MJDF Dental Public Health 2 — Questions and Answers
Question 1: What is the NHS dental contract system in England (from 2006), and what are UDAs (Units of Dental Activity)?
- UDAs measure the number of patients registered with a practice
- The NHS dental contract in England (2006) pays dental practices based on Units of Dental Activity (UDAs): Band 1 = 1 UDA (examination, radiographs, scale and polish), Band 2 = 3 UDAs (fillings, extractions, root canal treatment), Band 3 = 12 UDAs (laboratory work — crowns, bridges, dentures). Practices are contracted to deliver a set number of UDAs per year (Correct answer)
- UDAs are a quality measurement tool unrelated to payment
- The NHS pays dentists per hour of clinical time regardless of treatment provided
Correct answer: The NHS dental contract in England (2006) pays dental practices based on Units of Dental Activity (UDAs): Band 1 = 1 UDA (examination, radiographs, scale and polish), Band 2 = 3 UDAs (fillings, extractions, root canal treatment), Band 3 = 12 UDAs (laboratory work — crowns, bridges, dentures). Practices are contracted to deliver a set number of UDAs per year
The 2006 NHS dental contract in England replaced fee-per-item payments with Units of Dental Activity (UDAs). Each course of treatment falls into one of three bands with a fixed UDA value regardless of the complexity or number of procedures within that band. Band 1 (1 UDA): examination, diagnosis, preventive advice, radiographs, scale and polish. Band 2 (3 UDAs): all Band 1 plus fillings, extractions, RCT. Band 3 (12 UDAs): all Band 1 and 2 plus laboratory items. Criticisms include: no incentive for prevention, complex treatments undervalued, and perverse incentives around treatment banding.
Question 2: What is the role of Health Education England's 'Supervised Toothbrushing' programme and which age group does it target?
- It targets adults in care homes only
- It is a daily supervised toothbrushing programme in nurseries and primary schools targeting children aged 3-5 years (reception age), using fluoride toothpaste of at least 1000 ppm, to reduce caries inequalities in areas of high deprivation (Correct answer)
- It provides free electric toothbrushes to all school-age children
- It is a programme for training dental hygienists
Correct answer: It is a daily supervised toothbrushing programme in nurseries and primary schools targeting children aged 3-5 years (reception age), using fluoride toothpaste of at least 1000 ppm, to reduce caries inequalities in areas of high deprivation
Supervised toothbrushing programmes are evidence-based interventions recommended by PHE/OHID and NICE for reducing caries in young children, particularly in deprived areas. Children in early years settings and reception classes (typically 3-5 years) brush their teeth daily under supervision using fluoride toothpaste (≥1000 ppm). The programme addresses inequalities by reaching children regardless of home brushing habits, establishing brushing routines, and ensuring fluoride exposure. Evidence shows a 24% reduction in caries in primary teeth. The programme also serves as an opportunity for wider oral health education.
Question 3: What is meant by 'oral health inequalities' and which social determinants most strongly influence them in the UK?
- Oral health inequalities do not exist in the UK due to the NHS
- Oral health inequalities are systematic, avoidable, and unjust differences in oral health status and access to care between different social groups; the strongest determinants include socioeconomic deprivation, income, education level, ethnicity, geographical location, and disability (Correct answer)
- Oral health inequalities only relate to the number of dentists in an area
- They refer to differences in the quality of dental materials used by different practices
Correct answer: Oral health inequalities are systematic, avoidable, and unjust differences in oral health status and access to care between different social groups; the strongest determinants include socioeconomic deprivation, income, education level, ethnicity, geographical location, and disability
Oral health inequalities are persistent, measurable differences in oral health outcomes that follow a social gradient: children in the most deprived areas of England have more than twice the caries experience of those in the least deprived areas. Key social determinants include: socioeconomic position (the strongest predictor), income (affecting diet quality, fluoride toothpaste access), education (health literacy), ethnicity (cultural practices, access barriers), geography (urban/rural access differences, water fluoridation status), and disability (barriers to oral care and dental services). Addressing these requires 'upstream' interventions targeting the causes of the causes.
Question 4: What level of evidence is considered the highest quality in evidence-based dentistry, and what is the hierarchy of evidence?
- Expert opinion is the highest quality evidence
- Systematic reviews and meta-analyses of randomised controlled trials are the highest quality; the hierarchy descends through RCTs, cohort studies, case-control studies, case series, and expert opinion at the lowest level (Correct answer)
- Case reports provide the strongest evidence for clinical decisions
- All study designs provide equal quality evidence
Correct answer: Systematic reviews and meta-analyses of randomised controlled trials are the highest quality; the hierarchy descends through RCTs, cohort studies, case-control studies, case series, and expert opinion at the lowest level
The evidence hierarchy (from highest to lowest quality) is: systematic reviews and meta-analyses of RCTs (Level 1a); individual RCTs (Level 1b); cohort studies (Level 2); case-control studies (Level 3); case series and cross-sectional studies (Level 4); expert opinion, bench research, and animal studies (Level 5). In evidence-based dentistry, clinical decisions should be based on the best available evidence combined with clinical expertise and patient preferences. Cochrane systematic reviews are considered the gold standard for synthesising evidence.
Question 5: What is the 'Common Risk Factor Approach' in dental public health and how does it differ from a disease-specific approach?
- It is a technique for extracting teeth with the lowest possible risk
- It recognises that oral diseases share risk factors (diet, tobacco, alcohol, hygiene, stress) with other chronic diseases (cardiovascular disease, diabetes, cancer), so interventions targeting these common factors benefit multiple conditions simultaneously, making them more cost-effective and politically appealing than disease-specific dental programmes (Correct answer)
- It means treating all dental diseases with the same medication
- It refers to using the same dental materials for all types of restorations
Correct answer: It recognises that oral diseases share risk factors (diet, tobacco, alcohol, hygiene, stress) with other chronic diseases (cardiovascular disease, diabetes, cancer), so interventions targeting these common factors benefit multiple conditions simultaneously, making them more cost-effective and politically appealing than disease-specific dental programmes
The Common Risk Factor Approach (Sheiham and Watt, 2000) recognises that dental caries, periodontal disease, oral cancer, and obesity share risk factors with systemic diseases: poor diet (caries, obesity, diabetes, CVD), tobacco (oral cancer, periodontal disease, lung cancer, CVD), alcohol (oral cancer, liver disease), and psychosocial stress. Rather than mounting separate prevention programmes for each disease, addressing these shared risk factors through integrated health promotion benefits oral and general health simultaneously. This approach is more efficient, avoids duplication, and integrates oral health into wider public health frameworks.
Question 6: What are fissure sealants, when should they be applied according to NICE/DBOH guidelines, and what is the evidence for their effectiveness?
- Fissure sealants are only effective in adults over 50
- Resin-based fissure sealants should be applied to the permanent molars of children assessed as being at increased risk of caries, ideally as soon as the teeth are sufficiently erupted to allow moisture control; they reduce caries in sealed fissures by approximately 70-80% compared to unsealed teeth (Correct answer)
- Fissure sealants should be applied to all deciduous teeth
- There is no evidence supporting the effectiveness of fissure sealants
Correct answer: Resin-based fissure sealants should be applied to the permanent molars of children assessed as being at increased risk of caries, ideally as soon as the teeth are sufficiently erupted to allow moisture control; they reduce caries in sealed fissures by approximately 70-80% compared to unsealed teeth
Fissure sealants are resin or glass-ionomer based materials applied to the pits and fissures of teeth to create a physical barrier preventing bacterial colonisation and caries initiation. NICE and DBOH recommend their application to permanent molars in children and young people assessed as at elevated caries risk. They should be applied as soon as the tooth is sufficiently erupted to permit adequate moisture control. Cochrane evidence shows approximately 78% reduction in caries in sealed versus unsealed first permanent molars over 2 years. Regular review and reapplication of partially or fully lost sealants is essential to maintain effectiveness.
MJDF Dental Public Health 2
What is the NHS dental contract system in England (from 2006), and what are UDAs (Units of Dental Activity)?