ASSIGNMENT 1

USING THE EXAMPLE OF CARIES PROVIDE AN EXAMPLE OF

HEALTH PROMOTION ACTIONS FOR YOUTh . DISCUSS
YOUR POINTS ON HEALTH PROMOTION UNDER EDUCATION
,COMMUNITY ACTION , AND RISK FACTORS PREVENTION IN
PRIMARY CARE SETTING ..?

EDUCATION ON DENTAL CARIES :

Our team has decided to investigate the epidemiology

of dental caries in Scottish children, below the age of 16
inclusively from the 1970's to present. Scotland has the
highest prevalence of tooth decay in Europe. This is
evident from the numerous data sources ascertained.
There are associated inequalities found in geographic
and socio-economic subgroups which are at the
forefront of dental caries prevalence in Scotland.
The combination of bacteria with small food particles
and saliva creates a sticky film on the tooth which is
commonly known as plaque. Over consumption of sugary
food and drink, which is high in carbohydrate, provides
the bacteria with the energy it needs, whilst producing
acid simultaneously. If this plaque is neglected, it will
erode the tooth causing dental caries. In Scotland there
is a 'sweetie culture', where sugary snacks are too readily
available and so consumption levels are damaging
children's teeth. As a result the Scottish government are
making efforts to assess the problem and subsequently
trying to resolve it.
The classification of dental caries is done by several sets
of criteria, the primary one being the DMFT
(decayed/missing/filled teeth) which divides the
population into two groups and gathers the mean from
each of decayed missing and filled teeth. It's measured
from 0 to 32 in terms of affected teeth for people over
the age of 12 and from 0 to 20 in children. The
prevalence portrayed by this measurement has seen a
marked decrease in caries in children from 2.16 in 2006
to 1.86 in 2008. It's been of paramount importance to the
Scottish Government in assessing the levels of caries in
children and giving them direction in terms of policy
making and goal setting. This is evident from the Graph
15 portrayed in the appendix, which displays the
decrease in caries, which in this instance displays decay
that goes in to the dentine (d3mt) since the 1980s, with
the mean age of children being 5.54 years old. This
marked decrease has allowed the government to target
specific areas of Scottish society to enable an even
further reduction in prevalence in caries and
employment of even more defined classification models.
Another method used for assessing dental caries in
preschool children in Scotland is the DCRAM (Dundee
Caries Risk Assessment Model). This statistical analysis
tool provides an appropriate risk assessment model to
determine incidence in a community setting. The DCRAM
collects data from one year olds, and uses this data to
predict caries incidence over a three year timeframe, to
when they are at the age of four. Data is collected
following a dental and microbiological examination and
from information received via parental questionnaires.
This type of model makes it easier to differentiate
people into different sub-groups so as to investigate the
differing incidence levels of oral ill-health within these
sub-groups, for example urban and rural differences in
dental caries of five year old children in Scotland. Here
Scotland was split into six different geographies, namely
the four 'big' cities (Glasgow, Edinburgh, Dundee and
Aberdeen) to the smaller 'rural areas'. The findings of
this study were that the children in rural areas had a
better level of dental health than those living in urban
areas (mean DMFT of 1.87 for all of Scotland, the four
cities 2.16, other urban 1.81 accessible towns 1.88,
remote towns 1.86, accessible rural 1.31,remote rural
1.34).
Socioeconomic factors have been attributed to the cause
of caries in Scotland, where deprivation is positively and
significantly associated with having d3mft. In a three
year follow up study undertaken it was obvious that a
serious level of DMFT imbalances between the upper
class (SEG1) of society and the lower class (SEG2)
existed. As noted the percentage improvements found in
SEG1 were up to three times larger than those in
SEG2.This study undertaken in the 1980's led to the
development of further classification tools to give
greater transparency. The Dep Cat scale divided
communities into socioeconomic groups from 1 (most
affluent) to 7 (most deprived). In doing so it applied the
DMFT to reveal high levels of inequality with "findings in
this study rangved.
"Epidemiological principles, methods, tools and
information are applied in every aspect of public health
from policy setting at macro level to decision making at
individual level", therefore making the collection and
cohesion of information highly important. The result of
this work by the Scottish government and health officials
has given us tangible trends to decipher the level of
dental caries in the country. Graphs 312 and 412 in the
appendix clearly portray the level and improvement in
dental caries in Scotland. It is given expectation and
focus to the government in their implementation of
preventive measures for the future.
COMMUNITY ACTION :

Pit and fissure configuration on tooth can harbor bacteria

and lead to dental caries. Prevention of dental caries
would be most efficient when the interaction between
the host, causative agent and favoring environmental
factors is inhibited. Fissure sealant is a primary
prevention approach as it diminishes the risk of getting
dental caries by enhancing resistance against the
bacteria.
A systematic health review published by NHS Health
Scotland outlines fissure sealants as one of the early
childhood caries prevention measures. Three studies
were carried out on children under five years old to
prove sealants are effective against occlusal dental
caries depending on the retention rate, type of sealant
and method of application. Rather than treating sequel
of dental caries, preventive sealants are considered cost-
effective compared to expensive restorative procedures.
However, an article by Department of Paediatric
Dentistry, University of Glasgow, Scotland addressed the
efficiency of sealants depends on several factors. Caries
are more susceptible in molar tooth, at highest risk
during post-eruption period and whether resin-based or
glass ionomer fissure sealants were to be chosen is
influenced by moisture control. If sealants are used for
all cases and risk assessment is neglected, this will
reduce the cost-effectiveness.
On the contrary, fissure sealants are effective against
dental caries only if retained. Sealants require vigilant
management that they must be replaced over time.
Glasgow Dental Hospital and School reported out of 7000
sealants applied by private practitioners in Scotland, 23%
of failed sealants end up carious after 4 years. This study
concludes that maintenance of originally sealed fissures
is vital for success sealants in long run. The study
concluded that dental caries are bacterial, regardless of
age and the process of wearing sealants would be of the
same in any age group.
The use of fluorides, on the other hand, in either topical
(mouth rinsing solutions, tablets, toothpastes) or
systemic (fluoridated water, milk or salt) forms, has
shown to have a positive effect on the prevention and
reduction of dental caries experience among children
and adolescents, global. Although fluoridation of water is
considered one of the ten main achievements of public
health interventions, its real advantages to public health
remain controversial. Scotland rejected artificial water
fluoridation amidst public complaints of its harmful side
effects, namely fluorosis or "mottled teeth."
Over the past 50 years in the UK, fluoridated toothpastes
have played a crucial role in the declining trends of
dental caries in children (in terms of reduced DMFT
scores and overall oral health.) , There is also consensus
about 1000ppm Fluoride concentration per toothpaste as
optimal for ensuring protection from dental caries, and
has proved to be 25% more beneficial in preventing tooth
decay. Systematic review carried out by the University of
Dundee reinforces the superior preventive effect of
fluoride toothpastes compared to placebos (addition PF,
24.9%.) Researchers and public health authorities have
unanimously placed fluoride toothpaste as "the method
of choice for preventing caries, as it is convenient and
culturally approved, widespread, and it is commonly
linked to the decline in caries prevalence in many
countries."
One of the chief concerns associated with consumption
of fluorides is the incidence of fluorosis. Systematic
reviews of studies carried out across the UK indicate a
positive correlation between the concentrations of
fluoride and dental fluorosis. Moreover, there are two
major concerns associated solely with topical fluoride
use- a) noncompliance with tooth brushing regimens and
b) chronic overconsumption of toothpaste among
children leading to increased risk of fluorosis. While
some studies claim that fluoridated water is associated
with higher incidence of diseases like bone fractures,
senile dementia or cancer; no conclusive evidence has
been reported. Other concerns of fluoridation like its
effects on immunity, reproductive health and GI effects
have also not shown to be clinically significant.
A third prevention strategy called Child smile was fully
running since 2011. It is a children orientated, oral
health promotion programme driven by the NHS. The aim
is to improve the overall oral health of all children across
Scotland and reduce inequalities in dental public health
and access to related services.
Child smile has three components, the Core, which is
applied to all Scottish children, provides fluoridated
toothpaste and toothbrushes till five years of age and
advocates supervised tooth brushing. The Practice
component allows new parents to register easily with
local dental practices and is educated on oral health,
such as tooth brushing methods and diet. Risk
assessments are used to identify children at high risk,
who are then provided with varnish and fissure sealants.
The third component, Nursery and School, provides twice
per annum fluoride varnish applications to those living in
the most deprived local quintile of Scotland under the
Scottish Index of Multiple Deprivation (SMID).
In 1996, the Greater Glasgow Health Board introduced a
community-based oral health promotion for five year
olds in the most socially deprived areas in Glasgow,
comparable to Childsmile, which involved establishing
Oral Health Action Teams (OHATs). OHAT's main goals
are very similar to Child smile’s, including supervised
tooth brushing, providing information to parents and
supporting local dentists to further promote oral health.
A follow-up study was done and the D3MFT values has
shown to decrease from 5.5 to 3.6 and from 6.0 to 3.6
respective to DepCat 1 and 2 communities and the mean
D3MFT values of 5 year olds was reduced in all DepCat 7
communities from 4.9 to 4.1. "This change was of
sufficient magnitude to impact upon area-wide statistics
for Glasgow". This suggests that oral health education
interventions do give a positive impact on the population
if it is implemented rigorously.
Even though dental treatments are now relatively more
advanced and effective, it is difficult for the whole
population to benefit from these treatments, due to cost
and access, as a prevention strategy for further tooth
decay. Hence, it would be wiser to put into place public
health strategies to get the knowledge to the general
public and to promote the idea from young that
'prevention is better than treatment' for oral health.
But even with these health promotion programmes, there
is evidence that shows how it is not a sustainable way to
stop poor oral health because they do not tackle the
main underlying cause. This leads to an ethical dilemma;
creating a bigger inequality gap of access to oral
healthcare, with those being in higher SES groups
actually benefitting more than those who are in much
more need of these service in the most deprived
population.

WORKPLACE: -

Fortunately, a number of prevention and health

promotion interventions exist. In 1995, the World Health
Organization (WHO) launched the “Global School Health
Initiative” which is designed to improve the health of
students, school personnel, families and other members
of the community through schools. The direction of the
initiative is guided by the Ottawa Charter for Health
Promotion.
Schools have proven a powerful setting for secondary
socialisation. Students can be accessed during school
years, a period that runs from childhood to adolescence.
These are influential stages in people’s lives when
lifelong sustainable health related behaviours, as well
as beliefs and attitudes, are being developed. Globally,
approximately 90% of children attend primary schools,
yet the figure is somewhat lower in Sub-Saharan Africa
(77%) (UNESCO, 2011). A substantial part of the child
population can thus be reached through primary schools.
Children are particularly receptive during this period and
the earlier the habits are established, the longer lasting
is the impact. Moreover, the messages can be reinforced
regularly throughout the school years. Children may also
be equipped with personal skills that enable them to
make
healthy decisions, to adopt a healthy lifestyle and to
deal
with stressful situations such as violence and conflicts.
To get accurate data on health behaviours and protective
factors among school children the “Global School-based
Student Health Survey (GSHS)” has been developed
addressing the leading causes of morbidity and mortality
among children and adults worldwide (alcohol, diet, drug
use, hygiene – including oral hygiene -, mental health,
physical activity, sexual behaviours, tobacco use,
violence and unintentional injury)(WHO, 2012). The
manual “WHO Oral Health Surveys - Basic Methods”
(WHO, 2013a) provides the tools for gathering data on
oral health status of children and information about oral
health risk factors and quality of life. School health
programmes are important for promoting health and
healthy lifestyles of children and youth. Activities should
emphasise the development of healthy environments and
enable personal health practices. Health education is
one key element in health promotion and requires sound
planning based on theories of healthrelated behaviour.
Oral health has shown to be easily integrated into such
school health activities. A manual on how to incorporate
oral health in schools as well as recommendations on
how to evaluate community-based oral health promotion
and disease prevention has been developed by the WHO.

The range of approaches to oral health through

schools:

Around the globe oral health is being approached through

schools. How this is done, the scope, the strategies
applied
and the professionals involved varies widely across
countries and areas. It depends on a number of factors
such as organisation and financing of the health and
education sectors, the socio-economic situation of the
country/area, traditions and focus of the oral and
general
health sector, health policies, and the burden of oral
disease among the target group just to mention a few.

 FLUORIDE ADMINISTRATION THROUGH SCHOOLS

 SPECIFIC PREVENTIVE CARE PROVIDED THROUGH
SCHOOLS
 ORAL HEALTH EDUCATION
 ORAL HEALTH IN BROADER CONTEXT

RISK FACTORS PREVENTION :

Dental caries (i.e., tooth decay) is an infectious,

multifactorial disease afflicting most persons in
industrialized countries and some developing countries
(1). Fluoride reduces the incidence of dental caries
and slows or reverses the progression of existing
lesions (i.e., prevents cavities). Although pit and
fissure sealants, meticulous oral hygiene, and
appropriate dietary practices contribute to caries
prevention and control, the most effective and widely
used approaches have included fluoride use. Today, all
U.S. residents are exposed to fluoride to some degree,
and widespread use of fluoride has been a major
factor in the decline in the prevalence and severity of
dental caries in the United States and other
economically developed countries (1). Although this
decline is a major public health achievement, the
burden of disease is still considerable in all age groups.
Because many fluoride modalities are effective,
inexpensive, readily available, and can be used in both
private and public health settings, their use is likely to
continue.
Fluoride is the ionic form of the element fluorine, the
13th most abundant element in the earth's crust.
Fluoride is negatively charged and combines with
positive ions (e.g., calcium or sodium) to form stable
compounds (e.g., calcium fluoride or sodium fluoride).
Such fluorides are released into the environment
naturally in both water and air. Fluoride compounds
also are produced by some industrial processes that
use the mineral apatite, a mixture of calcium
phosphate compounds. In humans, fluoride is mainly
associated with calcified tissues (i.e., bones and teeth)
because of its high affinity for calcium.
Fluoride's ability to inhibit or even reverse the
initiation and progression of dental caries is well
documented. The first use of adjusted fluoride in
water for caries control began in 1945 and 1946 in the
United States and Canada, when the fluoride
concentration was adjusted in the drinking water
supplying four communities (2--5). The U.S. Public
Health Service (PHS) developed recommendations in
the 1940s and 1950s regarding fluoride concentrations
in public water supplies. At that time, public health
officials assumed that drinking water would be the
major source of fluoride for most U.S. residents. The
success of water fluoridation in preventing and
controlling dental caries led to the development of
fluoride-containing products, including toothpaste
(i.e., dentifrice), mouthrinse, dietary supplements,
and professionally applied or prescribed gel, foam, or
varnish. In addition, processed beverages, which
constitute an increasing proportion of the diets of
many U.S. residents (6,7), and food can contain small
amounts of fluoride, especially if they are processed
with fluoridated water. Thus, U.S. residents have
more sources of fluoride available now than 50 years
ago.
Much of the research on the efficacy and effectiveness
of individual fluoride modalities in preventing and
controlling dental caries was conducted before 1980,
when dental caries was more common and more
severe. Modalities were usually tested separately and
with the assumption that the method would provide
the main source of fluoride. Thus, various modes of
fluoride use have evolved, each with its own
recommended concentration, frequency of use, and
dosage schedule. Health-care professionals and the
public have sought guidance regarding selection of
preventive modalities from among the available
options. The United States does not have
comprehensive recommendations for caries
prevention and control through various combinations
of fluoride modalities. Adoption of such
recommendations could further reduce dental caries
while saving public and private resources and reducing
the prevalence of enamel fluorosis, a generally
cosmetic developmental condition of tooth enamel.
This report presents comprehensive recommendations
on the use of fluoride to prevent and control dental
caries in the United States. These recommendations
were developed by a work group of 11 specialists in
fluoride research or policy convened by CDC during
the late 1990s and reviewed by an additional 23
specialists. Although the recommendations were
developed specifically for the United States, aspects of
this report could be relevant to other countries. The
recommendations guide health-care providers and the
public on efficient and appropriate use of fluoride
modalities, direct attention to fluoride intake among
children aged <6 years to decrease the risk for enamel
fluorosis, and suggest areas for further research. This
report focuses on critical analysis of the scientific
evidence regarding the efficacy and effectiveness of
each fluoride modality in preventing and controlling
dental caries and on the use of multiple sources of
fluoride.
The prevalence and severity of dental caries in the
United States have decreased substantially during the
preceding 3 decades (39). National surveys have
reported that the prevalence of any dental caries
among children aged 12--17 years declined from 90.4%
in 1971--1974 to 67% in 1988--1991; severity
(measured as the mean number of decayed, missing,
or filled teeth) declined from 6.2 to 2.8 during this
period (40--43).

These decreases in caries prevalence and severity

have been uneven across the general population; the
burden of disease now is concentrated among certain
groups and persons. For example, 80% of the dental
caries in permanent teeth of U.S. children aged 5--17
years occurs among 25% of those children (43). To
develop and apply appropriate and effective caries
prevention and control strategies, identification and
assessment of groups and persons at high risk for
developing new carious lesions is essential (44). Caries
risk assessment is difficult because it attempts to
account for the complex interaction of multiple
factors. Although various methods for assessing risk
exist, no single model predominates in this emerging
science. Models that take multiple factors into account
predict the risk more accurately, especially for groups
rather than persons. However, for persons in a clinical
setting, models do not improve on a dentist's
perception of risk after examining a patient and
considering the personal circumstances (45).

Populations believed to be at increased risk for dental

caries are those with low socioeconomic status (SES)
or low levels of parental education, those who do not
seek regular dental care, and those without dental
insurance or access to dental services (45--47).
Persons can be at high risk for dental caries even if
they do not have these recognized factors. Individual
factors that possibly increase risk include active dental
caries; a history of high caries in older siblings or
caregivers; root surfaces exposed by gingival
recession; high levels of infection with cariogenic
bacteria; impaired ability to maintain oral hygiene;
malformed enamel or dentin; reduced salivary flow
because of medications, radiation treatment, or
disease; low salivary buffering capacity (i.e.,
decreased ability of saliva to neutralize acids); and the
wearing of space maintainers, orthodontic appliances,
or dental prostheses. Risk can increase if any of these
factors are combined with dietary practices conducive
to dental caries (i.e., frequent consumption of refined
carbohydrates). Risk decreases with adequate
exposure to fluoride (44,45).

Risk for dental caries and caries experience* exists on

a continuum, with each person at risk to some extent;
85% of U.S. adults have experienced tooth decay (48).
Caries risk can vary over time --- perhaps numerous
times during a person's lifetime --- as risk factors
change. Because caries prediction is an inexact,
developing science, risk is dichotomized as low and
high in this report. If these two categories of risk were
applied to the U.S. population, most persons would be
classified as low risk at any given time.

Children and adults who are at low risk for dental

caries can maintain that status through frequent
exposure to small amounts of fluoride (e.g., drinking
fluoridated water and using fluoride toothpaste).
Children and adults at high risk for dental caries might
benefit from additional exposure to fluoride (e.g.,
mouthrinse, dietary supplements, and professionally
applied products). All available information on risk
factors should be considered before a group or person
is identified as being at low or high risk for dental
caries. However, when classification is uncertain,
treating a person as high risk is prudent until further
information or experience allows a more accurate
assessment. This assumption increases the immediate
cost of caries prevention or treatment and might
increase the risk for enamel fluorosis for children aged
<6 years, but reduces the risk for dental caries for
groups or persons misclassified as low risk.

DIFFERENT FLOURIDE SOURCES :

 FLOURIDATED DRINKING WATER

 FLOURIDE TOOTHPASTE
 FLOURIDE MOUTHRINSE
 DIETARY FLUORIDE SUPPLEMENTS
 FLOURIDE GEL AND FOAM
 FLOURIDE VARNISH

WHAT ARE THE ADVANTAGES AND DIADVANTATGES OF

MASS MEDIA IN ORAL HEALTH CAMPAIGNS.?
ADVANTAGES :
1. It educates people. Through television and radio
programs, people get to learn about health matters,
environmental conservation, and much more.
2. People get the latest news in a very short time.
Distance is not a barrier. People get news daily
through the media and this keeps them updated on the
happenings around the world.
3. People get to bring out their hidden talents.
Through media showcase their talents such as comedy,
acting and singing.
4. Children’s knowledge increases. Children can learn
from quiz programs, animal programs and so on.
5. Radio is convenient as people do get short news and
with a mobile phone one can access it.
6. Great in promoting mass consumer products. This
can in turn increase sales of the product.
7. Serves as a good source of entertainment. People
get entertained through music and television
programs.
8. Television allows electronic duplication of
information. This reduces the production cost making
mass education possible.
9. Media leads to diffusion of different cultures. Media
showcases different cultural practices.
10. It helps people around the world to understand
each other and embrace their differences.
Disadvantages:
1. It leads to individualism. People spend too much
time on the internet and watching television. As a
result, socialization with friends, family and neighbors
is affected.
2. Some media contents are not suitable for children.
Limiting children’s access to such content can be
difficult.
3. Newspaper is geographically selective.
4. Increase in advertisements in television and radio is
making them less attractive.
5. Internet as a form of media opens up possibilities of
imposters, fraud and hacking.
6. Media can be addictive, e.g. some television
programs and internet. This can lead to decrease in
people’s productivity.
7. Health problems. Prolonged watching of television
can lead to eyesight problems and radio listening using
earphones exposes one to possible hearing defects.
8. It glamorize drugs and alcohol. Some programs make
the use of these things appear cool’.
9. It can lead to personal injury. Some people decide
to follow the stunts that are showcased in the media.
This can lead to injuries.
10. It can lead to ruin of reputation. It is possible for
one to create an anonymous account. Such accounts
can be used to for malicious reasons such as spreading
rumors. This can lead to ruin of reputation of an
individual or a company.

ORAL HEALTH GOALS FOR 2020:

GOALS:
To minimise the impact of diseases of oral and
craniofacial origin on health and psychosocial
development, giving emphasis to promoting oral health
and reducing oral disease amongst populations with the
greatest burden of such conditions and diseases.
To minimise the impact of oral and craniofacial
manifestations of systemic diseases on individuals and
society, and to use these manifestations for early
diagnosis, prevention and effective management of
systemic diseases.

Targets
By the year 2020 the following will have been achieved
over baseline:
(out of the 16 targets, some are presented here)

9. Dental caries

To increase the proportion of caries free 6-year-olds by

X%.
To reduce the DMFT particularly the D component at age
12 years by X% with special attention to high-risk groups
within populations, utilising both distributions and
means.
To reduce the number of teeth extracted due to dental
caries at ages 18, 35-44 and 65-74 years by X%.

11. Periodontal diseases

To reduce the number of teeth lost due to periodontal

diseases by X% at ages 18, 35-44 and 65-74 years with
special reference to smoking, poor oral hygiene, stress
and inter-current systemic diseases.
To reduce the prevalence of necrotising forms of
periodontal diseases by X% by reducing exposure to risk
factors such as poor nutrition, stress and immuno-
suppression.
To reduce the prevalence of active periodontal infection
(with or without loss of attachment) in all ages by X%.
To increase the proportion of people in all ages with
healthy periodontium (gums and supporting bone
structure) by X%.

14. Tooth loss

To reduce the number of edentulous persons by X% at

ages 35-44 and 65-74 years.
To increase the number of teeth present by X% at ages
18, 35-44 and 65-74 years.
 To increase the number of individuals with functional
dentitions (21 or more natural teeth) by X% at ages 35-44
and 65-74 years.

Global Goals for the Year 2000

The WHO in its World Health Assembly adopted a
resolution in 1979 calling for health for all by the year
2000. Subsequently in 1981 the WHO adopted as the first
global indicator of oral health status an average of not
more than 3 DMFT at the age of 12 by the year 2000. The
following global goals were proposed for year 2000 by
the WHO and FDI in 1981.

Goals:
50 per cent of 5-6-year-olds will be caries free.

The global average will be no more than 3 DMF teeth at

12 years of age.

85 per cent of the population should retain all their

teeth at the age of 18 years.

A 50 per cent reduction in present levels of

edentulousness at the age of 35-44 years will be
achieved.

A 25 per cent reduction in present levels of

edentulousness at the age of 65 years and over will be
achieved.
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