MDS3 PREVENTIVE ESSAYS

1. PREVENTION OF ORAL MUCOSAL LESIONS

Oral mucosal lesions include a variety of conditions affecting the mucous membranes of
the mouth. If left untreated, they can lead to significant morbidity and even mortality.
Hence prevention strategies are essential for mitigating the impact of these conditions
and promoting overall oral health.

Prevention of Oral Cancer

1) Oral cancer, most commonly squamous cell carcinoma, arises from local, chemical,
or mechanical irritants or from unknown causes.
2) Despite advancements in prevention and treatment, incidence of oral cancer
continues to rise, with a notably higher prevalence in men compared to women.
3) In the Maltese Islands, oral cancer accounted for 0.3% of cancers in males and 0.2%
in females, with a significant mortality rate due to late detection.
4) The most common sites for oral cancer include the lower lips, lateral border and
undersurface of the tongue, labial commissure, and buccal mucosa. Conditions like
leukoplakia often precede cancers in the labial commissure and buccal mucosa.
5) Treatment usually requires extensive surgery and plastic surgery, imposing
significant psychological and physical stress on patients and incurring high healthcare
costs.

Risk Factors and Prevention Strategies

1) Tobacco use, including smokeless tobacco and excessive alcohol consumption are
responsible for approx 90% of oral cancers, with risks exacerbated when combined with
areca nut use.
2) Therefore, prevention strategies must focus on reducing these risk factors through
education and social policies that promote healthy behaviors and discourage harmful
practices.

Preventive Measures

1) Cancers that are related to infectious agents, such as HPV in this case could be
prevented through vaccines, antibiotics, improved sanitation, or education.
2) Effective prevention of oral cancer can be achieved through regular screening and early
detection of precancerous lesions by healthcare professionals. This approach increases
the likelihood of successful treatment.
3) Dental health professionals play a critical role in identifying and referring cases for
immediate care.
4) Public education is vital to inform individuals about the risks of oral cancer, the
potential progression from precancerous lesions, and the importance of early diagnosis
and comprehensive treatment.
5) Oral Cancer Preventive Programs
 - To reduce the incidence of oral cancer and precancerous conditions, by focusing on
eliminating predisposing habits and increasing early detection through screening.
- These programs aim to lower mortality rate by ensuring more appropriate
treatment facilities are available.
- Public awareness campaigns should emphasize the consequences of oral cancer and
the significance of early intervention.
- Encourage giving up harmful habits such as smoking, betel tobacco chewing etc.,
through reinforcement of health education and health promotion supported by
government fiscal policy (taxes etc.) and health promotion strategy
- Individuals with clinical symptoms that might be associated with oral cancerous
lesions should be kept under careful observation and control

Role of Oral Health Professionals

1) Oral health professionals are crucial in smoking cessation efforts due to their frequent
and prolonged interactions with patients
2) By educating patients about harmful effects of tobacco and providing intervention
support, they can effectively contribute to reducing tobacco use and its associated risks.

Prevention of Other Oral Diseases

1) Preventive measures for other diseases of the oral mucosa, including infectious,
parasitic, nutritional, metabolic, and digestive system diseases, are also important eg.
Acute and chronic candidiasis.
2) Improving personal hygiene, providing safe water supplies, introduction of general
sanitary measures and enhancing individual nutritional status rich in essental vitamins
and minerals are essential components of primary healthcare programs.
3) Health education and promotion play a pivotal role in these preventive strategies.

Principles for Effective Prevention

1) An effective preventive program should be based on primary healthcare principles,

ensuring community participation and governmental support through national health
policies and strategies. This comprehensive approach is crucial for reducing the burden of
oral cancer and other related diseases, ultimately improving public health outcomes.
2. THE DENTAL TEAM

1) A team is a group of people with different skills and tasks who work together on a
common project, service or goal with a meshing of funcYons and mutual support.
2) EffecYve dental teams are built on foundaYonal values such as communicaYon, mutual
respect, jusYce, hard work, and good leadership. These values foster an environment
where cooperaYon and understanding thrive, enabling team members to work with
each other’s best interests in mind.

DENTAL TEAM

1) The composiYon of a dental team can vary significantly based on the se^ng and
geographic locaYon.
2) In a hospital dental department, the team might include specialists, surgeons,
anaestheYsts, dental hygienists, assistants, technologists, care workers, radiographers,
and administraYve staff.
3) Conversely, in a private clinic, the team might be smaller, consisYng of a single denYst or
a few team members, depending on the clinic's size and the owner’s preferences.
4) Regardless of the se^ng, acknowledging each team member’s role, rights, and
responsibiliYes is essenYal for seamless cooperaYon and achieving the team’s goals.
5) The goal of any dental team is to work together to provide the best care for the paYent
and have their interest as our priority. Dental team should inspire paYent confidence by
delivering quality dental care through coordinated efforts.

ROLES

1) Dental Assistants:
- responsible for preparing and maintaining the clinical environment
- ensuring infecYon control and control procedures to prevent physical, chemical and
microbiological contaminaYon
- recording dental charYng and oral Yssue assessment
- prepare and mixing dental materials, and
- providing chairside support.
- Keep accurate paYent records
- prepare and process radiographs,
- offer paYent support, parYcularly during medical emergencies.
- make appropriate referrals
- AddiYonal skills they could develop include further skills in oral health educaYon and
promoYon, assisYng in conscious sedaYon procedures and paYents with special
needs and ortho, photography, pouring and casYng study models, shade taking and
tracing cephalography and perhaps also fluoride varnish
- While dental assistants do not diagnose diseases or prescribe treatments, their role
in assisYng and ensuring smooth operaYons is invaluable.
 2) Dental Hygienists:
- Have a major role in health promoYon and oral disease prevenYon
- Obtain a detailed dental history from paYents and evaluate their medical history
- Clinical examinaYon within their remit and complete periodontal examinaYon and
charYng and use indices to screen and monitor periodontal disease
- Diagnose and treatment plan within their competence
- Prescribe radiographs and take and interpret them to monitor periodontal and other
oral diseases.
- Provide prevenYve oral care to paYents and liaise with denYsts
- Undertake supragingival and subgingival scaling and root surface debridement
- use appropriate anY-microbial therapy to manage plaque related diseases
- adjust restored surfaces in relaYon to periodontal treatment
- apply topical treatments and fissure sealants
- give paYents advice on how to stop smoking
- take intra and extra-oral photographs
- give local
- place temporary dressings and re-cement crowns with temporary cement
- take impressions
- care of implants and treatment of peri-implant Yssues
- idenYfy anatomical features, recognise abnormaliYes and interpret common pathology
- oral cancer screening and if necessary refer
- They do not restore teeth, carry out pulp treatment, adjust unrestored surfaces or
extract teeth

3) Dental Technicians
- OperaYng primarily in laboratories, dental technicians create dental devices such as
dentures, braces, and crowns based on denYsts’ prescripYons.
- They engage in treatment planning, design and manufacture custom dental devices with
the denYst, and ensure these devices meet quality and safety standards.
- They may carry out shade taking, infecYon prevenYon and control procedures to
prevent contaminaYon
- Make appropriate referrals
- Can see paYents directly for repairs of dentures
- While they do not perform clinical procedures, their experYse is crucial in producing the
appliances that paYents rely on for oral health and funcYon.
- do not work independently in the clinic to:
• perform clinical procedures related to providing removable dental appliances
• carry out independent clinical examinaYons
 • idenYfy abnormal oral mucosa and related underlying structures
• fit removable appliances

4) DenDsts
- As the primary healthcare providers within the dental team, denYsts diagnose
diseases,
- develop comprehensive treatment plans,
- prescribe and provide endo, fixed ortho, Prostho
- perform surgeries and extract
- prescribe treatments and medicaYons
- provide conscious sedaYon or carry out tx on pt under GA
- prescribe and interpret radiographs
- and manage overall paYent care.
- Their advanced training allows them to perform a wide range of procedures, from
restoraYve treatments to cosmeYc injectables, always adhering to their scope of
pracYce and competence.

ConYnuous professional development is a hallmark of the dental profession. Each team

member, whether a dental assistant, hygienist, technician, or denYst, must engage in
ongoing educaYon to stay updated with latest advancements and techniques in dental care.
This commitment to lifelong learning ensures that all team members are equipped to deliver
the highest standard of care, adapYng to new challenges and technologies as they arise.

The dental team exemplifies the power of collaboraYve, interdisciplinary work in healthcare.
By integraYng the skills and experYse of various professionals, the dental team can provide
comprehensive, paYent-centered care. The success of this team hinges on mutual respect,
clear communicaYon, and a shared commitment to paYent welfare, highlighYng the
importance of each member's role in achieving opYmal health outcomes for paYents.
 3. GENERAL EPIDEMIOLOGY

- Epidemiology is a crucial field in public health. It is the study of health and disease
distribuYon and determinants in groups of people over Yme.
- Whilst clinical pracYce studies the situaYon of one individual at any point in Yme,
epidemiology invesYgates groups of people in a parYcular locaYon over Yme to idenYfy
trends in a populaYon, enabling the development of strategies for prevenYon and
control.
- InvesYgaYng the differences between subgroups of people, paferns of disease/health,
their exposure to certain factors eg. sugar, one can study what causes disease and
possibly idenYfy possible cures.
- This knowledge can be gained by studying GROUPS of people not just individuals.

Fields of epidemiology in denYstry:

u 1) Measurement of dental disease amongst groups in populaYon – helps to

understand how disease is distributed and what factors influence the distribuYon eg.
Dental caries

u 2) IdenYficaYon of factors causing the disease eg. Sugar

u 3) EvaluaYon of new materials and treatment and their effecYveness in

treatment/management of dental diseases

u 4) Assessment of needs and requirements for dental services within a community

Protocol

- Epidemiological studies require a standardized protocol to ensure unbiased (random)

and representaYve data collecYon.
- A study should be planned and designed in detail before it is started so that no changes
are made along the way that can cause bias.
- The methodology of the study should be outlined in detail prior to starYng the study
and even when reporYng it in a paper.
- This protocol is needed to ensure that the study is well planned and thought out
- To allow the study to be evaluated for scienYfic and ethical factors prior to starYng
- To ensure that the invesYgators complete the study as planned
- allow others to complete the study for the original invesYgator if necessary
- To enable others to repeat the study (having a reliable protocol)

CounYng data

- Simple data counYng can be misleading without considering sample size and
proporYon. Thus, rates, proporYons, and percentages are essenYal for meaningful
epidemiological analysis
Prevalence vs Incidence

- Prevalence refers to the proporYon of people with a disease at a specific Yme or a period
of Yme, indicaYng how widespread the disease is.

- Incidence measures new cases within a defined period in a defined populaYon, helping
understand the disease's spread dynamics.

Types of studies

1. DescripYve - rouYnely gathered data to provide an overview of disease levels and

associated risk factors at a given Yme. While they are quick and easy to conduct, they do not
establish causality eg cross secYonal

2. AnalyYcal – eg. ObservaYonal Studies track disease progression over Yme without
manipulaYng risk factors, oien using cohort (prospecYve) or case-control (retrospecYve)
methodologies. In both cases, individuals with a higher exposure to a risk factor are
idenYfied, matched with controls (people who are not exposed to a risk factor) and are
monitored and quesYoned. Then one can study the potenYal associaYon between the risk
factor exposure and the disease

Eg. Experimental Studies - Randomized controlled trials (RCTs) are the gold standard in
research, they are always prospecYve and establish causal relaYonships by comparing
outcomes between randomly assigned treatment and control groups

E.g systemaYc reviews - aggregate data from mulYple studies to provide a comprehensive
analysis, ensuring a reliable synthesis of evidence on a specific topic

Measurement Indices

- To quanYfy and compare health outcomes, epidemiologists use indices such as the
Decayed, Missing, and Filled Teeth (DMFT) index for dental caries and the Basic
Periodontal ExaminaYon (BPE) for periodontal disease.
- An ideal index should have:
u 1)-Clarity: The examiner should be able to carry out the index rules in his mind.
-Simplicity: easy to apply, so there is no undue Yme lost during examinaYon.
-ObjecYvity: clear and unambiguous.
u 2)Validity: should measure what it is intended to measure. So it should correspond
with clinical stages of the disease, ex. number of missing teeth in adults is not a
valid measure of caries acYvity.
u 3) Reliability: The index should measure consistently at different Ymes and under a
variety of condiYons, by the same person or different persons.
 u 4) QuanYfiability: The index should be amenable to staYsYcal analysis. So that the
status of a group can be expressed by a number that corresponds to a relaYve
posiYon on a scale from zero to the upper limit.
u 5)SensiYvity: The index should be able to detect reasonably small shiis, in either
direcYon in the group condiYon.
u 6)Acceptability: should not be painful or demeaning to the subject.

Conclusion

Epidemiology is indispensable for understanding and controlling diseases within

populaYons. By employing rigorous study protocols and diverse methodologies,
epidemiologists can uncover the underlying causes of diseases and devise effecYve
intervenYons. This field's insights are essenYal for advancing public health, parYcularly in
specialized areas like dental epidemiology.
4. PRINCIPLES OF HEALTH PROMOTION

1) Health promoYon, as defined by the World Health OrganizaYon (WHO), is the process of
enabling people to increase control over, and to improve, their health. It moves
beyond focusing on individual behaviours and towards a wide range of social and
environmental intervenDons
2) The foundaYon of effecYve health promoYon is evidence-based public health. Reliable
evidence should be gathered from trusted sources such as WHO, BriYsh Dental Health
FoundaYon, and American Dental AssociaYon. This evidence must be appraised and
filtered to ensure it is accurate and up-to-date
3) PromoDng oral health is crucial because it affects several aspects of life, including
funcYon, speech, aestheYcs, nutriYon, general health, morale, and quality of life.In
Malta, for instance, one-third of toddlers are at risk of dental caries and we have an
ageing populaYon, indicaYng a significant public health challenge. Oral health
promoYon involves policy makers, dieYcian, pharmacist, gp, dental team, schools,
supermarkets etc..
4) Social Determinants of Health
- Health is shaped by various determinants - poliYcal, economic, social, cultural,
environmental, behavioural, and biological factors. They are like the causes of the
causes and can either enhance or impair health, necessitaYng a holisYc approach to
health promoYon.
- Understanding the social determinants is about looking at how and where people grow,
live, work, and age, and they play a criYcal role in determining health outcomes.
- The 10 social determinants of health include – social gradient, stress, early life, social
exclusion, work, unemployment, social support, addicDon, food, transport.
- The "social gradient" illustrates that those at the top of the social ladder tend to live
longer and healthier lives compared to those at the bofom, who face a higher risk of
serious illness and premature death.
- By looking broadly at what affects a person’s health, we can devise health promoYon
strategies that tackle more than the person’s knowledge about oral health and
introduce changes in the determinants of health that make it easier for the person to
live a healthier life and choose the healthier opYons.
- Eg. School food policies, oral health educaYon, tooth brushing iniYaYves, supermarket
policies, food labels, taxes on sugary/unhealthy foods, cheaper healthier food and oral
hygiene aids, improved access to dental services...
5) The OWawa Charter outlines 5 key acYon areas for health promoYon:

1. CreaDng SupporDve Environments: Recognizing the influence of the environment on

health and reorienYng it towards one that is conducive to health. Eg. water fluoridaYon
and school policies limiYng sugary snacks
2. Building Healthy Public Policy: Ensuring all public policies contribute to health. This
involves creaYng pricing and adverYsing policies on smoking and sugary products, as well as
implemenYng food labeling rules

3. Strengthening Community AcDon: Empowering individuals and communiYes to plan and

implement health improvement strategies. iniYaYves like community food cooperaYves and
classes on growing and cooking nutriYous food

4. Developing Personal Skills: Equipping individuals with the necessary skills to improve
their health. This might include self-care skills and community development iniYaYves

5. ReorienDng Health Services: Shiiing the focus of health services towards prevenYon and
health gain rather than just treatment

6) The Common Risk-Factor Approach

Oral disease is largely preventable, and is influenced by common risk factors such as diet,
hygiene, smoking, alcohol use, stress, and trauma. The common risk-factor approach
advocates for addressing these factors in a collaboraYve manner to prevent a range of
chronic diseases, rather than focusing on disease-specific intervenYons

7) Equity in Health PromoDon

Equity is a fundamental principle in health promoYon, aiming to reduce health dispariYes

and ensure that all individuals have fair opportuniYes to achieve good health. This involves

- prioriYzing at-risk groups,

- addressing the social determinants of health, and
- advocaYng for policies that reduce social inequiYes
- partnering with other organisaYons to deliver health iniYaYvs that focus on
building capacity and address health equity

8) Upstream and Downstream Approaches

Health promoYon strategies can be categorized as upstream or downstream. Upstream

approaches tackle the root causes of health issues at a higher level, such as implemenYng
policies to prevent problems before they occur. Downstream approaches, on the other hand,
focus on changing individual behaviors and addressing problems aier they have arisen

Conclusion

EffecYve health promoYon requires a comprehensive approach that addresses the broad
determinants of health, empowers communiYes, and reorients health services towards
prevenYon. By adhering to the principles in the Ofawa Charter and embracing strategies
that promote equity, health promoYon can significantly improve populaYon health and well-
being.
 5. PREVENTIVE STRATEGIES

1) Discuss the Whole Population and the High Risk strategies giving advantages,
disadvantages and examples of each strategy.

Dental diseases are largely preventable hence one can focus on preventive strategies.
Many factors contribute to these diseases so once these factors are identified,
strategies can be outlined to prevent exposure to the risk factors of the disease. The aim
of preventing diseases is based on reducing the risk of encountering these diseases,
identifying and minimising exposure to known risk factors.

When a disease is distributed in the population, a decision is made whether to try and
address the whole population – the whole population strategy or identify those at higher
risk and focusing on them – high risk strategy.

WHOLE POPULATION STRATEGY

If the diseases distribution is normal then all the population has an equal chance of
contracting the diseases. A population based intervention focuses on created changes
in organisations, policies and laws and would not focus directly on the individuals or
communities but rather on the systems that service them. Has greatest impact on the
individuals who form the community e.g. water fluoridation, seatbelt legislation and
smoke-free environments.

The advantages

1) Radical as it seeks to focus on the undermining determinants and focuses on

reducing the disease burden on the whole population. It is justified when the
impact of disease is great especially when there is no intervention.
2) Powerful - has an eJect on a large number of people and shift the normal
distribution to good health.
3) Appropriate – changing normal behaviour to an acceptable beahviour for good
health.

The limitations

1) Cost and safety - interventions are costly and benefits are seen long-term
2) Acceptability - may not be acceptable by the whole population who are not
willing to change their habits or support environmental changes,
3) Feasability - pressures in society and not always feasible due to lack of
resources.
HIGH RISK STRATEGY

The risk approach strategy is divided in 2

1) Targeted population approach - focuses on a population/group who is at a

higher risk of a disease when compared to the whole population e.g. geographical
areas of people and dental caries, caries in school children – providing fluoride
varnish application. It is useful when resources are limited. Evidence based
approach - The goal of this is to facilitate the timely and appropriate translation
into practice of research findings that results in the improved practice outcomes
2) High risk – focuses on individuals who are at risk of encountering the disease,
some being more at risk than others eg.dental staJ vaccinated against Hep B,
fissure sealants for high risk children and water fluoriation in schools .
Populations may be at high risk due to beliefs, behaviour or cultural patterns, and
they would need the most dental care.
It is good for risk vs exposure relationships where there is an increased risk of
disease only with high exposures to a risk factor e.g. increased periodontal care
for diabetic patients.

STRENGTHS:

1) Targeted and benefits the high risk

2) Acceptable to individuals
3) Cost-eXective – eJective use of resources
4) Does not involve those individuals not at risk.

LIMITATIONS:

1) Prevention is medicalized (stigmatization)

2) success is temporary,
3) short-term eXects,
4) no guarantee about future risk – does not prevent new cases from forming
5) overall control of disease is small
6) inappropriate behaviour when patient must change their behaviour towards a
better health

3) Common risk factor approach

4) Preventive measures by the team. -fissure sealants, topical fluorides, cleaning,
diet, smoking prevention..
5) OHI – 2x dly for 2 mins, fluoride toothpaste, floss, superfloss, cleaning of
dentures..

Health promotion is the process of enabling people to increase control over, and to
improve, their health. The Ottawa charter incorporates five key action areas in Health
Promotion; build healthy public policy, create supportive environments for health,
strengthen community action for health, develop personal skills, and re-orient health
services.
 6) PRINCIPLES OF PUBLIC HEALTH

Dental public health is the science and clinical practice dedicated to preventing oral disease,
promoting oral health, and improving quality of life through organized societal efforts. The
field addresses both individual and population health, emphasizing the public's needs over
those of individuals.

Public Health Importance of Oral Diseases

1) Oral diseases are prevalent, costly to treat, and have significant impacts on individuals'
lives. They are relatively easy to diagnose, with known causes such as poor hygiene
and diet, and are generally preventable through public health measures. However,
treatment is often unsuccessful, making prevention crucial.
2) Western dentistry often fails to prevent avoidable diseases and to address the root
causes of dental issues. There is an over-reliance on antibacterial treatments and
restorative procedures without considering broader health promotion strategies.

3) The traditional medical model views the body as a machine, focusing on repairing
malfunctioning parts. Treatment aims to restore normal functioning through
interventions. Dental public health differs from traditional medicine in its focus on
populations rather than individuals. While medicine emphasizes diagnosis and
treatment of individual patients, dental public health prioritizes disease prevention and
health promotion for entire communities. This involves understanding the broader
social, economic, and environmental factors influencing health and implementing
policies to address these determinants.

4) The Primary Health Care Approach (PHCA) emphasizes health as a basic human right
and seeks to reduce health inequalities through prevention, community involvement,
appropriate technology, and multisectoral efforts. It highlights the need for upstream
interventions, such as healthy public policies, rather than focusing solely on
downstream clinical prevention

Core Themes of Dental Public Health

1. Concepts of Health: Understanding health not merely as the absence of disease but
as a state of complete physical, mental, and social well-being.
2. Determinants of Health: Factors that influence health, such as genetics, behavior,
environmental exposures, and social circumstances.
3. Concepts of Need: Includes normative, felt, expressed, and comparative needs,
helping to identify and prioritize public health interventions.
4. Evidence-Based Practice: Utilizing current best evidence in making decisions about
the care of individual patients and the health of populations.
 Changes Affecting the Practice of Dentistry - the practice of dentistry is evolving due to
several factors:

• Epidemiological Changes: Shifts in disease patterns necessitate different public

health strategies.
• Shifts in Demographics: An aging population, increased cultural diversity, and
changing family structures impact dental health needs.
• Changes in Health Service Setup: Health service reforms and new models of care.
• Social Change: Increased patient expectations for care.
• Professional Development: Emphasis on teamwork and interdisciplinary
approaches.
• Political Pressure: Reduced funding for dental public health initiatives.
• Technological Change: Advancements in materials and techniques.

Conclusion

To address the limitations of current dental services, a shift towards preventive strategies,
public health programs, and a focus on social determinants is needed. Integrating public
health approaches into dental care will promote better health outcomes and reduce
inequalities, ultimately improving the quality of life for the population.
 7) PREVENTION IN THE CLINICAL PRACTICE

The clinical practice emphasizes both primary and secondary preventive measures to
promote oral health. These measures are essential for averting the onset and progression of
dental caries, ensuring optimal dental care from an early age.

A. PRIMARY PREVENTIVE MEASURES - focuses on preventing the onset of dental caries

B. SECONDARY PREVENTIVE MEASURES- aims to halt the progression of early caries to
cavitation

1) Regular visits: Children should start dental visits by their first birthday to monitor
oral health development and address any emerging issues promptly.visits every 6
months or adapted according to need and susceptiblity.
2) Dietary advice: Recommendations include

- avoiding sugar-filled medications

- For infants – breast milk best possible nutrition however after 1years old –
breastfeeding >7 times a day associated with decay.
- Soya milk since it contains sugar can only be used as a feed not drink.
- Juices not more than 180ml per day upto 6yrs old and in an open cup.
- <4 yrs – 16g free sugar/day
- 4-8 – 12.5g
- Adults – 25g
- Acid at mealtimes only and not swished around the mouth – erosion
- Limit sweetened foods/drinks to 3x dly and keep clear of bedtime by about
an hour

3) OHI: Parents are educated on proper brushing techniques for their children, and
supervised brushing routines. Use of floss.
4) Fluoride application: Utilization of fluoride toothpaste, supplements, drops, tablets,
and varnish helps strengthen enamel and prevent decay.
5) Fissure sealants: Applied to vulnerable teeth surfaces to protect them from decay-
causing bacteria and food particles.
6) Treatment planning: A collaborative team approach involving receptionists, dental
nurses, dentists, pediatricians, psychologists for behavioral advice, and dieticians for
nutritional guidance.
7) Avoid dummy/thumb sucking habits esp by age of 5 – ortho soothers allow mouth to
develop normally up to 18 months.
8) Secondary prevention of trauma – hold tooth by crown, rinse in cold tap water,
either place it back or put in a cup of milk and seek immediate treatment

Recommendations for the First Visit:

1) Children should start dental visits by their first birthday

2) Strategies include scheduling appointments at optimal times,
3) preparing children with role-play and visual aids
4) bring distractions for waiting and examination rooms eg. Videos, games..
 5) ask for a get acquainted visit
6) bring a support person to listen and write things down
7) research dental issues in books and journals
8) ask for the same staff
9) avoid saliva sharing behaviours eg cups

(for paeds) Followed by Home Care:

1) intolerance to toothpaste à gauze in 0.2% CHX, CHX gel rubbed w finger brush,
toothbrush dipped in fluoride mouthwash
2) Brushing – responsibility of parent supervised until 8years old, soft 2x dly, 1000ppm
fluoride. >7yrs – 1350-1500ppm unless high risk (>3 yrs), 2800ppm for high risk over
10yrs.

In general home care:

- Home care is criYcal

- Oral cleansing à beneficial oral motor therapy sYmulaYon and massage for
oral Yssues essenYal for circulaYon, cellular turnover and reducYon of oral
hypersensiYvity
- If paYent presents with debris: oral condiYon demonstrated to caregiver and
they are educated about implicaYons and trained on cleaning denYYon with
toothbrush. If extrinsic accreYons are present that cannot be removed -
prophylaxis

Conc :

EducaYon and training for caregivers standard of care in the first year of life for anyone with
developmental decay or who experiences an illness that compromises their ability to provide
self oral care
8) HEALTH CARE SYSTEMS – REMUNERATION

The oral health care system encompasses various players – the paDent, the denDst and the
government. To saYsfy all the players, the health care system must deliver quality, speed,
dependability, flexibility, and cost-effecDveness.

Each player has also unique demands and contribuYons. Understanding their roles and
needs is crucial for establishing a flexible, responsive system that adapts to changing
demands and resources, ulYmately aiming for improved health outcomes.

A. PATIENT
- the primary concerns are accessibility, quality, and empathy.
- Access involves having dental clinics in proximity, with convenient availability, and
physical accessibility (e.g., no stairs for those with mobility issues).
- Punctuality of appointments and the possibility of same-day consultaYons are also
important.
- PaYents expect treatments to be pain-free, and they value empathy from health care
workers, ensuring that their emoYonal and physical discomfort is minimized.
- Hygiene standards must be rigorously maintained to insYll confidence in the care
provided.
- They also expect treatment to be free.

B. DENTIST
- Dental professionals seek a supporDve work environment with appropriate
remuneraDon, reasonable working hours, and access to the latest equipment.
- ConYnuous training and development opportuniYes are essenYal to keep abreast of
advancements in dental care.
- DenYsts also rely on a flexible structure and robust support staff to efficiently manage
their pracYces.
- The quality of paYent care can significantly improve with a well-supported dental team,
enhancing overall job saYsfacYon and performance.

C. GOVERNMENT
- The government’s role is to ensure that the oral health care system runs smoothly and
efficiently, promoDng health and ensuring value for money.
- This involves providing access to quality dental care for all ciYzens and ensuring high
uYlizaYon of services.
- The government aims for minimal problems in the system, focusing on prevenYve
measures to reduce the burden of dental diseases.

In order to saYsfy those needs, the system has expenditures which can be divided into:

A. Capital expenditures - establishment of clinics, determining the number needed

based on populaYon demand and geographic distribuYon
B. Running expenses - Running expenses cover the maintenance of these faciliYes,
ensuring they remain funcYonal, clean, and equipped with up-to-date technology.
Funding and Reimbursement - Funding comes from taxes, insurances, or out-of-pocket
payments. Sustainable funding models are criYcal, given the increasing expenditure on
health care globally. Reimbursement methods for dental services vary, including salaried
payments, capitaDon, fee per item, and diagnosYc-related payments. Each method has its
advantages and disadvantages, affecYng the quality and quanYty of care provided.

1) Salaried
- ADV – good quality work, administraYvely simple, facilitates budgeYng,
treatments not influenced by profit, benefits for employee
- DISADV – does not work full hours, possible under treatment, lack of financial
incenYves
2) Fee per item
- ADV – tx done quickly, good in areas of high quality need, easy to measure
- DISADV – tendency to overtreat, no incenYve to stop disease from occurring,
difficult to budget
3) CapitaDon
- ADV – Good quality work, prevenYon, facilitates budgeYng, reward linked to
effort
- DISADV – supervised neglect, no knowledge of output, payments unfair in low
v high needs
4) Sessional
- ADV – regular income, reward for output, minimizes resources cost, opYon for
special needs
- DISADV – untried, potenYal for under treatment

Structure of the Health Care System - a complex, dynamic aspect that operates at three
levels: primary, secondary, and terYary care. Primary care focuses on prevenYve measures
and early detecYon, secondary care on more specialized services, and terYary care on
advanced, specialized treatments.

The funcDon of the health care system revolves around achieving health promoYon and
disease prevenYon. Personnel, being the largest expenditure, includes the various roles
needed to deliver comprehensive care.

The target populaDon includes groups prioriYzed based on need, such as those with special
needs, disadvantaged groups, nursing mothers, and the homeless. PrioriYzaYon varies by
country, influenced by cultural and historical contexts.

Conclusion

A high-performing oral health care system ensures access, safety, health promoYon, clinical
effecYveness, posiYve paYent experiences, equity, efficiency, and accountability. By
balancing the needs and contribuYons of the paYent, the denYst, and the government, the
system can adapt to changing demands and resources, ulYmately improving health
outcomes for all.
 9) INDICES

In oral epidemiology, indices serve as essential tools for measuring and comparing the
prevalence and severity of oral diseases. An index is a graduated, numerical scale with
upper and lower limits, where scores correspond to specific criteria.

3 primary measures of oral disease frequency:

1. Counting: The simplest form of measurement, counting involves tallying the

number of individuals aJected by a disease. It provides a straightforward
representation of disease prevalence within a population.

2. Proportion: This is the ratio of the number of aJected individuals to the total
number of individuals (aJected and non-aJected). Proportions oJer a more nuanced
view by contextualizing the number of cases within the broader population.

3. Rate: A rate is a specific type of proportion that uses a standardized denominator

and includes a time dimension. Useful for understanding the dynamic aspects of
disease spread and control over time.

Properties of an Index

1. Clarity, objectivity and simplicity: The criteria for an index should be clear and
unambiguous, with mutually exclusive categories to promote accuracy and
reproducibility. The index should be easy to apply and to remember. For example, the
bleeding index's criteria are clear: bleeding is either present or absent after gentle
probing.

2. **Validity**: An index must measure what it is intended to measure. It should

correspond with clinical stages of the disease at each point and be able to detect small
shifts in conditions. A valid measure of disease must be both sensitive (correctly
identifying true positive cases) and specific (correctly identifying true negative cases).

3. **Reliability**: should consistently produce the same results under diJerent

conditions and at diJerent times. For instance, if the DMFT (Decayed, Missing, Filled
Teeth) index is measured at diJerent times of the day, the values should remain
consistent.

4. **Quantifiability**: should be amenable to statistical analysis, enabling researchers

to derive meaningful conclusions from the data.

5. **Acceptability**: should not be painful or embarrassing for the subject. Acceptability

ensures that participants are willing to undergo the assessment, which is crucial for
obtaining accurate and comprehensive data.
Specific Indices in Oral Health Care

1. **Bleeding Index**: measures presence/absence of gingival bleeding after gentle

probing. It is more sensitive and less subjective than the gingival index, though it can be
influenced by pressure applied during probing.

2. **Gingival Index (GI)**: assesses the severity of gingivitis based on criteria such as
color change, texture change, and bleeding on probing. It is sensitive enough to
distinguish between mild and severe gingivitis but may lack sensitivity for middle-range
conditions.

3. **Plaque Index**: evaluates the thickness of dental plaque. Scores are calculated by
grading individual teeth or surfaces and dividing by the number of teeth or surfaces
examined. It is quick, practical, and suJiciently sensitive for evaluating dental plaque
levels.

4. **Community Periodontal Index of Treatment Needs (CPITN)**: records

periodontal conditions by sextants, assessing criteria such as gingival bleeding,
calculus, and pathological pockets. It categorizes individuals into treatment need levels
and assigns appropriate treatment times.

5. **Decayed, Missing, Filled Teeth (DMFT) Index*: expresses amount of treated,

untreated, and unsuccessfully treated dental disease. It accounts for filled teeth,
decayed teeth, and teeth missing due to caries. However, it assumes all missing teeth are
due to caries and does not consider the number of teeth at risk or the role of social factors
in dental disease variation. It does not distinguish individuals with diJerent health status.

Indices related to Qo L – OHIP, OHIP-14

Conclusion

Indices are vital tools in oral health care for measuring and comparing the prevalence and
severity of oral diseases. They provide clarity, validity, reliability, quantifiability, and
acceptability, enabling researchers and practitioners to accurately assess and address
oral health issues. By utilizing various indices, such as the bleeding index, gingival index,
plaque index, CPITN, and DMFT, oral health professionals can eJectively monitor and
improve oral health outcomes within populations.
 10) LOCAL EPIDEMIOLOGY

Malta with a population exceeding 400,000, is facing significant epidemiological shifts

which may cause a significant public health burden. These changes include:

- Significant population growth

- Immigration
- Rapidly ageing population
- Thriving service-based ceremony
- Changing social norms and practices
- Low fertility rate – decreasing births

Firstly, the significant population growth and increased immigration are central to Malta's
evolving epidemiological profile. By 2025, Malta's population is projected to exceed
418,000, a notable increase from the current figures. This growth results in heightened
population density, particularly in urban areas, which can strain existing healthcare
infrastructure and services. Additionally, immigration introduces diverse health
needs and challenges, as immigrants may bring varying health conditions and
require diJerent healthcare services compared to the native population.

Malta faces a significant challenge in dental healthcare due to a low number of practicing
dentists, with a ratio of one active dentist for every 3,072 residents. Furthermore, most of
these dentists are employed full-time in private practices, while a mere 1% work in the
public sector. This disparity in the distribution of dental professionals between private
and public sectors exacerbates issues of accessibility and aJordability of dental care for
the general population. The skewed distribution means that those relying on public
healthcare services may face long waiting times and limited access to dental care. This
situation is particularly concerning for vulnerable populations, including low-income
groups, the elderly, and immigrants, who may not be able to aJord private dental
services. The limited presence of dentists in the public sector highlights the need for
strategic policies to attract more dental professionals to public healthcare and to ensure
equitable access to essential dental services across Malta. Initiatives could include
oJering incentives such as higher salaries, better working conditions, and opportunities
for professional development to encourage more dentists to join the public sector.

Secondly, Malta's rapidly ageing population is a critical concern. Currently, 20.3% of the
population is aged between 50 and 64 years, higher than the EU average of 17.9%. An
ageing population increases the prevalence of age-related health issues such as non-
communicable diseases (NCDs), including heart disease, diabetes, and cancer. These
conditions not only aJect the quality of life for the elderly but also place a significant
burden on healthcare systems due to the increased demand for medical care, long-term
care, and support services.
Moreover, Malta's thriving service-based economy has both positive and negative
implications for public health. While economic growth can lead to better health
outcomes through improved healthcare funding and infrastructure, it can also result in
lifestyle changes that negatively impact health. For example, a service-based economy
often correlates with sedentary lifestyles, which contribute to the rise in obesity and
related health conditions such as diabetes and cardiovascular diseases

OBESITY, HEART DISEASE, DIABETES

1) They are major health issues in Malta accounting for >80% of deaths and they are
linked to each other.
2) One in 10 Maltese individuals suJers from diabetes, a condition exacerbated by
obesity and poor diet.
3) heart disease remains a leading cause of morbidity and mortality in Malta.
4) The consumption of high-sugar beverages and foods and lack of mediterranean
diet plays a critical role in the rising rates of obesity. These dietary habits lead to
not only obesity but also dental caries and diabetes and increasing the risk of
cardiovascular conditions.
5) The prevalence of these conditions underscores the need for dietary interventions
and lifestyle modifications among the Maltese population.

Cancer

1) New cases and deaths from cancer increasing over the years
2) Higher incidence in males

Caries

The mean DMFT scores in 12-year-old Maltese children is 1.33 with a higher incidence in
females and in state schools

Oral hygiene

28% had poor oral hygiene with the lowest scores in Gozo, south eastern district and
northern district. 69.8% of 12 year olds had calculus deposits

Policy Interventions

To combat these health issues, several policy interventions are proposed.

1) Subsidizing healthier food options and prohibiting unhealthy foods in schools are
key strategies. These measures aim to reduce the intake of high-sugar foods and
beverages, thereby lowering the incidence of obesity, diabetes, and heart disease.
2) Reformulating food products to lower sugar content while maintaining
palatability is another approach. However, this presents challenges, such as
reduced shelf life and the limited impact on imported foods. Given Malta's
 reliance on imported food products, reformulation eJorts must be coordinated at
a European level to be eJective.
3) The increase in mortality is partly due to a lack of preventive health check-ups.
Encouraging regular health screenings can help in early detection and
management of these conditions. Special attention is needed for males, who
show a higher incidence of these diseases, which increases with age.
4) integrating immigrants into the healthcare system and addressing their specific
health needs can enhance overall community health.
5) adapting healthcare infrastructure and services to accommodate an ageing
population will be crucial in ensuring sustainable health outcomes for all Maltese
residents.

Conclusion

Addressing the epidemic of non-communicable diseases in Malta requires a multi-

faceted approach. Policy interventions to promote healthier diets, food reformulation,
and preventive health measures are essential. By implementing these strategies, Malta
can reduce the burden of obesity, heart disease, and diabetes, improving the overall
health and well-being of its population.
 11) GENDER AND ORAL HEALTH

Oral health is a vital aspect of overall health and well-being. Various factors influence oral
health, including geneYcs, socioeconomic status, dietary habits, and access to healthcare.
Among these factors, gender plays a significant role, affecYng both the prevalence of oral
health issues and the approaches to their management. This essay explores the impact of
gender on oral health, examining biological, behavioural, and social dimensions that
contribute to differences in oral health outcomes between men and women.

Biological Differences

1) Biological differences between men and women significantly influence oral health.
2) Hormonal fluctuaYons in women, parYcularly during puberty, menstruaYon,
pregnancy, and menopause, can affect the oral cavity. For instance, hormonal
changes during pregnancy can lead to pregnancy gingiviYs, characterized by swollen,
bleeding gums due to increased blood flow and hormonal effects on the gum Yssue.
Similarly, menopause can lead to dry mouth (xerostomia) and an increased risk of
periodontal disease due to a decrease in oestrogen levels.
3) Men, on the other hand, are generally found to have a higher prevalence of
periodontal diseases compared to women. Studies suggest that the immune
response to oral bacteria may differ between genders, potenYally making men more
suscepYble to severe forms of periodontal disease.

Behavioural Factors

1) Women are generally more proacYve about their health and more likely to seek
regular dental care. They tend to adopt befer oral hygiene pracYces, such as regular
brushing and flossing, and are more likely to follow dental advice. This proacYve
approach contributes to befer oral health outcomes in women compared to men.
2) Conversely, men are less likely to visit the denYst regularly and oien delay seeking
treatment unYl they experience significant pain or discomfort. This tendency to avoid
prevenYve care and early intervenYon can lead to the progression of oral diseases,
resulYng in more severe outcomes. AddiYonally, men are more prone to neglect oral
hygiene pracYces, further exacerbaYng the risk of oral health issues.

Social and Cultural Influences

1) Gender roles and expectaYons can influence health behaviours and a^tudes toward
oral health care. For instance, societal norms oien encourage women to prioriYze
their appearance, including their smile and dental aestheYcs, leading to a higher
emphasis on maintaining good oral health. This cultural expectaYon can drive
women to be more diligent about their dental care rouYnes and more likely to seek
cosmeYc dental treatments.
 2) Men, on the other hand, may face societal pressures that de-emphasize the
importance of oral health and appearance. TradiYonal masculine ideals oien value
toughness and stoicism, which can discourage men from seeking medical or dental
help, viewing it as a sign of weakness. This cultural a^tude can contribute to
neglecYng oral health and delaying necessary treatments, resulYng in poorer oral
health outcomes.
3) AddiYonally, men are more likely to engage in risk behaviours such as tobacco use
and alcohol consumpYon, which are known to adversely affect oral health

ImplicaDons for Public Health and Dental PracDce

1) Understanding the impact of gender on oral health has important implicaYons for
public health and dental pracYce.
2) Tailoring oral health educaYon and intervenYons to address gender-specific needs
and behaviors can enhance the effecYveness of these programs.
3) For instance, public health campaigns can focus on encouraging men to adopt befer
oral hygiene pracYces and seek regular dental care, addressing the barriers and
misconcepYons that prevent them from doing so.
4) Dental pracYYoners can also benefit from being aware of gender differences in oral
health. By recognizing the unique challenges and risk factors associated with each
gender, denYsts can provide more personalized care. For example, they can offer
targeted advice to pregnant women on managing pregnancy-related oral health
issues or provide specific guidance to men on reducing risk behaviors such as
smoking and alcohol consumpYon.

Gender plays a significant role in oral health, influencing the prevalence, progression, and
management of oral diseases. Biological differences, behavioral factors, and social and
cultural influences all contribute to the dispariYes observed between men and women in
oral health outcomes. By acknowledging and addressing these differences, public health
iniYaYves and dental pracYces can improve oral health for both genders, promoYng overall
health and well-being. Understanding and addressing gender-specific needs in oral health is
essenYal for creaYng effecYve intervenYons and achieving equitable health outcomes for all.
12. ORAL HEALTH AND GENERAL HEALTH

Oral health is a crucial component of overall health and well-being, oien overlooked despite
its significant impact on general health. Good oral hygiene is not merely about maintaining a
bright smile; it is fundamental to prevenYng a range of health issues that extend beyond the
mouth.

1) Poor oral health, including condiYons like gum disease and tooth decay, can lead to
serious health complicaYons. For example, periodontal disease has been linked to
cardiovascular disease. The bacteria from inflamed gums can enter the bloodstream,
potenYally leading to the formaYon of arterial plaque and increasing the risk of heart
afacks and strokes.
2) Moreover, poor oral health can exacerbate condiDons such as diabetes by making
blood sugar levels more difficult to control. Conversely, individuals with diabetes are
more suscepYble to infecYons, including those affecYng the gums, creaYng a
bidirecYonal relaYonship between the two condiYons.
3) AddiYonally, oral health affects nutriDonal status. Painful dental condiYons can lead to
difficulty in chewing and swallowing, resulYng in poor nutriYon and further weakening
the immune system. This can create a vicious cycle, as a weakened immune system
making the body more suscepYble to infecYons and can lead to more severe oral health
problems, impacYng overall health even further.
4) The mouth is also a mirror reflecDng the state of the body's health. Symptoms of many
systemic diseases, such as HIV/AIDS and osteoporosis, oien first manifest in the oral
cavity. Early detecYon of these symptoms by a dental professional can lead to Ymely
and potenYally life-saving intervenYons.
5) Oral health also significantly impacts mental health and quality of life. Chronic oral
pain, tooth loss, and oral infecYons can affect speech, self-esteem, and social
interacYons. This can lead to anxiety, depression, and a lower quality of life. Ensuring
good oral health can thus enhance mental well-being and social funcYoning,
contribuYng to overall happiness and producYvity.

Maintaining good oral health is indispensable for overall health. Regular dental check-ups,
good oral hygiene pracYces, and a healthy diet are criYcal in prevenYng oral diseases and
their associated systemic health issues.

Public health intervenYons are vital in promoYng oral health and prevenYng oral diseases,
which have a profound impact on general health. By implemenYng measures such as water
fluoridaYon, increasing access to dental care, running educaYonal campaigns, integraYng
oral health with general health services, conducYng research, advocaYng for supporYve
policies, and developing community-based programs, public health can significantly improve
the oral health of populaYons. This holisYc approach ensures that oral health is recognized
as a criYcal component of overall health, leading to healthier individuals and communiYes.
Discuss the advantages and disadvantages of the three main types of remuneraDon
systems.

RemuneraYon systems are essenYal in determining how employees are compensated for
their work, directly influencing moYvaYon, performance, and job saYsfacYon. The three
main types of remuneraYon systems are salaried pay, fee-for-service (or fee per item), and
capitaYon. Each system has its disYnct advantages and disadvantages, impacYng both
employers and employees in various ways.

1. Salaried Pay

Advantages:

1. Financial Stability: Salaried employees receive a fixed income, providing them with
financial stability and predictability. This allows for easier budgeYng and financial planning.

2. Focus on Quality: Without the pressure to perform a specific number of tasks or services,
salaried employees can focus on the quality of their work, fostering a more thoughuul and
thorough approach to their duYes.

3. Job SaDsfacDon: Regular pay can enhance job saYsfacYon and loyalty, as employees feel
secure and valued. This can lead to lower turnover rates and a more commifed workforce.

4. Reduced AdministraDve Burden: For employers, a salaried pay system simplifies payroll
processing and reduces administraYve tasks related to tracking hours worked or services
provided.

Disadvantages:

1. Lack of IncenDve: Since pay is not directly Yed to performance or producYvity, salaried
employees may lack moYvaYon to exceed basic job requirements or improve efficiency.

2. PotenDal for Overwork: Employers might expect salaried employees to work beyond
standard hours without addiYonal compensaYon, leading to burnout and decreased job
saYsfacYon over Yme.

3. Equity Issues: High-performing employees may feel undervalued if they receive the same
pay as their less producYve counterparts, potenYally leading to dissaYsfacYon and
resentment.

2. Fee-for-Service (Fee Per Item)

Advantages:

1.Performance IncenDves: Fee-for-service remuneraYon directly Yes compensaYon to the

quanYty of work completed, incenYvizing employees to be more producYve and efficient.

2. Flexibility: This system offers flexibility for employees who can manage their workload
and potenYally increase their earnings by taking on more tasks or clients.
3. Transparency: It is straighuorward to link pay to specific outputs, making the
remuneraYon process transparent and easy to understand for both employers and
employees.

Disadvantages:

1. **Quality vs. QuanDty:** There is a risk that employees may prioriYze quanYty over
quality, potenYally compromising the standard of work to maximize earnings.

2. **Income Variability:** Earnings can be inconsistent, leading to financial instability for

employees if the volume of work fluctuates significantly.

3. **AdministraDve Complexity:** Tracking and verifying the number of tasks or services

performed can create addiYonal administraYve burdens for employers, increasing overhead
costs.

3. CapitaDon

Advantages:

1. **Cost Control:** CapitaYon systems, oien used in healthcare, provide a set fee per
paYent or client, encouraging providers to manage resources efficiently and control costs.

2. **PrevenDve Focus:** This system incenYvizes prevenYve care and efficient resource use,
as providers benefit from keeping paYents healthy rather than performing numerous
procedures.

3. **Predictable Revenue:** For providers, capitaYon offers predictable revenue, aiding in

financial planning and stability.

Disadvantages:

1. **Under-Service Risk:** There is a potenYal for under-service, as providers may aim to

minimize costs by limiYng services, which can negaYvely impact quality of care.

2. **PaDent Volume Pressure:** Providers might take on more paYents than they can
adequately manage to increase revenue, leading to reduced quality of care and paYent
dissaYsfacYon.

3. Complex AdministraDon: ImplemenYng and managing a capitaYon system can be

complex, requiring careful monitoring to ensure balanced service delivery and financial
viability.

Each remuneraYon system—salaried pay, fee-for-service, and capitaYon—has its unique set
of advantages and disadvantages. Salaried pay provides stability and job saYsfacYon but may
lack performance incenYves. Fee-for-service moYvates high producYvity but can lead to
quality concerns and income variability. CapitaYon promotes cost control and prevenYve
care but risks under-service and complex administraYon. Choosing the appropriate system
depends on the specific context, goals, and needs of the organizaYon and its employees.
Balancing these factors is crucial to fostering a moYvated, efficient, and saYsfied workforce.