Dentist In Society Year 3 Flashcards
1
Q
What does power mean in dentistry? (3)
A
- ability to ensure that a particular point of view prevails in a disputed situation
- capacity that someone acts in certain way
- ability to stifle opposition in particular perspective
2
Q
3 contributing factors of dentist-patient relationship
A
- environment of dental clinic
- dental consultation (physical, emotional, social)
- professional status of dentistry
3
Q
aspects of physical powerlessness in dental consultation
A
- mouth is v sensitive
- ortho-facial pain in debilitating
- difficult to communicate
- physically lower than dentist, and horizontal
- dentist controls movement (via chair)
- treatment focussed on mouth
- noisy atmosphere
- not easy to hear/ reply to instructions/ prompts
- within intimate zone
4
Q
3 aspects of physical/emotional powerlessness in dental consultation
A
3:
- people’s hands in your mouth is INVASIVE
- intimate v personal space
- requires trust
- dentist looks alien with mask etc
5
Q
4 levels of proximity for physical powerlessness
A
- public (over 3.6m, when addressing big group)
- social (2 arm lengths away, people you don’t know well)
- personal (1 handshake away, friends)
- intimate (2 fists away, emotionally close people)
6
Q
how is power rational?
A
constructed through patterns of social relations that are reproduced through processes of socialisation
7
Q
3 aspects of social powerlessness
A
3:
-professional role of dentist –> legitimacy and authority in consultation
(like a child being told off eg you should brush more)
-dentist can diagnose / undertakes clinical exam
-dentists decide and prescribe treatment
8
Q
Explain paternalistic communication model
A
Dentists get 'locked in' to role and control consultation with little input from patient. Dentist (6): -initiates, leads consultation -asks direct questions -limits amount/type of info to pt -deflects answers -offers diagnosis and treatment
Pt (4):
- explains symptoms
- listens to instructions/ info
- asks qs
- consents to tx
9
Q
Why does a dentist need to know about power?
A
3:
- helps dentist be more aware of ways patient thinks about dental visits
- better dentist-patient relationship
- helps empower patient
10
Q
a. 2 ways in which dentists represent authority
b. what is clinical autonomy?
A
a. -cultural authority: specialist knowledge on certain subjects, accepted by the state
- medical authority: having scientific knowledge to be able to describe and define health and illness and make decisions based on professional judgement and specialist knowledge. INCLUDING language (jargon) used
b. clinical autonomy: freedom of clinicians to make decisions based on their professional judgement and specialist knowledge
11
Q
L2, SCREENING AND ORAL HEALTH
9 purposes/advantages of screening
A
9:
- detect disease at pre-symptomatic stage, interrupt natural history of disease
- detect individuals vulnerable to disease
- enable informed reproductive choices
- protect public health
- prevention rather than cure
- reduce morbidity and mortality
- reduce cost (of healthcare and to economy-less days off work etc)
- less radical treatment
- reassurance for those deemed healthy
12
Q
draw the natural history and interventions flowchart
A
induction (ind) —> promotion —-> expression
initiation aetiology –>ini. pathology—> clinical detection —> outcome
screening intervention —> traditional intervention
13
Q
when is screening intervention active?
A
induction
14
Q
define screening
A
rapidly applied tests on a large scale –> identifying unrecognised conditions
15
Q
is screening diagnostic?
A
normally, no (requires follow up investigations and treatment)
16
Q
3 types of screening
A
- selective screening (single disease in limited population eg miners, multi-phasic- antenatal examinations)
- mass screening (single disease in large population eg breast cancer, multi-phasic- routine check ups for women)
- opportunistic
17
Q
main aim/of selective screening
A
convert at-risk groups to low risk by behaviour modification or intervention
18
Q
11 principles of screening. who are they by
A
set by UK NATIONAL SCREENING COMMITTEE CRITERIA
- condition should be important health problem
- natural history understood
- recognisable latent or early symptomatic stage
- suitable test for examination
- test should be acceptable
- evidence that program reduces morbidity/ mortality
- benefits should outweigh harm
- opportunity cost should be economically balanced
- adequate staffing and facilities for diagnosis and treatment
- should be an accepted treatment
- agreed policy on who to treat
19
Q
4 factors making a disease suitable for screening
A
- early therapy gives better results than late therapy (or no point screening early)
- condition has slow but progressive natural history
- prevalence is high
- disease has major effects
20
Q
4 stages of screening
A
- identification of at-risk group
- application of screening test
- application of appropriate diagnostic tests
- treatment of those with +ve results
21
Q
define sensitivity
A
probability that the test will be positive if disease is truly present (SEE TABLE)
22
Q
define specificity
A
probability that the test will be negative if the disease is truly absent
23
Q
how does screening link in with sensitivity and specificity?
A
screening is most effective for diseases which have screening tests with high sensitivity and specificity, so resources are not wasted on healthy individuals or diseases with known high prevalence
24
Q
explain predictive values of a test
A
both about the prediction being correct.
positive predictive value: has disease when screening was positive
negative predictive value: does not have disease when screening was negative
25
how has screening for caries in schools changed over the years?
3 times in school career until 2006, then deemed ineffective
now some school visits in at risk areas in England and Wales
Scotland has national inspection program, combining screening and epidemiology
26
is there screening for oral cancer? why?
so how is oral cancer screened for?
no. value of screening test unclear
- not cost effective
- low prevalence
- not clear how you would identify high risk groups
- what frequency
- how would you evaluate effectiveness
- -> opportunistic screening carried out eg during check ups
27
L3 HEALTH PROMOTION
| 5 factors influencing health
- human biology
- physical environment
- social environment
- behaviour/lifestyle
- health services
28
draw flowchart to socioenvironmental approach to health
(see lecture slide)
risk conditions (poverty, low status, dangerous stressful work, discrimination, poor housing, poor access to healthy food)
--> physiology (hypertension, obesity etc) and behaviour (smoking, exercise)
--> psychosocial (isolation, self-esteem, lack of control)
all --> oral health
BUT more complex than this: behaviour is a social and psychological product and is locked in to routines. also limited by physcial env/opportunites to make choices
29
3 examples of how inequalities affect health (black report)
-at every stage of life those in lower social classes have higher death rates
-children born in to lower social classes have lower birth weights and shorter stature
-all major diseases affect lower social classes more than higher ones
BLACK REPORT 1982
30
explain how behaviours are influenced by environment/ social class
behaviour locked in to routines, they are a social product
but behaviour also a psychological product
ie social AND physical environments provide OR restrict options of behaviour eg education of healthy food, but may not be able to afford it. also influenced by those around them
31
2 most common oral diseases
caries, periodontal disease
32
what % of schoolchildren worldwide have decay?
60-90%
33
what % of middle-aged adults have severe periodontal disease?
5-20%
34
incidence of cleft lip
1\500 to 700 births
35
what % of HIV positive people have oral fungal, bacterial or viral infections
40-50%
36
what % of public health expenditure relates to oral health in high income countries?
5-10%
37
what did Nancy Milio say can be done to improve health of populations?
make the healthy choices the easy (and cheaper) choices
38
define health promotion and give its aims 3
process of enabling people to increase control over and improve their health
- focus on tackling determinants of health by
- working in partnership with agencies and sectors in
- strategic approach to promote population health
39
a. principles of health promotion (4)
| b. 4 roles of HCPs in health promotion
a. -involves population as a whole
- directed towards action on determinants
- effective and concrete public participation
- not a medical service (but often involves HCPs for enablement, mediation, advocacy, education)
b. enablement, mediation, advocacy, education
40
5 approaches to health promotion
draw diagram (see lecture)
- prevention
- behaviour change
- education
- empowerment
- social change
41
draw approaches to health promotion diagram
see handout or camera roll (16/9/15)
42
explain prevention
reduce disease levels by prevention, eg fissure sealant. doesnt address underlying causes
43
explain behaviour change
individuals take responsibility.
one to one advice and mass media campaigns
increasing knowledge does not always lead to change in behaviour --> education is a seperate point
44
explain education
provides knowledge (as does behaviour change) AND skills and attitude to make choices. does NOT persuade change in behaviour
45
explain empowerment
community-led encouragement from the bottom up
46
what type of health promotion are smoking intervention groups
education
47
explain social change
physical, social, economic environment
| political arena eg fluoridation
48
difference between health promotion and health education
health promotion: umbrella term, including health promotion and education. concerned with empowerment (help people to help themselves). leads to public health policies
health education is about increasing health knowledge and skills only
49
why is an evidence base important in health promotion
need evidence for interventions because they all have cost
50
what is the opportunity cost
benefit of intervention compared to its cost
51
how is cost effectiveness measured
per QALY: quality of life adjusted years
52
explain/ draw common risk factor approach
see handout. diet, hygiene,smoking, alcohol, stress
53
is lack of fluoride a common risk factor ? why?
no. no serious health risks without fluoride
54
5 strategic elements of Ottawa charter
- building healthy public policy
- creating supportive environments
- strengthening community action
- developing personal skills
- reorienting health services
55
explain building healthy public policy. inc 3 types
-encourage policy makers in organisations/ governments to place health on their agenda
-identify/ remove obstacles to healthy policies so these become the easier choices
1-health impact assessments (transport, income, agriculture, energy)
2-legislation and regulation (seat belts, smoking, fluoridation, food labelling, reducing sugar in processed foods,-advertising bans for unhealthy foods)
3-fiscal policies (taxes, subsidies on food, tobacco, alcohol)
56
explain creating supportive environments, 3 areas
-create living and working conditions that are safe, stimulating, satisfying, enjoyable
-encourage communities to care for each other
-encourage communities to take responsibility for conservation of natural resources
1-wider environment (access to healthy foods, no sweets on checkout)
2-working and social environments (food and smoking policies, exercise facilities, health and safety, no vending machines in school,milk in schools)
3-home (facilities)
57
explain strengthening community action
```
community action to:
-set priorities
-make decisions
-plan local strategies
-implement plans
eg in food co-ops, farmers markets, cookery clubs, smoking cessation support groups
```
58
explain developing personal skills
-support of personal and social development
-provision of information and health education, eg not dipping dummies in sugar
-development of individual skills
eg knowledge attitudes behaviours (KAB), coping strategies, self-esteem, self-efficacy, empowerment
59
explain reorienting health services
-encourage health professional to look beyond clinical and curative services
-ensure health services are aimed at pursuit of health rather than only cure of illness (prevention over cure and health as more than just absence of illness)
eg sugar free medicine
60
explain primary healthcare approach (PHCA) 3
from treatment to prevention
from institutions to community
addressing the inverse care law
61
4 roles of health professionals in reorienting health services
advocacy
mediation
education
enablement
62
problems with health promotion
- long intervals between preventive strategy and measurable improvements
- time consuming (community consultation, health education, altering public policies)
- often politically controversial
- need to be rigorously evaluated
- politicians like to put emphasis on personal lifestyle choices (so individual rather than government is responsible)
63
example of when health promotion has been effective and how
smoking: 10% price rise ---> 1% reduction in smoking
banning advertising has reduced consumption
(but tobacco growing subsidised in some countries)
64
5 dilemmas for health promotion
- healthism
- victim blaming
- inaccessibility of information
- appropriation of health promotion by specialist groups
- evaluation and effectiveness
65
CHILD DEVELOPMENT LECTURE
| why, most often, are children referred to dental hospital?
behaviour (fear, temprament)
| NOT complex dental problems
66
examples of how to persuade children to treatment
- forced choice option
- bribery
- imagination (eg pretend chair is rocket)
67
types of development (in children) 4
- physical development (body structure)
- motor development
- cognitive development
- social development
68
what gene contributes to cleft
IRF6
69
influences on child development
nature (genetics, eg tooth development)
nurture (deprived v enriched. sensitive periods in development eg language should be picked up by 2yo)
interaction eg smoking during pregnancy
70
order of motor development
- support head
- rollover
- sit
- crawl
- stand
- walk
does not necessarily happen at same age, but order is usually the same
71
stages of cognitive development
1. sensory-motor (0-2yo. knowledge through movement and sensation, eg object permanence)
POCOFO
2. pre-operational stage (2-7yo. language development, role play, egocentrism)
3. concrete operational stage (7-11 yo. logical thinking, conversation)
4. formal operational stage (12yo- adulthood. deductive reasoning, understanding abstract ideas)
72
stages of language development
```
3 months- cooing
4 months- babbling
12 months- 1st word
18 months- 20 words, single utterance
24 months- 250 words, 2 word utterance
30 months 500 words, 3+ utterance
STAGE NOT AGE
```
73
development of fearful reactions
- 7-10 months stranger anxiety (declines in intensity over 2nd yr, may never subside completely eg stranger danger)
- separation anxiety (crying, clingy, withdrawn. usually becomes less frequent/ intense throughout pre-school period)
74
overcoming stranger anxiety in dental surgery 5
- keep carers close at hand
- social referencing (positive tone of voice)
- make setting more familiar (toys, posters, colours. allow time to become comfortable)
- don't be intrusive
- look 'normal'- no white coats, paeds scrubs
75
explain 2 types of conditioning
classical conditioning: A learning process by which a subject comes to respond in a specific way to a previously neutral stimulus after the subject repeatedly encounters the neutral stimulus together with another stimulus that already elicits the response (eg Pavlov's dogs, salivate on ringing of bell)
operant conditioning: type of learning where behavior is controlled by consequences. Key concepts in operant conditioning are positive reinforcement, negative reinforcement, positive punishment and negative punishment.
76
what is social learning
learning by watching what others do
77
behaviour associated with dental anxiety/ fear 6
-moving hands (30%)
-hands over mouth (24%)
-crying loudly (21%)
-shaking legs (18%)
moving body left and right (18%)
moving legs up and down (15%)
WATCH VIDEO
78
how to use learning schedules to influence child behaviour at the dentist
- observational learning
- ignore negative behaviour
- time between response and reinforcement important
79
ADHD: % and describe
5-10% of children
inattention, hyperactivity, impulsivity
most common behavioural disorder, more common in boys
respond less, poor oral health
80
other behavioural disorders %
learning difficulties 1-2%
| autistic spectrum 1%
81
how to adapt dentistry to children
- clear goals for each visit (reward good behaviour, work at appropriate speed. maybe some appointments for familiarisation)
- forced choice (closed questions eg would you like to get on chair from left or right)
82
behaviour management techniques 5PARCD
5:
- reinforcement (verbal, stickers etc)
- desensitisation (tell-show-do, modelling, distraction, euphemisms)
- communication (stop signals, non-verbal communication eg hand holding)
- aversion (voice control. used to use restraint/ hand over mouth)
- pharmacology (sedation)
83
how to measure pain in children
children do not always report pain; only 48% 4yo with caries recorded pain. so other ways to measure pain:
-variations in cognitive ability (perception, understanding, memory)
84
define child abuse
when adult harms person under 18
85
% of child abuse in UK
7% serious physical neglect
6% neglect
6% emotional and sexual abuse
86
what did Piaget theorise about pain perception in children
- at pre-operational stage: pain is global, a phenomenom
- operational/ concrete: understanding improves over time
- formal operational: understand what hurts, why and how much
87
how is dentistry relevant to social development
peer relationships:
| -teeth and appearance affect popularity, bullying
88
who are commonly 'abusers'
what % of young people suffer abuse?
2:
- those with stronger physiological reactions to all social signals
- those who were themselves abused/ neglected
7% serious physical abuse
6% neglect/emotional/sexual abuse
89
characteristics of children who are often abused
```
defiant
unresponsive
hyperactive
irritable
unwell
look different
```
90
what to do if we suspect child abuse
- speak to supervisor
- assess likelihood of harm
- (usually) explain to child/parent
- discuss with appropriate colleague
- refer to social services, back up in writing within 48 hours
91
5 mental health problems that impact dentistry
what should be considered if a patient has schizophrenia
scizophrenia, OCD, bipolar, eating disorders, pica
- side effects of medication: xerostomia, hypersalivation
- increased alchohol/ tobacco use, poor diet
92
what should be considered if a patient has OCD
associated with high levels of dental anxiety
| often bruxists
93
what should be considered if a patient has bipolar disorder
often have poor OH, calculus, periodontal disease, caries, xerostomia
94
what should be considered if a patient has an eating disorder
- erosion (esp bulimia)
- parotid gland hypertrophy
- saliva flow
- different gag reflex
- oral mucosal lesions
95
what is pica and why is it relevant to dentistry
Persistent Intake of non-nutritive substances (eating non food items eg paper, clay, metal). associated with learning difficulties
trauma to soft tissue/ tooth wear
96
Frankl behaviour rating scale
1: definitely negative. refusal of treatment, crying, fearful
2: negative. reluctant to accept treatment, unco-operative, sullen, withdrawn
3: positive. acceptance of treatment, willing to comply with reservation but follows direction
4: definitely positive. good rapport, interested in dental procedures, laughing, enjoy situation
97
PAIN AND DENTISTRY LECTURE
| how does pain effect economy
5.2 million work days lost
98
what % of dentate adults in England currently have toothache
9%
99
examples of ways pain perception varies in different groups of people
- more pain perception in those from routine/ manual occupations
- more pain perception in younger people
- more pain in anxious people
100
3 dimensions of pain. explain each
1. sensation (how much it hurts)- threatening context, accompanied by desire to reduce pain or escape
2. affect (mood)- unpleasant emotions, distress/fear. feeling about long-term implications of pain (anger, depression, anger etc) and impact on life (routine, sleep, work)
3. cognitive: evaluation, eg how to help pain by whats happened in the past
101
what changes occur in the brain during pain
increased alpha brain waves
decreased delta brain waves
deactivated cortex (thinking part of brain)
deactivated limbic system (emotion)
102
link between personality and pain
intensity of pain not affected
neurotic pt reports as more unpleasant, considers secondary impact eg sleep loss
pessimists more likely to have chronic pain, low pain tolerance and poor coping
103
is there clear link between magnitude of injury and pain experienced?
no
104
explain gate control theory of pain
automatic reflex: pain sensation and dorsal horn,eg moving hand from painful stimulus
excitatory pathway opens gate to brain and cortex --> pain perception, thought
inhibitory pathway prevents this pathway activating
105
explain phantom pain
when limbs amputated, excitatory/ inhibitory pathways not destroyed so brain pathways still activated even when stimulus not there
106
STRATEGIES FOR ORAL HEALTH LECTURE
| define strategy
plan for obtaining specific goal or result
107
4 functions of planning
- guides choices so best decisions made
- maximises results with limited resources
- proactive rather than reactive decision
- can set priorities
108
explain 3 principles of strategy design
aim: what you want to achieve
objective: steps taken to achieve aim
data collection: identify/ understand problem, possible solutions, evaluation and feedback
109
6 steps of McCarthy rational planning cycle
AODRIE
1. assessment of need
2. options
3. decisions of policy
4. available resources
5. implementation
6. evaluation
110
4 areas of information needs for planning
SPED
1. socio-demographic population profile (how need varies with age, ethnicity, deprivation, mobility)
2. disease levels (trends, epidemiological data, disease distribution)
3. public concerns (population priorities, views of services, demands
4. existing service provision (cost, location, access, range)
111
define a need for medical care
when individual has illness or disability for which there is an effective and acceptable treatment or cure
112
3 descriptors of a need
1. subjective: professional judgement varies
2. dynamic: new technologies, drugs, information
3. relative eg weight of fluoridation
113
what is a needs assessment
evidence-based approach to commissioning and planning health services using objective and valid methods
114
define 3 components of healthcare economics needs assessment
wants: individuals subjective assessment
demands: willingness to pay
needs: professional judgement about capacity to benefit
115
3 components of pain and examples of each
- sensory (discrimination of type and location of pain, perception) eg pulsing, throbbing
- affective (motivation. emotional feeling about pain) eg tiring, sickening
- cognitive (evaluation, past experiences) eg annoying, miserable
116
what physiological measurements of pain are there and issues with this
inc cortisol, HR, respiration sweating
117
2 self-report measures of measuring pain
1. visual analogue scales:
| 2. pain questionnaires
118
most common pain descriptors for dentistry:
1. sensory
2. affective
3. evaluative
1. sensory: throbbing
2. affective: sickening
3. evaluative: annoying
119
which component of pain should pain relief target and why
affective. it is the most long-lasting
120
examples of why/how pain relief varies between groups
- ethnic differences: prescription drugs/prayer more common with black people compared to talking to neighbours with hispanic people
- analgesia given more readily to extroverts and women
121
why is looking at facial expression to tell pain good/bad
- eyes tell the most
| - people change their expression when they know theyre being watched
122
why is it important to detect pain early in children
- prevents invasive treatment or GA
- reduce likelihood of dental anxiety
- reduce impact on family life
123
how to tell pain in young children
(may not vocalise pain and cannot use physiological measures)
-sleep loss
-negative behaviour
-crying, movement, muscle tension, facial expression
-eat less, refuse to eat nice foods
48% of 4yo with caries had reported pain
124
how to alleviate pain: sensory
by DISCRIMINATION of type/location/intensity of pain
- drugs, prevent neural pain pathways
- placebo effect: 35% effective, due to endorphin relief
125
how to alleviate pain: affective
MOTIVATION
promote neutral interpretation by:
a. distraction- visualisation is best. also radios, optimistic re-interpretation (eg pain is a sign of recovery)
b. enhancing control- stop signals
126
how to alleviate pain: cognitive
what influences success of hypnosis
- alter expectations, eg by avoiding emotive words
- hypnosis (dependent on personality) increases calm and well-being, effective up to 12 months
- outcome expectancies (more likely to work if they believe it)
- perceived control over pain
- imagery vividness (also part of distraction?)
127
why do a needs assessment? 9
- facilitates planning and commissioning
- health care inflation (due to pay increase etc)
- advances in medical care
- changing demographics
- limited resources
- inequalities in health
- inverse care law
- consumerism and accountability
- competing priorities
128
how to evaluate solutions to health problems
- evaluate possible interventions
- evidence base
- critical analysis/ level of evidence
- systematic review/ meta analysis
- funding and resources available
129
how to evaluate oral health strategies
2 main aims of oral health strategies
DURING strategy implementation
- does it work
- is it acceptable to people
- is it reaching people it's meant to reach
- how are resources being used
- has problem been solved- is it time to stop?
1. improve oral health
2. ensure access to high quality NHS dental services
130
3 target groups in strategic approach to oral health
1. whole population- aim to lower average level of risk in population
2. high risk- identify people at high risk through screening and offer prevention/ treatment
3. targeted population- identify communities at higher risk --> use whole population strategies in targeted groups
131
how whole population approach works and example of when it has been used in oral health strategies
reduce risk factors to whole population, eg fluoride for whole population
132
advantages of whole population strategies 5
- tackles underlying health determinants
- avoids victim-blaming
- enables healthy choices to be made
- benefits whole society
- it works! eg seatbelts, fluoridation, fluoride toothpaste, smoking
133
disadvantages of whole population strategies 6
- long timescale
- powerful vested interests (eg toothpaste companies?)
- mobilising action (forming alliances, lobbying and gaining support)
- adverse effects (eg sugar producers)
- issues of individual free choice
- 'prevention paradox'
134
explain prevention paradox
majority of cases come from low-risk group, because it is so much bigger than the high-risk group
--> whole population has to change behaviour/ be treated for the sake of few individuals
135
examples of high risk strategies
hep B vaccination for dental students, mammograms for women under 50 with strong family history
136
advantages of high risk strategy 3
- cost-effective use of resources
- intervention appropriate to individual
- readily accommodated within ethos and organisation of medical care
137
disadvantages of high risk strategy 4
- medicalizes prevention
- non-selected individuals are still at some risk- where is line drawn between high and low risk? low risk miss out
- contribution to overall control of disease may be small
- poor ability to predict future of individuals
138
positives and negatives of targeted population strategy and example
+: reduces inequalities, often cost effective, various types of interventions (environmental, clinical, skills)
-: not all at risk are in target group and vice versa --> no free choice
eg fluoride toothbrushing scheme in selected schools
139
compare the level of use of each type of strategy
- whole population: national, international
- targeted population: local high need communities, integrated with whole population strategy (aims to level high risk groups with population)
- high risk: local groups, integrated with targeted strategies
140
explain the common risk factor approach
recognition that many diseases share risk factors (eg smoking, drinking --> heart problems, cancer, oral disease, diabetes)
--> direct action to common risks and underlying social determinants (housing, education, employment etc)
this is an example of PARTNERSHIP WORKING
141
3 WHO oral health action areas
1. diet, nutrition and oral health: malnourishment/ dietary excess
2. oral health and fluorides: optimal fluoride level in water
3. tobacco and oral health: tobacco use has risen in some groups eg young people and women
142
what does 'choosing better oral health' include 5
- current level of oral health
- causes of poor oral health
- roles and responsibilities for improving oral health
- key areas of action
- workforce requirements
143
aims of 'choosing better oral health' 2
- reduce prevalence of oral disease
| - reduce oral health inequalities across all age groups in England
144
how is progress of this measured
- improvements in oral health of population
| - increased delivery of high quality preventive dental services
145
what is the 'Delivering Better Oral Health Guide'?
evidence-based toolkit. guidance for practitioners and advice to patients
146
DIET AND ORAL HEALTH LECTURE
| compare inequalities in food types between high and low incomes
high income: more fish, fruit, vitamin C
| low income: more calories,sat fat, sodium
147
what % of diet should come from
a. total fat
b. sat fats
c. total carbohydrate
d. free sugars
e. trans fats
f. protein
what % of diet should come from
a. total fat: 15-30%
b. sat fats:
LOOK AT LECTURE
148
recommended amount per day of
a. cholesterol
b. sodium
c. fruit/veg
recommended amount per day of
| a. cholesterol: 400g.day
149
recommended BMI
21-23kg\m2 (population)
18.5-24.9 kg/m2 (individual)
avoid weight gain of 5kg as adult
150
recommended physical activity
1 hour/day on most days, inc moderate activity eg walking
151
caries: what factors
a. increase risk
b. probably decrease risk
c. possibly decrease risk
d. decrease risk
what factors
a. increase risk: free sugars, freq of sugar intake
b. probably decrease risk: hard cheese, sugar free gum
c. possibly decrease risk: xylitol, milk, fibre
d. decrease risk: fluoride
of
152
what factors
a. probably increase risk
c. possibly decrease risk
of dental erosion
what factors
a. probably increase risk: soft drinks, fruit juice
c. possibly decrease risk: hard cheese, fluoride
of dental erosion
153
what factors
a. increase risk
b. decrease risk
of enamel defects
of
what factors
a. increase risk: excess fluoride (--> fluorosis), hypocalcaemia
b. decrease risk: vitamin D
of enamel defects
of
154
```
what factors
a. increase risk
b. decrease risk
c. insufficient evidence
of periodontal disease
of
```
what factors
a. increase risk: vitamin c deficiency
b. decrease risk: good OH
c. insufficient evidence: sucrose, antioxidants, vit E
of periodontal disease
of
155
classification of sugars
total --> intrinsic (in cell structure eg whole fruit), extrinsic
extrinsic --> milk, non-milk (inc processed hidden sugars)
156
how has sugar consumption changed in UK since 1900s?
peaked post war
| now less overall but inc hidden sugar due to less fat in foods
157
how sugar consumption varies in developed/ non-developed countries
more in developed countries
158
evidence for sugar and general health
no evidence of link between sugar consumption --> cancer, coronary heart disease, diabetes
BUT inc energy intake --> obesity --> diabetes, CHD, some cancers, resp disease etc
159
examples of evidence for sugar and caries
a lot!!
- animal studies: freq, conc, type of sugar
- lab studies: plaque pH, test tube experiments, enamel slab experiments
- experimental studies: Vipeholm (mental hospital patients given different conc/freq of sugar). Turku (students chewed sucrose v xylitol gum for a year)
- observational studies: Tristan da Cunha (compared low sugar groups eg dentists children, wartime diets with high sugar groups eg sweet factory workers, children on sugar-coated medicine)
160
strengths and weaknesses of evidence for relationship between sugar and caries
strength: strong body of evidence; all studies came to same conclusion
weakness: type of evidence weak; no double blind RCTs, ethical issues with Vipeholm
161
compare experiments/findings of Streebny and Woodward/Walker
Streebny: 47 countries, positive correlation between sugar consumption and DMFT
Woodward/Walker: >90 countries, positive correlation between sugar consumption and DMFT. BUT no correlation in industrialised countries (due to education, fluoridation etc)
162
WRITTEN COMMUNICATION LECTURE
| 3 types of response writing should provoke in the reader
cognitively
behaviourly
emotionally
163
2 ility s the reader needs to understand writing
- readability (40 different measures, EG legibility, legal, care with units, no abbreviations)
- comprehensibility (lexical items, syntax, communicative effectiveness
164
5 examples of when dentists use written communication
- prescriptions (drugs/lab)
- documentation (notes, consent forms)
- referrals
- patient info leaflets
- reports
- essays
165
what should you ensure when writing clear prescriptions 7
```
unambiguous, clear
be careful with units
no abbreviations
approved name
legal
care with IVS
weight/BSA dosing
```
166
what info should be included in documentation (notes) 3
- informed consent
- treatment, alternatives, risks, complications
- complaints policy- how, who, when
167
6 audit categories
- diagnosis and management
- examinations and tests
- corrections, abbreviations
- legible, dated
- identification
- front sheet
168
what are the most important audit categories and what % met standards
diagnosis 75%
| medical history 67%
169
give examples of audit areas that did not meet standards
- documented leaflets
- corrections signed and dated
- legible
- signature/name stamp
- next of kin
- allergies
170
what to include in paediatric referral letters for GA 8
- referrers full details
- GMPs full details
- medical history
- dental history
- reason for referral
- justification for GA
- radiographs
- treatment plan
171
what to include in urgent referral letter 6
- pt details
- urgency of referral
- about problem
- medical and dental history
- pt understanding of referral
172
advantages of educational resources (PIL) 6
disadvantages of PILs 6
- improve pt understanding of condition and treatment options
- increase involvement in care-awareness, prep for procedures
- encourage adherence/skills/behaviour change
- reduce anxiety and stress
- increase satisfaction with care
- can be referred to after event/consultation
- ves
- public ignores them
- difficult to understand
- poor readability
- pt does not retain info --> poor adherence and tx choice
- inaccurate
- out of date
173
define functionally illiterate and % of UK who are
would not pass English GCSE (reading level younger than 11)
| 16% of UK population (5 million)
174
when to use leaflets and why
use as 'gift' alongside what was discussed
| pts want info but ignore printed literature, may find it confusing
175
4 examples of purpose of leaflets
- improve awareness/ understanding
- prepare for procedures
- facilitate informed decisions/ reasoning/ patient involvement
- encourage behaviours/ patient skills eg how to brush teeth, diet
176
how to ensure information in leaflets is understandable
- ensure info is concise, specific
- risks, benefits and alternatives
- figures not values
- diagrams
- target audience (age group, social class etc)
177
how to ensure information enables reasoning (deliberation and decision making)
- rating scales to rank treatment options
- tick boxes to record feelings
- free text space to note concerns, questions, priorities
178
how to provide written info for people who don't read much
```
OBVIOUS:
short words/ sentences
legible font
interest of reader most important
avoid unnecessary capitals/bold/italics
```
179
what does SMOG stand for and how to calculate it
Simple Measure of Gobbledygook
| divide number of sentences in sample in to 30 and multiply by number of words longer than 3 letters
180
FLUORIDE AND FLUORIDATION
| F- conc of sea water
1.3PPM
181
ideal fluoride conc
history of fluoride
1ppm
thought to have effect on enamel since 1930s. water first fluoridated in Grand Rapids in 1945 --> levels of decay halved
182
is F- detectable in water in high conc?
only by scientific monitoring equipment (tasteless, odourless
183
mechanism of action of fluoride
fluorapatite crystals replace hydroxyl crystals in enamels
184
why is fluorapatite desirable?
stronger, less likely to be demineralised by acid
185
pre and post-eruptive effects of fluoride
pre-eruptive: enamel less susceptible to effects of acid
| post-eruptive: interferes with metabolism of plaque-forming bacteria, enhanced remineralisation of enamel
186
is fluoride given pre or post eruption and why?
post eruption
effects more important and too risky pre-eruption: children may swallow toothpaste, take too many tablets at once --> fluoride toxicity with >5mg/kg
187
methods of individual fluoride delivery, +/- of each 5
- toothpaste: simple, effective, free choice BUT risk of OD, toothbrushes expensive
- gels: 21% effective (systematic review), free choice BUT taste bad, risk of OD if swallowed
- tablets/drops: effective (40-50% caries reduction), free choice BUT compliance, OD risk
- mouthrinses: 26% effective, free choice BUT compliance/ability, OD risk
- fluoride varnish (2-4 times/yr): 46 or 33% effective, free choice BUT compliance, access (in surgery/community setting)
188
3 methods of population fluoride delivery
what has been done to aid fluoride toothpaste use in UK 2
- water
- milk
- salt
- toothbrush/toothpaste distribution schemes to high risk children
- supervised brushing schemes in schools/nurseries with fluoride toothpaste (BUT only on days childs attends, needs home support)
189
pros and cons of fluoridated milk
+: safe, effective (? inconclusive evidence)
| -: only when kids in school (not weekends, holidays), requires consent, untested in community settings
190
pros and cons of fluoridated salt
+: effective (as much as water), free choice
| -: conflicts with general health message about reducing salt intake
191
dose of salt fluoridation
250ppm
192
in what country has salt fluoridation been effective in reducing caries?
Jamaica
193
# define water fluoridation
evidence for water fluoridation
controlled addition of a fluoride compound to a public water supply in order to bring the fluoride conc up to a level that effectively prevents dental decay
- increases proportion of children without tooth decay by 15%
- children in areas of fluoridation have 2.25 fewer carious teeth
- no association with bone fracture/ cancer BUT aesthetic fluorosis= 12.5
194
what is fluorosis and when/where will it most likely occur
excessive fluoride uptake during tooth development --> mottled enamel
18-36 months risk age, maxillary central incisors
3% in fluoridated area --> don't use fluoride toothpaste
195
what % of UK has optimum fluoride level and where
10%
| West Midlands, North East england
196
in which countries is fluoridation common/rare
common: ROI 71%, USA 61%, NZ 64%, australia 60%
rare: Japan
(5. 7% worldwide)
197
how is water fluoridation ruled in UK
1985 water fluoridation act
1991 Water Industry Act: no obligation to fluoridate
2003: 5 -must fluoridate if requested to do so by relevant authorities eg council
-local public consultation to be organised through Strategic \health authority SHA
-indemnity for water companies to be arranged by Secretary of State for Health
-relevant authority to meet reasonable capital and operating costs
-review of dental health every 4 years
198
examples of bodies against fluoridation
Green party
national pure water association
soil association
campaign for fluoride free water in Ireland
199
compare pro and anti lobby of adverse health effects of fluoridation
public opinion on fluoridation (2 surveys)
pro-lobby (evidence based): fluorosis bad but rare at 1ppm. no effect on general health
anti-lobby (not scientific): overestimates fluorosis, uses bad evidence
-omnibus survey 2003: 2000 interviews with random adults across Britain. 43% think water already fluoridated
67% think it should be added if it reduces decay
-Southampton city PCT survey 2008: overall more in favour although 2/3 knew nothing about it and half expressed no opinion
200
compare pro and anti lobby of environmental effects of fluoridation
pro: Washington state review 2002 says no negative impact on environment. trace amounts of arsenic not traceable at 1ppm
anti: F- is waste product from fertilisation (toxic waste), contains impurities eg arsenic, bad for organic food industry
201
compare pro and anti lobby of effects on civil liberties of fluoridation
pro: F- present naturally in water, common good more important than personal preference eg seat belts, can choose bottled water
anti: mass medication, against (european) human rights
202
details of 2003 amendment to Water Industry Act 2003
local public consultation to be organised through SHA
- indemnity for water companies to be organised by Secretary for State of Health
- relevant authority to meet reasonable capital and operating costs
- review of dental health every 4 years
203
PREVENTION IN PRACTICE
| difference between health education and health promotion
education: any educational activity which aims to achieve a healthy goal
health promotion: process of enabling people to increase control over and to improve their health
204
which 2 approaches to oral health promotion does prevention in practice cover?
3 domains of learning in order
- behaviour change (DHE, one to one advice)
- prevention (led by HCPs)
- cognitive: acquisition of facts
- affective: attitudes and beliefs
- behavioural: skills and actions
205
explain health locus of control and 3 levels
the extent to which individuals believe their health is influenced by their own behaviour or by others
3:
-high internal locus of control: believe health influenced by own action
-high powerful others: believe in the influence of important people on outcomes
-high chance: believe health is down to chance
206
describe the health belief model
individual does their own cost/benefit analysis when considering behaviour change ie how much change will benefit them. needs a cue or trigger eg people not wanting MMR vaccine
207
5 steps in stages of change (transtheoretical model)
1. precontemplation (no awareness)
2. contemplation (aware, motivated, confident in ability to change)
3. preparation (negotiation)
4. action (commit, 3-6 months)
5. maintenance (problem solving)
(6. relapse (coping strategies))
208
goals of each stage of transtheoretical model
1. precontempla: encourage CONSIDERATION of behaviour change
2. contemplation: evaluation leading to DECISION to change
3. preparation: action plan implemented
4. action: successful action and establishment of change (6 months)
5. maintenance: long-term ESTABLISHMENT of new behaviour
209
examples of barriers preventing change 9
- lack of opportunity (restricted access)
- lack of resources (money)
- lack of support (bad influences)
- lack of knowledge
- conflicting info
- future rather than immediate consequences
- no clear goals
- put off by failure
210
what criticisms are there of stages of change model? 3
too simplistic:
- more of a continuum
- does not account for socio-cultural norms eg if everyone else smokes
- not included: current behaviour, quit attempts, intention to change
211
implications of stages of health model for health professionals 6
- may be several attempts before change succeeds
- motivations may not be health related
- behaviour determined by complex array of factors
- support essential
- information alone is not v useful
- no evidence that using one approach more successful than another (eg education, encouragement etc)
212
what did reviews of oral health education discover?
fluoride effective at reducing caries
| BUT chairside and school dental health education not useful
213
4As of smoking cessation
Ask
Advise
Assist
Arrange
214
describe a brief intervention for smoking 7
5-10 mins
- establish if they want to smoke
- set a date to stop
- review past experience
- identify future problems
- identify support from family and friends
- plan what to do about alcohol
- consider nicotine replacement therapy
215
who is the facilitator in smoking cessation
the patient (smoker)
216
barriers of smoking cessation at dentists
time and resources
217
problems with fissure sealant as caries preventative measure in children
-access to high risk children: difficult to do out of dental surgery
-problems with consent and compliance
(BUT slow release of fluoride with GIC (not resin))
218
why is chlorhexidine used?
reduce strep mutans --> prevent post op infection
| no evidence for caries reduction
219
why is xylitol used and how?
in chewing gum
--> mastication --> saliva flow, prevents caries
also has direct effect on s mutans
220
REVISION LECTURE
| main organisation for health promotion
WHO
221
explain why/how toothbrushing technique is important and what has been done to improve it
- brushing alone does not prevent caries- fluoride toothpaste should be used too
- normal brushing leaves plaque in fissures and other stagnation areas
- -> parental supervision advised under 7 years (proven less risk of decay)
- spit not rinse
- supervised brushing scheme in school and nursery
222
low income peoples barriers to oral health (12)
stress and the enormous amount of time involved to
find a dental provider;
2. when a provider is available, he/she tends to be overwhelmed
with low-income patients, which leads to
difficulty to schedule a timely appointment;
3. the provider may have rules to accommodate lowincome
patients, leading to excessive wait times in the
office on the day of the appointment (eg, the patient
may have to wait until all private insurance or self-pay
patients are seen first);
4. inconvenient or unreliable transportation, or total lack
of access to transportation;
5. children may miss school because of dental appointment
restrictions or because of transportation difficulties;
6. school absence policies, which may discourage parents
from taking their children out of school to go to an
appointment;
7. difficulties in accessing information on dental care
coverage;
8. feelings of embarrassment and shame to ask for help;
9. competing demands for limited financial resources;
10. racial/ethnic discrimination;
11. language barrier; and
12. powerlessness in the dental office, having to endure
the prejudice of staff, and being reluctant to complain
about it for fear of being dismissed.
