COMMUNITY DENTISTRY

MODULE 5
GLOSSARY 01
Q1: Define Prevention.
Prevention:
It is defined as the efforts which are made to maintain normal development,
physiological function and to prevent diseases of the mouth and adjacent
parts.
It is defined as the interception of the disease process.
Q2: How many levels of prevention are there? Describe them.
There are 4 levels of prevention:
Primordial Prevention:
 Primary prevention in its purest form
 Efforts are directed towards discouraging children from adopting
harmful lifestyles (use of tobacco, eating patterns, adverse oral habits
etc.)
Primary Prevention:
It can be defined as the action taken prior to the onset of disease, which
removes the possibility that the disease will even occur i.e. aims for
eradication of incident of disease by elimination or modification of risk
factors.
Example: control of sugar intake and use of fluoride toothpaste to prevent
caries
Secondary Prevention:
It employs routine treatment methods to terminate a disease process and
to restore tissues to as near normal structure as possible.
Prompt treatment, diagnostic interventions.
 Case finding measures
 Early diagnosis and mass screening surveys
 Cure and prevent disease process
  Prevent complications
 Shorten period of disability
Example: Fissure sealants in case of caries
Tertiary Prevention:
It employs measures necessary to replace lost tissues and to rehabilitate
patients to the point that function is near normal as possible after the failure
of secondary prevention.
Example: Root canal treatment or fillings
Q3: What are the procedure that come under primary prevention level?
Health Promotion:
It is the process of enabling people to increase control over the
determinants of health and thereby improve their health.
 Health education
 Good standard of nutrition
 Personality development
 Adequate housing recreation and agreeable working conditions
 Marriage counselling
 Periodic selective examinations
Specific protection:
 Use of specific immunization
 Attention to personal hygiene
 Protection against occupational hazards
 Use of nutrients
 Protection from carcinogens, allergens
 Use of environmental sanitation.
Establishing barriers against the agent in the environment:
 Adopting cross-infection control procedure
 Gloves, masks
 Eye wear
 Lab coats
Q4: Differentiate different levels of prevention
Q5: Define the concept of Primary health care.
 PHC for all especially needy which means equity every person has
the right to access health
 Services should be acceptable to the community with active
community involvement.
 Health services must be preventive, effective, promoting and
curative.
 Services should form an integral part of the country’s health system
 Programs need to be efficient, multi sectorial as health cannot work
in isolation
Q6: List the essential components of PHC programme.
1. Education – encompassing prevailing health problems and method
of identifying, preventing and controlling them
2. Promotion of food supply and proper nutrition, adequate supply of
safe water and basic sanitation
3. Maternal and child health care
4. Immunization against infectious diseases.
5. Prevention and control of locally endemic diseases
6. Appropriate treatment of common diseases and injuries.
7. Promotion of mental health
8. Provision of essential drugs.
Q7: What are the key concepts of PHC planning? Discuss them.
Equity:
Everyone is entitled for health care based on their needs.
Effectiveness:
Every program should have favorable effect which can be measured with
indicators as it must reach out to whole population at reasonable costs.
Efficiency:
PHC programs should be undertaken at low cost consistent with favorable
effects.
Q8: Discuss Basic rural health unit facilities of PHC in Pakistan.
Basic Health Unit:
Serves 5000-10000 population
Services provided are:
 Maternal child health services
 Child care
 Immunization
 Malarial control
 Diarrheal control
 School health services
Rural Health Unit:
 Has 25 beds
 Laboratory
 Ambulance
 Provision of minor surgery
 It is linked to Taluka hospital which is further linked to District
hospital.
Q9: Classify different types of sugars and also state their cariogenic
potentials.
Many different terms have been used to name and classify sugars. The
COMA classification is based upon where the sugar molecules are located
within the food or drink structure.
Intrinsic sugars:
Are found inside the cell structure of certain unprocessed foodstuffs, the
most important being whole fruits and vegetables (containing mainly
fructose, glucose, and sucrose).
Extrinsic sugars:
Are located outside the molecules of the foods and drinks. There are two
types: milk extrinsic sugars (MES) and non-milk extrinsic sugars (NMES)
The extrinsic milk sugars include lactose, found in dairy products such as
milk and milk products. NMES are found in table sugar, confectionery, soft
drinks, biscuits, honey, and fruit juice. The WHO and many other
international organizations use an alternative term, ‘free sugars’, to classify
the sugars responsible for the development of dental caries (WHO 2003 ).

Q10: What dietary recommendations would you give your patient to

address?
Based upon the available evidence, the following consensus national and
international recommendations have been proposed (Department of Health
1989; WHO 2003):
●The frequency and amount of NMES should be reduced. NMES
consumption should be restricted to mealtimes when possible.
●Intakes of foods and/or drinks containing NMES should be limited to a
maximum of four times per day.
●NMES should provide no more than 10% of total energy in the diet or less
than 60 g per person per day.
●Consumption of intrinsic sugars and starchy foods should be increased (5
pieces/portions of fruit/ vegetable per day).
Q11: What are the community wide initiatives that need to be taken to
prevent caries?
●Focus: address the underlying influences on food consumption and be
aware of the barriers that prevent certain groups from adopting
recommended diets.
●Evidence: be evidence-based and ensure that recommendations are
consistent and scientifically based.
●Food chain: adopt a multi-disciplinary approach in which a range of
relevant organizations, agencies, and professionals work together to
promote healthier eating.
●Action: utilize a complementary range of health promotion strategies that
move beyond a health education approach.

Q12: State the approaches/measures by which caries can be prevented or

reduced?
The established methods for preventing dental caries are:
1- Reduction in sugar consumption i.e. the amount and frequency of
ingestion
2- Optimal exposure to fluorides to strengthen the tooth against
solubility to acid
3- Appropriate use of fissure sealants
4- Antibacterial therapy: products such as chlorhexidine rinses are
effective
5- Salivary flow can be increased by chewing sugarless gum for
example xylitol
Q13: Write a brief note on Caries Vaccine.
Protection/ Prevention against Dental Caries by stimulating the defense
mechanism of the mouth.
Mechanism of action:
IgA enters the oral cavity through gingival crevicular fluid  May stimulate
opsonization and phagocytosis of bacterial cells  Have an inhibitory effect
both of glucosyl transferase and on acid production  Inhibit the
establishment of metabolic activity of Streptococcus Mutans  This could
favor the early establishment of non-cariogenic micro flora on the teeth
Delay colonization of bacteria  Reduce dental caries
The properties of an ideal dental caries vaccine are as follows:

Q14: What is the significance of Caries Activity Test?

The significance of caries activity tests is as follows:
1. Helps to determine the need for caries control measure
2. Help to determine the optimum time for restoration
3. Help in determine the results of preventive measures
4. Identify high risk groups and individuals
5. Monitor the effectiveness of oral health
6. Index help to reduce Streptococcus Mutans and lactobacilli.
7. Measure speed of progression of carious lesion.
Q15: List the tests carried out to assess the caries activity.
1. LACTOBACILLUS COLONY COUNT TEST
2. THE SWAB TEST
3. ALBAN TEST
4. STREPTOCOCCUS SCREENING TEST
5. DEWAR TEST
6. SALIVARY BUFFER CAPACITY TEST
7. STREPTOCOCCUS MUTANS LEVEL IN SALIVA

GLOSSARY 02
Q1: Describe dental plaque and calculus.
Dental Plaque:
A natural bio-film that forms on the tooth surface and consists of a
diverse microbial community embedded in a polymer matrix of
bacterial and salivary origin.
Calculus:
It is mineralized plaque which adheres on natural teeth and dental
prosthesis
Q2: Differentiate between plaque and calculus.
Plaque Calculus
Natural bio-film that forms on Mineralized plaque which
tooth surface adheres on teeth
It is soft and sticky It is a hard calcified build-up
It initiates diseases like It initiates severe forms of
gingivitis diseases like periodontitis
Primary bacterial colonization Secondary bacterial
takes place colonization takes place
Can be removed with correct Cannot be removed with
brushing and flossing brushing and flossing

Q3: Write a short note on dental plaque.

Dental plaque:
A natural bio-film that forms on the tooth surface and consists of a
diverse microbial community embedded in a polymer matrix of
bacterial and salivary origin.
Plaque Formation:
 After tooth brushing pellicle a conditioning film of proteins and glyco-
proteins is formed
 1st step: Fresh plaque interaction between pellicle and early bacterial
colonizers.
 2nd step: Mature plaque secondary bacterial colonizers adhere to
early colonizers through specific molecular interactions.
Nature of plaque:
 Reforms slowly till 3rd day and reaches maximum bulk after 7th day
 Various microbial interaction keeps bacterial composition
homeostatistically balanced and stable
 Sub-gingival plaque micro flora shifts from predominantly gram
+ve to anaerobic gram –ve (Porphyromonas Gingivalis,
Bacteroides Forsysthus) linked with bone loss and PDL
attachment loss.
 Spirochetes present in sub-gingival plaque are marker of disease
 Plaque is responsible for gingivitis.
 Supra-gingival and tooth associated sub gingival plaque is
responsible for calculus and root caries.
Benefits of plaque:
 Initial pellicle layer prevent intraoral colonization by exogenous
species.
 Promote remineralization.
Q4: Differentiate between sub-gingival and supra-gingival plaque.
Sub-gingival Plaque Supra-gingival Plaque
Present below gingival margin Present above gingival margin
Always tooth associated May be tooth or tissue
associated
Primary source of nutrition for Primary source of nutrition is
bacteria is saliva and ingested gingival crevicular fluid
food
Mainly responsible for gingivitis Responsible for calculus
formation, root caries and
destruction of soft tissues

Q5: How many theories have been proposed to describe the nature of
plaque? Discuss them.
 Three theories have been proposed to describe the nature of plaque.
They are as follows:
1. Ecologic plaque hypothesis:
Periodontal disease prevention should be geared towards plaque
control than plaque eradication.
 The goal is to prevent Fresh plaque from becoming Established
plaque
 Preventing supra gingival plaque from becoming sub gingival
plaque.

2. Continuous progressive model disease process:

 It states that periodontitis is a slow and continuously progressive
condition
 Based on the belief that gingivitis once developed would progress
into periodontium leading to loss of attachment, bone destruction
and eventually loss of teeth.

3. Burst theory:
 This complies with the current concept of disease stating its
episodic nature, in which short bursts of tissue destruction take
place in certain teeth at certain sites.
 These short periods of disease activity are followed by longer
periods of remission and healing.
 Loss of attachment is evenly distributed neither within mouth nor in
the wider population
 An average attachment loss observed is 0.05-0.10 mm per year.

Q6: List down the factors that predispose to plaque accumulation.

Factors Predisposing to Plaque Accumulation:
 Overhanging restoration
 Removable partial denture
 Calculus
 Tooth mal-alignment
 Genetic tooth disease

Q7: How can progression of periodontal disease be assessed?

 More plaque greater the amount of disease
 S shaped relationship of plaque- periodontal disease
 According to it there is a level of plaque which does not lead to
significant disease progression, this low level is termed as contained
gingivitis i.e. no progression, no regression.
 Beyond this level, the more plaque in mouth the more disease. This
straight line relationship exists to a certain point, after which an
increase in plaque has no effect on the disease levels.
Q8: What are the preventive strategies by which plaque can be
controlled?
1- Mechanical plaque removal by individual
2- Mechanical plaque removal by the dental professional
3- Chemotherapeutic method of plaque removal
Q9: Write a note on each preventive strategy.
(A)Mechanical plaque removal by individual
1- Tooth brush:
 Frequency of brushing: 2mins and 2 times a day
 Types of tooth brush:
Manual tooth brush
Power driven / electrical for handicapped
Smaller brushes for children
Soft brushes to minimize gingival trauma
 Tooth brushing methods: Fones / circular or Scrub technique is
most widely used and is easily adaptable
2- Inter dental cleaning:
There is evidence that interdental brushes reduces interdental
gingivitis and plaque more than the tooth brushing alone.
3- Dental floss and tape:
 Most widely recommended interdental aid
 Material: silk, nylon, expanded PTFE ( plastic monofilament poly
tetra fluoro ethylene)
 Types :
(a)Multifilament twisted/ non- twisted
(b)Bonded/ non-bonded
(c) Waxed/ non-waxed
(d)Thick/thin
Indications:
- Adjacent to wide embrasures with loss of interdental papilla
- Mesial and distal abutments and under pontic of fixed partial denture
or orthodontic appliances.
4- Knitting yarn:
 Indications:
- Wide proximal spaces
- Areas where regular floss too narrow to remove biofilm efficiently
- Abutments and under pontics (artificial tooth on fixed dental
prosthesis that replaces a missing natural tooth, restoring its function)
- Diastema (space or gap between two teeth)
- Distal surfaces of most posterior teeth.
5- Gauze strip:
Indications:
- Proximal surface of widely spaced teeth
- Surfaces of teeth next to edentulous area
- Distal and mesial surface of abutment teeth
6- Interdental brushes:
Indications:
- Proximal tooth surfaces adjacent to open embrasures,
orthodontic appliances, fixed prosthesis, periodontal splints.
- Concave proximal surfaces
- Exposed class iv furcation
- For application of chemotherapeutic agents (fluoride
dentifrices, antibacterial agents, desensitizing agents.

(B)Mechanical plaque removal by dental professional:

Manual scaling
Ultrasonic scaling
Prophylactic treatment for adults
Professional and personal care
(C)Chemotherapeutic method of plaque removal:
- Antibiotics (penicillin, vancomycin, erythromycin)
- Phenols (Listerine)
- Quaternary ammonium compound (cetypridinium Cl,
benzalconium Cl)
- Bis Biguanides (chlorohexidine)
- Enzymes (mutanase, dextranase)
- Metallic salts ( ZnSO4, Zn Citrate)
- Oral irrigation devices

Q10: What are the public health measures to reduce periodontal

diseases?
Public health measures:
1- Integrate oral hygiene into body cleanliness education at nurseries
and schools e.g. Tooth brushing drills
2- Incorporate the importance and skills of oral hygiene into training of
health, education and social care professionals
3- Use fiscal policy to reduce costs of oral hygiene aids and toothpaste
4- Organizational policy: ensure oral hygiene is placed on health-
promoting schools agenda structural change within schools regarding
provision and design toilet facilities.
Q11: What is the key health education message to promote
periodontal health?
Key health education message:
1- Children under 7yrs should be supervised with their brushing
2- Gentle scrub technique is an effective tooth brushing method
3- Gentle pressure hold brush with pen grip
4- Use of floss, sticks and interdental aides are optional and need
professional advice
5- Replace toothbrush when bristles become splayed
6- CHX is the most effective chemical plaque suppressant.

Q12: How can periodontal disease be prevented at Primary,

Secondary and Tertiary levels.
 Q13: State the primary prevention methods for oral cancer.
Primary Prevention Methods:
 Avoid / Cease consumption of all types of tobacco, alcohol,
betel/areca nut and other harmful substances.
 Add diet rich in fruits and fiber.
 Remove the cause of irritation and treat the oral infections.
 Appropriate anti-viral drug therapy to treat HPV infections.
 Avoid excessive sunlight exposure.
Q14: What are the different approaches through which oral cancer can
be prevented?
Approaches for prevention of oral cancer:
There are three main approaches for prevention i.e.
– Regulatory or legal approach
– Service approach
– Educational approach
Q15: Discuss the different approaches of preventing oral cancer in
detail.
Regulatory Approach:
• In India: Cigarette act 1975 – print warnings on cigarette packets.
• National Cancer Control Programme, 1985: health warning
displays & banning of advertisements on tobacco products.
• Italy, Norway, Portugal: ban on advertising tobacco products.
• Pakistan: printing on cigarette packets.
– Ban on advertisements on media.
– Display of precaution in media on its display (if displayed).
– Ban of sale of cigarette to children under 18 years is under
implementation.
– Increase in taxation and cost of product.
Service Approach:
• Active search for a disease is important for prevention---screening
1. Comprehensive medical history
2. Detailed and thorough oral examination
– Facilities for diagnosis and treatment exists
– Natural history of disease is known
– Screening tool should be inexpensive and safe
– Prompt and appropriate referral
3. Patient counseling
Dentists play an important role in early diagnosis of cancer. Many
diagnosis are missed because early oral cancers have an extremely
variable clinical appearance.
Educational Approach:
• People should be encouraged to give up harmful habits.
• Individual with clinical symptoms should be kept under careful
observation.
• The public should be informed about:
– Consequences of oral cancer.
– The risk that oral pre cancer lesions may develop into oral
cancer.
– Importance of early diagnosis and treatment of oral mucosal
lesions.
 Q16: How can oral cancer be prevented at primary, secondary and
tertiary level?

Q17: What are the measures that can help in preventing tobacco
consumption?
PREVENTIVE MEASURE FOR TOBACCO CONSUMPTION:
1. Tobacco Control:
• Counseling.
• Behavior modification (dentist/patient/specialist).
• Stop smoking.
• Alternatives to smoking e.g. nicotine gums or patches .etc
2. Referral to other health practitioners:
• Oral Medicine.
• Oral Maxillofacial Pathology.
3. Diet:
• Nutritional counseling.
 Q18: Illustrate the smoking cessation pathway.
Smoking cessation pathway includes:
• Ask
• Advise
• Assist
• Arrange

Q19: Which dietary routine helps in preventing against oral cancer?

The diet which helps in prevention of oral cancer is:
 Consumption of a diet high in fiber.
 Consume enough folic acid, vitamins and minerals.
 Eat at least five servings of fruits and vegetables daily.
 Provide nutritional supplements for individuals unable to intake
adequate quantities of food.
 Q20: What role do health care professional have in preventing oral
cancer?
ROLE OF HEALTH CARE PROFESSIONAL:
• Screen patients at risk.
• Provide dental care to improve response to cancer treatment.
• Treat oral complications.
• Provide referral to other specialists.
Q21: Enumerate and illustrate the different tooth brushing techniques?
Tooth Brushing Techniques:
i. The bass/sulcus cleaning techniques
ii. Still man’s technique
iii. Fones or circular or scrub techniques
iv. Charter’s techniques
v. Rolling technique
The bass cleaning techniques:
• Position the filaments up toward the root at a 45° angle to the teeth.
• Place the brush with the filament tips directed into the gingival sulcus.
• Using vibratory stroke brush back and forth with very short strokes for
the count of ten.
• Reposition the brush to the next group of teeth.
Still man’s Technique:
• Like the Bass Method the filaments are placed at a 45° angle to the
tooth.
• The filaments are placed half in the sulcus and half on the gingiva.
• The same stroke is used as the Bass.
Fones Technique:
• Use combination of horizontal, vertical, circular and vibratory
methods.
• Simplest brush technique.
• Most commonly used method around the world.
• Usually recommended in young children.
Charter’s Technique:
• Position the filaments toward the chewing surface of the tooth
• Place the sides of the filaments against the enamel and angle them at
a 45° to the tooth.
• Vibrate the filaments gently but firmly, keeping the filaments against
the tooth.
• Reposition on the next set of teeth.
Rolling Technique:
• Direct the filaments toward the root of the tooth.
• Place side of the brush on the gingiva and have the plastic part of the
brush even with the tooth.
• When the plastic portion is even with the tooth press the filaments
against the gingiva and roll the brush over the teeth.
• The wrist is turned slightly and the filaments follow the contours of the
teeth.
Q22: Write a note on following brushing techniques.
BASS TECHNIQUE:
Same as above (method)
Uses:
• Adaptable for interproximal areas.
• Cervical areas beneath the height of contour of enamel.
• Exposed root surfaces.
Advantages:
• Effective method for removing plaque.
• Provides good gingival stimulation.
Disadvantages:
• Cause injury to the gingival margins
• Time consuming.
• Dexterity.
STILLMAN’S TECHNIQUE:
Same as above (method)
Uses:
• Dental plaque removal.
• Cleaning tooth surfaces and gingival massage.
Disadvantages:
• Time consuming.
• Damage epithelial attachment.
CHARTER’S TECHNIQUE:
Uses:
• Missing papilla and exposed root surfaces.
• FPD and Orthodontic appliances.
• Periodontal surgery.
• Interproximal gingival recession.
. Advantages:
• Massage and stimulation of gingival.
Disadvantages:
• Poor removal of sub gingival bacterial accumulations.
• Limited brush placement.
• Dexterity are high.
 ROLL TECHNIQUE:
Advantages:
• Gingival stimulation.
• Used in combination with other techniques.
Disadvantages:
• Poor removal of sub gingival bacterial and plaque accumulations.

GLOSSARY 03
Q1: What do you understand by the term topical fluoride therapy?
Classify the topically applied fluoride therapy.
Topical Fluoride Therapy:
The term topical fluoride therapy refers to the use of systems
containing relatively large concentrations of fluoride that are applied
locally or topically, to the erupted tooth surface to prevent the formation
of dental caries.
CLASSIFICATION
 Professionally applied
1) Sodium fluoride preparation 2%
2) Stannous fluoride preparation 8%
3) Acidulated phosphate fluoride 1.23%
4) Fluoride varnish
- Duraphat
- Fluorprotect

 Self-applied
1) Fluoridated dentifrice
2) Fluoride mouth rinses
 Q2: List the indications and rational for the use of topical fluoride
therapy.
INDICATIONS
1. Caries active individuals
2. Children shortly after periods of tooth eruption
3. Those who take medication that decrease salivary flow or have
received radiation to head and neck
4. After periodontal surgery
5. Patients with RPD and FPD and after placement or replacement of
restorations
6. Patients with an eating disorder
7. Mentally and Physically challenged individuals

RATIONALE
 To speed the rate and increase the concentration of fluoride
acquisition above the level, which occurs naturally.
 Since, immature and porous enamel acquires fluoride rapidly and
teeth undergoes rapid maturation, it follows that best time to apply
topical fluoride is soon after eruption.
 Pretreating enamel with 0.05M phosphoric acid, in order to increase
enamel surface area, greatly enhances the uptake and retention of
fluoride
 Lengthening the time interval between the applications of a solution
also increases fluoride uptake.

Q3: What are the merits and demerits of using different topical fluoride
agents?

Advantages 1. Person must remember to

1. Does not cause fluorosis. use.
2. Cariostatic for people of all 2. Per capita cost is high
ages. compared to water
3. Available only to people fluoridation.
who desire it. 3. More concentrated
4. Easy to use. professional use products can
cause
Disadvantages 4. Short-term side effects like
nausea immediately after use.
Q4: Write a short note on stannous fluoride application for preventive
purposes.
Stannous Fluoride:
Available in powder form either in bulk containers or pre-weighed
capsules. The recommended and approved concentration is 8 percent.
Technique of application is Muhler’s technique.
Method of Preparation
The solution has to be freshly prepared as they are not stable. It can
be prepared by dissolving 0.8 gm of powder in 10 ml of distilled water.
The solution is acidic, with a pH of about 2.4– 2.8. The left over
solution should be discarded after application.
Method of Application
1. Cleaning and polishing of teeth is done.
2. Teeth are isolated with cotton rolls and dried with compressed air.
3. Freshly prepared SnF2 solution is applied using cotton applicator.
Care should be taken that all teeth surfaces are treated.
4. Repeated loading of cotton applicator should be done and swabbing
is continuously done so as to keep tooth surface moist for 4 minutes.
5. Patient is allowed to expectorate after cotton rolls are removed.
Recommended Schedule
A six monthly interval treatment schedule is advised.
Advantage
1. Recommended frequency is 6–12 months interval much less than as
in case of sodium fluoride.
2. Administrative difficulties, particularly in public health programs
created by the need to arrange 4 appointments are avoided
3. Expected Caries reduction 25%-35%
Disadvantages
1. Solution has to be freshly prepared each time before use.
2. A bitter metallic taste.
3. Can cause gingival irritation.
4. It causes brown pigmentation of teeth particularly in hypo calcified
areas and around margins of restorations.
5. In aqueous solution the material is not stable
6. Cause pigmentation of teeth
7. Tooth/filling discoloration
8. Not economical
Q5: Differentiate between systemic and topical fluoride use?
Systemic Fluoride
Applied through systemic route
during development of dentition
(maximum effect pre-
eruptively)
Usually lower concentrations of
fluorides are used
Effects of systemic fluorides
are there throughout the life
If excess amount of fluoride is
ingested during developmental
stages leads to dental fluorosis
Most of the time patients co-
operation and compliance are
not required
They are recommended in
general for whole population
Systemic fluorides are cost
effective and cheaper
Generally patient can avail and
utilize systemic fluorides on
his/her own (self-application)
Effects lasts longer and
throughout life
Q6: Compare and contrast self-topical application with professional
application.
Self-topical application
Dental visits are not required
It is economical
Health care professional is not
Topical Fluoride
Applied topically after eruption
of teeth (post-eruptively)
Normally very high
concentration of fluorides is
used
Effects are seen only for
shorter duration (used normally
from younger age to 15 years)
Even if higher concentration of
fluoride is applied topically it
does not lead to fluorosis
Patients compliance and
cooperation are absolutely
necessary
They are recommended for
special groups and high-risk
individual
Topical fluorides are not cost
effective and expensive
Normally topical fluoride
therapy has to be applied
professionally
Effect is for shorter duration
Professional application
Dental visits are required
It is costly
Health care professional is

Required
Compliance and comfort of
patient is not required
If fluoride is ingested more than
the normal amount, there may
be chances of fluorosis
required
Compliance and comfort of
patient is necessary
Side effects can happen for
e.g. pigmentation, discoloration
and irritation of mucosa

Q7: Define fluoride. How is fluoride circulated in the body?

Fluoride:
Fluorine is one of the most reactive elements and therefore is never
found naturally in its element form. The fluoride ion however is
abundant and universally present in soils and water.
Fluoride Physiology:
Ingested fluoride  95% of ingested F is absorbed in upper GIT 
plasma in ionic F (30 min)  Excreted in urine or deposited in calcified
tissues.
(A single ingestion of 5mg F by an adult is absorbed and cleared from
the blood in 8-9 hrs.)
Body burden of Fluoride:
The amount that can be safely absorbed and the point at which F
absorption becomes a health concern. It is measured by urinary
volume and plasma concentration. 24 hours sample is required for
accuracy
F Balance:
It is the net result from the accumulated effects of F ingestion, degree
of F deposition in bones and teeth, mobilization rate of F from bone
and efficiency of the kidneys in clearing absorbed F.
Fluoride Level:
 Plasma fluoride level 1umol/L
 Bone F level 800 to 10,000 ppm
 Dental Enamel 400 to 3000 ppm

Q8: Write a note on fluoride toxicity.

Fluoride Toxicity:
Dose response relationship- Beneficial in small amounts and toxic in
higher amounts
 A single dose of 5-10g of NaF (32-64 mg F/kg) = death in 2 - 4hrs
 10-25 mg F for a period of 10-20yrs = Crippling Skeletal Fluorosis
 0.2- 1.0 mg F/kg body weight = gastric complaints, osteosclerosis
Adverse Effects:
 Dental fluorosis
 Osteoporosis
 Nausea
 Stomach pain
 Pain in extremities
 Occasional diarrhea
1st AID:
 Induce vomiting as quickly as possible
 Give milk to person

Q9: How does fluoride help in caries prevention/ what is MOA of

Fluoride in preventing caries?
The mode of action (MOA) of fluoride in preventing caries is:
a. Pre-eruptive:
Enamel solubility is reduced in acidic medium by pre eruptive
incorporation of fluoride into the hydroxyapatite crystals
b. Post eruptive:
promotion of remineralisation and inhibition of demineralization of
early carious lesion
Inhibition of glycolysis, the process by which cariogenic bacteria
metabolise fermentable carbohydrates.

Q10: Sources and amount of Fluoride intake?

Sources:
-Sea Water -1.2-1.4 ppm
-Fresh Surface Water -0.2 or less
-Deep well water in Arizona- 29.5 ppm
-Boreholes in Kenya -40ppm
-Soil & Water- environmental omnipresence
Amount of fluoride intake:
-0.01 mg/day -0 to 6 months
-0.05 mg/day > 6 months
-Amount increases with increase in age
-Adults 19 or > 4mg/day males, 3mg/day females
Q11: Discuss fluoridation and Optimal Fluoride levels in drinking
water?
Fluoridation:
“Controlled addition of fluoride compound to a public water supply in
order to bring fluoride level which effectively prevents caries”
Optimal Fluoride level:
- Temperate climate – 1ppm
- Warmer climates - 0.5 ppm
- Colder Climate - 1.2ppm
Q12: What are the different modes of Fluoride delivery? Discuss them.
Modes of Fluoride delivery:
There are two different modes of fluoride delivery, systemic and topical
which are also given below
systemic:
-Water fluoridation
-Milk fluoridation
-Salt fluoridation
-Fluoride Drops
-Fluoride tablets
-Fluoride Lozenges

Topical:
Professionally applied:
-Sodium fluoride
-Stannous fluoride
-Acidulated phosphate fluoride

Self applied:
-Fluoride varnishes
-Fluoride mouth rinses
-Fluoride dentifrices

GLOSSARY 04
Q1: What historical developments have been carried out regarding
health promotion in the past? Explain briefly.
Historical Development of Health Promotion:
 Eminent social reformers such as Edwin Chadwick and South wood
smith highlighted the need to improve social conditions through
municipal reform.

In 1848 a Public Health Act was passed to control water supply,

sewage disposal and animal slaughter within industrialized towns and
cities

By late 19th century as the threat of epidemic disease receded the

focus had begun to shift away from environmental measures to
educating individuals against hazards of disease

Health education council (later to be called as Health Education

Authority) was formed in 1968 to develop national programs of
education for public

In 2000, Health Education Authority was shut down and Health

Development Agency was created

1974 – Marc Lalonde

 A new perspective on health of Canadians
 Major causes of death and disease were environmental causes,
individual behaviors and lifestyle factors rather than biochemical
characteristics.
 Shifted the focus to wider public health agenda once again.
WHO:
 WHO organized a series of international health promotion
conferences which facilitated the development and practice of
modern health promotion movement
 First was in Ottawa in 1986
 The Ottawa charter outlined the five key areas of action as follows:
- Create supportive environment
- Build healthy public policy
- Strengthen community action
- Develop personal skills
- Re-orient health services

Q2: What is Ottawa Charter?

 Ottawa Charter:
 It is part of the new public health approach and is based on the social
model of health.
 Influences the way public health programs are planned and delivered.
 Is a framework for health promotion.
 Identified the basic necessities or prerequisites for health – peace,
shelter, education, food, income, stable ecosystem, sustainable
resources, social justice and equality.

Q3: Describe the key areas of action outlined in the Ottawa Charter
along with examples of each.
Areas/Strategies in Ottawa Charter:
There are five major areas:
1) Building Healthy Public Policy:
A Healthy Public Policy is characterized by a concern for health and
equity and accountability for health promotion. Health should be made
a priority item on the agenda of policy makers in all sectors.
Example:
o Taxation on alcohol and cigarettes
o Reduced cost of healthy products
o Prohibited advertisement of tobacco products
2) Create Supportive Environment:
A supportive environment is one that promotes health and assists
people in making healthy lifestyle choices. Supportive environments
cover the physical, social, economic and political environment.
Example:
 Work safe initiatives-nonsmoking areas, exercise and changing
facilities.
 Quit line-offers support to smokers trying to quit(supportive social
environment)
3) Strengthen Community Action:
Enable and empower communities, provide resources so they actively
participate in health decisions which leads to better health outcomes.
Designed to give community a sense of ownership over health
promotion programs.
Example:
 Community cafes and food co-operatives.
 Self-help groups-people affected by particular oral health problem
share their experience and identify solutions.
4) Develop Personal Skills:
 Providing opportunities for people to develop knowledge and skills that
give them greater control over their health. Health education is life-long
so that people can develop the relevant skills to meet the health
challenges of all stages of life and to be able to cope with chronic
illness and disabilities.
Three basic educational objectives:
 Cognitive
 Affective
 Behavioral
Example:
o School based educational program
o Attending classes that teach healthy cooking techniques
o Oral hygiene aid
5) Re-Orient Health Services:
Shift of emphasis from provision of curative services. May necessitate
reengineering and organizational change, especially in the areas of
professional education and training, management, recruitment and
deployment of health personnel, and planning, development and
delivery of services.
Example:
o Doctors incorporating dietary advice during consultations
o ART
Q4: Define Health Promotion.
Health Promotion:
 Health promotion has come to represent a unifying concept for those
who recognize the need for change in the ways & conditions of living
in order to promote health.Health Promotion represents a mediating
strategy between people and their environments, synthesizing
personal choice and social responsibility in health to create a
healthier future.

Q5: Describe the important core elements of Health Promotion.

Core Elements:
 Focus on tackling the determinants of health and inequalities.
 Working in partnership with a range of agencies and sectors.
 Adopting a strategic approach utilizing a complementary range of
actions to promote the health of population.
Q6: What are the principles of oral health promotion? Describe them.
Principles of Oral Health Promotion:
1. Empowerment:
Enable individuals and communities to exert more control over the
personal, socioeconomic and environmental factors affecting oral
health.
2. Participatory:
Key stake holders should be encouraged to be actively involved in all
stages of planning, implementing and evaluating interventions.
3. Holistic :
Adopt a broad approach focusing upon the common risk and condition
that determine oral and general health and inequalities.
4. Inter-sectoral :
Partnership working across all relevant agencies and sectors.
5. Equity:
The need to focus action on addressing oral health inequalities should
be of paramount importance.
6. Evidence based:
Existing knowledge of effectiveness and good practice should be the
basis for developing future oral health improvement intervention.
7. Sustainable:
Achieving long-term improvements in oral health that can be
maintained by individuals and communities is crucial.
8. Multi-strategy:
Tackling the underlying determinants of oral health requires a
combination of complementary actions.

9. Evaluation:
Sufficient resources and appropriate methods should be directed
towards the evaluation and monitoring of oral health interventions.

Q7: List down determinants of health.

 Economic, political and environmental conditions:
 Socioeconomic status- family income, education, employment and
living conditions
 Health and social policy
 Access to affordable nutritious food and drinks
 Access to transport
 Access timely, affordable and appropriate oral health care and
information
 Social marketing
 Exposure to fluoride

Social, family and community context:

 Social and family norms regarding oral health knowledge,
attitudes, beliefs, values, skills and behaviors
 Peer groups
 Cultural identity
 Social support
 Self- esteem
  Self-efficacy
Oral health related literacy and behaviour:
 Diet
 Oral hygiene
 Smoking
 Alcohol
 Injury
 Oral health
 Literacy
 Use of oral health services
Individual factors:
 Age
 Sex
 Genetic and biological endowment
Oral health

Q8: Illustrate the common-risk factor approach.

Q9: List down the potential partners for oral health promotion.
Partners in Oral Health:
 Health professionals for example doctors, health visitors,
pharmacists, district nurses.
 Education services for example teachers, school governors, parents
 Local authority staff for example planning departments, social
workers, catering staff within care homes
 Voluntary sector for example age concern, preschool learning
alliance
 Commerce and industry for example food retailers, food producers,
advertising industry, water industry
 Government, local, national and international

Q10: How many types of different approaches to health promotion are

there? Discuss them.
Approaches to Health Promotion:
Preventive Approach:
 The aim of this approach is a reduction in disease levels.
 Preventive approach adopts a very top-down authoritative style of
working with health professionals acting as experts and patients
being recipients of preventive care.
 Examples: screening, immunization, fissure sealants.
Behaviour Change:
 This approach aims to encourage individuals to take responsibility for
their health and adopt healthier life style
 It is an expert-led approach utilizing a range of methods
 Examples: one-to-one advice and mass media campaigns
Educational Approach:
 Expert led approach allow individuals to make informed choice about
health related behavior
 Examples: school based educational programme.
Empowerment:
 This approach aims to assist people in identifying their own
concerns and priorities and in developing the confidence and skill
to address these issues
 It is essentially a bottom up approach
 Example: community development
Social Change:
 This approach acknowledges the importance of socio economic
and environmental factors in determining health
  It aims at changing the physical, social and economic
environments to promote health and well being
 Example: water fluoridation.

Q11: Compare upstream, midstream and downstream approach with

examples.
UPSTREAM: These are the determinants that occur at the macro level
and include global forces and government policies. 
MIDSTREAM: These are the determinants that are intermediate
factors such as health behaviours. It targets the defined populations to
prevent risk factors.
DOWNSTREAM:  involve individual-level behavioural approaches for
prevention or disease management. Its emphasis is on change, rather
than prevention.

Q12: What do you understand by the term ART?

Atraumatic Restorative Treatment (ART) is a preventive and
restorative approach for managing carious lesions teeth.
It is based on modern knowledge about minimal intervention, minimal
invasion, and minimal cavity preparation of carious tooth.
Q13: What are the advantages of ART technique?
ADVANTAGES
 Conservation of sound tooth structure
 Less trauma to tooth
 Painless
 Relatively easy to use after training
 Cost-effective
 Does not require extensive dental equipment
  The instruments and materials needed to perform ART are portable
 Hardly induces dental anxiety amongst children and adults.
Q14: What are the principles and rationale for application of ART?
Principles:
1. Removing carious tooth tissue using hand instruments only
2. Restoring the cavity with adhesive cements (glass ionomer)
Reasons for using hand instruments:
 It makes restorative care accessible to all population groups
 The use of a biological approach, which requires minimal cavity
preparation that conserves sound tooth tissues and causes less
trauma to the tooth
 The low cost of hand instruments compared to electrically driven
dental equipment
 The limitation of pain that reduces the need for local anesthesia to
a minimum and reduces psychological trauma to patients
 Simplified infection control, hand instruments can be easily
cleaned and sterilized after every patient
Reasons for using GIC:
 Fluoride is released from the restoration to prevent and arrest caries
 Glass ionomers are biocompatible, does not cause any irritation to
pulp and gingiva, and has co-efficient of thermal expansion similar to
tooth structure

Q.15 Why do use hand instruments and Glass ionomers in ART?

The reason for using hand instruments and glass ionomers is as
follows:
1. Makes restorative care available for all population groups.
2. Less trauma to the tooth-conservative preparation.
3. Low cost of hand instruments.
4. No need of anesthesia, reduces physiological trauma to patients.
5. Simplified infection control.
6. Chemical adhesion-minimizes cutting.
7. Fluoride release-prevents and arrests caries.
8. Does not cause pulp inflammation.
9. For these reasons ART provides preventive and curative treatment in
one procedure
Q16: How many different types of instrument are used in ART
procedure? Give functions of each.
INSTRUMENTS FUNCTIONS

MOUTH MIRROR: To look inside the mouth

EXPLORER/PROBE: For identification where soft carious dentine is
present. DO not poke the point into very small carious lesions. Do not
probe into deep cavities.
PAIR OF TWEEZERS: Used for carrying cotton wool rolls from the tray
to the mouth and back.
COTTON WOOL ROLLS: Absorption of saliva so that the tooth can be
kept dry.
COTTON WOOL PELLETS: Used for cleaning cavities.
PETROLEUM JELLY: Used to keep moisture away from the glass
ionomer filling and to prevent the examination glove from sticking to
the filling material as it sets.
PLASTIC STRIP: Used for contouring the surface on the side of the
tooth of multiple-surface restorations.
WEDGES: Used to hold the plastic strip close to the shape of the
surface on the side of tooth so that restorative material is not forced
between the gums and teeth.
SPOON EXCAVATOR: is used for removing soft carious dentine
DENTAL HATCHET: is used for widening the entrance to the cavity
(removing unsupported enamel)
APPLIER/CARVER: the blunt end is used for inserting the mixed
glass-ionomer into the cleaned cavity. The sharp end is designed to
remove excess filling material and shape the filled cavity.
MIXING PAD AND SPATULA: are necessary for mixing glass ionomer
filling material.
Q17: Differentiate between infected and affected dentine?

INFECTED DENTINE AFFECTED DENTINE

It is demineralised dentin
which is contaminated and
contains the microorganism
and their toxins.
Brownish black in colour
It is also demineralised dentine
which is not occupied by
microorganisms but it contains
toxins produced by
microorganisms of the infected
dentine
Light brown in colour
 Can be scooped off Cannot be scooped off
Should be removed Not necessary to remove
completely
No chance of remineralization Chance of remineralization

Q18: List the indications and contraindications of ART?

Indications:
-Only in small cavity/hole in the tooth.
-The hole can be accessible with your hand instruments
-Areas where skill manpower, resources, modern instruments
availability are less and demand is high
-Public health programs
Contraindications:
-There is presence of swelling (abscess) or pus fluid coming out
(opening from abscess to the oral cavity) near the carious tooth
-Cavity is too deep (so that the core/pulp of the tooth is exposed)
-Pain in the teeth for a long time and there may be chronic infection of
the pulp of the tooth
-Cavity opening cannot be reached by hand instruments
-There are clear signs of a cavity, for example on the side of a tooth,
but the cavity cannot be entered from the side or from the top of the
tooth direction.

Q19: How is ART performed? / Discuss in detail the procedure of ART

Application.
PROCEDURE:
1. Preparing the mouth:
An important aspect for the success of ART is the control of saliva
around the tooth being treated. Cotton wool rolls are quite effective at
absorbing saliva and can provide short-term protection from
moisture/saliva.
2. Preparing the cavity:
 Once tooth is isolated soft caries is removed using the
excavator by making circular scooping movements- like using a
spoon
 If the opening of the hole is narrow, widen the entrance of the
cavity by placing the blade of dental hatchet into the cavity and
 turning the instrument forward and backward (removing
unsupported enamel)
 Excavation is easy to do when the tooth is dry. After all the
caries is removed from the cavity, it is cleaned with wet cotton
wool

3. Cleaning the prepared cavity:

 In order to improve binding of the material to the tooth surface,
the cavity walls must be made clean. The surface is therefore
cleaned with dentine conditioner
 Apply one drop of conditioner on a mixing pad or slab. Hold a
cotton wool pellet with a pair of tweezers and dip it in the drop
and then clean the entire cavity for 10-15 seconds. Then
immediately wash the cavity at least twice with cotton wool
pellets, dipped in clean water. Dry the cavity with dry cotton
wool pellets
 If the cavity is contaminated with blood, stop the bleeding by
pressing with a cotton wool pellet on the wound. Wash the
blood away from the cavity. Then clean the cavity as described
above
4. Mixing the glass ionomer filling material:
 Follow the instruction according to the manufacturer. Place a
scoop of the powder on the mixing pad.
 Use the spatula to divide the powder into two equal portions,
and then put a drop of liquid next to the powder. Spread liquid
on the mixing pad with the spatula and start mixing by adding
one half portion of the powder into the liquid. As soon as the
powder particles are wetted the second portion of the powder is
included into the mixture. Use buttering movement to mix
 Mixing should be completed within 20-30 sec. Final mixture
should look smooth
 Insert immediately the mixture in small amounts into the cavity
using the blunt blade of the applier/carver. Use round surface of
an excavator to push the mixture into deeper parts of the cavity
 Clean the nozzle of the GIC liquid bottle
 Hold the liquid bottle horizontally to allow air to escape and then
move it to vertical position and allow one drop of liquid to fall
onto the slab
 Apply little pressure if necessary but do not squeeze
  Two drops should drop on the slab. First one drop must be
used for conditioning and the second drop must be utilized for
mixing
 Rub some petroleum jelly on the gloved index finger. Place the
index finger on the restorative material, press and remove
finger sideways after a few seconds (press finger technique)
 Remove visible excess of glass ionomer with a medium or large
excavator wait 1-2 minutes till the material feels hard, whilst
keeping the tooth dry
 Use carver to make sure that the filling is not high but is
flushed to the surface of the tooth
 Apply a new layer of petroleum jelly over the filling to protect it
from getting wet by saliva
 Remove cotton wool rolls from the mouth
 Ask the patient not to eat for at least one hour

GLOSSARY 05
Q1: Define health education.
Health Education:
In 1984 WHO defined health education as any educational activity
which aims to achieve a health related goal
OR
Health education is a process that informs, motivates and helps people
to adopt and maintain healthy practices and lifestyles, advocates
environmental changes as needed to facilitate the goals and conduct
professional training and research to the same end
Q2: What are the objectives of oral health education?
Objectives of oral health education:
1. Informing the people
Exposure of knowledge will melt away the barriers of ignorance,
prejudices and misconceptions
2. Motivating people
Change habits and life styles and ways of living
3. Guiding into action
People need help to adopt and maintain healthy practices and
lifestyles which may be totally new
 Q3: How many domains of learning are there? Describe them along
with examples
Domains of learning:
1. Cognitive
Understanding factual knowledge
Example: knowledge that eating sugary snacks is linked to the
development of dental decay

2. Affective
Emotions, feelings and beliefs associated with health
Example: belief that baby teeth are not important
3. Behavioral
Skills development
Example: skills required to effectively floss teeth

Q4: What is cognitive dissonance?

Cognitive Dissonance:
When knowledge conflicts with behavior it is known as cognitive
dissonance
Example:
 vast majority of smokers are fully aware that smoking is a major risk
factor for lung cancers this knowledge however does not stop them
from smoking
 Many smokers believe the habit is dirty and socially unattractive but
such attitudes do not stop people from smoking
Q5: State the most important core oral health preventive message for
maintaining good oral hygiene
Oral health preventive message:
 Sugar containing foods and drinks should be limited to mealtimes and
on no more than four occasions in the day
 Brush the teeth effectively twice per day. Use a small headed brush
and change when the bristles appear worn. Powdered toothbrushes
with an oscillating/rotating head are also effective
 Use a family strength fluoridated tooth paste with 1350ppm fluoride or
above, for children under 3years of age use fluoridated toothpastes
containing 1000ppm fluoride
 Spit do not rinse after brushing
 Do not smoke
 Drink alcohol in moderation and be aware of your units of
consumption
 Visit the dentist regularly

Q6: What are the principles of health education? Describe them

Principles of health education:
 Developing interest
 Active participation
 Known to unknown
 Comprehension
 Reinforcement
 Motivation
 Learning by doing
 Soil, seed and sower
 Good human relations
 Leaders

Q7: Describe the ways through which preventive messages can be

implemented?
1. Understand your patients and their needs:
 Information from patient’s medical, social and family histories
are all highly relevant to understand how best to help them
change their behavior to improve their oral health
 It is important to understand the patient’s circumstances and
needs
 Do not assume every patient has the desire, ability and
support to change his or her behavior
2. Tailor advice and support:
 Every patient is different and any advice and support offered
to them must be tailored to their circumstances and
characteristics
 It is also important to consider the timing of when to offer
advice and support
 At times of stress and pressure patients are less likely to
have motivation, interest and ability to change behavior

3. Communicate well:
 A range of communication skills should be used in
supporting patients to change behaviors
  Active learning, use of open questions, an encouraging tone
will help patients reflect and explore their experiences
 Care must be taken in the tone and style of communication
 The use of threatening, patronizing, prescriptive approaches
should be avoided as these do more harm than good.

4. Review benefit of changing and past experiences:

 A key element in supporting patients is to increase their own
self-confidence to change.
 Exploring the personal benefits of changing a particular
behavior can help person to become more motivated and
enthusiastic to change
 Learning from past experiences can again help to increase
people’s self-confidence and insight
5. Formulate SMART objectives:
 Specific
 Measurable
 Achievable
 Relevant
 Timely

Q 8: What do you understand by the Term “SMART” objectives?

1. Specific:
Clear and precise goals provide focus and clarity of purpose
2. Measurable:
Setting goals that can be easily measured and quantified is important
3. Achievable:
Set goals that are challenging but within the patients reach. Setting
unachievable goals merely demotivates people

4. Relevant:
It is essential that the goal is considered relevant to the patient’s
circumstances, motivations and needs

5. Timely:
It is important to check that the goal is the right thing for the patient to
achieve right now. Setting a clear frame is also important to help
maintain motivation and to monitor progress
Q9: List down the various health education methods and materials.
HEALTH EDUCATION METHODS:
 Selection depends upon aims of the intervention and appropriate
method of meeting it.
 One to one supervision
 Group work
 Interactive computer software
 Lectures
 Mass media
 Role play
HEALTH EDUCATION MATERIAL:
 Flip chart
 Leaflets
 Posters
 Videos
 Audio cassettes
 Overhead projectors transparencies
 Computer programs
Q10: Describe the quality criteria to assess the health education
materials.
QUALITY CRITERIA TO ASSESS HEALTH EDUCATION
MESSAGE:
 Funding source: conflict of interests?
 Process of development: indication of collaborative working?
 Objective: implied or stated?
 Target audience: is this clearly stated?
 Scientific content: Scientifically correct information.
 Presentation quality: use of appropriate images, layouts and style of
text?
 Appeal: interesting feel, stimulating, engaging?
 Equal opportunities: consideration given to population diversity?
 Understandibility: use of jargon, chunks of dense text, plain
language?
 Practical focus: application of content?
Q11: What skills are required to deliver effective health education to
the people?
Skills in Oral Health Education:
 Communication skills
 Appropriate questioning
 Active Listening
  Summarizing information
 Giving feedback
 Assessing needs
 Motivational interviewing
 Presentation skills
 Goal-setting
 Teaching skills
 Working with small groups
 Measuring & monitoring change
Q12: List the various settings where health education can be provided.
SETTINGS FOR ORAL HEALTH EDUCATION:
 Primary care
 Hospitals and clinics
 Schools and colleges
 Pre-school education and care
 Local authority services
 Commercial organization
 Work place
 Community-based initiatives
 Older people’s residential homes
Q13: List the potential partners in providing oral health education.
POTENTIAL PARTNERS IN ORAL HEALTH EDUCATION:
 General practitioners
 Health visitors
 School nurses
 Teachers
 School governors
 Pre-school carers
 Local authority staff
 Politicians- local and national government
 Media
 Business and commercial people
 Lecturers-FE colleges
Q14: Define health behavior.
Health Behavior:
 “Overt behavior patterns, actions and habits that relate to health
maintenance, to health restoration & to health improvement”
(Gochman 1982)
 “Any activity undertaken by people in order to protect, promote or
maintain health & prevent disease.” (Steptoe & Wardle 1994)
Q15: What does the educational theory state?
 This theory identifies that there are 3 domains of learning
1. Cognitive-acquisition of factual knowledge & intellectual
understanding of ideas.
2. Affective- attitudes, beliefs, and value.
3. Behavioral- Skills or actions performed.
 KAB MODEL = K => A => B
(Acquiring new knowledge would alter attitude and this in turn would
lead to change in behavior)
Q16: List different theories of change.
Theories of Change:
1. Health Locus of Control
2. Health belief Model
3. Theory of planned Behavior
4. Communication of innovation model
5. Stages of Change model
6. Sense of coherence

Q17: Write a short note on the following:

a) HLOC/Explain the HLOC theory with reference to periodontal
disease.
b) HBM
c) Stages of change model
d) Illustrate and explain Prochaska’s stages.
e) TPB model
a) HLOC: this concept was developed from social-learning theory
(Rotter et al. 1972) and measures the extent to which individuals
believe that their health is influenced either by their own behavior or by
external causes. It is not a measure of actual control of behavior but
rather perceived control. The first dimension is called internal HLOC,
which represents a person’s belief about the impact of his or her own
actions on health outcomes. The other two dimensions refer to external
influences on outcomes. Powerful others HLOC focuses on beliefs
about the influence of important people on outcomes, whereas chance
HLOC refers to the effect of chance or fate on outcomes.
With reference to periodontal disease, are as follows:
1) People with a high internal HLOC would believe that their periodontal
health is largely determined by their own ability and skill to effectively
remove plaque.
2) People with high powerful others HLOC would believe that to
maintain their periodontal health, dentists and hygienists are important.
These people would therefore believe regular visits to dentists are
important for the prevention of periodontal disease.
3) People who score high on chance HLOC would be likely to believe
that their periodontal health was determined by chance, and that they
could do little to influence the disease process.
b) Health belief model (HBM): The health belief model (Becker 1974;
Rosen stock 1966) is one of the best known models which explores
the function of beliefs in decision-making. Essentially, the HBM
proposes that when individuals consider changing their behavior they
engage in a cost/benefit analysis of the situation. This would include an
assessment of:
 Their susceptibility to the health threat;
 The perceived severity of that threat;
 The perceived value of changing the behavior in question.
In addition, the HBM suggests that before a change of behavior takes
place there needs to be a cue or trigger to initiate an alteration in
behavior.
c) Stages of change model: This model was developed by a US
research team (Prochaska and DiClemente 1983). The model has
since been revised and applied to a whole range of health-related
behaviors, including diet change, exercise, and drug use. It is based on
the assumption that behavior change is a dynamic, non-linear process
that involves several distinct stages. At the precontemplation stage,
an individual has not even considered changing his or her behavior,
whereas in contemplation a person is thinking over the pros and cons
of making a change. Decision is the stage when a person is making
definite plans to change, in active changes the actual behavior change
is initiated, and in maintenance the modified behavior is actively
sustained. The model recognizes that, for many people, changing
behavior is a difficult and prolonged process that may involve many
attempts, as relapses often occur in the process. Marlatt and Gordon
(1980) have identified that these relapses are most often caused by:
● Negative emotional states
● Interpersonal conflict
● Social pressures.

d) Prochaska’s stage model:

e) The Theory of Planned Behavior (TPB) model:

In this model it is postulated that a change in behavior will occur
through the transitional phases outlined in the model. Intentions are
central to this model in the sense that before change in behavior
occurs, people must have contemplated the change and formed
intentions to change. The formation of intentions is influenced by
attitudes and beliefs about the behavior, for example thinking that
going to the swimming pool is a pleasant thing to do, and the physical
activity is going to improve general fitness levels. In another case a
person believing that he/she can perform the behavior. In this stage, a
person weighs up what he/she knows and needs to do to execute the
behavior against factors such as joining a health club is expensive and
takes up valuable time. These variables are in turn influenced by
behavioral beliefs (going swimming will improve health), normative
beliefs (everyone thinks keeping fi t is a behavior that should be
encouraged), and control beliefs (the person holds beliefs that act as a
barrier to performing the behavior). Finally, these variables are
influenced by demographics, personality, and environmental variables.
While TPB is very comprehensive, it assumes that formation of
intentions leads to behavior change, yet this is not always the case.

Q18: How do we practically reflect on the theories of changes?

Discuss
The theoretical research into behavior change reviewed above may
appear very abstract and detached from the realities of clinical dental
practice. However, there are certain important issues of relevance that
should be highlighted. This is best achieved by reflecting back upon
personal experiences of behavior change.
Process of change
Very rarely do individuals manage to change an established behavior
at one attempt. For most people several attempts are required before
they can successfully change a habit. This process may take several
months, or even years, and for many people can be seen as a
constant battle. A whole host of factors, many of which may be outside
the control of the individual, influence progress with desired change.
Motivations to change
When you reviewed your experiences of changing a behavior, it may
have become very apparent that the initial motivation for changing was
not primarily health reasons. Clinicians often forget that for most
ordinary people, teeth and gums are not the single most important
issue in their complex lives. Individuals often reduce their sugars intake
not due to concerns about their caries risk but because of worries
about their weight or body shape (Watt 1997). Even with something as
potentially damaging to the health as smoking, people’s motivations to
quit are often far more complex and diverse. It is therefore important to
recognize the varying motivations individuals may have for changing
their behaviors. Health-directed behavior change may be important for
people who are especially concerned about their health. For many,
however, social, financial, and other practical concerns may be of
paramount importance in their motivations to change, with health
issues, so-called health related behavior change, being of secondary
concern. In a motivational intervention, for example, the dental team
might stress the benefits and self-efficacy beliefs around oral hygiene
behaviors. In contrast, a volitional intervention would emphasize
planning ‘the when, where and how of behavior change’
Barriers preventing change
Most of us, no matter how determined we may be to change, often do
not succeed with our attempt. This is principally due to the many
barriers that prevent us from achieving long-term sustained changes.
Clustering of behaviors
Often groups of behaviors such as smoking, alcohol misuse, and poor
hygiene habits cluster together in patterns and amongst particular
groups of people. Altering one behavior that is linked to another set of
behaviors may therefore prove problematic unless
 Q19: What barriers are faced in achieving long-term change? Discuss
them
 Lack of opportunity—for example, limited access to healthier snacks
in school tuck shops.
 Lack of resources—for example, unable to afford new toothbrushes
for large family.
 Lack of support—for example, living with a smoker when you want to
quit.
 Conflicting information on nature of change—for example, confusion
over health education messages.
 Conflicting motives—for example, enjoyment associated with eating
sugary snacks with friends.
 Long-term nature of benefit—for example, lung cancer does not
affect teenagers for another 40 years and smoking has immediate
personal and social benefits.
 Belief that change is not possible—for example, when someone has
tried to improve his or her tooth-brushing technique before without
success.
 No clearly defined goals—for example, asking someone to stop
eating sugar altogether when so many processed foods have sugars
added to them.
 Lack of knowledge on what to change—for example, people’s beliefs
that fruit juices are full of vitamins so they must be good for their
baby.

GLOSSARY 06
MODULE V
Q1: Define health care system. What are the factors that influence the
development of health care system?
 A system which comprises of all the organizations, institutions and
resources that are devoted to provide best health outcomes in a
country is a health care system.
 All organizations, people and actions whose primary intent is to
promote, restore or maintain health. This includes efforts to influence
determinants of health as well as more direct health-improving
activities”
(WHO 2007)
FACTORS
 Changing demographics of population
  Evolving patterns of disease and their impacts
 Expectations and demands of public
 Technology
 Globalization
 Economy

Q2: Discuss the key components of Health Care System

 Structure
 Functions
 Personnel
 Funding
 Reimbursement
 Target population

STRUCTURE: It is the one of the most complex and dynamic aspects

of health care system.
Majority of systems have 3 levels
i. Primary
ii. Secondary
iii. Tertiary
The delivery of health services is not confined to surgeries or hospital
there are numerous premises where advice, support, specific tests or
indeed care can be provided.
PRIMARY: - It is normally the first point of contact between an
individual and the HCS.
- General Medical practitioners (GMP), nurses and pharmacists and
General Dental Practitioners (GDP) are all regarded as primary care
workforce.
ii. SECONDARY
- More specialized care workers operate and diagnostic services tend
to be available.
- Consultant grades found at this level.

TERTIARY
- It is where center of excellence, especially that involving multi –
disciplinary activities occur
- These centers tend to play a major role in teaching, training as well
as research.

FUNCTIONS:
 I. Downstream Approach
The delivery of treatments to individuals who have presented
themselves with a perceived problem.
ii. Upstream Approach
When the system has moved towards a more preventive approach with
the need to tackle determinants of health
This has placed growing emphasis on health promoting activities and
earlier interventions based in the community.
PERSONNEL:

1. Clinicians – deals with diagnosis and treatment of diseases

2. Technicians – handle the complex machinery's in advanced care
3. Administrative staff – handles booking systems and finances
4. Managerial staff – handles catering, porters, and cleaners
FUNDING:
 The funding of health care provision are in general derived from 3
main sources
i. Taxation – general or specific health tax
ii. Insurance – compulsory or voluntary
iii. Out – of – pocket payment
a. Deductibles
b. Copayments
c. Costs that exceed those covered by a plan

A. DEDUCTIBLE
 A certain amount of the initial cost is paid by the person before an
insurance plan plays any benefits.
 A deductible may have to be paid only once during a given time or
each time certain services are provided
B. COPAYMENT
 Part of the cost of each service provided is usually paid by the
person. A copayment may be a fixed amount or percentage of the
cost.
C. COSTS THAT EXCEED THOSE COVERED BY A PLAN
 Plan may limit what they will pay for a given services (allowable
amount)
 Sometimes the limit is based on what plan defines as usual,
customary and reasonable
 Sometimes plans set a relatively low limit.
 REIMBURSEMENT:

1. Fee – for – service (most widely accepted in dentistry)

Care provider is paid for each item of care delivered to an individual or
group. E.g. type of filling, oral health promotion services or a scaling
and polishing.
2. Capitation: The payment to health care provider is linked to individual
patient in which the larger the number of patients that a care provider
has the larger their income
3. Diagnostic – related – payment:
 Payment to the care provider is linked to the condition that the patient
has and can be modified by the clinical characteristics. i.e whether
the patient has comorbidities
4. Salaried:
 The care provider is paid at a set rate for working as an employer.
This arrangement is usually based on an annual salary.

TARGET POPULATION: The targeting can take a number of different

forms
 Such as older people
 Pregnant women
 Infants and nursing mothers
 Disadvantaged people (homeless people, people at day centers)

Q3: What do you understand by the term reimbursement? What are

the mechanisms by which it is achieved?

(Reimbursement already discussed above)

MECHANISMS
Q4: How can a health care system be categorized as high –
performing? Discuss

1. Access – to
comprehen
sive
services
which is
timely and
convenient
2. Safety –
risk of
accidental
injury or
 death is
minimized
3. Health
Promotion –
it supports
individuals
to enable
them to
make
positive
decisions
about their
own health
and help
them
manage the
impact of
long-term
conditions.
4. Clinical
effectivenes
s – supports
the delivery
of
intervention
s that
improve
health
outcomes
based on
successful
treatment,
pan relief,
the
restoration
of function
and care
and
support.
5. Patient
experience
 – includes
use of
choice and
their
involvement
in decision
making
about the
care they
receive and
ensuring
that they
are treated
with dignity
and respect
6. Equity –
system is
equitably
funded and
resources
are
allocated
fairly based
on people’s
need.
7. Efficiency –
system
uses
available
resources
to the
maximum
effect
8. Accountabili
ty –
demonstrat
es
achieving
high
standard of
care by
 monitoring
activities
and views
of patient
and failing
is
addressed.

Q5: Describe Clinical Governance. List its key components.

It is an on-going program aimed at changing the culture of the whole
NHS and improving the quality of services. It is quality improvement
combined with financial management.
It includes:
NICE: National Institute for Clinical Excellence.
CHI: Commission for Health Improvement
 NICE
1. Improve Standard of care
2. Reduce unacceptable variations in clinical practice
3. Ensure best use of resources – patient benefit
CHI
1. Commissioning of health care
2. What health care service should provided
3. Primary Care Trust (PCT)
4. Local Health Groups (LHGs)
5. Local Health Care Co-operatives (LHCCs)
6. Health Trust
COMPONENTS OF CLINICAL GOVERNANCE:
 Clear lines of responsibility for the quality of clinical care
 A comprehensive program of activity that improves quality
 Clear policies for managing risk
 Procedures for all health care professionals to identify and remedy poor
performance.

Q6: What does NICE stands for? List its functions

NICE:
NICE stands for National Institute for Clinical Excellence
Functions:
 To provide evidence based guidelines on the most effective ways to
diagnose, treat and prevent disease and ill health.
 To develop quality standards, a concise set of statements designed
to drive and measure priority quality improvements within a particular
area of care.
 To undertake technology appraisal to ensure that people have equal
access to new and existing medicines that are deemed clinically and
cost effective.
 To provide public health guidance aimed at preventing ill health and
encouraging people to live a healthy and active lifestyle.
Q7: Briefly describe the primary, secondary and tertiary care provided
by health care delivery system.
Primary care:
It is normally the first point of contact between an individual and the
health care system.
General Medical Practitioners (GMP), Nurses, Pharmacists and
General Dental Practitioners (GDP) are all regarded as Primary care
workforce.
Secondary care:
More specialized care workers operate and diagnostic services tend to
be available
Consultant grades found at this level.
Tertiary care:
It is where center of excellence, especially that involving multi-
disciplinary activities occur
These centers tend to play a major role in teaching, training as well as
research

Q8: What are the main ways of paying for health care? List advantages
and disadvantages of each.
 Q9: What are fissure sealants? Classify them.
Fissure Sealants:
“A Fissure Sealant is a plastic professionally applied material (cement
or a resin) used to occlude the pits and fissure ( chewing surfaces) of
the teeth to provide a protective layer against the action of acid
producing bacteria and their substrates, hence rendering them into
non- retentive surfaces”.
Classification:
A. According to polymerization:
1. First-generation sealants:
Polymerized under ultraviolet light (UV) e.g. Bis – GMA.
2. Second-generation sealants:
Chemically polymerized.
3. Third-generation sealants:
Cured by visible light.
B. According to type of material:
1. Plastic material:
 Polyurethanes.
 Cyanoacrylates
  Bisphenol a glycidyl methacrylate(BIS-GMA)
1. Resin based sealants.
2. Glass ionomer sealant
3. Fluoride containing sealant
A. According to variety of format:
 Filled and unfilled
 Clear and tinted
 Opaque

Q10: Give the indications and contra indications of fissure sealants.

INDICATIONS:
 Individuals who are at a high risk for Dental caries with a history of
dental decay.
 Individuals with deep retentive pits and fissures.
 Individuals with early signs of dental caries such as incipient caries.
 Poor plaque control.
 Enamel defects, such as enamel hypoplasia.
 Orthodontic appliances.
CONTRAINDICATION:
 In individuals who are at low risks of dental caries such as those
with:
1. A balanced diet low in sugars or carbohydrates.
2. Exceptional oral hygiene.
3. Teeth with shallow, self-cleaning pits and fissures.
4. Teeth that are partially erupted without adequate moisture
control.
Q11: What is the procedure of applying fissure sealant?
PROCEDURE:
1. Select the tooth to be sealed
2. Rinse the tooth and apply pumice.
3. Remove pumice and rinse the tooth
4. Isolate the tooth
5. Dry the tooth
6. Etch the tooth with acid to demineralize the surface layers.
7. Rinse the etchant after 30 sec and dry the mouth.
8. Apply sealant and polymerize the sealant according to the generation
being used.
9. Cure the sealant.
10. Check with explorer.
11. Check the occlusion for hyper-spots.
12. Apply varnish and tropical fluoride.

GLOSSARY 07
MODULE V
Q1: What are the aims/principles of planning dental services? Or how
can planning be justified?

Principles of Planning:
 Planning aims to guide choices so that the decision are made in
the best manner to reach the desired outcome
 Planning provides a guide and structure to the process of
decision making to maximize results within the limited
resources available
 It provides opportunity to be proactive in decision making rather
than constantly reacting to pressure and demand
 It enables priorities to be set and identifies where resources can
be directed to have the greatest impact
Justification of Planning:
 It provides an opportunity to be proactive in decision making
rather than consistently reacting to the pressure and
demands
 It enables priorities to be set
 It identifies where resources can be directed to have
greatest impact
Q2: Illustrate and discuss the steps of the Rational planning model
proposed by McCarthy.

Steps of Rational Planning Model (McCarthy 1982)

a. Assessment of needs: Identify the oral health care problem
and concerns of the population
b. Identifying priorities: Agreeing the target area of the
population
c. Developing aims and objectives: Aims are overall goal to be
achieved, objectives are the steps needed to reach the aim
d. Assessing resources: Identify resources to facilitate the plans
e.g. personnel, material and equipment
e. Implementation: Turning plans into action
f. Evaluation: Measuring the changes resulting from the plan

Q3: What basic information is used in planning health? Illustrate or

state
Q4: What is quality Dental care? How can it be achieved?
Quality of Dental Care:
A key element in planning dental care is to ensure that the quality of
care provided is of highest quality
Maxwell 1984 has proposed a definition of quality in health services
that have been widely accepted
Royal college of General Practitioners 1985 proposed a definition that
has a more clinical focus
Maxwell 1984
The definition has following components:
 Effectiveness: services are intended to benefit
 Access: easily available in terms of cost, time distance
 Socially acceptable: satisfy the expectation of the users
 Efficiency and economy: maximum benefit with minimum cost
 Relevance to need: services what the user actually needs
 Equity: fairly distributed to those in need
Royal College of General Practitioners 1985
Features:
 Interpersonal skills: ability to communicate effectively with
user
 Clinical competency: perform core clinical task
  Professional values: importance of ethical and professional
values
 Access: ability to utilize and benefit from care
Donabedian 1974
Quality of health care should have 3 interrelated elements
 Structure: refers to the physical elements of care, such as
facilities, equipments and premises
 Process: clinical techniques employed, the administrative
and managements and appointment procedures
 Outcome: consequences of contact with the services

Q5: Define Clinical Governance. List down the components of Clinical

Governance.
Clinical Governance:
It is an ongoing program aimed at changing the culture of the whole
NHS and improving the quality of services.

Definition by Scally and Donaldson 1998:

Continuous improvements in the quality of services, where high
standards of care are safe guarded by creating an environment in
which excellence in clinical care flourishes
Components:
 Clear lines of responsibility for the quality of clinical care
 A comprehensive program of activity that improves quality
 Clear policies for managing risk
 Procedures for all health care professionals to identify and
remedy poor performance

Q6: What are the themes of Clinical Governance.?

Themes of clinical Governance:
a. Infection control
b. Child protection
c. Dental radiograph
d. Staff – patient public and environmental safety
e. Evidence based practice and research
 f. Prevention and public health
g. Clinical records, patient policy and confidentiality
h. Staff involvement and development of all staff
Q7: Describe evaluation. Differentiate between formative and
summative Evaluation.
Evaluation:
Evaluation is an integral part of the planning process
 Evaluation is intended to determine the value of the program to
see if it has been carried out as prescribed, and to discover
whether the required performance and objectives have been
achieved
 It should demonstrate the extent of the contribution to oral
health in the target population and whether each part of the
program is relevant and appropriate

FORMATIVE
EVALUATION
Refers to the internal
evaluation of the program
It is the examination of
the process or activities
of a program as they are
taking place
Usually carried out to aid
in early phase of program
development
It plays an important role
in pilot phase and control
phase of program
implementation
SUMMATIVE
EVALUATION
Judges the merit or worth
of a program after it has
been in operation
It is an attempt to
determine
Determines whether fully
operated program is
achieving its goals
It is done for actualization
and final phases of the
program

Q8: What basic steps are involved in the process of evaluation?

Steps of Evaluation:
a. Determine what is to be evaluated
b. Establish standards and criteria
 c. Plan the methodology to be applied
d. Gather information
e. Analyze the results
f. Take actions
g. Re evaluate

Q9: Illustrate the Quality Assurance Cycle.

Q10: What are the Micro and Macro levels of Problems that are a part
of health care delivery system?
Micro level problems:
I.e. how the health care is delivered, (access issue) one-to-one
communication and interaction with the patient and members of the
dental team (communication and adherence)
Macro level problems:
I.e. overall policy for and structure of health care

Q11: What are the common problems faced by population with the
health care delivery?
Macro level (overall policies and structure of health care)
 Treatment focus
 Unclear goals
 Mal distribution of resources
 Structure and configuration of health care services
 Lack of accountability
Micro level
 Communication problem
 Adherence with dental advice
 Access to dental care

Q12: Define Inverse Care Law.

Inverse care law:
When there is unequal access of health care for example people living
in deprived communities with greater health need have fewer doctors
and dentist compared to the richer areas with fewer health needs, this
phenomenon has been described as inverse care law.

Q13: Define Access problem.What are the different phases of Access

Problem?
Access problem:
These are the difficulties experienced with service use
Phases of Access problem:
First phase:
It is influenced by sociological and psychological factors that determine
whether a person will contact with health services
Second phase:
It is the fit between the health care services and the patient
Factors influencing this relates to how health care is organized and
costs

Q14: List the factors influencing access.

Q15: Discuss the 5 aspects of Access Problem.

Availability of Services:
This refers to how well the health services are distributed e.g. the ratio
of the dentist to the population in a locality
Another consequence of the perception of the availability of service is
the impact on the uptake of care. If it is perceived that services are
limited then demand for the care becomes suppressed.
Accessibility of Services:
It has 2 dimensions
1. Location --- (how far? Transportation?)
2. Spatial --- (physical access?)
Affordability of Services:
1. Direct cost: ( payment for treatment can act as a barrier to people
using dental services)
2. Indirect cost: (time taken off work, travel cost)
Acceptability of Services:
 The acceptability of practice to the patients is important
 Dentist want to attract to their practice patients who pay on
time, behave well in waiting room, and enhance the image of
practice
 Patients feel welcome to the practice, get information relating to
their problems, dealt with professionally but treated as an
individual
Accommodation of Services:
This refers to the way in which care is provided in terms of:
- Extended opening hours
- Emergency and drop in clinics
- Late night clinics
- Waiting time and ease of getting an appointment

Q16: List the barriers to the recipient of dental care?

Two main barriers:
 Fear
 Cost
Other barriers:
 Reception and waiting room procedures
 Loss of control
 Personality of the dentist
  Clinic smell
 Hearing the sound of dental treatment
 White coat and bright lights
 Feeling vulnerable in dental chair
 Getting treated like you are a mouth
 Travel time, time off work

Q17: How can the barriers to recipient of dental care be overcome?

Overcoming the barriers:
 The dentist should be friendly
 Explain more
 Have an approachable manner
 Help them manage their dental anxiety
 Dental practices should extend their opening hours, have open
days and drop in clinics
 Mobile surgeries
 Location in near vicinity

GLOSSARY 08
1. Define the concept of two party and third party system?
Two Party System:
It involves Dentist and Patient
Three Party System:
It involves Dentist, Patient and Carrier/ insurer/ administrative agent
and public finances of care
2. Discuss the principles of insurance
Principles of Insurance:
 Precisely definable
 Of sufficient magnitude, that if it occurs , it causes a major loss
 Infrequent
 Of an unwanted nature
 Beyond the control of individual
3. List the problems encountered by insurance carriers.
 Problems Encountered By Insurance Carriers:
 Having patients pay a share of the costs
 Limiting the range of services covered
 Offering coverage only to groups
 Including waiting periods after enrollment before benefits
became payable
 Using preauthorization and annual expenditure limits
4. Describe different types of insurance plans.
Types of Insurance Plans:
 Copayment:
The portion of the cost of the service that a patient pays
 Deductible:
Set amount of money that the patient must pay towards the cost of
treatment before the benefits of the program go into effect
 Coinsurance:
The patient pays a percentage of the total cost of treatment
 Coverage:
Covered charges, schedule of benefits- some services are paid for and
some are not
5. Describe the factors responsible for increase in the cost of health
care expenditure.
a. Increasing costs:
Incomes of health care workers have risen faster than the income for
many other workers
b. Difficult economies of scale:
Increasing the amount of care provided requires a nearly proportional
increase in the workforce
c. The practice of defensive medicine:
Tests carried out to protect the provider against possible litigation,
rather than to protect the patient

d. The aging population:

Older people use more health care service
e. Development in technology:
Some innovation aggravate the cost of care e.g. treatment of end
stage renal disease
 f. Third-party payment:
State and private insurance e.g. benefits for the elderly and poor
g. Fee for service dental care:
Two party arrangement in which patient is responsible for the fee
6. Describe the different types/ forms of 3rd party reimbursements.
I. Usual fee:
The fee that an individual dentist most frequently charges for a given
dental service
II. Customary fee:
The fee level determined by the administrator of a dental benefit plan
from actual submitted fees for a specific dental procedure
III. Reasonable fee:
The fee charged by a dentist for a specific dental procedure that has
been modified by the nature and severity of the condition
IV. Table of allowances:
A list of covered services with an assigned amount that represents the
total obligation of the plan with respect to payment for such services
but does not represent the dentist’s full fee for that service
V. Fee schedule:
A list of the charges established or agreed to by a dentist for specific
dental service. Represents payment in full
VI. Discounted fee:
Participating dentist charges lower than the usual fee by many dentists
in that area
VII. Capitation:
Dental benefit program in which the dentist contracts with the
administrator to provide all or most of the dental services covered
under the program to subscriber in return for a payment on a per capita
basis
7. Write short notes on the following:
a. Managed care:
 A comprehensive set of health care services
 Selected providers
 Financial incentive to use
 Common forms HMOs ( Health Maintenance Organization) and
PPOs ( Preferred Provider Organization)
b. Health maintenance organizations:
 A legal entity which provides a prescribed range of health services to
each individual who has enrolled in the organization in return for a
prepaid, fixed and uniform payment
c. What do you understand by the term dental team?
A group of various personnel in dentistry with different role, functions
and periods of training all working together to treat the patient
8. How many types of dental personnel make up a dental workforce?
Types of Dental Personnel:
A. DENTIST:
A person who is permitted to practice dentistry under the laws of the
relevant state, province, territory or nation
B. DENTAL AUXILIARIES:
It is a generic name for all the persons who assist the dentist in treating
the patients
9. Define a dentist. What are the requirements and duties of a dentist?
Dentist:
A person who is permitted to practice dentistry under the laws of the
relevant state, province, territory or nation
Requirements of a dentist:
 Completion of a specified period of professional education in an
approved institution
 Demonstration of competence
 Evidence of satisfactory personal qualities
Duties of a dentist:
 Dentists are concerned with the prevention and control of the
diseases of the oral cavity
 Treatment of unfavorable conditions resulting from these
diseases or from trauma or inherent malocclusion
 A dentist is legally entitled to diagnose and treat the patient
independently
 Prescribe certain drugs to the patients
 Employ and supervise auxiliary personnel
10. Define and classify Dental Auxiliaries.
Dental auxiliaries:
It is a generic name for all the persons who assist the dentist in treating
the patients
 Classification of Dental Auxiliaries:
1) OPERATING AUXILIARY:
- Dental hygienist
- Dental nurses/ therapist
2) NON OPERATING AUXILIARY:
- Dental assistants
- Dental technicians
- Denturist
- Receptionist
- Janitors

11. List the duties of different types of Auxiliaries.

a) Dental hygienist:
DUTIES:
 Concerned with prophylaxis
 Concerned with health of the supporting tissue
of teeth
 Prevention of further diseases by direct
clinical procedures and by scaling/polishing
and applying fluoride
 Education of individual patients and group
 Instruction of oral hygiene
b) Dental nurses/ therapist:
An operating auxiliary who in some countries is legally permitted to
treat special population groups usually children with little direct
supervision from a dentist
DUTIES:
 Oral examination
 Prophylaxis
 Topical fluoride application
 Cavity preparation and placement of filling in
teeth
 Pulp capping
c) Dental assistants:
Non-operating auxiliary who assists the dentist in treating the patient
but who is not legally permitted to treat patients independently
 DUTIES:
 Immediate chair side assistance in handling
of dental equipment and materials used by
the dentist
d) Dental laboratory technician:
Non-operating auxiliary who fills the prescription provided by the
dentists regarding the extra oral construction and repair of oral
appliances
DUTIES:
 Fabricate crowns, bridges, dentures,
orthodontic appliances
e) Denturist:
It is a term applied to those dental laboratory technicians who are
permitted in some states to fabricate dentures directly for patients
without a dentist’s prescription. These denturists must be licensed
DUTIES:
 Casting of models from impressions made by
the dentist
 Include fabrication of dentures, orthodontic
appliances, inlays, crowns and special trays
12. Compare different roles of auxiliaries with each other.
(Same as above- compare on the basis of duties)

13. What are EFDA? List the duties that will be performed by them.
EFDA: (Expanded Function Dental Auxiliary)
EFDA are those who have received further training in duties related to
the direct treatment of patients although still working under the
supervision of the dentist e.g.
Dental hygienist
Dental assistant
DUTIES:
 Applying topical fluorides
 Applying desensitizing agents
 Applying pits and fissure sealants
 Placing, carving and polishing amalgam restorations
 Placing removing matrix bands
 Placing and removing rubber dams
  Monitoring nitrous oxide use
 Taking impressions for study casts
 Exposing and developing radiographs
 Removing sutures
 Removing and replacing ligature wires on orthodontic
appliances

14. Write brief notes on Dental aide & Dental Licentiate.

Dental Licentiate: (new auxiliary type)
They are semi-independent operators trained for 2 years to perform
 Dental prophylaxis
 Cavity preparation and filling of primary and permanent teeth
 Extraction under local anesthesia
 Drainage of dental abscesses
 Treatment of most prevalent diseases of supporting tissues of
teeth
Dental Aide: (new auxiliary type)
They perform duties which include elementary first-aid procedure for
the relief of pain including:
 Extraction of teeth
 Control of hemorrhage
 Recognition of dental disease important enough to justify
transportation of the patient to a center where proper dental
care is available

15. Give a brief description about the levels of supervisions

proposed by ADA.
The American Dental Association acknowledged four levels of
supervision
 PERSONAL SUPERVISION
- The dentist is personally operating on the patient
- The dentist authorizes the allied dental personnel to
aid treatment concurrently by performing a supportive
procedure
 DIRECT SUPERVISION
- The dentist is in the office, personally diagnosis the
condition to be treated
 - Personally authorizes the procedure and remains in
the treatment facility while procedure is being
performed by the allied dental personnel
- And before dismissal of the patient, evaluates the
performance of the allied dental personnel
 INDIRECT SUPERVISION
- The dentist is in the office, personally diagnose the
condition to be treated
- Authorizes the procedure
- Remains in the treatment facility while the procedure is
performed
- And will evaluate the performance of the allied dental
personnel
 GENERAL SUPERVISION
- The dentist is not required to be in the office when the
procedure is being performed by the auxiliary
- But has personally diagnosed the condition to be
treated
- Has personally authorized the procedure
- And will evaluate the performance of the allied dental
auxiliary

GLOSSARY 09
Q1: Define Ethics? Why is it important to study Ethics?
Ethics:
“The branch of philosophy and theology concerned with principles that
allow us to make decisions about what is right and wrong is called
ethics”
Ethics are involved in everything.
-To understand why some choices have been made against others.
-Helps us to choice right from wrong
Q2: Describe the principles of Ethics?
Beauchamp and Childress (2009) developed four Ethical Principles:
Respect for autonomy:
It is about respecting other people’s wishes and supporting them
in their decisions
”Autonomy can be defined as,
self-rule with no control, undue influence or interference from
other”
Beneficence:
- It is the principle of doing good and providing care to others
- Promotion of well-being.
Non-Maleficence:
-Obligation not to inflict harm on others
-It Goes hand in hand with beneficence.
Justice:
Simply defined as “equal treatment of equal cases”
-Treating everyone the same
-However, some people need to be treated differently if they
require special care over
and above what other people may need.
-Justice is about meeting everyone’s individual needs fairly.

Q3: Describe the Ethical Standards?

Aspirational: A broadly worded statement of ideals. No precise
definitions of right or wrong behaviour is given.
Educational: Combine the principles with explicit guidelines that can
assist decision making.
Regulatory: which goes a step further and include a set of detailed
rules to govern professional conduct. Such rules are assumed to be
enforceable with a range of sanctions imposed by the profession if the
rules are contravened

Q4: What are the professional obligations required of a Dentist?

Professional obligations required of a dentist are:
- Respect autonomy
- Act justly & fairly
 - Protect life & health
Do good - acting in other persons interest
- promoting oral health
- relieving pain and infection
- restoring function
Do not harm - cross infection control
- protect airway
- health & safety procedures
- maintain professional competence

Q5: How Ethics does apply to Dental Public Health and Research?
Ethics in Dental public health:
- Meeting human need
- Moral importance of prevention versus cure.
- Resource allocation
- Care for priority groups
- Justice in healthcare
- Evidence based health care
- Effective & efficiency in the use of resources

Ethics in Research:
- Research subjects be able to exercise choice
- Have legal and intellectual capacity to give consent
- Be able to understand to what they are consenting.

Q6: What do you understand by the term Clinical Ethics?

Clinical Ethics:
Clinical ethics is a practical discipline that provides a structured
approach for identifying, analysing and resolving ethical issues in
clinical dentistry
Example:
 The request for complete mouth extraction by a patient who has an
essentially intact dentition that can be easily saved
 Management of the questionable child abuse case where the
dentist’s actions could help the patient but damage the parent
Q7: Describe the following Terms:
 a. Complaints:
Accidents, mistakes, errors will happen, dentists may be dishonest or
negligent
 Deal promptly and truthfully
 Do not be afraid to say sorry
 Professional indemnity
 Prevention is better than cure
b. Informed Consent:
 Person must be competent
 Appropriate explanations must be given about the problem,
treatment procedure, options, risks, benefits, cost, time
 Information must be understood
 Consent must be given freely
c. Confidentiality:
Information should be used only for the purpose for which it was given
 Practice policy
 Training
 Secure note storage
 Privacy in the surgery
 Inadvertent breach of privacy
 Reassure patients

Q8: What are the routes of spread of infection in a dental setting?

 Direct contact:
Such as blood, oral fluids or other patient materials
 Indirect contact:
With contaminated objects e.g. instruments, equipments or
environmental surfaces
 Contact with conjunctival, nasal or oral mucosa with droplets:
Spatter containing microorganisms generated from an infected person
and propelled a short distance (sneezing, coughing)
 Inhalation:
Inhalation of air-borne microorganisms that can remain suspended in
the air for longer periods
Q9: Define the following terms/ write short notes on the following:
a. Standard Precautions: (universal precautions)
 A set of procedures based on the assumption that any patient/ person
working in dental office might carry a serious infection
A simple, consistent and effective approach to infection control
Minimize contact with blood and body substances by utilizing safe work
practices and protective barriers
b. Body Substance Isolation:
Focuses on reducing transmission of infectious material from moist
body substance of patient to health care worker
c. Blood borne pathogen standard: (1992)
It requires each dental office to prepare an exposure control which is
intended to minimize employee exposure to infection
 It applies to all activities in which health care workers come into
contact with human blood or other bodily fluids
 Applies to hospitals, medical facilities, paramedics and ambulance
services, blood banks, research facilities and dental offices
 Instrument sterilization and storage
 Handling of potentially contaminated equipment
 Disposal of medical waste
 HBV vaccination of staff
 Reporting “ incidents”
d. Cross infection control:
Cross infection is defined as the transmission of infective agents
between patient, dentist and medical staff

e. Standard infection control procedure:

 Barrier procedures i.e. gloves, mask, eyewear, scrubs
 Proper disposal of one-time use materials
 Routine sterilization of instruments and equipment
 Proper handling of potentially infectious materials
Q10: What are the measures through which Cross-infection can be
prevented?
 Medical history
 Universal/standard precautions
 Personnel health elements
a. Education and training
b. Immunization programs
 c.Exposure, prevention and post exposure management
d.Hand hygiene
e.Personal protective equipment
f.Barrier techniques:
 Masks, protective eyewear, face shields
 Protective clothing
 Gloves
 Rubber dam
 High velocity air evacuation
 Sterilization and disinfection of patient care items
 Dental unit waterline (DUWL) contamination
 Environmental infection control
Q11: Write a note on HIV.
HIV infection typically begins with a brief acute retroviral syndrome that
transitions to a chronic illness that, over a period of years,
progressively depletes CD4 T-lymphocytes, which are critical for
maintenance of effective immune function; left untreated, this
progression can result in symptomatic, life-threatening
immunodeficiency. With treatment, this late stage of infection, known
as acquired immunodeficiency syndrome (AIDS), develops over
months to years, with an estimated median time of approximately 11
years.2

While no cure for HIV currently exists, with effective medical treatment
and care, HIV can be controlled. The medication used to treat HIV is
termed antiretroviral therapy.

Q12: What are the oral manifestation of an HIV infection?

ORAL MANIFESTATIONS OF HIV INFECTION
 Oral Candidiasis: Fungal infection, Semi adherent white plaque on
palate. Palate can be sore. Glossitis. Angular stomatitis.
 Oral Hairy Leukoplakia: Highly predictive of future signs of AIDS.
Mostly on lateral surface of tongue.
 Kaposi’s sarcoma: Diagnostic for AIDS and present in 20-34%
patients. Most common site is palate.
 Q13: Give the mode of spread of HIV and HCV infection.
HIV:
 Sexual contact
 Injection drug use
 Pregnancy, child birth, Breast feeding
 Occupational exposure
 Blood transfusion/ organ transplant.

HCV:
 Sexual contact
 Sharing needles
 Perinatal transmission

Q14: What disinfectants and sterilization procedures are used in dental

setting?
DISINFECTANTS:
 Inhibition of pathogenic organisms on inanimate objects by chemical
or physical means.
 They contain 70 – 79% Ethyl alcohol and are effective when applied
to a thoroughly cleaned surface
 Sterilants used for high- level disinfection are Glutaraldehyde at 2- 3
% concentration.
STERILIZATION:
 Defined as killing all forms of life, including most heat – resistant
forms i.e. bacterial spores.
 Methods:
 Steam Pressure Sterilization(autoclave)
 Chemiclave
 Dry heat Sterilization
 ETOX sterilization
 Boiling water
 Q15: Discuss about dental amalgam and environmental issues related
to it.

 Amalgam is a special type of alloy in which mercury is one of the

component.
 Mercury from amalgams constitutes 6% to 12% of daily intake for
adults with amalgam restorations. 
 Average urinary levels of mercury among dentists were 19.5
microgram/liter.
 Minimal risk level according to ADA is o.3 micrograms for long term
human exposure. (ADA.)
 No need to remove amalgams from patients except in the rare cases
of mercury allergy
 Disposal of scrap amalgam 

Environmental issues:
 Proper suction during amalgam fillings
 Use of rubber dams and proper isolation in patients mouth while
treatment
 Proper disposal of mercury after use
 Mercury from dental amalgam can end up in the soil, atmosphere,
surface water and ground water through several routes, including
wastewater discharges from dental practices, and emissions to air
and soil resulting from the cremation or burial of individuals
with dental amalgam fillings.

GLOSSARY 10
MODULE V
Q1: Define economics and health economics
Economics:
“Science of Scarcity”
 Economics analyses how choices about scarce goods and services
are structured and prioritized by individuals in order to maximize
welfare. (Haycox 2009)
• The study of the application of economic theory in health and health
care to make use of finite and scarce health resources and help
identify solutions to some common problems of health care
Health Economics:
The study of the application of economic theory to decision-making
about health and health care. (Mooney 2003; Morris 2007)
Q2: What should be the pre-requisite of health economics?
Pre requisites of health economics:
 Decision-making must prioritize choices about intervention with
respect to both cost and benefit.
 Value for money – achieve maximized health goal at least
cost/resources
 Opportunity Cost of a programme - is described as the “value of
resource when it is put to its best alternative use”.
 Efficiency
Maximum benefits from available resources.
i. Allocative Efficiency – Measures the extent to which there is optimal
allocation of resources to individual and population who can benefit
the most
ii. Technical Efficiency - effectiveness with which resources are used to
achieve a maximum outcome or the minimum amount of resources
that can be combined to give a desired outcome.

Q3: What are the components of economic analysis? Define them

Components of Economic Analysis:
INPUTS/ COSTS:
1. Direct costs: largely used in health sector, includes salaries and costs
of consumables.
2. Indirect costs: also called production losses, i.e. when someone
cannot attend work while receiving therapy
3. Intangible costs: includes pain and suffering, difficult to measure as
related to emotions. Socio-dental indicators have been developed to
measure these type of costs.

OUTPUTS/ CONSEQUENCES:
1. Natural units: e.g. tooth surfaces saved by fissure sealant treatment.
Used in cost-effectiveness studies
2. Utility measures: these are measures of an individual’s preference for
a particular health outcome. E.g. quality-adjusted life years (QUALY).
Used in cost-utility studies
3. Monetary units: benefits in terms of money. Used in cost-benefit
analysis
Q4: What is the difference between cost effectiveness and cost
benefit?
(Same points as given below)
Q5: Discuss different types of economic analysis?
1. Cost effectiveness:
• Used to compare any intervention with any other intervention,
provided the same outcome measure is used.
• For example: compare fissure sealants with fluoridated tooth-paste,
where the outcome i.e. no. of tooth surfaces saved can be measured
in the same unit.
• This approach tell us about technical efficiency.
2. Cost utility:
• It analysis the effects in terms of an intervention on morbidity and
mortality.
• Utility means the preferences people or society have for a set of
health outcomes.
• Useful to overcome the concerns of expressing all benefits in terms of
money.
• E.g. Effects in terms of ability to function at work after administration
of lingual anesthesia for tooth extraction on two professionals i.e.
one nurse and one tea taster
• Utility analysis allows quality of measure “quality-adjusted life years”
to be incorporated as an outcome measure. E.g. cost per life year
gained.
3. Cost benefit:
 • It analysis whether something is worth doing. It puts a monetary
value on both cost and benefit.
• Example: compare the cost per surface saved and the reduction in
the amount of toothache for both interventions
• It is expressed in terms of money, and address the concept of
allocative efficiency.
4. Cost minimization:
• A type of cost-effectiveness study.
• Outcomes of a program are tested through controlled clinical trials. If
the clinical outcomes of the interventions are same then only the
costs need to be compared.
• Therefore, the intervention with the lowest cost would be selected.
• Rarely applied.
• Refers to reduction in expenditure.

GLOSSARY 11
MOD V

Q1: What do you understand by the term SPECIAL PATIENT in

dentistry?
Special Patient:
The term special patient is used in the oral health field to describe an
individual with special needs, including physical, medical,
developmental and/or cognitive conditions, resulting in limitations in
their ability to receive dental services and prevent oral diseases by
maintaining daily oral hygiene.
Q2: List the disabilities which are considered under the heading of
special.
 Physical disabilities
 Mental disabilities
 Learning disabilities
 Syndromes ( e.g. Down syndrome)
 Cerebral palsy
 Autism
Q3: What problems are faced in the delivery of care to people with
special needs?
1. The development of personal dental services
2. Lack of funding for training
3. Cost of specialist services and facilities
4. Unwillingness of some general dental practitioners to provide dental
treatment for such groups.
Q4: What is the status of dental caries in special needs patients and
how it can be prevented?
STATUS
 Dental caries prevalence in patients with impairments is higher
 More untreated decay
 More missing teeth
 Fewer restorations
(Oral health can be maintained at high level if preventive and treatment
services were provided for such target group)

PREVENTION
 Topical Fluorides ( High doses)
 High Fluoride toothpastes ( for certain groups)
 Tooth pastes alternatives ( Fluoride mouthwash)
 Dietary constituents and form
 Liquid oral medicines
 Chlorhexidine ( gel , varnish)
 Atraumatic Restorative Treatment (ART)
 Carisolv: Chemo-mechanical minimal invasive approach that
removes necrotic decayed dentin only leaving healthy tooth structure.
 Ozone therapy: no need for using dental hand piece or local
anesthesia …useful method.
Q5: How can tooth wear be prevented in special needs patient?
Tooth wear in patients with special needs:
Neurological impairment  clenching or grinding  causes attrition
Cerebral palsy  gastroesophageal disease  vomiting  causes
erosion
Bizarre oral habits  abrasion
 Prevention of tooth wear :
 If no toleration for extensive treatment remove badly worn teeth
 With tolerance  under sedation  full coverage of affected teeth
and molars
 Cleaning aids not to be erosive
Q6: What are the causes of gingivitis in special needs patient and how
can it be prevented?
Causes of Gingivitis:
 Poor oral hygiene resulting in plaque accumulation and gingivitis
 Down syndrome  more prevalent periodontal disease and early
tooth loss
 Epilepsy medications  gingival hypertrophy
Prevention of gingivitis:
 Change medication or modify dose
 Modified manual tooth brushes
 Mouth cleaning resistant patients  powered tooth brush or “super
brush” (opposing bristles clean 3 surfaces with one stroke)
 Difficult cases (extremely ill)  mouth care carried out in bed by
nurse or carer  tooth paste or tooth brush dipped in mouthwash or
chlorhexidine gel (sustained up to 6 months)
 Patients refusing or resisting cleaning aids  behavior modification
 desensitization

Q7: How can self-inflicted trauma and hyper salivation in special needs
patient be prevented?
Self – inflicted trauma in patients with special needs:
 Self-mutilation involving oral tissues in certain syndromes
 Teething sometimes triggers it
 Lip and tongue biting  pain and swelling  mouth is too sore to
drink or eat  dehydration  hospitalization
Prevention of self-inflicting trauma:
 If offending teeth were primary  extract
 Use soft splints to prevent soft tissue trauma
 If malocclusion  teeth adjustment and orthodontic treatment
depending on case
 Prevention of Hyper salivation:
Excessive drooling happens in patients with poor neuromuscular
control (cerebral palsy or cerebro- vascular accident
 Surgical
 Pharmacological
 Radio therapy
 Palatal training aids (hyoscine patch / anticholinergic)
 Behavior modification
Q8: What causes xerostomia in special needs patients and how can
they be prevented?
Causes of xerostomia:
 Syndromes
 Medications (elderly patients)
 Patients on radiotherapy
Xerostomia results in increased rate of dental caries and ill-fitting
dentures
Prevention of Xerostomia:
 Radiotherapy : preoperative dental care to avoid extractions
 High dose fluoride
 Chlorhexidine mouth wash or gel
 Saliva stimulation (Pilocarpine)
 Saliva substitution