The phrase “Everyone smiles in the same language” is often attributed to American comic George Carlin. While the sentiment rings true, smiling and its intended meaning may not be as universal as we’d like to think.
What’s in a smile?
Smiling can be a way of communicating with others, but it may not be a genuine expression of feelings. In fact, when it comes to smiling, culture and geographic locale may be more reliable predictors of intent than emotions or sentiment. Pro-smiling countries such as the United States see smiling as an important part of body language used to convey contentment, and we may feel wounded by those who don’t smile in return.1
In Japan, smiling is not as readily accepted as in Western cultures and is used to show respect, or on the opposite end of the spectrum, to hide true feelings. Eastern European countries such as Russia smile rarely and only with good cause, and those who smile excessively may be perceived as suspicious. Smiles are abundant in Thailand but can mean a variety of things, including happiness, embarrassment, or even fear.1 And if you travel to Norway and smile at a stranger, you might be viewed as mentally unstable. In societies with high corruption indicators, a smile can undermine trust and convey negative attributions.2
The United States is home to more than 90 million immigrants and their children—which by any count is a sea of foreign smiles. Twenty-eight percent of the overall US population is made up of legal permanent residents, refugees, visa holders, and naturalized citizens from around the world, in addition to the 12 million undocumented immigrants. These numbers are expected to rise due to complex factors involving displacement from conflict, natural disasters, environmental changes, stateless persons, or asylum-seekers.3
While the majority of immigrants have traditionally been from Mexico, recent arrivals are more likely to come from Asia, with India and China in the lead. Migration from the Middle East has increased more than sevenfold, and it’s estimated that one in seven US residents is foreign-born.4
Underutilization of dental care and higher levels of dental disease have been reported among immigrants compared to those born within the US, making migration a social determinant of oral health.5 Immigrants are more likely to get extractions as opposed to conservative alternatives.6 Of those who sought dental treatment, more than half of noncitizens were diagnosed with periodontal disease and 38% had dental caries. Lack of insurance was a major factor in poor oral health, with over half having no insurance; however, other reasons also play a role.7
Acculturation can be slow and difficult for newly arrived families, especially those with multifamily or multigenerational households. A crying child who keeps others awake may be placated with a bottle. One study illustrates that Mexican-American mothers recognized sugary beverages and candy as cariogenic, but could not always discern the role of fermentable carbohydrates such as those found in breads and crackers. Grandparents may look to homeopathic treatments and disregard the utility of preventive dental care. In many Chinese, Filipino, and African immigrant families, dental care is not considered necessary if a child is not complaining of pain. In fact, many cultures believe dental caries to be a rite of childhood with no expectation for healthy primary dentition. A study of West African immigrants shows that family financial responsibilities in their home country may take precedence over their own dental needs.8
Immigrants face other challenges as well, especially women and children who may have limited opportunity and resources due to cultural constraints.9 Of immigrants, 52% are women. According to the Migration Policy Institute, children of immigrants are more likely to live in low-income households, and 47% live below the poverty line.9 Families oftentimes have a “mixed status,” such as US citizen children with undocumented parents.
Dental insurance and health-care coverage
Many immigrants hesitate to seek dental or health coverage, even though they are eligible for affordable programs and services. “Eligible, but not enrolled,” highlights complications in the system including confusing eligibility rules, lack of proper training for enrollment aids, and misinformation in immigrant communities.10
Questions on application forms may lead people—even those who are citizens or legal immigrants—to believe information will be shared with authorities. Undocumented immigrants may fear providers will report them to immigration authorities. Mixed status families may not seek medical care believing it could jeopardize their legal status or risk a family member’s deportation.11
Furthermore, the fear of being considered a “public charge” leads many immigrants to avoid seeking health care altogether. United States Citizenship and Immigration Services (USCIS) uses the term “public charge” to define those who are likely to become dependent on the government for subsistence. However, noncash benefits—such as public health care and nutrition programs—are not considered in the public charge evaluation. Also, the public charge test doesn’t apply to those who are naturalized citizens or who already have a green card. To ease concerns with this, U.S. Immigration and Customs Enforcement (ICE) issued a memo in October 2013, reassuring immigrants that under the Affordable Care Act it was safe for their US children to apply for coverage without fear of public charge.11
Approaches to health care outside the US
An individual’s worldview is closely associated with his or her background and can profoundly impact health. Loss of culture, religious customs, and social support, as well as adjusting to a new culture, can create division and isolation. The need for regular, preventive care may be a foreign concept to immigrants. Many relied on holistic practices in their native countries and are unfamiliar with modern American medicine. For example, the balance of hot and cold as a necessity for health is practiced by several cultures, including Latinos and Asians.12 African Americans use bitter foods and herbs to neutralize the blood. Fatalism, or belief in a predetermined fate, may prevent those with chronic illnesses from seeking treatment or adhering to medical advice. Disease causation is sometimes viewed as having both physical and spiritual origins, which may factor into health-care decisions.13 Exploring a patient’s beliefs should be done respectfully and within the context of the patient’s culture and religion.
Understanding and celebrating diversity in the dental setting may be challenging but can unite providers and patients, improving access to care. My next article will discuss a series of steps to implement best care practices.
- Bhana Y. The meaning of a smile in different cultures. Translate Media. June 25, 2015. Accessed August 24, 2020. https://www.translatemedia.com/us/blog-us/the-meaning-of-a-smile-in-different-cultures
- Krys K, Vauclair C-M, Capaldi CA, et al. Be careful where you smile: Culture shapes judgments of intelligence and honesty of smiling individuals. J Nonverbal Behav. 2016;40:101-116. doi:10.1007/s10919-015-0226-4
- Batalova J, Blizzard B, Bolter J. Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute. February 14, 2020. Accessed August 31, 2020. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
- Dahlan R, Ghazal E, Saltaji H, et al. Impact of social support on oral health among immigrants and ethnic minorities: A systematic review. PLoS One. 2019;14(6):e0218678
- Wilson FA, Wang Y, Stimpson JP, et al. Use of dental services by immigration status in the United States. J Am Dent Assoc. 2016;147(3):162-169.E4. doi:10.1016/j.adaj.2015.08.009
- Wilson FA, Wang Y, Borrell LN, et al. Disparities in oral health by immigration status in the United States. J Am Dent Assoc. 2018;149(6):414–421.e3.
- Suphanchaimat R, Kantamaturapoj K, Putthasri W, Prakongsai P. Challenges in the provision of healthcare services for migrants: a systematic review through providers’ lens. BMC Health Serv Res. 2015;15:390. https://doi.org/10.1186/s12913-015-1065-z
- Crespo E. The importance of oral health in immigrant and refugee children. Children (Basel). 2019;6(9):102. doi:10.3390/children6090102
- Spotlight on immigrant women. Status of Women in the States. https://statusofwomendata.org/immigrant-women/. Accessed July 28, 2020.
- Batalova J, Blizzard B, Bolter J. Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute. February 14, 2020. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
- Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72(11):2267-2274. Accessed August 31, 2020.
- Hsu WC, Yoon HH, Gavin JR III, et al. Building cultural competency for improved diabetes care. J Family Pract. 2007;(Suppl):S3-S31.
- Section 7. Building culturally competent organizations. Community Toolbox. University of Kansas. https://ctb.ku.edu/en/table-of-contents/culture/cultural-competence/culturally-competent-organizations/main
Nichole Jarnagin, BSDH, RDH, has been a dental hygienist for over 20 years, practicing in both general dentistry and periodontics. She received her bachelor of science degree from Weber State University in Ogden, Utah, and has worked in Wyoming, Utah, and Texas. Currently she lives in the Dallas Metroplex and works as a dental hygiene educator.