Ebook Textbook of preventive and community dentistry (3/E): Part 2

Part 2 book “Textbook of preventive and community dentistry” has contents: Dental auxiliaries, school dental health, payment for dental care, ethical issues, dentists act and association, prevention of oral diseases, primary preventive services, fluorides in caries prevention, applied biostatistics and research methodology, behavioural sciences,… and other contents.

of the dental team encompasses the various providers of dental care who havedifferent roles, functions and periods of training and who combine to treatpatients.

With increasing health consciousness the demand for dental careincreases among the public There was a necessity to make it affordable andavailable to all In order to provide cost effective services and satisfy demand,the dedication of some responsibility to suitably trained para-professionalsbecame inescapable in the dental field These new para-professionals receive

a less rigorous training of a shorter duration compared to the dentist Theywere expected to perform well demarcated tasks efficiently Dental auxiliary

is a generic term for all persons who assist the dentist in treating the patients

In Britain, they have been known as “dental ancillaries”.1

A dental auxiliary or ancillary is a person who is given responsibility by adentist so that he or she can help the dentist render dental care, but who is nothimself or herself qualified with a dental degree.3

Clinical: This is a person who assists the professional in his clinical

work but does not carry out any independent procedures in the oralcavity

Laboratory: This is a person who assists the professional by carrying

out certain technical laboratory procedures

2 Operating Auxiliary

This is a person who, not being a professional is permitted to carry out certaintreatment procedures in the mouth under the direction and supervision of aprofessional

Operating ancillaries

School dental nurseDental therapistDental hygienistExpanded function dental ancillaries

1 Dental Surgery Assistant

The employment of women as dental assistants was started in the USA morethan a century ago Dr C Edmund Kells of New Orleans employed a woman

as a “lady in attendance” in 1885, so that unaccompanied female patientscould come to his clinic This practice became popular.4 The assistantsstarted helping the dentist in his business office as well as by chair Theutilisation improved during World War II due to acute shortage ofprofessionals to meet the demands of the armed forces The dental assistantsnow assist the dentist in performing certain tasks which are non-technical innature and do not require any or much training The dentist thus canconcentrate and devote full attention to care of patient In fact, at many placesincluding India, the assistant gets on-the-job training from the dentist heserves

The duties of the dental surgery assistants are as follows:

Reception of the patient

Preparation of the patient for any treatment he or she may need

Preparation and provision of all necessary facilities such asmouthwashes and napkins

Sterilization care and preparation of instruments

Presentation of documents to the surgeon for his completion and filing

3 Dental Laboratory Technician

A non-operating auxiliary who fulfills the prescriptions provided by dentistsregarding the extra oral construction and repair of oral appliances and bridge-work

This category of personnel have also been known as dental mechanics.The functions of dental technician in addition to the casting of models fromimpression made by dentists, include the fabrication of dentures, splints,orthodontic appliances, inlays, crowns and special trays

Denturist is a term applied to those dental lab technicians who arepermitted in some states in the US and elsewhere to fabricate denturesdirectly for patients without a dentist’s prescription They may be licensed orregistered

The desire for autonomy among dental laboratory technicians has led tothe formation of “denturists” Their craft is called ‘denturism’ That is, if thepatient is in need of a denture, the process of fabricating a denture, from theimpression onwards, is done by the technician in direct relationship with the

Several countries have allowed laboratory technicians to work directlywith the public Tasmania, a state in Australia, was the first place wheretechnicians were legally permitted to provide a prosthetic service Denmarkuses the term ‘Denturist’ to describe a special category of dental technicianwho sits at an examination, to enable him to prescribe, make and fitremovable dentures without supervision In the state of Maine, denturists arepermitted to make impressions and fit dentures but only under the direction

of a dentist

The ADA has vigorously opposed the denturists movement at thepolitical level The Association’s principal argument is that denturists areunqualified to treat patients and the poor-quality care and even actual harmcould result to patients.5

4 The Dental Health Educator

This is a person who instructs in the prevention of dental disease and whomay also be permitted to apply preventive agents intraorally

In a few countries, the duties of some dental surgery assistants have beenextended to allow them to carry out certain preventive procedures InSweden, two additional weeks of training are given, after which ancillariesare allowed to conduct fluoride mouthrinsing programmes to groups ofschoolchildren They are, however, not allowed to undertake any intraoralprocedures

5 School Dental Nurse

School dental nurse is a person who is permitted to diagnose dental diseaseand to plan and carry out certain specified preventive and treatment measure,including some operative procedures in the treatment of dental caries andperiodontal disease in defined groups of people, usually schoolchildren

Interest to improve dental conditions among children in New Zealandbecame evident in 1905 Treatment of children was particularly difficult onaccount of the distance which often separated small communities The DentalNurse Scheme was established in Wellington, New Zealand in 1921 due toextensive dental diseases found in army recruits during World War 1914–

Upon completion of training, each school dental nurse is assigned to aschool where she is employed by the government to provide regular dentalcare of between 450 and 700 children.

School dental nurse is accepted as a member of the school They areexpected to provide care for the children at nearly 6-month intervals Theyare under general supervision of a district principal dental officer

The duties of the school dental nurses as listed by the New ZealandDepartment of Health Division includes:

Oral examination

Prophylaxis

Topical fluoride application

Advice on dietary fluoride supplements

Administration of local anaesthesia

Cavity preparation and placement of amalgam filling in primary andpermanent teeth

Pulp capping

Extraction of primary teeth

Individual patient instruction in tooth brushing and oral hygiene

Classroom and parent – teacher dental health education

Referral of patient to private practitioners for more complex services,such as extraction of permanent teeth, restoration of fracturedpermanent incisors and orthodontic treatment

6 The Dental Therapist

This is a person who is permitted to carry out to the prescription of asupervising dentist, certain specified preventive and treatment measuresincluding the preparation of cavities and restoration of teeth.1 In the UnitedKingdom, they came into being because of a shortage of dentists to work inthe school dental service They are likened to New Zealand type school

The training of dental therapists is for about a period of two yearsinvolving both the reversible and irreversible procedures The functions of atherapist vary Their training includes clinical caries diagnosis, technique ofcavity preparation in deciduous and permanent teeth, material handling andrestorative skills, vital pulpotomies under rubber dam in deciduous teeth andextraction of deciduous teeth under local anaesthesia They have a littletraining in interpretation of X-rays They are not trained to provide enodonticcare The dental therapists are widely used in the public dental service.

Apart from Australia and the United Kingdom, other countries using theservices of therapists include Hong Kong, Singapore, Vietnam andTanzania.2

7 Dental Hygienist

Earlier, the Ohio college of dental surgery had developed a program forhygienists and assistants in 1910, but it had to be discontinued due topressure from the dentists The duration of training is 1–2 years

As per the Indian Dentist Act of 1948, a dental hygienist means a personnot being a dentist or a medical practitioner, who scales, cleans or polishesteeth, or gives instructions in dental hygiene

A dental hygienist is an operating auxiliary licensed and registered topractice dental hygiene under the laws of the appropriate state, province,territory or nation The dental hygienists work under the supervision ofdentists

The usual functions of dental hygienists are:

Cleaning of mouths and teeth with particular attention to calculus andstains

Topical application of fluorides, sealants, and other prophylacticsolutions

Screening or preliminary examination of patients as individuals or in

Instruction in oral hygiene.

Resource work in the field of dental health

8 Expanded Functions Dental Auxiliary

They have been referred to as expanded function dental assistant, expandedfunction dental hygienist, expanded function auxiliary, technotherapist,expanded duty dental auxiliary

EFDA is a dental assistant, or a dental hygienist in some cases, who hasreceived further training in duties related to the direct treatment of patients,though still working under direct supervision of a dentist They are allowed tocarry out reversible procedures that is which could be either corrected orredone without undue harm to the patient’s health They do not preparecavities or make decision as to pulp protection after caries has beenexcavated, but work alongside the dentist and take over routine restorativeprocedures, as soon as the cavity preparation and base have been completed.3

Duties of dental assistant in extended function

Retraction of gingiva

Impressions for cast restoration, space maintainers, orthodonticappliances

Etching of teeth

Determine root length and fitting of trial endodontic filling points

Pit and fissure sealants

Duties of dental hygienist in extended function

Retraction of gingiva

Impressions for cast restoration, space maintainers, orthodonticappliances

Temporary stabilization procedures

Debridement of the periodontal surgical site

Suture placement

In 1958, WHO introduced two new types of auxiliaries.

1 Dental Licentiate: He is a semiindependent operator trained for 2

years Their dental knowledge and skill are equivalent to New Zealand dentalnurse They work under a wider variety of conditions and for all age Theirfunctions include dental prophylaxis, cavity preparation and fillings ofprimary and permanent teeth, extraction under local anaesthesia, drainage ofdental abscesses, treatment of prevalent diseases of supporting tissues, earlyrecognition of serious conditions

They are responsible to the chief of the regional or local health service.Their service would probably occur in rural or frontier areas and so,supervision and control would probably be remote

2 Dental aide: Among native populations the dental aides provide

elementary first aid procedures for the relief of pain, including extraction ofteeth under local anesthesia, control of haemorrhage, recognition of dentaldisease

They would operate only within a salaried health organization and beunder supervision, the closer the better, particularly at first The formaltraining extends from 4 to 6 months, followed by a period of field trainingunder direct and constant supervision

Frontier auxiliaries: They include capable lay people, in particular

nurses and former dental assistants with minimum training Their functionsinclude dental prophylaxis, dental health education, relief of pain, referral,fluoride rinse program, simple denture repairs

Future developments: Predicting the future is a thankless task at best,

and the task of attempting to predict future developments in dental care ismore thankless than most Rate of population growth, types of healthcaresystems that evolve, economic developments, consumers demands, andlegislative action will all be major factors in shaping the future of the dentalcare system Within dentistry, the growth of specialists, the ability to increaseproductivity in the dental office, and the apparent growing restlessness ofauxiliary groups will all exert their influences The demands of society meanthat the cherished autonomy of the dental profession may be curtailed tosome extent

Dunning J.M Principles of Dental Public Health 1986.

Geoffrey L Slack and Brian Burt Dental Public Health—AnIntroduction to Community Dentistry 1980

Louis P Di Orio Clinical Preventive Dentistry 1983

David F Striffler, Wesley O Young, Brain A Burt Dentistry DentalPractice and the Community 3rd edition

15

School Dental Health

It is well recognized that the children of today are the citizens of tomorrow.The prosperity of a nation depends upon the health of its future citizens

School health is an important aspect of any community healthprogramme The school health programme is a powerful, yet economicalapproach towards raising the level of community health Its basic aim is toprovide a comprehensive healthcare programme for children of school goingage

The school age is a formative period, physically as well as mentally,transforming the schoolchild into a promising adult Health habits formed atthis stage will be carried to the adult age, old age and to the next generation.Thus a school dental health service is a giant leap for the improvement of thenation

Aims of School Dental Service

To help every schoolchild appreciate the importance of a healthymouth

To help every schoolchild appreciate the relationship of dental health,general health and appearance

To encourage the observance of dental health practices, includingpersonal care, professional care, proper diet and oral habits

To correlate dental health activities with the total school healthprogramme

To stimulate the development of resources to make dental careavailable to all children and youths

To stimulate dentists to perform adequate health services for children

Peep into the Past

No authentic records are available in India regarding initiation of schoolhealth services Way back in 1909 medical examination of schoolchildren isreported to have been carried out in Baroda city for the first time in India In

1946, Bhore committee noted that school health services were non-existent inIndia

In 1960, Government of India constituted a school health committee toassess the standards of health and nutrition and also assigned the task ofsuggesting ways and means to improve the health status of school goingchildren

In 1961, the committee submitted its report, which contained many usefulsuggestions and recommendations

In view of the crucial importance of school health, the Government ofIndia constituted a task force to propose an intensive school health serviceproject The task force submitted its report in 1982 and identified thefollowing reasons for the poor state of school health programme

Lack of transport facilities for the primary healthcare medical officer.Lack of budget for printing health cards, etc

Lack of properly trained schoolteachers, multipurpose workers andother education and health personnel who can ensure effectivefunctioning of the school health programme

Lack of proper documentation and evaluation

Lack of co-ordination between

Different schemes and health programmes within the healthdepartment

Health department and outside agencies particularly theeducation department

The task force then suggested an intensive pilot project fully sponsored

by the central government It was started in 25 blocks from remote andunderdeveloped areas of different states in 1982–83 Then in 1984–85 it wasextended to 75 more blocks

The central government’s school health project is a step in the right

direction, but it suffers from the major drawback that it is essentially a project

of the health department, there being very little coordination with theeducation department

Insisting on high standards of cleanliness.

Introducing healthy practices in the diet

Demonstrating personal hygiene like tooth-brushing, cutting nails,dressing of hair The teacher plays a very vital role in all elements ofthe school health programme especially in health education

Personnel involved in Dental Education

Brushing the teeth.

Rinsing the mouth

Second grade to fourth grade

Teach the importance of preservation of the teeth through proper care.Teach the importance of visit to the dentist and keeping teeth clean

Fifth grade to sixth grade

Teach the importance of good dental health to overall physical health

Junior high

This is the scientific age and the beginning of interest in appearance.Emphasis can be made on

Chemical aspects of tooth formation

Importance of preventive measures

Problems of Dental Education in Schools

According to Kennedy there are four prime reasons

Parents and community leaders are not committed to oral health.

Public health officials have not demonstrated aggressive leadership inestablishing meaningful school oral health programme

Individual dentist show a little support of school health programmes

Healthcare Services

It should be promotive, protective and curative as well as rehabilitative.Initial care and maintenance care is together called comprehensive dentalcare

Less money spend on permanent teeth

Interruptions are less

Psychologically better

Usually self-motivated teenagers are treated here, so it is psychologicallybetter as they are in need for the treatment and because of the same reasonthey avoid interruption to treatment

Disadvantages

Disease has already occurred

Initial cost of controlling the disease is more

More dental man-hours required

A strong emphasis on preventive dentistry programmes would reduce thelearning time lost in going and coming from a treatment facility as well asactual operative time In comprehensive care we not only think in terms ofeliminating pain and infection but in terms of restoration of serviceable tooth

to good functional form, replacement of missing teeth, maintenance care forcontrol of early lesion of dental disease and also preventive and educationalmeasures so that the population may experience a lower prevalence ofdisease

Comprehensive Health Service Criteria

Provision of adequate preventive, curative and promotive healthservice

To be as close to the beneficiaries as possible

To have the widest co-operation between the people, the service andthe profession

To be available for all irrespective of their ability to pay for it

To look after more specifically the vulnerable and weaker section ofthe community

To create and maintain a healthy environment both in home andworking places Such a care needs to be complete, competent,continuous, co-ordinate compassionate and for the community

INCREMENTAL DENTAL CARE

It is defined as a periodic care so spaced that increments of dental diseasesare treated at the earliest time, consistent with proper diagnosis and operatingefficiency in such a way that there is no accumulation of dental needs.2

In schoolchildren incremental dental care represents ideal pattern for thecare and appreciable incidence of new dental disease is to be expected eachyear

In private practice 6 months is the commonest, though not the onlyinterval between the visits In public health programmes one-year interval isusually employed

It is basically a rational approach on annual basis to the dental problems and

a plan for life long dental care

Advantages

Aims at prevention and maintenance as the programme starts at anearly age It provides a complete oral examination during earlychildhood

Initial cost is less

Man-hours for initial care is less

Early lesions of dental caries are treated before the involvement ofpulp

Topical and other preventive measures can be maintained on a periodicbasis

Periodontal disease is interrupted at/near beginning

Bills for services are equalized and regularly spaced

Child develops the habit of visiting the dentist periodically

The programme helps the community to obtain a favourable impression

on the dentist

Disadvantages

Time consuming, e.g multiple fillings

Psychologic: Young people develop their own habits, so habits learned

in childhood would not necessarily be carried to adulthood

There is exhaustion of financial resources as it is a long and periodicprogramme

Interruptions in dental healthcare programme may occur due tomigration

Dunning has pointed out that there are several advantages to a school-basedprogramme

The children are available for preventive or treatment procedures

3

4

School clinics are less threatening than private offices

A school dental programme facilitates central education on dentalsubjects

The dental service supplements, the nursing services by helping toprovide total health care for schoolchildren

Student Participation in School Programme

Programmes devoted to schoolchildren have been particularly popularbecause children have been highly susceptible to dental caries Many childrenespecially those with the highest disease levels whose families may not beable (or) interested in providing for their oral health needs, do not visit dentaloffices Yet virtually all of them attend school and therefore, would beexposed to a school-based programme.3

In developing countries like India such care for participation impliesawareness and acceptance of modern concepts in health and sickness and itinvolves a change in traditional pattern of living and availability of basicsanitary amenities

Philosophically all children should be entitled to receive maximumprimary preventive dental care that includes the use of fluorides, pit andfissure sealants, reduced sugar consumption, plaque control and education

How to Start a School Health Programme?

Organize the principals of schools

Motivate and involve the teachers

Provide health education to teachers

Develop resource materials and child-to-child activities

Implement the programme It is essential to form a coordinating healthcommittee for this purpose, consisting of the principal, teachers,community leaders, parents and children

•

•

SCHOOL DENTAL HEALTH PROGRAMMES1

1 Askov Dental Health Education

It is a classical example of a school dental health programme

Askov is a small farming community in Minnesota It showed very highdental caries in the initial survey made in 1943 and 1946 During 1949–1957,Minnesota health department supervised a demonstration school dental healthprogramme in Askov including caries prevention and control, dental healtheducation and dental care All recognized methods for preventing dentalcaries were used in the demonstration with the exception of communal waterfluoridation

Dental findings are available through a 10-year period, which includes:

28% reduction in dental caries in deciduous teeth of 3–5 years old.34% reduction in caries in permanent teeth of children 6–12 years old.14% reduction in children 13–14 years old

The cost of the programme was greater and the caries reduction wassmaller than are now occurring with water fluoridation in the samecommunity

But fluoridation is by no means a substitute for such a programme Goodhealth habits are valuable even for persons with resistant teeth, and dentalcare for the indigent is still needed in the fluoridated areas

2 School Dental Health Nurse Programme

The New Zealand School Dental Nurse Plan was introduced in the year 1921.When the service began, care was offered only to younger school-agechildren, but eligibility now extends to all children in primary andintermediate school (2 V to 13 V) years of age

The New Zealand school dental nurse plan has attracted tremendousattention in dental circles all over the world Other countries that haveadopted similar programmes, with modifications to suit the local governmentinclude Canada, Britain, Australia, Malaysia, Singapore, Brunei, Hong Kongand Indonesia

In Canada, Saskatchewan dental nurse programme was introduced in

1974, where children aged 3–12 years are to be treated by dental nurses andservices provided are free of direct charge

In Britain, “New Cross” dental nurse model was introduced in 1962 forschool dental service They also started child-to-child health programme.Several Australian States have now started wide dental plans in whichdirect patient care for children up to 15 years of age is provided by dentaltherapists

3 Learning About Your Oral Health

(A Prevention Oriented School Programme)

Development

‘Learning about your oral health’ was developed by ADA, Bureau of dentalhealth education and its consultants in response to a request from 1971 ADAhouse of delegates

The programme is available to school systems throughout the UnitedStates

Programme Philosophy and Goals

Learning about your oral health is a comprehensive programmecovering current dental concepts

The goal of the programme is to develop the knowledge, skills,attitudes needed for the prevention of dental disease

The priority of the programme is to develop effective plaque controlknowledge and skills

A plaque control kit is also available

Cost of Materials

The teaching packet for each level costs $8.00 (₹ 256/-) per level The cost ofplaque control kit for a class of 35 is $12.95 (₹ 426/-)

Programme Evaluation

The behavioural objectives provide the basis for evaluating the effectiveness

of lessons at all levels

The tattle tooth programme was developed as a cooperative effort between

Texas dental health professional organization

Texas department of health and

Texas education agency

Programme Philosophy and Goals

Tattle tooth programme relates dental health of the individuals andfocuses on a total person

The goal of the programme is to reduce dental disease and developdental habits to last a lifetime

Programme Implementation

Statewide implementation plan

Teachers are trained to present dental health information

Philosophy and Goals

Capitalizes on reinforcement activities and helps children to developpersonal responsibility for healthcare

Primary goal of tooth keeper programme is education rather than oralhygiene With emphasis on establishing positive health values

Implementation

Teachers are trained each year by dental health consultants

All necessary information and teaching resources are provided by thissystem

The teachers are requested to carry out the programme for 16consecutive weeks

Developed by the United States public health service division of dentistry.

Philosophy and Goals

Utilizes qualified dental personnel to train interested high schoolstudents to teach preventive dentistry to elementary students

The programme goal is to give young children the knowledge andskills to start them on the way to lifetime of preventive dentistrypractice

Implementation

Suggested guidelines and a THETA teacher’s manual are forwarded to theinterested party

Cost of Materials

Training manual cost is $0.50

Plaque control kit for a class of 35 is $8.00

It is presented in formats like flip charts, slide, and video cassette

The content covers dental disease problems and their prevention aswell as diet

It also describes characteristics of children’s dental development

ranging from prenatal to late adolescence.

SCHOOL HEALTH PROGRAMMES IN INDIA

Dental health is a part of general health in programmes run by certainvoluntary association of India They conduct teacher trainingprogrammes in which a dental health is a part of total healthcurriculum

Voluntary agencies like the Lions, Rotary and others conduct schooldental health programme

Colgate’s Bright Smiles, Bright Futures Education Programme (BSBF)

—Bright Smiles, Bright Future (BSBF) is committed to educatingchildren about oral healthcare The aim is to spread awareness amongchildren about the correct oral health habits, basic hygiene and diet,using engaging aids to ensure they retain the learning

Indian Dental Association launches ‘Smile Through The Millennium’National Oral Health Programme—A key element of the Programme isthe ‘Oral Health Week’ which will be conducted for both the generalpublic as well as school children across the country it will include freedental check-ups, dental health exhibitions, brushing demonstrations aswell as contests for children like the Beautiful Smile Contest, CollageCompetitions, Painting Competitions and Elocution Contests

India Smiles campaign: India Smiles campaign, a joint initiative ofSaveetha University and Times of India, to create awareness on theimportance of oral hygiene and dental healthcare among the children,their parents and teachers The children were given pamphlets onmaintaining oral health and various types of treatment were suggested

A total of 1,01,309 schoolchildren were screened for dental problems

in a single day at 77 centres across the country, earning the event anentry in the Guinness Book of Records

Healthcare services traditionally have been provided on a fee for servicebasis, whereby the patient receives specific services and pays the provider forthem directly This two party system is a private contract in which the onlyparties involved are the provider and the recipient of services.

Dentistry’s entry into the third party system has been relatively recent,but third party dental care is now a major and still expanding part of dentalservices As the cost of health care continue to rise, methods will be sought toease costs either by legislation or by the development of a variety of fundingapproaches.3

The acceleration in the rate of increase of healthcare costs have beenattributed to a number of factors, principally

The public’s increasing demand for health services

The ever-growing technology of health care

The probably higher quality of care now being delivered

General inflation

The lack of incentives in medical care to keep costs down

The increasing practice of “defensive medicine” in whichdiagnostic tests and prescribed treatment are aimed at avoidinglawsuits rather than at meeting the patients real needs

MECHANISM OF PAYMENT FOR DENTAL CARE

The mechanism by which dental practitioners receive payment for theirservices can be grouped into the following general categories.3

Private fee for service

Post payment plans

Private third party prepayment plans

Commercial insurance companiesNon-profit health service corporations such as delta dental plansand blue cross/blue shield

Prepaid group practice including health maintenanceorganization and independent practice associations

Capitation plansSalary

Public programmes

MedicareMedicaidVeterans administration (VA)National health insurance (NHI)