oestrogen coupled with immature oestrogen receptors in their gums. In effect, their oral hygiene remains the same, but the response of young girls bodies to dental plaque bacteria has changed. Similar patterns are observed when oestrogen peaks just before ovulation, during pregnancy and during the perimenopause when oestrogen can spike wildly. Sex hormones even have an impact on the oral microbiome, changing it’s composition and making it more disease promoting during certain life phases.

Hormones don’t just affect gums. They can affect the mouth in other ways including chronic pain disorders such as burning mouth syndrome, taste disturbances, mouth ulcers, dry mouth, increased risk of dental decay, and bone loss around teeth.

However, the impact of oral health on women isn’t limited to their physiology. I recently led the analysis of the National Federation of Women’s Institutes (NFWI) Dental Health Matters Campaign; responses from over 900 women about their dental access. We found that women bear the intergenerational, financial, temporal, physical and mental health burdens of dental care for themselves and their families, and that the NHS access crisis created uniquely gendered inequalities.

Intensive mothering norms in society led women to selflessly care-give; leading women to forgo access to dental care for themselves and carry the mental load of seemingly impossible health care navigation required to obtain, regain or retain dental access.

Oral health deeply affects groups of vulnerable women. For example, my research interviewing and holding art workshops with 21 on-street sex workers identified how the appearance of their crumbling teeth (affected by drug use) metaphorically imprisoned women with the stereotypes associated with dental appearance. Dental appearance directly stopped women from reconnecting with their families. The appearance of their mouths meant that even when they detoxed and wanted to reclaim their lives they were held back by dental stigma and social judgement where broken teeth were seen as a “dead give away you’re a smackhead”. Accessing comprehensive rehabilitative dental care was an impossibility for most of these women.

Oral health is the canary in the coal mine, signalling gendered physiological and social inequalities in society. Gendered oral health is rarely discussed in clinical dental care outside of the physiological effects of pregnancy. This substack is a place for patients and clinicians alike to learn more about how gendered oral health and oral health stigma harm and dehumanise, and to consider what we can do about it.

The above is a short flavour of the kind of topics I’ll be covering in this substack. Follow me for more hand-written, typo-riddled, AI-free content like this! :)