Diploma of the Faculty of Dental Surgery (MFDS) Dental Public Health, Prevention and Special Care Syllabus

Describe the Stephan curve and its significance for dietary advice on caries.

The Stephan curve plots plaque pH over time after a sugar exposure: pH drops rapidly below the critical pH (~5.5) within minutes due to bacterial acid production, then gradually recovers over 30-60 minutes as saliva buffers and clears the acid. Frequent sugar intakes keep pH below critical for longer, so reducing FREQUENCY (not just amount) of intake is key preventive advice.

What are the main indications for placing a fissure sealant?

Deep, retentive pits and fissures; teeth at high caries risk (e.g. caries in other teeth, medical/social risk factors); newly erupted permanent molars; non-cavitated (early/initial) occlusal caries that can be sealed over; and patients with special needs where prevention is a priority.

What is a preventive resin restoration (PRR) and how does it differ from a simple fissure sealant?

A PRR (also called sealant restoration) combines a minimal composite/GIC restoration of a small area of frank occlusal caries with a fissure sealant covering the remaining sound fissures. Unlike a simple sealant (which only seals sound or non-cavitated fissures), a PRR involves removing localised carious tissue first while conserving sound tooth structure.

Which materials are most commonly used for fissure sealants, and when is glass ionomer preferred over resin?

Resin-based (BIS-GMA) sealants are the gold standard, offering superior retention, but require good moisture control. Glass ionomer cement (GIC) sealants are preferred when moisture control is difficult (e.g. partially erupted teeth, uncooperative or special-needs patients) because they tolerate moisture and release fluoride, though retention is lower.

What are the eight evidence-based interventions/areas covered by the Delivering Better Oral Health (DBOH) toolkit?

DBOH covers: 1) Healthier eating/diet and reducing sugar; 2) Toothbrushing with fluoride toothpaste; 3) Fluoride (varnish, higher-strength pastes, supplements); 4) Fissure sealants; 5) Smoking/tobacco cessation; 6) Alcohol reduction; 7) Periodontal/gum health and plaque control; 8) Prevention of erosion. It is the national evidence-based prevention toolkit for the dental team.

What is the purpose of the Delivering Better Oral Health (DBOH) toolkit?

DBOH is an evidence-based prevention toolkit produced by Public Health England/OHID for the whole dental team. It summarises the best available evidence and provides consistent, practical advice on preventing dental disease (caries, perio, erosion, oral cancer) for patients of all ages and risk levels.

Define motivational interviewing (MI) and state its core 'spirit'.

MI is a patient-centred, collaborative, goal-oriented counselling style for strengthening a person's own motivation and commitment to change by exploring and resolving ambivalence. Its spirit is captured by PACE: Partnership, Acceptance, Compassion, and Evocation — drawing motivation out of the patient rather than imposing it.

What does the OARS acronym stand for in motivational interviewing?

OARS describes the core communication micro-skills: Open questions, Affirmations, Reflective listening, and Summarising. These are used to evoke 'change talk' and guide the patient toward behaviour change.

Name the stages of the Transtheoretical (Stages of Change) model of behaviour change.

Precontemplation, Contemplation, Preparation (Determination), Action, and Maintenance — with Relapse recognised as a possible part of the cycle. Interventions should be matched to the patient's current stage.

What is the difference between the wider determinants of health and individual lifestyle factors?

Wider (social) determinants are the structural conditions in which people are born, grow, live, work and age — e.g. income, education, housing, employment, environment and access to services. Individual lifestyle factors (diet, smoking, hygiene) operate within and are shaped by these wider determinants; addressing only lifestyle without the upstream determinants tends to widen inequalities.

Explain the Common Risk Factor Approach (CRFA) and give an example.

The CRFA (Sheiham & Watt) proposes tackling risk factors common to several chronic diseases simultaneously, rather than disease by disease. Example: reducing sugar consumption lowers risk of dental caries, obesity, type 2 diabetes and cardiovascular disease; addressing smoking reduces oral cancer, periodontal disease, lung disease and CVD. It is more efficient and reduces inequalities.

What does the Dahlgren and Whitehead 'rainbow' model of health determinants illustrate?

It depicts health determinants as concentric layers around the individual: fixed factors (age, sex, genetics) at the centre, then individual lifestyle factors, social and community networks, living and working conditions (housing, education, work, services), and finally general socioeconomic, cultural and environmental conditions — showing health is influenced by multiple, interacting layers.

State the three levels of the Ottawa Charter / health promotion 'prevention' classification (primary, secondary, tertiary) with a dental example of each.

Primary prevention = preventing disease before it occurs (e.g. water fluoridation, fissure sealants, oral health education). Secondary prevention = early detection and intervention to halt progression (e.g. screening, fluoride varnish on early lesions, scaling). Tertiary prevention = limiting disability and rehabilitating established disease (e.g. restorations, dentures, managing advanced periodontitis).

What are the five action areas of the WHO Ottawa Charter for Health Promotion (1986)?

1) Build healthy public policy; 2) Create supportive environments; 3) Strengthen community action; 4) Develop personal skills; 5) Reorient health services (toward prevention/health promotion rather than just treatment).

Define the 'inverse care law' and how it applies to dental access.

The inverse care law (Tudor Hart, 1971) states that the availability of good medical/dental care tends to vary inversely with the need of the population served. Those with the greatest oral health needs (deprived communities) often have the poorest access to dental services, widening inequalities.

Distinguish between 'proportionate universalism' and a purely targeted approach to health inequalities.

Proportionate universalism (Marmot Review) delivers universal services/interventions to the whole population but with a scale and intensity proportionate to the level of disadvantage. A purely targeted approach focuses resources only on high-risk groups, which can miss the bulk of cases (prevention paradox) and stigmatise; universalism alone may widen gaps. Proportionate universalism balances both.

What is the 'prevention paradox' described by Geoffrey Rose?

The prevention paradox states that a preventive measure bringing large benefit to the population (whole-population/high-risk strategy) often offers little apparent benefit to each participating individual. Conversely, most cases of a disease arise from the large number of people at low/moderate risk, not the small high-risk group — justifying population-wide strategies.

Give examples of community-based and population-level interventions to improve oral health.

Water fluoridation; supervised toothbrushing schemes in schools/nurseries; fluoride milk/salt programmes; targeted free toothpaste/brush distribution; sugar reduction policies such as the Soft Drinks Industry Levy (sugar tax); school-based fissure sealant programmes; community water/health education campaigns; and food/advertising regulation.

What evidence supports water fluoridation as a population intervention, and what is the typical optimal concentration?

Water fluoridation is associated with a significant reduction in caries prevalence and severity (and a reduction in health inequalities, benefiting deprived groups most). The target optimal concentration in the UK is approximately $1 \text{ ppm}$ ($1 \text{ mg/L}$) of fluoride. Mild dental fluorosis is the main adverse effect.

When managing a patient with a learning disability, what reasonable adjustments might be appropriate in dental care?

Longer/quieter appointments, desensitisation visits and acclimatisation, accessible (easy-read) information, use of social stories and visual aids, consistent clinician, domiciliary or special-care settings, support from carers, consideration of sedation or general anaesthesia where needed, and assessment of capacity for each decision. Reasonable adjustments are a legal duty under the Equality Act 2010.

What oral health challenges are particularly associated with older and frail patients?

Root caries (gingival recession + xerostomia), polypharmacy-induced dry mouth, increased perio disease, retained heavily restored teeth, denture-related problems (stomatitis, candidiasis), reduced manual dexterity affecting hygiene, dependency on carers, and links between poor oral health and aspiration pneumonia and malnutrition.

Define xerostomia, name common drug classes that cause it, and outline its dental consequences.

Xerostomia is the subjective sensation of dry mouth, often from reduced salivary flow (hyposalivation). Common causes include anticholinergics, antidepressants (tricyclics, SSRIs), antihypertensives, diuretics, antihistamines, antipsychotics and opioids — common in polypharmacy among the elderly. Consequences: increased caries (especially root caries), candidiasis, difficulty eating/speaking/denture wearing, and mucosal soreness.

What are the five statutory principles of the Mental Capacity Act 2005 (England & Wales)?

1) Presumption of capacity; 2) Support to make their own decision (all practicable steps taken first); 3) Unwise decisions do not equate to lack of capacity; 4) Any act/decision for someone lacking capacity must be in their best interests; 5) The least restrictive option (least restrictive of rights and freedom) should be chosen.

Outline the two-stage test for assessing mental capacity under the Mental Capacity Act 2005.

Stage 1 (diagnostic test): Is there an impairment of, or disturbance in, the functioning of the mind or brain? Stage 2 (functional test): Does that impairment mean the person is unable to (a) Understand the information relevant to the decision, (b) Retain it long enough to decide, (c) Use or weigh it as part of the decision, or (d) Communicate the decision? Inability in any one means they lack capacity for that specific decision.

What are the key features of valid consent in dentistry?

Consent must be Voluntary (given freely without coercion), Informed (the patient understands the nature, purpose, risks, benefits and alternatives, including doing nothing — per Montgomery, material risks must be disclosed), and given by a person with Capacity. Consent is decision-specific and can be withdrawn at any time.

How are decisions made for an adult who lacks capacity, and what tools support this?

Decisions are made in the patient's best interests (MCA 2005, s.4), considering their past/present wishes, feelings, beliefs and values, and consulting relevant others (family, carers, an Independent Mental Capacity Advocate where no one else is available). A valid Lasting Power of Attorney (health & welfare) or court-appointed deputy/advance decision may determine or constrain the decision.

What does the Montgomery v Lanarkshire (2015) ruling establish about consent?

Montgomery established that clinicians must disclose any 'material risk' — a risk that a reasonable person in the patient's position would attach significance to, or that the clinician knows this particular patient would. It shifted the standard of disclosure from the doctor-centred Bolam test to a patient-centred standard, reinforcing informed consent and shared decision-making.

Define safeguarding of vulnerable adults and list categories of abuse under the Care Act 2014.

Safeguarding means protecting an adult's right to live in safety, free from abuse and neglect. Care Act 2014 categories of abuse include: physical, sexual, psychological/emotional, financial/material, neglect and acts of omission, discriminatory, organisational/institutional, domestic abuse, modern slavery, and self-neglect.

What signs during a dental examination might raise a safeguarding concern, and what should the dentist do?

Signs include unexplained injuries (especially head/neck/orofacial), injuries inconsistent with the history, dental neglect, fearful behaviour, or carer behaviour suggesting control/coercion. The dentist should recognise, record (clear contemporaneous notes), respond, and refer/raise the concern according to local safeguarding policy, sharing information appropriately and acting in the person's best interests; do not delay if there is immediate risk.

What is dental neglect and how does it differ between children and vulnerable adults?

Dental neglect is the persistent failure to meet a person's basic oral health needs, likely to seriously affect their development or health (e.g. untreated rampant caries, abscesses, severe pain not acted upon). In children it is a child protection issue (failure by parent/carer); in vulnerable adults it is a safeguarding issue relating to carers or self-neglect. Both require recognition, record-keeping and referral.

Which patients require antibiotic prophylaxis against infective endocarditis before invasive dental procedures, per current NICE/SDCEP guidance?

Routine antibiotic prophylaxis is NOT recommended for the general population. It should only be considered, on an individual basis after discussion, for patients defined as being at the HIGHEST risk of infective endocarditis (e.g. previous IE, prosthetic heart valve/material used for repair, certain congenital heart disease, cardiac transplant with valvulopathy) undergoing invasive dental procedures. The decision is made jointly with the patient and cardiologist.

What dental precautions are needed for a patient taking warfarin who needs an extraction?

Check the INR ideally within 24 hours (within 72 hours if stable) of the procedure. If INR is below 4.0, do NOT interrupt warfarin; treat using local haemostatic measures (atraumatic technique, sutures, oxidised cellulose/haemostatic packing, pressure). If INR is $\geq 4.0$, delay invasive treatment and seek advice. Avoid NSAIDs and use caution with interacting drugs (e.g. metronidazole, azole antifungals).

What are the key dental management considerations for a patient with poorly controlled diabetes mellitus?

Risk of hypoglycaemia (schedule morning appointments after normal meal/medication; have glucose available), greater susceptibility to infection and periodontal disease, impaired wound healing, and possible candidiasis/xerostomia. Confirm HbA1c control, avoid long stressful sessions, ensure good perio care, and be ready to manage a hypoglycaemic emergency (oral glucose if conscious).

What special considerations apply when treating a patient on bisphosphonates or other antiresorptive/antiangiogenic drugs?

Risk of medication-related osteonecrosis of the jaw (MRONJ), particularly after extractions or bone surgery. Assess risk (IV/high-dose, duration >5 years, concurrent steroids/antiangiogenics, oncology indication increase risk). Optimise oral health and complete invasive treatment before starting therapy where possible, prefer prevention and non-surgical options, use atraumatic technique, and obtain informed consent regarding MRONJ risk; refer high-risk cases to a specialist.