Overall assessment of the literature reviewed
Each piece reviewed exhibited one or more deficits which detracted from its overall usefulness with respect to the primary purpose of this article. While more recent works tended to display fewer and less serious deficits, the available literature on this general topical area is not yet extensive or robust. Deficits were of several types: 1) lack of conceptual clarity and specification of the population under examination; 2) use of a limited set or inappropriate type of method; and, 3) a sketchy coverage of pertinent topics.
Lack of conceptual clarity and specificity
Authors frequently generalized, even stereotyped, population groups. Little account was taken of the considerable within-group diversity that exists in all populations. This diversity is due to socio-economic class, income, education, geographic or regional location, religion, language, and history of migration (to US), or level of acculturation. There is also heterogeneity in specific beliefs, values and practices around health, prevention of disease, help-seeking and self-care practices. Rarely do cultural beliefs come in just one standard form but usually in a variety of closely related forms; compared to men in the group, women, for example, may hold similar but nonetheless variant or more elaborated views on health-related issues, especially with respect to children, because women are often deemed to be primarily responsible for monitoring and ensuring a family's health and well-being. Other socio-demographic factors, such as age, can have a similar effect in producing with-in group diversity in ideas and practices. Further, published works usually lack detailed demographic information about the study population; and make very poorly explicated connections to other aspects of culture. Many works proved to be old, anecdotal, and offer little evidence of how cultural beliefs might have metamorphosed in the years since the study was conducted. Often studies are overly generic, with little acknowledgement or identification of crucial features that make for important cultural distinctions. Language is one such feature; for example, which of many dialects did a Chinese population under study actually speak? – Cantonese, Mandarin, Toishanese, Fukienese, and so forth. The name of the specific minority or ethnic group studied is rarely provided; for example, did the Hispanic/Latino group being researched originate in Cuba, Puerto Rico, the Dominican Republic, Mexico, or Nicaragua? What religion does the study group espouse; so, for instance, does the Filipino group comprise mainly Protestant, Catholic or Muslim adherents and so come from different geographic regions of their homeland, speak different languages, have different beliefs and practices, and different access to dental services, education, economic resources? How does the migration experience of poor Salvadoran or Guatemalan refugees, escaping war and torture, differ from that of Mexican farm workers or Puerto Rican or Cuban migrants? Are the migration experiences of poor Hispanics comparable in any way to those of wealthy Chinese from Hong Kong? Where geographically does the group live? For example, familial experiences and present-day connections to the US health care system are different for African-Americans from rural Louisiana compared to those in middle-class urban areas or in inner-city slums.
Limited methods
A rather limited – and not always appropriate – repertoire of investigative methods has been brought to bear on the issues of concern in this review. Some studies resorted to use of structured questionnaires and telephone surveys, not the best means to explore cultural phenomena that are not already fairly well understood. While many works did use qualitative methods, very little ethnographic work was represented in this literature and there was a tendency to prefer a focus group method over other styles of qualitative inquiry, such as face-to-face, individual interviews. Too often the method used was inappropriate to the kinds of questions posed or the general intent of investigations. Focus groups, for example, are frequently employed but this approach is best when used to establish consensus of opinion within a group and not for eliciting variations in beliefs and experiences. Relatively few authors appeared to have extensive familiarity with the logic or procedures of qualitative inquiry in general.
Method of inquiry is intimately connected to underpinning theory. However, the social or psycho-social theory guiding the study procedures and data analysis were usually absent. Disjuncture between the epistemological assumptions and processes of a study's topical intent/procedures and the implicit socio-psychological theory/method employed, is a common although still vastly under-recognized problem in the kind of biomedical investigations reviewed here [
33,
60].
Topical content
Some works were initially identified as possibly relevant but ultimately excluded from this review, usually because they made unsubstantiated comments or assertions in the text. Thus, their inclusion was not justified. Epidemiological accounts were not included if they posited "culture" as an explanation for findings but the specific aspects of culture were not further revealed.
There is little discussion in the literature on basic health care beliefs, ideas about health and disease, health care seeking behaviors, diet, and cultural beliefs about the function of teeth at various life stages. Overall, very few studies were found that discussed cultural beliefs related to oral pain and methods for relieving it. It may be, however, that pain and swelling in any region of the body is treated similarly and therefore that there is no distinct reference to folk or other remedies for treating oral conditions. Some recent studies have found that caregivers of young children frequently feel first teeth are not as important as permanent teeth [
7,
60,
74]. Tooth loss in old age appeared to be commonly accepted as a norm in all four cultural groups examined [
18,
20,
35,
36,
55,
63]. The timing of care seeking (whether for preventive, routine or emergency care) has rarely been studied in association with cultural beliefs. Cultural beliefs related to preventive strategies were rarely discussed; indeed, some of these cultural groups did not have a strong preventive orientation. More detailed understanding of culture as it relates to oral health is needed because minority groups have high oral disease rates, and are dentally underserved.
Since the information reported in the literature is so slim, and cultural beliefs and practices diverse even among these ethnic/racial groups (e.g., by socio-economic class, religion or language), generalizing the results presented below should be done with extreme caution. When the data in the original literature report were not rigorously collected or findings were not replicated in other studies, the actual content of beliefs or practices has not been reiterated here. Overall, in the literature reviewed, the most comprehensive, detailed accounts of culturally-based ideas and practices of direct relevance to oral health come from studies of Chinese populations. Some relevant works were located for African-American and Hispanic/Latino populations; almost no work exists on Filipinos. Sparse, poorly connected and incomplete as they are, the major findings for each group are summarized below, organized roughly by the five domains identified as pertinent in the introductory section of this article.
African-American
Most African-Americans subscribe to broadly the same set of ideas as the dominant white/Anglo-European population in the US with some continuing ideas from previous eras, when self-care and "folk" practices were the only available resorts. Despite comprising a large minority group, relatively little work has investigated African-American (oral) health beliefs and practices. Additionally, most reports in the literature on African-Americans examine cultural beliefs and behaviors among the low-income sector of the population and not those with higher incomes.
No discussion was found of African-American cultural beliefs about the function of teeth at various ages, from infancy to old age; associations between physical and oral health; or about the relationships between diet and oral health in late childhood or adulthood. One study from the Midwestern U.S. claims that the mother's diet during pregnancy is thought to be an essential factor in the later causation of "soft teeth" or dental caries in the child [
18]. Some works suggest that African-Americans believe that caries can progress to become a serious problem if it is not treated [
21,
22]. Most (70%) African-American respondents in one study believed that pain in the oral cavity was an early symptom of oral cancer [
25]. Among African-American elders, oral pain was often associated with needing dental care [
30].
Norman and colleagues report that parents who had fatalistic beliefs (such as: most children eventually develop dental cavities) have less knowledge about their children's oral health needs. They also are less likely to brush their child's teeth and seek dental care [
31]. Broder and colleagues report the frequent use of bottle with juice, soda or other sweetened drinks by children at bed-time [
32]. Kelly and colleagues compared African-American parents who utilize or do not utilize dental services for their children, reporting contrasting beliefs between the two groups. African-American families that visit a dentist regularly tend to have stronger preventive beliefs, were more knowledgeable about infant gum and tooth care and long-term consequences of oral diseases. Some of the parents not utilizing dental services expressed dissatisfaction with the care they had previously received, an attitude that shaped their present practices [
33].
Commonly reported home remedies comprised methods to relieve pain and swelling (e.g., use of cotton balls soaked in aspirin solution, alcohol or salt water) or to relieve toothache pain (e.g., cotton balls soaked in turpentine and sugar or oil of cloves) and self-medication with over-the-counter pain medication [
18,
19,
33]. Sketchy reference was also made to cleaning teeth in order to maintain good oral hygiene [
18,
20‐
23], although flossing has also been reported [
22,
24]. Practices such as self-medication could vary by geographic location and be different among younger or more middle class African-American adults due to their greater education or income levels and willingness to access professional dental care [
18]. Traditional practices, however, could continue especially among low-income African-American families and those without dental or health insurance.
Dental visits are said to be mostly problem – rather than prevention-oriented [
26,
30,
33], with women more likely than men to see a dentist on a regular basis [
27]. Consistent with a strong cultural focus on spiritual practices and religious participation, African-American church-attendance was related to concerns about oral health status and utilization of dental services [
28,
29]. Treatment preferences are said to be for extraction rather than to save a tooth, although this claim is likely to be strongly affected by income and socio-economic status [
19,
24].
Gilbert and colleagues report self-extraction is a commonly employed method of relieving tooth pain among African-Americans in Florida [
24]. Esthetic appearance or "looking good" is commonly associated with having good teeth [
18,
26], and is said to motivate some African-Americans in Detroit to seek professional dental treatment [
22].
Chinese
Underlying philosophies and conceptual frameworks ground Chinese health beliefs. Traditional Chinese Medicine (TCM) emphasizes the universe-human body relationship [
34,
75]. Chinese beliefs about health and illness management are holistic, woven into the social and cultural fabric of daily life, conceptualized within the context of yin-yang, hot-cold, and dry-wet balances, as well as qi and holism [
37‐
39,
75]. Another theory the Chinese use is the Meridian Theory, which assumes that any disorder within a meridian or energy pathway generates disharmony along that meridian. For example; maxillary toothache may result from a disorder of the stomach meridian; likewise mandibular toothache may result from a disorder of the large intestine meridian because the large intestine and the mandible run along the same energy channel [
40]. Inadequate sleep or stress affects the meridian involving the stomach and are also believed to cause gum disease [
35,
42].
Based on the concepts of TCM, the Chinese believe that tooth health depends on the condition of the kidneys. The kidneys determine the condition of the bone, as the bone is filled and nourished by marrow, which is believed to derive from the vital essence of the kidneys. The teeth are considered the odds and ends of the bone. Therefore, problems such as loosening of teeth are considered to be an expression of the imbalance between the two vital forces (yin/yang) in the kidneys. Similarly, the gums are related to the stomach via meridians through which vital forces (yin/yang) move. Gum inflammation is believed to result from intense heat or flaring fire in the stomach [
37,
43].
The Chinese tend to use traditional medicine in conjunction with western medicine for minor, well-understood or common health problems; for uncommon or more serious ailments they often seek biomedical treatment [
35,
37,
59]. Western medicine is considered good for the treatment of symptoms while Chinese medicine is believed to be more effective in curing the disease [
37]. TCM is considered culturally appropriate, holistic, convenient, cost effective, and without side effects. It can be used by people who fear going to the dentist [
59]. TCM is also commonly used in response to oral mucosal lesions and periodontal disease [
59]. These ideas lead to a strong reliance on self-care, which leads to delay in seeking care according to biomedical dental standards [
38].
From a clinician's point of view, treatment based on TCM is initiated based on etiology. Periodontal diseases may be treated in different ways based the presentation of the periodontal tissue. For example, if there is inflammation and bleeding of gums, suppuration and halitosis, this combination is believed to be due to 'heat in the stomach'. However, if there is tooth mobility, a diastema due to tooth migration, exposure of root surface due to gingival recession, sensitivity and slight redness, this combination is believed to be due to 'deficiency of the kidneys' [
34]. The presentation of the tongue is considered an important diagnostic tool in TCM [
44]. For example, pale or normal tongue with wet sides accompanied by loss of appetite, distension of the abdomen, soft stools, general fatigue or malaise, and impaired memory indicates 'spleen chi deficiency'. A tongue with red sides accompanied by anger, insomnia, irritability, aching pain in the head and neck and stress is considered to be indicative of 'liver fire rises' [
44].
Drinking a cooling tea or taking herbal medicine is a common practice in treating 'hot' gum diseases [
35,
37,
43,
44]. Foods or medicines are described as 'hot' or 'cool' not on their physical temperature so much as on their effect on the disease state and symbolic associations with other resources. Powdered alum, musk and frankincense, for example, are regarded as 'cool' materials and so used to treat 'hot' gum disease [
34]. Now classed as quackery, a prevalent idea and connected practice in ancient China and in parts of rural China until recently [
46], was that of caries being due to a burrowing worm and the use of leek seeds soaked in sesame oil to drive the tooth worm out of carious lesions.
Wong and co-workers in the US [
60] noted that although parents would frequently use a traditional remedy for themselves, they were less likely to use it for their child. Most parents brought the child to the dentist or pediatrician in response to pain [
60]. This research team reports a widespread belief that treatment for primary teeth was not essential, and that many more conservative-minded Chinese consider Western medicine aggressive and in some instances used too extensively [
60]. Young Chinese adults and teenagers residing in the UK report trusting dentists, who are thought capable of relieving most dental problems; elderly Chinese, however, do not trust the dentist's competence in the same way [
54,
55,
58].
Reported in the literature for Chinese populations are a variety of widespread preventive dental practices. These include: mouth rinsing and use of toothpicks after meals [
12,
40,
41,
44,
47,
48], use of salt to swab the teeth or in solutions for gargling to prevent gum disease [
34] and scraping the tongue in the morning [
47]. Other oral health beliefs reported in the literature are: tooth problems being considered a sign of aging, a natural process that may not be reversed or altered [
35,
47]; frequent childbirth is associated with tooth loss due to calcium deficiency; giving birth to a child with teeth is a sign of bad luck; and parents who have teeth in advanced old age is considered to bring bad luck to their children [
12,
40,
47]. Piercing the tongue and cheeks to please the Gods is a religious practice for some Chinese people [
49].
These traditional practices and beliefs should not be generalized to all sectors of the Chinese population, however; they may not be practiced in all regions of China, nor among all language groups, social classes, and so forth. Urban dwelling Chinese adolescents residing in China tend to have beliefs shaped by modern scientific knowledge mixed with traditional Chinese theories of disease and health [
62]. For example; gum disease was believed to have been caused by a combination of the following: mixing hot and cold foods, incorrect tooth cleaning, unhealthy diets and general illness [
62].
A concern for esthetics, appearance and freedom from pain often motivate Chinese people to maintain good oral hygiene [
12,
36,
47,
50]. Pain or troubles with teeth are common reasons for seeking oral health care [
36,
48,
50,
54,
55,
60]. White wine or vinegar applied directly to the hurting tooth is believed to ease tooth pain temporarily [
60]. Acupuncture is occasionally used for local dental anesthesia in China [
51]. There is widespread belief that tooth brushing is necessary to prevent caries [
39,
57,
58]. The Chinese consider the appearance of teeth psychosocially important, and able to influence social interaction. A person with carious or discolored anterior teeth, for example, is considered to have low intellectual competence [
51]. Orthodontic treatment to enhance appearance is common among Chinese residing in the US [
52,
53].
Hispanic/Latino
Despite being the largest minority group in the US, there has been relatively little research that documents Hispanic/Latino beliefs and practices in relation to oral health. Hispanic/Latino cultural beliefs regarding underlying basic concepts of health, help-seeking behaviors, function of teeth at various ages, from infancy to old age, and associations between physical and oral health are sparsely reported in the oral health literature. The literature suggests that Mexican Americans residing in various parts of the US lack adequate knowledge about the role of fluoride in caries prevention, and lack knowledge about the connection between oral health and consumption of sweets and frequent snacking [
64‐
67]. Some reference has been made to a belief among Mexican immigrants in rural California that diarrhea and or fever is common when the child's teeth erupt [
10,
70]. Certain dietary and infant feeding practices are commonly reported by Mexican Americans and Puerto Ricans, such as putting an infant to bed with a bottle of sweetened liquid, giving a child a pacifier dipped in honey, or sharing eating utensils among siblings and caregivers [
22,
64,
66,
68,
73]. There is reference to Mexican American migrant farm workers in Washington state that caregivers prefer to do something extra (like using fluoride varnish) for the child's oral health rather than to alter the child's feeding patterns that may cause sleep and familial disruptions [
69]. Puerto Rican parents may be more likely to follow advice from elders in the family regarding a child's feeding, advice which at times may conflict with the medical advice provided by pediatricians [
73]. There are reports that elderly Latinos residing in Wisconsin believe the purpose of tooth brushing is to freshen breath rather than to prevent oral disease [
71]. Hispanics/Latinos from Wichita, Kansas fear loosening teeth due to oral prophylaxis [
72] and Latinos from the Washington DC area believe that tooth loss is inevitable as one gets older [
67]. Puerto Rican parents are said to value the aesthetic appearance of white, healthy looking teeth and so encourage their children to maintain "a bright smile" [
73] but reportedly do not seek regular preventive dental services [
64]. Some Puerto Rican parents consider eruption of teeth during the usually specified period reassuring of the child's normal growth and development [
73]. Some Mexican-American migrant farm workers are said to have a fatalistic attitude toward health, including oral health [
64,
65], an idea possibly consistent with a claim that Hispanics/Latinos seek oral health care mainly in response to pain and concern over esthetic appearance [
65]. Only one study, by Lopez and colleagues, [
73] references Latino beliefs about the etiology of oral disease among infants as infection, bad breath or
sapo (candidosis) [
73]; Puerto Ricans believe that babies get infections in their mouth from milk. This study also suggests use of "pink honey" available over the counter to clean the baby's tongue. Cleaning the mouth with leaves of a plant,
la hoja del gandul, was a folk remedy used in the past but now slowly disappearing [
73].