Board Review DH227
Community Oral Health
Lisa Mayo, RDH, BSDH
Concorde Career College
Public Health in US
• Public Health
– Prevents epidemics and the spread of disease
– Protects against environmental hazards
– Prevents injuries
– Promotes and encourages healthy behaviors
– Responds to disasters and assists communities in
recovery
– Assures the quality and accessibility of health
services
Public Health in US
• Essential Public Health Services
– Monitor health status to identify community health
problems
– Diagnose and investigate health problems and health
hazards in the community
– Inform, educate, and empower people about health
issues
– Mobilize community partnerships to identify and solve
health problems
– Develop policies and plans that support individual and
community health efforts
Public Health in US
• Essential Public Health Services
– Enforce laws and regulations that protect health
and ensure safety
– Links people to needed personal health services
and assure the provision of health care when
otherwise unavailable
– Assure a competent public health and personal
health care workforce
– Evaluate effectiveness, accessibility, and quality of
personal and population-based health services
Public Health in US
General Public Health
• WHO: World Health Organization
• Public Health: 1920
– The science and art of preventing disease,
prolonging life and promoting physical health and
efficiency through organized community efforts
– Criteria for Public Hl Problem
1. The disease or other threat to health is widespread
2. The disease is one that can be prevented, alleviated
or cured
3. Such knowledge is not being applied
Public Health
• Characteristic of a Public Hl Measure
1. Not hazardous to life or function
2. Effective in reducing or preventing the targeted
disease or condition
3. Easily and efficiently implemented
4. Potency maintained for a substantial time period
5. Attainable regardless of socioeconomic status,
education or income
6. Effective immediately on application
7. Costs are inexpensive and within the means of the
community
What is Dental Public Health
• Concern for and activity directed toward the
improvement and promotion of the dental
health of the population as a whole
• Form of dental practice that serves the
community as the patient instead of the
individual
Board Alert – Know This!
PRIVATE PRACTICE
DENTAL PUBLIC HEALTH
1 practitioner
Team
1 patient
Group
Dental Office
Health Center
Hl Hx & Exam
Survey & Needs Assessment
Exam
Survey
Diagnosis
Data Analysis
Treatment Plan
Program Plan
Case Presentation
Selling Program
Treatment
Program Implementation/Operation
Fee Payment
Budget/Financing/Funding
Patient Evaluation
Program Evaluation/Appraisal
Board Question
The Department of Health and Human Services
is a branch of which level of government?
a.
b.
c.
d.
State
Local
Federal
International
Board Question
The Department of Health and Human Services
is a branch of which level of government?
a.
b.
c.
d.
State
Local
Federal
International
Community Hl Programs
• Collect needs Assessment data
• Planning steps:
1.
2.
3.
4.
5.
6.
7.
8.
Analyze data
Rank needs (prioritize)
Identify goals
Develop objectives (performance, condition, criteria)
Identify resources/make budget
Plan activities
Implement plan
Evaluate (on-going)
Question
The first step in establishing a community dental
health program is to:
a. Identify community needs
b. Appoint consumer advocates to the
planning committee
c. Identify current dental health programs
d. Determine dental manpower in the
community
Question
The first step in establishing a community dental
health program is to:
a. Identify community needs
b. Appoint consumer advocates to the
planning committee
c. Identify current dental health programs
d. Determine dental manpower in the
community
Question
Which of the following demonstrated the most
effective and efficient of a community hygienist’s
time?
a. Conducting regular oral cancer screenings
b. Rendering oral prophy’s and topical fluoride
treatments
c. Delivering dental health instruction to
elementary school
d. Organizing teachers to implement a schoolbased program involving self-application of
topical fluoride
Question
Which of the following demonstrated the most
effective and efficient of a community hygienist’s
time?
a. Conducting regular oral cancer screenings
b. Rendering oral prophy’s and topical fluoride
treatments
c. Delivering dental health instruction to
elementary school
d. Organizing teachers to implement a schoolbased program involving self-application of
topical fluoride
4 Government Levels of
Community Dental Health
1.
2.
3.
4.
International
Federal
State
Local
4 Government Levels of Community Dental Health
1. International
– Coordinates programs for underdeveloped nations and gather
epidemiological data for comparisons across nations
– Develops means to summarize tx needs of international
populations utilizing minimal equipment
– WHO
2. Federal
– Acts on oral health problems of national significance
– Primarily within the jurisdiction of the Dept of Hl and Human
Services (DDHS)
– Board Alert! DDHS published Healthy People 2010
– Ex: CDC, Health Resources and Services Admin, National
Institute of Health, NIDRC, Agency for Healthcare Research and
Quality
4 Government Levels of Community Dental Health
3. State
– Provides consultation services to local health dept,
directly administers some programs
4. Local
– Directly administers county and city programs,
initiates dental health legislative measures (ex:
Fluoridation)
Epidemiology
• Science of the measurement of the circumstances
under which a disease (or health problem) occurs
among groups of people
• Study of the occurrence and distribution of
disease (patterns)
• Multi-factioral: involves the host, agent and/or
environment
• Relates factors affecting health and disease in
population to factors in the environment
Epidemiology
• Terms of related concepts
1. Epidemic: occurrence of a group of illnesses of similar
nature clearly in excel of the normal expectancy and
derived from a common source
2. Endemic: the usual levels of a disease that is found within
a certain population; continuing problem: fluorosis
3. Pandemic: a disease affecting the majority of the
population or a large region or one which is epidemic at
the same time in many parts of the world
4. Mortality: # of deaths in a population
5. Morbidity: amt of diseases or illness in a population
Epidemiology Research
1. Descriptive Rsrch
-Describes the sample group and includes
interpretation of data to evaluate a current
event/situation
-Incidence: # NEW cases of disease w/in a
population OVER A PERIOC OF TIME (Ratio)
-Prevalence: # of persons in a population
affected by a condition at any one time (%
ratio)
Epidemiology Research
2. Analytic Rsrch
-Determined the cause of disease, or if a causal
relationship exists between a factor
-Prospective Cohort Study: planned before data
is collected – over along period of time to see
who develops the disease
-Retrospective Study: study using data collected
in the past – after study is over
-Case Control Study: comparing one population
that has the disease with one that does not
Epidemiology Research
3. Experimental Rsrch
-Demonstrates cause and effects
-Tests hypotheses (predict relationships among
variable)
-Experimental design
-Use of sample to allow for generalization
-Can allow for interference if study is deemed to
be valid and reliable
-Interference: generalizing from a sample to the
general population of interest
Epidemiology
• Studies usually reports findings in terms of either
PREVALENCE or INCIDENCE of disease (Board Alert!)
– Prevalence: refers to the estimated population of people
who are managing a disease at any given time
– Incidence: refers to the annual diagnosis rate or the
number of new cases of a particular disease diagnosed
each year
– These 2 stats can differ: a short-lived disease like flu can
have high annual incidence but low prevalence while a lifelong disease like diabetes has a low annual incidence but
high prevalence
Uses for Epidemiology
Board Alert – know this list!
• Collecting data to describe normal biological processes
• Understanding the natural hx of a disease process
• Measuring the distribution o a disease in a given population
• Id determinant of disease
• Testing hypotheses for prevention and control of a disease
through studies
• Planning and evaluating health care services
Indices of Epidemiology
• Key is to know the acronyms and what they are
measuring such as perio, caries, etc…
• Another key = if you get a case that gives you
numbers. Remember that the smaller the #, the
less amount of disease. Ex: Measuring decay if
the number is 1 then this means low levels of
decay
• Dental Index: mathematical description of a
disease or condition based on carefully
determined criteria under specific circumstances
Index
Board Alert!
Characteristic of ideal index
Simple
Utility: clear, simple, objective
Valid: measures what is intended to be measured
Reliable: measures consistently at different times,
reproducibility, stability of measurement
Clear
Sensitive: to shifts in disease in either direction
Quantifiable: amenable to statistical analysis
Objective
Acceptable: to subjects involved
Index
• Validity and Reliability
– An index is valid when it accurately measures what was
intended to be measured
– An index is reliable when it consistently gives same results
each time
• Calibration is a method of standardizing examiners,
increases reliability, decreases variation in assessing
and recording observations of a study
– Blind: when either subjects or raters, but not both, are
unaware of subject placement into experimental grps
– Double Blind: when both raters and subjects are unaware
of which tx the subject is receiving
Index
• General Categories
1. Reversible: measured conditions that can be
resolved or reversed (Gingivitis)
2. Irreversible: measures cumulative conditions
that CANNOT be resolved (Caries & Perio)
3. Simple: measures the presence or absence of a
disease
4. Cumulative: measures all evidence of a condition
(past & present)
Irreversible Index
• Dental Caries: Irreversible
– DMFT: Decayed, missing, filled teeth surfaces. Do
NOT include 3rd molars, unerupted, congenitally
missing, primary tooth retained w/ perm
successor erupted, teeth restored for reasons
other than dental caries such as trauma, teeth
removed for reasons other than caries
– DEF, DF, DMF: Indicates teeth to be extracted due
to decay (lower case letters would indicate
primary teeth)
– RCI (Root Caries): Requires recession!!!
Irreversible Index
• CAMBRA
– Caries management by risk assessment
– Id the cause of disease through the assessment of risk factors
for each indv patient and then managing those risk factors
through behavioral, chemical and minimally invasive procedures
– Risk assessment grounded in the use of a CARIES RSK
ASSESSMENT FORM
– Separate form for pedo patients
– Based on answers = divide into low, mod, high, extreme risk
– Sealants are recommended for indv at moderate or higher risk
levels
– Frequency of recall caries exams and BWX increase risk level
increases
– Salivary testing is optimal for low-risk and mod-risk indv
Gingivitis Index
• GI (gingival Index)
– Reversible
– Based on severity versus extent of inflammation
– Can be used in individuals or study participants
• SBI (Sulcular Bleeding Index)
– Reversible
– Detects EARLY signs of gingivitis
– Useful in short-term trials
Periodontal Index
• PDI (Periodontal Disease Index)
– Irreversible & reversible (measures gingivitis separately)
– Developed by Ramfjord
• PI (Periodontal Index)
– Irreversible
– Developed by Russel
– Looks at surrounding tissue, Questionable for validity (no CAL)
• PSR (Periodontal Screening and Recording)
– Rapidly assesses perio health
– Required a special probe, useful as a preliminary screening technique
and for use in large populations
• CPITN (Community Periodontal Index of Treatment Needs)
– Developed by WHO
– Determines periodontal NEEDS versus periodontal STATUS requires
special probe
OHI Index: on Last Year’s Boards!
•
•
•
•
OHI-S (Simplified Oral Hygiene Index)
– Reversible
– Measures oral hygiene status by assessing sub-&-supra plaque and calculus
– Better for group vs individual assessment
PII (Plaque Index)
– Reversible
– Developed by Silness and Loe
– Used in conjunction with the Gingival Index
– Scores plaque according to its thickness at the gingival margin
PHP (Patient Hygiene Performance)
– Reversible
– Measures plaque after toothbrushing
VMI (Volpe-Manhold Index)
– Reversible
– Used to test agents for plaque control and calculus inhibitions, measures supra
calculus formation following a prophy
Index
A lot of Index-style questions appear in the case
study section
Know which index should be used for each case
Board Question
All the following are characteristics of an ideal
index EXCEPT one.
a.
b.
c.
d.
Valid
Reliable
Complex
Objective
Board Question
All the following are characteristics of an ideal
index EXCEPT one.
a.
b.
c.
d.
Valid
Reliable
Complex
Objective
Summary of Current Diseases Trends
• Dental Caries
– Age: root caries increase with increase age
– Gender: females higher
– Race/Socioeconomic Status: Hispanics, African-Americans
higher
• Periodontal Disease
– Not as well understood as dental caries, but knowledge of
disease and accuracy of measurement increasing
– Prevalence of severe gingivitis 7-15% worldwide
– Age, gender, race/socioeconomic status: only increase age
equals increase risk perio
Summary of Current Diseases Trends
• Tooth Loss
– Caries principle cause tooth loss at almost all ages with the
exception of the oldest age groups (over 60)
– Edentulouism decreasing in US
– Gender: females more
– Race: slightly higher among whites
• Oral Cancer
–
–
–
–
–
Life and death implications
Most persistent environmental risk factor is tobacco use
Also related to alcohol, HPV
Age: young and old
Gender: twice as much in males, females starting to gain
with HPV
Summary of Current Diseases Trends
• Utilization of Dental Services
– Diminishing number young people
– Increased # persons living in poverty
– Patterns
• Age: peak ages: late teens, adults, more elderly due to
tooth retention
• Gender: more women but both increasing
• Race/Socioeconomic Status: high SES = greater use
Question
One method to decrease variation in assessing and
recording observation when conducting a study is to:
a. Use a more sensitive index instead of the simple
ones
b. Have examiners eval common subjects, compare
results and come to an agreement
c. Have examiners take more time in scoring subjects
d. Increase the number of examiners
e. Rotate the number of examiners
Answer
One method to decrease variation in assessing and
recording observation when conducting a study is to:
a. Use a more sensitive index instead of the simple
ones
b. Have examiners eval common subjects, compare
results and come to an agreement
c. Have examiners take more time in scoring subjects
d. Increase the number of examiners
e. Rotate the number of examiners
Question
Epidemiological studies of dental caries suggest all
trends except:
a. Caries occur where there is gingival recession
b. Males have higher DFM scores than females
c. Caries experience increases steadily with age
d. Females have higher DFM scores than males
e. Overall caries rates are declining
Answer
Epidemiological studies of dental caries suggest all
trends except:
a. Caries occur where there is gingival recession
b. Males have higher DFM scores than females
c. Caries experience increases steadily with age
d. Females have higher DFM scores than males
e. Overall caries rates are declining
Question
The def index is designed to determine
a. Decayed, missing and filled primary teeth
b. Decayed, missing, and filled permanent
teeth
c. Decayed, indicated for extraction due to
decay and filled primary teeth
d. Decayed, erupted and filled primary teeth
Answer
The def index is designed to determine
a. Decayed, missing and filled primary teeth
b. Decayed, missing, and filled permanent
teeth
c. Decayed, indicated for extraction due to
decay and filled primary teeth
d. Decayed, erupted and filled primary teeth
Question
The amount of untreated dental caries in a
population at a given point in time is the
caries:
a. Index
b. Incidence
c. Increment
d. Prevalence
e. Morbidity rate
Answer
The amount of untreated dental caries in a
population at a given point in time is the
caries:
a. Index
b. Incidence
c. Increment
d. Prevalence
e. Morbidity rate
Question
Which of the following is characteristic of stratified
sampling?
a. Each subject has an equal chance of being
selected
b. Every nth subject is chosen from a
representative sample
c. Subjects are randomly chosen from a
previously subdivided population
d. Subjects are randomly chosen from individuals
with special characteristics
Answer
Which of the following is characteristic of stratified
sampling?
a. Each subject has an equal chance of being
selected
b. Every nth subject is chosen from a
representative sample
c. Subjects are randomly chosen from a
previously subdivided population
d. Subjects are randomly chosen from individuals
with special characteristics
Community Dental Health Programs
• Steps in developing a community program
1. Assessment: First step is to conduct NEEDS
ASSESSMENT (Board Alert!)
2. Planning
3. Implementing
4. Evaluation
Needs Assessment
• Reason: define extent & severity of problem, id cause, provide a
profile of the community, collects baseline data
• Board Alert – know which method works best for the target
population – analyze time, costs and community constraints
• Ways to conduct needs assessment
– Direct observation
– Interview
– Questionnaire
– Survey (BEST choice for large groups)
– Epidemiological surveys (rsrch based)
– Records, documents, charts (time consuming)
Needs Assessment Considerations
1. Access to Care Issues
1. Needs: type of care available (office accepting Medicaide
pt in a town of 65,000)
2. Demand: type of care desired (whitening vs restorative
procedures)
3. Utilization: actual use of services available by the public
4. Barriers: obstacles which interfere with care to be
provided or received (lack of funding for low cost dental
services)
Needs Assessment Considerations
2. Ways to Observe Needs
– Through eyes of the PLANNER
• Real needs based on health issues
• Objective
– Through eyes of the TARGET POPULATION
• Perceived needs or wants, opinion, subjective
• Ex: the study participants want wht vs rest procedures
Needs Assessment Considerations
3.
Population Profile
– Gathers info about target population
– Info included
1.# indv who will be part of program
2.Geographic distribution of the target population
3.Rate of growth in the community
4.Degree of urbanization
5.Ethnic & language profile
6.Nutritional status
7.Standard of living
8.Amt & type of community services and utilities
9.Profile of school system
10.Gen health profile
Needs Assessment Examination Methods
• Type I: Comp exam using mirror, explorer,
lighting, x-rays, study models, diagnostic tests,
percussion, pulp vitality tests, transillumination,
lab tests
• Type II: limited exam using mirror, explorer,
lighting, limited x-rays. Useful when program
may include dental tx for individuals and when
time/money permit
BOARD ALERT!!
Needs Assessment Examination Methods
• Type III: Exam using mirror & lighting only. Adv: OHI
basis, establishing rapport and planning motivational
strategy, baseline info on dental needs of a group.
Disadv: need for complete assessment overlooked, no
value unless follow-up occurs
• Type IV: Exam using tongue depressor & lighting only.
Id glaring needs for assessment in program planning
Type III & IV are most common method used in dental
public health and in developing countries
BOARD ALERT!!
2. Planning Community Program
• Systematic approach involving:
– Collection of Preliminary Info
• Funding: Medicare, Medicaid, COBRA, Black grants, Line
item grants
– Establishment of Priorities: rank problems
– Determine Goals/Objectives
• Goals: broad-based statement of desired outcome
• Objectives: must be measurable
– Consulting/Coordinating Activities
• Facility, manpower, plan of action
– Drafting a Plan
• Lesson plan, implementation strategy
3. Implementing
• Principles of Learning
– Motivational factors, learning only progresses as far as
learner wants
– External motivation or Internal motivation
• Principles of Teaching
– Teach way skills are to be used, id learner needs,
establish goals/objectives, design learning strategies
based on objectives, plan an evaluation, info delivery
• Formal Delivery: lecture, demonstration, discussion
• Informal Delivery: brochures, pamphlets, billboards
3. Implementing
• Principles of Learning
– Motivational factors, learning only progresses as far as
learner wants
– External motivation or Internal motivation
• Principles of Teaching
– Teach way skills are to be used, id learner needs, establish
goals/objectives, design learning strategies based on
objectives, plan an evaluation, info delivery
• Formal Delivery: lecture, demonstration, discussion
• Informal Delivery: brochures, pamphlets, billboards
3. Implementation
• Stages of Learning (BOARD ALERT!)
1. Unawareness: learner has incomplete or inaccurate
info
2. Awareness: correct info is given but it does not have
personal meaning for learner
3. Self-Interest: learner personalizes info
4. Involvement: old ideas replaced by new ones, learner
is motivated to act
5. Action: learner tests new concept based on perceived
needs
6. Habit: learner begins to experience gratification and
self-satisfaction, behavior is modified at this stage
4 Evaluation
•
•
•
•
•
Also called program appraisal
Provides info for future program revisions
Analyses whether or not goals & objectives were met
May be formal or informal
Must be continuous from the beginning of the
program
• Dependent from baseline data from needs
assessment
Board Question
The first step in implementing a community
health program is
a.
b.
c.
d.
Selection of a venue
Recruitment of volunteers
Conduction of a needs assessment
Determination of goals and objectives
Board Question
The first step in implementing a community
health program is
a.
b.
c.
d.
Selection of a venue
Recruitment of volunteers
Conduction of a needs assessment
Determination of goals and objectives
Community Dental Health Programs
Fluoride
• Fluoridation Programs
– 1part to 1 million parts water: range = 0.7-1.2ppm
• Depends on mean daily temperature
• Warmer = lower
– 17-40% reduction cost
– Compounds used
1. Na silicofluoride (solid)
2. Na fluoride (solid)
3. Hydrofluosilic acid (liquid)
• School Water Fluoridation (next slide)
• Fluoride Drops
• Pit and Fissure Seals
Community Dental Health Programs
Fluoride
• School Water Fluoridation
– Fluoridated 4.5x the optimal concentration
recommended for the community
– Reduce caries by 25%
• F Drops
– 0.125, 0.25, 0.50mg
– Tablets: 0.50 and 1.0mg, oral rinse 1mg/15ml
– Antifluoridationists are most successful at local
levels rather than state or national
Community Dental Health Programs
Health Education Pgrms
• Is the provision of health information to people that they
apply in everyday living; a process with intellectual,
psychological and social dimensions relating to activities
that increase the ability of people to make informed
decisions affecting their personal, family and community
well being
• Cognitive vs Behavioral Learning
• Special Needs Populations: elderly, disabled, medically
compromised, indigent
Community Dental Health Programs
Tx Pgrms
•
•
•
•
Limit services
Target populations
Consider Resources/Money/Facilities
Demand
– Effective Demand is the desire for care and the
ability to obtain it
– Potential Demand is the desire for care and the
inability to obtain it
Community Dental Health Programs
Financing Pgrms
• Medicare, Medicaid
• Local, county state, federal
• Private foundations, organizations,
corporations
• Fee for service, third party plans
• Managed care
Question
Which of the following should be considered in
planning learning activities for dental health
education?
a. Content to be learned
b. Previous dental health knowledge
c. Developmental levels of the group
d. Environment in which learning will take
place
e. All the above
Answer
Which of the following should be considered in
planning learning activities for dental health
education?
a. Content to be learned
b. Previous dental health knowledge
c. Developmental levels of the group
d. Environment in which learning will take
place
e. All the above
Question
Select the first step of the following to formulate a dental
program aimed at an underserved community
a. Assess the needs of the community and develop
program goals
b. Establish priorities for dental health problems of
the community
c. Analyze factors that interfere with dental health
care in the community
d. Select strategies to meet dental needs of the
community
e. Evaluate effectiveness of the community dental
health program
Answer
Select the first step of the following to formulate a dental
program aimed at an underserved community
a. Assess the needs of the community and develop
program goals
b. Establish priorities for dental health problems of
the community
c. Analyze factors that interfere with dental health
care in the community
d. Select strategies to meet dental needs of the
community
e. Evaluate effectiveness of the community dental
health program
Question
In evaluation, both reliability and validity are
important considerations. If an author states that
his data are reliable, that means the date:
a. Would be reproductive
b. Would relate positively to an outside
criterion
c. Were obtained in an honest manner
d. Can be generalized to a larger population
e. Were collected by 1 person
f. All the above
Answer
In evaluation, both reliability and validity are
important considerations. If an author states that
his data are reliable, that means the date:
a. Would be reproductive
b. Would relate positively to an outside
criterion
c. Were obtained in an honest manner
d. Can be generalized to a larger population
e. Were collected by 1 person
f. All the above
Question
Select the first step in correct order for the
following research steps.
a. Data collection
b. Conclusion
c. Hypothesis
d. Problem identification
e. Analysis and interpretation
Answer
Select the first step in correct order for the
following research steps.
a. Data collection
b. Conclusion
c. Hypothesis
d. Problem identification
e. Analysis and interpretation
Question
In developing a community profile, the information
gathered does all the following except:
a. Is only necessary for large dental health
programs
b. Is limited to geographic boundaries, population
size and demographic data
c. Is useful when working wit large or small
communities
d. Provides a comprehensive overview of the
community
e. Is a crucial step in the planning process for
many reason
Answer
In developing a community profile, the information
gathered does all the following except:
a. Is only necessary for large dental health
programs
b. Is limited to geographic boundaries, population
size and demographic data
c. Is useful when working wit large or small
communities
d. Provides a comprehensive overview of the
community
e. Is a crucial step in the planning process for
many reason
Question
In a nonfluoridated community, which preventive
dental health program would have the maximum
cost benefit for the control of caries in
elementary school children?
a. Dental health education program
b. Fluoride mouth rinse program
c. Restorative care program
d. Parent-teacher education program
e. Pit and fissure sealant program
Answer
In a nonfluoridated community, which preventive
dental health program would have the maximum
cost benefit for the control of caries in
elementary school children?
a. Dental health education program
b. Fluoride mouth rinse program
c. Restorative care program
d. Parent-teacher education program
e. Pit and fissure sealant program
Question
The most effective way to provide oral hygiene
instruction in a nursing home
a. Hand out pamphlets to residents
b. Train the nurses/caregivers
c. Teach the nursing home residents
d. Send written material to the
administrator
Answer
The most effective way to provide oral hygiene
instruction in a nursing home
a. Hand out pamphlets to residents
b. Train the nurses/caregivers
c. Teach the nursing home residents
d. Send written material to the
administrator
Preventing & Controlling Disease
• Oropharyngeal Cancer: HPV, alcohol, tobacco
• ADHA Smoking Cessation Initiative: refer to
Wilkins/Darby
• Craniofacial Birth Defects: cleft lips/palate, prenatal
care
• Facial injury or trauma: mouthguards