Community

Community dentistry Dr.
Dalia
Dental numbering systems
There are three different numbering systems used to identify the teeth in
dentistry.
1.The Universal Numbering System has been adopted by the ADA. Tooth
number 1 is the tooth farthest back on the right side of your mouth in the
upper (maxillary) jaw. Numbering continues along your upper teeth toward
the front and across to the tooth farthest back on the top left side number
16. The numbers continue by dropping down to the lower (mandibular)
jaw. Number 17 is the tooth farthest back on the left side of your mouth on
the bottom. Numbering continues again toward the front and across to the
tooth farthest back on the bottom right side of your mouth number 32. In
this system, the teeth that should be there are numbered. If you are missing
your third molars, your first number will be 2 instead of 1, acknowledging
the missing tooth. If you’ve had teeth removed or teeth missing, the
missing teeth will be numbered as well.
2.The Palmer Notation Numbering System. The mouth is divided into four
sections called quadrants. The numbers 1 through 8 and a unique symbol
is used to identify the teeth in each quadrant. The numbering runs from the
center of the mouth to the back. In the upper right quadrant tooth, number
1 is the incisor. The numbers continue to the right and back to tooth number
8, which is the third molar. The numbers sit inside an -shaped symbol
used to identify the quadrant. The is right side up for the teeth in the
upper right quadrant. The teeth in the upper left use a backwards . For
the bottom quadrants, the is upside down following the same pattern
from the uppers. Letters such as UR or URQ for the upper right or upper
right quadrant may also identify the quadrants.
3.The Federation Dental International Numbering System (FDI).

Internationally the two- digit system is used worldwide. Every branch of
dentistry uses this system. Each quadrant is assigned a number. The
maxillary right quadrant is assigned the number 1, the maxillary left
quadrant is assigned the number 2, the mandibular left quadrant is assigned
the number 3, and the mandibular right quadrant is assigned the number
4.The teeth within each quadrant are assigned a number from 1 through 8
with 1 being the central incisor and 8 being the third molar.
Dental Indices
Index is a numerical value describing the relative status of a population
on a graduated scale with definite upper and lower limits, which is designed
to permit and facilitate comparison with other populations classified by the
same criteria and methods.
Ideal properties of an index:
 Clarity: The examiner should be able to carry out the index rules in
his mind.
 Simplicity: The index should be easily to apply.
 Objectivity: The index criteria should have clear-cut.
 Validity: The index should be measure what it is intended to
measure. So it should be correspond with clinical stages of the disease, (ex.
number of missing teeth in adults is not a valid measure of caries activity
?).
 Reliability: The index should measure consistently at different times
and under a variety of conditions, by the same person or different persons.
 Quantifiability: The index should have meaning to statistical
analysis. So that the status of a group can be expressed by a number that
corresponds to a relative position on a scale from zero to the upper limit.
 Sensitivity: The index should be able to detect reasonably small
shifts, in either direction in the group condition.
 Acceptability: The use of the index should not be painful or
demeaning to the subject.
Uses of dental indices:
1. To provide data for epidemiological studies by studying prevalence,

incidence, and severity of disease.
2. To study and compare oral health status of individuals and population

and finding out etiological and predisposing factors for the diseases.
3. For planning of oral health policy and evaluating the success and
effectiveness of preventive programs.
Community dentistry Dr. Dalia
Classification of indices:
A- Depending on the direction in which their scores can fluctuate:
1. Irreversible index …………….. DMF
Index that measures conditions will not return to the normal state. Once
established cannot decrease in value on subsequent examinations.
2. Reversible index ……………… GI
Index that measures conditions that can be return to the normal state.
Reversible index scores can decrease or increase in value on subsequent
examinations.
3. Composite index ……………… PDI
Index that measures conditions that can be return to the normal state and
conditions will not return to the normal state.
B- Depending on the extent to which areas of oral cavity are measured:
1. Full mouth index ……………… Dean's Fluorosis Index
These indices measure the patient's entire dentition.
2. Simplified index ……..………… CSI
These indices measure only a representative sample of teeth.
C- Depending on the entity which they measured for:
1. Disease index …………………. D M F
2. Treatment index ……………… D M F
3. Symptom index ……………….. PBI
Scales
There are three types of scales:
1. Ordinal scale: It is a scale of measurement that lists conditions in some

order. Use of this sort of scale merely attempts to order a condition
progressively, without attempting to define any mathematical relation
between the categories defined. For example, classifying the condition of
inflammation of gingival tissues as mild , moderate, severe.
2. A nominal scale is even less rigidly defined; it simply gives names to

different conditions and therefore is not strictly a scale at all. An example,
classifying the condition of gingival tissues as good, poor, fair, which
merely attaches names to variously defined conditions.
3. An interval or a ratio scale is one in which the numbers used in the

measuring scale
Indices used for dental caries assessment

1- Indices used for coronal caries.
A- Permanent teeth. B- Primary teeth.
2- Indices used for root caries.
-Permanent teeth index:

(Decayed-Missing-Filled)Index (DMF) which was introduced by
Klein, Palmer and Knutson in 1938 and modified by WHO:
1-DMF teeth index (DMFT) which measures the prevalence of dental
caries/Teeth.
2- DMF surfaces index (DMFS) which measures the severity of dental
caries.
The components are:
D component:
Used to describe (Decayed teeth) which includes:
1. Carious tooth.
2. Filled tooth with recurrent decay.
3. Only the root are left.
4. Defect filling with caries.
5. Temporary filling.
6. Filled tooth surface with other surface decayed.
M component:
Used to describe (Missing teeth due to caries) other cases should be
excluded these are:
1. Tooth that extracted for reasons other than caries should be excluded,
which include: (Orthodontic treatment, Impaction, Periodontal disease)
2. Unerupted teeth.
3. Congenitally missing teeth.
4. Avulsion teeth due to trauma or accident.
F component:
Used to describe (Filled teeth due to caries). Teeth were considered filled
without decay when one or more permanent restorations were present and
there was no secondary (recurrent) caries or other area of the tooth with
primary caries. A tooth with a crown placed because of previous decay was
recorded in this category.
Teeth stored for reason other than dental caries should be excluded, which
include:
1. Trauma (fracture).
2. Hypoplasia (cosmatic purposes).
3. Bridge abutment (retention).
4. Seal a root canal due to trauma.
5. Fissure sealant.
6. Preventive filling.
Note :
1- A tooth is considered to be erupted when just the cusp tip of the occlusal
surface or incisor edge is exposed. The excluded teeth in the DMF index
are:
1- Supernumerary teeth.
2- The third molar according to Klein, Palmer and Knutson only.
Limitations - DMF index can be invalid in older adults or in children
because index can overestimate caries record by cases other than dental
caries.
Principle and rules in recoding:
1-DMFT:
A- A tooth may have several restorations but it counted as one tooth, F.
B- A tooth may have restoration on one surface and caries on the other
surface, it should be counted as decayed D.
C- No tooth must be counted more than once, D M F or sound.
2-DMFS
Each tooth was recorded scored as 4 surfaces for anterior teeth and 5
surfaces for posterior teeth.
 Retained root was recorded as 4 D for anterior teeth, 5 D for
posterior teeth.
 Missing tooth was recorded as 4 M for anterior teeth, 5 M for
posterior teeth.
 Tooth with crown was recorded as 4 F for anterior teeth, 5 F for
posterior teeth.
Calculation of DMFT \ DMFS:
Minimum score = Zero

Maximum score:
1- DMFT = 32
3- DMFS = 12 * 4 + 20 * 5 = 48 + 100 = 148 or 128
*Primary teeth index:

1- dmft / dmfs
Maximum scores: dmft = 20 , dmfs = 88
2- deft / defs , which was introduced by Gruebbel in 1944
d- decayed tooth .
e- decayed tooth indicated for extraction .
f- filled tooth.
3- dft / dfs
In which the missing teeth are ignored, because in children it is difficult to
make sure whether the missing tooth was exfoliated or extracted due to
caries or due to serial extraction.
Mixed dentition:
Each child is given a separate index, one for permanent teeth and another
for primary teeth.
Information from the dental caries indices can be derived to show the:
1. Number of persons affected by dental caries (%).
2. Number of surfaces and teeth with past and present dental caries (DMFT
/ dmft -- DMFS / dmfs).
3. Number of teeth that need treatment, missing due to caries, and have
been treated ( DT/dt , MT/mt , FT/f t).
Differentiation between tooth missing due to caries and due to
exfoliation?
1- By age of the patient if it is near to exfoliation time or not.
2- The shape of ridge is concave in carious missing tooth and straight in
exfoliated one and permanent successor may be seen.
3- DMF/dmf index is higher in association with carious missing tooth
especially adjacent and the contra lateral teeth.
4-Bad oral hygiene mainly associated with carious teeth.
Differentiation between tooth missing due to caries and due to
orthodontic treatment
1- By type of teeth, in ortho. treatment most teeth should be extracted are
4,5/c, d while in carious missing teeth any teeth may be involved.
2- Bilateral and /or opposing missing generally associated with ortho.
treatment, while in carious missing teeth it is not necessary.
3- DMF/dmf index is higher in association with carious missing tooth
especially adjacent and the contra lateral teeth with bad oral hygiene
mainly associated with carious teeth.
1- Crowding or appliance may be seen in ortho. treatment.
DENTAL CARIES SEVERITY CLASSIFICATION SCALE

 0-surface sound : no evidence of treated or untreated clinical caries.
 D1-initial caries : no clinically detectable loss of substance For pits
& fissures, there may be significant staining, discolouration, rough
spots in the enamel that do not catch the explorer but loss of
substance cannot be positively diagnosed.
 D2-Enamel caries : demonstrable loss of tooth substance in pits,
fissures or on smooth surfaces, but no softened floor or wall or
undermined enamel. The texture of the material within the cavity
may be chalky or crumbly, but there is no evidence that cavitation
has penetrated the dentin.
 D3-caries of dentin : detectably softened floor, undermined enamel
or a softened wall, or the tooth has a temporary filling. On proximal
surfaces, the explorer point must enter a lesion with certainty
 D4-pulpal involvement : deep cavity with probable pulpal
involvement. pulp should not be probed (usually included with D3
in data analysis)
*Root Caries Index (RCI), which was introduced by Katz in 1979:
RCI is based on the requirement that gingival recession must occur before
root surface lesions begin. Therefore, only teeth with gingival recession are
examined.
1. All teeth are examined in both the lower and upper arch.
2. To obtain the RCI, each of the four surfaces the mesial, distal, buccal
(labial), and lingual, of a root are examined for a single tooth.
3. When multiple types of root surfaces are exposed, the most severely
affected root surface be recorded for that tooth.
(R-D) is no. of root surfaces with decay.

(R-F) is no. of root surfaces which have permanent filling.
(R-N) is the no. of sound root surfaces.
Dental Indices
Index used for plaque assessment:
*Plaque Index (PlI) … which was introduced by Silness and
Loe in 1964
 Used together with GI, and should be preceded the
gingival examination.
 Used on all teeth (28, wisdom teeth are excluded) or
selected teeth (6 teeth) .
 No substitution for any missing tooth.
 Used on all surfaces (4)(M, B, D, L).
 This index measures the thickness of plaque on the
gingival one third of the teeth.
-The six index teeth are:
Score Criteria
0 No plaque
1 A film of plaque adhering to the free gingival margin and
adjacent area of the tooth, which can not be seen with the naked
eye. But only by using disclosing solution or by using probe.
2 Moderate accumulation of deposits within the gingival
pocket, on the gingival margin and/ or adjacent tooth surface,
which can be seen with the naked eye.
3 Abundance of soft matter within the gingival pocket and/or
on the tooth and gingival margin.
Index used for gingival disease assessment:
*Gingival Index (GI).... which was introduced by Loe and
Silness in 1963
teeth or selected teeth.
lesion and third molars should be excluded and there is no

substitution.
Score Criteria
0 No inflammation.
1 Mild inflammation, slight change in color, slight edema, no
bleeding on probing.
2 Moderate inflammation, moderate glazing, redness, bleeding
on probing.
3 Severe inflammation, marked redness and hypertrophy,
ulceration, tendency to spontaneous bleeding.
0.1 - 1 Mild gingivitis

1.1 - 2 Moderate gingivitis
2.1 - 3 Severe gingivitis
Indices used for periodontal disease assessment:
*Periodontal Disease Index (PDI) which was introduced by
Ramfjord in 1959
 Which is composed of three components.
 All the three components will be scored separately using
six Ramfjord selected teeth.
1-Gingival and periodontal component.
1-The criteria ranged from
2-All areas (M, D, B, L) is scored as a one unit.

3-Only fully erupted teeth are scored .
4-There is no substitution for excluded teeth.
2-Plaque component:
1-The criteria ranged from 0 - 3 .
Scoring criteria:
0 No plaque
1 Plaque present on some but not on all interproximal, buccal,
and lingual surfaces of the tooth.
2 Plaque present on all interproximal, buccal, and lingual
surfaces, but covering less than one half of these surfaces..
3 Plaque extending over all interproximal, buccal and lingual
surfaces, and covering more than one half of these surfaces.
2-All areas ( B , L , M , D ) are scored as one unit.
3-Only fully erupted teeth are scored .
4-There is no substitution for excluded teeth.
3- Calculus component:
1-The criteria ranged from 0 - 3 .
Scoring criteria:
0 Absence of calculus.
1 Supragingival calculus extending only slightly below the free
gingival
margin (not more than 1 mm).
2 Moderate amount of supragingival and sub gingival calculus
or sub gingival calculus alone.
3 An abundance of supra gingival and sub gingival calculus.
*Community Periodontal Index of Treatment Needs

(CPITN)…… which was introduced by WHO / FDI in 1982
 The mouth is divided into six parts (sextants).
 The examination done by special probe (WHO probe).
 The score is identified by examination of specified index
teeth or all teeth.
CPI score criteria
0 No periodontal disease.
1 Bleeding on probing.
2 Calculus with plaque seen or felt by probing.
3 Pathological pocket 4 – 5 mm.
4 Pathological pocket 6 mm or more.
x When only 1 tooth or no tooth are present.
TN score criteria
0 No need for treatment.
1 Personal plaque control (Oral hygiene instruction).(1- 4).
2 Professional plaque control (scaling and polishing). (2- 4).
3 Deep scaling , root planning, surgical procedure. (3- 4).
Indices used for dental fluorosis assessment:
Dental fluorosis: is a hypoplasia or hypomineralization of tooth
enamel produced by the chronic ingestion of excessive amount
of fluoride during the period of tooth development.
* Dean's Fluorosis Index–Modified criteria which was
introduced by Dean in 1942.
Classification criteria
Normal No dental fluorosis.
Questionable The enamel discloses slight aberrations from the
translucency of normal enamel ranging from a few white flecks
to occasional white spots.
Very mild Small, opaque, white areas scattered irregularly
over the tooth, but not involving 25% of the tooth surface, (no
more than 1 -2 mm of white opacity at the tip of the cusps of
bicuspids or second molars.
Mild The white opaque areas in the enamel of teeth are more
extension, but not involve as much as 50% of tooth.
Moderate All enamel surfaces of teeth are affected and
surfaces subject to attrition show wear, brown stains is a
disfiguring feature.
Severe All enamel surfaces of teeth are affected and
hypoplasia is so marked that the general form of the tooth may
be affected, pitting surface with brown stain.
BASIC EPIDEMIOLOGY
Definition of epidemiology
The study of the distribution and determinants of health related status or
disease, in specific populations. It also involves the application of the
results of such study for the control of health problems.
The epidemiological sequence:

1- Observation.
2- Counting cases or events.
3- Relating cases or events to the population at risk.
4- Making comparisons.
5- Developing the hypothesis.
6- Testing the hypothesis.
7- Making scientific inferences.
8- Conducting experimental studies
9- Intervention and evaluation.
 Scope of epidemiology
 Concern with communicable diseases.(etiology )
 Non-communicable diseases.
 Nutritional problems.
 Health status of the human population.
 Environmental aspects of health.
 Importance of epidemiology
 Allows greater knowledge of community and its problems
 To find out what are the prevalent diseases in the community and
their causes
 To find the susceptible groups (groups that are vulnerable to
certain problems)
 To calculate some measures of disease frequency by using
epidemiological tools.
 Assist in putting priorities for action
 For planning and evaluation of the effectiveness and efficiency of
health services .
 Measurements in epidemiology:
Measurements in epidemiology usually comprise the followings;
1- Measurements of mortality.
2- Measurements of morbidity
3- Measurements of disability.
4- Measurements of natality.
5- Measurements of the presence, absence or distribution of the
characteristics or attributes of the disease.
6- Measurements of the presence, absence or distribution of the
environmental and other factors suspected of causing the disease.
7- Measurements of the medical needs, health care facilities, utilization
of health services and other health related events.
Tools of measurements in epidemiology:
1- Rate: the rate measures the occurrence of some particular event
(disease, death) in a population during a given time period. It is a
statement of the risk of developing a condition.
A
Rate = ------------ x K
B
(A is a component of B) (K= constant = 10, 100, 1000, 10000, 100000)
2- Ratio: ratio is also a measurement of disease frequency.
A
Ratio = ---------- x K
C
(A is not a component of C) (K= constant = 10, 100, 1000, 10000, 100000)
e.g. Dentist / Population ratio, gender ratio Male / Female.
3- Proportion: proportion is a rate which indicate the relation in

magnitude of a part to the whole, it is usually expressed as a
percentage. E.g. proportional death rat of a cause to all deaths.
A
Proportion = ------------ x 100
B
(A is a component of B)
 Example: hypothetical data of the frequency of oral cancer in 2

cities:
City New cases Reporting

period
A 58 2015
B 35 2014-2015
So oral cancer is more common in city A than B if we only consider the
time period of the data collected (1 year in A and 2 years in city B)
* If we know that the population size is: A = 25 000 B = 7 000
Then the annual rate of occurrence of oral cancer will be:
A = 58/25 000/ 1 year = 232/100 000/Year.
B = 35/ 7 000/ 2 year = 250/100 000/Year.
So city B is more commonly affected with oral cancer than A.
BASIC EPIDEMIOLOGY
Prevalence:
It is the frequency of all current cases of disease in a population at a
specified time. It can be measured at a single point in time (Point
Prevalence) or over a period of time (Period Prevalence).
Current cases include those previously diagnosed and those
diagnosed in the current years or at the time of our survey or
examination.
 Prevalence rate = Number of people with the disease at a specified time x K
Total population at the specified time
Example: Periodontal examination survey in a city among individuals 35-

45 years of age . 310 of 2 477 persons examined had periodontitis at the
time of survey.
The prevalence of periodontitis in this age group is therefore 310/2 477
or 125 per 1 000 or 12.5% (proportion) .
 Uses of prevalence rates

o Understand magnitude of current health problems in a
population
o Compare magnitude of various health problems to set priorities
o Assessing the need for health care and the planning of health
services.
o It's often used to measure the occurrence of conditions for
which the onset of disease may be gradual, such as
Periodontitis, Type 2 diabetes or rheumatoid arthritis.
Prevalence rate mesurment best used for :
o Chronic, long-term illness
o Monitoring of changes in chronic diseases
 Factors influencing prevalence rate
o The severity of illness (if many people who develop a disease
die its prevalence rate is depressed)
o The duration of illness (if a disease lasts a short time its
prevalence rate is lower than if it lasts a long time)
o The number of new cases (if many people develop a disease its
prevalence rate is higher than if few people do so)
Incidence:
It is the frequency of new cases in the population at risk during a
specified period of time.
Incidence rate = Number of NEW CASES xK

Total population at risk
- Uses of incidence
 Monitor progression of new cases over time
 Compare incidence of various health problems to set priorities
- Incidence rate measurment best used for the :
o Short-term, acute illness
o Monitoring of epidemic illness
Example:
In a class of 100 students some of the students become ill with
mumps during the month of Oct. On the 30th Sept., 5 students reported
mumps recovered within 5 days, during Oct. 30 students had got mumps.
Calculate . Incidence during Oct.
. Period prevalence on Oct.
. Point prevalence at 30th Sep.
Incidence during Oct.= Number of NEW CASES xK

Total population at risk
30
= ----------- x 100
100-5
 Prevalence rate = Number of people with the disease at a specified time x K
Total population at the specified time
5
Point prevalence in 30th Sep. = -------------- x
100
5+30
Period Prevalence at Oct = ------------------- x K
100
Endemic:
It is the habitual presence of a disease within a geographical area or the
usual occurrence of a disease within such area. A disease continuously
present in a population is endemic to that population.
Epidemic:
It is an unusual increase in frequency of disease above the expected
(endemic) occurrence, revealing itself in a relatively short period of time.
Types of epidemiological studies:

 Descriptive studies: Describing disease by person, time and place.
 Analytical studies : looking for associations and testing hypotheses
 Experimental studies (Interventional studies): testing the effect of
interventions or services on disease
1- Descriptive Studies:
- Descriptive epidemiological studies provide Information on
characteristics which will provide clue to epidemiological hypothesis.
These studies concerned with; disease distribution according to
person (population subgroups), Place (certain area), and time (certain
time)
- Person; The characteristics of the person must include the
unalterable but essential descriptors of age, gender; in addition
religion, marital status, personality type, race, education, lifestyle
variables, food, medications, income, or occupation can be
considered.
- Age and gender should always be routinely considered in any study,
fundamental characteristics. The observed difference between male
and female in risk of CHD might also merely reflect difference in
levels of risk factors such as smoking, cholesterol, BP, physical
activity, social class, access to health care, or dietary patterns.
- Age may reflect general exposure during a specific period
- Place; Geographical distribution of disease; among countries, within
countries, rural and urban
- Descriptive characteristics related to place can provide major
insights into disease etiology by geographic comparisons of disease
frequency between countries or between regions within a single
country this may reflect genetic and environmental aspects of the
disease.
- Time; There are two types of time patterns that suggest possible
etiologic hypotheses, cyclic changes (such as seasonal patterns,
important in acute diseases with short latent periods), and secular
trend, or changes in disease frequency that take place over years or
decades.
1
Benefits of descriptive studies;
 These studies are fairly quick and easy
 Enables health care provider and administrator to allocate resources
efficiently and to plan effective preventive or education programs
 Provide first important clues about possible determinants of disease
 Useful for formulation of hypothesis not for testing it (so can be
tested subsequently using an analytic design)
Types of descriptive studies:

1- Cross-sectional studies
2- Correlational studies
3- Case report and case series
1-Cross-sectional studies (CSS):
Characteristics:
- Also called prevalence studies
- Describes status of an individual with respect to absence or presence
of disease and exposure, (both) assessed at the same point of time.
- Provides information about the frequency and characteristics of a
disease by describing the health experience of the population at a
specified time that will be of value in public health administration to
assess health status and health care needs of a population.
- CSS can also be used to provide information on the health outcomes
in certain occupations.
- Since exposure and disease were assessed at the same single point in
time, CSS can not always distinguish whether the exposure preceded
the development of disease or presence of disease affected individual
exposure level.
2-Correlational studies:
These studies were useful for formulation of hypothesis, they were
using already available data from entire population to compare disease
frequency between different groups during the same period of time or in
the same population at different points time
- E.g. percapita daily consumption of sugar Vs rate of dental caries in
Iraq ( positive correlation)
- E.g. percapita daily consumption of meat Vs rate of ca colon in
women from large number of countries (positive correlation)
2
- E.g. decrease CVD death over time, decline might be due to
improvement of life style habits and subsequent risk factors
(preventive), or fewer people who gets the diseases were dying from
improvement in treatment (therapeutic)
Limitation of correlational studies;
1- Study refers to whole population rather than to individuals, it is not
possible to link exposure to occurrence of disease in the same person
(inability to link exposure with disease in particular individual)
2- Lack of ability to control for the effects of potential confounding
factors (correlation between percapita no. of colored TV sets and
CHD mortality rates in various countries . which is related to other
life-style variables that are known to increase risk of CHD, such as
BP, cholesterol, smoking, physical in activity)
3-Case report and case series studies:
Characteristics:
1-Basic type of epidemiological studies
2-Case report consist of a single patient, show the association between
factor and disease risk
3-Individual case report can be extended to a case series to describe the
characteristic of a number of patients
4-Accumulating case reports will suggest emergence of new disease or
an epidemic
5-Raise hypothesis about some aspects could be related to risk of
disease
Methods of hypothesis formulation;
1- Method of difference; recognizing that if the frequency is markedly
different in two sets of circumstances, the disease may be caused by
some particular factor that differs between them. E.g. certain cancer
are very rare in one country but very common in another, this
became part of the basis for the current belief of prevention by
manipulation of environmental or life style variables
2- Method of agreement; Single factor is common to a number of
circumstances in which a disease occurs with high frequency. E.g.
AIDS, unusually high frequency among iv drug abusers, recipient of
transfusions (e.g. haemophiliacs)
3
Types of epidemiological studies:
2-Analytical studies:
As you have seen, with descriptive studies we can identify several
characteristics of persons with disease, and we may question whether these
features are really unusual, but descriptive epidemiology does not answer
that question. Analytic epidemiology provides a way to find the answer.
The comparison group or groups, which provide baseline data, are a key
feature of analytic epidemiology. The investigator simply observes the
natural course of events (noting if the persons exposed or not, and if they
developed outcome or not).
For example, in one outbreak of hepatitis A, it was found that almost all of
those infected ate pastries from a particular bakery and drank city water.
However, without knowing the habits of persons without hepatitis, it was
not possible to conclude that pastries, city water, or both were risk factors
for hepatitis. Therefore, a comparison group of healthy persons from the
same population were questioned.
Analytical studies is of two basic types;
1-Case - control studies
2- Cohort studies.
1-Case - control study: A case group or series of patients who have
disease of interest, and a control or comparison group of individuals
without the disease are selected for investigation, the proportion of
exposure in each group are compared
Characteristics:
- Efficient in time and cost relative to other analytic studies
- Suited to the evaluation of rare diseases
- Provide valuable information on the association between exposure
and disease but still clarification of temporal sequence between
exposure and disease is an issue in case-control study.
Selection of cases;
- Sources include;
1
 Patients treated in hospital or medical care facility during a
specified period of time (Hospital-based); which is more common and
relatively easy and inexpensive to conduct.
 Persons with disease in a defined general population (all or
picked at random) at a single point or during a period of time
(Population-based) to avoid selection bias, to allow the description of
entire picture of disease, and direct compute of the rate of disease in
exposed and non-exposed individuals.
Selection of controls;
It is a difficult and critical issue, and any exclusion or restrictions
made in the identification of cases must apply equally to the controls
and vice versa.
Sources of controls;
 Hospital controls: Patients at the same hospitals who have
been admitted for conditions other than the disease being studied.
Advantage; easily identified, readily available in sufficient number,
minimal cost and effort. Also they are likely to have been subject to
the same selection factors that influence the cases to come to
particular physician or hospital. More willing to cooperate than
healthy individuals thus minimizing the bias due to non-response.
Disadvantage: they are ill so differ from healthy individuals, more to
be smokers, heavy drinker of alcohol. Regarding association they may
either positively or negatively associated with exposure of interest
which should be excluded from the control series.
 General population controls: households in targeted
neighborhood, or the identification of individuals from population
registers or voting lists. Disadvantage; costly and time consuming,
population list are not always available, difficult to contact healthy
people with busy work and leisure activity schedule, low quality of
information, less motivated to participate and thus refuse to participate,
those who agree may systematically differ from those who refuse that
may be related to the risk of developing the disease of interest.
 Special control series, friends, neighbors, relatives of cases:
Advantage; they are healthy but also more likely to be cooperative
with interest in the case. Offer a degree of control of confounding
2
factors related to ethnic background, environment. Underestimate of
the true effect of the exposure of interest may result.
Size of the sample of the control:
- The optimal size of the controls to cases is 1:1 ratio, but the ratio
can be increased to be 2:1, 3:1, 4:1, to increase the power of the
study when the sample size of cases is limited, with only a small
number being available for study or high cost.
- Multiple controls can be used when one selected group has a
specific deficiency that could be overcome by the inclusion of
another control group. There may be 1, 2, or more control groups,
this may provide useful information as to the nature of the
association under study and to decrease the possible biases that could
be present.
Bias in case-control studies:
Bias is any systematic error in the determination of the association
between the exposure and the disease.
Role of bias;
- Selection bias (where response rates are either low or unequal for
cases and controls).
- Observation bias (knowledge of disease status may influence the
reporting of information by the subject or the recording or
interpretation of this information by the investigator).
- Recall bias (differences in the ways exposure information is
remembered or reported by cases who have experienced an adverse
health outcome, and controls who have not), and Misclassification
(errors in categorization of either exposure or disease status)
2-Cohort studies;
subjects are classified on the basis of the presence or absence of
exposure to a particular factor and they must be free from the disease at
the time of exposure ,and then followed for a specified period of time
(at least several years in duration to allow for an adequate number to
develop the outcome) the disease frequency between exposed and non-
exposed individuals are compared to determine the development of
disease in each exposure group.
Advantages of cohort studies;
3
1- The temporal sequence between exposure and disease can be more
clearly established
2- Well suited for assessing effects of rare exposures.
3- Allows the investigators to identify adequate number of exposed and
unexposed subjects
4- Allows the examination of multiple effects of a single exposure so
can provide information on the full range of health effects of a single
exposure
5- Minimize the potential for selection bias
- Disadvantages;
1- Time consuming and expensive.
2- Conducted after a hypothesized relationship has been explored and
evaluated in a case-control design.
3- Serious bias associated with the losses to follow-up that are likely to
occur when participants must be followed for months, years, or even
decades.
4- Selection of design depend on; particular hypothesis being tested, the
resources available, and current state of knowledge.
Types of cohort;
Cohort is divided into types depending on the temporal relationship
between the initiation of the study and the occurrence of the disease.
1- Retrospective cohort; all relevant events both exposure and outcome
of interest have already occurred when the study is initiated. It is
quicker and cheaper than prospective cohort, but data needed may be
inadequate in details as collected from pre-existing records (collected
for other purposes rather than for investigation)
2- Prospective cohort; the relevant exposure may or may not have
occurred at the time of the study is begun, but the outcome of interest
have certainly not yet occurred. In it we can often use more recent
records or even assess the exposure directly or through questioning the
participants themselves and information on potential confounders can
also be obtained from study subjects.
-After selection of the cohort, participants must be followed in to the
future to assess the incidence rate of disease
Retrospective & Prospective:
- Retrospective: looks backward from a disease to a possible cause.
4
- Prospective; looks forward from an exposure to an outcome.
- The feature that distinguishes a prospective from a retrospective
cohort is simply and solely whether the outcome of interest has
occurred at time of study initiation.
5
3- Experimental studied (Intervention studies):
The investigator himself allocates the exposure then follows
subjects for the subsequent development of disease.
Characteristics:
1. Also referred to as clinical trials, may be viewed as a type of
prospective cohort study
2. Participants are identified on the basis of their exposure status and
followed to determine whether they develop the disease
3. The exposure is assigned by the investigator
4. Often considered as providing the most reliable evidence from
epidemiologic research
5. It has the unique strength of randomization as a mean of determining
exposure status in a trial, which will control all other factors that may
affect diseases risk
6. It is a powerful epidemiological strategy as it controls both known
and unknown influences especially small to moderate effects.
Types of experimental studies:

1- Preventive type: trial involves the evaluation of whether an agent or
procedure reduces the risk of developing disease among those free
from that condition at enrollment (conducted among healthy at usual
risk or those already recognized to be at high risk of developing a
disease)
2- Therapeutic type: trails are conducted among patients with a
particular disease to determine the ability of an agent or procedure
to diminish symptoms, prevent recurrence or decrease risk of death
from that disease.
Limitations of experimental studies:
1
1. Ethical concerns preclude the allocation of exposures that are known
to be hazardous, efficient medical treatments should not be withhold
from any affected individuals
2. Difficult to find large number of individuals willing to forego a
treatment or practice believed to be beneficial for the duration of a
trial
3. Cost; although studies now conducted with streamlined protocols
carefully designed to minimize time and expenses.
Selection of a study population;
- The experimental population; is the actual group in which the trial is
conducted, preferable not differ from the reference population, should
be sufficiently large (will experience sufficient number of end points or
outcomes of interest within a reasonable period of time), and obtaining
complete and accurate follow-up information for the duration of the trial.
- Reference population; is the general group to whom the investigators
expect the results of the particular trial to be applicable. The reference
population may include all human beings, may be restricted by
geography, age, gender, or any other characteristic thought to modify
the existence or magnitude of the effects seen in the trial, it represents
the scope of the public health impact of the intervention.
Once experimental population has been defined, subjects must then be
invited to participate after being fully informed as to the purpose of the
trial, procedure, possible risks and benefits, knowledge that they may be
allocated to a group receiving no active treatment (placebo) they may
not know the treatment they received until the end of the trial. Then
those willing to participate must then be screened for eligibility
according to predetermined criteria. Excluded for; previous history of
any end points under study, definite need for the study treatment.
2
MEASURMENTS OF RISK
1. Realative Risk(RR):
*It is an estimation of the association between exposure and
disease.
*It indicates the likelihood of developing the disease in the exposed
group relatively to those who are not exposed.
*It is defined as the ratio of the Incidence of disease among
exposed group (Ie) divided by the corresponding Incidence in the
non exposed group (Io)
Incidence rate among exposed

RR=-------------------------------------------------
Incidence rate among non exposed
Interpreting RR of a disease:
*If RR= 1 Risk in exposed equal to risk in unexposed (no association).
*If RR> 1 Risk in exposed is greater than the risk in unexposed
(positive association, possibly causal).
*If RR < 1 Risk in exposed is less than the risk in unexposed (negative
association, possibly protective)
Attributable Risk (AR):

 Incidence rate among exposed –incidence rate among Non exposed
 It indicates how much of the disease is attributed to that particular
risk factor... or the other way round... how much those of the non –
exposed will develop or get the disease if they are exposed to the
risk factor
3
Example:
In a study of two toothpastes, 10 out of 100 caries-free children using a new toothpaste
(exposure) develop caries after 1 year. In another group of 100 caries-free children
using a standard toothpaste, 25 develop caries
---+VE----- -VE --- Total

New toothpastes 10 90 100
Standard toothpaste 25 75 100
Total 35 165 200
Incidence of caries among children using new toothpaste =10/100*100 = 10%

Incidence of caries among children using standard toothpaste =25/100*10 =25%
Ie
RR= ----- = 10% / 25% = 0.40 (negative association, less than one)
Io
So caries among children using new toothpaste have 0.4 times less chance
of developing caries among children using standard toothpaste (new
toothpaste has protective effect)
AR = 10% -25%= 15%
So 15% of cases have caries because they use standard toothpaste or it
means that 15 % of those used new toothpaste will have caries if they start
to use standard toothpaste.
Example: In a prospective study of the risk of alcohol consumption on
developing TB
TB
---+VE----- -VE --- Total
Alcoholic 40 10 50
Non-Alcoh 10 90 100
Total 50 100 150
Incidence of TB among Alcoholics =40/50*100 = 80%

Incidence of TB among non-alcoholics =10/100*10 =10%
Ie
RR= ----- = 80% / 10% = 8
Io
4
So alcoholics have 8 times more chance of developing TB than
nonalcoholics
AR = 80% -10% = 70%

So 70% of cases have TB because they are alcoholics or it means that 70 %
of those non-alcoholics will have TB if the start to consume alcohol.
Example: A study on smoking had shown the followings:-

 LUNG CANCER:
Death rate/1000 for smokers = 0.90
Death rate /1000 for non-smokers =0.07
RR = Ie /Io = 0.90/0.07 = 12.86
AR = Ie-Io =0.90-0.07 = 0.83/ 1000
 CORONARY THROMBOSIS:
Death rate /1000 for smokers =4.87
nonsmokers = 4.22
RR = 1.15
AR = 0.65/1000
 ALL CAUSES :
Death rate /1000 for smokers =15.78
nonsmokers=13.25
RR=1.19
AR=2.53\1000
 So among smoker there is excess of death from lung cancer,

coronary thrombosis and all causes of death.
The RR is greater for lung Cancer.
5
STATISTICS
Statistics is that field of science concerned with the collection,

organization, presentation, and summarization of data, and the drawing of
inferences about whole body of data when only a small part of the data is
observed or examined.
Biostatistics:
Is that field of statistics in which the data being analyzed were derived
from the biological sciences and medicine.
There are two main objectives from statistics;
1-In, which we are, concerned with only collection, organization,
presentation and summarization of data that is called descriptive
statistics.
2-In which the objective is to reach a decision about a large group of data
by examining only a small part of the data, and it is called inferential
statistics (analytic statistics).
Uses of statistics:
1-To measure the health state of the community and identify its health
problems.
2-To compare health condition (status) of a community with others.
3-For planning of health services.
4-For evaluation of health services.
5-For estimating the future needs.
6-For research.
Data:
The raw material of statistics is called data; it is obtained either as
measurement or as process of counting. It represents a collection of
values (single of data is called datum).
Value:
It is the numerical representative of the measurement of the variable.
Sources of data:
1-Routinely kept records, such as hospital medical records.
2-Surveys, if the data needed to answer a question are not available from
routinely kept records.
3-Experiments, such as in evaluation of the different strategies might
enable the doctor/ dentist to apply most effective measures to the patient.
4-External sources, in form of published reports, or the research
literature.
Variable:
Any characteristic that can take different values in different occasions,
places, persons, and time. e.g. Height, weight, age, etc...
Variables are one of two types
1-Quantitative variable (numerical); is that variable that can be measured
by units such as height, weight, age, etc…
2-Qualitative variable (categorical); is that variable that cannot be
measured by usual sense or units, it can only be assessed by number or
percentage e.g. Gender, ethnic group, colour of the eye, race, education,
occupation, type of disease.
Quantitative variables are of two main types:
1-Discrete quantitative variable; characterized by gaps or interruptions in
the values that it can assume, these gaps or interruptions indicate the
absence of values between particular values that the variable can assume,
e.g. Daily admission of patients to hospital, the number of decayed teeth
per child.
2-Continuous quantitative variable; it is also called continuous variable, it
does not possess the gaps or interruptions characteristic, it has fractions of
units, and the variable can assume any value within a specified interval,
as height, weight, etc.. in fact, most of the biological data are of the
continuous quantitative type.
There is another classification of variables according to;
1-Nominal scale: must be mutually exclusive (male-female, well-sick,
child-adult, and married-unmarried).
2-Ordinal scale: ranked in terms of graded order (high-intermediate-low,
not smoker, light, moderate, heavy smoker)
3-Intervale scale: equal spaced (20-, 30-, 40-, Temp).
4-Ratio scale: has true zero point & equal intervals( length, time, mass).
Population:
It is the largest collection of entities of which we have an interest at a
particular time, sharing at least one characteristic in common. Populations
may be finite or infinite. If a population of values consist of a fixed
number of these values, the population is said to be finite (sampling
frame exist), if on the other hand, a population consists of an endless of
values, the population is called an infinite one (patients visiting the
outpatient department, we do not have exact number of how many
patients came during the day).
Sample:
The sample may be defined as a part of population chosen in a
representative way to be as much as possible representative for the
population (random, or non random).
Sampling
Data collection:
It is difficult for us to study all population of interest to reach a
conclusion regarding certain parameter (variable) and the effect of
different factors on such parameter (variable), as it needs time, money,
efforts, and manpower. Through census of the population which is done
in our country every 10 years (1957, 1977, 1987, 1997) but also census
will give us only a demographic characteristics of the population (no
medical information can be gathered from census, as it is done by
professionals but not doctors or medical staff), so a sample is taken from
the population by sampling which is as representative as possible for the
population and if it is done properly we can generalize our finding on the
population. A major purpose of doing a research is to infer or generalize
from a sample to a large population, inference depend on statistical
methods based on probability.
Reasons for sampling:
1-Sample can be studied quickly (population needs more time, money,
manpower).
2-Sample results are usually more accurate than results obtained from
population. More time and resources can be spend to train personnel, and
more expensive and more accurate procedures can be used.
3-If samples are properly selected, probability methods can be used to
estimate the errors in the resulting statistics.
4-To reduce heterogeneity, so that a sample of specific characteristics can
be studied, i.e. not whole population.
There are many kinds of samples that may be drawn from a
population. Not every kind of sample, however, can be used as a basis for
making valid inferences about a population. In general in order to make a
valid inference about a population, we need a scientific sample from the
population. There are two main types of sampling;
1-non-probability sampling (non-random sampling) .
The probability that a subject is selected is unknown, it is not always
possible to take a random sample (busy physician who wants to make a
study on 50 patients attending the outpatient clinic).
Non-random sampling includes:
A-quota method (Accidental sampling): by market research
organizations by interviewing and seeking of certain number of people to
fit. For example, in the street. It is unsatisfactory, not representative and
we cannot generalize our finding on the population. But it is easy and
quick method give quick results and not expensive and done in a very
short time. So the selection of a predetermined size of sample in a
predetermined place, time and even persons (giving a big role for bias to
affect our results).
B-systematic method: by which the selection is down through a
predetermined regular interval (e.g. Each 3rd, each 10th, each house in the
corner, etc..).
2-probability sampling (random sampling): which is the best method
that allows us to infer from the sample drawn to the population. In which
the probability of being included in the sample is known (and equal) for
each subject in the population.
Random sampling:
In this type of sampling, each person in the population has an equal
chance (equal probability) to be included in the sample as the others. So
there is no Bias or no other thing that prefer any person to be included in
the sample. This method allow us to select a sample that is as
representative as possible to the population, making us able to generalize
our findings in the sample on the population, so only the chance factor
has an effect on our sample that is made as very small as possible.
There are different methods of random sampling;
A-Simple random sampling:
B-Systematic random sampling
C-Stratified random sampling
D-Multistage random sampling
E-Cluster random sampling
1-Simple random sampling:
The simplest of the methods used for sampling in which we give each
person in the population an equal chance to be present in the sample. So
that every person in the population has the same chance of being selected
in the sample.
There are two methods either with replacement or with out replacement ,
it is done by; List, Code, cards, coins, random digit table, or by computer
So in simple random sampling, the first step is to draw up a list of all the
individuals in a population, this list is called sampling frame. Then
coding by numbers (to make it more random than names). Next, the
required number of individuals is selected, and each one has the same
chance of being chosen in he sample. This selection can be achieved by
labeling a card for each individual in the population, shuffling them well,
and then selecting the appropriate required number of cards. A more
convenient method is to use a random digit table. The selection also can
be done by computer program
2-Sytematic random sampling:
Sometimes, the sampling frame does not exist, in case if we are dealing
with infinite population (population composed of endless number, such
as patients attending the outpatient clinic), while in finite population,
there is a sampling frame. So it is convenient to carry out sampling in
systematic way (through regular interval), the interval is determined
according to the total number of population assumed and the number of
the sample required;
Assumed total number of population

-------------------------------------------- = nth
Number of sample required
Example: the total number of patients attending outpatient clinic is

assumed to be 1000 daily, and we want to select a sample of 200 patients,
so the interval is 1000 / 200 = 5 th .. The starting point from the first 5
digits is chosen at random by simple random sampling, suppose it was
taken as 4, so the sample will comprise individuals with numbers 4, 9, 14,
19, 24, 29, etc….
Data Summarization
Data summarization is either by;
1-Measurements of central tendency
(average measurements)
{ Mode
{ Median
{ Mean
1. What is the Mode?
Most frequently occurring score (f = frequency)
The highest “peak” in the distribution
X f
9 19
8 25
7 52
6 36
5 31
4 20
3 15
2 10
1 6
What is the mode???
2. What is the Median?

Score that divides distribution in half
Score that corresponds to 50th percentile
Middle location in a distribution
You can encounter 2 general cases:
a) When N is odd
b) When N is even
How do you find the median when N is odd?
a) Arrange all values (N) from smallest to largest
b) The median is the center of the list
c) Find it by counting (N + 1) /2 observations up from the bottom
1 2 2 3 5 6 7
(N + 1) / 2: (7 + 1) / 2 = 4 up from bottom
The observation number 4 is the median
So Median = 3
How do you find the median when N is even?

a) Arrange all values (N) from smallest to largest
b) The median is the average of the center two values
c) Count (N /2) observation up from the bottom
d) Count (N /2 ) +1 observations up from the bottom

Ex. 1 2 2 3 5 6 7 8
N/2
8/2=4
(N / 2) + 1
(8/2)+1=4+1 = 5 up from bottom
The average of observation number 4 &5 is the median
So the average of 3 & 5 is the median
3+5/2=4
The median =4
3. What is the Mean?

The mathematical center; average value
The “balancing point” of the distribution
How is the mean calculated?
Mean for a sample & a population are calculated the same way, but
the symbols in the formula vary somewhat:
For Samples:
( X )
X
n
Example:
1, 3, 5, 4, 3, 7, 2, 8, 3, 54
( X )
X
n
n = 10
mean = (1 + 3 + 5 + 4 + 3 + 7 + 2 + 8 + 3 + 54) / 10
mean= 9
2-Measurments of variability (dispersion measurements)

Measurements of variability:
The degree to which numerical (quantitative data) tend to spread about an
average value is called variation or dispersion of the data. The variability
is something that is in the nature of data, i.e. the data always have a
variation (not came as one value). There are various measures of variation
or dispersion but the most common being used are;
1-Range:
It refers to the difference between the smallest and the largest value in a
set of values.
Range(R)=Largest value (XL) – Smallest value (XS)
The range is of limited use in statistics as a measure of variability because
it takes in consideration only two values and neglect the others (if we
have 10 values, the range will consider only 2 values and neglect the
other 8 values), and these two values considered by the range are the two
extreme values (smallest and the largest values) which are not of that high
interest in biostatistics to describe perfectly the variation.
The uses of range;
1-It gives an idea about the extent of data distribution (the scale or range
on which the data extend or spread).
2-In determining the width of class interval in case of class interval table
(W=R/K).
2. Interquartile Range (IQR)
The interquartile range is a measure of where the “middle fifty” is
in a data set. Where a range is a measure of where the beginning and end
are in a set, an interquartile range is a measure of where the bulk of the
values lie. That’s why it’s preferred over many other measures of spread.
The IQR formula is:
IQR = Q3 – Q1
Where Q3 is the upper quartile and Q1 is the lower quartile.
Steps:
 Step 1: Put the numbers in order.
1,2,5,6,7,9,12,15,18,19,27
 Step 2: Find the median.
1,2,5,6,7,9,12,15,18,19,27
 Step 3: Place parentheses around the numbers above and below
the median.
Not necessary statistically, but it makes Q1 and Q3 easier to spot.
(1,2,5,6,7),9,(12,15,18,19,27)
 Step 4: Find Q1 and Q3
Think of Q1 as a median in the lower half of the data and think of
Q3 as a median for the upper half of data.
(1,2,5,6,7), 9, ( 12,15,18,19,27). Q1=5 and Q3=18.
 Step 5: Subtract Q1 from Q3 to find the interquartile range.
18-5=13.
What if I Have an Even Set of Numbers?

Sample question: Find the IQR for the following data set: 3, 5, 7, 8,
9, 11, 15, 16, 20, 21.
Step 1: Put the numbers in order.
3, 5, 7, 8, 9, 11, 15, 16, 20, 21.
Step 2: Make a mark in the center of the data:
3, 5, 7, 8, 9, | 11, 15, 16, 20, 21.
Step 3: Place parentheses around the numbers above and below the
mark you made in Step 2–it makes Q1 and Q3 easier to spot.
(3, 5, 7, 8, 9), | (11, 15, 16, 20, 21).
Step 4: Find Q1 and Q3
Q1 is the median (the middle) of the lower half of the data, and Q3
is the median (the middle) of the upper half of the data.
(3, 5, 7, 8, 9), | (11, 15, 16, 20, 21). Q1 = 7 and Q3 = 16.
Step 5: Subtract Q1 from Q3.
16 – 7 = 9.
This is your IQR.
3-Variance:
The variance is defined as the average of the squared deviation of
observations away from their mean in a set of observations. It represents
a squared value (so it has no units mostly, as it is not accustomed to use
meter2 for length square as a measurement).
The variance is obtained simply through this data, suppose we have five
persons with their haemoglobin level (g/dl) measurements (8, 9, 10, 11,
12). The mean value can be obtained simply by summation of all
observations and divided by 5 (mean=x/n) =50/5=10 g/dl, then we are
going to obtain the difference (deviation) of each value away from its
mean (d), then summation of these deviations (d) to obtain the average
of deviations from mean by divide the sum of deviations by the number
of deviations (d/n).
But it is found that d always equals to zero (as the mean is the average
or center of set of data and all the data spread around it equally in both
directions whether higher than its value or lower than its value). So to get
rid of this problem we are going to square the value (d2) of differences
(deviations) to get rid of the signs (+ or -), and then sum the squared
deviations (d2) and then divide it by the number of observations to
obtain (d2/n) which will
show us that in such example only 4 out of 5 values have actual deviation
(in fact one of the values have no deviation from the mean value d=0, in
fact it is the mean itself, so it have no deviation or squared deviation) so
we will divide the (d2) by (n-1) value (which is called the degree of
freedom “d.f.”) so we obtain the variance value (d2/n-1);
Haemoglobin Difference, d2 X2
level (g/dL) deviation
D=(X-X)2
d=(X-X)
8 8-10= -2 4 64
9 9-10= -1 1 81
10 10-10=0 0 100
11 11-10=+1 1 121
12 12-10=+2 4 144
x=50 d= d2= x2=510

(X-X)=0 (X-X)2=10
X=x/n = 50/5=10 g/dL

Variance (S2)= d2/(n-1) = 10/(5-1)=10/4=2.5
Another more simple equation can be derived from;
d2=(X-X) d2= x2 - (x)2/n
d2 x2-(x)2/n
Variance (S2) = -------- = -----------------
n-1 n-1
= 510-502/5
------------- = 2.5
4
3-Standard deviation:
The SD is defined as the squared root of the variance, or it can be
defined as the average of the deviation of observations away from their
mean in a set of observations. It is the measure that is accustomed and
widely used in biostatistics as a measure of variability. If the value of SD
is high it means a large variation the data posses, and if it is of small
value it mean a less variation the data posses.
3-Stratified random sampling:

This type of sampling is used when we have a population composed of
quite different strata or distinct subgroups. As if we have a population
composed of males and females, the selection of a sample that does not
respect these distinct subgroups will give us a sample that may be totally
composed of males or of females or of different percentages of males and
females as that of the population.
So we use stratified random sampling, in which we divide the population
according to these subgroups and then we select by simple random
sampling from each subgroup the required number by probability
proportional to size, and by this method we select a sample that the
percentage of males and females are the same of that in the population.
4-Multi-stage random sampling:
When we have a large population extended over a large geographical
area, it is better to carry a multi-stage random sample. By this method we
select stage by stage and in each stage the selection is done by simple
random sampling with (probability proportional to size), e.g. to take a
sample from the population for studying the vaccination coverage in
children across Iraq, and 25% of population want to be selected as
sample,
so we select stage by stage, governorate, town, districts, sections, streets,
and finally the houses from the selected streets and in each stage we
select by simple random sample with (probability proportional to size).
5-Cluster random sampling:
This type of sampling is the same as multi-stage random sampling but it
is used when we have a very little extra cost, effort, manpower, so we can
investigate or choose the whole last stage rather than only taking a sample
of them. The last stage is referred to as cluster.
Sampling error:
When repeated samples from the same population are taken, the
results obtained from one sample will differ to some extent from the
results of another sample because the data obtained is from a sample
rather than the whole population, this variation is called sampling error.
The causes of sampling error due to samples variation:
a- Sample size (the larger is the sample the less is the error).
b- Natural variation of individual readings.
The causes of sampling error not due to samples variation:
a- Inadequately calibrated instrument.
b- Observer variation.
c- Incomplete coverage achieved in examining subjects seleced.
d- Conceptual errors.
Standardization:
Each examiner should diagnoze the condition by the same way on
every occasion by using the same criteria. The repeatability of a
diagnostic method is measured by carrying the examination on two
occasions and then comparing the results (test – retest).
Reproducibility:
When an examiner satisfy himself by being able to reproduce the same
diagnosis of the same condition on an another occasion this is called
reproducibility: This is done before commencing a study by examining a
group of individuals on two occasions separated by short interval of time
(re- examining, say 10% of the individuals of a sample).
Calibration:
An exercise that measures intra- examiner and inter- examiner
variability. This is done to examine the standardization and
reproducibility during a study and when the study takes a long time.
These exercises should be repeated at intervals to ensure that they
continue to diagnoze the same diagnosis in the same manner.
Intra-examiner: one examiner
Inter examiner: more than one examiner
Data Summarization
Presentation of Data
Data collected and complied from different types of epidemiological
studies are raw data. These are unsorted and are not much helpful for
understanding the underlying trends or its meaning. So, the next step after
data collection is to sort and classify the data into characteristic groups or
classes like, according to age, sex, social class, number of DMFT, etc.
The objective of classification of data is to make the data simple, concise,
meaningful, interesting and helpful in further analysis.
There are two main methods of presenting data:
1. Tabulation
2. Diagrams
1. Tabulation:
Benefits of the presentation of data by using tables are:
1. They represent data in an orderly and summary fashion
2. They serve as points of reference checking for the discussion and
conclusion of the reports
3. They get quick grasp of the findings reported in the articles
The data can be classified mostly into qualitative and quantitative data.
The two elements of the classification are the variable and the frequency.
The frequency is the number of units belonging to each group of the
variable. A most common way of presenting data in the tables is known
as frequency distribution table.
The basic rules have to be followed while forming a frequency

distribution tables are :
1. Every table should contain a title as to what is depicted in the table
2. Each row and column should be clearly defined with the headings
for each row and column
3. Units of measurements should be specified
4. If the data is not original, the source of the data should be
mentioned at the bottom of the table
5. All the above principles aim to make the table self-explanatory as
far as possible.
Example
Distribution of study group according to gender, age
Study group Number Percentage

categories %
Male 87 50.9
Gender
Female 84 49.1
30-39 years 17 9.9
40-49 years 29 17.0

Age category
50-59 years 64 37.4
60-69 years 61 35.7
Presentation of Data
2. Diagrams:
By arranging the data into tables, we simplify the entire mass of the
data, but sometimes it is difficult to understand and compare two or
more tables. Diagrams and graphs are one of the most convincing and
appealing ways of depicting statistical results, they are extremely
useful because they are attractive to the eyes, give a bird eye view of
the entire data, have a last impression on the mind of the layman and
they facilitate comparison of the relating to different time periods and
regions.
The basic rules in the construction of diagrams and graphs are:
1. Every diagram must be given a title that is self-explanatory
2. It should be simple and consistent with the data
3. Usually, the values of the variables are presented on the horizontal
or X-axis and the frequency on the vertical line or Y-axis
4. The number of the lines drawn in any diagram should not be many
so that it does not look clumsy
5. The scale of presentation for the X and Y axises should be
mentioned at the right hand top corner of the graph
Types of diagrams:
Depending on the nature of the data, whether it is qualitative or
quantitative, the following diagrams may be chose:
1. Bar diagram: This diagram is use to represent qualitative data.
Each bar represents only one variable, the bars can be either
vertical or horizontal
Figure 1: The distribution of 600 extracted teeth in college of

dentistry clinics according to the cause of extraction
Figure 2: The Percentage of 600 extracted teeth in college of
dentistry clinics according to the cause of extraction
2. Multiple bar: this diagram is used to compare qualitative data

with respect to a single variable, like gender wise or with respect to
time or region. This diagram is similar to the bar diagram except
that for each category of the variable we have a set of bars of the
same width corresponding to the different sections without any gap
between the width and the length corresponds to the frequency.
3. Proportional bar diagram: this diagram is use to represent
qualitative data. When it is desired to compare only the proportion
of subgroups between different major groups of observations, then
bares are drawn for each group with the same length (either as 1 or
100%), these are then divided according to the subgroup proportion
in each major group.
4. Pie diagram: these are popularly use to show percentage

breakdowns for qualitative data. It called so because the entire
graph looks like a pie and its components represent slice cut from a
pie. A circle divided into different sectors corresponding to the
frequencies of the variables in the distribution. The sectors are
drawn in the circle are shaded with different shades or colors and
an index is provided for these shade colors.
Figure 3: The distribution of 600 extracted teeth in college of
dentistry clinics according to the cause of extraction presented by
number and percentage
5. Line diagram: this diagram is useful to study changes of values in

the variable over time. On the axis X, the time such as hours, days,
weeks, months or years are represented and the value of any
quantity pertaining to this represented along the axis-Y.
6. Histogram: this diagram is used to depict quantitative data of
continuous type. A histogram is a bar diagram without gap between
the bars. It representsthe frequency distribution. The histogram is
constructed as follows. On the X-axis, class interval is marked and
on the Y-axis, the frequencies is marked. A rectangle is drawn
above each class interval with height proportional to the frequency
of that interval.
Figure 4: The haemoglobin level in g/dL for 70 females attending

clinic in college of dentistry/Al-Mustansiriya university
7. Cartograms or spot map: These maps are used to show
geographical distribution of frequencies of characteristic.
Figure 6: (a) Dental caries levels (DMFT) of 12-year-olds worldwide.

(b) Dental caries levels (DMFT) of 35–44-year-olds worldwide in
(2003)
COMMUNITY DENTISTRY
lec:1 ‫مها العاني‬.‫د‬
Infection control
Introduction
Healthcare associated infections are caused by a wide variety of organisms
and cause a range of symptoms from minor discomfort to serious disability
and in some cases death. Standard Precautions must be applied by all
healthcare staff at all times in healthcare settings, regardless of whether a
patient’s infectious status is confirmed, suspected or presumed.
Infectious disease occur as a result of invasion of micro- organisms in

to living system, or due to the actions of the products of micro- organisms
or a combination of both.
Micro-organisms that may responsible for disease in a human host are:
• Bacteria, Viruses, Fungi and Protozoa.
Concepts of disease transmission:
Virulence •
• is the ability of an agent (micro-organisms) to cause disease after it
has invaded the host
Invasion
• Is the process in which micro-organisms enter the host cell?
Infection, is the multiplication of an infectious agent (micro-
organisms) with in the host
Infection
• is the multiplication of an infectious agent(micro-organisms) with
in the host
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The acquisition means of pathogens

1-Direct contact—> skin to skin or skin to mucous membranes
2-Air born mechanisms—► inhalation of pathogens.
3-Indirect contact —^droplets or body secretions
4-Vehicle borne mechanisms —> contaminated food, water, drugs .
5-Vectors —> animals or insects.
Transmission of infectious diseases:

A-Transmission of infection from infected patients to dental health care
workers.
B-Transmission of infection from infected workers to the general public.
C-Transmission of infection from infected patient to another.
The chain of infection:

Number of micro-organism
Virulence.
Susceptible host
Portal of entry.
The common infectious condition:
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COMMUNITY DENTISTRY
Dental patient and Dental Health Care Workers (DHCW) may be exposed
to a variety of micro-organisms via blood or oral or respiratory secretions
including:
 Viral Hepatitis ► hepatitis B&C are the more prevalent to dental

health workers.
 Herpes virus infections► herpes simplex virus is the more
prevalent to dental health workers.
 Syphilis.
 Acquired Immune Deficiency Syndrome (AIDS) ►caused by
human immunodeficiency virus (HIV).
 Tuberculosis (TB)^ caused by bacteria (Mycobacterium
tuberculosis).
 Upper respiratory tract infections.
Control of infection control

The effective procedures of infection control are designed to kill or to
protect against contamination (micro-organism shared between people) by
using the proper equipment and supplies.
Basic infection control procedures or later renamed by the Centers for

Disease Control (CDC) as the Universal Precautions
1.Personal barrier techniques:
(a)Hand washing
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B-Gloves
 Protect the dental team members from direct contact with patient
microbes.
 Protect patients from contact with microbes on the hands of the
dental team members.
Gloves should be:
1. Changed between patients and are not to be washed with detergents
at any time.
2. Tom or punctured gloves should be removed as soon as possible.
c-Masks. Facemasks should be worn to—►
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COMMUNITY DENTISTRY
 Prevent spatter from patients' mouths or splashes of contaminated

solutions and chemicals from contacting the
 mucous membranes of the mouth and nose, (whenever there is

 Risk of aerosolizing, spraying, spattering, or splashing of patients'
oral fluids or chemicals used at chair side or in other parts of the
office).
 The reduction in the inhalation of airborne particles.
Face masks should be:
 Provide a minimum filtration particles and should have the ability to
block aerosols as well as larger particles of blood, saliva and oral
debris.
 Changed once per hour or between each patient contact.
 The outside of the mask should not be touched as it significantly
decreases the filtration quality of the mask.
 Masks should be properly disposed off after each use and not left
hanging around the neck.
D- Eye wear
The eyes due to limited vascularity and lower immune abilities are
susceptible to macroscopic and microscopic injury. Protective eyewear
should be worn by all dental personnel involved in treatment in the form of
glasses and/or face shield to prevent trauma to the eye tissue from flying
droplets or aerosols.
Dental personnel are at ocular risk from the herpes simplex virus and
hepatitis B may develop after the initial contamination of eye tissue.
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Protective eyewear should be available to the patients as well as the ►

dental personnel. The supine position 'renders the patient susceptible
to falling objects in the head and neck area.
►
All protective eyewear should be cleansed after every appointment. ►

Eyewear should be washed with soap first, then rinsed with water and
a surface disinfectant can be used later.
E-Protective clothing
Protective clothing is the outer layer or covering of garments that would
first be contacted by the contaminating droplets, generating sprays,
splatter, splashes or spills of body fluids, contaminated solutions or
chemicals
This protection can be provided by high neck, long sleeve, knee length
garments.
The garment should be worn only in the dental environment and should
be changed at the end of the treatment schedule, also it should be
changed immediately if soaked or spattered with blood or other
contaminants.
All protective clothes should be water proof
2. Immunization
All dental health care workers should be immunized by taken a vaccine
against the most prevalent infectious disease because they are at risk of
infection.
Medical history of patient
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COMMUNITY DENTISTRY
Complete screening of patient medical history must be taken
4. Protection against aerosols and spatter

Reduces the number of microbes contaminating the dental team by
reducing the amount of spray and spatter that exit patient's mouths during
care, by using the personal barrier techniques.
1-The use of rubber dam.
High volume evacuation.

low volume saliva ejection.
Patients rinsing their mouths with an antimicrobial
mouth rinse just before care (pre procedure mouth
rinsing) has shown to reduce the number of bacteria
that exit the mouth in the form of aerosols and spatter
during operative procedures.
(3) Instrument processing (sterilization of instruments)
Instrument processing involves:
1-Presoaking and cleaning
Presoaking of contaminated instruments keeps them wet until a thorough
cleaning can occur. This procedure prevents blood and saliva from
drying on the instruments and facilitates cleaning of instrument which is
achieved by;
Hand scrubbing of contaminated instruments, but this may increases
chances of exposure to body fluids through cuts and punctures.
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COMMUNITY DENTISTRY
Ultrasonic cleaning is a mechanical cleaning system that reduces handling of

contaminated instruments and has been shown to be effective in removing
dried blood and saliva. A cleaning solution manufactured for use in
ultrasonic cleaners should be used and changed at least daily, protecting
one’s self against splashing and direct contact with this contaminated
solution. Usually 2-20 mins. Is needed to clean instruments ultrasonically.
2-Packaging
After cleaned instruments have been rinsed and dried, they are to be
packaged in functional sets before sterilization. This packaging protects the
instruments from becoming contaminated after sterilization and before use
at chair side. A lot of packaging materials are available, with self-sealing,
paper- plastic, peel pouches being the most convenient cassettes that hold
instruments at chair side during ultrasonic cleaning, packaging and
sterilization.
3-Sterilization
Sterilization: It is a process of removing or killing all viable micro-
organism including substaintial No. of resistant bacterial spores using
physical &chemical procedure.
Disinfection: It is a process of removing or killing most, but not

all, viable organism (e.g bacterial spores) using physical &chemical
procedure.
1. Heat sterilization:
 Sterilization must be performed correctly to ensure that processed
instruments are safe for patient care. All items within sterilizer must
be exposed to the proper temperature. It is important that the
sterilizing agent (e.g. steam, unsaturated chemical vapor, dry heat)
gains sufficient access to the items being sterilized within the set
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COMMUNITY DENTISTRY
cycle time. This is why the instruments must be cleaned up to remove

debris that could insulate the underlying microbes. It is important to
fill up the water or chemical reservoirs so that enough steam or
chemical vapor can be generated.
 The common heat sterilization methods available for dental office
 Steam sterilization (Autoclave) 20-30 min. at 121°C and 2-10 min. at
134°C.
 Unsaturated chemical vapor 20 min, at 134°C.
Dry heat (oven type) 1-2 hrs. at 160rtC.

 Dry heat (rapid heat transfer type) 6-12 min. at 191 °C .
2-Chemical sterilization A few plastic reusable items must be
sterilized including:
1. Rubber dam frames.
2. X-ray positioning rings.
3. Rulers, and orthodontic de banding guns.
Because these items may melt in heat sterilizers thus, the dental office
must resort to use of a liquid sterilant at room temperature for
processing these heat labile items. This involves use of one of the
several products consisting of 2.0%-3.2% solution of glutaraldehyde
for a contact time of 10 hours
4-Drying, cooling, storage and distribution of instruments

•Drying—» Instrument packages sterilized in steam become wet and
must be allowed to dry before handling so that the packages do not
tear.
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COMMUNITY DENTISTRY
• Cooling —►of warm packages must be done slowly to avoid

formation of condensation on the instruments. Using fans to cool
down items should also be avoided as, it causes undue circulation
of potentially contaminated air around the packs.
• Storage—> sterile instrument packages are stored in a cool, dry,
protected area, up off the floor, a few inches away from the walls
and ceilings and away from sinks, heat sources, and overhead
pipes.
• Radiographic asepsis •For operator A convenient way to prevent
spread of contamination on film packs is to use plastic disposable
covers on the packs before they are placed into the patient's mouths.
When the covers are subsequently removed and discarded, the film
packs are free of contamination, and can be handled without gloves,
or use gloves.
•For patient Simply using plastic barrier material on the portions of cone
and tube head and on the exposure switch will reduce the cross
contamination between patients.
(5) Use of disposables For patients
Using of disposable items to prevent patient-to-patient cross-contamination
Numerous disposable items are available in dentistry which include :
Gloves, masks, gowns, surface covers, patient bibs, saliva ejector tips, air
water syringe tips, high volume evacuator tips, prophylaxis angles,
prophylaxis cups, some instruments, impression trays, fluoride gel trays and
high speed hand pieces.
Asepsis of Operatory Surfaces

It is essential to maintain a "disinfected environment" within the working
area. There are two general approaches to surface asepsis:
10
COMMUNITY DENTISTRY
1. To clean and disinfect contaminated surfaces.

2. To prevent the surface from becoming contaminated by the use of
surface covers.
Environmental cleaning contaminated worktops must be disinfected
between patients. The surgery (dental chair•, dental unity worktops and
floors) must be thoroughly cleaned at least every day and more frequently if
thei'e is obvious contamination. All cleaning agents must be used in
accordance with the manufacturer’s instructions applied to the
contaminated surface either by spraying or by using a saturated pad.
Active agents in disinfectant products include hypochlorite, iodophor, water
based synthetic phenol , alcohol based synthetic phenolics and alcohol
based quartemary ammonium compounds. Any such products can provide
surface asepsis when used properly.
the simplest and the most cost effective method of protecting the delivery
system is perhaps through the use of barrier materials, such as plastic food
wrap, plastic bags, aluminium foil or custom made barrier covers should be
discarded and replaced after completion of each patient.
Dental patient chair
The dental patient chair should be smooth. with a minimum of accessories.
All chair functions should be controlled from a foot switch to avoid
contamination of hand operated switches.
The head rests should be covered by disposable covers and the underside of
chair arms should be properly cleaned and disinfected.
Common switches in the chair have a number of cracks and crevices to
harbor micro-organisms. These switches _should be covered by a clear
plastic.
Dental operator stool
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COMMUNITY DENTISTRY
Covermg the. lever with plastic barrier material will control cross-
contamination
Care should be taken that the operator does not touch the seat covering with
contaminated hands.
Cleaning and disinfecting porous seat covering may be done with soap and
water.
Cabinetry
All support cabinetry should be made from materials that can With stand
repeated cleaning and disinfection. The sinks should be of stainless steel or
porcelain
(a)Major utility systems
Air^ The dental treatment room should be properly air conditioned and
should have excellent air circulation with an exhaust to the outside Water—
> Purifying measures for water systems include use of a water sediment
filter and softening and/or de ionization of incoming water supply.
The suction apparatus-^ The sediment trap on the incoming tube is a real
source of contamination for the staff. The trap should be placed in a well
lighted and accessible area and cleaned daily.
The air compressor^ intake filter must be placed in a clean, cool and dry
area.
Tubing and hoses

Bacteria form a biofilm that coat the Inside of these tubes enter the
flowing water inside the tubes and exit through the hand piece or air
water syringe, which could be reduced by:
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COMMUNITY DENTISTRY
• activating the control unit to flush water through the dental unit water
lines. •Bacterial filters can be placed into the waterline of the hand piece
and air water syringes.
•The tubing should be preferably straight, not coiled; smooth on the outer
surface, free of grooves and made of non-absorbent materials.
Hand pieces and hand instrument
All instruments and items that are used in the mouth must be heat sterilized
between patient sessions. Included in this are hand pieces, ultrasonic and
sonic scalars, curing light tips, matrix retainers, cutting, finishing and
polishing instruments.
All dental hand pieces should be heat/pressure sterllizable which should be
thoroughly scrubbed with soap and water, rinsed and all traces of water
removed from the internal and external parts before lubrication and
sterilization.
Hand instruments should also be properly sterilized. Dry heat or chemical
vapor pressure sterilization is normally the most practical method for these
items. Caution must be exercised, to ensure that the items are dry before
sterilization to prevent corrosion.
Healthcare Risk Waste Management
Healthcare risk waste is categorized as waste contaminated with body
fluids, items soiled with blood and saliva, and other infectious waste. It
must be handled and disposed of safely in order to protect human health
and the environment. Items listed as clinical waste include:
•Patients’ cups-
•Cotton wool rolls-
•Gloves-
•Patient bibs.
13
COMMUNITY DENTISTRY
•Tray paper-
• Plastic saliva ejectors.
• Masks
•Used rubber dam- •Tissues used in treatment-
Contaminated sharps (Needles/disposable syringes).
14
COMMUNITY DENTISTRY
Lec: 2 Forensic dentistry ‫مها العاني‬.‫د‬
Forensic dentistry or forensic odontology:
It is the proper handling, examination and evaluation of dental

evidence, which will be then presented in the interest of justice.
Forensic odontology is derived from Latin, meaning a forum or
where legal matters are discussed.
It is the identification discipline based upon the recognition of
unique features present in each person's dental structures.
It comes into use when identification by the use of skin (ex:
fingerprints) is not possible.
Most forensic dentists are board certified and members of
professional organizations.
Forensic dentistry relies on the detailed knowledge of the teeth
and jaws possessed by a dentist.
This skill incorporates an education in dental anatomy,
radiographs and their interpretation, pathology, dental materials,
and developmental anomalies & others.
Forensic identification plays a major role in man-made or natural
disaster.
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COMMUNITY DENTISTRY
Dental identification of humans occurs for a number of different
reasons:
The bodies of victims of violent crimes, fires, and motor vehicle
accidents.
1. Persons who have been deceased for some time prior
to discovery,
2. Those found in water, can be disfigured to such an
extent that identification through conventional
methods are difficult.
In the case of forensic dentistry, experts (forensic dentists)

can use dental records for:
I. Identification of found human remains.
II. Identification the suspect through the assessment of bite mark

injuries in cases of abuse in (child, spousal, elder) and in
women during sexual attacks.
Identification of found human remains:
It is done by using dental records.
2
COMMUNITY DENTISTRY
The principle of dental identification is that postmortem
dental remains can be compared with antemortem dental
records, including:
> written notes,
> study casts,
> radiographs,
> photographs etc, to confirm identity.
Explainable discrepancies
It is normally relate to the time elapsed between the antemortem
& postmortem records.
Ex: it includes the teeth extracted or restorations placed were

found in postmortem records.
Unexplainable discrepancy:
Ex: a tooth is not present on the antemortem record but is present

on the postmortem record then exclusion must be made. If there
are no antemortem dental records, a postmortem dental profile
will provide information on the victim's:
1) Age:
2) Race.
3) Gender.
3
COMMUNITY DENTISTRY
4) Socio-economic status.
5) Occupation, dietary habits & dental or systemic disease.
1-Age:
In children:
The patterns of tooth eruption, the root length, tooth wear were
assessed.
In young adults:
The third molar development.
In middle-aged and older adults:

Periodontal disease progression, excessive wear, multiple
restorations, extractions, bone pathosis and complex restorative
work were assessed.
2- Race:
It can be assessed fwm
■ Skull shape and form.
■ Gusps of Carabelli,
■ Shovel-shaped incisors,
■ Multi-cusped premolars.
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COMMUNITY DENTISTRY
3- Gender:
It can be assessed from
Skull shape and form, (no gender differences regarding
teeth morphology), Presence or absence of Y-chromatin
in teeth, DNA analysis, Mandibular canine's size.
4- Socio-economic status:
It can be assessed from
quality, quantity and presence or absence of dental treatment. .
5- Occupation, dietary habits and dental or systemic diseases.
■ The presence of erosion can suggest alcohol or an eating
disorder while stains can indicate smoking, tetracycline.
■ Unusual wear patterns may result from pipe stems, cigarette

holders.
II- Identification the suspect through the assessment of bite

mark injuries in cases of abuse in (child, spousal, elder) and
in women during sexual attacks.
5
COMMUNITY DENTISTRY
Bite marks can be found on:
• The victim (by the attacker),
• The attacker (suspect) when a victim attempts to

defend himself,
• An object found at the crime scene
Typical presentation of bitemark injuries:

 Human bite-marks may be found on almost all parts of the
human body skin.
 In defensive circumstances, the arms and hands are

often bitten.
 The injuries caused by teeth can range from bruises to scrapes
and cuts or lacerations.
It is possible to identify specific types of teeth by

their class characteristics:
□Ex: incisors produce rectangular injuries and canines

produce triangular injuries.
□Other characteristics include fractures, rotations, attritional
6
COMMUNITY DENTISTRY
wear, congenital malformations, etc.
□When these are recorded in the injury it may be possible to

compare them to identify the specific teeth (person) that
caused the injury.
Evidence collection from the bite victim
□Dentists should be familiar with the general principles of

evidence collection.
1. Documentation:
□Make a descriptive record of the injury, including the

physical appearance, color, size and orientation of the injury,
location on the body, relative contour and elasticity of the
site, and types of injuries.
2. Photographs:
□Take photographs, either color or black-and-white films.
□A reference scale (ruler) should be placed in the same

plane as the injury and visible in the photographs to enable
subsequent measurements.
3. Impression:
7
COMMUNITY DENTISTRY
□Fabricate an impression of the bitten surface to record any
irregularities produced by the teeth.
4. Saliva swab:
1. Saliva will have been deposited on the skin during

biting and this should be collected and analyzed.
2. A buccal swab or a sample of whole blood must be

collected from the victim at this time to assess the victim's
DNA.
Evidence collection from the bite suspect:
The following evidences are recovered during examination

of the bite-mark suspect:
1-Clinical examination : The extra & intra-oral

structures are examined & noted on a dental chart.
Special attention is focused on the status of the dental health,

occlusion & mandibular articulation, tooth mobility, periodontal
pocketing, dental restorations, diastemata, fractures, caries, etc.,
& the function of masticatory muscles.
2. Photographs:
Full facial & profile photographs are produced in addition
8
COMMUNITY DENTISTRY
to frontal & lateral views of the teeth in occlusion.
3. Impressions:
It is necessary to produce extremely accurate study casts of the
teeth that record all characteristics of the dentition.
4. Bite sample
A sample of the suspect's bite is recorded in centric occlusion
using a wax.
5. Salivary sample: it is also taken for DNA testing.

**Forensic physical and biological techniques for comparison:
1. The suspect's study casts with the actual or photographs of

the bitemark,
The suspect's teeth pattern of dental cast using tracing with

photographs of the bitemark
2. The suspect's test bites with the actual bitemark.
The conclusions are often based on the expert's level of personal

experience.
Factors that may affect the accuracy of bite mark

identification include:
9
COMMUNITY DENTISTRY
1) Time-dependent changes of the bite mark on living
bodies,
2) Effects of where the bite mark was found,
3) Damage on soft tissue,
4) Similarities in dentition among individuals,
5) Poor in techniques,
ex: photography & impressions.
The dental profiles of the suspect are subject to change any
time. For example:
1. Loss of teeth.
2. Teeth attack by dental caries.
So, the suspect's DNA profile obtained from saliva or blood with
salivary DNA surrounding the bite-mark area proves to be a more
reliable form of identification.
* Dentist not only improves health by doing treatment in private
clinic or preventive program in a community, but also plays a
major role in justice achievement.
Even if the dentist cannot match the available evidence,
to someone's existing dental records, the dentist can
provide important clues to identity which may help the
investigators.
For example,
10
COMMUNITY DENTISTRY
The dentist can make estimates about age, socioeconomic class
and history based on examination of the teeth.
By collating this evidence with evidence from other forensic
examiners investigators can narrow down the identity
possibilities
11
Community dentistry
12
LEC : 3 Community ‫ مها العاني‬.‫د‬
Dental Manpower
Manpower Is the total number of people

who can work to get something done.
Manpower The number of people working or
available for work or service. All the people who are
available to do a particular job or to work in a
particular place.
Manpower surplus: there are more people than
available jobs.
Manpower deficit: available people are fewer than
jobs.
Dental Manpower
A dentist is a person licensed to practice dentistry
under the law of the appropriate state province
territory or nation.
Dentist are concerned with the prevention and control
of diseases of the oral cavity and the treatment of
unfavorable conditions resulting from these diseases,
from trauma or from inherent malformations.
1
Manpower planning
The process by which an organisation ensures that it
has the right number of people and the right kind of
people at the right place at the right time, doing
things for which they are economically most useful.
Dental manpower planning
The process of estimating the number of persons and the
kind of knowledge and skills they need to achieve
predetermined dental health targets and optimal
improvements in dental health of population
Steps in manpower planning

1. Analysing the current manpower
inventory
2. Making future manpower forecasts
3. Developing employment programmes
4. Design training programmes
1. Analysing the current manpower

inventory- the current manpower status
has to be analysed. For this the following
things have to be noted-
• Type of organization
• Number of departments
• Number and quantity of such
2
departments
• Employees in these work units
2. Making future manpower forecasts-

Once the factors affecting the future
manpower forecasts are known, planning
can be done for the future manpower
requirements in several work units.
3. Developing employment programmes-

Once the current inventory is compared with
future forecasts, the employment
programmes can be framed and developed
accordingly, which will include recruitment,
selection procedures and placement plans.
4. Design training programmes- These will

be based upon extent of diversification,
expansion plans, development
programmes,etc. Training programmes
depend upon the extent of improvement in
technology and advancement to take place. It
3
is also done to improve upon the skills,
capabilities, knowledge of the workers.
4
Dental auxiliaries
Dental auxiliaries: is a person who is
given responsibility by a dentist so
that, he or she can help the dentist in
providing dental care, but who is not
himself or herself qualified with a
dental degree.
a. “Dental auxiliary” means a person who may perform dental
supportive procedures authorized by the provisions of these regulation
under the specified supervision of a licensed dentist.
b. “Dental assistant” means an unlicensed person who may perform
basic supportive dental procedures' specified by these regulations under
the supervision of a licensed dentist.
a. “Registered dental assistant” or “RDA” means a licensed
person who may perform all procedures authorized by the
provisions of these regulations ancj/in addition may perform all
functions which may be performed by a dental assistant under
the designated supervision of a licensed dentist
Registered dental hygienist” or “RDH” means a
licensed person who may perform all
procedures authorized by the provisions
of these regulations and in addition
may perform all functions which may be
performed by a dental assistant and
registered dental assistant, under the
designated supervision of a licensed
dentist.
Registered dental assistant in extended functions” or RDAEF”
means a person licensed as a registered dental assistant who has
completed post licensure clinical and' didactic training appro
ved by the board and satisfactorily performed on an examination

designated by the board for registered dental assistant in extended
function applicants.
Registered dental hygienist in extended functions”
or RDHEF” means a person licensed as a registered
dental hygienist who has completed post licensure
clinical and didactic training approved by the board and
satisfactorily performed on an examination designated
by the board for registered dental hygienist in extended
functions applicants
Classification
Based on the nature of duties they perform auxiliaries can

be classified into two categories:
World Health Organization (WHO) Classification Non-

operating Auxiliary:
a. Clinical: This is a person who assists the professional in his
clinical work but does not carry out any independent
procedures in the oral cavity.
b. Laboratory: This is a person who assists the professional by

carrying out certain technical laboratory procedures.
Operating Auxiliary
According to WHO, this is a person not being a

professional, is permitted to carry out certain treatment
procedures in the mouth under the direction and
supervision of a professional.
Revised Classification
Non-operating
Dental surgery assistant
Dental secretary/receptionist
Dental laboratory technician
Dental health educator

Operating
• School dental nurse
• Dental therapist
• Dental hygienist
• Expanded functions of operating dental

auxiliaries
Types of supervision
In all instances, a dentist assumes responsibility for determining, on the

basis of diagnosis, the specific treatment patients will receive and
which aspects of treatment may be delegated to qualified personnel.
The degree of supervision required to assure that treatment is
appropriate and does not jeopardize the systemic or oral health of the
patient varies with the nature of the procedure and the medical and
dental history of the patient.
Supervision and coordination of treatment by a
dentist are essential to comprehensive oral health care.
Unsupervised practice by allied dental personnel reduces
the quality of oral health care, fails to protect the dental
health of the public and is opposed by the American
Dental Association. The types of supervision are:
Personal Supervision
“Personal Supervision” means the
dentist is personally operating on
a patient and authorizes the dental
auxiliary to aid his/her treatment
by concurrently performing a
supportive procedure.
Direct Supervision
“Direct supervision” means the dentist is in the dental office, personally
diagnoses the condition to be treated, personally
authorizes the procedure(s)/duty(ies), remains in the dental office while
the procedure(s)/duty(ies)are being performed and examines the patient
before his/her dismissal.
Indirect Supervision
“Indirect supervision” means the dentist is in the dental office, personally
diagnoses the condition to be treated, personally authorizes the
procedure(s)/duty(ies),and remains in the dental office while the
procedure(s)/duty(ies) is being performed.
General Supervision
“General Supervision” means the dentist has authorized the

procedure(s) /duty (ies) and suchis being carried out in accordance with
his/her diagnosis and treatment plan.
General supervision is not acceptable to the American Dental

Association because it fails to protect the health of the public. Personal,
_direct, and indirect supervision are appropriate for delegation of
duties to allied dental personnel providing direct patient care. However,
in some states, licensed dental hygienists are permitted to perform
duties, except for intraoral expanded functions, under general
supervision, as delegated by the supervising dentist.
Public Health Supervision
That oversight where a licensed dental hygienist may

provide dental hygiene services, as specified by state law or
regulations, when such services are provided as part of an
organized community program in various public health
settings, as designated by state law, and with general
oversight of such programs by a licensed dentist
designated by the state.
Nonoperation Auxiliaries
Dental Surgery Assistant
Also called as dental assistant. An individual who may or may not have completed an
accredited dental assisting education program and who aids the dentist in providing
patient care services and dental care to patients. The scope of the patient care
functions that may be legally delegated to the dental assistant varies based on the
needs of the dentist, the educational preparation of the dental assistant and state
dental practice acts and regulations. Patient care services are provided under the
supervision of a dentist.
Traditionally, they were given responsibility for the management
of instruments, equipments, materials including the cleaning, sterilizing
and recycling of these waste product.
Dental assistants perform some or all of the following duties:
1. Prepare patients for dental examination and assist the dentist during the examination
2. Asking about the patient’s medical history and taking blood pressure and pulse
3. Helping patients feel comfortable before, during and after dental treatment
4. Sterilize and maintain instruments and equipment
5. Prepare dental instruments and filling materials
6. Educate patients concerning oral hygiene
7. Schedule patient appointments and record dental procedures performed
8. Invoice patients for dental services.
9. Order dental and office supplies
10. Providing patients with instructions for oral care following surgery or other dental
treatment procedures, such as the placement of a restoration (filling)
Serving as an infection control officer, developing infection control protocol and preparing
and sterilizing instruments and equipment
Dental Secretary/Receptionist
This is person who helps the dentist in his secretarial work and
patient reception.
Dental Laboratory Technician/Certified
Dental Technician
An individual who has the skill and knowledge in the

fabrication of dental appliances, prostheses and devices in
accordance with a dentist’s laboratory work authorization.
They are also called as dental mechanic.
Dental Laboratory Technology is both a science
and an art. Since each dental patient’s
needs are different, the duties of a dental
laboratory technician are comprehensive and
varied. Although dental technicians seldom
work directly with patients, except under the
direction of a licensed, dentist, they are
valuable members of the dental care team.
They work directly with dentists by following detailed written instructions and using
impressions (molds) of the patient’s teeth or oral soft tissues to create:
• Full dentures for patients who are missing all of their teeth
• Removable partial dentures or fixed bridges for patients who are missing only one or a few teeth
• Crowns, which are caps for teeth that are designed to restore their original size and shape dental
auxiliary.
• Veneers that enhance the esthetics and function of the patient
• Orthodontic appliances and splints.

Denturists are those dental laboratory technicians who are permitted in
some states in the United States and elsewhere, e.g. Denmark to
fabricate dentures directly for patients without the prescription of a
dentist.
A denturist may perform some or all of the following duties:
 Measure patients5 jaws to determine size and shape of dentures

required
 Make impressions of patient’s teeth, gums and jaws

 Construct dentures or direct other workers to construct
dentures
 Fit and modify new dentures
 Repair dentures
 Reline and rebase dentures
 Fabricate mouth protectors, antisnoring prostheses and

removable prostheses on implants
 May prepare partial dentures.
• Dental Health Educator
This is a person who instructs in the prevention of dental disease. They impart
important information about oral diseases and help educate the community
about how to maintain good oral health how to prevent the occurrence of oral
diseases.
Operating Auxiliaries
School Dental Nurse
This is a person who is permitted to diagnose

dental diseases and to plan and carry out
certain specified preventive and treatment
measures in the treatment of dental diseases in
school children.
The New Zealand school dental nurse plan was established in 1923
(training began in 1921). The stimuli for this program were the presence of
extensive dental diseases in children.
The treatment of children was difficult because of insufficient dentist and the
large distances between communities. The government trained young women
to be known as school dental nurse, who would provide bulk of the treatment
in the school dental service. After a training period of 2 years each nurse was
assigned to a school.
Duties include:
1. Oral examination
2. Prophylaxis
3. Topical fluoride application
4. Administration of local anesthesia
5. Advice on dietary fluoride supplements
6. Cavity preparation and placement of amalgam and silicate fillings in primary and
permanent teeth.
Pulp capping
Extraction of primary teeth only
Classroom and parent-teacher dental health education
Individual patient instruction in tooth brushing and oral

hygiene
Referral of more complex cases to dentist.

Advantages
• Care can be provided to children in areas where no care would otherwise is available.
• Dental nurses are presumed to provide cheaper dental care than dentists.
Disadvantages
• It is thought that recipients do not develop self-responsibility for seeking dental health care.
• Another debatable issue is whether increased availability of less expensive care leads to decreased
quality of care, as dental nurse cannot provide the same quality of care as dentists can.
Dental Therapist
This is a person who is permitted to carry out certain
specified preventive and treatment measures to the
prescription of the supervising dentist including
cavity preparation and restoration of teeth. They are
also called as dental nurse. They may work in public
health service as in United Kingdom or may work under a
dentist in private practice (Australia). Duties are
almost similar to those of the New Zealand school
dental nurse except that they are not allowed to
diagnose and plan dental care.
Duties are almost similar to those of the New Zealand
school dental nurse except that they are not allowed
to diagnose and plan dental care. The supervising
dentist is responsible for determining the degree of
supervision required in each individual case,
according to the capacity and working experience of
the therapist concerned.
Dental Hygienist
Dental Hygienist is an individual who has completed an accredited

dental hygiene education program and an individual who has been
licensed by a state board of dental examiners to provide preventive
care services under the supervision of a dentist. Functions that may
be legally delegated to the dental hygienist are based on the needs of
the dentist, the educational preparation of the dental hygienist and
state dental practice acts and regulations, but always include, at a
minimum, scaling and polishing the teeth.
Dental hvgienists may perform the following tasks:
• Educate and counsel children and adults on dental health, plaque

control, oral hygiene and nutrition
• Patient screening procedures; such as assessment of oral health

conditions, review of the health history, oral cancer screening, head and
neck inspection, dental charting and taking blood pressure and pulse
• Remove deposits and stains from teeth by scaling and root planing
• Give local anesthetic for dental procedures
•
• Assist in the prevention and control of dental caries (decay) and
gum disease
• Select and use appropriate fluoride treatments and polish tooth

restorations.
• Taking and developing dental radiographs (x-rays)
• Make impressions of patient’s mouth for the construction of
study casts and mouth guards
• Apply and remove periodontal packs
• Instruct patients on how to look after their teeth and mouth
after operations
• Assist in the management of periodontal disease
• Teaching patients appropriate oral hygiene strategies to maintain
oral health; (e.g. tooth brushing, flossing and nutritional
counseling)
• Performing documentation and office management activities
• Applying preventive materials to the teeth (e.g. sealants and

fluorides).
Four - Handed Dentistry
Four-handed dentistry is a team concept where highly skilled

individuals work together in an ergonomically designed
environment to improve productivity of the dental team,
improve
the quality of care for dental patients while protecting the

physical well-being of the operating team.
Four-handed dentistry is not simply transferring instruments

from one person to another.
This system of four-handed dentistry is based on the following principles:
1. Positions: The dentist (or hygienist), assistant and patient are seated and positioned
properly.
2. Assistant utilization: The operator uses the skills of competent, full-time chair side
assistant.
3. Treatment organizations: Every aspect of the patient’s treatment is organized and

repetitive tasks simplified to take maximum advantage of the chair side time available.
4. Equipment arrangement: The equipment used is selected carefully and positioned properly
to enable the operating team to use the principles of work simplification and motion
economy.
The two most frequent issues facing dentists are (1) the need to minimize
stress and fatigue and (2) the need to maintain or even increase productivity
without sacrificing the quality of care.
The use of this concept of four-handed dentistry enables the dentist to spend
their time at chair side actually working on the patients more efficiently.
TEAM - Training in expanded auxiliary program provides a framework

where dental students are trained to work and supervise the operating and
non-operating auxiliaries.
COMMUNITY DENTISTRY
lec: 6 Dental Health Education Dr. Maha Alani
Dental Health Education
The scope of dental health is broader than the term implies and it might be more
correct to use the expression "oral health".
Dental health cannot be separated from general health, since oral disease may be a
manifestation of some systemic disorder.
WHO defines health education as "It is concerned with changes in

knowledge, attitude and behavior of people?"
It is a procedure which involves the translation of what is known about health into
desirable individual & community behavior by means of the educational process.
THE OBJECTIVES
The ultimate objective of dental health education activities is to obtain and

maintain optimum oral health status for all individuals throughout life by:
1. Informing people.
2. Motivating people.
3. Guiding into action.
Major problems in developing a positive dental health:
The development of a concept of positive dental health is made difficult by:
1. The chronic, irreversible, cumulative, and prevalent nature of dental

disease. These characteristics contribute to the belief that dental
problems are non-preventable.
COMMUNITY DENTISTRY
2. The un-dramatic nature of most dental diseases.

3. The association of dental treatment with pain, discomfort,
and anxiety.
4. The refuse of many individuals to carry out on a regular.
The Principles of health education:
1) Credibility. It is the degree to which the message to be communicated is

perceived as trustworthy by the receiver.
2) Interest. It is the most important principle of health education. If the health
education topic is of no interest to the people, they will not listen to it.
3) Participation. The health educator should encourage people to participate in
health education programs, to get their acceptance in the program.
4) Known to unknown. Before the health education program starts, the health
educator has to find out how much the people know about that new program.
5) Comprehension. This is the principle that refers to the level of understanding,
and the level of literacy of the people who receives the health education. Words
that are strange or new to the people should not be used.
6) Motivation. It can be defined as "a combination of forces which initiate, direct
and sustain behaviors toward a goal". "It is the fundamental desire for learning
in an individual”.
7) Reinforcement Refers to the repetition needed in health education. It helps
people to understand new ideas better.
8) Learning bydoing. Just by hearing or seeing about new ideas and
practices, it is difficult to follow them. By doing the new practice, the
people understand it better.
9) Soil. Seed & Sewer The audience can be considered as to the soil, the health
facts can be compared to the seeds and the media used can be compared to the
COMMUNITY DENTISTRY
sower. For any health education program to be successful, all the three
elements should be carefully selected.
10) Good human relations. The health educator should be able to
maintain friendly relations with the people.
11) Community Leaders. The leaders can be used to reach the people of the
community. The leaders can also be used to educate the people as they will
have a more friendliness with the people of their community (ex. teacher).
12) Feedback. The health educator can modify the elements of the system (ex:
message) in the light of feedback from his audience.
The educator: He is the ones who send message of health, such as dentist,
teacher or mother.
The learner: He is the ones who receive the message; the audience may be
individual or groups.
The message: It is the information that the educator tries to transmit to the
audience, to influence their behavior.
The media: The methods and materials used for transmitting the message.
The achievement dental health education goals can affected by many

factors, include:
1. Communication barriers, such as language.

2. Geographical barriers, such as people living far from sources of dental care.
3. Physiological barriers, difficulties in hearing, expression.
4. Psychological barriers, emotional disturbance, neurosis, level of
intelligence.
5. Cultural barriers, illiteracy, beliefs, customs, religion, economic & social
class differences.
COMMUNITY DENTISTRY
Principles for planning dental health education programs:
1) Background information:
Epidemiological data, Etiology of the disease, Effective control factors.
2) Define objectives:
3) Target populations:
4) Facilities:
5) Timing:
6) Evaluation of the program:
7) Fallow up.
■ The dentist:
• The dentist is responsible for the over-all planning of the dental health
program; whether he works in a health institution or in private practice, and
in consultation with the health education specialist.
■ Other dental personnel:
• Ex: dental assistants, dental hygienists, and other types of dental auxiliaries.
■ Related health personnel:

• All health personnel, such as physician & nurses, should be aware of dental
health education.
■ The role of the local reader in dental health education:
• Ex: the village headman, the schoolteacher or the political worker.
Approaches to dental health education:

1) Community Approach.
COMMUNITY DENTISTRY
2) Group Approach.
3) Family Approach.
4) Individual Approach.
Types of communication:
One-way communication (Didactic method).
The flow of communication is “one-way” from the communicator to the

audience. Ex: lecture method in the classrooms.
Two-way communication (Socratic Method).
Both the communicator & the audience take part. The process of learning is
active & democratic. It is more likely to influence behavior than one-way
communication
COMMUNITY DENTISTRY
Lec 6:
Community Dentistry
Occupational hazards of dentistry.
In carrying out their professional work, dentists are exposed
to a number of occupational hazards.
These cause the appearance of various illnesses, specific to
the profession, which develop and intensify with years.
In many cases they result in diseases, some of which are
regarded as occupational illnesses.
Dental professionals are at risk for exposure to numerous
biological, chemical, environmental, physical, and
psychological workplace hazards.
Occupational hazard can be defined as a risk to a person
usually arising out of employment. It can also refer to a
work, material, substance, process, or situation that
predisposes, or itself causes accidents or disease, at a work
place.
Major occupational hazards are:
Biological health hazards •
Physical hazards •
Chemical hazards •
Musculoskeletal disorders and diseases of the •
peripheral nervous system
Hearing loss •
1
Radiation exposure •
Stress •
Legal hazards •
Other risks •
Biological Health Hazards •
Dentists are likely to become exposed to biological •
health hazards. These hazards are constituted by
infectious agents of human origin and include prions,
viruses, bacteria and fungi.
All members of the dental team are at risk of exposure to
hepatitis B virus (HBV), hepatitis A virus, hepatitis C,
HIV infection and other types of communicable
infections. It is desirable all the staff be vaccinated
properly against hepatitis B infection because of the risk
of body fluid borne infection.
Several of the common viral agents that can cause hepatitis
have been detected in body fluids including saliva and
blood.
Direct infection, microorganisms can pass into the body,
through a cut on the skin of the hand while performing a
medical examination, as a result of an accidental bite by the
patient during a dental procedure, or through a needle
wound during an anesthetic procedure.
Indirect infection sources include: Aerosols of saliva,
gingival fluid, natural organic dust particles mixed with air
2
and water, and breaking free from dental instruments and
devices.
The following are the main entry points of infection for a
dentist:
-Epidermis of hands, oral epithelium,, nasal epithelium,
epithelium of upper airways, epithelium of bronchial tubes,
epithelium of alveoli, and conjunctival epithelium
Physical Hazards
The dentist and the clinical staff are at risk of
physical injuries during many dental procedures.
Sources of physical injury can include:
---debris from the oral cavity striking the eyes,
cuts from sharp instruments,
---or puncture wounds from needles or other sharp
instruments.
***Such injuries can result in the transmission of serious
infectious disease to the dental worker.
Percutaneous exposure incident (PEI) is a broad descriptive
term that includes needle stick and sharp injuries, as well as
cutaneous and mucous exposures to blood and serum.
The most common of them is from needles and-drilling
instruments such as burs. From the occupational viewpoint,
PEI represents the most efficient method for transmitting
3
blood borne infections between patients and health care
workers.
Occupational injury related to the use of dental curing lights
.and high-speed rotary instruments, injury from splatters and
particles including calculus and flying debris during cavity
preparation.
Eye injuries may occur from:
Projectiles such as bits of calculus during scaling -
procedures
Splatters from body fluids (bacterial and viral aerosols) -
while using high-speed hand pieces.
The intense dental curing light. -
The use of protective eyewear is an important means of
preventing eye injuries
Chemical Hazards
The chemical, environment is one of the most rapidly
expanding components of the work environment because
new chemicals and solutions are being introduced regularly.
Many of these chemicals are among those whose health
effects may not be known and may pose health problems
taking years to manifest.
Hazardous chemical agents used in clinical dentistry include
mercury, powdered natural rubber latex, disinfectants, and
nitrous oxide (N20).
4
By far the most important and most dangerous of these
agents is mercury.
Mercury
Its use in dental amalgam, has the potential for continuous
occupational exposure of a dental practitioner to mercurial
vapor which can be absorbed via the skin and the lungs. The
active component In the mercurial vapor has a particular
..... affinity for brain tissue.
Mercury poisoning can be characterized by tumors of the
face, arms, or legs.
It is advisable to conduct regular mercury vapor level
assessments in clinical settings; receive episodic individual
amalgam blood level tests; and use goggles, water spray,
and suction during the removal of old amalgam restorations.
Latex Hypersensitivity
Latex gloves powder are most often used. The gloves and
the mask form an efficient barrier against most pathogens;
However, they may also be a source of allergies, primarily
in those persons who use rubber products on a regular basis.
The continued use of powdered natural rubber latex (NRL)
gloves and disinfectants has predisposed clinical dental
workers to contact dermatitis and allergic dermatitis
Nitrous Oxide (N20)
5
It has been associated with neurological abnormalities&
number of health problems in healthcare workers
chronically exposed to N20. .
Cyanoacrylate (CA) Toxicity
Cyanoacrylate (CA) and its homologues have a variety of
dental applications as adhesives. The increasing use of CA
in dentistry has raised concerns regarding its potential
toxicity in humans. It manifest as conditions such as
urticaria, contact dermatitis and other dermatoses.
Others
Transient irritative reactions of the eyes and airways have
been observed mostly associated with exposure to volatiles
from resin based materials, X-ray chemicals, and
cleansers, procaine, soaps, eugenol, iodine, formalin,
phenol, and other disinfectants
Musculoskeletal Disorders and Diseases of the Peripheral
Nervous System
The most common injuries reportedly experienced by the
dental health care practitioners are musculoskeletal in
nature. At work, the dentist assumes a strained posture (both
while standing and sitting for long period of time in a fixed
working position), which causes an overstress of the spine
and limbs.
The overstress negatively affects the musculoskeletal system
and the peripheral nervous system, it affects the peripheral
6
nerves of the upper limbs and neck nerve roots. The posture
of the dentist at work, with the neck bent and twisted, an
arm abducted, repetitive and precise movements of the hand,
are a frequent cause of the neckache and pain within the
shoulder and upper extremities and lower backache. Carpal
tunnel syndrome is also seen in dental professionals due to
the vibrations of hand instruments.
Operations carried out during extractions stress not only the
elbow joint and the wrist joint but may result in chronic
tendon sheath inflammation. The long-term effect of all
those adverse circumstances occurring in the work of the
dentist may lead to diseases described as cumulative trauma
disorders.
Hearing Loss
The noise of suctions, saliva ejectors, turbines, engines,
amalgamators, compressors, etc. may causes impaired
hearing. The noise levels of modern dental equipments have
now generally fallen below 85 dB (A)
Radiation Exposure
Exposure to both ionizing and nonionizing radiation may
occur in dental practice.
The effect of low levels of exposure to ionizing radiation
over periods of time may accumulate and could represent a
potential hazard to health. Radiation effects are generally
categorized as somatic and genetic. Somatic effects appear
within time depending on the dose received and its duration.
7
Genetic effects are also a cause for concern at the lower
doses used in dental radiology.
Dental staff should take steps to protect themselves during
exposure by standing behind protective barrier, use of
radiation monitoring badges and regular equipment checks
and maintenance.
Nonionizing radiations; the use of ultraviolet and blue light
to cure or polymerize various dental materials such as
composite resins, sealants and bonding agents can cause
damage to the eyes, so the use of protective shields and
glasses are recommended.
Stress
Stress is the most common psychological condition that
occurs in the dental profession. Stress situations form an
inherent part of a dentist's everyday work.
Many clinical situations are the source of stress to a dentist
and these include, procedures connected with
anesthetization of patients, overcoming of pain and fear,
unexpected emergency situations in which a patient's health
or life is in danger, or procedures with uncertain prognosis.
Other factors, such as the necessity to keep a proper
professional standard and to achieve technical perfection,
causing pain or fear in patients, late arrivals by patients,
having to do cooperation with patients, are some of the very
important sources of stress in everyday dental practice.
8
Legal Hazards
In every country there are relevant statutes and regulations
which apply to the practice of dentistry.
The contravention of any of these may warrant that legal
actions be brought against a dental practitioner particularly
in developed countries where the citizens appear more
aware of their rights. To help assure a safe work
environment in dental treatment, the hazard awareness and
prevention of legal risks should be made.
Other Risks
Mild neuropathy among dental professionals has been
shown to be associated with high frequency vibrations from
dental equipment's, particularly high and low speed hand
pieces and ultrasonic scalers.
Prevention of Occupational Hazards in dentistry:
Health risks in dentistry may arise as new technologies and
materials are developed. However, once identified and
recognized as risk, new guidelines and precautions are
instituted to greatly reduce or even eliminate the
occupational hazard.
Education
is one of the important strategies for the prevention of
occupational injuries and diseases. In any occupation ,
workers should understand any possible negative health
implications of their jobs and how to minimize them.
9
Infection control and proper handling of potentially -
infected materials & barrier techniques include gloves,
masks, protective eye wear, high power suction and
good ventilation to reduce aerosols and vapor dangers.
-Hypoallergenic nonlatex gloves are proposed to deal with
latex allergy.
-Prevent radiation hazard: Lead aprons, periodic
maintenance of the X-ray machine, Modern equipment ,fast
film ,lead-lined collimators, and radiation level sensors.
-Sitting in correct posture during work practice
Physical exercise:
A-Athletic activity helps to counteract some of the
physically limiting of dental practice.
B-Frequent breaks should be taken when the dentist can
stand, move around and perform stretching exercise of his
spinal column.
C-Optimizing room ventilation and using special air
conditioning filters in the working environment may be
useful in minimizing the toxicity of volatile chemicals.
Noise control.
10

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Community dentistry Dr.

3.The Federation Dental International Numbering System (FDI).

Ideal properties of an index:

Uses of dental indices:

1. To provide data for epidemiological studies by studying prevalence,

2. To study and compare oral health status of individuals and population

A- Depending on the direction in which their scores can fluctuate:

1. Irreversible index …………….. DMF

2. Reversible index ……………… GI

3. Composite index ……………… PDI

B- Depending on the extent to which areas of oral cavity are measured:

1. Full mouth index ……………… Dean's Fluorosis Index

These indices measure the patient's entire dentition.

2. Simplified index ……..………… CSI

These indices measure only a representative sample of teeth.

C- Depending on the entity which they measured for:

1. Disease index …………………. D M F

2. Treatment index ……………… D M F

3. Symptom index ……………….. PBI

There are three types of scales:

1. Ordinal scale: It is a scale of measurement that lists conditions in some

2. A nominal scale is even less rigidly defined; it simply gives names to

3. An interval or a ratio scale is one in which the numbers used in the

Indices used for dental caries assessment

-Permanent teeth index:

Minimum score = Zero

*Primary teeth index:

DENTAL CARIES SEVERITY CLASSIFICATION SCALE

(R-D) is no. of root surfaces with decay.

lesion and third molars should be excluded and there is no

0.1 - 1 Mild gingivitis

1-Gingival and periodontal component.

1-The criteria ranged from

2-All areas (M, D, B, L) is scored as a one unit.

*Community Periodontal Index of Treatment Needs

The epidemiological sequence:

3- Proportion: proportion is a rate which indicate the relation in

 Example: hypothetical data of the frequency of oral cancer in 2

City New cases Reporting

 Prevalence rate = Number of people with the disease at a specified time x K

Total population at the specified time

Example: Periodontal examination survey in a city among individuals 35-

 Uses of prevalence rates

Incidence rate = Number of NEW CASES xK

Incidence during Oct.= Number of NEW CASES xK

 Prevalence rate = Number of people with the disease at a specified time x K

Total population at the specified time

Types of epidemiological studies:

Types of descriptive studies:

Types of epidemiological studies:

Types of experimental studies:

Limitations of experimental studies:

Incidence rate among exposed

Attributable Risk (AR):

---+VE----- -VE --- Total

Incidence of caries among children using new toothpaste =10/100*100 = 10%

Incidence of TB among Alcoholics =40/50*100 = 80%

AR = 80% -10% = 70%

Example: A study on smoking had shown the followings:-

 So among smoker there is excess of death from lung cancer,