Taking responsibility for the tooth: A semiotic and thematic analysis of oral health and disease in the TV show ‘Embarrassing Bodies’

Semiotic and thematic analysis

This study adopted a semiotic approach to look at all cases in the series that have displayed the relationships between dental professionals and participants. Semiotics is well suited to this analysis of the dental elements within ‘Embarrassing Bodies’ as it allows for an exploration of the deeper meanings surrounding the concepts of oral health and dentistry (Bryman, 2008) present within the programme. Pawson (1999) described thematic analysis as being a type of semiotic analysis that is concerned with the identification of ideological themes. It would, therefore, be appropriate to describe this research as being a semiotic thematic analysis. McNeill and Chapman discuss the importance of analysing visual media, highlighting the dominance of this media form within arts, entertainment and advertising (McNeill and Chapman, 2005). In this approach, the objects of analysis in their self-contained positions or states are referred to as ‘texts’, regardless of whether they are verbal, visual or otherwise (Bell, 2001). In the context of this research, the dental cases taken from Embarrassing Bodies are the texts that will be used in analysis.

The researchers located a total of 14 dental cases across all series originally aired between 2007 and 2012 in the United Kingdom. Not every season or episode featured dental cases. While the researchers believe that there are other cases that were featured on the show, these were not obtainable for the purposes of this analysis. The process of analysing the content of the videos was based on a modified version of that described by Gibson and Brown (2009). One author (A.C.L.H.) watched and re-watched the cases several times. Separate sections of the video cases were watched cyclically and repeatedly to allow full understanding of the themes and signs present. The process of watching the videos and then transcribing the cases allowed the analysis of the data set to begin at an early stage, with deeper meaning, common themes and symbolisms within the cases being identified and developed. The transcription process helped to identify specific areas of interest within the interactions between the different participants of the show. The videos were watched and discussed collaboratively, with the research team developing a shared interpretation of the meaning within the data. This was carried out through the use of Skype to discuss the data set. The research team consisted of two academic dentists with clinical and social research experience and two medical sociologists with experience in the sociology of dentistry and oral health. This helped to develop the range of insights into the data collected and produced a richer analysis of the semiotics and themes within the videos.

Social semiotics is concerned with the socio-political context of texts. In this analysis, the development of the position of the viewer, influenced by social interactions and how these are portrayed and valued within the programme, is of interest. The assessment of the order of values and signs within the texts analysed will indicate the immediate and deeper meanings within the professional/patient interactions documented. Social semiotics operates under the hypothesis that all meaning-making performs three functions that Halliday termed ‘metafunctions’ (Halliday, 1973). Kress and van Leeuwen (1996) modified these metafunctions, defining them to be the representative, interactive and compositional metafunctions. The aspect of the analysis concerned with representation examines the meaning of the texts in relation to what they tell us about the world. Throughout this analysis, how actors and their environments are portrayed will be discussed and explored. The interactive metafunction examines the positions of the characters within the cases and how these relate in turn to the viewers of the programme. This involved looking at all characters within each case, indicating what this suggested about the process of having dental treatment. This also involved examining the social distance created by the programme between the different characters and the viewers (van Leeuwen, 1999). How this is achieved will be discussed by reference to positioning within the programme and camera frame, use of camera angles and how the actors ‘interact’ with the viewers. The final metafunction, composition, relates to how the video cases are set out, their organisation as a collection of scenes, but also within the programme itself. Elements within this include how the passage of time is presented. This aspect of the analysis sought to develop an understanding of how the components of each case are linked together. The use of the metafunctions to analyse visual text allows for a systematic approach to analysing the video cases.

The data set was coded using a combination of concept coding and narrative coding. Concept coding is a style of analytical coding that references a ‘bigger picture’ beyond that which is tangible and apparent (Saldana, 2016). Given that much of the analysis is examining signs, symbolism and hidden meanings within the texts, coding that explored common concepts helped to develop a view of what the texts represented. Observable behaviours and objects within the texts were of interest, but it is through the ideas that underpinned these that the deeper nature of the texts could be understood. Concept coding is especially helpful in the analysis of the data set transcribed from Embarrassing Bodies; it is often used to harmonise units of data with a larger concept, which in this study allowed for the analysis and linkage of individual scenes with their parent cases, as well as the collection of cases as a whole. The use of narrative coding was also used to allow examination of professional–patient interactions within the texts. The positioning of the participants within the relationships was of particular interest. The narrative approach to coding allowed a rich analysis of the therapeutic context of the encounters recorded (Murray, 2003, 2008); this approach helped to reveal aspects of oral health, dental disease and dentistry as life experience. Analytical memos were used as a way of navigating through the data and evolving understanding relating to the phenomena encountered. As an example of the coding process, in the initial scenes of Tracey’s case, we saw that she was introduced to the viewer in the waiting room of the dental practice. The camera operates to contrast her appearance within the context of the plush waiting room, and this was coded in terms of the relationship between social distance and stigma. Tracey then goes on to give a negative evaluation of her dental health and lack of self-care, which is then validated by the show’s narrator to the audience, and this was coded as neglect and blame. A subsequent process of categorisation was developed through several different iterations, and this involved developing these codes into a select grouping of categories, being condensed further into five core themes: intimacy and social distance; discipline, blame and personal responsibility; carnography; disciplining gaze and authority; and redemption and rebirth. This process of categorisation and re-categorisation helped to develop meaning, as well as impart structure and order to the data (Anfara, 2008).

Intimacy and social distance

It is unsurprising, given the show’s mantra of ‘There’s no shame, we’re all the same’, that the concepts of intimacy and social distance would act as a major theme within cases. The cases all share a commonality that the trauma inflicted by dental diseases has negatively affected participants’ ability to fulfil their social roles. Some participants are presented as being unable to engage with family life, which is referenced in several cases; ‘I’d definitely like to take the kids out more and run around with them a lot more and just be more like what normal dads are. Until I get my teeth sorted out, I just don’t have the confidence’ (Rob) with another participant, Kelly, stating, ‘One of the most simple things in the world, a lot of children do give their parents a kiss, mine won’t because I look a bit strange, and I can understand that. I just feel I look like a freak’. Rob also states that he feels that his girlfriend of 9 years is ‘holding back’ when he tries to kiss her. Children of participants are asked for their opinions of their parent’s teeth. The children respond, giving negative evaluation of dental appearance; ‘They look like witch’s teeth and they are just ugly’ and ‘they look like a circus freak teeth; rotten to the core’. The demonstrated impact of dental appearance on oral health status on relationships and intimacy supports research on ‘mouth rules’ (Falk, 1994; Gibson and Exley, 2013; Thorogood, 2000). This states that behaviours relating to the use of the mouth both influence and are influenced by the nature of the relationship between individuals. The show uses the narrator, Dr James, and even the participants’ children to validate the feelings of shame that are elicited by a spoiled dental identity. The show’s slogan, ‘There’s no shame, we’re all the same’, seems not to apply to the dental cases; it is only after the participants’ dental transformation that they are permitted to shed their feelings of deficiency. The show actively normalises and encourages the association of shame and dental disease, and this is visible throughout the themes discussed in this analysis.

Participants frequently reference an inability to smile due to dental disease;

I don’t smile with my teeth, I hate seeing my teeth on photographs. They are quite embarrassing. I just get a bit, kind of, it’s a bit hurtful, I just look at them and go, ‘they’re horrible’ do you know what I mean?

Shame is given to be the most social of the social emotions due to the threat to the social bond that it presents (Scheff, 2000). Shame has been given to be more pervasive than other threats to the social bond as although individuals may only occasionally experience shame, they are constantly anticipating it (Wilkinson and Pickett, 2009).

Many of the participants state that their motivation for seeking treatment is related to desiring a restored dental appearance, ‘just to have a look in the mirror and have a smile come back at me; that would be amazing’. Other participants state that their confidence was relatively good but that their smile was still something they were conscious of, preferring to smile with a closed mouth. The narrator of the cases acknowledges the high visibility of the mouth and smile; ‘many of us hide our embarrassing bodies under clothes, but when it comes to teeth, there’s nowhere to hide’. Moeller et al. (2015) noted that judgements of dental appearance are more likely to be associated with lower socio-economic status than so-called ‘invisible diseases’ such as diabetes and heart disease. It is this visibility that we would argue helps constitute the mouth as a ‘traumascape’.

Participants are often first introduced to the viewer, sitting alone in the waiting room of the dental surgery. They are presented to the viewer as subordinate. The camera pans around the featured participant, who typically is wearing a flat, neutral expression and a fixed gaze away from the line of the camera. This emphasises the social distance, low self-esteem and ultimately disempowerment that these participants experience as a result of their poor oral health. They frequently contrast with the practice environment. The waiting room is a plush room that appears more similar to a hotel lobby than a health facility. Participants typically wear baggy, unflattering clothing with little make-up. They are presented to emphasise their lack of belonging in their luxurious surroundings; here, the body itself becomes a traumascape, presented as matter out of place (Douglas, 2000). This is compounded by the depiction of some of the participants within their own daily lives; most of the participants are depicted as being from low socio-economic backgrounds. The most obvious of these is Jay, a 21-year-old individual working as a binman, who feels his ambition is inhibited by his teeth.

I’d like to work in sports or physiotherapy, but, because of my teeth, it doesn’t really feel right to do it. I feel embarrassed to tell someone how to look after themselves, when I haven’t really taken care of my teeth.

He is presented as unkept and dishevelled, with his teeth being cited as the reason for his unkept appearance. For Jay, the neglect of his oral health and dental appearance is portrayed as having proliferated outwards, affecting the rest of his being.

Jay’s case highlights a common concept within the cases that poor oral health holds those affected by dental disease from reaching their full potential. The subtext within many of these cases is that those who are most affected by dental ill-health are those who are concurrently afflicted by poverty with dental disease presented as a barrier to success; ‘In business, you present yourself as a professional and there you are with rotten teeth, it doesn’t really go’. The insinuation postured is that through their deficits in oral health, the participants suffer low social status along with poor employment and life prospects; the purpose of the show is to repair the participant’s oral health, and in doing so, the implication is that this will elevate their social status. Lawler (2008) suggests that the British upper/middle classes hold a preoccupation with critique of the lower social classes and an obsession with pursuing the betterment of those with low status.

Discipline, blame and personal responsibility

The concept of discipline, blame and personal responsibility is focused on throughout the cases. When participant Tracey is introduced, the narrator tells the viewer that she suffered a nervous breakdown that is a contributory factor for her dental disease. Tracey states, ‘It’s total neglect of myself, self-being, self-worth’. Other participants give similar narratives: ‘Basically, I’ve neglected my teeth, I’m drinking 2 litres of fizzy drink a day at work, eating sugary sweets, chocolate, cakes and they’ve just slowly got worse and worse’ and ‘Over the years, I’ve eaten the wrong foods, drank lots of fizzy drinks and I haven’t really taken care of them, brushed them or flossed or anything like that’. The insinuation given is that Tracey and many of the other participants find themselves in their current oral condition because of a lack of self-control. Here, the role of the narrator and Dr James is to discipline the participants to induce conformity to norms of appearance and oral health. The participants attribute their dental conditions to personal choices and lack of care, rather than to any factors beyond their control or intrinsic inequalities within society. Peacock, Bissell and Owen (2014) have noted a similar pattern of attribution in their study of perspectives on inequality terming this thematic as having ‘no legitimate dependency’. It is through the cosmology of discipline, blame and personal responsibility that the traumascape of the body as diseased receives its place in the order of things.

For many of the participants, shame is compounded through the validation of their disgust by Dr James. When participant Kelly states that clinical photographs taken of her mouth ‘makes me feel disgusted’, Dr James replies, ‘It’s pretty shocking isn’t it really actually, and, in terms of pure decay, I’ve got to be honest here; it’s one of the worst situations that I’ve seen’. Within the structure of the cases, participants are confronted with close-ups of photographs taken as part of the clinical examination and jointly critiqued. Negative reactions are prompted by Dr James asking, ‘When you’re looking at this . . . what does it make you feel like?’ The confrontation of the participants with their own dental health and appearance is designed to increase and reinforce the participants’ feelings of shame, but also tend to illicit reactions from the participants relating to perceptions of personal blame for their condition. Scheff (2000) states that shame underpins conformity and obedience to authority. In this context, Dr James’ validation of the participants’ shame acts as a contextual tool to amplify his power as a disciplining authority.

The narrator is also suggestive that those with dental disease are ‘careless’ for their loss of teeth. Dr James provides patients with complex dental treatments such as crowns and implants. However, before he is prepared to do this, he places emphasis on the need for participants to change their behaviour. He cuts deals with patients to reduce smoking and sugary drink consumption in exchange for treatments. These commitments often appear superficial; Lynne states, ‘I haven’t had a fizzy drink for five days now, and I feel absolutely fantastic, inside. I don’t feel lethargic, just, absolutely amazing actually’. Lynne is also reported not to have smoked for 6 days. The role of the dentist as a disciplining authority has been suggested by Nettleton (1994). Dr James’ disciplining role is well portrayed; the clinical examination and the power of the dentist’s conditions for treatment are promoted as the only required stimulus for lifestyle change. This furthers the predominant narrative of a ‘laissez-faire’ approach to oral health within the programme; personal responsibility is king, oral health improvements are simply a matter of will power and one has to be deserving of the attention of Dr James.

Personal responsibility is a key aspect of this theme and is explored within the programme through examination of the status of participants as being either initially deserving or nondeserving. Matt is 19 years old and is portrayed as having neglected his mouth. To receive treatment, ‘Dr James wants Matt to promise that he will mend his ways and change his sugary diet’; to accomplish this, Matt is made to ‘promise’ that he will engage in homecare. The tone is patronising; ‘Dr James sends him away for 3 months to clean up his act and keep his teeth free of plaque. That means brushing every morning and evening’. Through engaging with oral hygiene practices, Matt becomes deserving, the narrator stating, ‘Matt’s earned his new set of top-notch gnashers by changing his neglectful ways’. Dr James affirms this at the end of the case; ‘The way you’ve changed your lifestyle is admirable, so well done’. The cases are often suggestive of the effectiveness of Dr James’ intervention; most participants are filmed at the end of cases brushing their teeth and watching themselves in the mirror.

Contrasting with this is the case of Zoe. She has lost teeth because she is suffering from a dry mouth, a side effect of having chemotherapy to treat non-Hodgkin’s Lymphoma. Zoe is portrayed as having ‘been attacked’ and there is no associated blame or responsibility attributed to her in the same way as with Matt. On completion of treatment, Dr James states, ‘You know you deserve it and I’m really really happy’.

Disciplining gaze and authority

Dr James’ gaze is powerful, allowing him to make personal judgements on patients that extend beyond objective statements relating to their condition, that also act to enhance their feelings of inadequacy; ‘it’s time for us to be pretty honest about what’s going on really, and, for someone of your age, I’m pretty shocked at how things are looking’. This concept ties closely with the theme of discipline, blame and responsibility. Through his authority, Dr James exercises his disciplining gaze on the participants of the show. Through this presentation of the interaction between dentist and participant, Dr James develops his status as a disciplining, professional authority (Foucault, 1977; Nettleton, 1994).

The show is presented by three medical doctors who are portrayed as figures of authority and medical wisdom. Dr James is presented as being separate, but equal to these figures. He is the main dentist within the cases, with others being introduced as advanced practitioners who will provide more specialist services. Dr James’ authority is enforced through the display of professional diplomas and certificates which cover the entirety of one wall within the room. Within sight of the cameras, a collection of professional trophies and awards occupies a corner of the surgery. These enhance Dr James’ authority and confer the right to act as the arbiter of oral health needs, as an emissary of dental knowledge, paralleling the presentation of cosmetic surgeons in other analyses of medical reality TV (Heyes, 2007).

The authority of Dr James is elevated beyond that of the other dental professionals on the show in several different ways. He is the only dentist featured, along with the medical presenters, within scene cutaways. These cutaways are typically used as punctuation between changes in topics, to show skips in time (before and after intervention) and last a couple of seconds. They feature one of the presenters in a medically provocative stance, for example, one of the doctors poses with an outstretched hand that literally drips with lubrication gel. In the cutaways featuring Dr James, his dominance is enforced through using the interactive metafunction. He holds a strong, unbroken gaze into the camera, sometimes from behind a surgical mask. He is the only dental professional in the show to ever make direct eye contact with the viewer. Kress and van Leeuwen (1996) state that direct contact in this manner typically ‘demands’ something from the viewer. This is illustrated well through the example of the infamous First World War recruitment poster featuring Lord Kitchener. The cutaways place the viewer in the position of a patient who is about to be subjected to examination. Frequently, they are filmed from positions where Dr James is placed in a more superior position to the camera. This gives the impression that he is looming over the viewer, examining them as well. While other dentists are interviewed and named, Dr James is the only professional who is presented as equal to the medical presenters of the show. This is compounded by the comparison that may be made between the presentation of Dr James and the hygienist who works within the same practice that participants are sometimes sent to. In contrast to Dr James’ overexposed, white, bright surgery, that act to expose him as well, the hygienist works in a small, darkened room where she is never named or identifiable.

Dr James is presented to the viewer as being part of an old establishment of powerful and all-knowledgeable healthcare professionals. His approach is paternalistic, often acting as a gatekeeper to treatments, especially those that are deemed expensive; ‘(dental implants) are very expensive. So Dr James will not give Jay this treatment unless he changes his unhealthy habits’ and ‘Once the scan is analysed, James will decide if she should have temporary dentures or posh implants’. Unlike in many real-world dental encounters, money is never overtly discussed. The viewer is left to assume that due to the commentary on expensive treatments such as implants, the patient is not being expected to fund the treatment they are receiving on the show, contributing to the presentation of the participants receiving dental treatment as being of a lower class. This is reinforced by the social status given to different treatments; while dentures are not directly signified as being a symbol of poverty, they are contrasted with and inferior to implants which are described to the viewer as ‘posh’. The narrative created by the show seems to suggest that the patients receiving treatment should be grateful for whatever they receive, that their own social status is elevated by receiving treatments that they might otherwise not afford. Treatment goals are presented as Dr James’ personal goals, rather than making reference to a shared process. In one instance, Dr James tells a patient that he is doing well, before asking him if this is the case; ‘Richard, you’re doing really, really well, how are you doing?’ Patients are not positioned by the relationship with themselves and Dr James to be the authorities on their own realities. The surgery is positioned to allow Dr James to assert his authority; the chair is the focus of the room in the centre, where it symbolises the submission of the patient to examination. This is always followed by the confrontation of participants with the stripped-back view of their current oral condition, presented alongside a computer-generated representation of what could be. The participants are nearly always positioned nearer the camera and sit in profile. In contrast, Dr James sits facing the direction of the camera when he is talking and presenting the case and treatments he recommends. This helps to frame within the scene that the participant is there, being passively acted upon by the dentist, Dr James (van Leeuwen and Jewitt, 2001).

Carnography

Carnography is typically associated with gratuitous scenes of violence, flesh and blood. Within the context of this study, carnography references the stark portrayal of dental diseases and invasive dental treatments. Several scenes within the cases are heavily laden with explicit dental procedures. The removal of teeth, insertion of implants into surgical sites and the preparation and completion of root canal treatments are all shown featuring blood, extracted teeth and exposed bone, often in extreme close-up camera shots. Voyeuristic undertones are given by filming being carried out through the surgery door window, which is shaped like a ship’s porthole. The fascination of the macabre becomes more overt when implantologist, Zaki Kanaan, makes a potentially ill-judged comment relating to the sourcing of bone substitute material for use in implant procedures; ‘in America they actually use bone from dead people, it’s totally safe . . . don’t worry we’re not using that for you!’

Despite the purpose of the programme being to provoke conversations relating to medical conditions perceived to be underdiscussed, the exposure of intimate procedures is voyeuristic carnography. This happens when participants are asked to critique their dental appearance and oral health, in doing so the viewer is also invited to do the same. The exposure of the mouth reveals the participant’s disease to an extent that is far greater than would be possible normally through the use of cheek retractors. This procedure is completed for each participant in a ritualistic fashion subsequent to the examination. It allows the viewer to participate in the dental examination, the critiquing exercise and subsequent treatment. This would normally occur behind the closed surgery door. In this manner, the show transforms the normal process of dentistry into a panoptic.

The exposure of the participants’ pathology at the beginning of each case, combined with the horror of the participant’s lived realities with the impact of dental disease on their daily lives, sets the standard of what is classified as ‘normal’ in gendered and classed terms. In doing this, it also maintains a fascination with the abnormal, described by Subramanian (2013) as being, ‘grotesque’ (p. 109). Through the transformative process, we see a diseased mouth becomes further disordered; teeth are taken from bone and blood is a frequent sight, often oozing from naked bone. The ‘unruliness’ of the mouth before treatment gives way to one that is more conventionally normal, desirable and acceptable (Rowe, 1995). The process of the development of participants’ alter egos or the creation of doppelgangers within makeover television has been paralleled to the horror genre where transformations hold similar carnographic fascination (Subramanian, 2013).

Rebirth and redemption

Participants are introduced on the shows as holding the belief that they are deficient due to their current oral condition, and these views are quickly confirmed by the show to be accurate and correct. Often this relates to confidence, self-esteem and/or self-disgust within the context of their oral health. This also is attached to the participants’ social class and position within society, with individuals being presented as having failed to reach their full potential. Through the process of examination and confrontation, Dr James takes them through a course of treatment towards rebirth. The narrative is very strong within the show that by receiving treatment, they are not only made well but also made to be their best selves. Participant Matt states, ‘To go from that, to this is absolutely amazing. I’ll be able to walk down the street with my head held high’. He is proud of his new-found confidence and boost in appearance.

While most of the transformations within the show are highly visible, the most noticeable change comes from participant Jay. When first introduced, Jay wears a scruffy beard with long, unstyled hair. On his final appointment, Jay has already undergone a transformation before receiving his final treatment; ‘I’ve shaven off the beard and got a little bit of a haircut, the reason for that is I had a beard to hide my teeth, so that people wouldn’t really spot it that much’. As noted above, Jay dreams of being involved professionally with healthcare. After receiving his new implants, he talks about how things have changed.

Now I’m brushing twice a day, flossing every day, doing an awful lot more to keep these teeth that I have now. I’m a much more happier person; I’m definitely going to be going forward to fulfil my dreams really.

Within many of the cases, the concept that the impact of a cosmetically pleasing smile is wide-reaching is frequently encountered. Zoe talks about her new smile giving her closure; ‘I think now, we can put the Non-Hodgkin’s Lymphoma behind us. Totally, it’s just as if it’s closure to that now and I can start look forward to the future, with my new teeth’. For her, the act of regaining her smile following her cancer therapy has symbolised the end of a chapter in her life that she would prefer to leave behind. Redemption is complete, dirt removed from the traumascape, restoring order (Douglas, 2000).

The use of participant’s children to explore this concept also occurs. In Lynne’s case, one of her children asks, ‘Mum, when your teeth get fixed, will you be able to take me swimming and everything?’ Lynne’s reply is an affirmation of her aspiration to be more involved. Kelly, who is sensitive of her children’s reaction to her dental appearance, after her ‘big reveal’ states that she cannot wait to kiss her son, and Tracey imagines the possibility of new love; ‘I haven’t smiled for almost a decade. It actually feels amazing to smile with confidence. I’ve been single 7 years so something might happen!’ Lynne’s transformation, like that of Jay, seems to affect other aspects of her appearance; ‘I’m going to need to buy a new dress, a new pair of shoes and some lipstick as well, because I haven’t had lipstick on for about 10 years. It’s just the start of a new me, definitely’. The idea of a ‘new me’ or ‘new chapter’ is common to many of the cases. Within the theme of intimacy and social distance, the lack of belonging that the participants demonstrate is apparent on their first presentation to the audience. Through treatment, they develop conformity to professional and societal ideals, and they are subsequently ready to be portrayed as citizens who belong (Jones, 2008). Jones points out that the immediate reaction to the idea that surgical intervention might create ‘a new me’ or expose the true self is one of absurdity but notes that within a media-obsessed culture, perhaps these statements are increasingly true. The treatment is valued based upon its immediacy; the audience is never exposed to the inevitability of restoration failure and the need for replacement. The higher status of certain dental treatments is vicariously transferred to the participants receiving them, further contributing to the show’s narrative which associates a damaged and neglected dental appearance with low social class.