COURSE TITLE:

COMMUNITY AND PREVENTIVE

DENTISTRY

COURSE LECTURER: ITOE MARGRET

ANNE
COURSE CONTENT

CHAPTER ONE:
Concept of preventive dentistry
1.1 Prevention of oral diseases
1.2 Primary preventive services
1.3 Fluoride in caries prevention

CHAPTER TWO:
Dental caries and periodontal disease.

CHAPTER THREE:
Prevention of sport injuries to the mouth.
CHAPTER FOUR:
Oral health education and promotion.

CHAPTER FIVE:
Effects of smokeless tobacco.
Chapter One: Prevention of oral diseases

 Oral health problems arise mainly as a result of two oral

diseases; dental caries and periodontal disease.

 Itis known that a satisfactory oral health is difficult to

achieve throughout the developing world not only
because of increase in oral diseases but also because of
lack of preventive programs.

 This chapter looks into preventive approach of dental

diseases, which can be implemented at all levels of
development.
Prevention
 It is defined as the efforts which are made to maintain normal
development, physiological function and to prevent diseases
of the mouth and adjacent part (Philip E. Blackerby).

 Itwas also defined by Clark and Learell as the interception of

the disease process.

Preventive dentistry
 It encompasses all aspects of dentistry and those practice by
dental professionals, individuals and communities that affect
oral health.
A. Levels of Prevention

 Itis divided into three main levels: Primary, secondary

and tertiary levels.

a) Primary prevention;
 It is defined as the action taken prior to the on set of
disease which removes the possibility that a disease will
ever occur.

 The concept of primary prevention is now being applied

to the prevention of chronic diseases such as coronary
heart disease, hypertension, dental caries, periodontal
disease based on elimination or modification of risk
factors of disease.
 WHO recommended the following approaches for the
primary prevention of chronic diseases where the risk
factors are established;

i) Primordial prevention
ii) Population (mass) strategy
iii) High risk strategy

i. Primordial prevention;
* This is primary prevention in its purest sense.
* Here, efforts are directed towards discouraging children
from adopting harmful lifestyles through individual and
mass education.
ii. Population (mass) strategy;
* This approach is directed at the whole population
irrespective of individual risk levels. Example; water
fluoridation.

iii. High risk strategy;

• Here the aim is to bring preventive care to individuals at
special risk.
• This requires detection of individuals at high risk.
Note;
• Primary prevention is a desirable goal, hence to have an
impact on the population all the above approaches
should be implemented.
b) Secondary prevention;
• It employs routine treatment methods to terminate a
disease process and to restore tissues to as near normal
as possible,

c) Tertiary prevention;
• It employs measures necessary to replace lost tissues
and to rehabilitate patient to the point that function is as
near normal as possible after the failure of secondary
prevention.

B) Modes of Intervention (Preventive Services)

• It can be defined as any attempt to intervene or interrupt
the visual sequence in the development of disease in
man.
• The modes of intervention include;
i. Health promotion
ii. Specific protection
iii. Early diagnosis and treatment
iv. Disability limitation
v. Rehabilitation

i. Health promotion;
• It is the process of enabling people to increase control
over and to improve health.
• It is not directed against any particular disease but is
intented to strengthen the host through a variety of
approaches, the well known intervention in this area
are; health education, environment modification,
nutritional intervention, and lifestyle and behavioural
changes.
ii. Specific protection;
* to avoid disease altogether, it is the ideal but this is
possible only in a limited number of cases.

Examples; immunization, chemoprophylaxis, protection

against occupational hazards, accidents, carcinogens.

iii. Early diagnosis and treatment;

• They are the main interventions of disease control.
• The earlier a disease is diagnosed and treated the better
it is from the point of view of prognosis.
• And it helps prevent the occurrence of further cases or
any long term disability.
Iv. Disability limitation;
• Disability is defined as any restriction or lack of ability
to perform an activity in the manner or within the range
considered normal for a human being.
• Hence, the objective of this intervention is to prevent the
transition of the disease process fro; impairment to
handicap.

v. Rehabilitation;
* It refers to as the combined and coordinated use of
medical, social, educational, vocational measures for
training and retraining the individual to the highest
possible level of functional ability.
1.2 Primary Preventive Services

 Primary prevention refers to strategies or methods put in

place in order to avoid occurrence of disease either
through eliminating disease agents or increasing
resistance to disease.

 Examples includes; Plaque control, caries activity, pit

and fissure sealants, caries vaccine, minimal
intervention dentistry and atraumatic restorative
treatment (ART).
1. Plaque Control;
 It refers to the removal of microbial plaque and
prevention of its acummulation on the teeth and adjacent
gingival surfaces.

 It also retards the formation of calculus.

 Lets also note that, the removal of microbial plaque
leads to the resolution of gingival inflammation in its
early stages.
 Plaque control is an effective way to treating and
preventing gingivitis and is therefore a critical part of all
the procedures involved in the prevention of periodontal
diseases.
 It is one of the keystones of the practice in dentistry.
I. Classification; plaque control has been classified into
02 main groups;
A) Mechanical plaque control; to date, it is the most
dependable mode of controlling microbial plaque.

 Examples include; tooth brushes, dentifrices, and

interdental oral hygiene aids
 Mechanical plaque control is safe and effective.
 It permits the patients to assume responsibility for their
own oral health.

i. Tooth brushs; 02 types exist namely

a) Manual toothbrush;
 A manual toothbrush is made up of a handle, a head, and
bristles (Tufts when bunched together).
 There is a constriction between handle and the head;
termed the shank.
 The head is arbitrarily divided into the toe (found at the
extreme end of the head) and the heel (found closer to
the handle).
 Manual toothbrushes are manufactured in 03 different
sizes Large, medium and small, to adapt to the oral
anatomy of different individuals

 Manual tooth brushs also differ in their defined hardness

or stiffness, usually as hard, medium and soft.

b) Electric toothbrush; the head of the electric toothbrush

is smaller than that of a manual toothbrush, and it is
removable for replacement.
 The 03 main patterns that the head follows when motor
is started are;

Reciprocating; that is a back and forth movement.

Arcuate; that is the up and down movement.
Elliptical; that is a combination of both the reciprocating
and arcuate movements.

 Special uses of electrical toothbrush they include;

parental brushing of childrens teeth, use for mentally
retarded, and aged patients. Patients with poor dexterity.

ii) Interdental oral hygiene aids;

 They are used to remove plaque and debris that are
adherent to the teeth, restorations, orthodontic appliance,
and gingival in the interproximal embrasures.
 It polishes the surface as it removes the debris.
 They are used for massaging the interdental papillae and
to reduce gingival bleeding.
 It contributes to general oral sanitation and the control
of halitosis.

iii) Dentifrices;
 It is defined as a substance used with a toothbrush for
the purpose of cleaning the accessible surfaces of the
teeth.

 Theyare either cosmetic or therapeutic.

 Cosmetic dentifrice; it must clean and polish the teeth.
• Therapeutic dentifrice; it must reduce some disease
process in the mouth. Usually to reduce caries
incidence, gingivitis, calculus formation, tooth
sensitivity

 Dentifrice ingredients (Assignment)

B) Chemical plaque control;

It may involve prevention of plaque formation, removal
or the dispersion of existing plaque, inhibition of
calcification of existing plaque, or altering the
pathogenicity of plaque, chemical interfere at various
stage of development of plaque.
 Microorganisms responsible for plaque formation may
be removed or eliminated or reduced in number.
 Established plaque maybe dissolved.

 Calcification of plaque maybe counteracted.

 The formation of bacterial and salivary products which
constitute the intermicrobial substance in plaque may be
inhibited.

 Colonization of bacterial on the tooth surface may be

inhibited.

 Pathogenicity of plaque may be reduced by interference

with the metabolism of plaque bacterial. They include;
a) Antibiotics;
 Penicillin, vancomycin, erythromycinm niddamycin,
and kanamycin were tried as antiplaque agents.

 Vancomycin is a bacterial antibiotic and is poorly

absorbed after oral dose. It was found to be quite
effective in hospitalized patients for control of plaque
formation.

b) Phenols;
 Antibacterial action of phenols depends on its ability to
penetrate the liquid component of the cell walls of gram
negative organisms.
 Listerine is a phenol containing mouthwash that is
widely used, it has been found to be and effective
inhibition of plaque formation when used as an adjust to
mechanical methods.

c) Enzyme preparation;
 Enzymes capable of breaking down the matrix of
already formed plaque were considered for inhibition of
plaque and calculus formation.
 Examples; mucinase, dehydrated pancrease, mutanase,
dextranase, etc.

d) Quaternary Ammonium compounds;

 These are cationic antiseptics and surface active charge,
which reacts with the negatively charged cell membrane
phosphates and the cell wall structure of microorganism is
disrupted.
 Cetylpyridinium and benzethonium chloride have been
found to inhibit plaque.

e) Bisbiguanides;
Chlohexidine gluconate and alexidine are the most
effective antiplaque agents.
 It reduces the gingival inflammation also. 0.2%
chlohexidine used as mouth rinse twice daily is quite
effective in total plaque inhibition.

f) Metallic salts
 Zinc sulphate and zinc citrate have been found to have
inhibiting effect on plaque formation.
g) Therapeutic dentifrice;
 It may be described as a dentifrice that contains a drug
substance that has been incorporated into the
formulation in an effort to produce a beneficial effect
upon the oral tissues.

 The most commonly used active agent added to

dentifrice is fluoride, which aids in control of dental
caries.

 Tetrasodium phosphate and disodium dihydrogen

pyrophosphates are used to significantly reduce the
amount of calculus (anticalculus dentifrices).

 Dentifrices used in hypersensitivity are with active

agents like potassium nitrate, strontium chloride, etc
h) Therapeutic mouth rinse;
 A mouth rinse may be defined as a substance that is
swished around the oral cavity and then expectorted in
order to freshen the mouth and breath.

 A therapeutic mouth rinse can be defined as a

formulation containing a drug substance and used to
transfer this drug substance to hard and soft tissues of
the oral cavity.

 This drug substance then imparts a chemical,

physiological or pharmacologic action that is manifested
clinically as a reduction in the incidence of plaque,
caries, calculus and gingival disease.
i) Oral irrigation devices;
 Mouth rinse provide a means to irrigate the entire
mouth; irrigation devices provide a means to irrigate
specific areas of the mouth.

 There are 02 types; the Spray (provides aerosols) and

irrigation which provides a steady or pulsating steam of
fluid.

03 situations to use irrigation devices;

 To help remove accumulated debris from interproximal
areas where there is difficulty to acces.
 To irrigate deeper gingival sulci
 The aid in personal oral hygiene program of individuals
with orthodontic devices, complex restorations, crowns
and fixed bridge, etc

 Types include home irrigation and professional

subgingival devices.

 In conclusion, plaque is formed so rapidly and its

removal by the patient is so difficult that complete
freedom from plaque over extended periods of time is an
unrealistic goal.
 The goal of clinical plaque control is periodic chemical
or mechanical plaque removal at intervals spaced closed
enough together to prevent recurrent plaque formation
and any resulting significant pathological effects.

 Assignment; further study plaque disclosing agents and

methods of plaque testing.

2. Caries Activity Test;

 Caries is a multifactorial disease, the many contibuting
factors can be grouped into three categories; namely
 i. Those microorganisms that constitute a challenge to
the intergrity of the tooth.
 ii. Toothand host resistance to the challenge and
 iii. Remineralisation capacity (Repair).

 The objective of caries testing is to identify some

parameters related to the triad of challenge, defense and
repair that will indicate impending or existent caries
activity or inactivity.

 Such information can be used to help estimate the

probability for caries but more importantly to formulate
strategies for the prevention of disease.

A. Criteria of Caries Activity Test;

 The test should be reproducible.
 Test should be valid
 Test should be simple and in expensive to perform
 The test should be non invasivem easy to evaluate and
applicable to any clinical setting.
 There should be a minimal occurrence of false
responses.

B) Advantages of caries activity test

 Permits the identification of the individuals with
probability of developing dental caries.
 Helps to understand the caries process better.
 Helps to screen large specimen of population such as
school chlidren.
 Providea patent on individual preventive program to be
implemented before extensive dental restorative
procedure are accomplished.

 Institutes
intensive effective primary preventive
measures designed to arrect and to reverse the disease
process before the irreversible point of the caries has
been reached.

C. Types of Caries activity test; includes

1. Lactobacilli colony count test
2. Synder’s Test
3. Alban’s test (modified Synder’s test)
4. Salivary buffer capacity test
5. Enamel solubility test
6. Salivary reductast test
7. Streptococcus mutans level in saliva.

Assignment; discuss each type of caries activity test

mentioned above.

3. Pit and Fissure sealants;

 They are defined as a cement or a resin which is
introduced into unprepared occlusal pits and fissures of
caries susceptible teeth forming a mechanical and
physical protective layer against the action of acid
producing bacteria and their substrate.
A. Indications; should be called out on a deep occlusal
fossa or ling pit.

B. Contraindication; opened oclusal carious lesions,

caries exist on other surfaces of the same tooth, and a
large oclusal restoration is already present.

C. Types; three different types of plastics have been used

as oclusal sealant.

1. Polyurethanes;
 They are among the first to appear in the market.
 They proved to be too soft and totally disintergrated into
the mouth after 2-3 months but
 Was still use as s means of applying fluoride to the teeth
than a sealant.

2. Cyanoacrylates;
 They were tried as sealant but they too disintergrate
after slidely longer compared to polyurethane.
 The ADA counsil canceled its use as a dental material
because formaldehyde was formed as part of their
biodegradation in the oral fluids.

3. BIS-GMA (Bisphenol-A glycidylmethy-acrylate);

 It is now the sealant of choice.
 Note; lately, more effective second and third generation
sealants have become available.
 Some of them contain fillers, which makes it desireable
to classify the commercial products as filled and unfilled
sealants.

 This fillers are coated with products such as silane, to

fascilitate the combination with BIS-GMA.

D) Polimerizing of the sealants;

 Two methos have been employed to catalyze
polymerization. Namely

 1.light curing by use of either an ultra-violet or visible

blue light (photocure, photoactivation or light
activation).
Advantages
 The operator can initiat polymerization at any suitable
time.
 Polymerization time is shorter.
 High compressive strength and smoother finish.

Disadvantages
 Expensive

2. Self-curing where a monomer and a catalysed are

mixed together (cold cure, autopolymerization, che;ical
activation).
Advantages
 Does not reauire expensive light cure.
Disadvantages
 Polymerization process can not be controlled.
 Requisites for sealant retention
 The surface of the tooth should have a maximum surface
area.
 The tooth should have deep, irregular pits and fissures.
 The tooth should be clean.
 The tooth should be uncontaminated by saliva residues.

Procedure of pit and fissure sealants

application.

1. Clean tooth Surface; all heavy stains, deposites and

debris should be off the occlusal surface before applying
the sealant.
2. Dry the tooth surface; the tooth must be dried at the
time of sealant placement.
 A dry field can be maintained by using rubber dam,
cotton rolls, etc
 Tooth isolation can be done mainly using cotton rolls.

3. Prepare the tooth for sealant application;

 After the selected teeth are isolated and thoroughtly
dried for approximately 10 seconds,
 The liquid etchant is then placed on the tooth with a
small plastic sponge.
 Etching solution is gently daubed, not rubbed on the
tooth surface for 1minute for permanent teeth.
 At the end of the etching period, for 10 seconds water if
flowed over the occlusal surface and tried for 20
seconds.

 The dried tooth surface should have a white, dull, frosty

appearance. This is due to the fact that the etchant has
remove approximately 5 to 10 micrometer of the
original surface.

4. Appilcation of the sealant ;

 When applied, the plastic sealant flows over the
prepared surface, penetrating the finger-like depressions
created by the etching solution.

 Thematerial should be placed in the fissure where is

maximum depth.
 Following the polymerization, the sealant should be
examined carefully for voids.
 Incase of any voids, additional sealant can be added
without need of any additional etching.

Note; Retention of sealants

 Plastic sealants are retained better on newly erupted
teeth.
 It is better on first molars than on second molars.
 It is better retained on mandibular teeth than on the
maxillary teeth.

4. Caries Vaccines;
 There exist the possibility of preventing caries by
stimulating the defense mechanism of the mouth.
 Mobilization or augmentation of the defense system of
the body is perhaps the most attractive approach to the
prevention of infectious diseases, as it involves working
with natural functions rather than cutting across them,

5. Minimal intervention dentistry

 The ideal way of preventive dentistry is to avoid disease
altogether, but is not possible in all cases.

 However, we can aim for both an early diagnosis and a

minimal invasive therapy to ensure the existing early
carious lesion is treated and the progress arrested.
 The minimal invasive approach in treating dental caries
incorporates the dental science of detecting, diagnosing,
intercepting and treating dental caries at microscopic
level.

Principles of Minimal Intervention Dentistry

 The four (04) core principles can be summarized as
follows;

1. Recognition;
To identify and assess any potential caries risk factors
early, through lifestyle analysis, saliva testing and using
plaque diagnosis.
2. Reduction;
 To eliminate or minimize caries risk factors, through
altering fluid balance, reducing in intake of distary
cariogenic foods, addressing lifestyle habits such as
smoking, and increasing the pH of the oral environment.

3. Regeneration;
 To arrest and reverse incipient lesions, regenerating
enamel subsurface lesions and arresting root surface
lesions using appropriate topical agents including
flurides and casein phosphopeptide-amorphous calcium
hosphates (CPP-QCP).
 4. Repair; When cavitation is present and surgical
intervention is required as much as possible of the tooth
structure is maintained by using conservative
approaches to caries removal.

 Bioactive materials are used to restore the tooth and

promote internal healing of the dentine, paricularly in
cases of deep dentine caries where the risk of iatrogenic
pulpal injury is high.

Note; Minimal invasive modalities point to a direction of

potential consistent benefit in prevention slowing the
progression or reserving early carious lesion.
6. Atramatic restorative treatment (ART);
 Although dental caries has substantially decreased in the
industrialized countries, it remains to be a wider spread
problem all over the world.

 Most of the carious teeth in the developing countries tend to

go untreated to such an extend that the only treatment option
available is extraction.

 Atraumatic restorative treatment approach was developed to

suit the needs of the developing countries.
 ART includes both preventive and treatment of dental caries.

 This procedure/technique is simple enough to train non-

dental personnels or primary healthcare workers.
 The procedure is based on excavating and removing
caries using hand instruments only and restoring the
tooth with an adhesive filling material such as glass
ionomer cement.

 Unlike conventional methods ART is non-threatening

not painful, therefore does not need anesthesia, does not
use expensive electrically driven equipment and can be
provided at low cost.

Requirments; all one needs is;

 A flat surface for the patient to lie.
 A stool for the operator to seat and
 Necessarily instruments and materials for ART which
can easily be carried in a small bag.

Note; ART is suited for people residing in remote area

and for field practice and can be carried out in schools,
village halls on in health centers with minimum
equipment and resources.

The two (02) main principles of ART are;

 1. Removing carious tooth tissue using hand instruments
only.
 2. Restoring the cavity with a glass ionomer cement.
Reasons for using hand instruments rather
than electrically driven handpieces

 Itmakes restoration care accessible to all population

groups.

 The use of a biological approach which required

minimal cavity preparation that conserves sound tooth
tissues and causes less trauma to the teeth.

 The low cost of hand instruments compared to

electrically driven dental equipment, the limitation of
pain that reduces the need for local anaesthesia to a
minimum and reduces psychological trauma to patients.
 Simplified infection control; hand instruments can be
easily cleaned and sterilized after every patient.

Instruments and materials essential for ART

 Instruments; only hand instruments are needed (cotton
wool rolls, mouth mirrior, explorers, pair of tweezers,
pellets, petroleum, spoon escarvators, hatchets or hoes
and carvers.
 a mixing pad and spatulla are also necessary to mix the
filling material.
 Plastic strips to shape the restorations and wedges to
hold the plastic strips to the teeth.

 Note; excessive material is removed with a carver.

Indications of ART
 In genetral ART is carried out in the cavities (involving
dentine) and ,
 In those cavities that are accessible to hand instruments.

Contraindications of ART
 When there is an abscess near the carious tooth
 When the pulp of the tooth is exposed
 Carious lesions not reachable by hand instruments.

Conclusion;
 ART is a biological approach which requires minimal
cavity preparation that conserves sound tooth tissues and
causes less trauma to teeth.
 It is painless the need for local anaesthesia are reduced
and so is the psychological trauma to patients.

1.3 Fluoride in caries prevention

 Fluorides play a pivotal role in the prevention of
dental caries.

 It is the most effective and most extensively

tested of current anti-caries agents.

 It is one of the best armamentariums used in the

prevention and control of dental caries.
 Natural occurrence of fluoride (sources)
 Fluorideis on extremely reactive member of the
halogens group of element.

 Itis widely found in;

 1. Water (fluoride occurs in most springs, well,
seawaters and plants).
 The fluorides contained in drinking water is commonly
the largest single contributor to the daily fluoride intake.

 2.Fluorides in food; fluoride is absorbed by plants to a

degree determined mostly by the types of plant,
moisture conditions, etc
 Other sources are; sea food, tea, leafy plants, airborne
fluoride emissions, fluoride in drinks, and fluoride in
pharmaceutical products (e.g vitamin pills, fluoride
dentifrices, etc).

Administration of fluoride
A. Systemic means; they includes
 1. Water fluoridation (can be community and school
water fluoridation)

 Definition; fluoridation is ‘the upward adjustment of the

fluoride ion content of a domestic water supply to the
optimum physiologic concerntration that will provide
maximum protection against dental caries and enhance
the appearance of the teeth with a minimum possibility of
producing abjectionable enamel fluorosis.

Optimum levels; Water in temperature climate; 1ppm

 Warmer and colder climates; approximately 0.7ppm to
1.2ppm.

Benefits of water fluoridation

1. esthetic purposes (helps in appearance of teeth).
2. Dental caries reduction in primary and permanent teeth.
3. Helps in reduction of root caries by approximately 50%.
Reduces the rate of extraction of first molar.
4. Prevents malocclusion (can be due to the fact that there
is a reduction in first molar extraction).
 Helps in reduction of interproximal and coronal caries.
 Helps in the economy by reducing the lost of public
health expenditure.

2. Salt fluoridation;
 It is the most effective method to deliver fluoride to a
target population where water fluoridation is not
possible, and avoiding the firestorm of anti-fluoridation
opposition.

Mode of preparation;
Done in 02 types
 Type 1; fluoride is added to salt by spraying
concentrated solution of sodium fluoride and potassium
fluoride on salt on a conveyor belt.
 Type 2;
Sodium fluoride and calcium fluoride are first mixed with
slightly moist salt or mixed with a flow condtioner such
as tricalcium phosphate and there premixed granules are
added to the salt.

Advantages of salt fluoridation

 The possibility of fluorosis is minimal.
 It is safe.
 Low cost.
 Individual monitoring not required.
 Freely available.
 Distribution can be easily monitored.
 Supply can be effectively controlled.
 Readily accepted.
Disadvantages of salt fluoridation
 There is no precise control, as the salt intake varies
greatly among people.
 There is now international efforts to reduce sodium
intake to help control hypertension.

3. Milk fluoridation
 Milk is a reasonable vehicle for fluoride since it is a
food used universally by infants, pregnant woman and
children.
 Milk is an excellent source of calcium and phosporous
and when fortified with Vitamin D, contains all
essentials for the development of bones and teeth.
Advantage
 Staple food for children and infants.

Disadvantage
 Cost of fluoridated milk would be considerably higher.
 Centralized milk supply should exist.
 Variation in intake and quantity of milk.

4. Fluoride tablets;
 Itprovides systemic effect before mineralization of
primary and permanent dentition and a topical effect
there after.
 They are commercially available as NaF tablets of
2.2mg, 1.1mg and 0.55mg yielding 1mg, 0,5mg and
0.25mg fluoride respectively.
Effect on deciduous teeth;
 When fluoride administration in the tablet form before
2years of age and it is continued for minimum 3-4years,
it helps in caries reduction.

Effect on permanent teeth;

 There is little or no marginal reduction of caries (20-
40%) on permanent teeth when fluoride is administered
in tablet form.

Advantages
 Requires a little time to dispense.
 Some tablets have a flavour that enhances child
motivation to participate in the daily ingestion of
fluoride tablet.
 Ready for use.

5. Fluoride Drops
 They are used to suppliment fluoride intake until a child
is big enough to swallow fluoride tablets.
 Parents should be cautioned to use the prescribed
number of drops and not assume that just because on
drop is effective, two will be better.
 It is expected to produce a caries reduction on the order
of 40%.

Mechanism of action of systemic fluorides

 Rendering enamel more resistant to acid dissolution.
 Itacts in the inhibition of bacterial enzyme systems-
enzymatic action.
 By reducing tendency of the enamel surfaces to absorb
proteins
 Modification in the size and shape of teeth.

B. Topical Fluorides;
 Definition; Topical fluoride therapy refers to the use of
systems containing relatively large, concentrations of
fluoride that are applied locally or topically, to erupted
tooth surfaces to prevent the formation of dental caries.

Classifcation;
1. Operator administered; examples
 Fluoride solutions ;- sodium fluoride 2%,
Stannous fluoride 8%.
 Fluoride gels;- acidulated phosphate fluoride 1.23%,
duraphat (fluoride varnish) and fluorprotector (floride
varnish)

 2. Self-administered e.g fluoride dentifrice, sodium

fluoride, fluoride mouth rinse, dentifrices containing
monofluoro-phosphates.

Flruoride Varnish
 The two (02) commonly used varnishes are;

 1. Duraphat (NaF varnish)

 2. Fluoroprotector (silane fluoride).
 Mode of Varnish Application
1. Oral prophylaxis.
2. Teeth are dried
3. Do not isolate teeth with cotton rolls as varnish being
sticky has a tendency to stick to cotton.
4. The application is done first on the lower arch as saliva
collects more rapidly around it, and then on the upper
arch.
5. Carryout application with single tufted small brush.
6. After application, ask patient to site with mouth open
for 4 minutes.
7. Instruct patient not to eat anything solid but take liquids
and semisolids only until next morning.
8. Maintaine contact between varnish and tooth surfaces
for 18 hours for prolonged interaction between fluoride
and enanel.

Mechanism of action
 When varnish is applied topically under controlled
conditions, a reservoir of fluoride ions gets build up
around the enamel of teeth.

 Fluoride keeps on slowly releasing and conditionously

reacting with the hydrozyapatite crystales of enamel
over a long period of time leading to deeper penetration
of fluoride and formation of fluorapatite.
 Toxicity of fluoride
 The term toxicity refers to the symptoms manifested as
a result of over dosage or excessive administration.

 Acute; Due to single ingestion of large amounts of

fluoride
 Chronic; due to long-term ingestion of smaller amounts
of fluoride.

Defuoridation
 The need to fluoride water supplies to reduce dental
caries is balanced by a similar need to remove excessive
amount of fluorides from naturally fluoridate waters.
Defluoridation of water is more than 10times as
expensive as fluoridation.

Methods;
 the ideal method to defluoridate an area is to blend the
water from the well with the excess amount of fluoride
with another water supply deficient in fluoride.

Advantage;
 the only expenditure is the connecting pipes.

Disadvantage;
 it can be used only in areas where extremely in
concentration exists.
Note; Chemical methods used in defluoridation of water
includes;

1. Additive methods; here chemicals are added to

precipitate the fluoride and then the fluoride is passed
through mixing basins,
 Floccolation units, setting basins and filtering beds.

2. Absorption methods; here the water rich in fluoride is

run over contact beds, where the fluoride is removed by
ion exchanged.

3. Indian Perspective; this defluoridation technique

requires skills operations.
here the chemical lime, bleaching powder and filter alum
is added in sequence to the fluoride water.

 The water is then, passed through the flocculation

sedimendation and filtration chambers.

 Fluoride Alternative; they include

- Theobromin
 - Nano hydroxyapatite (HA) casein phosphapetde
(CPP), etc
 They were proposed for their anti-cariogenic properties.
CHAPTER 2; ORAL HEALTH EDUCATION
AND PROMOTION
Definition
 Health education is any combination of learning
opportunities and teaching activities designed to
facilitate voluntary adaptations of behaviours that are
conducive to health (By WHO).

 Health education is the process that informs motivates

and helps people to adopt and maintain healthy practices
and lifestyles, advocates environmental changes as
needed to facilitate the goal and conducts professional
training and research to the same end. (National
conference on preventive medicine 1997 in USA.
 Health education is the very foundation of every
successful public health programme, thus is an essential
part of prevention.

 The purpose of HE is to positively influence the health

behaviour of individuals and communities as well as the
living and working conditions that influence their
health.

 Itaims at bridging the gulf (gap) between the health

knowledge and health practices among people.

1.1 Objectives
 The three (03) main objectives of health education are;
1. Informing the people;
 The primary objective of HE is to inform the people or
provide scientific knowledge about prevention of
disease and promotion of health.
 Exposure to knowledge will melt the barriers of
ignorance, prejudices and ,isconceptions, people may
have about health and disease.

2. Motivation People;
 Informing people about health is not merely enough,
 they must be motivated to change their habits and the
ways of living, since many present day problems of
community health requires alteration of human
behaviour or change in health practices which are
detrimental to health. E.g cigarette smoking, etc
 The accent should be on motivating the ‘consumer’ to
make his own decision and choices about health matter,
that is what kind of actions to be taken, and when under
what conditions to take them.

3. Guiding into action;

 People need to adopt and maintain healthy practices and
lifestyles, which maybe totally new to them.

 Every service and facilities will not be fully effective

unless the people not only make use of the services but
also undertake various practical self-help measures to
improve their own health status and the communities in
in which they live in.
 Note;the final aim of HE is to make realistic
improvements in the basic quality of life of people.

 Assignment; Differentiate between health education

and propagation.

Content of Health education

 The scope of HE extends beyond the conventional
health sector, it covers every aspects of family and
community health.
 The content of HE can be divided into the following
divisions for the sake of simplicity;

1. human biology; understanding health demands on

understanding of the human body.
2. Nutrition; the aim of education people about nutrition
is to inform them on the importance of optium and
balanced diet.

3. Hygiene; the people are taught about the importance of

hygiene and methods of maintaining hygiene.
 it is 02 aspects; personal and environmental hygiene.

4. Family health; the aim is to strengthen the health of the

family as a unit rather than as an individual.

5. Disease prevention and control; the aim is to provide

knowledge about the nature of communicable and non-
communicable diseases and methods of preventing
them.
 6.
Mental health; the aim is to help people to be
mentally health and to prevent a mental breakdown.

 7.Prevention of accidents; it has become a major

feature of modern human life. People have to be taught
on how to prevent them.

 8.Use of health services; individuals have to be

educated and informed about the various health services
and preventive programmes available to them.

2.2 Principles of Health Education

 The main principles of health education include;
1. Credibility; it is the degree to which the message to be
communicated is perceived as trustworthy by the
receiver.
 unless the people have trust and confident in the
communicator, no desired action will be carried out after
receiving the message.

2. Interest; Health education should be related to the

interest of the people.

3. Participation; it is the key word to HE.

 People should be encouraged to be a part of the health
education programme. E.g group discussions, panel
discussion, etc
4. Motivation;
 All individuals have a desire to learn, and awakening
this desire is called motivation.
 Primary motivation; refers to the inborn desire which
initiate people to take action e.g hunger, survival, etc
 Secondary motivation; these motives are based on
desires created by external forces or incentives e.g
rewards, praises, etc.
 In health education, we make use of motivation to
change behaviours.

5. Comprehension; In health education, we must know

the level of understanding, education and literacy of
people to whom the teachings are directed.
 One barrier to communication is using words which can
not be understand.

6. Reinforcement; learning new things in a single period

is difficult. This requires constant repetition.

7. Learning by doing; learning is an action process; not a

memorizing one in a narrow sense.

In chinese proverb; if I hear; I forget; if I see, I remember;

if I do; I know. Illustrate the importance of learning by
doing.

8. know to unknown; that is starts where the people are

and with what they understand and then proceed to new
knowledge.
9. Setting an example; the health educator himself
should set an example in the things he is teaching which
will help people to look upon him and lead a healthy
lifestyle.

10. Good human relations; it is utmost importance the

health educator must be kind and sympathetic.

11. Feedback; it is of paramount importance.

 The health educator can modify the elements of the
system (e.g message, channels, etc) in the light of
feedback from his audience.
12. Leaders; we learn best from people who we respect
and regard. In the work of health education, we try to
penetrate the community through local leaders.

13. Soil, seed and sower; in the content of HE,

 Soil refer to people to whom education is given.
 Seed refers to the health facts to be given to the people.
 Sower refers to the transmitting media (it should be
attractive, palable and acceptable).

2.3 Communication in health education

 Itcan be regarded as a two way process of exchanging
or shaping idea; feelings and information.
 The art and science of communication forms the
principal foundation of HE and disease prevention.
 The health educator should know how to communicate
effectively with the people to whom he imparts health
education.

A. Key Element in Communication

 Communicator (Originator of the message)
 Audience (consumer of the message e.g group, etc)
 Message (it’s the information a communicator wishes
his audience to receive, understand, accept and act
upon).
 Channels of communication (medium of
communication).
 Types of Communication
1. One-way communication (didactic method);
 Involves flow of communication in one direction, from
the communication in one direction, from the
communicator to the audience. E.g lectures method in
classroom.

2. Two-way communication ( Socratic methods);

 This involves both the communicator and audience with
exchange of information.

3. Verbal communication; it’s the traditional way of

communicating by words of mouth.

4. Non-verbal communication; it involves a whole range

of body movements and facial expressions. E.g silence.
5. Formal and informal communication; formal
communication follows lines of authority whereas
informal communication is conversing with friends or
colleagues.
6. Visual Communication; it comprises charts and
graphs, maps, tables, etc

Barrier of Communication
1. Physiological; difficulties in hearing, expression, etc
2. Psychological; emotional disturbances and neurosis.
3. Environmental; Noise, invisibility, congestion.
4. Cultural; levels of knowledge and understanding,
custome, beliefs, attitudes.
Note; barriers should be identified and removed in order to
achieve effective communication.

Methods in health Communication

 they maybe be grouped into 03 main types; individual,
group and mass approach.
 Anyone or a combination of these method can be used
selectively at different times, depending upon the
objectives to be achieved, the behaviour to be influenced
and available funds.

1. Individual Approach;
 it maybe given in personal interviews in the
consultation room of the doctor or in a health centre or
in homes of the people.
Advantages;
 We can discuss, argue and persuade the individual to
change his behaviour.
 Provides opportunities to ask questions in terms of
specific interest.

Disadvantages;
 The number reach is always small and
 Health education is given only to those one who comes
into contact with.

2. Group Approach (e.g schools); it methods include

i. Chalk and talk (lectures); defined as carefully prepared
oral presentation of facts, organized thoughts, and ideas by
a qualified person.
 Lecture effectiveness depends on speaker’s ability to
write eligibly and draw on black board.

Disadvantages;
 Students are involved to a minimum extend.
 Learning is passive
 Do not stimulate thinking or problem solving capacity.
 The health behaviour of listener are not necessarily
affected.

 ii.
Demonstration; a demonstration is a carefully
perpared presentation to show how to perform a skill or
procedure step by step in front of audience making
them understand and involve in the discussion.
 Other types include; Group discussion, symposium,
workshop, panel discussion, role play, conferences and
seminars, etc

3. Mass Approach (education of general group);

 These are one-way communication approach and are
useful in transmitting messages to the people even in
remodest places.
 Means used; telephones, health magazines, news
papers, radio, direct mailing, films, health museums and
exhibitions.

Sites of Oral health education includes; dental

office or clinic, in schools, in the community.
B. Health promotion
 Various steps in health promotion includes;
1. Diet counselling with specific instructions on limiting
frequency of sugar intake.
2. Dental health education programs for children giving
them instructions about aetiology and prevention.
3. Plaque control programmes to ensure proper
maintenance of good oral hygiene.
4. Community water fluoridation in area with deficient
fluoride levels in drinking water.

5. Create increase awareness on the various dental

services provided to the community hence making
them open to seek for these services.
 Chapter three; Dental caries and
Periodontal diseases
1. Dental Caries;
 Dental caries is an infectious microbial disease that
results in localized dissolution and destruction of
calcified tissues of the teeth.
 The enzymes produced by the bacteria act upon the
fermentable carbohydrates to produce acids.

 These acids react with the enamel leading to dental

caries as a result of demineralization.

 Dental caries maybe considered as a disease of modern

civilization.
A. Aetiology of dental caries;

 Dental caries being multifactorial, several theories have

adapted to explain it’s aetiology. These theories
includes; chemical (acid) theory, parasitic theory,
Miller’s chemoparasitic theory, peotrolysis theory and
the proteolysis chelation theory.

1. Chemical (acid) theory;

 In the 17th and 18th centuries there emerged the concept
that teeth were destroyed by acids formed in the oral
cavity by fermentation of food particles around teeth.
2. Parasitic theory; it indicated that microorganisms were
associated with the carious process.

3. Miller’s chemicoparasitic theory (acido genic

theory);
 This theory was proposed by MD Miller in 1890.
 The microorganisms found in the oral cavity produce.

Enzymes that act upon the fermentable carbohydrate to

produce acids (lactic acids, succinic acid, etc).
 These acids act upon the enamel of the tooth resulting in
its demineralization leading to dental caries.
4. Proteolysis theory (By Gottileb 1934);
 According to this theory, the organic matrix would be
attacked, before the mineral phase of the enamel.
 The proteolytic enzymes liberated by the oral bacteria
destrol the organic matrix of enamel, loosening the
apatite crystals, so they are eventually lost and tissue
collapes.

5. Proteolysis chelation theory (by Schatz and Martin

in 1955);
 It proposes that some of the products of bacterial action.
 on enamel, dentine and salicary constituents can form
chelates with calcium.
 Since chelates can be formed at neutral or alkaline ph,
the theory suggested that demineralization of the enamel
could arise without acid formation.

Epidemiological triad of dental caries

I. Host factors;
1. Tooth;
 Composition the enamel consists of 96% inorganic
matter and 4% water and organic matter.
 Morphology presents of deep, narrow, occlusal fissures
or buccal and lingual pits tends to trap food, bacterial
and debris, leading to rapid development of caries in
these area.
2. Saliva; helps in removal of bacteria and food debris by
flushing action.

 The quantities of inorganic and organic constituents of

saliva varies from person to person.
 As the viscosity of saliva increases, the caries activity
also increases.

3. Sex; most of the studies have shown that dental caries is

more common in females.

4. Race; dental caries is more in whites compared to the

blacks.
5. Age; it is commonly seen in childhood. Over 60 years of
age , root caries is seen which is mainly due to gingival
recession and deterioration of oral clearance ability.

6. Oral hygiene habits; dental caries is found to be less

among those who maintain good oral hygiene.
 Other host factors include economic status, familial
heredity, etc

II. Agent factors; consist of plaque forming streptococci

(Strep. mutans).

Properties of cariogenic plaque

 Theyhave higher rate of sucrose consumption
 Forms more lactic acid
 Synthesize more intracellular polysaccharides
 Produce twice as much extracellular polysaccharides
 Higher level of Strep. Mutans
 Lower levels of Strep. Sanguis and Actinomyces

III. Environmental factors; include

Diet is defined as the types and amount of food eaten daily

by an individual.

 Differences in caries incidences was noted among

population with dissimilar diets.
Geographic variations;
 Decayed, missing and filled teeth (DMFT) is found to
be decreasing in developed countries, and increasing in
developing countries.
 the use of fluoride, oral hygiene practice and diet play a
cause for this differences.

Soil;
 population depend largely on locally grown food
products it is logical to look to differences in soil
consumption to help differences in caries experience.

Urbanization;
 dental caries is said to increase with urbanization.
Climate;
 sunlight is said to decrease caries, UV light from sun is
known to promote vitamine D production thus tend to
reduce dental caries, whereas rainfull is said to increase
dental caries.

Social factors;
 good economic status and social pressure in the
direction of good health appearance are both strong
factors in creating demand for dental treatment.
 A good economic status carries with it a low caries rate.

Industrial hazards;
 Carbohydrate dust and acid fumes are both known to be
deleterious to the teeth, one promoting caries and the
other chemical erosion.
 Prevention of dental caries
A. Primary prevention; includes
 Health promotion
 Specific protections such as appropriate use of fluoride,
preventive resin restorations, topical fluoride
supplements

B. Secondary prevention;
includes periodic screening and referral, simple restorative
dental procedures.

C. Tertiary prevention; includes utilization of dental

service, complex restorative treatment and RCT, and
removable and fixed prosthesis.
 Prevention and Control of Dental caries
1. increase the teeth resistance. It can be done either
systemic use of fluoride or by topical use.
2. Combat the microbial plaque by both physical and
chemical methods.
3. Modify the diet. Can be done by reducing the intake
and frequency of refined carbohydrates, stimulate
salivary flow with sugarfree chewing gums, etc

Preventive Interventions
 The use of pit and fissure sealants and application of
fluoride varnish help in slowing down the development
of caries.
 Preventive restorations should be carried out.
 Atraumatic restorative treatment (ART) should be use as
a community based aprroach for the treatment and
prevention of dental caries

Note; Study and master the various dental

caries indices.
2. Periodontal diseases

 Periodontal disease is a term which includes all

pathological conditions of the periodontium (gingiva,
alveolar bone, cementum, and periodontal ligament).

 Traditionally,it were classified into gingival and

periodontal diseases.

 Progress was slower in periodontal diseases compared to

dental caries.

 Itsimportant to note that in 1961, the expert committee

of WHO said that gingivities invariably developed to
periodontitis.
 Gingivitis and periodontitis are associated with bacterial
flora that have some similarities but also some
differences
 Though periodontal disease is usually related to age, it is
not a natural consequence of aging.

Epidemiologic indices
 One of the most valuable techniques employed in study
of the epithemiology of periodontal disease is the use of
indices.
 Some of the indices used are;

Periodontal index, periodontal disease index, papillary

marginal attachment index, and gingival index.
 Epidemiological triad

I. Host Factors
1. Age; chronic destructive periodontal disease has been
associated with older age groups (>40 years).
2. Sex; more common in males than females.
3. Race; Blacks are more affected than whites.
4. Intraoral variations; gingivitis is more seen on the
interproximal area than the buccal and lingual area,
and shows more on the upper arch.

 Severity of bone loss, incisor and molar areas are

severely involved than canine and premolar. Also
maxillary teeth experience more bone loss.
5. Endocrine changes; puberty, menstruation and
pregnancy, hyperthyroidism, hyperparathyroidisim
increase the chances of gingivitis.

6. Food impaction; causes chronic gingivitis which if left

to continue lead to periodontal disease.

7. Tooth position; irregular alignment makes it difficult to

keep these areas clean. This may allow for insufficient
intervening alveolar support resulting in early pocket.
8. Occupational habits; these habits include biting thread, holding
nails between teeth, etc can have traumatic effects on the
peridontium.
9. Use of tobacco; the components present in tobacco lower the
tissue resistance and increase susceptibility to gingivitis and
periodontal diseases.
10. Education; Severity of periodontal disease and level of education
are inversely related.
Other factors include; income, concomitant disease, misuse of
toothbrush, and neuroses.

ii. Agent factors

1. Plaque; it is the primary aetiologic factor for periodontal disease.
 Plaque is defined as soft deposits that form the biofilm adhering to
the tooth surface or other hard surfaces in the oral cavity, removable
and fixed restorations.
 Dental plaque is divided into supragingival and subgingival plaques.
 Marginal plaque is responsible for gingivitis whereas supragingival
and tooth associated subgingival plaque is responsible for
periodontitis.
 2. Calculus; it is an adherent calcified mass that forms on the surface
of natural teeth and dental prosthesis. It consists of meniralzed
plaque.
 Calculus would be divided into; supragingival calculus and
subgingival calculus.
 Assignment; Differentiate between supragingival and subgingival
calculus.
 iii.Environmental factors
 1. geographic variation; underdeveloped and dentist
deprived areas have increase scores for periodontal diseases.
 2. Nutrition; it is a secondary factor to periodontal diseases.
 Trend towards a higher prevalence and severity of periodontal
were found in areas with protein malnutrition and vitamin A
deficiency.
 3. Degree of urbanization; rural population seems to suffer
more from periodontal diseases compared to urban population.
 4. Stress; stress is said to predispose to acute necrotising
ulcerative gingivitis and is often seen in military groups and in
exam going student.
CHAPTER 4; SMOKELESS TOBACCO
 Spit or chewing or smokeless tobacco is less lethal, but
still unsafe.
 Alternative to smoking tobacco.
 This tobacco comes as loose leaves, plugs or twists of
dried tobacco that may be flavored.
 It is chewed or placed between the cheek and gum or
teeth. Then, the nicotine in the tobacco is absorbed
through the mouth tissues.
A. Types;
1. Snuff or dipping tobacco; it is finely ground tobacco
package in cans or pouches.
 It is sold as dry or moist and may have flavoring added.
 The snuff is made up of 02 main types;
 i. Moist snuff; which is used by putting it between th
lower lip or cheek and gum.
 ii. Dry snuff; is sold in a powdered form and is used by
sniffing or inhaling the powder up the nose.
 2. Dissolvable tobacco; this refers to flavored,
dissolvable forms of smokeless tobacco which are
available as tobacco lozenges, orbs, or pellets, strips
(like melt away bread strips), and toothpick sticks.
 All have tobacco and nicotine.
 Depending on the type, they are held in the mouth, chewed,
or sucked until they dissolve.
 The juices are swallowed.

Health risks of smokeless tobacco

 Using any kind of spit or smokeless tobacco is a major
health risk, though it is considered to be less lethal but it is
not safe.
 Overall, people who dip or chew get about the same amount
of nicotine and tobacco as smoking tobacco.
 Serious health risks of smokeless tobacco include;
 1. Cracked/ bleeding lips and gums.
2. Increased heart rates, high blood pressure and irregular
heartbeat.
3. Receding gums, which can eventually lead to periodontal
diseases hence teeth loose.
4. Higher chances of heart attacks and strokes.
5. Cancer (Oral cancer but can also have throat, bladder and
stomach cancer because chemicals from tobacco gets into the
digestive tract.
6. It also causes bad breath, yellowish brown stains on the
teeth, and mouth sores in most users.

7. Leukoplakia can also be present in smokeless tobacco users.

 Strategies to quit smokeless tobacco
 Use nicotine gum or a nicotine patch, but this can be
done only after talking with your physician.
 Start practicing healthier activities such as swimming,
weight lifting, biking, etc in order to distract yourself.
 Ask family, friends and colleagues for support during
this period.
 Try using substitutes for smokeless tobacco such as hard
candy, dried fruits, beef, jerky, sugarless gum, sunflower
seeds, etc.
THANK YOU