Community Dentistry Department HBS Medical and Dental College, Islamabad

1. {
Preventive &
Community Dentistry
Dr Qurat-Ul-Ain
Head of Community Dentistry Department
HBS Medical & Dental College

2.  Follow the ethics of classroom
 Personal reflection
 Note down lecture notes during lecture
 Follow-up reading (reading lists)
 Always feel free to contact me for questions/support
 Self-belief
 Involvement in group discussions/ out reach activities
 Punctuality
What I expect from you?

3.  Dental Public Health /
 Community Dentistry /
 Public Health Dentistry /
 Preventive Dentistry
 Leading Specialty of the Developed World, Still
in nascent stage in Developing Countries
 A Major Subject In BDS Curriculum
Dental Public Health –
Subject

4. BLOCK 4
 Module 7, Dental Public Health
 Module 8, Oral indices & health care systems
BLOCK 5
 Module 9, Oral Epidemiology
 Module 10, Introduction to Bio-Statistics
BLOCK 6
 Module 11, Preventive dentistry
 Module 12, Behavioral Sciences
Theory/OSPE Topics
Community Dentistry
(LGIS/SGDs)

5.  Logbooks
 Practical Demonstrations
 School Visits ( annual target of 14 school/
class)
 Oral Hygiene Instructions
 Community Programs ( Hazrat Bari-imam
Sarkar)
Community Dentistry -
Practical

6. Community Dentistry Books

7.  A textbook of Public Health Dentistry by CM
Marya
 Textbook of Preventive & Community Dentistry
by Hiremath
 Essential Dental Public Health by Daly, Watt,
Batchelor & Treasure. 2nd Edition
 Dentistry, Dental Practice & The Community by
Burt & Eklund. 6th Edition
 Textbook of Preventive & Community Dentistry
by Joseph John
Community Dentistry - Books

8. {
Introduction to
Dental Public Health
- 1
Def: Health & Oral health
Dimensions of health
Concepts of health
Determinants of health

9. What is health?

12.  “a complete state of physical, mental and social well-
being and not merely the absence of disease & infirmity”
 This definition makes the ultimate aim of achieving
perfect healthy status, impossible
(WHO, 1948)
Health

13.  “standard of health of oral & related tissues which enables
an individual to eat, speak & socialise without active
disease, discomfort or embarrassment and which
contributes to general well-being”
 Oral Health is essential to general health and should not
be considered in isolation
(Department of Health UK, 1994)
Oral Health

14. Oral Health is essential to general health and should not
be considered in isolation
(Department of Health UK, 1994)

15. HEALTH

16.  Ewles & Simnett outlined the 6 dimensions of health
 Physical Health
 Mental Health
 Emotional Health
 Social Health
 Spiritual Health
 Societal Health / Environmental Health
Dimensions of Health

17.  Health is not perceived the same way by all the members
of a community including various professional groups
i-e,
biomedical /social scientists, ecologists, administrators
etc and giving rise to confusion about the concept of health.
Concepts of Health

18.  Health has evolved over the centuries from the concept
of individual concepts of health as follows:
Biomedical concept
Ecological concept
Psychosocial concept
Holistic concept
Concepts of Health

19. 1. Biomedical Concept
 Health means “absence of disease”. Later developments
proved this concept to be inadequate
2. Ecological Concept
 Health is viewed as a dynamic equilibrium between man &
his environment and disease is a maladjustment of the
human organism to environment
Concepts of Health

20. 3. Psychosocial Concept
 Scientific advances showed that health is not only a
biomedical phenomenon but one which is influenced by social,
psychosocial, cultural, economic & political factors of the
people concerned
Concepts of Health

21. 3. Holistic Concept
 Holistic concept is synthesis of all above concepts
 Recognizes the strength of social, economic, political &
environmental influences on health.
 Emphasizes that health is influenced by all the sectors
like;
 Agriculture,
 Animal husbandry,
 food industry ,
 Education,
 Housing,
 Public works and other sectors.
Concepts of Health

23.  The factors which have been found to have the
most significant influences – beneficial or
harmful – are known as Determinants of Health
Determinants of Health

24. Determinants of Health

25.  To a large extent, factors such as where we live, the
state of our environment, genetics, our income and
education level, and our relationships with friends
and family all have considerable impacts on health
 The more commonly considered factors such as access
and use of health care services frequently have less
of an influence
Determinants of Health

26.  The context of people’s lives control their health,
and so blaming individuals for having poor
health or crediting them for good health is
inappropriate
 High to low Socioeconomical class within our
society can get different diseases
 Individuals are unlikely to be able to directly
control many of the determinants of health
Determinants of Health

27.  These factors include, but are not limited to:
1. Income & social status
2. Education
3. Employment
4. Social environments
5. Physical environments
6. Healthy child development
Determinants of Health

28. 7. Personal health practices & coping skills
8. Health services
9. Social support networks
10. Biology & genetic endowment
11. Gender
12. Culture
(DO NOT CONFUSE WITH SOCIAL DETERMINANTS OF HEALTH)
Determinants of Health

29. QUESTIONS ?

30. {
Introduction to
Dental Public Health
- 2
Disease, Illness & Sickness
Theories of Disease Causation

31.  Disease is described as named pathological entities
diagnosed by means of clinical signs & symptoms.
Determined by professionals
 Illness refers to the subjective response of the
individual to being unwell. Refers to show how the
person feels & what effects this has on their normal
everyday life. Sickness is a state of social dysfunction
 Ill Health an umbrella term used to refer the
experience of disease plus illness
Disease, Illness & Sickness

32. 1. Germ theory
• Disease caused by transmissible agents
• One-to-one relationship; mono-causal in essence
Agent ---- Host == Disease
Theories of Disease
Causation

33. 2. Epidemiological triad
• Exposure to an agent does not necessarily lead to
disease
• Disease is the result of an interaction between
agent, host & environment
Theories of Disease
Causation

34. 2. Epidemiological triad (contd.)
 Agent; An organism, a substance or a force whose
presence or absence is essential for a particular
disease or condition to occur.
Theories of Disease
Causation
Agent
Non-living/
inanimate
nutritive
chemical
physical
Living/
biological

35. 2. Epidemiological triad (contd.)
 Host; The characteristics of a human being that determine how
he reacts to the agent in the environment
 Behavior factors
 Demographics
 Socio-economic factors
Theories of Disease
Causation

36. 2. Epidemiological triad (contd.)
 Environment; Refers to extrinsic factors that affect the agent and the
opportunity for exposure.
 Environmental factors include physical factors such as geology and
climate, biologic factors such as insects that transmit the agent, and
socioeconomic factors such as crowding, sanitation, and the
availability of health services
Theories of Disease
Causation

37. 3. Web of causation
 Disease results from a complex interaction of various risk factors
 Controlling even one factor may stall the disease process
 Ideally suited to explain chronic diseases
Theories of Disease
Causation

38. Theories of Disease
Causation

39. 4. Theory of general susceptibility
• Regardless of the cause, some social groups have higher
mortality & morbidity rates
• Social class linked to health status is an example
5. Socio-environmental approach
• More explicit form of theory of general susceptibility
• Health influenced by social as well as physical factors
• Forms the basis for health promotion
Theories of Disease
Causation

40. {
Dental Public Health
3

41. {
• Def: DPH
• Tools /Procedural steps in DPH
• DPH problems/ criteria for DPH &
• 5-step comparison
• Differences between clinical and Community
Dental Public Health

42.  “science & art of preventing oral diseases,
promoting oral health and improving the
quality of life through the organised efforts
of society”
Dental Public Health

43. Tools are the sciences, approaches
& principles essential for the
practice of dental public health
Tools of Dental Public
Health

44.  These include:
1. Epidemiology
 Concerned with the study of disease patterns and causation
Tools of Dental Public
Health

45. 2- Biostatistics
 Science of collecting, organizing, analyzing, tabulating
and interpreting data relating to living
organisms/human beings
Tools of Dental Public
Health

46. 3. Social sciences
 Includes sociology, cultural anthropology & psychology
4. Principles of Administration
 Appropriate administration & management is essential
for the success of any public health project
5. Preventive Dentistry
 Actions aimed at eradicating, eliminating or minimizing
the impact of diseases & disability
Tools of Dental Public
Health

47.  Survey (examination)
 1st step in public health practice
 Assessment of the community
 Analysis (diagnosis)
 Information collected in the survey is statistically
analyzed
 This provides meaning to the obtained data
Procedural Steps in
Dental Public Health

48.  Program planning (treatment planning)
 Specialist plans but ultimate decision lies with the
community
 Ethics & planning approval (informed consent)
 Ethical clearance & approval from concerned authorities is
necessary before commencing the program
 Program operation (treatment)
 Program is implemented by an appropriate team
Procedural Steps in
Dental Public Health

49.  Finance (payment)
 Funds are pre-allocated & generated from autonomous
bodies
 Required meticulous planning in formulating the budget
 Program appraisal (evaluation)
 Effectiveness of the program is assessed and
adjustments are made if deemed necessary
Procedural Steps in
Dental Public Health

50.  To allow a health problem to be properly managed, it is
important that there is a set of rules or criteria to follow
which determines what is defined as a public health
problem and
 what is the best way to manage health problems in
communities.
Criteria to determine a public
health problem

51.  Criteria for a dental public health problem is:
1. Condition should be highly prevalent (if not, it should be
perceived as a threat by the public-life threatening)
2. Impact on individual
3. Impact on wider society
4. Condition is preventable & effective treatments are
available
Dental Public Health
Problem

52. 1 - WHAT IS THE PREVALENCE OF THE CONDITION?
 What is the prevalence of the health problem?
 Is the disease widespread?
 Who has the disease?
 What is the distribution of the disease within the community?
 Is the prevalence increasing or decreasing?
Criteria for a dental public health
problem is:

53. 2- WHAT IS THE IMPACT OF THE CONDITION ON AN
INDIVIDUAL LEVEL?
 How severe are the effects of the disease on the patient?
 Do people die because of it?
 Do they suffer pain, discomfort or loss of function?
 Can they perform their normal social roles?
 Are they prevented from going to school or becoming
employed because of their problem?

54. 3- WHAT IS THE IMPACT ON THE WIDER SOCIETY?
 What are the costs to the health service of treating
the condition?
 How much time do people take off work to get
treatment and care?
 What effects does the condition have on economic
performance and productivity of the country?

55. 4- WHAT CONDITIONS ARE PREVENTABLE AND EFFECTIVE
TREATMENTS AVAILABLE?
 Is the natural history of the disease fully understood?
 Can the early stages of the conditions be recognised?
 If so, are there interventions that can be implemented to
stop the disease progressing?
 If it does progress, are there effective treatments available?

56. 5-step comparison
CLINICAL DENTISTRY
1. Initial assessment of
patient medical and oral
health status
2. Diagnosis of oral health
pathology
3. Treatment plan based on
patient needs and
priorities
4. Payment method
determined
5. Evaluation of treatment at
specific intervals
COMMUNITY DENTISTRY
1. Survey of community oral
health status and
demographics
2. Analysis of survey data to
determine health needs
3. Program plan based on
resources available and
priorities
4. Financing obtained
5. Monitoring and evaluation
of program progress

57. CHARACTERISTIC CLINICAL DENTISTRY PUBLIC HEALTH DENTISTRY
Target Individual patient Community/group of
people
Collection of Info History taking/examination Public morbidity records
Investigations X-rays, biopsy, Epidemiological survey
Conclusion Diagnosis Situational analysis
Remedial
measures
Treatment plan based on
patient’s
consent/affordability
Program plan based on
needs, resources, priorities
Emphasis Curative and restorative Preventive and promotive
Success Patient cooperation Community participation
Service provider Dentist and assistant Public health professional,
para-team and community
volunteers
Intervention Appropriate dental
procedure
Program activities
Differences between clinical and
Community

58. CHARACTERISTIC CLINICAL DENTISTRY PUBLIC HEALTH DENTISTRY
Supporting discipline Psychology Sociology, social psychology,
education, epidemiology and
biostatistics
Organization/
management
Not relevant Very relevant
Perspective Immediate Long-term
Evaluation & results Relief of symptom
and restoration of
function
Formal evaluation
Aftercare Recall and follow up Self sustaining community
Funding By patient/insurance Funding agency
(govt/agencies)
Cont’

59. Questions ?

60. {
Preventive Strategy
Approaches
-4

61.  Proposed by Geoffrey Rose in 1992
 Preventive Strategies/Preventive
approaches/Approaches of Rose
 Mainly divided into two distinct groups
i. Whole-population Approach
ii. Risk Approach
a) Targeted/ Directed Approach
b) High-risk Approach
Preventive Strategy
Approaches

62.  Aimed at the whole population without any
discrimination
 If a disease is normally distributed in the
population then everyone has some disease. Risk
factors affect all who live in the society and it is
therefore more effective to work with the whole
population
 Severity of the disease & cost of treatment
The Whole Population
Approach

63. Caries vaccine
water fluoridation –
community water supply

64.  Radical: seeks to remove the underlying impediments
by addressing the social & political factors confronts the
root causes
 Powerful: small shift in population distribution of risk
factors may have a large effect on the number of
people affected
 Appropriate: changes the normal behaviour of
population to accepted behaviour for good health
The whole population
approach - Benefits

65.  Acceptability: population may not be willing to
accept the changes/interventions
 Feasibility: other social pressures within the society
may make the changes very hard to bring about
 Costs & safety: immediate costs might be high but
benefits are long-term. Reducing access to risk
factors may adversely affect some people
The whole population
approach - Limitations

66.  Aimed at certain sections of the population
which are identified, either as a group or as
individuals
 Where population subgroups are identified its
called “directed or targeted approach”
 Where individuals are identified it is known as
“high-risk approach’
Risk Approach

67.  Based on the principle that some groups of
the population are at greater risk than the
whole population
 Important to understand that not all the
people who are at risk of the disease will be
included in the target group
 Differs from High-risk approach in that not
every person within the targeted group is at
a higher risk but as a whole the group is
1-Targeted-population
Approach

68.  It is used when treatment of only those at the
greatest risk is considered most appropriate
 Only of benefit if it can identify those in the
population who are at most risk of developing a
condition
2-High-risk Approach

69.  Intervention is appropriate to the individual
 Avoids interference with those not at special risk
 Readily inculcated within health care delivery
system
 Cost-effective use of resources
 Improved benefit-to-risk ratio
High-risk Approach -
Benefits

70.  Prevention becomes medicalized
 Success can be palliative and temporary
 Poor overall control of a disease
 Might be behaviorally inadequate
 Limited by an inability to predict the future of
individuals
High-risk Approach -
Limitations

71. 1. Upstream – downstream
phenomenon
2. The Iceberg Phenomenon
3. The Top 10 Public Health
Achievements in the 20th Century

72. Upstream – downstream
phenomenon
In public health, we try to catch people upstream
before they get sick and fall down the stream where
the hospital has to then care for them

73. The Iceberg Phenomenon
Part above water:
Presented at the
healthcare facilities
Part below water:
Hidden part of disease –
pre-symptomatic, latent,
undiagnosed, carriers
Water level:
demarcation between
apparent and hidden
disease
DISEASE IN A COMMUNITY CAN BE COMPARED TO AN ICEBERG

74.  Split in 4-5 groups and think about any
disease and put it as example in
iceberg phenomena and then give
your own recommendation that what
u can do to prevent that disease
 Every group will present their points
one by one
Discussion task 10 min

75. Iceberg Phenomena
For Example
Part above water:
Presented at the
healthcare facilities
Part below water:
Hidden part of
disease – pre-
symptomatic, latent,
undiagnosed, carriers
Preventive strategies
• Oral cancer in late
stages - Late report
in hospital
• ?
• Undiagnosed oral
cancer cases-
because
population didn’t
have knowledge
about disease
• ?
• Educate people by
mass media
• Community level
screenings
program
• ?

76. The Iceberg Phenomenon
Part above water:
Presented at the healthcare
facilities
Part below water:
Hidden part of disease – pre-
symptomatic, latent,
undiagnosed, carriers
Water level:
demarcation between
apparent and hidden disease
e.g. hypertension, diabetes,
periodontitis far exceed
known morbidity
Disease in a community can be compared to an iceberg

77. DISTRIBUTION OF DISEASE

78. 1. Immunizations.
2. Motor vehicle safety.
3. Workplace safety.
4. Control of infectious
diseases (which includes
immunizations)
5. Declines in deaths from
heart disease and stroke.
6. Safer and healthier foods.
7. Healthier mothers and
babies.
8. Family planning.
9. Fluoridation of drinking
water to prevent dental
caries (cavities
10. Reduction of tobacco use
CDC: The Top 10 Public Health
Achievements in the 20th Century

79. Questions ?

80. TOPIC:
1. Criteria for a public health
problem
2. Top 10 achievements of
public health in 20th
century
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