Preventive Dentistry

and
Dental Public Health
Part 2
For Fourth Year Students

Dr. Wael Mahmoud AbdAlkhalek

A. Professor of Pediatric and Pediatric and Preventive
Dentistry and Dental Public Health
2020-2021
 CONTENTS

Page
No Subject
No
1 Introduction in Epidemiology. 2

2 Epidemiology of Dental caries. 4

3 Epidemiology of Periodontal diseases. 19

4 Handling of data 37

5 Dental needs, resources and objectives. 44

6 Organization of Dental care. 51

7 Group Practice. 57

8 Team Work. 58

9 The dental health programs. 59

10 Forensic Dentistry 65

-1-
 Epidemiology

The word "epidemiology" is derived from the Greek epi= upon,

demos = the people, and logos-science. The scope of this branch of
science was originally confined to the origin, development a wider t,
and distribution of communicable disease or epidemic infections, but
nowadays, it hand more literal meaning. It can be defined as: "a
science concerned with the occurrence, distribution and determinants
of states of health and disease in human groups and populations."
Epidemiology is chiefly concerned with the diagnostic
procedure in mass disease and other conditions in human populations
where the group rather than the individual is the unit of interest

There are two basic types of epidemiology:

1. Descriptive epidemiology: (Including descriptive surveys):
It is concerned with the observation and reporting of the distribution
of a disease or condition in a population or populations. Later,
hypotheses may be formulated to explain those observations.
2. Analytical epidemiology (Including analytical surveys and
experiments):
It is designed to test the hypothesis formulated to explain these
observations or studies. In this type of investigation the
epidemiologists seek to discover factors and mechanisms associated
with the distribution and prevention of the disease.

-2-
Epidemiologic studies have 3 main uses:
1. They serve as a diagnostic purpose in mass disease (community
diagnosis or group diagnosis), i.e. epidemiologic studies provide the
required information about the determinants of health and disease in
his specific community or group.
2. Epidemiologic studies can throw light on etiology and natural
history of the disease.
3. Epidemiologic studies contribute to the evaluation of health care.

Epidemiologic Problems in Dental Field:

1. Dental caries.
2. Periodontal diseases.
3. Dental cleanliness, stain, calculus.
4. Enamel opacities and fluorosis.
5. Malocclusions and handicapping dentofacial anomalies.
6. Oral neoplasms.

Epidemiologic investigation should follow the following pattern:

I. Establishing the objectives.
II. Design of the investigation.
Ill. Selection of the sample.
IV. Conducting the examinations.
V. Analyzing the data.
VI. Drawing the conclusions.
VII. Publishing the report.

-3-
I. Establishing the objectives:
In many scientific experiments the objectives can be stated in the
form of a hypothesis which is to be tested.
The investigator must be absolutely clear about the objectives of the
investigation before considering its design as the latter is entirely
dependent on the former. The starting point of a study is frequently
the expression of a "null hypothesis", that is the assumption, for
example, that there is no difference in the extent of dental disease
between the groups to be investigated (descriptive surveys) or in
cases of clinical trial (experiment), that one method is not better than
another in preventing or treating disease or condition. The objective
of the study is then to test this hypothesis.
In other circumstances, the objective may be settled by describing
what is to be measured, for example, to determine the resources
necessary to provide a service which will render particular
population caries free. In this case, it is necessary to define each of
these terms in ways that are measurable.

II. Design of the Investigation:

A. Types of studies:
1. Prevalence study or cross sectional study:
Where the occurrence of a disease or condition in a population is
expressed at a given point of time, so prevalence study means "the
condition existing at a particular point of time", i.e. the state of the
population at the time of examination. Prevalence studies are

-4-
commonly used for making comparison between two or more
populations.
2. Incidence or longitudinal study:
Where the amount of new disease in a population is measured over a
period of time usually one year. It is the change in a condition over a
period of time. In a progressive disease such as dental caries, it is
necessary to measure the increase by the extent of new disease, often
referred to as the increment. This is obtained by observing the same
groups of individuals on two occasions and subtracting the extent
found at the first examination from that observed at the second.
B. Controls:
Where an investigation is to be carried out into the possible
effect of a factor on the prevalence or incidence of disease in a group
of individuals, it is not enough to confine the examination to the
group exposed to the factor under examination but a parallel group,
not exposed to the factor must also be studied in the same way, this
is called the control group. This control group must be as similar as
possible to the test group except in respect of the factor under
investigation.
C. Blind Study:
It is a study in which the investigator does not know whether a
subject is a member of a test or a control group. If the subject does
not also know whether he is using a test product or a placebo (an
uneffective material having the same appearance as the material
under testing), the study is termed a double blind. This is to avoid
unconscious bias in diagnosis.

-5-
III. Selection of the sample:
When designing a study it is usually impossible to examine
every individual in the population or universe under investigation as
resources in terms of money, time and man power are not available
for the collection and analysis of such vast amounts of data. For this
reason, a small number of individuals or a sample must be chosen
from the population.

a. Selected sample:
Is one in which a criterion is set for the inclusion of each individual
in the study, and each individual satisfies this criterion will be
included in this sample.
b. Random sample:
This technique will provide more valid data from a population. For
the sample to be truly random, each individual must have an equal
chance of being included in the sample. One of the easiest ways of

-6-
doing this is to use random number tables. The basic procedures in
such sampling are:
1. To prepare a sampling frame (i.e. a list showing all the units from
which the sample is to be selected and it is arranged in any order).
2. To decide the size of the sample. 3. To select the required number
at random.
C. Stratified random sample:
If the condition under investigation is known to be related to various
factors such as age, sex, or area of residence, the population is first
divided into these groups (strata) and a random sample taken within
each group (stratum). For example, dental caries is an age-specific
disease and so any population on which a survey is to be done for
detecting the prevalence or extent of the disease should be stratified
by age.
d. Cluster sample:
In some cases, it is more convenient for administration and economic
reasons to sample from clusters rather than from individuals.
In cluster sampling, a simple random sample is selected not
from individual subjects but of groups or clusters of individuals. The
clusters may be schools, villages.. etc.

The size of the sample:

The sample size is the number of participants or specimen required
in a study and its estimation is important for both in vivo and in vitro
studies. The size of the sample is dependent on the statistical
characteristics of the data to be collected.

-7-
 Types of samples

IV. Conducting the Examinations:

For the scientific study of any dental disease and conditions, three
aspects are of great importance, the examination methods and
diagnostic aids, the diagnostic criteria, and the indices used for
measuring and reporting.
Basic requirements for the mouth examination are a chair, preferably
with a head rest, on which to seat the subject, a source of
illumination, and some method of cleaning the teeth to remove loose
debris.

Dental Caries:
The criteria for caries diagnosis should be defined before starting the
examination. The commonest definition postulates that a tooth is

-8-
considered carious when a sharp explorer catches in a cavity with a
detectably soft floor and/or some undermined enamel or a
breakdown in the walls of a pit or fissure.
For numerical evaluation of caries in a group of population, certain
measures or indices had been devised.

An index:
It is defined as a numerical value describing the relative status of a
population on a graduated scale with definite upper and lower limits
designed to facilitate comparison with other population classified by
the same criteria and method. An index describes the prevalence of a
disease in a population and also describes the severity or intensity of
the condition.

Indices Used For The Assessment of Dental Caries:

1. Prevalence Index:
It is the simplest index used for dental caries. It describes whether
the disease is present or absent. This is useful mostly when
observing and comparing populations with wide difference in
caries+ experience. Here, a simple count of persons (units of
measurement) with and without signs of caries may be adequate to
establish the relative prevalence. Modification of prevalence index
includes expressing proportions of the population with minimum of
specified number of the affected teeth.
The prevalence rate= Number of all cases affected Total population
Total population

-9-
2. DMF Index:
Decayed plus missing plus filled teeth. It is the commonest of the
current dental caries measurements. Each permanent tooth is
considered individually and if it is decayed (D), missing due to
caries (M) or filled (F) it scores one. The total number of the affected
teeth in an individual gives an individual dental caries experience
(individual DMF).
The average number of DMF teeth for a group is found by dividing
the total number of the affected teeth of the individuals by the
number of individuals in the group.
N.B.: Here the unit of measurement is the tooth.

3. The def Index:

This is an index for the primary dentition where (d) denotes decayed
deciduous teeth indicated for filling, (e) indicates decayed deciduous
tooth indicated for extraction, and (f) indicates filled deciduous
teeth: Teeth missing, for any reason were not recorded, and because
of this it may be regarded as a measurement of observable dental
caries prevalence.
A disadvantage of this index is that when a population of children
has received widespread extraction because of dental caries may
actually show a lower def average than children in another
population with fewer carious lesions in primary teeth.
Often, however, the index has been used in the same way as the
DMF index for the permanent dentition (i.e. dmf) thus making it a
measurement of the past and present dental caries experience.

- 10 -
4. DMF-S Index:
Decayed, Missing, Filled-Surfaces Index. This is a more
sensitive measure of dental condition per person, reaching its
greatest usefulness where accurate work is to be done involving the
use of dental X-ray, and for measurements during clinical trials of
caries preventing agents. This index counts the number of the
affected tooth surfaces (surface counts). Here the unit of
measurement is not the tooth (as in DMF) but the tooth surface.
Certain difficulties are encountered in the use of surface indices. One
of them is the score to be allocated to extracted teeth, which may
have been attacked by one surface only, although its extraction
results in the loss of four or five surfaces. The extracted teeth are
given score five (for posterior teeth) or four (for anterior teeth) as
advocated by some authors. Full crowns score 5 while 34 crowns
score 4 and so on.

5. Slack Index:
A sensitive classification of the extent of carious lesions was
advocated by Slack et al.,(1958) where the size of the lesion is
indicated on a scale running from I to 3.
Di: The probe catches in a pit or fissure but does not penetrate to the
dentin.
D2: Obvious carious lesion involving the dentin, but cavitation had
not proceeded to more than one quarter of the crown.
D3: Cavitation had proceeded so that more than one quarter of the
crown is involved.

- 11 -
Slack index of an individual equals the total number of the affected
teeth scores divided by the total number of the affected teeth.

Factors Affecting The Epidemiology of Dental Caries:

The conquest of most diseases depends upon several factors other

than a mere knowledge of the biological mechanism which operates
after the agent of the disease has entered the host.
Thus the first step in epidemiologic or (ecologic) analysis involves a
separation of the factors involved in a disease into three main
groups; those pertaining to the host (namely man), those pertaining
to the agent, and those pertaining to the environment.

I. Host factors in dental caries:

1. Race or ethnic group:
Race has long been considered to be an important factor in the
frequency of dental caries, yet little work has been done which
would differentiate racial or ethnic heredity from environment. In a
study upon army recruits during World War II, including various
racial groups, all gathered in the same geographical area, specially
both Chinese and Negro population have been shown to have lower
caries rates than corresponding white population.
2. Age:
It is generally believed that dental caries was essentially a disease of
childhood and that its incidence among adults was very low
compared with its pre- and postpubertal period.

- 12 -
It was found that the greatest intensity of caries incidence in
permanent teeth occurs in the decade between 15 -25 years of age.
Pit and fissure caries is the predominant type occurring at this
period. The period between 25 - 35 years showed a pronounced
decrease in caries incidence. This is because the more susceptible
tooth surfaces has already affected by caries.
Another increase in caries incidence occurs at about 45-55 years
which is of the proximal type. Over 60 years of age, acute root caries
occurs because root surface becomes denuded by gingival recession.
3. Sex:
Many statistical studies have been made to differentiate between the
dental caries experience among males and females. In young people,
caries has been seen to be higher in females, but some studies show
no significant difference between the sexes and few showed slightly
higher caries for males at certain ages.
An impression has long been held that pregnancy accelerates dental
caries in the females. No evidence has been found to substantiate this
impression, in spite of several careful studies.
4. Inheritance:
There is a wide spread clinical impression that dental caries varies
considerably from family to family, and that inheritance of a
characteristic tooth structure or form either good or poor is common.
Good genetic studies of caries incidence are few in number and in
such studies it is difficult to distinguish between true inheritance
through the chromosomes and the dietary and other habits in the
family.

- 13 -
5. Emotional disturbance:
There is a wide spread clinical impression that emotional
disturbances, particularly transitory anxiety states, influence the
incidence of dental caries, such statement is difficult to document
because of the difficulties of defining stress and of relating it
accurately to a chronic disease such as caries. One study is available
on dental caries, attempting to relate dental examinations in terms of
DMF teeth to mental diagnosis among psychiatric patients.
Statistical analysis demonstrated a higher dental caries experience at
all ages among the manic depressive group than in the base line
hospital population.
Another study involving 661 patients, reported close correlation
between severe mental stress and dental caries.
6. Nutrition:
Nutrition can be called a host factor to the extent that individual
instinctively selects specific foods from the array available to him.
Health education, directing a choice among foods, is an
environmental factor.
7. Variation of caries within the mouth:
Observation on the variation of caries within the mouth could be
grouped under three main headings:
a) Observations on types of caries according to tooth surfaces
attacked.
b) Observations upon frequency with which the different teeth in the
mouth are attacked and,
c) Observation upon bilateral symmetry.

- 14 -
II. Agent Factors:
1. Bacterial factors:
Since the days of Miller, dental caries research has been directed
toward the identification of a microbial agent for the disease. At first,
many workers have drawn the attention to the relation which
appeared to exist between dental caries rate and the number of
lactobacilli, in the mouth.
Attention now centers on various groups of streptococci.
The potential of certain strains of streptococci to induce plaque and
multisurface cavitation has been conclusively established in animals
and strongly implicated in humans.
2. Role of carbohydrates:
Freely fermentable carbohydrates have an essential role in caries
process. Not all carbohydrates are equally conductive to plaque
formation and multisurface caries. The rate of clearance from the
mouth also affects the rate by which bacteria may act upon
carbohydrates to produce acids.
Carbohydrates with rapid oral clearance seem to be less dangerous
than those which remain in the mouth for a long time.

III. Environmental Factors:

1. Geographic variations:
So many detailed environmental factors are dependent in one way or
another on the geography. In order to study geographic variations in
dental diseases apart from racial or ethnic variations, it is necessary
to select an area for study inhabited either by one racial or ethnic

- 15 -
group predominantly or by such a mixture of ethnic groups even out
in large samples.
In studies performed in the United States, the occurrence of dental
disease suggests two striking associations: latitude, distance from
seacoast. This is mainly due to climatological factors including
sunshine, rainfall, temperature and humidity.
a) Sunshine: is one of the factors most commonly thought to vary
with latitude. In one study in U.S.A., there was an inverse relation
between the mean annual sunshine and dental caries expressed as
DMF. The reason for this relation is that as the annual sunshine
increase the amount of ultraviolet rays increases which insure
enough supply of vit. D by mobilizing its precursor from the fat depo
under the skin. The effect of vit. D on the formation of calcified
tissue is well known. Also in many areas of the world the
temperature is in direct relation with sunshine and as sunshine
increases temperature increases and there will be increased demand
for water consumption. The increased water intake will help wash
away food debris from the mouth,
b) Temperature: varies almost entirely with latitude. Temperature in
turn, acts to vary the caloric requirements and water intake of human
beings, Since carbohydrate food is a quick and cheap source of
caloric energy, so in localities of low temperature, the carbohydrate
consumption specially sweets is high and there is a decrease in water
intake and therefore caries incidence increases. The reverse occurs in
localities of high temperature.

- 16 -
c) Relative humidity: It is the ratio of the amount of moisture in the
atmosphere to the maximum amount that can occur without
precipitation at a given temperature and barometric pressure. Data
from some studies in Australia and U.S.A. proved a higher
correlation between DMF, and relative humidity, as relative
humidity raises, the DMF rises too. This is because of decreased
demand of water intake in areas with high humidity levels.
d) Rainfall: Most of the crops utilize in their growth the upper thirty
centimeters of the soil, as the rainfall increases leaching of the
minerals specially fluorides will lead to reduction of fluoride
concentration in the crops. Another factor to be considered is that
rainfall is accompanied by heavy clouds which block sunlight.

2. Fluoride:
Especially fluoride in the communal water supplies affects to a great
extent the DMF index.

3.Total water hardness:

Usually measured in terms of calcium carbonate, is an etiologic
factor in dental caries. Some authors have reported an inverse
relation between DMF and the total water hardness.

4. Trace elements:
A number of trace elements deserve attention, some are found in
water supplies but most are found in greater concentration in
common food-stuffs. It has been found that there is marked increase

- 17 -
in dental caries in areas where selenium was high both in water and
food-stuffs.
On the other hand, molybdenum and vanadium have caries inhibiting
influences.

5. Degree of urbanization:
Urbanization may be accompanied by an increase in dental caries.
This may be due to the type of diet in urban areas.

6. Social factors:
Good economic status and social pressure in the direction of good
mouth appearance are both strong factors in creating demand of
dental treatment.

- 18 -
 PERIODONTAL DISEASES
Periodontal diseases are inflammatory conditions affecting the
periodontium. The periodontium comprises the gingiva, the
periodontal ligament, the alveolar bone and the cement covering the
roots of the teeth.

Indices Used For Assessment of Gingival and Periodontal

Diseases:

1. P.M.A. Index:
Is the first successful attempt to design a numerical system of
recording gingival conditions. The three letters stand for gingival
papilla mesial to the tooth, i.e. papillary (P), Marginal (M) and
attached gingiva (A). From clinical experience it was postulated that
periodontal disease starts from the interdental papilla (P), spreads to
the marginal area (M) and continues to the attached gingiva (A).
Thus all the present teeth are examined (sometimes this index would
be confined to an area or quadrant). The number of the affected
P.M.A. units are counted, and considered as separate estimates.

Cases are called:

"mild" if I to 4 papillae and 0 to 2 margins are affected,
"moderate" if 4 to 8 papillae and 2 to 4 margins are affected,
"severe" if more than 8 papillae and more than 4 margins are
affected.

- 19 -
Involvement of attachments is associated with severe cases. The
average P.M.A. for the group is determined by totaling the number
of gingival units affected and dividing by the number of cases under
study.

2.The gingival Index (GI):

The index is developed by Loe and Sillness. The severity of the
gingival condition is indicated on a scale running from 0-3.
0: No inflammation.
1: Mild inflammation, slight redness, slight odema, probing with a
blunt probe does not result in bleeding.
2: Moderate inflammation: oedema, redness, glazing the marginal
gingiva is swollen; probing with a blunt probe elicits bleeding.
3: Severe inflammation: marked redness and oedema, spontaneous
bleeding and/or ulceration.
It is a partial recording system; six teeth are selected for the
examination.
62 4
4 26

For each of the six teeth, mesial, distal, buccal and lingual gingival
unit is scored independently. The tooth scores are summed and
divided by 4 gives the gingival index of the tooth. The scores of the
6 teeth are summed and divided by their number, given the GI of the
individual.

- 20 -
 Average Gingival Interpretation
Index

2.1 - 3.0 severe inflammation

1.1 - 2.0 moderate inflammation

0.1 - 1.0 mild inflammation

< 0.1 no inflammation

3. The periodontal index (P1) Russel's Index;

The criteria of the P1 index are:
0: Negative: There is neither obvious inflammation in the investing
tissue nor loss of function.
1. Mild gingivitis: There is an obvious area of inflammation in the
free gingiva, but this area does not circumscribe the tooth.
2. Gingivitis: inflammation completely circumscribes the tooth but
there is no apparent break in the epithelial attachment.
6. Gingivitis with pocket formation: The epithelial attachment has
been broken, and there is pocket. There is no interference with
normal masticatory function, the tooth is firm in its socket.
8. Advanced destruction with loss of masticatory function, the tooth
may be loose, may have drifted, may have dull sound or percussion,
may be depressive in its socket.
The data of PI is computed by examining all the present teeth. The
teeth scores are summed and divided by their number, this will give

- 21 -
the PI of the individual. PI of a group equals to the summation of the
PI scores of the individuals in the group divided by their number.
The author writes 6 after 2 since:
- If the P1 score of an individual is small (i.e. I or 2) this indicates
that this individual has gingival affection but if it is high (6-8), this
indicates that this individual has only periodontally affected teeth.
- If the score is in between 2 and 6, this indicates that this individual
is affected by both gingival and periodontal disease. This index is
most suitable for assessment of the gingival and periodontal
condition in adult populations.

Lilienthal et al. (1964) modified Russel's classification of

periodontal condition using partial recording system to be easier with
large surveys.
The teeth used are;
7 14
41 7

Here the authors take 7 instead of 6 due to the frequent loss of the
latter due to caries.

4. The oral hygiene index (OHI) and the oral hygiene index
simplified (OHI-S):
These indices were first developed by Greene and Vermillion 1964.
The criteria used to assign the scores to the tooth surface in the OHI-
S are the same as those used for the OHI. The OHI-S and the OHI
have two components, the debris index and the calculus index. Each

- 22 -
of these indices, in turn, is based on numerical determinations
representing the amount of debris and calculus formed on the
selected surfaces.

For the OHI:

Each jaw is divided into 3 segments a molar, premolar and anterior
segment, i.e. the canines and incisors. After examination of the
whole mouth, the worst tooth in each segment is taken as
representative of the segment
The buccal and lingual surfaces of each tooth are scored. Therefore,
the OHI comprises 12 surfaces of six teeth.

For the OHI-S: The examination is limited to 6 permanent tooth

surfaces. The labial surface of the upper right central incisor, the
labial surface of the lower left central incisors, the buccal surfaces of
the upper first permanent molars and the lingual surfaces of the
lower first permanent molars. When any of these teeth are missing, a
comparable adjacent tooth is substituted. Only fully erupted teeth are
scored.

A. Oral Debris DI
0: No debris or extrinsic stain.
1: Soft debris covering not more than one-third of the tooth surface,
or extrinsic stain without debris regardless of the surface area
covered.

- 23 -
2: Soft debris covering more than one-third but not more than two-
thirds of the exposed tooth surface.
3: Soft debris covering more than two-thirds of the exposed tooth
surface.

B. Oral calculus CI:

0: No calculus present.
1: Supra-gingival calculus covering not more than one third of the
exposed tooth surface.
2: Supra-gingival calculus covering more than one third but not more
than two thirds of the exposed tooth surface or individual flecks of
subgingival calculus around the cervical portion of the tooth.
3: Supra-gingival calculus covering more than two thirds of the
exposed tooth surface or a continuous heavy band of subgingival
calculus around the cervical area of the tooth.

For determining OHI:

The mean of DI and CI of the examined 12 surfaces is computed
and then we sum Dl and CI, i.e. Dl equals the summation of the Dl
scores of the 12 surfaces examined divided by 12 and also Cl equals
the summation of the CI scores of the 12 surfaces examined divided
by 12.
So, OHI = DI + C1.
For determining OHI-S:
The mean of DI and CI of the examined 6 surfaces is computed and
then we sum Dl and CI.etc.

- 24 -
Community Periodontal Index of Treatment Need | CPITNI
This index is designed by Ainamo et al. (1982) to asses periodontal
treatment needs rather than periodontal status i.e. for initial screening
and for monitoring changes in periodontal needs of the individual of
the community.
With this information appropriate oral care service can planned for
populations and for individuals.
The CPITN records the common treatable conditions, namely
periodontal pockets, gingival inflammation (identified by bleeding
on the gentle probing), and dental calculus and other plaque retentive
factors. It does not record non-treatable or irreversible changes such
as gingival recession.
Thus the term (treatment need) is intended as a guide to the level or
magnitude for care when accepted periodontal criteria are followed.

The use of CPITN in epidemiology and in clinical practice:

The most common use for CPITN is to identify the prevalence and
severity of periodontal conditions with respect to treatment needs
whether in epidemiological studies or in clinical practice.
Compared with other epidemiological indices for periodontal heath
(e.g. periodontal index), the CPITN is not only simple and practice
but also more objective in its choice of clinical criteria and
methodology. In particular the data offer appreciation of the
periodontal condition of a population and their treatment needs and
personnel required.

- 25 -
The procedure
The dentition is divided into six parts (sextants) and each sextant is
given s score.
For epidemiological purpose, the score is identified by examination
of specified index teeth, while in clinical practice the highest score in
each sextant is identified after examination all teeth. Sextant.

(Sextants of the dentition)

The mouth is divided into six sextants defined by teeth numbers.

7-4 3-3 4-7

7-4 3-3 4-7

Third molars are not included, except where they are functioning in
the place of second molars.
The treatment need in a sextant is recorded only when 2 or more
teeth are present and not indicated for extraction. The indication of
extraction because of periodontal involvement is that the tooth has
vertical mobility and causes discomfort to the patient.
If only one functioning tooth remains in a sextant it is included in
the adjacent sextant.
Missing sextants are indicated with a diagonal line through the
appropriate box.

- 26 -
Index Teeth
In epidemiological surveys for adults aged 20 years or more, only 10
teeth known as the index teeth, are examined. These teeth have been
identified by (WHO 1984) as the best estimators of the worst
periodontal condition of the mouth. The ten specified teeth are:

7,6 1 6,7
7,6 1 6,7

Although 10 index teeth are examined, only 6 recordings, one

relating to each sextant, are made.
When both or one of one designated molars are present, the worst
finding from these tooth surfaces is recorded for the sextant.
If no index teeth are present in a sextant qualifying for examination,
all remaining teeth in that sextant are examined and the worst finding
is recorded resembling that sextant.
N.B. whenever possible, the findings in every tenth or twentieth
subject should be recorded both by examination of the index teeth
and by the worst finding per sextant, so the results obtained by
partial examination partial recording system) can be subjected to
analysis of reliability.
In oral health screening examinations for the determination of
treatment needs of individual patients, partial recording system using
index teeth is considered insufficient , the recording for each sextant
is based on the worst finding from all teeth in that sextant.

- 27 -
For young people, up to 19 years, full sextant recordings have little
advantage over partial recordings and only six index teeth
resembling the six sextants are only examined.
These teeth are: 6 1 6
6 1 6

The second molars are excluded as index teeth in young ages

because of the high frequency of false non-inflammatory pocket
associated with eruption.
When examining children less than 15 years, pockets are not
recorded although probing for bleeding and calculus are carried out
as routine.
For recording CPITN the following (chart index) is recommended

The CPITN probe and probing procedure

The CPITN probe (WHO probe, tactile probe or sensing instrument)
should be considered to be an extension of the examiners fingers.
The probe has a thin handle and of very light weight .This probe is
particularly designed for gentle manipulation of the sensitive soft
tissue around the teeth.
The pocket depth is measured through colour coding with a black
mark starting at 3.5mm and ending at 5.5mm (Fig 1). The probe has
a ball tip of 0.5mm diameter that allows easy detection of
subgingival calculus. This feature, combined with light probe
weight, facilitates the identification of the base of the pocket, thus
decreasing the tendency for false reading by over measurements.

- 28 -
 Fig. (1): CPITN probe

A sensing force is used both to determine the pocket depth and for
detecting subgingival calculus. The probe is inserted between the
tooth and the gingiva. The pocket depth is sensed and readed against
the color code
The direction of the probe during insertion should, whenever
possible, be in the same plane as long axis of the tooth. The ball end
should be kept in contact with the root surface. Pain to the patient
during probing is an indication of a too heavy sensing force.
The recommended sites for probing are mesial, mid line and distal of
both buccal and lingual surfaces. With the probe tip remaining in the
surfaces, it should be waked around the tooth.

Codes and criteria:

The appropriate code for each sextant is determined with respect to
the following criteria:
Code 0: healthy periodontal tissues.

- 29 -
Code 1: Bleeding observed during or after gentle probing
Code 2: Supra- or subgingival calculus or other plaque retentive
factors such as ill-fitting crowns or poorly adapted edges of
restorations are either seen of felt during probing.
Code 3: Pathological pocket of 4-5 mm, that is, when the
gingival margin is on the black are of the probe.
Code 4: pathological pocket of 6 mm or more, that is, the black area
of the CPITN probe is not visible.
Code X : when only one tooth or no teeth are present in a sextant
(third molars are excluded unless they function in place the second
molars ) i.e. It is considered as missing sextant and is indicated with
a diagonal line through the appropriate bone and that single tooth , if
present, will be included in the adjacent sextant.

Classification of treatment Need :

Population groups or individuals are allocated to the appropriate
treatment Need (TN) category on the following basis:
TN 0: A recording of code 0 or X (missing) for all six sextants
indicates that there is no need for treatment.
TN 1: A code of 1 indicates a need for improving the personal oral
hygiene of that individual.
TN 2: (a) A code of 2 indicates need for professional cleaning of the
teeth scaling) and removal of plaque retentive factors. In addition,
then patient obviously requires oral hygiene instructions.
(b) A code of 3 ( shallow to moderate pocketing of 4 or 5 mm
depth indicates need for scaling and oral hygiene instructions. This

- 30 -
will usually reduce inflammation and bring 4 or 5 mm pockets to
values of 3 mm or below. Thus sextant of code 3 is placed in the
same treatment category as scaling i.e. treatment need 2 (TN 2)
TN 3: Sextant scoring code 4 (6 mm or deeper pocket ) may or may
not be successfully treated by means of deep scaling and efficient
personal oral hygiene measures. Code 4 is therefore assigned as
“complex treatment“which can involves deep scaling, root planning
and complex surgical procedures.

Utilization Of CPITN recordings

The CPITN is designed for rapid and practical assessment of
various periodontal treatment needs in population surveys and for
initial screening of patients attending for regular dental care.
The time needed for the CPITN in recording the codes of the six
segments should not exceed 1-2 minutes. The information obtained
is illustrated by the following examples.

Case 1:

4 2 3
2 2

There is at least one deep pocket in the right posterior and one or
more moderately deep pocket in the left posterior sextants of the
maxilla. Three sextants have no pocket depths over 3 mm but do
require scaling. One sextant is missing.

- 31 -
Case 2:

1 2 1

The maxilla is edentulous. The lower anterior sextant requires

scaling. The mandibular posterior sextant requires improved
personal oral hygiene.

Case 3:
3 0 3
3 1 3

There are modertly deep pocket in all posterior sextants (require

scaling). There is bleeding on gentle probing in the lower anterior
sextant (a need of improved personal hygiene in this area) and no
treatment need in the upper anterior region.

Factors Affecting The incidence and Prevalence of

Periodontal Diseases:
I- Host Factors:
1. Age:
In all surveys in which severity has been taken into account,
periodontal disease has been found to progress steadily throughout
life.
Gingivitis is common in the primary dentition of most children, in

- 32 -
the teenage the prevalence of gingivitis increases with increasing
age, from age 13 upwards the proportion of persons with periodontal
pockets increases and so the number of teeth with bone loss. The
strong correlation between periodontal destruction and age suggests
at first glance, that age is an etiologic factor. The explanation is most
likely that periodontal disease is a cumulative disease and the linear
increase with age reflects this feature.
2. Sex:
In particularly all surveys carried out in U.S.A. and Europe, the
periodontal conditions are found to be significantly better in females
than in males when the status of oral hygiene is compared in the two
sexes females are found to be considerably better than males. In less
developed countries the sex difference seems to be absent, or
reversed, i.e. the periodontal conditions are worse in females than in
males, at least after age 20. Even when males and females of the
same oral hygiene status are compared. The females have
periodontal disease.
The most possible explanation of this discrepancy is that female in
developing countries give birth to many children, and that the
frequent pregnancies and lactation periods drain the mother from
nutrients. During pregnancy gingivitis scores increases with a peak
in its last months of pregnancy. There is also marked increases in
pocket depth. Both these characteristics return to normal values after
delivery.
3.Correlation with oral hygiene:
Regardless whether gingivitis, periodontitis, or bone destruction is

- 33 -
measured, there is a strong correlation between the severity of these
conditions and oral hygiene. This association comes particularly well
out when an oral hygiene index is used.
4. Association with socioeconomic status:
Several surveys have demonstrated that the periodontal conditions
improve as the years of formal education increases, and income goes
up. The appreciation of these simple facts may be of value to the
public health worker when he plans how to improve periodontal
conditions on a community basis.
5. Effect of tobacco:
The effect of tobacco is consistent and convincing, particularly the
prevalence of ulcerative gingivitis in young cigarette smokers is
dramatic but also simple gingivitis as well as periodontitis with bone
resorption increases with increasing tobacco consumption. This may
be due to effect of the tobacco material itself and the heat derived
during smoking.
6.Correlation with general disease:
Epidemiological investigations have failed to correlate a widely hold
opinion from the early days of periodontology that general diseases,
and psychiatric disorders predisposes to periodontal disease. Only
the unfavorable influence of diabetes seems to be established.
7. Nutritional factors:
Reliable statistical data regarding the effect of nutrition on
periodontal diseases are rare, particularly the effect of various
vitamins has been in focus of interest, and for a long time they were
considered to play a very important role.

- 34 -
8. Correlation with traumatic occlusion:
Malocclusion is difficult to characterize in a numerical way, and so
far no fully acceptable index has been developed. Data accumulated
up to the present time indicate that there is some correlation between
periodontal disease and some criteria of malocclusion, and that the
most important factor in malocclusion is crowding of the teeth.
9. Effect of race:
The extreme difference in prevalence and severity of periodontal
conditions in Asia and Africa on one side and U.S.A. and
Scandinavia on the other, suggests at first glance that a racial
predisposition may be responsible for it. Such a difference also exists
between Negro and white in U.S.A. However when education,
professional dental care and oral hygiene were kept equal, no clear
cut difference was observed.

Il- Agent Factors:

The most important factor in the etiology of diseases are bacteria,
and calculus. There is a strong positive correlation between the
amount of bacteria as expressed by the plaque index and the degree
of gingival inflammation expressed by the gingival index scores.
Furthermore, all epidemiologic surveys showed a strong correlation
between oral hygiene status and the severity of periodontal
destruction.

III. Environmental Factors:

1. Geographic distribution of periodontal diseases:

- 35 -
Difference in geographic distribution of periodontal diseases can
only be estimated when the same researcher or the same research
group carry out the examination in various places. It has been found
that periodontal diseases are much more prevalent and much more
severe in some Asian and African countries than in U.S.A. Some
South American countries seem to fall in between these two
extremities.
2. Fluoride concentration In drinking water:
The accurate data on this point are few but finally consistent and
show that periodontal health improves as fluoride intake increases.
However, no statistical data to this effect have apparently been
documented.
The association between fluoride concentration and periodontal
condition is mainly due to the decrease in number of carious cavities
especially cervical and proximal.
3. Oral environment:
a) Prosthetic restoration: Several reports have shown that gingival
inflammation, mobility and bone destruction increase in teeth
adjacent to partial dentures.
b) Dental caries: There is positive association between DMF scores
for caries and scores for gingivitis and periodontitis, although the
degree of correlation may vary considerably. Research data fail to
substantiate commonly held opinions that there is an inverse
correlation between these two dental diseases.

- 36 -
 HANDLING OF DATA

The data accumulated from surveys, records or investigations are

usually in the form of raw information. These data can be handled,
systematized, classified or analyzed either.
a) Direct from the forms or records,
b) Transferred to ordinary cards, e.g. reference cards, or
c) Transferred to cards with holes round the edges (Chopechat
cards).
The basis of the system is a rectangular card with a series of holes
punched along one or more edges. The statistical data (variables) are
recorded on the body of the card and the relevant holes are clipped
out. This system is suitable for smaller type of investigation.
d) Machine punched cards:
The use of machine punched cards provides a mean of performing
mechanically statistical sorting operations more rapid. The basis of
the system is a thin flexible or rectangular shape. The ordinary
Hollerith or (I.B.M) card has 80 columns each with 12 different
entries; the punching machine enters like a typewriter. Each hole
represents a figure of letter, and holes are punched in various
positions according to the values, descriptions or designations
assigned to them. Preceding of times or questionnaire is desirable, all
questions can be coded where the answers fall under the limited
number of heads,
e.g. column 10 represents the marital status, and we may code as
follows: Single =1, married = 2, divorced 3.

- 37 -
TABULAR PRESENTATION OF STATISTICAL DATA
The purpose of tabulation is to arrange observations that are alike
and to put together similar cases so that their frequency of
occurrence in the whole group is made apparent
A statistical table presents numerical findings of a study or
investigation in a compact form with the data arranged in continuous
columns and rows. Such a device apart from being clear and concise
facilitates comparison.
The necessary parts of the table are:
1. The title which usually appears above the table. It is usually
preceded by an identifying number if two or more tables are
presented. The title should be brief (clearly worded statement
declaring what the table shows.
2. A base (Stub) which is the column at the extreme left and this
includes the heading of that column.
3. A box head which includes all of the column headings and
subheading except the heading of the first column (Stub).
4. The body, which is all the rest of the table proper, i.e., the part
which contains the figures.
5. A table may have one or more boxes for totals.

Frequency Distribution:
Forming a frequency is one method of organizing and summarizing
statistical data. In a frequency table, a series of observations is
classified into groups with given properties, and the number of
observations following in each group is studied.

- 38 -
A frequency table enables us to classify and better understand a
series of raw and unclassified data.
Suppose a surgeon recorded the systolic blood pressure of one
hundred patients, and got the following table:
100 120 115 145 110 120 125 125 120 110
125 105 130 120 115 115 120 120 105 130 110 130 120
100 120 130 140 105 135 115
120 110 125 105 115 105 110 135 120 100
110 120 110 140 130 115 135 110 120 125
130 150 120 110 125 140 120 125 160 115
120 120 115 120 120 120 130 120 115 120
145 115 125 150 110 125 135 120 140 165
120 155 120 115 135 120 115 125 130 120
115 120 135 120 165 125 135 150 125 133
When data are presented as in the above form, one will find it
difficult to find the highest and lowest systolic blood value around
which the measurements tend to concentrate.
One way of getting over these difficulties is by arranging the data
either in ascending or descending order. Such an arrangement is
called an array. However, an array is troublesome to construct
because of the need to rearrange all the items of the series.

Frequency Distribution:
Having a look at the data, we find that the recorded blood pressure
goes by steps of five, and that the hundred measurements can be

- 39 -
easily summarized into 14 groups or classes as shown in the
following frequency distribution table.
A frequency table gives much more information more rapidly. From
this table we find at a glance that 87 of our 100 individuals have a
systolic blood pressure between 100-135 mmHg.
In general, the frequency distribution arranges the items of a series
into groups or classes and indicates the number of cases occurring in
each group.

Systolic blood pressure

(mm of Hg) Number of individuals
100 3
105 5
110 11
115 10
120 27
125 11
130 9
135 7
140 4
145 2
150 3
155 1
160 1
165 2

The number of classes to use depends on the number of observations

in the series and the regularity with which the frequencies are
distributed within the range of measurements. The greater the

- 40 -
number of measurements, the more classes we may need, also the
more classes we may use. This is because data having a high degree
of regularity may be divided into a large number of classes without
showing gaps and irregularities in frequencies.
In general, fewer than 6 classes should rarely be used. It is usually
best to keep class-intervals at equal width.

Measurements of Central Tendency:

1. Mean (arithmetic mean):
It is the sum of the readings (values) divided by their number. The
mean has a disadvantage where it is affected by strange readings.

2. Medium (Median):
Here we arrange the values in an ascending or descending order and
then we take the center of series. If the number of readings is single
we take the central reading, but if the number of readings is paired
we take the average of the central two readings.

3. Mode:
It is the value of the greatest frequency in the series.

Measurement of Dispersion:
The arithmetic mean, the median and the mode are measures used to
describe the central tendency of frequency distribution. Knowing
where the measurements tend to concentrate however is not enough

- 41 -
to describe completely a mass of data. We need also to know about
the dispersion or the spread of data.
If we have five persons with age 30, 34, 32, 36 and 28 years, the
average age is 160/5%= 32 years.
We get the same average age of 32 years if the five individuals have
their ages 12, 30,8,62 and 48 years.
A simple way to measure the variation of a series of measurements
is to get the range. This is the difference between the highest and the
lowest value in the series. Thus in the first series of ages above the
ranges is 36 28=8 years. For the second series the range is 62-8=54
years. This shows that in the first series we have less variation than
in the second series of measurements, one reason why the range is
not considered as a good measure of variation is that it depends only
on the two outlying values of the readings. In general, the more the
readings we have the larger the range we get.
The most commonly used measure of dispersion and generally the
best is the "standard deviation".
The computation of the standard deviation starts like by obtaining
the deviation of each value from the arithmetic mean. In the first
series of ages above, for which we calculated the average deviation
we get.
30-32=-2 4
34-32= 2 4
32-32= 0 0
36-32= 4 16
28-32= 4 16

- 42 -
Then we square the deviation from the mean. This squaring is done
on the oretical grounds, but it also does take care of the sign of
deviations.
The squared deviations are then summed and divided by the number
of observations minus one (n-1) to get the variance 52. The square
root of the variance gives us the standard deviations (S).

S=
S = 40/4 = 10 = 3.22
The most convenient interpretation then, of the standard deviation is
that together with the mean, it defines a central range within which
two-thirds of + the measurements be. From two standard deviations
above the mean lies about 95% of observations.

- 43 -
 DENTAL NEEDS, RESOURCES AND OBJECTIVES
I. Dental needs
II. Dental demands
Bradshow (1972) has described a "taxonomy of need" which is
helpful in clarifying the concepts.

a. Normative need:
It is a condition which an expert or professional persons defines as
requiring some action. For example, the existence of a carious cavity
is usually described as a need.

b. Felt need:
It is equated with want. An assessment of the need for a service can
be made by asking people whether they feel that they need it. It is
inadequate since in some asymptomatic conditions, some people feel
that they do not need it On the other hand, it may be inflated by
others to unnecessary needs.

c. Expressed need or demand:

It is felt need turned into action, i.e. a service is not demanded unless
a need is felt. For example, a patient feels pain or a cavity or even
sees stain may demand a service.

d. Comparative need:
It is identified by making comparisons with other areas or services.

- 44 -
If the area in question has a higher level of disease or lower service
than elsewhere, a need is said to exist.

I. Dental Needs:
Raw data obtained from surveys will not present cleary the dental
needs, ultimate figures are needed in order to implement dental
health service. After interpretation of the results of such surveys,
dental needs can be recognized. Dental needs vary from country to
country and from society to another. The following factors should be
considered.

I. Degree of development of the area:

In many countries it might be considered adequate dental service
merely to alleviate acute dental pain. Elementary exodontia requires
very little of a dentist time. In such situation certain amount of dental
health education which may lead to the prevention of dental disease
is considered sufficient.
Instructions of oral hygiene and nutrition can be given and even
water fluoridation may occasionally be valuable. In this primitive
situation of underdeveloped areas, detailed surveys are of little value.
The basic demand of such population is to be kept alive and free
from acute pain. This can be met by the most elementary public
health or medical service almost without the aid of dentistry as a
specialty.
The demand for restorative dentistry may be felt but there is no urge
for it as all the members of the community share, the same problem.

- 45 -
In these areas, the needs are simple and the demands can easily be
satisfied.
In slightly developed areas (e.g. developing countries or the third
world), because of lack of education; lack of dental manpower or
lack of economic resources, there will be neither prevention of dental
diseases nor conservation of affected teeth.
Dental needs as well as demands for dental treatment will certainly
exceed those of primitive areas. The demands here are mainly for
exodontia and prosthodontia. Painful and broken down teeth are
extracted at local hospital or private practices. This may be followed
in some areas by the insertion of full dentures or parietal dentures of
simple design.
The dental demands increase as the socioeconomic level of such
community improves, an effort must be made, it assesses the
readiness of the area for better dental service and to provide dental
health education as soon as it may be reasonably expected to achieve
results.
Prevention and early control of dental disease can be emphasized for
a new generation taught to save their teeth, can avoid, at least the
vast restorative problems of a half edentulous adult society.
In an economically capable society, we shall be thinking not only in
terms of pain and infection elimination, but in terms of restoration of
serviceable teeth to a good functional form, placement of missing
teeth, maintenance care for the control of early lesions of the dental
disease, and most important of all, preventive measures, educational

- 46 -
measures, so that the population may experience a lower prevalence
of disease. This is termed comprehensive dental care.

2. Age and dental needs:

The results of many dental surveys show that the incidence of certain
diseases is correlated to age.
The incidence of trauma to anterior teeth reaches a maximum of
more than 10% at an age of 12-14 years, and then continues to
increase steadily but at a slower rate.
The number of teeth needing filling per person usually reaches a
peak between 15-24 years.
The need for extractions increases steadily throughout life. The need
for periodontal treatment reaches a slight peak around age of 40
years, but is high throughout the interperiod of middle age.
The need for crowns and fixed bridge work is greatest in middle life
when only small groups of teeth have been lost.
The need for partial dentures follows.
The need for full dentures reaches its peak in later years of life. Oral
cancer is also a disease of later life.

3. Dental needs by sex:

The need for fillings and periodontal care is more or less the same
for both sexes.
Women, however, are more attentive to the health of their teeth and
more anxious to prevent cosmetic disfigurement than men are.
The need for extraction is consistently lower among women than

- 47 -
among men.
The proportion of women needing both upper and lower dentures is
also lower than the proportion of men needing them.

4. Dental needs and income:

In developed societies, dental needs are generally lower among
patients with high income. This may be due to better preventive
measures, towards which the high income group is better educated. It
is also correlated to more frequent visits to the dentist by this group.
In underdeveloped societies the picture is not the same. People of
higher income may need more dental care than in developed
countries. This is clearly obvious in the younger age group in
underdeveloped societies.
It is important to remember that dental needs are the resultant of two
forces the disease susceptibility and previous care. Great many
factors may operate to alter the balance between forces.

II. Demand For Dental Care:

Demands for dental care can be influenced by a number of factors,
two groups of them are most important: The first of them may be
called automatic factors which include:
1. Gross increase in population.
2. Urbanization.
3. Education.
4. Occupational changes.
5. Income per capita.

- 48 -
These factors are termed automatic because any increase in one or
more of them is automatically associated with a similar increase in
the demand for dental care and the level or quality of the treatment
offered.
The second group of factors concerns the extent of the dentist's effort
to stimulate demand for dental services. This includes some sort of
dental health education.
A successful effort should be spent to make the patient recognize
the sequelae of neglected oral and dental condition and to be away of
the possibility of maintaining reasonably functioning and healthy
situation.

Manpower:
The supply of dental care available in a given area, and to a certain
extent also the demand for dental care are linked with the number of
people in the dental profession and the way they make use of their
time. The dentists themselves, of course, are the most important
people to consider, but we must also consider the auxiliaries that
make up the rest of their team.

Dentists:
The number of dentists available varies from country to another. In
Africa, for example, the number of population per dentist in 1968 is
as follows:
South Africa 13,400
A.R.E. 24,000 (1980).

- 49 -
Upper Volta 2,429, 0002.
The figures in U.S.A. and Western Europe are between 2,000 and
10,000.

The number of the dentists in Egypt:

In (1999-2000) is about 15000 dentists, this represents a ratio of one
dentist/4000 individuals which is very reasonable.
In 2005 are about 23448, 2010 are about 34878, 2015 are about
50829 while in 2019 are about 62154 dentists.
Unfortunately the distribution is unsuitable , about two thirds of
private offices are present in the great Cairo area wearers other
governorates probably suffer dentists and dental specialists. Most of
the dentists are non specialists but there is increasing number of
specialists i.e. limiting their practice to one specialty of dental
services as orthodontics, oral surgery etc. . Also most dentists are
practicing in private offices; smaller, but increasing numbers join
together and form group practices.
There is no ideal figure for population per dentist because of the
difference between dental needs and dental demands depending upon
the various factors mentioned before.
Any increase in the number of dentists should be associated with an
increase in the number of other dental auxiliaries and facilities
required to provide dental services.

- 50 -
 ORGANIZATION OF DENTAL CARE:
Dental care can be given more efficiently when more workers share
the task. The need to apply in one area more knowledge than can be
possessed by one man is not the only reason for teamwork. Some
tasks actually require more than two hands. Other tasks are more
quickly or better performed if one worker confines himself to part of
the task, leaving other parts to other workers. A reason for division
of labor lies in the different levels of knowledge attainable within
one field by persons of differing attitude and apportunity for training.
Certain parts of a task require top level skill and knowledge. In
dentistry these are called "professional services". Other parts of the
task require less skill and knowledge. These safely be delegated to
auxiliaries personnel.
Until now, dentists outnumber the professionally trained auxiliaries.
Since auxiliaries of all levels of training are important part of the
dental team, the various types will be considered.

1. The Dental Assistants:

There is great variability in the utilization of dental assistants from
office to office, and it is difficult to lay down rules concerning the
training and duties of assistants. The duties of dental assistants
generally include:
1. Reception of the patient.
2. Preparation of the patient for any treatment.
3. Preparation and provision of all necessary facilities such as
mouthwashes, napkins, receivers.

- 51 -
4. Sterilization, care and preparation of instruments.
5. Preparation and mixing of restorative materials, including filling,
and impression materials.
6. Care of the patient after treatment until the patient leaves.
7. Preparation of the surgery for the next patient.
8. Preparation of documents to the surgeon for his completion and
filling of these
9. Assistance with X-ray work and the processing and mounting of
X-rays.
10. Instruction of the patient, where necessary, in the correct use of
the tooth brush.
11. After care of persons who have had general anaesthetic.

2. Chair-side Dental Assistant:

It has been found that the addition of one dental assistant increases
the number of patients treated by a dentist by 33 percent if he was
using one chair side dental assistant and by 62 percent if he was
using two chair side dental assistants. The increase in output depends
upon standardized operative techniques which use a minimum
number of instruments and careful attention on the assistant to
anticipate the operator's needs. The quality of service and patient
control are both improved under such a system because the operator
will work under less physical and mental strain.
Currently, the utilization of dental assistant is an accepted item of
dental operating. The term "four-handed dentistry" is now given to
the art of setting both the dentist and the dental assistant in such a

- 52 -
way that both can easy reach of the patient's mouth. The patient is in
a fully supine position.
Newly designed dental equipments and carefully planned trays
containing instruments for the operations scheduled for a given
session permit the assistant to handle the dentist a particular
instrument at the amount he needs it She also performs additional
duties as retraction or aspiration.

3. Dental auxiliaries:
For some time now, experimental efforts have been made in some
countries to train dental auxiliaries to perform operations of limited
nature in the mouths of patients.
Dental assistants have been chosen for these trials, and the duties
involved in those procedures which were generally agreed to be
repairable, that is, could be either corrected or redone without undue
harm to the patient's health. The assistants would not prepare cavities
or make decisions as to pulp protection after caries had been
excavated, but would work alongside the dentist and take over
routine restorative procedures as soon as the cavity preparation had
been completed, the training for this type of dental assistants is over
two years period and include basic instructions in dental science and
instructions to perform the following operations:
1. Placing and removing rubber dam.
2. Placing and removing temporary restorations.
3. Placing and removing matrix bands.

- 53 -
4. Condensing and carving amalgam restorations in previously
prepared teeth.
5. Applying the final polish to the previously placed restorations.

4.Dental Hygienist:
Dental hygienists are usually of two ranks: Public health dental
hygienists and clinical dental hygienists.

a. Public health dental hygienists:

They receive one or more years of health education and public health
training beyond dental hygiene certification.
The public health hygienists do a great deal as a resource person.
They screen or preliminary examine patients such as school children
or industrial employers in order that they may be referred to dentists
for treatment. Actual classroom teaching is possible where additional
training in education has been received. In a public health program
the hygienist goes where dentists cannot, and presents a point of
view much closer to that of the children with whom she is usually
working than could the dentist.

b. Clinical dental hygienists:

This receives less training than the public health hygienist. Their
duties are limited, and the usual functions of clinical dental hygienist
are cleaning of the mouth and teeth with particular attention to
calculus and stains, polishing of the restoration, topical fluorides
applications and other prophylactic solutions.

- 54 -
5. Dental Laboratory Technicians:
This group has little effect in the field of preventive dentistry and
dental care for young children but affects in a very important way
the efficiency of dental treatment for older patients.
The work is done mainly by men rather than by women. Originally
training was carried out in the dental office and this resulted in
variation in the quality of the training. There are two reasons which
encouraged the presence of commercial dental laboratories working
for a number of dentists.
1. Few dentists have enough work to justify the employment of a
full-time technician.
2. The procedures involved in dental laboratory work are often such
as to profit by division of labor. One technician becomes an
excellent porcelain man, another an expert gold man, one for
Orthodontic appliances, the other for chrome cobalt partial dentures,
and so on. Simple plastic work can be delegated to the apprentices in
the laboratory.

6. New Auxiliary Type for Underdeveloped Areas:

Some countries have an acute dentist shortage and have no facilities
for training dentist The WHO suggests two types of dental auxiliary
for such situation:
a. The dental licentiate: they should be a semi-independent operator
trained for not less than 2 calendar years to perform dental
prophylaxis, cavity preparation and fillings of primary and
permanent teeth, extractions under local anesthesia drainage of

- 55 -
dental abscess, treatment of the most prevalent diseases of
supporting tissue of the teeth, and the early recognition of more
serious dental conditions. These people, presumably men, might be
responsible to a fully trained dentist at the national level or to the
chief of the local health service. Supervision and control would
probably occur in rural or frontier areas. Measures should be taken to
increase the duration of their training and their educational
requirements.
b. The dental aides are conceived to be persons of even briefer
training who would perform functions as elementary first aid
procedures for the relief of pain including extraction of teeth under
local anesthesia, the control of hemorrhage, and the recognition of
dental disease important enough to justify transportation of the
patient to a center where proper dental care is available. Supervision
and control are important particularly at first. The formal training
period might last from 4-6 months followed by a period of field
training under dental aides will probably disappear so soon as a
sufficient number of dental licentiates or full qualified dentists
become available.

- 56 -
Group Practice:
The term group practice is most often applied to small numbers of
practitioner responsible only to themselves, but the principles of
organization used by these people are equally applicable to larger
clinics, whether they are independent or are operated by a more all-
inclusive agency such as an industry or a government.
The dentists are a group of partners or may be employs of an
organization; all of them have more or less equal voice in
management of the groups when it comes to professional standards.
Group dental practices perform their best service where the various
dental specialties are to be coordinated with the services of the
general practitioner of dentistry. In all types of group practice the
chief advantages to the patient are easy referral from office in the
same building and easy consultation between operators. Regular staff
meetings provide not only an excellent chance to discuss those cases
where more than one practitioner is concerned but also give
members of the staff an unusual chance to keep up with new
development in their profession.
The economic advantages to group practice are considerable;
working hours can be stabilized at an optimum level. Emergency
duty, regular hours, and vacations can be adjusted in such a way as
to even the load, make vacations presentable; and give an
opportunity for post-graduate instruction, attendance at conventions,
and the like.
Other economic advantages are those which may be realized by the
pooling of physical facilities, equipment and technical personnel.

- 57 -
Waiting rooms, dark rooms and wash rooms are among the facilities
most commonly shared. X-ray and laboratory equipments are also
frequently shared. The best size for a group in independent practice
seems to be from 6 to 12 men.

Team Work:
Where complete dental care is to be rendered to large population
group, the group practice principle is often extended until one seems
large dental clinics or dental treatment facilities.
Clinics of this sort are most commonly found in government
programs such as the Armed Forces, Division of labour here is
carried much further than would be the case in of ordinary group
practice. Diagnosis and emergency treatment usually are separated in
special areas. Other specialties may also be separated such as
prosthetics.
In this way laboratories can be close to the operating room most in
need of their services and the various members of the group become
familiar with each other operating methods. The function of the
general dentist is cut down almost to that of operative work.

- 58 -
 DENTAL HEALTH PROGRAMS
The most important task in the field of public health dentistry and
the one occupying most time for most personnel is the administration
of dental health programs at the local level.
Before planning of any health program, the hypothesis has to be
formulated. The investigation has to be designed; the study may be
cross sectional or longitudinal. A parallel group has to be studied as
a control. The samples may be: selected, random or stratified
random.
The dental health programs may be designed for school children,
handicapped, industrial workers... etc. The basic principles for
designing any program are the same.
Concerning industrial dentistry, an added factor, should be put into
consideration, where industrial projects are conducted profit, the cost
of caring for illness or injury which results from the occupation of
the worker constitutes a legal charge upon the receipts of the
industry. Industry's responsibility for the care of occupational
injuries, including dental injuries, is universally recognized, and the
employer's liability insurance is compulsory
Children with medical handicaps are increasing numerically
following the great advances in pediatrics. Young patients are now
surviving who would hither to have died, and even those with quite
severe handicaps are leading a life within the family unit. Programs
for the handicapped differ from other programs on the basis that
specialized techniques are sometimes required to do routine

- 59 -
operations such as the placement of filling. More often the problem
involves the general management of the patient.

SCHOOL DENTAL HEALTH PROGRAMS

School based oral health programs are considered an important part
of general public health programs but to develop relevant program
that address the needs of today's children is a complex task. So in
order to maximize its affectivity, its objectives should mostly contain

CAPITE.
C- Compatible with the need of the population served.
A-Administratively sound i.e. politically, professionally,
educationally accepted.
P- Preventive and promotional regimens as a part of school
curriculum.
I- Identify any abnormal conditions from screening.
T- Treatment or referral for giving optimum student oral health care.
E- Health Education is necessary as it supports knowledge and
creates positive attitudes.
Planning for school health program require setting preliminary broad
scheme objectives then selection of those needed according to each
population need.

Objectives of school health dental program are:

1- Provide an optimum oral health to every school child.

- 60 -
2- Address the need of each stage separately according to their
problems.
3- Preventing oral diseases mainly dental caries and periodontal
diseases.
4- Spot light on traumatic injuries, occurrence and emergency first
acid treatments.
5- Interceptive screening for malocclusion and referral to
orthodontist.
6- Nutritional counseling with School dietitians.
7- Assessment of fluoride's application needs.
8- Pit and fissure comprehensive delivery programs to school
students. The duties of school health dentist can be listed as follows.

1. Case Finding:
It might seem wasteful to examine children for a disease which
occurs almost universally. It is more logically to organize a sound
dental health program based upon a system of dental inspections
which provides base line information about dental needs. There are
several possible approaches.
A. Complete dental examination with all aids: This is obviously
unsuited to case finding in entire school populations because of the
expense and time involved.
B. Limited examination using mouth mirror and explorer, bite- wing
X-rays; and if necessary periapical X-rays, In mouth with
uncomplicated dental disease, this examination may well suffice as a
basis for treatment with further review.

- 61 -
C. Inspection using mouth mirror and explorer and adequate
illumination: This type lends itself very well to school procedures
and can be performed either by a dentist or dental hygienist This
inspection will require review later, no matter who has done the
work, since proximal caries can often be detected in its early stages
only by X-ray. This type however, identifies major dental needs in
most instances. It can be made in the school with portable
equipments.
D. Screening using tongue depressor and available illumination:
This is dental case finding at its lowest efficiency yet the procedure
is needed sometimes where dental personnel is not available to do a
better job. A great danger exists that children who don't seem to have
dental defects by tongue depressor screening will consider their
mouths to be healthy and will therefore not seek adequate dental
examination.

2. Referral for Dental Care:

In some countries, children with dental disease may be referred to
private dentists for treatment; in other countries, they may be
referred to government treatment institutions such as hospitals,
dental clinics, school health units etc. On referral for treatment, the
parents must be informed about the child dental condition and the
type of treatment needed and probably a consent form may be signed
by the parent. In cases where extraction of permanent teeth is
indicated, the signing of consent forms by the parents is essential.

- 62 -
3- Dental health Education:
This includes instructions related to the maintenance of proper oral
hygiene such as tooth brushing and the value of balanced diet, the
danger of excessive intake of refined carbohydrate both during the
meal and between meal snacks. The importance of periodic check up
visits to avoid emergency visits associated with severe pain.

4. Follow up of Dental Inspection:

It is the responsibility of dental health officer to make sure that
children referred for treatment have been receiving the proper
treatment. The dental hygienist or the school nurses are the logical
person to conduct a follow-up system.

5. Excuse from School For Dental Treatment:

Children should be excused to keep appointments with the physician
or dentist during school hours, Abuses of the school excuse system
can often be avoided if simple excuse forms are printed with space
for date and hour of the appointment, the signature of a school
official, signature of parents and signature of the dentist finally to
assure that the appointment was actually kept.

Dental Care For The Disadvantages:

In most communities there are school children who cannot afford
dental care in accordance with their needs and with the
recommendations which are made to them. It is usual for such
communities to make some effort to provide dental care for

- 63 -
disadvantaged children, whether through a school dental clinic,
health-center dental clinic, or perhaps some other clinics maintained
by a voluntary organization.

- 64 -
 Forensic Dentistry
LEGAL JURISDICTION
Age determination:
The best way to determine the age of a subject up to 25 years is by
examining the condition of the jaws and teeth. The mandible at birth
is made up to two segments joined at the symphysis by
fibrocartilage. This symphysisal fibrocartilage becomes calcified
during and up to six months after birth. So the two halves of the
mandible, in the cadaver, can be moved against each other up to six
months after birth. The mouth is completely edentulous during that
period.
At six months and with the eruption of the two lower central
deciduous incisors, the mandible will be made up of one solid bone
because of the complete ossification of this symphysial
fibrocartilage.
The angle of the mandible at birth is about 170°. The condyloid
process is situated at the same horizontal level as the upper border of
the mandible. Changes in growth of the mandible and ramus will
reduce this angle gradually till it reaches 110° at adult age.
On the inside of the front part of the mandible we observe four
genial tuberdes, two on either side. The upper pair is for the insertion
of the genioglossus muscles while the lower pair is for the geiohyoid
muscles. These four genial tuberdes are sharp, exaggerated and
thomy in males, while in females they are reduced, smooth and
rounded.

- 65 -
On the inferior border, at the posterior end of the body of the
mandible at the region of the angle, we observe some roughness for
the insertion of the masseter muscle on the outside and for the
internal pterygoid muscle on the inside. These insertion marks are
rough and protuberant in males while they are reduced and smooth in
females.

The Teeth:
First, we should know the difference between a socket and a crypt: A
socket receives the roots of an erupted tooth, while a crypt
accommodates the developing unerupted tooth.
At birth, the jaw (maxilla or mandible) appears smooth with
intact mucous membrane covering its oral part. If we remove the
mucosa and examine the bony jaw, we observe six crypts in each
half of each jaw; five". crypts for the deciduous developing teeth and
one crypt for the developing first permanent molar, At this stage, the
crypts are made up of a floor and sides, but without a roof. So, if we
invert the mandible the bits of calcified parts will fall out because the
crypts lack the roof to support them. After fifteen days from birth, all
the crypts will have developed roofs and so, if we invert the
mandible the bits of the teeth will not fall out as they will be retained
by the calcified roofs of the crypts.
If we take an X-ray of the jaw at birth we will find the following
classified parts:
1/2 crown of "A", 1/3 crown of "B" Tip of crown of "C" Joined

- 66 -
cusps of occlusal surface of "D". Separate cusps of occcusal surface
of "E". Tip of one cusp of "6".
Six months after birth the lower two deciduous central incisors erupt,
and then the sequence will be as follows:
Lower A, upper A, upper B, lower B, upper and lower D, lower C,
upper C, lower E, upper E. At the end of two years the deciduous set
will be usually completely erupted.

7 8 18 11-12 20-24
ABC D E
Months
ABC D E
6 9 16 11-12 20-24

So, we can safely determine the age from birth up to six months by
an X-ray picture and from six to 24 months by observing the
erupting teeth clinically.
From 2-6 years no more teeth will erupt, but on X-rays we can
observe the completion of formation of the roots of the deciduous
teeth and then their beginning of resorption.
The phase from six to twelve years is called the phase of
mixed dentition, because the first permanent molar begins to erupt at
the age of six years to be followed by resorption and shedding of the
first deciduous incisor. During this phase the deciduous teeth will be
shed and are replaced by the permanent succedaneums teeth up to

- 67 -
the age of twelve years. At twelve years the second permanent molar
erupts.
So, by knowing the dates of eruption of each permanent tooth, we
can decide fairly accurately the age of the subject from 6-12 years. It
takes three years for the roots of erupted teeth to get completed and
calcified. So, by taking X-rays to observe the amount of root
formation we can decide the age up to 15 years.
After fifteen years, we rely on the condition of the crown and root
formation of the third molar for age determination by means of x-
rays.
The crown of the third molar is completely formed at fifteen years,
the roots will form and will be completed at the age of twenty two
years, so in between stages can be determined by X-rays and thus the
age can be fairly decided upon. We should not rely on the date of
eruption of the third molar as it presents many variations, only X-ray
detection of the amount of tooth formed is of help to us.
After the age of twenty two years, the teeth will slowly but surely
present signs of attrition. Contact points will be changed into contact
areas. The sharp points of the cusps will present fiat fact and so on.
This will progress as life goes on till at the very late stages dentine
may be exposed. The type of diet may accelerate this process.
The epithelial attachment will also give us a clue about the age of the
subject. The epithelial attachment has two points: the point at the
depth of the gingival sulcus and the apical end of the epithelial
attachment. Clinically the first point is the one that can be detected.
The four stages of the epithelial attachment are as follows:

- 68 -
Up to the age of
20 years on enamel Above C-E junction
20-35 years On E. at C-E junction
35-50 years at C-B Junc. On C
Above 50 years On C On C
The first point can be ascertained clinically or on a dead body, while
the second point cannot be ascertained clinically but may be defined
on a dead body or by taking out the tooth and its surrounding
integuments during surgical operations necessitating removal of part
of the jaw. Microscopical examination of sections will then
determine the apical end of the epithelial attachment Sections of gum
tissue reveals a sex difference:
1. The cells of the basal layer of epithelium shows a bright chromatin
dot at the nuclear membrane in females only,
2. The fibers in the subepithelium tissue are soft, thin and genuy
interlacking in females, while they are rough and angular in males.
After the menopause, the fibers attain the male characteristics. To
determine the actual sex of an individual in cases of false
hermaphrodites and in the Olympic games (because sometimes it
happened that males, impersonating as females, participated in
female Olympic competitions, the sex chromatin test is performed. A
smear is taken form buccal mucous membrane and examined for the
chromatin mass at the nuclear membrane in case of females.

Ramus and Body of Mandibles:

The relation of the ramus to the body of the mandible is of great

- 69 -
interest in age determination. The ramus rises immediately behind
the second deciduous molar at the completion of eruption of the
deciduous set. It remains as for two years then a space begins to be
observed behind the second deciduous lower molar from the age of 4
years up to the age of 6 years when the first permanent molar
appears in the mouth.
The ramus seems to rise immediately after the first permanent molar
from the age of 6 years up to the age of 10 years. Then a space
begins to appear behind the first permanent molar at 10-11.5 years.
At that time the second molar begins to erupt and the ramus rises
immediately behind it and remains so for three more years. From the
age of fifteen on wares a space is observed behind the second molar
to give allowance for the third molar to appear later on.

Journey of The Mental Foramen:

At birth, the mental foramen appears near the lower border of the
mandible.
By further apposition of bone at the lower border of the mandible,
the MOF. appears to move upwards till it becomes seated just above
the midway line between the upper and lower borders of the
mandible and the deciduous teeth are now completely erupted.
By the advent of the phase of the longer sockets of the permanent
teeth, the M.F. appears to descend below the midway line.
With the loss of the permanent teeth and the disappearance of the
alveolar process the M.F. rises upwards to be seated just over the
upper border of the mandible.

- 70 -
Age Determination From One Tooth:
If we just got one tooth (on the floor or at the seat of a crime etc), we
can still determine the age of the subject by noting the following:
1. The type of tooth: Deciduous, permanent, incisor, second molar
etc.
2. Root formation: incomplete, complete, beginning resorption etc.
3. Signs of attrition and its amount.
4. In a longitudinal section:
a) Presence of pulp horns.
b) Presence of secondary dentine and its amount
c) Presence of secondary cementum and its amount
There are certain tables giving points to each of the above
characteristics and by adding all the points, the approximate age of
the subject can be determined. Separate data are given for each
tooth.
It becomes more accurate if more than one tooth is obtained from the
same subject.
To summarize, we can determine the age from birth to 25years by
observing the jaw, the deciduous and permanent teeth clinically.
Then by X rays we determine the amount of root formation.
After 25 years we have to rely on the amount of attrition and the
condition of the epithelial attachment, amount of secondary dentine
and hypercementosis of the roots.
Important Medico-Legal Dates:
1. Age of starting education in primary schools: Six years. Age of
eruption of first permanent molars.

- 71 -
2. Maximum age for juveniles: fifteen years. Age of complete
calcification of the roots of the second permanent molars. Under this
age a child is tried in front of juvenile courts.
3. Age of marriage for females: sixteen years. X-rays show complete
calcification of roots of all permanent set up to the second molar,
formation of the crown of the four third molars and one millimeter of
the root trunk. It also shows the union of the distal ends of the
metacarpal bones.
4. Age of consent for females: 18 years. Union of lower end of
radius and the formation of the crown and the undivided trunk of the
root of the four wisdom teeth. Any intercourse with females below
this age, whether consentingor not, is considered as rape.
Eighteen years is the age of allowance for marriage for males.

The skull (without the mandible)

Fontanelles: The posterior fontanelles dose at birth. The anterior
fontanelles dose at two years of age.
Sex differences Male skull Female skull
Frontonasal junction Angular, Smooth
Parietal eminence Prominent Smooth
Sppercilliary ridges Prominent Less marked
Mastoid process Long Short
Occipital condyles Long Short &broad
and narrow
External occipital Rough Smooth
Protuberance prominent less marked

- 72 -
Apart from age and sex determination, the dental surgeon may be
able to give his advice in the following three cases: poisoning, bite
marks and identification of bodies.

1. Poisoning:
Taking a sample of saliva for analysis may quickly reveal the type of
poison taken or administered to the victim. A characteristic colored
line appears on the gums at the margin. This line is reported to
appear on the roots at the cervical border: Blue line Lead. Grey
line=Mercury, Green line copper, Black line = Bismuth, Yellow line
= cadmium.

2. Bite Marks:
Bite marks are observed on victims of rape or on the rapist inflicted
by his victim. The dental surgeon consulted should first ascertain
that the bite is caused by human teeth.

The bite of an animal is represented by two parallel horizontal lines,

while a human bite presents two curved rows of abrasions meeting
each other in an elliptical form. The bite may also be detected on a
piece of cheese, on an apple on part of a loaf etc. The dental surgeon
can pour plaster over the bite mark and after setting, can obtain
model of the assailants’ teeth.
3. Identification of bodies, unconscious subjects, patients
suffering from amnesia, false impersonators etc. :
Unidentified bodies in great fires, air plane crashes, exhumed bodies

- 73 -
or bodies floating in the Nile depend mainly for identification on the
dental condition; because fire usually destroys finger prints and
drowning, burial or fire usually distorts or destroys the features
beyond recognition.
Records from the treating dental surgeon's office with attached x-
rays are of utmost help. Prints to be looked for are:
Teeth present, teeth extracted, teeth impacted, remaining roots
endndontic work, periodontal condition, periapical condition, any
anomalies or pathologic conditions (cyst, abscess, old fracture etc.)
crowns, bridges, inlayes, fillings, dental prosthesis etc.
It became evident that if we try to observe all these points that no
two mouths are similar.
Bodies of Hitler and Ava Brown, burnt beyond recognition, were
definitely identified by her dental record.
The body of the American lady found burnt in old Shepherd's Hotel
during the fire of Cairo on January 26th, 1952, was definitely
identified by their dental record presenting the types of prosthesis
and bridge work in her mouth. Recently In October 1985, the body
of Leon Klinghofer which was thrown out of the ship Achill Laure
and which remained in sea water for seven days, was picked up at
Tarsus, Syria and was definitely identified by his dental X-rays
flown from the United States.
In cases of crimes, a fallen part of prosthesis, a bite mark or certain
characteristics of the dentition remembered by the victim will help to
mark the criminal. The rapist of Scotland is an example.

- 74 -
Liability:
The dentist is liable to prosecution and to pay damages if he is
convicted of Gross Negligence. Attempted rape may be imagined by
female patients under G.A. if no female relative is present.

- 75 -