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Preface to the Fourth Edition As initiators of Clinical Dentistry, and editors of the first three editions, we are not only pleased to note the impressive success of the book internationally but, in our increasingly busy senior academic roles, are also delighted to pass the reins to our long-time colleague and friend, Professor Crispian Scully CBE, and wish him and the contributors continued success with the 4th edition. Professor Ivor Chestnutt Cardiff Professor John Gibson Glasgow The primary objective of this Pocketbook was to provide a readily accessible source of information when it is most needed, as an aidemémoire prior to carrying out clinical tasks or to enable students (at undergraduate and postgraduate level) to apprise themselves of important details prior to tutorials and seminars. Those aims remain. In a publication of this nature, information must be presented in a concise and, at times, didactic fashion. The intent is to include sufficient basic information to permit examinations to be passed. However, the desire of an educationalist is always to promote deep learning and the layout and content of the text are intended to motivate and guide the reader to the appropriate parts of more substantive texts, many of which have proven both inspirational and motivational for the editors and contributors of this book throughout their careers. This textbook is widely used by more and more undergraduate dental students, vocational dental practitioners, general professional trainees, dental surgeons in primary care and in the hospital service, as well as dental care professionals in-training and post-qualification. I was requested to take on the editing of the 4th edition. For this edition I have expanded the size and type of authorship. Although a large proportion of current contributors were involved in earlier editions, some previous authors were unavailable to help, so we have also recruited a range of other top people in their fields. The current authors are all experienced clinicians, teachers and/or managers within their individual specialties and emphasis has been given to information of practical clinical significance. Descriptions of rarely encountered conditions and situations have been deliberately minimized.
Preface to the Fourth Edition
In updating this edition, each author has addressed significant changes within his or her areas of expertise and I am grateful to them for their enthusiasm and great industry and particularly for complying with deadlines. Thus this new 4th edition has not only been invigorated and enhanced but also the chapter order has been rearranged. We have also expanded on practical aspects related to the regulator – the General Dental Council; and on the dental team roles, and practice management. The book has been written to be used in conjunction with Scully’s Handbook of Medical Problems in Dentistry (Elsevier 2016) and now includes issues related to overseas dental staff, access for disabled, advertising, aetiopathogenesis of dental disease, assaults on staff, behaviour at work and outside (GDC standards), building design, chaperoning, clothing, finance management, foundation and vocational training, governance, health and safety, hiring and firing, identifying staff, independent practice, infection control, information technology, management skills, marketing, NHS regulations, overseas staff, professionalism, protected characteristics, significant event analysis, time-keeping and things staff must do before starting work and leaving a job. The aims and objectives remain the same – to educate and inspire each member of the whole dental team, whether in-training or post-qualification. I am indebted for support from the authors, Professor Ivor Chestnutt, Professor John Gibson, Professor Justin Stebbing and at Elsevier, Mrs Lynn Watt and Mrs Alison Taylor. Our thanks are also due to former contributors, including Iain. B. Buchanan, Barbara. L. Chadwick, Ivor. G. Chestnutt, John Gibson, Jason Leitch, Joe McManners, Jeremy Rees and Dave Stenhouse. Crispian Scully London, 2016
Contributors Stephen Barter BDS MSurgDent RCS Specialist Oral Surgeon Perlan Specialist Dental Centre Hartfield Road Eastbourne, UK Stephen Barter is Clinical Director of Perlan Specialist Dental Centre, Eastbourne; Specialist in Oral Surgery and Hon. Lecturer in the Department of Periodontology, UCL Eastman Dental Institute, London; ITI Fellow and past Chairman of the UK and Ireland ITI Section and has been involved in the teaching and development of dental implantology for over 20 years.
John A.D. Cameron BDS DGDP LLB (Hons) Senior Clinical/Dental Adviser Practitioner Services NHS National Services Scotland Edinburgh; University of Aberdeen Dental School Aberdeen, UK John Cameron is Senior Dental Adviser at NHS National Services Scotland, Senior Clinical Lecturer at the University of Aberdeen Dental School, Lead for Law, Ethics and Professionalism. He is also Chairman of the Dentists Health Support Programme and Trust.
Iain Chapple BDS FDSRCPS PhD FDSRCS CCST (Rest Dent) Periodontal Research Group and MRC Centre for Immune Regulation School of Dentistry College of Medical and Dental Sciences University of Birmingham Birmingham, UK Professor Iain Chapple is Head of Periodontology at the University Birmingham’s School of Dentistry and Clinical Lead for an NHS service base of 6 million. He is Associate Editor of Journal of Clinical Periodontology and Periodontology 2000 and former Scientific Editor of the British Dental Journal and former Associate Editor of Journal of Periodontal Research. President of The British Society of Periodontology (2014–2015), President of The Periodontal Research Group of the International Association of Dental Research (2007), Treasurer and Executive Committee member of the European Federation of Periodontology (EFP) (2007–2013), EFP Scientific Advisory Committee Chairman (2013–2015), Secretary General (2016–), EFP Workshop Co-Chairman (2009–current). He has written and edited seven books and 16 book chapters and published over 140 full papers on Medline. He was awarded the Tomes Medal by the Royal College of Surgeons of England in 2012.
Fiona Cox B.Ed MInstLM Ferndale Dental Clinic Ltd Devizes, UK
Fiona Cox is co-owner at Ferndale Dental Implant and Cosmetic Clinic. She has a wide experience in management within the private health sector and the NHS dental and medical health fields.
Martyn Cox BSc (Hons) BDS MFGDP RCS (Eng) FRSM, PhD Clinical Director Ferndale Dental Implant Clinic Implant mentor and tutor Dentale Advanced Implant course, Honorary Specialist Oral Surgeon, Solihull Hospital Lecturer Martyn Cox is the Clinical Director at Ferndale Dental Implant and Cosmetic Clinic, Devizes. He is a clinical trainer/lecturer and mentor in Advanced Implantology in Bristol and Shrewsbury, an Honorary Oral Surgeon at Solihull Hospital, Birmingham and a lecturer on the FGDP Oral Surgery course. Martyn has been awarded numerous research prizes in the UK and has published widely in both UK and international peer-reviewed journals including several oral cancer textbooks and has lectured on implantology, oral cancer and human papilloma virus genetics in the UK, Europe and the USA.
Dr Daljit Gill is a Consultant Orthodontist at Great Ormond Street NHS Foundation Trust and UCLH Eastman Dental Hospital. He has written a number of textbooks and is involved in training orthodontists, therapists and nurses.
Nikos Donos DDS MS FHEA FDSRCSEngl PhD Head Centre for Oral Clinical Research Professor and Chair Periodontology and Implant Dentistry Honorary Professor, UCL Eastman Dental Institute, UK Honorary Professor, University of Hong Kong Honorary Professor, Griffith University, Australia Centre for Clinical Oral Research Institute of DentistryBarts and The London School of Medicine and DentistryQueen Mary University of London (QMUL) Awarded the title of Honorary Professor at the Faculty of Dentistry in Hong Kong (2009) and the title of Adjunct Professor at the Dental School, Griffith University, Australia (2012), Professor Donos is involved as editorial board member in a number of international and national peer-reviewed journals in the field of Periodontology and Implant Dentistry and has published extensively. In 2011, he was awarded the prestigious annual IADR-Periodontology Group Award in Periodontal Regenerative Medicine. His clinical expertise is in the field of Periodontics and Implant Dentistry and he has significant experience in periodontal/bone regeneration and implant related surgical procedures as well as treatment of peri-implantitis, topics which he regularly lectures on at a national and international level.
David H. Felix BDS MB ChB FDS RCS (Eng) FDS RCPS (Glasg) FDS RCS(Ed) FRCP(Ed) Dean of Postgraduate Dental Education NHS Education for Scotland Edinburgh, UK
Dr David H. Felix is Postgraduate Dental Dean, NHS Education for Scotland and Chair of the Joint Committee for Postgraduate Training in Dentistry. Previously Consultant in Oral Medicine Glasgow Dental Hospital and School. He is a former Dean of the Faculty of Dental Surgery of The Royal College of Surgeons of Edinburgh and a former President of the British Society for Oral Medicine.
Mark Griffiths MBBS FDS RCS BDS Visiting Professor, UCL (Eastman Dental Institute); Honorary Research Fellow, School of Physiology, Pharmacology and Neuroscience University of Bristol Bristol, UK Mark Griffiths is Visiting Professor, UCL (Eastman Dental Institute), London, UK and Honorary Research Fellow, School of Physiology, Pharmacology and Neuroscience at the University of Bristol. He is a retired NHS Consultant in Special Care Dentistry at the Bristol Dental Hospital. Holder of Patent: Monitoring electrical activity (Electroencephalograph) and Member of University of Bristol Neuroscience Community.
Athanasios Kalantzis DipDS MFDSRCS MBChB MRCS FRCS (OMF) Oral and Maxillofacial Surgery Consultant Central Manchester Foundation Trust Manchester, UK
After qualifying in Dentistry in Athens, Greece and in Medicine in Sheffield, UK, Mr Kalantzis trained in Oral and Maxillofacial Surgery at the Oxford University Hospitals and served as Members Representative and Fellows in Training Representative of the British Association of Oral & Maxillofacial Surgeons as well as Officer of the Junior Trainees Group. He is a member of the Royal College of Surgeons of England and has taught oral and maxillofacial trainees for several years. He has presented papers nationally and internationally and has experience in organizing as well as chairing national and international conferences. Mr Kalantzis is co-author of the books Oxford Handbook of Dental Patient Care 2e and the Oxford Specialist Handbook of Medicine and Surgery for Dentists and is on the Editorial Board of Medical Problems in Dentistry 6e, and is a regular reviewer for journals such as Oral Oncology and British Journal of Oral & Maxillofacial Surgery.
Tatiana Macfarlane BSc PhD MICR FHEA Senior Research Fellow University of Aberdeen, Dental School Aberdeen, UK
Dr Tatiana Macfarlane is a Senior Research Fellow at the University of Aberdeen Dental School, UK. She previously worked at the University of Manchester in England, European Institute of Oncology in Italy and International Agency for Research of Cancer in France. Her main research interests are in epidemiology of head and neck cancer and oral health epidemiology. She has been involved in major international collaborations such as Alcohol-related Cancers and Genetic Susceptibility in Europe (ARCAGE) and International Head and Neck Cancer Epidemiology Consortium (INHANCE). She is a Fellow of the Royal Statistical Society (RSS), Fellow of the Institute of Learning and Teaching in Higher Education (ILTHE), member of the International Epidemiological Association (IEA), member of the American Association for Cancer Research (AACR) and professional member of the Institute of Clinical Research (ICR). She has authored over 120 peer-reviewed papers.
Avril Macpherson BDS (Edin) FDS RCSEd MFDS RCSEd MSND RCSEd DipConSed (N’castle) PGCTLCP (Edgehill) FHEA Clinical Director Liverpool University, Dental Hospital Liverpool, UK
Avril Macpherson was appointed Consultant/Honorary Senior Clinical Lecturer in Special Care Dentistry, Liverpool University Dental Hospital and School of Dentistry, in 2010. She is a member of the British Society of Disability and Oral Health Executive Committee, the Specialty Advisory Committee in Special Care Dentistry (RCSEng), the Specialty Advisory Board in Oral Medicine and Special Care Dentistry (RCSEd) and is a Regional Specialty Advisor in Special Care Dentistry (RCSEng). Avril teaches widely in conscious sedation and special care dentistry and is a member of teaching faculty of the Society for the Advancement of Anaesthesia in Dentistry and a Resuscitation Council Advanced Life Support instructor. She is a RCSEd examiner for MFDS and MSCD examinations.
Jasmine Murphy BDS (Hons) MSt (Camb) MFGDP UK MFDS RCS (Edin) MFDS RCS (Eng) MRes (Manc) FDS RCS (Eng) FFPH Consultant in Public Health (Children and Young People, Sexual Health, Dental Public Health) Leicester City Council Leicester, UK Jasmine Murphy is a Consultant in Public Health at Leicester City Council and registered as a Specialist in Dental Public Health with the General Dental Council. Children in Leicester have been reported to have the worst level of dental health in England and therefore Jasmine established the Oral Health Promotion Partnership Board and is driving forward the implementation and mobilization of Leicester’s first Oral Health Promotion Strategy for pre-school children. Leicester’s dental public health programme ‘Healthy Teeth, Happy Smiles!’ is an early intervention programme that is modelled on Scotland’s ChildSmile. Jasmine also contributed to Public Health England’s ‘Commissioning Better Oral Health’ guidance, is a core member of the National Institute of Health and Care Excellence (NICE) Public Health Advisory Committee and is also currently contributing to NHS England’s Commissioning Guide on Paediatric Dentistry. Jasmine has also recently been invited to join the Editorial Board of Oral Diseases journal.
Farhad B. Naini BDS (Guy’s) MSc (Lond) PhD (KCL) FDSRCS (Eng) MOrthRCS (Eng) FDSOrth.RCS (Eng) GCAP(KCL) FHEA Consultant Orthodontist Maxillofacial Unit Kingston Hospital and St George’s Hospital London, UK Dr Naini is the Consultant Orthodontist in the Maxillofacial Units at Kingston Hospital and St George’s Hospital, Chair of the multidisciplinary Cranio-OrbitoFacial Surgery Group and Research Lead for Dentistry and Orthognathic Surgery. He has over 80 peer-reviewed publications and is editor of major textbooks on orthodontics and orthognathic surgery. He is also author of the reference textbook Facial aesthetics: concepts and clinical diagnosis.
Tim Newton BA PhD CPsychol AFBPsS CSci Unit of Social and Behavioural Sciences King’s College London, Dental Institute Guy’s Hospital London, UK
Professor of Psychology as Applied to Dentistry and Honorary Consultant Health Psychologist at King’s College London Dental Institute, Tim has worked in the behavioural sciences in relation to dentistry for over 20 years, and his particular interests include the management of dental anxiety, interventions to enhance oral health related behaviour and the working life of the dental team. He has published over 250 peer-reviewed articles in scientific journals.
Paul P. Nixon BDS FDSRCS (Eng) DDRRCR Consultant in Maxillofacial Radiology School of Dentistry Liverpool University, Dental Hospital Liverpool, UK
Paul Nixon is Consultant in Maxillofacial Radiology in Royal Liverpool University Hospital, clinical lead in the Dental Radiology Department and is also a specialist in Oral Surgery. He is an honorary clinical lecturer of the University of Liverpool and has an honorary contract at Alder Hey Children’s Hospital. He has authored or coauthored 26 publications. He is on the council of the British Society of Dental and Maxillofacial Radiology where he is audit lead and is responsible for their website. He recently served as external examiner for the MSc in Maxillofacial radiology at King’s College London for 6 years, is an examiner for the MJDF examination of the Royal College of Surgeons of England and is a member of the Royal College of Radiologists.
Will Palin BMedSc MPhil PhD FADM Biomaterials Unit, The School of Dentistry College of Medical and Dental Sciences University of Birmingham Birmingham, UK
Will Palin is a Reader in Biomaterials at the School of Dentistry, University of Birmingham. With a background in materials science, his developmental research for both dental and wider medical applications has attracted grant funding from the EPSRC, BBSRC, NIHR, Ministry of Defence and various industrial partners. He has authored over 70 publications and six book chapters. He is Editor of the European Journal of Prosthodontics and Restorative Dentistry, Subject Editor for Biomaterials Adhesion, International Journal of Adhesion and Adhesives and Board Member for Journal of Biomaterials Applications, Dental Materials and Journal of Dentistry.
Andrew Paterson LLM BDS (Hons) FDSRCPS DRDRCS (Edin) MRDRCS (Edin) Consultant in Restorative Dentistry, NHS Ayrshire and Arran; Honorary Clinical Senior Lecturer, University of Glasgow; Maxillofacial Unit The University Hospital Crosshouse Kilmarnock, UK Andrew Paterson is a Consultant in Restorative Dentistry mainly involved in the prosthodontic management of head and neck cancer, trauma and hypodontia patients in a District General Hospital. Formerly an NHS Consultant at Glasgow Dental Hospital with 20 years’ experience in a private specialist restorative and prosthodontics referral practice dealing with all aspects of restorative dentistry. Part-time associate dento-legal adviser with an indemnity insurer. Contributor to all previous editions of this textbook.
Crispian Scully CBE PhD MD MDS MRCS FDSRCPS FFDRCSI FDSRCS FDSRCSE FRCPath FmedSci FHEA FUCL FSB DSc DChD DMed (HC) Dr HC Emeritus Professor University College London London, UK Professor Crispian Scully is a Director of the WHO Collaborating Centre in Oral Health-General Health; journal Founder and Editor of Oral Oncology and Oral Diseases; and author or editor of 50 books, 200 book chapters and over 1000 papers on MEDLINE. He is UCL Professor Emeritus, has been Dean at UCL and Bristol, and president of several international and UK societies and has medals from Universities of Helsinki, Santiago de Compostela and Granada; Fellowship of UCL; and Doctorates from Universities of Athens, Granada, Helsinki and Pretoria.
John C. Steele MB ChB BDS MFDS RCSEd FDS (OM) RCSEd Dip Oral Med PGCTLCP FHEA Consultant and Specialist in Oral Medicine The Leeds Teaching Hospitals NHS Trust; Honorary Senior Lecturer in Oral Medicine Faculty of Medicine & Health University of Leeds Leeds, UK Dr John C. Steele is dual qualified in both medicine and dentistry and is currently Consultant, Honorary Senior Lecturer and Specialist in Oral Medicine based in Leeds. He has previously worked in a number of medical and surgical posts including emergency medicine. He has co-authored 14 articles published in peer-reviewed journals and has reviewed manuscripts for five national and international dental and medical journals. He is a current member of Council of the British Society for Oral Medicine.
Damien Walmsley PhD MSc BDS FDSRCPS The School of Dentistry College of Medical and Dental Sciences University of Birmingham Birmingham, UK
Professor Walmsley is a recognised both for his research and teaching. His research is on the the use of ultrasonics in dentistry including its use in periodontology, endodontics and its healing effects in repairing teeth. His present research funding includes imaging biofilm and observing its real time removal via ultrasonic instruments. He is very active in Interdisciplinary doctoral training centres at the University of Birmingham and is Graduate Director for Dentistry. He publishes his work in high impact scientific journals which has resulted in research and advisory roles for all the major dental companies. He is a well respected educator in Prosthodontics and also contributes to courses on Information Technology and Law/ethics courses. Clinically his work evolves around Prosthodontics and he is the leader of a busy NHS department. He is Scientific Advisor to the British Dental Association and enjoys a high profile in the media. He is a past President of the British Prosthodontic Society. International roles include Past President of the Association for Dental Education in Europe and deputy chair of U21 Health Sciences. Editorial duties include past Editor of the Journal of Dentistry and he is on the Editorial boards of the BDJ, European Journal of Dental Education, Journal of Dental Education, Journal of Endodontics. European Journal of Restorative Dentistry and Dental Update.
Richard Welbury Professor of Paediatric Dentistry School of Dentistry University of Central Lancashire Preston, UK
Richard Welbury is Professor of Paediatric Dentistry at the University of Glasgow Dental School and currently Dean of the Dental Faculty and VicePresident of the Royal College of Physicians and Surgeons of Glasgow.
Paul H.R. Wilson BSc BDS MSc FDSRCPS FDS(RestDent) DipDSed Consultant in Restorative Dentistry Oxford University Hospitals NHS Foundation Trust, Headington, Oxford UK The Circus Dental Practice Bath, UK Paul H.R. Wilson is Consultant in Restorative Dentistry at Oxford University Hospitals NHS Foundation Trust and he works in private specialist dental practice in Bath. He is visiting Senior Clinical Lecturer at the Universities of Aberdeen and Bristol. He completed postgraduate training at Guy’s & St Thomas’ Hospitals, London and King’s College London.
Graeme Wright BDS FDS(Paed Dent) RCPSG MPaed Dent RCSEd PGCLTHE FHEA Consultant in Paediatric Dentistry Royal Hospital for Sick Children Edinburgh, UK
Graeme Wright is Consultant in Paediatric Dentistry at Edinburgh Royal Hospital for Sick Children. He is an Executive Board member of BSPD, organizer of the IAPD 2015 International Congress and editorial board member of ‘Dental Traumatology’. His sub-specialty interests are Dental Traumatology and Oncology/Haematology related to dentistry.
Preface to the Fourth Edition Contributors
1. Dental public health, epidemiology and prevention Tatiana Macfarlane, Jasmine Murphy
2. Social and psychological aspects of dental care Tim Newton
3. Dental disease Crispian Scully
4. The dental team Crispian Scully, John Cameron
5. Law, ethics and quality dental care John Cameron
6. Practice management Fiona Cox, Martyn Cox
7. History and examination Mark Griffiths
8. Dental and maxillofacial radiology Paul Nixon
9. Pain and anxiety management Avril Macpherson
10. Drug prescribing and therapeutics Mark Griffiths
11. Dental materials William Palin, Damien Walmsley
12. Implantology Stephen Barter, Nikos Donos
13. Oral medicine David H. Felix
14. Oral and maxillofacial surgery Athanasios Kalantzis
15. Orthodontics Daljit Gill, Farhad Naini
16. Paediatric dentistry Graeme Wright, Richard Welbury
17. Periodontology Iain Chapple
18. Removable prosthodontics Andrew Paterson
19. Operative dentistry Paul H.R. Wilson
20. Special care dentistry Avril Macpherson
21. Emergencies John Steele
Appendices Appendix A: Average dates of mineralization and eruption of the primary dentition Appendix B: Tooth notation Appendix C: Tooth eruption
638 640 640
Dental public health, epidemiology and prevention Dental public health 1 Oral health epidemiology 3 The prevention of oral diseases 4 The wider determinants of health 5 Oral health promotion 6 Common risk factors 6 Barriers to healthy behaviours 7 Changing disease levels 8 Caries risk 9 Diet and dental caries 10 Fluoride 12 Modes of action 12 Smoking and oral health 16 Smokeless tobacco and oral health 17 Electronic cigarettes and oral health 18
Hookah (shisha) and oral health 19 Alcohol consumption and oral health 19 Other substance abuse and oral health 21 HIV infection and oral health 21 Prevention of dental neglect 22 Sport trauma 23 Temporomandibular disorders 23 Frequency of dental attendance 23 Routine scale and polish 23 Prevention in older patients 24 Pregnancy and oral health 25 Oral health in special population groups 25 Conclusion 26
Dental public health Definition
This is a non-clinical specialty involving the science and art of preventing oral diseases, promoting oral health to the population rather than the individual. It involves the assessment of dental health needs, developing policy and strategy and ensuring appropriate dental health services to meet the needs of the population.
Dental Public Health (DPH) is concerned with the oral health of a population rather than individuals and has been defined as the science and art of preventing oral diseases, promoting oral health and improving the quality of life through the organized efforts of society. Dental public health practice requires an understanding of the challenges in the delivery, planning and management of health services in order to ensure that the provision of health services meets the needs of the population. This dental specialty requires specific skills in undertaking oral health needs assessments and developing specific oral health policies and strategies that protect and promote
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population level oral health. It also involves a comprehensive understanding and appreciation of the principles and methods that underpin oral health promotion, oral health inequalities, the wider determinants of health and health behaviour. Oral health has improved in the UK over the last 30 years, but there is evidence that inequalities have widened. With limited funding and the ever-growing evidence base for interventions, dental public health specialists must make decisions, develop policies and implement strategies that are based on the best available scientific evidence in order to meet oral health goals, reduce oral health inequalities and sustain necessary resources. Such activities also involve the systematic use of data and information systems, application of programme planning frameworks, engagement with the communities in the decision-making process, conducting sound evaluation and disseminating lessons that have been learnt. The evidence-based decision-making process which is applied in dental public health integrates best available research evidence, practitioner expertise and other available resources including the characteristics, needs, values and preferences of those who will be affected by the intervention. Once health needs are identified through a community assessment, the scientific literature can identify programmes and policies that have been effective in addressing those needs. However, the amount of available evidence can be overwhelming. There are many types of evidence (e.g. randomized controlled trials, cohort studies, qualitative research) and the best type of evidence depends on the question being asked. Not all types of evidence (e.g. qualitative research) are equally represented in reviews and guidelines. The concept of a ‘hierarchy of evidence’ can be problematic when appraising the evidence for public health interventions as not all populations, settings and health issues are necessarily represented in evidence-based guidelines and/or systematic reviews. An important objective for those engaged in evidence-based dental public health is to improve the quality, availability and use of evidence in public health decision-making. The wide-scale implementation of evidence-based dental public health requires not only a workforce that understands and can implement the evidence base for dental public health efficiently but also sustained support from health department leaders, practitioners and policy makers. Evidence-based practice guidelines are based on systematic reviews and/or meta-analyses of research-tested interventions and can help practitioners select interventions for implementation.
Systematic reviews use explicit methods that focus on a particular research question which locates and critically appraises all high quality research evidence relevant to that question. They result
Dental public health, epidemiology and prevention
in reports and recommendations that summarize the effectiveness of particular interventions, treatments or services and often include information about their applicability, costs and implementation barriers. • Meta-analysis is a statistical technique to combine pertinent data from several studies to develop a single conclusion that has greater statistical power. The benefits of meta-analysis include a consolidated and quantitative review of the large, complex and sometimes conflicting body of literature. The Cochrane Library (http://www.cochranelibrary.com) is an online collection of databases that contain different types of highquality, independent evidence to inform healthcare decision-making. The Centre for Evidence-based Dentistry (CEBD; http://www.cebd.org) sets out an approach to systematizing the evidence for different research questions, with the highest level of evidence being systematic reviews and randomized clinical trials, with case series and expert opinion as the lowest level of evidence. To find evidence tailored to their own context, practitioners may need to search resources that contain original data and analysis. Peer-reviewed research articles, conference proceedings and technical reports can be found for example in PubMed (http://www.ncbi .nlm.nih.gov/pubmed). Maintained by the US National Library of Medicine, PubMed is the largest and most widely available bibliographic database of biomedical literature.
Oral health epidemiology Epidemiology, which is defined as the study of disease distribution and its determinants in specified populations, is the basic science of public health because it studies the patterns, causes and effects of health and disease conditions in human populations. It is the cornerstone of public health and informs policy decisions and evidencebased practice by identifying risk factors for disease and targets for preventive health care. Furthermore, epidemiology has been used to generate much of the information required by public health professionals to develop, implement and evaluate effective intervention programmes for the prevention of disease and promotion of health, such as the eradication of smallpox, the anticipated eradication of poliomyelitis, and prevention of diphtheria, tetanus, measles, meningitis and mumps, heart disease and cancer. The ‘art’ of epidemiology is knowing when and how to apply the various epidemiological strategies to answer specific health questions. Such designs include descriptive epidemiological studies (such as cross-sectional or surveys) and analytical (such as cohort studies, case-control studies and randomized clinical trials).
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Dental caries is a public health concern and collecting data on its prevalence, incidence and trends is an important field in oral health epidemiology. Definitions used include:
Prevalence: the proportion of individuals with disease (cases) in a population at a specific point in time. • Incidence: the number or proportion of individuals in a population who experience new disease during a specific time period. • Trend: the changes or differences in the prevalence or incidence of disease with respect to time.
The prevention of oral diseases The major oral diseases – dental caries, periodontal disease and mouth cancer (see Chapter 3) – are not inevitable, but are to a large extent influenced by the wider determinants of health, i.e. psychosocial, economic, political, environmental, social and lifestyle factors. The aetiology of these conditions is increasingly well understood and prevention is largely possible if appropriate policies and strategies are in place which influence or assist people in adopting appropriate changes in behaviour. Prevention is defined in three stages: prevention – steps taken to ensure disease does not occur • Primary • Secondary prevention – promoting early intervention in those already affected to halt progression at incipient stage of disease • Tertiary prevention – treatment of well-established disease to restore function and avoid further episodes
The prevention of oral diseases can also be regarded as measures applied either on a population basis, or at an individual level. Examples of measures applied on a population basis include water fluoridation and health promotion campaigns. Preventive measures on an individual basis can be applied either by a dental professional (e.g. fluoride varnish, fissure sealants, diet counselling, smoking cessation) or by the individual, e.g. tooth-brushing. In the developed world, dentistry has traditionally taken a ‘treatment-oriented’ approach, with the view that individuals were reliant on dental professionals for maintenance of oral health, but recent decades have seen a change to a more ‘preventive-oriented’ approach. Factors influencing this transition include:
increased understanding of the nature of dental caries, periodontal disease and other oral diseases • increased appreciation of the shortcomings of traditional restorative dentistry
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increased evidence based on preventative approaches changing aspirations of patients (perhaps of importance).
The wider determinants of health Oral health and general health are determined by a complex interaction between individual characteristics, lifestyle and the physical, social and economic environment. People living in poorer areas tend to have worse oral and general health when compared to those living in more affluent areas. Given the close links between oral health and other indicators such as family income, there is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. The wider social determinants of health (Figure 1.1) are the circumstances in which people are born, grow up, live, work, and age. These circumstances are in turn shaped by a wider set of forces: economics, social policies and politics. Oral health inequalities are the ‘differences in oral health status between different population groups’. Inequalities in oral health exist between social classes, countries within the United Kingdom and among certain minority ethnic and population groups. Oral health inequalities can only be reduced through the implementation of effective and appropriate oral health promotion policies and strategies which tackle the wider social determinants of health. The
General socioeconomic, cultural and environmental conditions Living and working conditions Social and community networks Individual lifestyle factors
• • • •
Work environment Unemployment Education Healthcare services
Individuals (age, gender and genetic factors)
• Housing • Water and sanitation • Agriculture and food production
Figure 1.1 Determinants of health (based on Dahlgren G & Whitehead M 1991 Policies and strategies to promote social equity in health. Institute for Future Studies, Stockholm (Mimeo).
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improvements in oral health over the last 30 years have been largely a result of fluoride toothpaste and social, economic and environmental factors.
Oral health promotion Health promotion is the process of enabling people to increase control over, and to improve their health (World Health Organization [WHO]). It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions. Health promotion describes activities and actions designed to enhance positive health and prevent ill-health by a combination of prevention, health education and health protection. There are a number of approaches that can be chosen when planning an oral health promotion initiative including: settings (e.g. nurseries, schools, care homes), population group (e.g. children, pregnant women, adults, vulnerable groups) and topic based (e.g. dental caries, periodontal disease, oral cancer). Prevention. Described above. Health education. Any combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes (WHO). It involves the provision of information aimed at influencing beliefs, attitudes and behaviour relating to oral and dental health. In its widest sense, it also includes provision of information about access to and appropriate use of health services. The key messages for oral health (see Chapter 3) are: reduce the intake of sugar-containing food and drink, particularly the frequency of sugar consumption and avoid between-meal sugar snacks; brush teeth twice daily with a toothpaste containing fluoride; attend the dentist regularly; do not use tobacco; reduce alcohol consumption. Health protection. The practice of a nation to protect, improve and restore health of individuals in a community or entire populations. It functions through collective societal activities, programmes, services and institutions aimed at improving health of people. It comprises laws, regulations, policies and voluntary codes of practice aimed at preventing disease and enhancing health, e.g. legislation making use of car seat-belts compulsory, thereby reducing the prevalence of maxillofacial injuries due to road traffic accidents.
Common risk factors Traditionally, there has been an emphasis on dental health education, either with individuals or groups, which has focused on imparting knowledge. It has been shown that conventional oral health