ABSTRACT BACKGROUND The importance of physical appearance in social and professional situations has been well studied. It has been suggested that improving dental appearance may increase

employment prospects. This scoping review aims to map the current literature regarding the impact of dental appearance on employability. METHODS A scoping review was carried out in

accordance with guidance from the Joanna Briggs Institute. Inclusion and exclusion criteria were developed iteratively, databases were searched and decisions on inclusion made in duplicate.

Data were charted in Excel and synthesised using a visual map, study summary table and narrative description. RESULTS We identified 16 relevant articles: ten experimental simulation studies,

willingness to apply for jobs have also been documented. CONCLUSIONS The applicability of this evidence base to the UK health system context is uncertain and demonstration of real-life

impact on employment is lacking. Further research is needed before programmes to improve dental appearance could be justified on the basis of improving employment outcomes. KEY POINTS * Maps

the existing literature on the link between dental appearance and employability. * Identifies where there are gaps in the literature and makes recommendations for further research. *

Questions the NHS definition of 'clinically necessary' dental treatment. You have full access to this article via your institution. Download PDF SIMILAR CONTENT BEING VIEWED BY

OTHERS SUPPORTING DENTISTS' HEALTH AND WELLBEING - WORKFORCE ASSETS UNDER STRESS: A QUALITATIVE STUDY IN ENGLAND Article 20 July 2021 GLOBAL PERSPECTIVE ON CHILD AND ADOLESCENT ORAL

HEALTH: A SYSTEMATIC REVIEW AND META-ANALYSIS OF ORAL IMPACTS ON DAILY PERFORMANCE Article 27 February 2024 WIMPOLE TIMINGS STUDY Article 08 July 2024 BACKGROUND Healthy teeth are not only a

vital component in maintaining good health, but they also make a significant contribution to physical appearance. There is abundant literature demonstrating that ratings of personal

characteristics such as competence, intelligence and trustworthiness are influenced by facial attractiveness.1,2,3 Such judgements have been shown to take place in as little as 100

milliseconds, below the threshold of conscious awareness.2 Furthermore, attractiveness has been shown to influence judgements regarding suitability for employment, particularly for

consumer-facing roles.4,5,6 Smiling has been shown to increase positive ratings of characteristics including agreeableness, trustworthiness and intelligence, and the negative impact of not

smiling may be greater for women than men.7,8,9 Oral health in developed countries has drastically improved over the last 50 years.10,11 Alongside these improvements, patient expectations

and social norms around what is an acceptable dental appearance have also changed.12 In the past, missing, discoloured or misaligned teeth were as acceptable as they were common.12 In more

recent times, television makeover programmes, social media and advertising have all been credited with changing attitudes towards what is an acceptable dental appearance.13,14,15 What may

have once been termed the 'Hollywood smile' has become increasingly transatlantic; cosmetic dentistry was the most desired non-surgical cosmetic treatment among UK adults in

2018.16 Straight, white teeth are a prominent outward-facing display of social and economic capital; a signifier of class, self-control and success.15 Poor dental appearance may negatively

impact employment opportunities through a variety of mechanisms. Fifteen percent of adults in England, Wales and Northern Ireland report difficulty smiling or laughing without embarrassment

because of their teeth.17 Nearly 18% of US adults have reported that the appearance of their mouth and teeth affected their ability to interview for a job, increasing to 29% for those in

low-income households.18 Reduced ability to speak and smile confidently, combined with expectations of negative appraisals, could hinder performance at interviews.19 Furthermore,

interviewers may make less favourable judgements of ability based solely on appearance, because of conscious or subconscious biases. Social differences in oral health are more likely to be

explained by attributing blame to poor 'lifestyle choices' than for other conditions such as diabetes or cancer.20 This is despite abundant evidence that the greatest contributors

to inequalities in health and oral health are environmental, rather than behavioural.21 Stable employment is beneficial for the individual and society; long-term unemployment increases the

risk of depression, cardiovascular disease events and all-cause mortality.22 At present, 'return to work' support programmes in the UK23 do not include supported access to dental

care, but this is something that has been examined in other countries.24 This scoping review aims to map the current literature regarding the impact of dental appearance on employability and

identify areas for future research. METHODS Scoping reviews are used to map the existing literature on a particular topic, to identify the number and types of studies available. They are

particularly useful where the body of literature is complex and varied, or where a systematic review with precisely defined _a priori_ inclusion criteria could result in an overly narrow

pool of evidence. This scoping review has been carried out in accordance with the guidance produced by the Joanna Briggs Institute25 and is reported following the PRISMA extension for

scoping reviews (PRISMA-ScR)26 (see online supplementary information). The research questions of interest were: * 1. Does poor dental appearance negatively impact employability in adults? *

2. Can dental treatment improve employment outcomes? We developed a protocol in advance, which is available on request from the corresponding author. The searches were undertaken iteratively

in September 2019. Firstly, a broad search was undertaken using Google and Google Scholar, to identify grey literature and scope out the potential numbers of studies and the types of

journals they were found in. The search terms used were: (dental appearance/oral health/dental treatment and employment). Secondly, a database search using PsychINFO, Social Policy and

Practice, Embase and Medline via Ovid was carried out using the following search terms: (worklessness OR job OR employment OR employability OR unemployed) AND (dental treatment OR oral

health OR dental appearance OR dental attractiveness OR smile). Informed by the terms found in some of the identified studies, a further search was carried out, replacing the

employment-related terms with: (social perceptions OR social judgements). Studies were limited to human, English language and from 1980. The authors did not have the capacity to translate

other languages and we felt that, before 1980, social norms around appearance may not be relevant for today. We placed no restriction on study type. The reference lists of the retrieved

full-text articles were scanned for further relevant studies. Titles and abstracts were screened and assessed in relation to the following inclusion and exclusion criteria: * Participants

aged over 16 * Studies investigating the relationship between dental appearance, dental treatment or oral health and employment * Studies investigating the relationship between dental

appearance and judgements of employment suitability * Studies investigating the relationship between dental appearance and judgements about personal characteristics related to employment

(for example, intelligence) * Studies concerning purely aesthetic judgements, extraoral craniofacial conditions and orthodontic appliances were excluded. Studies identified as potentially

relevant for inclusion were obtained in full text and reviewed by DM and RK to inform the final decision. Data charting/extraction was carried out in Microsoft Excel, under the following

headings: study reference, study type, aim, country, participants, sample size, intervention or exposure, comparator group, outcomes used, key findings, authors' conclusions and

reviewers' conclusions. The data charting was completed by DM and cross-checked for accuracy by RK. Due to the heterogeneous nature of the included studies and in common with most

exploratory scoping reviews, we did not undertake a formal critical appraisal of each individual study.25 RESULTS A PRISMA flowchart illustrating the iterative search process is provided in

Figure 1. After completion of data charting, we synthesised the results by creating a study summary table (Table 1) and a visual map of how the studies related to each research question

(Fig. 2). Studies represented with a green circle provided supportive evidence in response to the research question. Studies represented by a red circle provided evidence of a negative or

equivocal response to the research question. The number within the circle relates to the number of studies. The study summary table (Table 1) and the visual map (Fig. 2) informed the

narrative synthesis which is presented below in response to each research question. DOES POOR DENTAL APPEARANCE NEGATIVELY IMPACT EMPLOYABILITY IN ADULTS? Three studies specifically

investigated the impact of dental aesthetic conditions on employment or suitability for employment.27,28,29 One cross-sectional study investigated the association between an

individual's number and severity of aesthetic dental conditions (measured using a 'Dental Problem Index') and current employment status.29 The authors found that a one-point

increase in the Dental Problem Index was associated with 7.70% (CI: 5.15-10.19%) lower odds of being employed, after taking account of age, gender, marital status, years of education,

poverty level and health status.29 Two experimental studies modified photographs to illustrate dental aesthetic conditions and asked participants to make judgements about the subjects'

employment prospects.27,28 Pithon _et al._ found that perceptions of intelligence and hiring potential were negatively impacted by malocclusion, while those of honesty and work efficiency

were not.27 In a similar study where photographs were also accompanied by a CV, no significant impacts were observed on the likelihood of shortlisting for interview or expected performance

in earning commission.28 Two qualitative interview studies identified themes related to the impact of poor dental appearance on employment prospects.30,31 Douds _et al._31 interviewed 30 US

adult male parolees about their experiences of prison dental care. Kerr30 interviewed six recent patients of a dental outreach organisation about the impact of the dental care they had

received. Participants felt that their poor dental appearance was assumed to be related to past or current drug use,30,31 likelihood of re-offending31 and expectations of needing time off

from work to attend dental appointments.31 The social disadvantage incurred by not smiling was raised as a barrier to employment in both studies.30,31 A particularly impactful quote is

reproduced below: 'They kept telling us in a job training class that we need to look like the job we want. "Dress for success." Ha! You can put me in an Armani suit, and I

still won't have any teeth.'31 The majority of the studies that we identified in relation to this research question assessed the impact of aesthetic dental conditions on

perceptions of work-related character traits.32,33,34,35,36,37,38,39 While these studies did not specifically set out to explore the relationship between dental appearance and employability,

they were included because they contribute towards the theoretical and conceptual basis for such a relationship. All of these studies found that images which had been modified to illustrate

visible dental conditions received less favourable judgements compared to unmodified dentition. A large variety of conditions were tested: caries,32,33,34,37,38 stained dentine,33 pulpal

necrosis,32,33 tooth shade,35,37 malocclusion36 and fluorosis.38,39 The types of characteristics that were perceived more negatively included intelligence,32,33,34,35,36,37,38,39

education,33,34 trustworthiness,35 laziness,34 reliability,38,39 sociability32,37,38,39 and friendliness.32,35 CAN DENTAL TREATMENT IMPROVE EMPLOYMENT OUTCOMES? All of the studies of

relevance to this research question were conducted in Canada.30,40,41,42 A systematic review included seven heterogeneous studies and concluded that there was little evidence to suggest that

dental care could improve employment outcomes and the available studies were of poor quality, with the majority lacking a comparator group.40 A large retrospective cohort study using

administrative data42 investigated if recipients of an employment-assistance programme who utilised the offer of free basic dental care were more likely to leave the programme than those who

did not. The authors found that employment outcomes were not significantly different 12 months after receiving dental care.42 A small pilot study found that the 'job-seeking

self-efficacy' of the 31 participants increased one month after receipt of public dental care, which consisted mainly of urgent treatment and/or dentures.41 This self-reported increase

in willingness to apply for jobs was also raised in one of the qualitative interview studies.30 The participants felt that the dental treatment they had received had improved their job

prospects by increasing their self-confidence and willingness to make applications and attend interviews: 'Prior to having the dental work done, I would not have had any vested interest

in sending out resumes or making appointments for job interviews. Now, I send out my resume. I don't have a problem going to meet with anybody'.30 DISCUSSION This study aimed to

map the existing literature regarding the impact of dental appearance on employability and to identify gaps in the evidence base. The search revealed a diverse array of study types, although

relatively few that directly addressed both dental appearance and employment_._27,28,29,30,31 All but one28 of those studies provide some evidence to support the notion that dental

aesthetic conditions may negatively impact employment outcomes or employment prospects.27,28,29,30,31 Similarly, the studies which measured the impact of dental appearance on perceptions of

work-related personal characteristics all reported negative impacts.32,33,34,35,36,37,38,39 This finding aligns with existing research on facial attractiveness, which has demonstrated that

the stereotype that 'what is beautiful is good'3 holds for a range of characteristics, particularly social competence and intelligence.43,44 However, despite the number of studies

which suggest that poor dental appearance can negatively impact employment-related outcomes,27,28,29,30,31,32,33,34,35,36,37,38,39 only one41 of the three studies which specifically

investigated the impact of dental treatment on employment-related outcomes reported any evidence of benefits.40,41,42 Furthermore, the benefits of dental treatment that were reported related

to intermediate steps of increased confidence and ability to apply for jobs, rather than actually becoming employed.30,31,41 A strength of this review was the scoping review methodology,

which allowed for a broad consideration of the evidence base around this topic. If we had limited the review strictly to the highest levels of evidence suitable for this research question,

we would have found very little to learn from. The qualitative interview studies in particular provided rich insight into how poor dental appearance may hinder job-seeking, but unfortunately

we did not identify any that were carried out in the UK context.30,31 The systematic search strategy and large range of databases searched were also strengths, although the majority of

studies were identified through the Medline database. Limitations are that studies were restricted to English language because of a lack of translation facilities and the review protocol was

not registered, as we were unaware of a suitable repository at the time. We have since learned that the Centre for Open Science hosts a publicly available repository which we would utilise

in future.45 In accordance with guidance on scoping reviews, we did not undertake any formal assessment on the quality of the included studies. However, the majority were experimental

simulation studies using modified photographs.27,28,32,33,34,35,36,37,38,39 How well these reflect judgements made in real-life social situations is unknown. It has been shown that viewing

distance and being asked to look specifically at teeth can affect judgements of dental aesthetic conditions.39,46 Many such photograph-based studies have also demonstrated that the social

judgements made are affected by characteristics of the judge themselves, such as age, sex, ethnicity,27,47,48 actual and self-perceived attractiveness,49,50 and intelligence.50 Many of the

included studies did not adequately control for these variations in the perceivers themselves, because they used different groups to judge different sets of images. Epidemiological

observational29 and intervention40,41,42 studies provide a more robust level of evidence than experimental simulations and the findings of these were mixed. Furthermore, applicability to the

UK context is uncertain, as all of the studies were conducted in countries where dental care is funded either by the individual or through private insurance.29,40,41,42 In the UK, the

partial funding of dentistry through the NHS means that for adults receiving certain employment, disability or low-income-related benefits, dental care is provided free of charge.51 For

those not receiving benefits, dental care is subsidised. Despite these provisions, cost is cited as a barrier by 20% of adults from routine and manual occupations,52 and people experiencing

homelessness report multiple barriers to accessing NHS dental care.53 Two studies35,37 reported positive benefits of a lighter tooth shade on perceptions of character traits related to

employability (intellectual ability,35,37 academic performance, trustworthiness, friendliness,35 and social competence).37 The scope of NHS dentistry is broadly defined as any treatment that

is 'clinically necessary' to achieve and maintain good oral health, as opposed to purely cosmetic treatments such as tooth whitening.54 Despite this, it is accepted that the

majority of NHS orthodontic care delivers aesthetic, rather than functional, improvements.55 This is justified by evidence that social wellbeing is improved by correction of

malocclusion.55,56 This more holistic view of health aligns with the World Health Organisation definition, agreed in 1948, which frames health as 'complete physical, mental and social

wellbeing and not merely the absence of disease or infirmity'. The complex relationships between social judgements, psychological wellbeing, social inequalities and the role of publicly

funded dental care are an interesting area for debate. Perhaps NHS provision of tooth whitening or other cosmetic treatments could be justified if a patient's dental appearance was

found to negatively affect their social, or even economic, wellbeing? Further investigations of the interactions between social and economic disadvantage, visibly poor oral health, and

subconscious bias and discrimination in a UK context are warranted. Qualitative studies would be informative, including those seeking the views of potential employers on the impact of poor

dental appearance at interview. Public health interventions are often advocated for in terms of the potential for cost savings and 'return on investment'. While we did find

evidence suggestive of a negative impact of poor dental appearance on employment prospects,27,28,29,30,31,32,33,34,35,36,37,38,39 we did not find any to suggest that including dental care

within 'return to work' programmes could improve employment outcomes or result in economic gains. The most compelling evidence to support a role for dental care in reducing the

social and economic impact of unemployment would be a randomised controlled trial of an integrated pathway into NHS dental care as part of a package of 'return to work' support,

with employment status as the outcome. However, it is important to remember that facilitated access to dental care for marginalised groups can also be justified in light of the legal duty of

NHS Commissioners to 'have regard to the need to reduce inequalities between patients with respect to their ability to access health services, and [...] the outcomes achieved for

them'.57 CONCLUSIONS There is a relatively abundant and diverse array of research to support the conceptualisation that poor dental appearance may have negative impacts on employment.

The applicability of this evidence base to the UK health system context and demonstration of real-life impact on employment are more tenuous. Similarly, we did not identify any evidence to

suggest that improving dental appearance could improve rates of employment. Further research is needed before programmes to improve dental appearance could be justified on the basis of

improving employment outcomes. However, this does not mean that this type of support could not be justified already in terms of reducing health and social inequalities and capacity to

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https://www.legislation.gov.uk/ukpga/2012/7/contents/enacted (accessed August 2020). Download references ACKNOWLEDGEMENTS The authors gratefully acknowledge the input of Mrs Sandra White in

identifying the research topic. This study was funded by Public Health England. The views expressed are those of the authors and not necessarily those of Public Health England or the

National Health Service. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * University of Manchester, Division of Dentistry, Dental Health Unit, Williams House, Lloyd Street North, Manchester,

M15 6SE, UK Deborah Moore & Ross Keat Authors * Deborah Moore View author publications You can also search for this author inPubMed Google Scholar * Ross Keat View author publications

You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to Deborah Moore. ELECTRONIC SUPPLEMENTARY MATERIAL PRISMA CHECKLIST (DOCX 0B) RIGHTS AND

PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Moore, D., Keat, R. Does dental appearance impact on employability in adults? A scoping review of quantitative and

qualitative evidence. _Br Dent J_ (2020). https://doi.org/10.1038/s41415-020-2025-5 Download citation * Received: 12 March 2020 * Accepted: 14 May 2020 * Published: 20 October 2020 * DOI:

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