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Community Dentistry final


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1. How is fluoride deposited in calcified tissues?

2. How is fluoride released from the body?
1. -via plasma
2. -it is excreted in the urine
How long does it take for fluoride to clear the body?
8-9 hours
Is fluoride stored or excreted in the child? The adult?
-child= stored
-adult= excreted
What is fluoride balance?
fluoride storage efficiency
Where is fluoride absorbed?
In the upper GI tract
What is the acute fatal poisoning level in an adult?
2.5-5 g of fluoride w/in 2-4 hours
What is the acute fatal poisoning fluoride level in a child?
435 mg F in 3 hours
What are adverse effects of fluoride toxicity?
gastrointestinal effects = stomach pain, nausea, diarrhea
Who recomended that fluoride concentration in dental health products be limited?
How much fluoride do home products contain?
no more than 300mg F
What type of first aid should be administered if too much Fluoride is injested?
induce vomiting initially and then have the person ingest material that will bind fluoride such as milk.
How is fluoride application the most effective in caries prevention?
in constant low levels
In what stage of tooth erruption is fluoride most effective? (the primary role of fluoride occurs in this stage)
the post-erruptive stage
How does the primary role of fluoride in carries prevention work?
-enhances the ability to remineralize a lesion
-it is incorporated into dental plaque and relaesed in response to lower pH
-inhibits bacterial glycolysis/ metabolism
-has a direct bactericidal action on S. mutans
What is the secondary role of fluoride and when does it take place?
-incorporation of fluoride into developing enamel hydroxyapatite crystals. This reduces enamel solubility in acid
-pre- erruptive stages
What are the benefits of fluoride in the saliva?
constant bathing of teeth in fluoride allows for remineralization
Where is caries reduction greatest as a result of fluoridation?
on free smooth surfaces and proximal surfaces
In the market, where is fluoride mostly found?
In toothpaste
How does fluoride help older adult's teeth?
in the prevention of root caries
When fluoride toothpaste is used, is caries reduction proportional to the fluoride concentration in the toothpaste?
Is MFP fluoride or NaF (neutral sodium fluoride) more efficient in carries prevention?
What problem does acidulated phosphate fluoride in professional products cause and what type of fluoride would be safe to use?
-will etch resins and veneers
-neutral sodium fluoride
What propery of acidulated phosphate fluoride enhances fluoride uptake?
-the acidic environment
What is a benefit of high concentrations of fluoride?
it will form a reservoir on the tooth surface that becomes available for remineralization
Fluoride is the main type of modality used in community prevention programs. What type of programs are available?
-fluoride varnish programs
-school fluoride mouthrinse programs
-fluoride tablets
-salt/milk fluoridation
-community water fluoridation
What is a fluoride varnish and what are advantages of its use?
-professionaly applied NaF adhesive
-can remineralize an existing incipient lesion
- is not easily ingested- used on small children
What is the only toothpaste additive that has been shown to reduce cavities?
What is the "into the mouth of babes program?
Program that asked physcisians to look into babies mouths.
-do a risk assessment for oral disease
(what is put in bottle)
-oral screening for disease-DDS referal
-application of fluoride varnish
-health education for primary caregivers
Where are NaF mouthrinse programs used?
Is this cost effective?
-in areas without water fluoridation
-no, especially when compared with water fluoridtion but is reasonable for high risk groups
Is fluoride recommended for preschool children or children living in communities with water fluoridation? Why?
-because fluoride is toxic and they might swallow the fluoride, may cause fluorosis
How do dietary fluoride supplements work?
-contain naF
-child should chew, swish, swallow naF tablet
-primary effect is post erruptive
Are prenatal supplements ever recommended?
-no, they have not been shown to provide any effect
When would one use salt fluoridation?
Where is it used?
-if there is no community water you must fluoridate something else
-places with water wells, or little political acceptance of fluoride in the water- Europe, Central and South America
Who does milk fluoridation target?
Where is this favored?
-favored in eastern european countries
Where is school water fluoridation provided?
drinking water of school in rural areas
Is school water fluoridation advocated by the CDC anymore?
What are the advantages of school water fluoridation? Disadvantages?
Advantage= targets population at risk, reduced decay
-began F treatment at age 5-6
-only receive F while in school
-higher than normal dose to aid in last comment.
What is community water fluoridation?
Addition of fluoride to public water supply w/ intent to privent decay
What is water fluoridation?
adjustment of the natural fluoride content of water to optimal levels to reduce disease
What is the optomal fluordation level w/ greatest caries reduction & least risk of fluorosis?
1.0 ppm
What level of fluoridation is recomended by the World Health Organization?
What country has mandatory fluoridation law?

What countries have banned adding anything to the water?
-Denmark & Sweden
What type of grant has the CDC provided to fund expertice and water fluoridation?
The prevention block grant
What two large US cities are currently nonfluoridated?
-Portland, OR
-Honolulu, HI
Do most Texans drink fluoridated water?
What two cities in Texas are not optimally fluoridated?
Texarkana and San Angelo
When did San Antonio get fluoride in their drinking water?
August 1, 2002
What is the definition of efficacy?
How well the procedure worked under ideal conditions.
-example a study such as a controlled clinical trial
What is the definition of effectiveness?
the degree of achievement of the intended result under real world conditions.
-example a field trial
What is the definition of efficiency?
A result expressed in terms of money, time spent or saved
-example: quality of life measures = days of work/school saved because of lack of dental pain
What is the justification for a prevention-based approach to oral health care?
efficacy, effectiveness, efficiency
What are some of the benefits of community water fluoridation?
-provides protection w/out regard to social status
-reduces need/cost for dental fillings
-modest cost
-decreased abscence from work or school
-increase in learning/productivity
What is the halo effect?
exposure to fluoride from processed foods and other sources rather than water
Is caries preventive benefits additive?

Will decay increase if fluoride is taken away?
-Yes, topical Fluoride application + water fluoridation shows a greater decrease in decay

What did the workshop on cost effectiveness of caries prevention in dental public health ,Ann Arbor MI 1989 establish?
water fluoridation is the most effective preventive measure and the least costly
What are some recommendations from the clinician's handbook of preventive services?
-asses fluoride exposure and supplement as needed
-counsel pt on dietary impacts
-instruct partents to wipe teeth after feeding an limit exposure to bottle in evenings after the first year
Is there a mortality difference between fluoridated cities and non-fluoridated cities?
Can fluoride cause cancer?
only if way above optimal levels, affects all sizes and shapes of people equally
Can fluoride cause osteoporosis?
-Not at optimal levels
-Some studies show high doses of Fluoride increase vertebral mass but appendicular skeleton fractures increase
What happened at Hooper Bay, Alaska?
-The community was poisoned by fluoride, thought they had the flu

-results= periodoic plant inspections
fail safe overfeed devices put into place
Do most brands of bottled water include fluoride?
Do commercial water filtration systems remove fluoride from the water?

Do reverse osnosis filtration systems eliminate fluoride from the water?

Has fluoride been shown to cause birth defects of differences in bone density?
Politically, who approves of the fluoridation of the water?

Has a court ever ruled against water fluoridation?
-state law or city/municipal mandate

What are some reasons for opposition to water fluoridation?
-holistic health approach
-polution of "pure" water
-dental disease is no longer a problem
-freedom of choice
What was the purpose of the CDC's report on the recommendations for using fluoride to prevent and control dental caries in the US
to evaluate professional and scientific eveidence by grading the quality of the evidence and assess the strength fo each recommendation
What is fluorosis most likely caused by?
multiple and poorly controlled fluoride exposures
What is diet?
What is nutrition?
-food & drink that passses through the mouth
-absorption and metaboliam of nutrients
What is acidogenic food?
Any food that contains sugar or other readily available fermentable carbohydrate
-is a necessary cause for decay
What is cariogenic food?
ability of food to foster caries in human conditions conducive to caries formation
What is fermentable CHO?
term used to define sugars and refined starches
How do sugar subsitues reduce the prevalence of S. mutans?
they suppress the availability of nutrients (fermentable CHO)
Name two noncariogenic sugar substitutes
sorbitol and xylitol
How does xylitol work?
-does not lower the pH of plaque to point where demineralization occurs
-xylitol gum can inhibit caries by a decrease in the quantity of supragingival plaque
-may promote remineralization and arrest established decay
How does sorbitol work?
-does not lower the pH of plaque to point where demineralization occurs
-does not promote caries & may help to reverse early demineralization
What type of protective foods can decrease the rishk of development of dental caries?
-Dairy- reduces the acidity of plaque and the cariogenicity of food

-Phosphates (in animals)

-reduction in sugar intake (drinks w/ sugar)
How should one counsel people on good food choices?
-choosing unrefined CHO
-moderate amounts of protein
-reduce consumption of foods high in fat
What type of systemic diseases has been causally implicated to perio disease?
-Type 2 diabetes
-cardiovascular disease
What are some eating disorders that affect oral health?
-binge eating
What are some oral manifestaion sof eating disorders?
-enamel erosion-(does not cause change in caries prevalence)
-salivary gland enlargement(parotid)
-tooth erosion (loss of vertical demension)
How should you handle someone with an eating disorder?
-Assesment( look for signs)
-intervention (increase dental visits)
What is a fissure sealant?
a plastic professionally applied material used to occlude the pits and fissures of teeth
What are preventive sealants?
applied to at-risk, caries free pits and fissures to prevent caries in community dentistry we focus on these
-can be light cured or chemical cured
What are therapeutic sealants?
applied to pits and fissures where caries is confined to enamel to arrest progression of incipient lesions
When is the loss of sealants most likely to occur?
Are sealants better retained in older children?
-in the first six months after placement
Is retention of sealants better in bicuspids or molars,mandibular or maxillary teeth?
Can sealants be placed over an incipient lesion?
-yes, caries-active lesions become inactive under sealant
What did the national preventive dentistry demonstration project do?
-combined fluoride mouthrinse program with community based sealant program
-showed that dental sealants work
Who is targeted by community sealant programs?
-Lower SES
-people with high # of unmet dental needs
-people around a shortage of dental professionals
Can trained auxiliaries apply sealants in public health programs in texas?
yes- as of last year
What is the definition of cost-effectiveness?
the least expensive way, among competing alternatives of meeting a defined objective, targets preventive procedures
- example: sealants to all teeth
What is cost-benefit?
the ratio of the cost of providing the service to the monetary benefit
-how much money will this save us if we do this procedure
-example: sealants only to those teeth with early lesions
Are sealants more cost effective in non-fluoridated areas?
yes, in non-fluoridated areas there are more lesions to prevent
What teeth are at highest risk for pit and fissure caries?
first and second permanent molars
What is the foundation for the Ecological Plaque Hypothesis?
Perio prevention should be geared toward plaque control not plaque eradication because it is ubiquitous
What happens to supragingival plaque if it is left undisturbed?
becomes subgingival plaque that can be colonized by periodontopathogenic bacteria
What is plaque?
Natural biofilm that forms on the tooth surface, consisting of a diverse microbial ecology embedded in a matrix of bacterial/salivary origin
How do you prevent periodontitis?
prevent gingivitis
What is the primary prevention of gingivitis?
plaque removal,The cause of gingivitis is related to plaque mass
How is subgingival plaque removed?
Requires professional intervention to remove it
What is the initial step in destructive periodontal disease?
What starts plaque formation?

What causes the buildup of plaque?
-microbial adhesion
-microbial multiplication
What does Plaque accumulation around the gingival margin leads to?
an increase in crevicular fluid
Subgingival plaque microflora shift from predominantly gram-positive aerobes to what?
to more gram-negative anaerobes.
What is calculus?

What is subgingival calculus closely associated to?
-a calcified matrix that can harbor periodontopathogenic bacteria

-both gingivitis and periodontitis.
What types of plaque must be removed by a professional?
-Subgingival Plaque
-Supragingival Calculus
-Subgingival Calculus
How often should plaque be removed by an individual?
24- 48-hours
Is there a difference in effectiveness of power or manual toothbrushes if the person is normal?
What type of brushing technique should children use?

-Scrub technique for patients with limited motor skills (ie. children)

-Modified Bass technique for adults
What is the most recognized method of interdental cleaning?
What are some examples of interdental floss aids?
-Threaders: Patients with FPD
-Floss Holders: Assistance with dexterity
-Interdental brushes or Stim-U-Dent are preferred to floss when papillae have diminished and interdental spaces are pronounced
What does Chlorhexidine gluconate do to prevent plaque?
adheres to residual biofilm and is released over 8-12 hours
What are some characteristics of Chlorhexidine gluconate?
-Reduces gingivitis, gingival bleeding, and plaque deposits
-Inhibits formation of supragingival plaque
-Does not inhibit formation of subgingival plaque
-Can be used in caries control
-Effective against S. mutans for patients with elevated levels in saliva
What are Adverse Side Effects of Chlorhexidine gluconate?
-Staining of teeth and tooth colored restorations
-Potential for colonization of resistant organisms
What are the uses of Chlorhexidine gluconate?
-Improve plaque control following surgery
-Used 3-4 weeks after surgery
-Oral hygiene aid for patients with immobilized jaws
-Institutionalized patients with limited ability to manage own oral care
Is listereine accepted by ADA as effective antiplaque rinse?

Should you recomend this to alcoholics?

How does stannous fluoride's antiplaque properties work?
Affects the growth and adherence of bacteria
What are some examples of anticalculus toothpastes?

What are their action?

Action: Adsorbing to the tooth surface
-May have anti-inflammatory effect
-Prevents plaque deposition
-Reduces gingival bleeding
What is the HP 2010 Goal?
to Reduce Periodontal Disease
What is the primary focus of community based efforts to reduce periodontal disease on community level?
Oral hygiene education and tobacco education
What art the principal oral cancer risk factors?
-Smokeless tobacco (because of the method of use) is key factor in young persons
-Chronic cigarette smoking is a key factor in mature persons
-Synergistic effect when used in combination
-sunlight exposure and previous cancer experience
What is another principal Risk Factors not listed on the other slide?
-Low SES- poor, homeless, unemployed
-Underutilization of dental services
-Reduced chance of having an early lesion detected and treated
What is the definition of Social responsibility?
Broad term encompassing professionalism, personal and professional ethics, and the role of a profession in the context of the greater society.
What do Physicians for social responsibility stand for?
They are devoted to nuclear disarmament, violence prevention and environmental health
What do Educators for social responsibility
Are concerned about teaching young people develop the convictions and skills needed to shape a safe, sustainable and just world.
What do Business for social responsibility organizations stand for?
Strives to help member companies achieve success in ways that respect ethical values, people, communities and the environment.
What do Computer Professionals for social responsibility organizations stand for?
Provides the public and policymakers with realistic assessments of the power, promise, and problems of information technology.
What is the Societal role of social responsibility include?
-The professionÂ’s obligation to raise the oral health IQ of the community

-Assuring the health and well being of the public

-A persons right to health care
What are the Special rights and responsibilities of the health care professional based on?
-must have Competency- pass clinical tests
-must have Virtues
-must have Professionalism
what does the Intensive training and acquired specific skills of the health care professional involve?
-Includes technical skills, via certifications, licensing, credentials

-Requires appropriate knowledge and critical judgment and applying knowledge

-Most important***- Caring, is the greatest opportunity for professional services and satisfaction
What is professional ethics?
-Standards of conduct that distinguish between right and wrong, good and bad, virtue and vice, justice and injustice.
- how we ought to behave
-the development of moral behavior
Is oral health care a right or a privilege?
-The US constitution does not specifically guarantee a “right to health”
-Health and access to health care are not so much a legal right but a “moral” right
-Society has not universally accepted this responsibility, this is where we can make a difference
What are Structural barriers?
Lack of health care insurance, high out-of-pocket expenses, lack of transportation, language difficulties
What are Cultural barriers?
characteristics of minority groups, such as styles of interaction and expectations
What is the Pluralistic health care system
US system with numerous, distinct health care delivery systems coexisting simultaneously
What is health care Need?
Those services deemed by the health professional to be necessary after a variety of assessment and diagnostic tools and past experiences
What is health care Demand?
The health care services desired by societyÂ’s perception of what is acceptable and unacceptable in terms of health and aesthetics
Do males or females get more oral cancer?
What are the primary risk factors for oral cancer?
-Tobacco Use: Smokeless/Smoking
-Alcohol Consumption
-Exposure to Sun (Lip Cancer)
The prevention for current T&A users is to increase cessation. How do you increase cessation?
-Increase the price (tax)
-Mass media campaigns
-Telephone quit lines- effective when coupled with other measures
-Smoking bans
-Reduction of cost of nicotine replacement theapies
How would one reduce initiation for future users of T&A?
-Increase the price (tax)
-Mass media campaigns- removal of the ash trays
For nonusers of T & A how would one reduce environmental tobacco exposure?
-reduce exposure in the home
-smoking bans in public
What do smoking bans lead to?
a. Reduced exposure to ETS
-A change in attitudes
-Reduced initiation
-Reduced consumption
-Increased quit attempts
-Increased cessation
-****Ultimately reduced morbidity and mortality
What are some recomended interventions to increase cessation of T & A
-Provider education programs (alone)
-Provider feedback systems
How do Provider Reminders form an Analytic Framework?
-Provider knowledge
-Patient smoking status
-Advice to quit
-Attempts to quit
-Quit = decreased morbidity/mortality
How do Prevention of Sales to Minors (T & A) Programs help?
-retailer knowledge----retailer perceptions-----retailer behaviors

-Community Norms---enforcement---is the main arm that makes a difference

-Youth knowledge---youth perceptions---youth tobacco purchases---other sources may obtain tobacco for youths, this can harm instead of help prevention
What are some guidelines for school health programs to prevent tobacco use and addiction?
-Develop and enforce a school policy

-Provide education about short- and long-term effects, both social and physiological

-Provide tobacco prevention education in K-12

-Provide program specific training for teachers

e. Involve parents/families in support of school based programs
What does the National Spit Tobacco Education Program target?
-prevention of starting smokeless tobacco

-targets at risk groups- baseball clubs, 4-H clubs, little league baseball
What is the COMMIT program?
Community-based intervention program encourages modification of the social environment to discourage high risk behaviors and attitudes
What is the major result of COMMIT?
Community based interventions are effective for light and moderate smokers
What does the study ASSIST do?

What is the result of ASSIST?
-Is a smoking intervention study at the state level

-ASSIST states had lower adult smoking prevalence than non-ASSIST states
What are the 5 A's regarding tobacco use history with all patients?
Anticipate, Ask, Advise, Assist, Arrange
What type of patients are at risk for oral cancer?
-the age of 50 years, With a history of tobacco and/or alcohol use

-Men under the age of 50 years, with a history of ST use

-Women with a history of tobacco and/or alcohol use
When should you begin to talk to children about smoking?
Begin when children are early elementary school age
What are some Clinical Events to look for at the patient exam?
ƒÞ Changes in Soft and Hard Tissue
ƒÞ Leukoplakia
ƒÞ Halitosis
ƒÞ Tooth Discoloration
ƒÞ Abrasion and Wear
ƒÞ Gingival Recession
ƒÞ Periodontal Involvement
ƒÞ Oral Cancer (primary sites
Does smokeless tobacco contribute to oral cancer?
yes, Smokeless tobacco use contributes to leukoplakia (precancerous lesion) which becomes malignant in 3-5% of the cases
What is the principal market for Smokeless tobacco?
Adolescent and young adult white males
What is indicated as the strongest influence in ST use?
Peer pressure
In adults, do blacks or whites use more ST?

What occupation uses the most ST?

-baseball player
What did the Comprehensive Smokeless Tobacco Health Education Act enforce?
-Warning labels on smokeless tobacco products

-Prohibition of radio and television advertising

-Prevention of sales to minors

-Development of health education materials for the public
What is the prevention of smokeless tobacco use based on?
Based on public and private prevention
Who is the target for primary prevention of tobacco use?
-Target children to not begin using tobacco.

-Intervene early with those individuals who are at greatest risk for tobacco use= White males of MS or HS age
Who is the target for secondary prevention for tobacco use?
-Encourage those who are currently using to stop
What is the five A list and who is it for?
-Ask, Advise, Assess, Assist, Arrange

-Cessation Protocol for Tobacco Users who are Ready to Quit
What is the five R list and who is it for?
-Relevance, Risks, Rewards, Roadblocks, Repetition
-Cessation Protocol for Tobacco Users who are NOT Ready to Quit
What are healthy people 2010 goals for reduction in oral cancer?
-50% of oral cancers detected in Stage I
- 20% of individuals report having had an oral cancer screening in past 12

-Reduce tobacco use in adults

-Reduce tobacco use in adolescents
What are some strategies to prevent oral injury?
-Seatbelt use/legislation
-Child safety seats
-Helmet use/legislation
-Mouthguard programs
How many states have seatbelt laws?
What are primary laws concerning safetybelts?
Allows police officer to stop a vehicle solely for not wearing a safety belt (without having other reasons for stopping the vehicle)
What are secondary laws concerning safetybelts?
Police officer may issue a safety belt law citation only if vehicle has been stopped for another violation.
Do all 50 states have child safety seat regulations?

Is primary or secondary enforcement used?
What are some Child Safety Seat Programs?
1.Enhanced Enforcement Campaigns- Combinations of mass media and enforcement with penalties

2.Distribution and Education Programs-
Provide free/reduced cost seats with educational program

3.Incentive and Education Program-
Provide incentives for use of seats
Do dentists have a legal requirement to report suspected cases of child abuse?
What are different Types of abuse and neglect?
-Child abuse (must be reported)
-Spousal/partner abuse
-Elder abuse
-Dental neglect
What are Potential signs of abuse?
-Bruises around the head and neck

-Bruises of multiple colors (indicate multiple stages of healing)

-Injuries that are inconsistent with events relayed to provider

-Inappropriate clothing for temperature

-Unusual shyness, withdrawal, or reaction to an oral procedure
Where do most child abuse injuries occur?
in the head and neck region.
Are abusers most likely to take child to dentist or doctor?
-Abusers are more likely to take the child to the DDS than the MD and are more likely to return to the same DDS.

-More often, abusers will NOT return to the same physician or ER.
MISC summary points
-dentists need to recognize their roll in overall health care

-dentists need to inform pts of risks of oral injury

-only 10% of dentists counsel on smokeless tobacco use behaviors
What is the definition of an underserved popultation
Any group of people without access to resources, either human or material, to enhance their quality of life.

-Because demographically diverse, lack of geographic and/or financial access to oral health care, inadequate attention to prevention
What is the definiton of a special needs population?
Persons who have difficulty accessing dental services because of complicated medical, physical, social or psychological situations.
What is the definition of a caregiver?
Individual who provides care for the patient on a routine basis

-Could be a parent or family member, direct staff member in a residential care facility, licensed vocational nurse in a nursing home
Why are Dental services available in the institutional setting not always available for special needs patients in the community?
-Dental providers are not trained to serve special needs patients

–Limited third party payment for delivery of complex services

–Treatment usually focused on ‘crisis care’
Americans for Disabilities Act (1990) requires what?
modification of physical space for access and provision of dental services
What is the leading cause of disability over age 75?

Do 50% of seniors report some level of diability?
-dementia-AlzheimerÂ’s Disease, ParkinsonÂ’s Disease

Can Dental hygienists practice under general supervision in the nursing home?
What problems do nursing home residents face?
-Have limited access to dental care

-Lack of awareness among caregivers about the importance of oral health

-Under nutrition is a critical problem that effects oral health
What type of barriers to care do mentally and emotionally challenged people have?
What are some issues special populations face?
-Determination of Legal Guardianship
-Difficulties in Transfer of Patient from Wheelchair.
-Turnover of Caregivers
-increased Risk for Certain Diseases
What are some prevention considerations for the special needs patient?
•Use of fluoridated toothpaste on a mechanical toothbrush.
•Promotion of a healthy diet
•Consider xylitol gum for patient’s who can tolerate chewing gum
•Increase fluoride exposure (varnish applications)
•Regular dental visits for plaque removal and fluoride application
•Consider chlorhexidine gluconate rinse

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