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 A Textbook of
Public Health Dentistry
 A Textbook of
Public Health Dentistry

CM Marya BDS MDS

Professor and Head
Department of Public Health Dentistry
Sudha Rustagi College of Dental Sciences and Research
Faridabad, Haryana, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • St Louis • Panama City • London
Published by
Jaypee Brothers Medical Publishers (P) Ltd

Corporate Office
4838/24, Ansari Road, Daryaganj, New Delhi 110 002, India
Phone: +91-11-43574357, Fax: +91-11-43574314

Offices in India
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e-mail: [email protected], [email protected]
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e-mail: [email protected], Website: www.jphmedical.com
• Europe Office, UK, Ph: +44 (0) 2031708910
e-mail: [email protected]

A Textbook of Public Health Dentistry

© 2011, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the
publisher.

This book has been published in good faith that the material provided by the contributors is original. Every effort is made to
ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In
case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2011

ISBN 978-93-5025-216-1

Typeset at JPBMP typesetting unit

Printed at
 To
My mother Veena Marya for making me what I am today,
My father Prof Dr RK Marya, a continuous motivational force in my life.
My wife Vandana for her constant encouragement and support.
My children for making life worthwhile.
—CM Marya
 Contributors

Abdul Rashid Khan MBBS MHSc Manik Razdan BDS MS

Associate Professor and Head PhD Student in Health Services Research and Policy
Public Health Medicine Department of Health Policy and Management
Penang Medical College University of Pittsburgh Graduate School of Public Health
Penang, Malaysia Pittsburgh, Pennsylvania
United States of America (USA)
Anil Ankola MDS
Professor and Head
Department of Public Health Dentistry Rakesh Dhankar MD
KLE Institute of Dental Sciences Associate Professor
Belgaum, Karnataka, India Department of Radiotherapy
Pt BD Sharma University of Health Sciences
Anil Gupta MDS Rohtak, Haryana, India
Professor and Head
Department of Pedodontics
RK Marya MD PhD
Desh Bhagat Dental College and Hospital
Professor and Head
Muktsar, Punjab, India
Department of Physiology
Avinash Jnaneswar MDS Faculty of Medicine
Professor AIMST University, Malaysia
Department of Public Health Dentistry
Sudha Rustagi College Dental Sciences and Research Sadanand Kulkarni MDS
Faridabad, Haryana, India Professor and Head
Bhavana Gupta MDS Department of Pedodontics
Reader Pravara Instistute of Medical Sciences
Department of Pedodontics Rural Dental College
Sudha Rustagi College of Dental Sciences and Research Loni, Maharashtra, India
Faridabad, Haryana, India
Swaroop Savanur MDS PG Diploma in Medicolegal Systems
Gurkeerat Singh MDS
Professor
Professor and Head
Department of Orthodontics
Department of Orthodontics
Sinhgad Dental College
Sudha Rustagi College of Dental Sciences and Research
Pune, Maharashtra, India
Faridabad, Haryana, India

KA Narayan MD Vandana Dahiya BDS

Professor and Head Postgraduate Student
Community Medicine and Medical Education Department of Conservative and Endodontics
Faculty of Medicine Sudha Rustagi College of Dental Sciences and Research
AIMST University, Malaysia Faridabad, Haryana, India
 Preface

This textbook is designed for undergraduate and postgraduate students in dentistry as well as health professionals with an
interest in understanding and promoting oral health within communities. Although Public Health Dentistry is concerned with
oral health of the population rather than dental needs of an individual patient, the ultimate beneficiary of public health programs
is an individual.
As expected in a book of Public Health Dentistry, epidemiology, etiology, and preventive measures in context of dental
caries, periodontal diseases and oral cancer have been discussed in detail. Extensive coverage has been given to the role of
fluoride in the prevention of dental caries. The principal diseases of the mouth such as caries, periodontal disease and oral
cancer are lifestyle dependent. A sound public health program can provide effective measures.
Some of the topics have been contributed by highly experienced colleagues from other dental colleges, bringing greater
depth to the subject. The contribution of some chapters such as epidemiology, statistics, and nutrition, by senior teachers in
Faculties of Medicine, Malaysia is gratefully acknowledged.
Forensic dentistry, Occupational hazards, Ergonomics in dentistry and Financial aspects of dental health practice are attracting
greater attention these days. These topics have been included in this book.
The book incorporates the latest syllabus. The study of Public Health Dentistry also involves an appreciation of aspects of
several disciplines including sociology, psychology and health-related behavior, health economics, health promotion and health
service organizational methods in preventive dentistry. All these topics have been given adequate attention.
This textbook deliberately takes a broader international perspective of the dental preventive measures. Optimal solutions of
health service provision are often hard one and one can often benefit from experiences in other countries.
An important aspect of this book is the large number of illustrations, mostly in color, as well as tables. Must-know information
has been highlighted in a large number of boxes.

CM Marya
 Acknowledgments

My teacher and guide Dr BR Ashok Kumar is the base of my academic career in Public Health Dentistry, who has always
inspired me in becoming a good academician.
I would like to express my sincere thanks to all the contributors Dr RK Marya, Dr KA Narayan and Dr Abdul Rashid Khan,
Dr Anil Ankola, Dr Avinash J, Dr Swaroop Savanur, Dr Sadanand Kulkarni, Dr Anil Gupta, Dr Bhavna Gupta,
Dr Manik Razdan, Dr Gurkeerat Singh, Dr Rakesh Dhankar, Dr Vandana Dahiya.
I thank all my colleagues and postgraduate students of Department of Public Health Dentistry at Sudha Rustagi College of
Dental Sciences and Research, Faridabad for their invaluable help in compiling this book. A special thanks to Dr Vartika Kathuria,
Dr Nidhi Pruthi, Dr Sonal Dhingra and Dr Shekhar Grover for helping me in checking and rechecking the manuscript of this
book. I would also like to thank World Health Organization for allowing me to use their world map on dental caries prevalence.
I greatly appreciate Dr Sanjay Tewari, Dean and Principal, Dental College, Pt BD Sharma University of Health Sciences,
Rohtak and Dr KR Indushekar, Director, PG Studies, Sudha Rustagi Dental College, Faridabad for their encouraging words and
support in this work.
I would like to thank my friends and colleagues Dr Vishal Juneja, Dr Hind P Bhatia, Dr Ashwani Pruthi,
Dr Ashish Gupta, Dr Baiju, Dr Navin A Ingle, Dr Suhas Kulkarni and Dr Pradeep Tangade for their support.
I would like to thank my Chairman Mr Dharamvir Gupta and Mr Deepak Gupta, Secretary, Wing Cdr Dr Niraj Rampal VSM,
Principal, Sudha Rustagi College of Dental Sciences and Research, Faridabad for providing me with a congenial environment to
compile this book.
My sincere thanks to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director Publishing),
Mr KK Raman (Production Manager), Mr Rajesh, and Mr Radhey Shyam of M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi and their team for their cooperation in the publication of this book.
 Contents

SECTION 1: PUBLIC HEALTH

1. Changing Concepts of Health and Prevention of Disease ......................................................... 3

CM Marya
Determinants of Health 3
Theories of Disease Causation 4
Levels or Categories of Prevention 6
Levels of Prevention 6
Approaches of Prevention 8

2. Basic Epidemiology ....................................................................................................................... 9

Abdul Rashid Khan, KA Narayan
Introduction to Epidemiology 9
Measuring Health 11
Epidemiological Studies 13
Screening 20
Association and Causation 21

3. Biostatistics .................................................................................................................................. 23
KA Narayan, Abdul Rashid Khan
Why Learn Statistics? 23
How Data is Collected? 24
Data Display and Summary 24
Data Summary 26
Statistical Distributions 28
Chi Square Distribution 29
Tests of Significance 29
Statistical Significance 30
Sampling 31

4. Environment and Health .............................................................................................................. 34

CM Marya
Water Quality—Criteria and Standards 39
Hardness of Water 42
Special Treatment of Water 43
Air 43
Noise 44
xii A Textbook of Public Health Dentistry
Radiation 45
Housing 46
Waste Management 47

5. Organization of the Health System in India ............................................................................... 49

CM Marya
Voluntary Health Agencies in India 50
Indian Council for Child Welfare (ICCW) 50
Family Planning Association of India 51
Nutrition Foundation of India 51
Voluntary Health Association of India (VHAI) 51
The Kasturba Gandhi Trust 51
Action for Autism 52
Ajit Foundation 52
Chethana 52
All India Women’s Conference (AIWC) 52
Pragati 52
The Hind Kusht Nivaran Sangh 52

6. Primary Health Care ..................................................................................................................... 55

CM Marya
Concept of Primary Health Care 55
Origin of Primary Health Care 55
Alma-Ata 56
Components of Primary Health Care 56
Declaration of Alma-Ata 58

7. Health Agencies of the World...................................................................................................... 61

CM Marya
International Red Cross and Red Crescent Movement 62
CARE USA 62
Refugee and Disaster Relief Organizations 63
WHO (World Health Organization) 63
PAHO (The Pan, American Health Organization) 66
FAO (The Food and Agriculture Organization) 67
UNDP (The United Nations Development Program) 68
PAHEF (The Pan-American Health and Education Foundation) 68
ICRC (International Committee of the Red Cross) 69
The World Bank 70
UNFPA (United Nations Population Fund) 70
CARE (Cooperative for American Relief Everywhere) 72
The Rockefeller Foundation [RF] 72
The Ford Foundation 73
World Health Days 73
Important Dates – World Health 74

8. Nutrition and Health ..................................................................................................................... 75

RK Marya
The Basal Energy Requirement 75
Physical Work 75
Total Caloric Requirements 75
Minerals 79
Fat Soluble Vitamins 79
Water Soluble Vitamins 81
 Contents xiii
Disorders of Malnutrition (Undernutrition) 82
Disorders of Overnutrition 84

SECTION 2: DENTAL PUBLIC HEALTH

9. Introduction to Public Health Dentistry ...................................................................................... 87
CM Marya
Definitions of Public Health 87
Essential Public Health Services 88
Concepts of Public Health 88
Public Health Problem 88
Impact of Oral Disease 88
Milestones in Dental Public Health 90
Historical Overview 90
Aims of Dental Public Health 92
Tools of Dental Public Health 93
Procedural Steps in Dental Public Health 93
Functions of Public Health Dentistry 95
Public Health Milestones in Independent India 95

10. Epidemiology of Dental Caries ................................................................................................... 98

CM Marya
Definition 98
Epidemiology 98
Trends in Dental Caries 100
Reasons for Caries Decline and Rise 100
Dental Caries Pandemic 100
Caries Incidence in Europe 100
Caries Incidence in the United States 100
Indian Scenario 100
Dental Caries in Underdeveloped Countries 101
Probable Reasons for the Marked Decline in Dental Caries in Most Western Industrialized
Countries 101
The Caries Process (Pathogenesis) 102
Theories of Dental Caries 103
Areas Prone to Dental Caries 104
Importance of Diagnosis of Dental Caries 104
Classification of Dental Caries 104
Enamel Changes During Early Caries Lesion Development 105
Changes Recorded in Enamel Covered by Dental Plaque 105
Histopathology of Dental Caries 105
Caries of the Enamel 105
Caries of the Dentine 106
Various Zones of Caries of Dentine 107
Caries in Dentine 108
Root Caries 108
Susceptibility of Different Teeth 108
Factors Affecting the Epidemiology of Dental Caries 108
Factors Affecting Development of Dental Caries 109
Host and Teeth Factors 109
Agent Factors 110
Environmental Factors 111
Early Childhood Caries 111
Root Caries 111
xiv A Textbook of Public Health Dentistry
11. Epidemiology of Periodontal Disease ....................................................................................... 114
CM Marya
Disease Process and Changing Concept 114
Epidemiology 114
Prevalence of Gingivitis 114
Prevalence of Periodontitis 115
Causes of Periodontal Disease 116
Risk Factors in Periodontal Disease 117
Structure of the Periodontal Tissues 117
Gingivae 117
Periodontal Ligament 118
The Natural History of Periodontal Disease 118
Periodontitis 119
Classification of Periodontal Disease 119
Determinants of Periodontitis 119

12. Epidemiology, Etiology and Prevention of Oral Cancer ......................................................... 126

CM Marya, Rakesh Dhankar
Incidence 126
In India and Sri Lanka 126
Western Countries 126
Trends 126
Smoked Tobacco 127
Types 127
Constituents of Tobacco Smoke 129
Smokeless Tobacco 130
Alcohol 131
Mouthwash Use 131
Vitamins and Essential Minerals 131
Occupation 131
Sunlight 131
Chemical Agents 131
Potentially Malignant Lesions 131
Viral Infection 132
Trauma 132
Pathogenesis 132
Pathological Types 133
Diagnostic Evaluation 135
Staging 135
The Exam Review 136
The Importance of Early Detection 140
Levels of Prevention of Oral Cancer 140
Public Health Approaches to Prevention of Oral Cancer 142
Tobacco/Smoking Cessation 142

13. Epidemiology and Etiology of Malocclusion ........................................................................... 144

Gurkeerat Singh
An Epidemiological View of Malocclusion 144
Classification of Malocclusion 144
Angle’s Classification of Malocclusion 144
Dewey’s Modification of Angle’s Classification of Malocclusion 147
Bennette’s Classification of Malocclusion 147
 Contents xv
Skeletal Classification 148
Ackerman-Profitt System of Classification 148
Incisor Classification 148
Prevalence of Malocclusion 150
Etiology of Malocclusion 153
Untreated Malocclusions 155

14. Dental Health Education ............................................................................................................ 156

CM Marya
Definition 156
Contents of Health Education 156
Principles of Health Education 157
Models of Health Education 158
Communication 159
Key Elements in Communication 159
Barriers or Road Block of Communication 160
Aids in Health Education 160
Methods in Health Education 161
Steps in Health Education Planning 162
Steps of Learning 163
Various Health Education Methods and Media 163

15. Oral Health Survey Procedures ................................................................................................ 165

CM Marya
Scientific Method in Conducting a Dental Survey 165
Oral Health Surveys (WHO-1997) 167
Pathfinder Surveys 168
Organizing the Survey 170
Reliability and Validity of Data 170
Implementing the Survey 171
Assessment Form 173
Obtaining Assistance from WHO 181
Post Survey Action and Preparation of Survey Reports 181

16. Dental Indices ............................................................................................................................. 185

CM Marya
Definition 185
Properties of an Ideal Index 185
Types of Indices 186
Purpose and Uses of an Index 186
Indices Commonly Used in Dentistry 187
Periodontal Indices 187
Plaque Control Record 188
Navy Plaque Index 188
Oral Hygiene Index (OHI) 189
Patient Hygiene Performance Index (PHP Index) 192
Gingival Index (GI) 193
Calculus Surface Index 193
Periodontal Index (PI) 193
Periodontal Disease Index (PDI) 194
Gingival Bleeding Index (GBI) 195
Papillary-Marginal-Attached Gingival Index 196
Gingival Bone Count Index 197
xvi A Textbook of Public Health Dentistry
Community Periodontal Index of Treatmant Needs (CPITN) 197
Community Periodontal Index (CPI) 201
Turesky-Gilmore-Glickman Modification of the Quigley-Hein Plaque Index 202
The Navy Periodontal Disease Index (NPDI) 202
Indices for Dental Caries 204
Decayed, Missing and Filled Teeth (DMFT) Index 204
WHO Modification of DMF Index 205
Dental Caries Index for Deciduous Teeth (dmft and dmfs) 205
Mixed Dentition 206
WHO Index for Dental Caries 206
Significant Caries Index 207
Fluorosis Index 207
Thylstrup-Fejerskov Index of Fluorosis (TF) 208
Tooth Surface Index of Fluorosis (TSIF) 208
Indices for Malocclusion 210
The Index of Orthodontic Treatment Need (IOTN) 210

17. Dental Auxiliaries ....................................................................................................................... 212

CM Marya
Dental Team 212
Comprehensive Dental Care 212
Definition 212
Classification 213
Types of Supervision 213
Nonoperating Auxiliaries 214
Operating Auxiliaries 215
Auxiliaries Personnel in India 216
Four-Handed Dentistry 216

18. Finance in Dentistry ................................................................................................................... 218

CM Marya
Preventive and Diagnostic Dental Care 218
Basic Dental Care and Dental Procedures 218
Major Dental Care 218
Common Terms 218
Mechanism of Payment for Dental Care 219
Postpayment Plan 219
Private Third Party Prepayment Plans 219
Reimbursement of Dentists in Prepayment Plans 220
Private Third Party Prepayment Plans 220
Health Maintenance Organization (HMO) 222
Staff Model 222
Group Model 222
Independent Practice Association (IPA) 222
Capitated Network or Direct Contract Model 222
Capitation Plan 222
Public Programs 223
Medicare 223
Medicaid 223

19. Oral Health Promotion ............................................................................................................... 224

CM Marya
Concept of Health 224
 Contents xvii
Definition of Health Promotion 224
Principles of Health Promotion 224
Oral Health Promotion 225
Strategies of Oral Health Promotion 225
Approaches in Oral Health Promotion 226
Concepts in Health Promotion 226
Elements of Health Promotion 226
Methods of Oral Health Promotion 227
Stages of Behavior Change 227
Goals of Oral Health 228
Global Oral Health Goals 228
National Oral Health Program in India 230
The Magnitude of the Problem 231
Status of Oral Health Care System in India 231
Economic Burden of Oral Diseases 232
Strategies for Implementation 232
Additional Measures Suggested 233
Involvement and Reorientation of the Dentists Working in Urban Areas 234
Implementation of Primary Preventive Package through the School Health Schemes in the Different Urban
Areas 234
Reorientation of Dental Education in India 235
Involvement of Other Allied Departments 235
National Institute of Dental Research (NIDR) 235
National Training Center 235

20. Planning and Evaluation ............................................................................................................ 236

CM Marya
Definition 236
Purpose of Planning 236
Uses of Planning 236
Planning Cycle 236
Evaluation 238
Reasons for Evaluation 239

21. School Dental Health Programs ................................................................................................ 240

CM Marya
Models 240
The Three-Component Model 240
The Eight-Component Model 240
Definition 241
Health Promoting Schools 242
Objectives of School Based Dental Health Program 243
Partners in School Oral Health Programs 243
Self-Applied Fluorides 243
School Based Sealant Program 243
School Water Fluoridation 244
Topical Fluoride Application Program 244
Oral Health Education 244
Guidelines for an Ideal School Dental Program 244
School Dental Health Programs 246
Learning about your Oral Health 246
Tattle Tooth I Program 246
Tattle Tooth II Program 247
Theta Program 247
xviii A Textbook of Public Health Dentistry
Yukon Children’s Dental Health Program 247
Askov Dental Health Education 248
The Maine School Oral Health Program 248
Elements of School Oral Health Program 248
Some School Based Oral Health Programs in Various Countries 249
Smiling Schools Project in Namibia 250
Dental Public Health Programs in Seychelles 250
School-Based Oral Health Education Program in China 250
School Oral Health Program in Kuwait 251
School Oral Health Program in India 251
Incremental Dental Care 251

22. Dental Council of India .............................................................................................................. 253

CM Marya
Introduction 253
Objectives/Duties 253
Constitution and Composition of Council 254
Incorporation of Council 254
Mode of Election 254
Term of Office and Casual Vacancies 254
President and Vice-President of Council 254
The Executive Committee 255
Recognition of Dental Qualifications 255
Nonrecognition of Dental Qualifications 256
Qualifications of Dental Hygienists 256
Qualifications of Dental Mechanics 256
Effect of Recognition 256
Withdrawal of Recognition 256
Withdrawal of Recognition of Recognized Dental Qualification 256
Professional Conduct 257
The Indian Register 257

23. The Dentist Act of India and Indian Dental Association ......................................................... 258
CM Marya
The Dentists Act (29th March, 1948) 258
Introduction 258
The Dentists (Amendment) Act, 1993 (2nd April, 1993) 259
Indian Dental Association (IDA) 261
Objectives of IDA 261
Types of Membership 262
Head Office 262
State Branch 264

24. Ethics in Dentistry ...................................................................................................................... 265

CM Marya
Definition 265
Principles of Ethics 265
Code of Ethics for Dentists by Dental Council of India 267
Duties and Obligation of Dentists towards Patients and Public 267
Duties of One Dentist towards Another 267
Unethical Practices 268
General Principles for a Dental Professional Ethical Code in the Countries of the EU
(European Union) 268
 Contents xix

SECTION 3: PREVENTIVE DENTISTRY

25. Dental Plaque .............................................................................................................................. 273
CM Marya
Formation of Dental Plaque Biofilms 273
Supra and Subgingival Plaque 276
Significance of Dental Plaque 276

26. Plaque Control ............................................................................................................................ 277

CM Marya
Definition 277
Guidelines for Acceptance of Chemotherapeutic Products 277
Approaches in Plaque Control 277
Manual Toothbrushes 278
Powered Toothbrushes 279
Sonic and Ultrasonic Toothbrushes 281
Ionic Toothbrushes 281
Bionic Toothbrush—Soladey 281
Toothbrushing Techniques 282
The Bass Method: Sulcular Brushing 282
Modified Bass Technique 283
Stillman’s Method 283
Modified Stillman’s Technique 284
The Rolling Stroke 284
Charter’s Method 284
Circular: The Fones Method 285
Vertical: Leonard Method 285
Physiologic: Smith’s Method 285
Interdental Oral Hygiene Aids 285
Dental Floss 286
Floss Holder 288
Toothpicks 288
Interproximal Brushes 289
Single Tuft Brushes 289
Knitting Yarn 290
Gauze Strip 290
Pipe Cleaner 290
Wedge Stimulator 290
Adjunctive Aids 291
Ingredients 292
Abrasives 292
Humectant 293
Water 293
Binding Agent 293
Detergents 293
Flavoring Agent 293
Preservative 293
Therapeutic Agent 293
Sweetening Agents 293
Therapeutic Dentifrices 294
Anticaries 294
Anti-plaque Agents 294
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