MODUL 1 CRITICAL THINKING LEARNING SKILLS & EVIDENCE BASED LEARNING PROBLEM BASED LEARNING

By : LAILA FATMAWATI DESY RISKA IMA KUSUMA PERDANI BALQIS CHARISA AMANDA YUNITA MARWAH AMANDA PUJI DHARMA SAPUTRI TRI DESIANA KURNIAWATI HARTONO NUR ARISKA NUGRAHANI ADAM BIMASAKTI ERINA FATMALA YULI ANDARI FITRIAH HASAN ZABA AYU LARISSA PUTRI ISNAINY NOVIANTARI ZULFAH HUSNAN PUTRI ANDIKA S SHUFIYAH NURUL AINI RIZKI TRI HANDAYANI (021211131001) (021211131002) (021211131003) (021211131004) (021211131005) (021211131006) (021211131007) (021211131008) (021211131009) (021211131010) (021211131011) (021211131012) (021211131013) (021211131014) (021211131015)

FACULTY OF DENTISTRY AIRLANGGA UNIVERSITY SURABAYA 2012

PREFACE Praising to Allah, for completing of a paper on " Modul 1 Critical Thinking Learning Skills & Evidence Based Learning, Problem Based Learning " well. This scientific paper is written based on scientifical sources which includes oral health in pregnant woman. So we believe the reader can use this paper as a means of learning or studying. Authors realize that this paper can be realized because the instructions, guidance, criticism, encouragement, and assistance from various parties. Therefore, on this occasion the authors thank to: 1. Thalca Hamid, drg., MhPED., PhD., Sp.Ort(K) as Lecturer PJMA in charge of 1st modules 2. Dr. drg. Didik Hadi Mulyana, MS., Sp. Ort as mentors who have supported and given guidance so that this paper can be arranged 3. Friends and all those who have supported directly or indirectly. We wrote this paper to fulfill the scene 2 of first module of Critical Thinking Learning Skills & Evidence Based Learning, Problem Based Learning. We hope this module may be able to give great benefit to the reader, especially to increase the knowledge of oral health in pregnant woman. The authors recognize that this paper is far from perfection. Hopefully this paper is beneficial to both the author and those who take advantage. We need criticism and suggestions from the readers of this paper for improving it on the future. Surabaya, December 2012

Authors,

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ABSTRACT Background : Pregnancy is a unique period in a woman's life and is characterized by physiological and hormonal changes which are complex. Pregnancy can cause physiological changes in all body systems including the endocrine system, which is influenced by the hormones estrogen and progesterone. Purpose: After completing this module, students first semester Faculty of Dentistry, University of Airlangga will be able to apply the skills of independent learning, critical thinking, and be able to trace scientific study that is valid and relevant to the basic level of medical knowledge. Able to implement independent learning skills in the learning process, apply critical thinking skills in solving health problems, and use information technology to locate scientific studies, assess the relevance and validity to be used in solving medical problems according to the depth of knowledge. Result: We explain that disease is gingivitis especially gingivitis gravidarum, because the symptoms from the scenario same with symptoms of gingivitis gravidarum there are morning sicknes, swollen and bleeding gums, and also caries. Conclusion: In the first trimester of pregnancy until the third period of pregnancy pregnant women often gingivits gravidarum disease / pregnancy gravidarum / hyperplas. This situation is caused by the hormonal activity of the hormone estrogen and progesterone. Provision of dental hygiene is recommended for pregnant women and other therapies, but this does not heal completely because hormonal fluctuationss condition. Gingivitis will decline in the nine months of pregnancy and the few days after giving birth. The situation will return to normal as before pregnancy.

Key words: pregnancy, gingivitis, therapies

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CONTENTS TITTLE PAGE ......................................................................................... i PREFACE.............. .................................................................................. ii ABSTRACT. ............................................................................................ iii CONTENTS.............................................................................................. iv CONTENTS OF FIGURE ........................................................................ vi CONTENTS OF TABLE ......................................................................... vii CHAPTER 1 INTRODUCTION 1.1 1.2 1.3 Background ............................................................................ 1 Identification of the Problems................................................. 3 Purposes of Discussion........................................................... 3 1.3.1 General Purpose............................................................. 3 1.3.2 Specific Purpose............................................................ 3 1.4 2.1 Benefits of Discussion............................................................. 4 Dental Caries ......................................................................... 5 CHAPTER 2 LITERATURE REVIEW 2.1.1 Definition .............................................................................. 5 2.1.2 Etiology ................................................................................. 5 2.1.3 Mechanism ............................................................................ 6 2.1.4 Symptomps ........................................................................... 8 2.2 Gingivitis ................................................................................ 9 2.2.1 Definition .............................................................................. 9 2.2.2 Etiology ................................................................................. 9 2.2.3 Mechanism ............................................................................ 10 2.2.4 Symptoms .............................................................................. 11 2.3 Morning Sickness ................................................................... 11 2.3.1 Definition .............................................................................. 11 2.3.2 Etiology ................................................................................. 12 2.3.3 Mechanism ............................................................................ 12 2.3.4 Treatments ............................................................................. 14 2.3.5 Symptoms .............................................................................. 15

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2.3.6 Tips............. ........................................................................... 16 2.3.7 Other Tips .............................................................................. 18 2.4 Salivary ................................................................................ 18 2.4.1 Definition .............................................................................. 18 2.4.2 Salivary Glands ..................................................................... 18 2.4.3 Major Glands ......................................................................... 18 2.4.4 Minor Glands ........................................................................ 19 2.4.4.1 Labial Glands ............................................................ 19 2.4.4.2 Buccal Glands ........................................................... 20 2.4.4.3 Palatal Glands ........................................................... 20 2.4.4.4 Lingual Glands .......................................................... 20 2.4.5 Flowrate ................................................................................. 21 2.4.6 Viscosity ................................................................................ 21 2.4.7 Function ................................................................................. 21 2.4.8 Hyper-salivation .................................................................... 22 2.4.9 Hypo-salivation ..................................................................... 23 2.4.10 Conclusion ........................................................................... 24 2. 5 Hormone ............................................................................... 24 2.5.1 Estrogen ................................................................................. 24 2.5.2 Progesterone .......................................................................... 26 2.5.3 HCG....................................................................................... 27 2.5.4 Prostaglandin. ........................................................................ 27 2. 6 2. 7 2. 8 3.1 3.2 Behaviour ............................................................................. 27 Oral Hygiene ......................................................................... 28 Life Pattern ........................................................................... 28 Oral Health during Pregnancy................................................. 30 Relationship between Pregnant Women & Oral Health Disease..32

CHAPTER 3 DISCUSSION

3.2.1 Relationship between Pregnant Women & Gingivitis............ 32 3.2.2 Relationship between Saliva & Gingivitis............................. 34 3.2.3 Relationship between pH Saliva & Caries............................. 35 3.2.4 Relationship between Morning Sickness& Caries. ............... 37

3.2.5 Relationship between Oral Hygiene & Life Pattern............... 38 3.2.6 Relationship between Plaque & Gingivitis. .......................... 38 3.3 3.4 Eat HealthyPregnancy Woman............................................... 39 Treatments............................................................................... 41

3.4.1 Prenatal Care Helath Professional ......................................... 41 3.4.2 Oral Health Professional........................................................ 42 CHAPTER 4 CONCEPTUAL MAPPING AND HIPOTESIS 4.1 4.2 5.1 5.2 Conceptual Mapping............................................................... 46 Hypothesis............................................................................... 47 Conclusion.............................................................................. 48 Suggestion. . ............................................................................ 48

CHAPTER 5 CONCLUSION AND SUGGESTION

REFERENCES.......................................................................................... 50

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CONTENTS OF FIGURES Figure 1. Sevee Adult Dental Caries....................................................... 6 Figure 2. Salivary Glands.........................................................................9

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CONTENTS OF TABLE Table 1.Summary of Consumption during Pregnancy................................... 18

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CHAPTER I INTRODUCTION 1.1 Background Pregnancy is a unique period in a woman's life and is characterized by physiological and hormonal changes. Pregnancy can cause physiological changes in all body systems including the endocrine system, which is influenced by hormone estrogen and progesterone (Sam A, 2008). The effect of hormonal changes will affect almost every organ system, including the oral cavity. Pregnant women who believe that every pregnancy will cause the loss of the teeth. This opinion is wrong, because the tooth is not directly caused by the pregnancy, but due to poor oral hygiene and lack of maintenance of oral health. Some studies suggest that the effects of hormonal changes will affect the dental health of pregnant women by 60% with 10-27% have swollen gums(Diana D, 2009). According to the Household Health Survey (Household Health Survey, 2001), 60% of Indonesia's population suffers from gum disease, and one of them is periodontal disease, amounting to 87.84% of the population in Indonesia. Increased prevalence of this occurs with increasing age and the symptoms observed in the whole population, and one of those most vulnerable to her problem is a group of women who experienced pregnancy(Departmentof Health, 2001). Periodontal disease is an infectious disease caused by the bacteria found in dental plaque. Dental plaqueisa complex mass of bacteria and products containing metabolites, toxins, viruses, food scraps and dead cells. Periodontal diseases include gingivitis, periodontitis and other periodontal disease( LF Rose&MealeyBL, 2004). During pregnancy the most common disease is Gingivitis, with a prevalence of 60% to 75%.Approximately one half of women with preexisting gingivitis have significant exacerbation during pregnancy (Hey-Hadavi JH, 2002).

And also in pregnant woman of 1st trimester, the oral cavity is exposed more often to gastric acid that can erode dental enamel. Morning sickness is a common cause early in pregnancy; later, a lax esophageal sphincter and upward pressure from the gravid uterus can cause or exacerbate acid reflux. Patients with hyper emesis gravidarum can have enamel erosions (ADA, 2006). Sustainability increased acidity in the oral cavity (result from frequently nausea), sugary dietary cravings, and limited attention to oral health in pregnant women, causes demineralization or tooth decay. Caries are at higher risk in pregnant women(Hey-Hadavi JH, 2002). Dental caries is a disease of porous starting at a specific location on the teeth, and followed the process of decay or tooth decay rapidly. Dental caries begins with the erosion of minerals from the tooth enamel surface or organic acid fermentation of carbohydrate foods, especially sugar and starch-patian that remains attached to the parts and between teeth by lactic acid bacteria (Koswara, 2006). Periodontal disease, namely inflammation and changes in the gingival and periodontium recessive. Gingivitis is an inflammatory process limited to the gingival (no attachment loss). Besides almost ubiquitous condition gingivitis caused by plaque, gingival changes are also detected during the period of hormonal imbalance, systemic disease, or as a side effect of medication. If the network supporting alveolar bone is also affected by the inflammatory process in periodontium, then it is called periodontitis. The term refers to the decrease in gingival recession gingival or alveolar bone apical direction, which usually occurs on the labial aspect of the teeth were clinically free of inflammation (Klaus H, et al., 2004). Periodontitis is an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both (Elisabetta C, et al., 2010). Periodontitis lesions showed gingival inflammation and destruction of periodontal ligament and alveolar bone. This leads to bone loss and apical migration of the junctional epithelium, resulting in the formation of periodontal pockets (Li X, 2010).

Periodontitis can progress from pregnancy gingivitis (inflammation or infection of the gums) were not treated (Wiriawan&Elly, 2002). The infection will spread from the gums to the bone under the teeth, causing greater damage to the periodontal tissues (BM Eley JD & Manson, 2002). Based on the research showed that 4% of pregnant women are lazy to brush teeth because it can cause nausea and vomiting. If things are left unchecked, will eventually lead to dental caries even with a very high prevalence (Diana, 2009). Awareness of the importance of protecting pregnant women oral health is very important. Knowledge, attitudes, and behavior of pregnant women on oral health will determine the health status of the oral cavity. In addition, the health behavior of pregnant women also have a huge influence for themselves and the fetus (baby). According to the 2002 National Health Survey which states that 67% of pregnant women suffer from gingivitis gave birth prematurely (Santoso, 2003). An acidic diet or high sugar levels can lower the pH of saliva and the presence of nausea and vomiting that make pregnant women lazy to clean the oral cavity. Therefore, actions such as brushing, flossing, and scaling highly recommended. Based on the above background, in this report we would like to discuss more about the oral health in pregnant woman, so as a professional dentist in the future we can solve the problems with every variant, such as in pregnant woman. 1.2 Identification Problems 1. Why does pregnant woman oftenly have oral health diseases? 2. Why do the therapies apllied to this pregnant woman dont help her? 3. What is the relevation between the new caries showed up and the pregnancy? 1.3 Purposes of Discussion After completing this module, students Semester 1 Faculty of Dentistry, University of Airlangga will be able to apply the skills of independent learning, 1.3.1 General Purpose :

critical thinking, and can trace scientific study that is valid and relevant to the basic level of medical knowledge. 1.3.2 Specific Purpose : 1. Able to implement independent learning skills in the learning process. 2. Able to apply critical thinking skills in solving health problems. 3. Able to use information technology to locate scientific studies, assess the relevance and validity to be used in solving medical problems according to the depth of knowledge. 1.4 Benefit : 1. Able to apply self-learning skills and critical thinking. 2. Able trace scientific study that is valid and relevant to the basic level of medical knowledge. 3. Able to solve health problems.

CHAPTER II LITERATURE REVIEW 2.1 Dental Caries Dental caries is an infectious, communicable disease resulting in destruction of tooth structure by acid-forming bacteria found in dental plaque, an intraoral biofilm, in the presence of sugar. The infection results in the loss of tooth minerals that begins with the outer surface of the tooth and can progress through the dentin to the pulp, ultimately compromising the vitality of the tooth.(The Journal of the American Dental Association July 2000 vol. 131 no. 7 887-899) Dental caries is a bacterially based disease. When it progresses, acid produced by bacterial action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the carbonated hydroxyapatite minerala process called demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lactobacilli), salivary dysfunction, and dietary carbohydrates are related to caries progression. Protective factorswhich include salivary calcium, phosphate and proteins, salivary flow, fluoride in saliva, and antibacterial components or agentscan balance, prevent or reverse dental caries. (The Journal of the American Dental Association July 2000 vol. 131 no. 7 887-899) 2.1.2 Etiology One fourth of women of reproductive age have dental caries, a disease in which dietary carbohydrate is fermented by oral bacteria into acid that demineralizes enamel (Figure 1). Pregnant women are at higher risk of tooth decay for several reasons, including increased acidity in the oral cavity, sugary dietary cravings, and limited attention to oral health. Early caries appears as white, demineralized areas that later break down into brownish cavitations. Fillings or crowns are a sign of previous caries. Untreated dental caries can lead to oral abscess and facial cellulitis. Children of mothers who have high caries levels are more likely to get caries.Pregnant patients should decrease their risk of caries by brushing twice daily with fluoride toothpaste and limiting sugary foods.

2.1.1 Definition

Patients with untreated caries and associated complications should be referred to a dentist for definitive treatment. (Journals AFPP April 15, 2008 vol. 77/No. 8)

Figure 1. Severe adult dental caries. (Journals AFPP April 15, 2008 vol. 77/No. 8) The presence of cariogenic bacteria, fermentable carbohydrates, and a susceptible host are needed for the development of dental caries (Keyes 1960). Cariogenic bacteria in dental biofilm produce organic acids during metabolism of fermentable carbohydrates (Loesche 1986), and these organic acids dissolve minerals in hard dental tissue. The main groups of bacteria needed in the caries process are mutants streptococci and lactobacilli (Featherstone 2008). Frequent consumption of fermentable carbohydrates increases the amount of these bacteria (Marsh 1994). The progression of dental caries is a dynamic process since periods of demineralization and remineralization alternate (Kidd and Fejerskov 2004). Remineralization is achievable if fluoride, calcium, and phosphate are present in saliva, and it may completely arrest the progression of a lesion (Nyvad et al. 1999). Saliva has good buffering capacity, and salivary flow can clear bacteria from the tooth surface. Dental caries is a transmissible infectious disease, and the cariogenic bacteria mutants streptococci are usually transmitted to young children from their mothers (Alaluusua et al. 1996). 2.1.3 Mechanism Dental caries arises from an overgrowth of specific bacteria that can metabolize fermentable carbohydrates and generate acids as waste products of their metabolism. Streptococci mutants and Lactobacillus acidophilus are the two principal species of bacteria involved in dental caries and are found in the plaque biofilm on the tooth surface.2,3,4 When these bacteria produce acids, the acids diffuse into tooth enamel, cementum, or dentin and dissolve or partially dissolve

the mineral from crystals below the surface of the tooth. If the mineral dissolution is not halted or reversed, the early subsurface lesion becomes a cavity.( Lethbridge Undergraduate Research Journal. 2007. Volume 2 Number 2). Streptococcus mutans has been implicated most of all as the initiator of dental caries. Streptococcus mutans such a potent initiator of caries because a variety of virulence factors unique to the bacterium have been isolated that play an important role in caries formation. First, S. mutans is an anaerobic bacterium known to produce lactic acid as part of its metabolism. Then there is the ability of S. mutans to bind to tooth surfaces in the presence of sucrose by the formation of water-insoluble glucans, a polysaccharide that aids in binding the bacterium to the tooth. Mutant strains developed to produce water-soluble glucans instead have extremely diminished cariogenicity, especially on the smooth surfaces of the teeth which require greater tenacity for binding to occur (Loesche 1986). Waterinsoluble glucan has also been found to lower the calcium and phosphate concentration of saliva, decreasing its ability to repair the tooth decay caused by bacterial lactic acid (Napimoga, Kamiya et al. 2004). The most important virulence factor, however, is the acidophilicity of Streptococcus mutans. Unlike the majority of oral microorganisms, S. mutans thrives under acidic conditions and becomes the dominant bacterium in cultures with permanently reduced pH. Additionally, unlike many species present in plaque, whose metabolisms slow considerably at such a low pH, the metabolism of S. mutans actually improves, as the proton motive system used to transport nutrients through its cell wall in environments of low pH or high glucose concentration is modulated by hydrogen ion content, which increases with acidity (Hamilton and Martin 1982). In this way, S. mutans can actually continue to lower or maintain the oral pH at an unnaturally acidic value, leading to conditions favorable for its own metabolism and unfavorable for other species it once coexisted with. It is this lowered pH that results in demineralization and cavitation of the teeth, both of which increase with increased rates of S. mutans. Under acidic conditions, S. mutans succeeds in creating a cycle that is favorable for itself and unfavorable for others involved in the oral ecology

becoming,

in

effect,

pathogen.(Lethbridge

Undergraduate

Research

Journal. 2007. Volume 2 Number 2) 2.1.4 Symptoms Bacteria are normally found in your mouth. These bacteria change foods -especially sugar and starch -- into acids. Bacteria, acid, food pieces, and saliva combine in the mouth to form a sticky substance called plaque. Plaque sticks to the teeth. It is most common on the back molars, just above the gum line on all teeth, and at the edges of fillings.(Journals AFPP April 15, 2008 vol. 77/No. 8). Plaque that is not removed from the teeth turns into a substance called tartar. Plaque and tartar irritate the gums, resulting gingivitis and periodontitis. Plaque begins to build up on teeth within 20 minutes after eating. If it is not removed, tooth decay will begin.(Journals AFPP April 15, 2008 vol. 77/No. 8) The acids in plaque damage the enamel covering your teeth, and create holes in the tooth (cavities). Cavities usually do not hurt, unless they grow very large and affect nerves or cause a tooth fracture. An untreated cavity can lead to a tooth abscess. Untreated tooth decay also destroys the inside of the tooth (pulp), which leads to tooth loss.(Journals AFPP April 15, 2008 vol. 77/No. 8) Carbohydrates (sugars and starches) increase the risk of tooth decay. Sticky foods are more harmful than non-sticky foods because they remain on the teeth. Frequent snacking increases the time that acids are in contact with the surface of the tooth.(Journals AFPP April 15, 2008 vol. 77/No. 8) During pregnancy, the oral cavity is exposed more often to gastric acid that can erode dental enamel. Morning sickness is a common cause early in pregnancy; later, a lax esophageal sphincter and upward pressure from the gravid uterus can cause or exacerbate acid reflux. Patients with hyper-emesis gravidarum can have enamel erosions. Management strategies aim to reduce oral acid exposure through dietary and lifestyle changes, plus the use of antiemetics, antacids, or both. Rinsing the mouth with a teaspoon of baking soda in a cup of water after vomiting can neutralize acid. Pregnant women should be advised to avoid brushing their teeth immediately after vomiting and to use a toothbrush with soft bristles when they do brush to reduce the risk of enamel damage. Fluoride mouthwash can protect eroded or sensitive teeth. (Journals AFPP April 15, 2008 vol. 77/No. 8)

2.2

Gingivitis Gravidarum

2.2.1 Definition Pregnancy gingivitis is a common form of gum disease known to develop in almost half of all pregnant women likely due to the change in hormones. When kept at-bay, pregnancy gingivitis generally ends shortly after the birth of the child, although it should be monitored by a dentist periodically during pregnancy in order to prevent this form of gingivitis from progressing into more serious periodontitis, an advanced and irreversible form of gum disease that has been linked with preterm birth. 2.2.2 Etiology The physiologic changes in the mouth that occur during pregnancy are welldocumented. Combined with lack of routine exams and delays in treatment for oral disease, these changes place pregnant women at higher risk for dental infections. Gingivitis is caused by a build up of dental plaque which, when left to collect, will irritate and sometimes inflame your gums, causing them to bleed. Gingivitis due to accumulation of plaque is the most common clinical periodontal condition of women during pregnancy, occurring in 60-75% of women, 81 which speaks to the importance of establishing periodontal preventive and treatment measures during pregnancy. Gingival changes generally occur between three and eight months of pregnancy and gradually decline after delivery. While gingival changes usually occur in association with poor oral hygiene and local irritants, especially bacterial flora of plaque, the hormonal and vascular changes that accompany pregnancy often exaggerate the inflammatory response to these local irritants.82 The most marked changes are seen in gingival vasculature. This type of gingivitis, known as pregnancy gingivitis, is characterized by gingival that is dark red, swollen, smooth and bleeds easily. Gingival changes associated with pregnancy have been observed in women who are taking oral contraceptive agents. In general, changes include an increase in gingival inflammation that appears out of proportion to the amount of supragingival plaque present. This condition clearly does not occur in all women. Two mechanisms may cause this significant response:
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1. There may be an increase in some pathogenic bacteria, such as porphyromonas gingival is and Actinobacillus actinomycetemcomitans 2. There may be an increase in prostaglandin E, a mediator of inflammation 2.2.3 Mechanism The hormonal changes during pregnancy change the bodys natural response to dental plaque, and thus exaggerate the way the gum tissues react to the bacteria in plaque, thus resulting in a higher chance of pregnant women getting gingivitis. Generally, if extra care is taken of the teeth and possible plaque buildup, it can be prevented. It is even more important to have a good oral hygienic routine during this time. It is very important for expecting mothers to take care quickly if they have gum disease because they have a six times greater risk of having preterm and lowbirth weight babies! If expecting mothers had untreated tooth decay and/or consumed a lot of sugar, their children had four times the risk of developing tooth decay as opposed to children of other mothers. As far as hormones are concerned, expecting mothers (and also women who take oral contraceptives) generally experience elevated levels of estrogen and progesterone. This is why pregnant women have a 65 to 70% chance of The risk of getting gingivitis developing gingivitis during the pregnancy. ninth month. If you already have gingivitis going in to a pregnancy, it will likely get worse during pregnancy if you do not get treatment. Keep in mind that it is the bacteria in plaque that causes gingivitis by infecting the gum tissue and not the hormonal changes. The problem with gum disease (periodontal disease) is that the infected gums are toxic reservoirs of disease-causing bacteria. The toxins released can attack the ligaments, gums, and bones surrounding your teeth to create infected pockets similar to large infected wounds in the oral cavity. throughout your body. These pockets, unfortunately, can provide access to your bloodstream and allow bacteria to travel

increases beginning with the second month of pregnancy and decreases with the

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Since the bacteria that cause gingivitis can enter the bloodstream, the bacteria can travel all the way down to the uterus. This triggers the body to produce prostaglandins, which is a natural fatty acid that normally controls inflammation and smooth muscle contraction. When a woman is pregnant, her level of prostaglandins increases and peaks when she goes into labor. It is possible that if extra prostaglandins are produced when the body is reacting to infected gums, a pregnant womens body may think it is a signal to go into labor sooner than expected, thus causing a baby to be born too early or too small. 2.2.4 Symtomps Plaque irritates the gum tissue, making them tender, bright red, swollen, sensitive, and easy to make bleed. Gum tissue will appear red rather than pink, may be swollen, and bleed easily. It is usually painless. The gums may be moveable rather than tight against the teeth. Pregnancy gingivitis is typically seen in the second month of pregnancy, being at its worst at the end of the pregnancy. Gums may remain swollen for months after delivery. The severity of pregnancy gingivitis depends upon the condition of the mouth before pregnancy. A woman who has gum problems before pregnancy may see her gingivitis worsen dramatically 2.3 Morning Sickness Morning sickness, also called nausea gravidarum, nausea, vomiting of pregnancy (emesis gravidarum or NVP), or pregnancy sickness is a condition that affects more than half of all pregnant women. Sometimes symptoms are present in the early hours of the morning and reduce as the day progresses. However, in spite of its common name, it can occur at any time of the day. For most women it may stop around the 12th week of pregnancy. Related to increased estrogen levels, a similar form of nausea is also seen in some women who use hormonal contraception or hormone replacement therapy. The nausea can be mild or induce actual vomiting, however, not severe enough to cause metabolic derangement. In more severe cases, vomiting may cause dehydration, weight loss, alkalosis and hypokalemia. This condition is known as hyper-emesis gravidarum and occurs in about 1% of all pregnancies. Nausea and

2.3.1 Definition

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vomiting can be one of the first signs of pregnancy and usually begins around the 6th week of pregnancy (counting gestational age from 14 days before conception). 2.3.2 Etiology Proximate causes of pregnancy sickness include: a. An increase in the circulating level of the hormone estrogen. Estrogen levels may increase by up to a hundredfold during pregnancy. However, there is no consistent evidence of differences in estrogen levels and levels of bilirubin between women that experience sickness and those that do not. b. Low blood sugar (hypoglycemia) due to the placenta's draining energy from the mother, though studies have not confirmed this. c. An increase in progesterone relaxes the muscles in the uterus, which prevents early childbirth, but may also relax the stomach and intestines, leading to excess stomach acids and gastroesophageal reflux disease. d. An increase in human chorionic gonadotropin. It is probably not the human chorionic gonadotropin itself that causes the nausea. More likely, it is the human chorionic gonadotropin-stimulating the maternal ovaries to secrete estrogen, which in turn causes the nausea. e. An increase in sensitivity to odors, which over stimulates normal nausea triggers. f.An increase in bilirubin levels due to increased liver enzymes. (Note that Gastro esophageal reflux disease can also be caused by pregnancy, and may result in nausea and vomiting.) 2.3.3 Mechanism Morning sickness is believed to be an evolved trait that protects the fetus against toxins ingested by the mother. Many plants contain chemical toxins that serve as a deterrent to being eaten. Adult humans, like other animals, have defenses against plant toxins, including extensive arrays of detoxification enzymes manufactured by the liver and the surface tissues of various other organs. In the fetus, these defenses are not yet fully developed, and even small doses of

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plant toxins that have negligible effects on the adult can be harmful or lethal to the embryo. Pregnancy sickness causes women to experience nausea when exposed to the smell or taste of foods that are likely to contain toxins injurious to the fetus, even though they may be harmless to her. There is considerable evidence in support of this theory, including: a. Morning sickness is very common among pregnant women, which argues in favor of its being a functional adaptation and against the idea that it is a pathology. b. Fetal vulnerability to toxins peaks at around 3 months, which is also the time of peak susceptibility to morning sickness. c. There is a good correlation between toxin concentrations in foods, and the tastes and odors that cause revulsion. Women who have no morning sickness are more likely to miscarry. This may be because such women are more likely to ingest substances that are harmful to the fetus. In addition to protecting the fetus, morning sickness may also protect the mother. Pregnant women's immune systems are suppressed during pregnancy, it is presumed to reduce the chances of rejecting tissues of their own offspring. Because of this, animal products containing parasites and harmful bacteria can be especially dangerous to pregnant women. There is evidence that morning sickness is often triggered by animal products including meat and fish. If morning sickness is a defense mechanism against the ingestion of toxins, the prescribing of anti-nausea medication to pregnant women may have the undesired side effect of causing birth defects or miscarriages by encouraging harmful dietary choices. On the other hand, many domestic vegetables have been purposely bred to have lower levels of toxins than in the distant past, and so the level of threat to the embryo may not be as high as it was when the defense mechanism first evolved. 2.3.4 Treatments

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There is no evidence to demonstrate the effectiveness of home treatments for morning sickness. Suggested treatments typically aim to lessen the symptoms of nausea, rather than attacking the root cause(s) of the nausea. Frequently suggested treatments include: If the vomiting/nausea is due to acid reflux, taking an antacid or two before bed may help reduce the stomach acid and prevent morning vomiting. a. If the vomiting/nausea is due to reduced stomach motility then reducing fiber and fat intake may help. (For example, white bread instead of brown bread, well cooked fruits and vegetables instead of raw, avoiding high-fiber foods, removing skins from fruit or vegetables, avoiding fatty meats and high-fat foods.) Also, walking after meals may help to increase stomach motility. b. If the vomiting/nausea is due to acid reflux or reduced stomach motility, eating more small meals during the day (instead of several larger ones) may help. This will also help to keep blood sugar levels more consistent. c. If the vomiting/nausea is due to iron pills (or multivitamins containing iron) a slower-release form or several lower-dose iron pills may help. d. If the vomiting/nausea is due to low blood sugar, avoiding an empty stomach may help (e.g. snacking throughout the day with several smaller meals instead of a few large ones.) e. Folk remedy: Lemons, in particular the smelling of freshly cut lemons. f. Accommodating food cravings and aversions. g. Ginger, in capsules, tea, ginger ale, or ginger snaps. Safety concerns have been raised in the medical community due to the powerful pharmacological activity of ginger, especially its anticoagulant action. h. Eating dry crackers in the morning. Some women benefit from eating crackers before rising out of bed in the morning. This may be because it helps to absorb the stomach acid. i. Drinking liquids 30 to 45 minutes after eating solid food. j. If liquids are vomited, sucking ice cubes made from water or fruit juice or trying lollipops.

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k. Sucking on a hard candy seems to help with nausea due to morning sickness. A doctor may prescribe anti-nausea medications if the expectant mother suffers from dehydration or malnutrition as a result of her morning sickness, a condition known as hyper-emesis gravidarum. 2.3.5 Symptoms Remember, not all vomiting may be due to the pregnancy - you can still get other illnesses such as a urinary tract infection. You should see a doctor urgently if you develop any symptoms that you are worried about and particularly if you develop any of the following: a. Very dark urine or not passing any urine for more than 8 hours. b. Stomach pains. c. High temperature (fever). d. Pain on passing urine. e. Headache. f.Diarrhea. g. Jaundice (yellow skin). h. Severe weakness or feeling faint. i. Blood in your vomit. j. Repeated, unstoppable vomiting. k. Thirst l. Dizziness or fainting. 1st Trimester Fatigue, backaches, mood swings Nausea and vomiting / morning sickness Frequent urge to urinate Dizziness 2nd Trimester 3rd Trimester Gradually getting used to Definite physical changes Stabilizing of systemic changes Physical changes begin appearing alterations Significant increase in weight Difficulty in moving around

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Snacking binges Fetal organogenesis begins

Uterus becomes more gravid Development of the fetal systems

Danger of premature labour Almost completion of fetal

Development Table 1. Summary of maternal changes during pregnancy. 2.3.6 General tips for managing morning sickness a. Eat small meals often. Skipping meals can make nausea worse. b. Drink lots of fluid between meals. c. Avoid foods with strong smells. Eating food at room temperature or cold foods can help. (Note: remember to avoid the at-risk Listeria foods like cold meats, smoked seafood, soft cheeses or left-overs that are cold or more than 24 hours old). d. Avoid spicy foods and fatty foods. 2.3.7 Other helpful tips a. Avoid caffeine-containing drinks (tea, coffee, cola). b. Ginger has been shown to help with morning sickness. Try ginger tablets, ginger lollies or ginger ale. c. Vitamin B6 may also help manage morning sickness. Speak with your pharmacist about the correct dose as too much can be harmful. d. 8. Iron supplements or iron in your pregnancy supplement may upset your stomach. In severe cases, your doctor may need to prescribe some medication to help control your nausea and vomiting. You may lose a small amount of weight because you cant eat very much or from vomiting. Do not be too concerned as this weight will usually return. However, if you are having difficulty regaining this weight or you are struggling to eat a balanced diet please speak to your doctor, midwife or dietitian. This table shows foods and drinks to try if you have mild, moderate or severe morning sickness.

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Stage of Morning Sickness Severe

Strategy Try sipping cold, clear fluids

Examples Flat lemonade/ginger ale Sports drinks, cordial, sweet jelly Ice-blocks

Keep your mouth fresh

Barley sugars, Boiled sweets When feeling a little better, Dilute fruit & vegetable juices increase the variety of drinks Weak tea, soft drinks & soda water Moderate Bonox, clear soups & broths Try to eat something plain as Plain dry biscuits or a slice of soon as you wake in the morning toast Eat small, frequent meals Eat/drink slowly & chew foods well Avoid having drinks with meals Choose high carbohydrate foods Rest after mealtimes Plain, dry crackers or popcorn Cereal or toast with spreads Plain, boiled rice/pasta Plain Mild fruit & starchy vegetables Avoid high fat, fried or spicy Use low-fat dairy foods foods Limit butter, margarine, oils Choose lean cuts of meat Try to include some low-fat, Try plain lean meat, chicken protein rich foods or fish Try cooked eggs or baked beans You may need to use high protein meal replacement eg: Sustagen, Ensure Before bed have a snack that Cheese & crackers, fruit & contains carbohydrate
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protein

and yoghurt or custard

Table 1. Summary of consumption during pregnancy. 2.4 Salivary Flow rate and PH Saliva is a watery substance located in the mouths of organisms, secreted by the salivary glands. Human saliva is composed of 99.5% water, while the other 0.5% consists of electrolytes, mucus, glycoproteins, enzymes, and antibacterial compounds such as secretory IgA and lysozyme (Fejerskov, E; Kidd 2008). 2.4.2 Salivary Glands Salivary glands are exocrine glands that have ducts empties into the oral cavity and secrete saliva with many functions and introduction assist mastication of food. Salivary glands can be distinguished according to the size and composition of the secretory unit. There are 2 type of glands according to the size, major and minor glands. And also 2 types according to composition of secretory, mucus and serous (McKinney BE, 2009). 2.4.3 Major Glands Three major glands that occur in pairs, located symmetrically on both sides of the head: Parotids, Submandibulars (sometimes referred to as Submaxillarys), and Sublinguals (Figure 2).

2.4.1 Definition of Saliva

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Figure 2. (1)Parotid Gland, (2)Subamndibular Gland, (3)Sublingual Gland Adapted form Michelle Hurlbut The parotid glands are the largest of the glands and are located subcutaneously, below and in front of the ear. The saliva is carried into the oral cavity from the parotid via the Stensens duct, opposite the maxillary second molar. Although the parotid glands are the largest, they only produce a quarter of the saliva volume. The submandibular glands lie on the medial side (inside) of the mandible, in the submandibular fossa, below the mylohyoid ridge. Each submandibular gland has a duct that runs forward through the structures in the floor of the mouth and opens via the Whartons ducts located at the lingual caruncles. The submandibular glands are the most active glands, contributing the most saliva volume. The sublingual glands are the smallest of the major glands and lie under the tongue in the floor of the mouth and contribute the least to the total saliva volume. 2.4.4 Minor Glands Minor salivary gland is a small salivary glands, located on the cheeck mucosa, lips, and palate. Some minor glands are labial, buccal , palatal, anterior lingual glands, glands van Ebner and posterior lingual glands. 2.4.4.1 Labial Glands labial glands located on the upper and lower lip sub mucosal and abundant in midline areas. Labial gland is mixed gland seromucous, where mucus is more dominant (Dubrul et al, 2000). 2.4.4.2 Buccal Glands Buccal mucous glands located on the cheek, which a continuation of the layers in the posterior labial glands. This gland is thin and irregular distances on the cheek while the anterior posterior cheeks, glands more

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numerous and widespread muscle reach buccinators. Buccal glands contain seromucous where mucus is more dominant (Short MJ, 2002). 2.4.4.3 Palatal Glands Palatal glands form a compact gland body lies in the sub mucosal layer of the hard and soft palate. In the anterior part of the palate, the gland is thin and sparse in the posterior palate, gland sub mucosal thickening and expanding reach soft palate. Palatal glands is pure mucous glands (Short MJ, 2002).. 2.4.4.4 Lingual Glands Lingual glands is divided into three glands, the glands found on the lingual anterior that is 2/3 anterior tongue and produces rich mucous saliva, Von Ebner glands located near the papilla serous circumphalate and produce saliva and lingual glands located in posterior the lingual tonsil close to 1/3 posterior tongue and produces mucous saliva (Short MJ, 2002). Salivary secretions are classified as serous, mucous, or mixed. As the name implies, serous secretions contain more water than mucous. Each gland produces a different type of saliva (Table II). When salivary flow is unstimulated, such as in resting saliva (RS); the parotid, submandibular, sublingual and minor salivary glands contribute approximately 25%, 60%, 7%-8%, and 7%-8% respectively to the whole saliva volume.38-39 The flow rate of RS for all three glands is very low, approximately one-tenth of that during stimulated flow (McKinney BE, 2009) The total amount of saliva secreted varies among individuals and environmental factors. Salivary flow is greater standing vs. sitting as well as during cool weather compared to hot weather. In addition, saliva is subject to a circadian rhythm, with the highest flow in mid-afternoon and the lowest around 4:00 AM.40 Approximately 0.5 1.7 liters of saliva is secreted into the oral cavity each day (Mese H, Matsuo R. 2007). Mucous (slime) is a saccharide glycoprotein called mucin. With water it makes the slippery lubricant used in many parts of the body, where it lines the moving parts, surfaces and tubes. Here it lubricates the mouth, throat and

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alimentary canal. The mucous also has antiseptic qualities: it contains lysozyme and immunoglobulins. Mucous, with its antiseptic molecules and slime, traps fungi, bacteria and viruses and prevent infections. The body produces about a liter of mucous per day, in the mouth and other places. The serous fluid contains the enzyme amylase which acts in the digestion of carbohydrates. Minor salivary glands on the tongue secrete the amylase. The parotid gland produces purely serous saliva. The other major salivary glands produce mixed (serous and mucus) saliva. Another type of serous fluid is secreted by the two layered serous membranes which line the body cavities. The serous fluid between the two layers acts as a lubricant and reduces friction from muscle movement 2.4.5 Flow rate Salivary flow rate is determined by measuring the amount of stimulated saliva (SS) produced in a given period of time. Usually, a patient is provided a piece of unflavored wax which he or she chews for five minutes. All saliva produced during this time is collected and measured. Dividing the amount of saliva produced by the time provides the stimulated flow rate. A patient can subjectively look or feel xerostomic, but until the flow rate is quantitatively measured, a conclusion that the patient has salivary gland hypo function cannot be made. For a salivary gland hypo function diagnosis, one would have to have less than 0.7 ml/min of flow. Since a sample of SS has been collected, it is an ideal time to further test for saliva buffering capacity and use the saliva sample to culture MS and LB. 2.4.6 Viscosity Viscosity of the saliva relates to its thickness and is determined during the intra-and extra-oral examination. Here the clinician should assess the patency (unobstructed), consistency, and flow of the saliva. Saliva is 99% water and should look like water; not thick and stringy or frothy and bubbly. A low resting pH (less than 6.6) indicates lack of proper salivary quality and demineralization of tooth structure could occur. Since most people do not stimulate their saliva in-between meals, the resting pH becomes a valuable

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tool in correcting the intra-oral chemistry of the individual patient. 2.4.7 Function Saliva plays a critical role in the maintenance of optimal oral health and the creation of an appropriate ecologic balance. The function of saliva includes: a. Lubrication and protection of oral tissues b. Buffering action and clearance c. Maintenance of tooth integrity d. Antibacterial activity e. Taste and digestion Saliva contains electrolytes such as sodium, potassium, calcium, magnesium, bicarbonate, phosphate, as well as, immunoglobulins, proteins, enzymes, mucins, urea, and ammonia. These components help to modulate: 1) the bacteria attachment in oral plaque biofilm; 2) the pH and buffering capacity of saliva; 3) antibacterial properties and; 4) tooth surface remineralization and demineralization. These various components give saliva its overall quality and character. With the recent emphasis on the extended ecological plaque hypothesis, most noteworthy are salivas pH and buffering capacity. The pH can be either acidic or basic, and the buffering capacity stabilizes the salivary pH. In other words, as buffering capacity increases, the pH of the mouth fluctuates less. When the pH of the mouth decreases (or becomes acidic), cariogenic bacteria are likely to thrive(Humphrey SJ, Williamson RT. 2001). 2.4.8 Hyper salivation Hyper salivation (also called ptyalism and sialorrhea ) is excessive production of saliva. It has also been defined as increased amount of saliva in the mouth, which may also be caused by decreased clearance of saliva. Hyper salivation can contribute to drooling if there is an inability to keep the mouth closed or in difficulty in swallowing the excess saliva. Hyper salivation also often precedes emesis (vomiting), where it accompanies nausea (a feeling of needing to vomit) (McKinney BE. 2009). Cause of hyper salivation include
a. Rabies

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b.Gastroesophageal

reflux disease, in such cases specifically called a water

brash, and is characterized by a sour fluid or almost tasteless saliva in the mouth
c.

Pregnancy starch intake

d.Excessive

e. Pancreatitis f. Liver

disease syndrome ulcers

g.Serotonin h.Mouth i. Oral

infections

2.4.9 Hypo salivation The salivary glands derive their fluid from the circulating blood. This fluid, with its electrolytes and small organic molecules, is modified by the glands and, together with the macromolecules synthesized by the gland cells, secreted into the oral cavity. Secretion occurs in response to neural stimulation. Disturbances of the blood supply to the gland, of its secretory apparatus, or of the stimuli that elicit secretion may lead to a decrease in the production of saliva. As mentioned earlier, a person experiences oral dryness when the volume of saliva decreases to about half the normal flow rate; in xerostomia, the most extreme form of dry mouth, the decrease is significantly greater. For the resting flow of saliva to fall to such a level, more than one gland must be affected. The loss of activity of a single gland, observed in patients with salivary gland tumors and of sialoliths, does not result in oral dryness. Thus, xerostomia is the result of multiglandular salivary hypo function, frequently as a result of the intake of xerogenic drugs, therapeutic irradiation, or certain systemic conditions. Age and decreased mastication may also contribute to the feeling of oral dryness. The most common causes of salivary gland hypo fuction. 2.4.10 Conclusion Saliva plays an important role in optimal oral health and new research suggests that salivary pH is even more critical to the development and progression

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of dental caries than once thought. Science suggests it is pH, rather than sugar, which is the selective factor for cariogenic plaque biofilms. Low salivary pH promotes the growth of aciduric bacteria which then allows the acidogenic bacteria to proliferate creating an inhospitable environment for the protective oral bacteria. This allows for a shift in the environmental balance to favor cariogenic bacteria, which further lowers the salivary pH and the cycle continues. Hyposalivation exacerbate oral health problems in pregnant women. Thick viscosity, decreases buffer capacity of saliva dramatically allowing oral ph reaches a low level, can lead to remineralization (caries), aggravating and cleansing teeth can not be performed optimally. If serous secretion is reduced, it will affect the maternal immune to infections that result as gingivitis and caries. So, saliva has an important role in oral health. 2.5 Hormone Hormonal changes that occur during pregnancy include increased concentrations of the sex hormones estrogen and progesterone, HCG and prostaglandin. 2.5.1 Estrogen Estrogen (naturally) produced mainly by the theca interna cells of ovarian follicles in the primary, and in much smaller amounts are also produced in the adrenal gland through the conversion of androgen hormones. In men, also partly produced in the testes. During pregnancy, also produced by the placenta. Serves as the stimulation of growth and development (proliferation) in various female reproductive organs. Estrogen levels increased slowly until the end of pregnancy. In early pregnancy, estrogen and is produced by the corpus luteum. Then came the turn of the function of the corpus luteum to the placenta, which occurred in the sixth week until the eighth week of pregnancy, in which the placenta acts as a novel endocrine organ. At first trimester, estrogen has increased very significantly. Estrogen levels are also increased in the state of ovulation, precocious puberty, gynecomastia, testicular atrophy, ovarian tumors and adrenal tumors. Levels will decline in the state of menopause, ovarian dysfunction, infertility, turner syndrome,

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amenorrhoea due hipopituitari, anorexia nervosa, the state of stress, and testicular ferninisasi syndrome in women. Estrogens have important biological actions that can affect other organ systems, including the oral cavity. For estrogen receptors can be found in the periodontal tissues. As a result, endocrine system imbalances may be an important cause in the pathogenesis of periodontal disease. Research conducted by Mascarenhas P has shown that changes in periodontal conditions can be associated with changes in sex hormone levels. The increase in sex steroid hormones can affect vascularization gingiva, subgingival microbiota, specific periodontal cells and local immune system during pregnancy. Several clinical and microbiological changes in periodontal tissues during pregnancy are as follows: a. Increased vulnerability of the occurrence of gingivitis and periodontal pocket depth increased. b. Increased susceptibility to infection. c. Decrease in neutrophil chemotaxis and suppression of antibody production. d. Increased number of periodontal pathogens (Porphyromonas gingivalis in particular). e. Increased PGE2 synthesis. Estrogen is produced by the placenta during pregnancy, may play a role in regulating the local immune system and help protect the developing fetus from the mother's reaction to rejection. Increased concentrations of sex hormones, namely estrogen and progesterone are also utilized by periodontal pathogens such as Porphyromonas gingivalis and Prevotella intermedia as their food source. These bacteria generally increased in sulkular gingival fluid of pregnant women, a condition that is positively associated with the severity of pregnancy gingivitis. 2.5.2 Progesterone Progesterone is the primary sex hormone of pregnancy. Levels are elevated up to the eighth month of pregnancy and become normal again after giving birth. Progesterone (natural) produced mainly in the corpus luteum in the ovary, mostly

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produced in the adrenal glands, and the pregnancy was also produced in the placenta. Progesterone causes changes in the secretory (secretion phase) on endometriumuterus, which prepares the uterine endometrium in a state of optimal case of implantation. Progesterone together with estrogen plays an important role in the regulation of female sex hormones. In women, pregnenolone is converted into progesterone or 17ahidroksipregnenolone and this change depends on the ovulation phase in which progesterone secreted by the corpus luteum in large numbers. Progesterone is also a precursor to testosterone and estrogen, during the metabolism of 17 hydroxyprogesterone into dehydroepiandrosterone were converted into 4 androstenedione 17 hydroxylase enzyme with the help of pregnenolone. Whereas progesterone secreted by the corpus luteum and placenta responsible for building the middle layer of the uterus during menstruation and pregnancy. Increased concentrations of sex hormones begins at fertilization, embryo implantation continues to occur and be maintained until the time of the birth. Progesterone is produced by the placenta during pregnancy, may play a role in regulating the local immune system and help protect the developing fetus from the mother's reaction to rejection. Lapp reported that high concentrations of progesterone during pregnancy increases the incidence of gingival inflammation by inhibiting the production of interleukin - 6 (IL-6). IL-6 stimulates the differentiation of B lymphocyte function, cells activate T lymphocytes and macrophages and NK cells, which are cells attacking role and memfagositosis bacteria into the blood circulation, so that the inhibition of the production of IL-6 resulted in less efficient gingival inflammation against attacks of bacteria. Progesterone also stimulates the production of prostaglandin (PGE2) where PGE2 is a potent mediator in the inflammatory response. By PGE2 that acts as an immunosuppressant, resulted in increased gingival inflammation when the concentration of PGE2 and high mediator PGE2. Levels are elevated in pregnancy, ovulation, ovarian cysts, adrenal tumors, ovarian tumors, molahidatidosa. And decreases in state amonorea, abortion, and

26

fetal death. Factors affecting the examination is the use of steroid hormone progesterone, progesterone, and oral contraceptives. 2.5.3 HCG (Human Chorionic Gonadotrophin) Being produced since the age of 3-4 weeks gestation by trophoblastic tissue (placenta). Levels increased up to 10-12 weeks of pregnancy (up to about 100,000 mU / ml), and then fell in the second trimester (around 1000 mU / ml), and then rose back to the end of the third trimester (about 10,000 mU / ml). Works to increase and maintain the function of the corpus luteum and the production of steroid hormones, especially during periods of early pregnancy. It may also have immunologic functions. 2.5.4 Prostaglandin Prostaglandins are derivatives of cellular membrane fatty acids and exert complex and multiple physiologic and pathologic effects. They are known to be implicated in inflammation, including periodontitis and peri-implantitis. Prostaglandin also can promote extracellular matrix destruction in the gingival and stimulate bone resorption. The determination that periodontal tissue destruction is primarily due to the host response.

2.6

Behaviour A womans pregnancy is a thing that every spouse expecting of. This kind

of good news is something that they really want to happen, indeed. Unfortunately, nowadays a woman who plans to have a baby is lack educated when it comes to keep her oral stay health. The life pattern of her pre-pregnancy is definitely important because it can impact the oral health when she hold a baby, otherwise she will have any kind of oral disease, such as gingivitis and periodontal disease. The habit of snacking a lot in pregnant woman causes a physical transformation, including oral hygiene and life pattern. 2.7 Oral Hygiene

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The pregnancy of a woman cause physically transformation of her body, including the condition of her opening. The first and the most seen transformation is the gingival. This happens due to the transformation of hormonal and vascular system with the resembling of the factors of local irritation in the opening (Burket, 1971 :Barber and Graber, 1974; Sallis dkk,1995). The increasing amount of estrogen and progesterone during the pregnancy affect the gingival, in which proliferation of capillary, dilatation of blood vessel, the increase of vascular permeability, edema, infiltration, leukocyte, and degeneration of epithelium cells are microscopically visible (Mustaqimall, 1988). The casual of a pregnant woman that has to undergo the morning sickness or feeling queasy and followed by vomiting in the morning can make her oral health becomes poor. This sickness makes the email of teeth erupted due to the acid increasing of saliva and this condition also increasing the risk of caries. 2.8 Life Pattern When a woman holds a baby, she usually snacks all the time. That one thing that connects this with her oral health is the snacks are highly containing sugar (Forest, 1995). The frequencies of queasiness and about to vomit make her too lazy to keep her oral stay healthy. Due to this situation, the acid attack from plaque be accelerated by the acid from saliva and simplified the process of caries (Forest, 1995). The side effect of the acid situation of her mouth causes not only caries, but also gingivitis and other periodontal diseases. Casually, a pregnant woman will come to a dentist and tell him that her gingival inflamed. This is normal due to the transformational hormone system. On the other side, the lay pregnant woman will ignore this and keeps the poor oral health. In fact, she will be lazier to brush her teeth because her gingival will bleed. This will amass plaque and aggravating the situation in her mouth. As a matter of fact, pregnancy is not directly cause caries to a woman. The increasing risk of caries during pregnancy happens due to the transformation of oral condition and lack of good treatment (Burket, 1971 ; Forest, 1995). If there are no preventive actions pre-pregnancy, the grievance of oral diseases will increase. The systemization of good life pattern for oral health is something

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important. As an example, if a pregnant woman suffers from a gingival gravidarum (gingivitis during pregnancy), the baby she holds will infected. A study suggests that oral disease in a pregnant woman stimulates prostaglandin, a hormone in which stimulates activity of uterus to contract and makes the risk of premature baby born. During pregnancy, it is necessary to make an optimal and good condition of oral health. Doing a plaque control is a good thing to do to prevent gingivitis of local irritation, unstable hormonal trouble, and another mouth disease during pregnancy. There are some important things for a pregnant woman to know to keep her oral stay healthy due to avoiding from oral disease during pregnancy, such as: a. Right after a pregnant woman vomits, clean the inside of the mouth with brushing teeth or gargling. b. Make a good food and life pattern by consuming fruits and vegetables and avoiding cariogenic foods. c. Brush the teeth regularly with the right method. d. A pregnant woman must have her oral condition examined by a dentist. This is not a contra-indication thing. e. It is suggested that right after a pregnant woman meals, she better chewing a gum with the amount of 67% xylitol for about a minute. By chewing a gum, the condition of the oral will be refreshed and become healthier.

CHAPTER III DISCUSSION

3.1 Oral Health During Pregnancy

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In the first month of pregnancy due to increased production of the hormone estrogen which provoke an increase in the acidity of the stomach. If the frequency of nausea and vomiting more often in the morning, it's because of the distance between dinner time with a long breakfast. As a result, an empty stomach secrete gastric acid that makes the mother feel more nauseous. In addition it is a factor of HCG (Human chorionic gonodotropin). This hormone produced by the placenta (afterbirth) during early pregnancy. Changes in the mothers body are then triggered by hormones cause nausea. Placental function as circulating and giving food to the fetus will grow to a maximum when the age of 12-14 weeks gestation. At this time usually nausea, vomiting will stop. The cells of the placenta attached to the uterine wall was initially rejected by the body because it is considered as foreign. Immunological reactions that trigger reactions. Changes in liver glycogen metabolism due to pregnancy are also considered as a cause of nausea and vomiting. However, after adjusting for placental cells and occurs compensation glycogen metabolism in the body, then the nausea goes away. The cause of hyper-emesis gravidarum is one of them, the hormone HCG excessive. It may also be due to maternal adaptation in hormones that occurs during pregnancy is not good. Adaptability of pregnant women, in fact it is very idiviudal as well as allergic reactions. Enzyme disorder also expected to cause nausea, vomiting excessively. Ulcer, for example, can aggravate the condition of nausea and vomiting in pregnancy. This may be contrary to the theory that if mothers with mag, then during pregnancy pain will disappear. The assumption, pregnancy making bowel movements slow to follow gastric emptying was so slow. Such a situation is in some mothers can create pain magnya no recurrence during pregnancy, but there is also a permanent ulcer. This is due to the wrong diet. For example, pregnant women often eat salad when the stomach is empty. As a result, increases stomach acid. The hormones that seem to have the most to do with this process include the pregnancy hormone human chorionic gonadotropin (HCG), estrogen, and progesterone. Abnormal levels of thyroid hormones have also been reported in

30

women with severe vomiting, although a cause-and-effect relationship remains unclear. Some studies have shown that nausea is worse when your blood sugar level is low. Women who are more likely to have nausea from birth control pills, migraines, or motion sickness are at higher risk for nausea and vomiting in pregnancy. Thyroid function in early normal pregnancy was evaluated with reference to morning sickness using a newly developed free thyroxin (T4) radioimmunoassay and a highly sensitive TSH immunoradiometric assay. A significant increase in serum free T4 and a decrease in serum TSH were observed in early pregnancy relative to the levels in non-pregnant controls. The increased free T4 and HCG and decreased TSH correlated with the severity of morning sickness, and these changes were especially marked in subjects with nausea and vomiting. The individual serum levels of HCG in the pregnant group correlated significantly, directly with the levels of free T4 and inversely with those of TSH. The increased free T4 and decreased TSH in subjects with emesis returned to the normal ranges of non-pregnant controls after improvement of emesis. These data indicate that the thyroid gland is physiologically activated in early pregnancy, possibly by HCG or a related substance, which may induce gestational emesis. On the other hand, an increased level of free T4 and a reduced level of TSH in early normal pregnancy are not indications of thyrotoxicosis and may not necessitate anti-thyroid drug treatment. Hyper salivation occurs frequently in pregnant women, where as the incidence of duodenal ulcers in such cases is very low. The nature of the "oral regression" in ulcer patients and in pregnant women is discussed. In the first instance, the regressive intensification of oral-instinctual impulses results from unsuccessful mastery of interpersonal conflicts and is thus interpreted as a pathologic phenomenon. In pregnant women, however, oral regression is the result of primarily internal physiologic changes and is interpreted accordingly as a normal concomitant of pregnancy. This difference in the nature of the oral regression may account for the very low incidence of duodenal ulcers in pregnant women.

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3.2

Relationship between Pregnant Women and Oral Health Disease The relationship between gingival changes with pregnancy experts say

3.2.1 Relationship Between Pregnant Women With Gingivitis pregnancy usually manifests towards an increased incidence and severity of gingivitis. But pregnancy itself is not causes gingivitis. Gingivitis in pregnancy is caused by plaque bacteria, similar to the non-pregnant state. Therefore, no change in the gingival during pregnancy when there is a cause local factor. In addition, a significant factor during pregnancy, it is an increase in the hormone estrogen and especially progesterone, which can lead to high degrees of severity of gingivitis. Clinical features of gingivitis in pregnant women, gingival inflammation and the color will experience will vary between red till bright bluish red. Marginal and interdentally areas having edema, hyper plastic, smooth and shiny surface, some fruits such as mulberry, common inflammation of the gingival when brushing your teeth or chewing food thoroughly can change and local. Gingivitis occurs during the first trimester of pregnancy, when it happens over and gonadtrophin production in the third trimester it will happen increased estrogen and progesterone. This hormone factors exacerbate the gingival response to local factors. The interaction of bacteria with hormones can alter the composition of the plaque, which causes gum inflammation. Increased hormone progesterone was associated with gingival vasodilatation of blood vessels, static circulation and increased susceptibility to mechanical irritation. The hormone progesterone causes pronounced effects on micro vascular gingival, capillary permeability changes and additions krevikuler fluid flow. The degree of severity of gingival inflammation during pregnancy also influenced the development of anaerobic microbial flora krevikuler fluid. Microbial changes that occur because the hormones estrogen and progesterone hormone affects growth factor pathogenic bacteria in periodontal tissues. So the relationship between pregnant women with gingivitis caused by local factors and hormones, namely estrogen and progesterone hormone. 1. Hormonal changes during pregnancy Hormonal changes that occur during pregnancy include increased concentrations of sex hormones, namely estrogen and progesterone.

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Progesterone is the primary hormone of pregnancy sex. Levels are elevated up to the eighth month of pregnancy and normal until become the baby was born. In early pregnancy, estrogen and progesterone produced by the corpus luteum. Then came the turn of the function of the corpus luteum to the placenta that occurs in the sixth week until eighth week of pregnancy, in which the placenta acts as a novel endocrine organ. At the end of the third trimester, progesterone and estrogen reaches its peak of 100ng/ml and 6ng/mg which are 10 and 30 times higher than the concentration at the time of menstruation. Estrogen is secreted by the ovaries and placenta plays an important role in the development and maintenance of secondary sex characteristics and uterine growth. Whereas progesterone secreted by the corpus luteum and placenta, responsible for building the middle layer of the uterus during menstruation and pregnancy. Increased concentrations of sex hormone begin at fertilization, embryo implantation continues to occur and be maintained until the time of birth. Estrogen and progesterone have important biological actions can affect other organ systems, including the oral cavity. Receptors for estrogen and progesterone can be found in the periodontal tissues. As a result of endocrine system imbalances may be an important cause in the pathogenesis of periodontal disease. Research has shown that changes in periodontal conditions may be associated with changes in sex hormone levels. The increase in sex steroid hormones can affect vascularization gingival, sub gingival microbiota, specific periodontal cells and local immune system during pregnancy (Mascarents P, et al, 2000). Several clinical and microbiological changes in periodontal tissues during pregnancy are as follows: a. Increased vulnerability of the occurrence of gingivitis and periodontal pocket depth increased. b. Increased susceptibility to infection. c. Decrease neutrofil chemotaxis and antibody production emphasis.

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d. Increased number of periodontal pathogens (especially Porphyromonas gingivitis) e. Increased synthesis of PGE. 3.2.2 Relationship Between Saliva Ph With Gingivitis The flow of saliva can reduce the accumulation of plaque on the tooth surface as well increasing ability cleaning action of the oral cavity. When the amount of salivary secretion decreases, it will cause the frequency of dental caries will increase. The degree of salivary pH and buffer capacity is always affected by the changes caused by: a. Rhythm of day and night High buffer capacity immediately after waking up, but then quickly dropped, high quarter of an hour after a meal (mechanical stimulation) but usually within 30-60 minutes down again, slightly up until tonight, after it went down. b. Diet Carbohydrate diet for example, lowering the capacity of the buffer while ainterdiet rich in vegetables and protein-rich diet has the effect of increasing the capacity of the buffer. c. Stimulation of secretion rate Salivary secretion regulated by the nervous system. Stimulation of the sympathetic nerve that would cause the glandular salivary secreation vascontruction bit and organic components in saliva increases. Stimulation of the parasympathetic nerve will cause vasodilatation so that secretion of salivary glands into lots, and dilute organic components in saliva slightly.

d. Plaque Plaques were in contact with dietary sugars (carbohydrates) will be fermented by bacteria that produce lactic acid Palk which can lower the salivary pH to reach critical point.

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The relationship between salivary pH with gingivitis is due to the presence of plaque, plaque is the organism or a layer of software that deposits on the tooth surface, which includes the substances interbacterial extracellular polysaccharides, enzymes, endotoxins and antigens. Antigen on these plaques stimulate an immune response and cause tissue damage. Dental plaque microorganisms that release the active biology components lipopolysaccharide, chemotactic peptide and fatty acids. These components stimulate gingival epithelial cells produce a variety for active biological mediators dominated by citoxin. Gingival epithelium also responds to the components of plaque microorganisms by inducing the body's defense system by producing antimicrobial peptides. In addition, salivary defense system works to limit the growth of bacteria through saliva flow flushing action that cleans bacteria from the surface of the oral, factor bacteria, antimicrobial proteins, and others. While a woman is having an unusual habit with it because of his habit of snacking and do not want to brush my teeth, so that it will accumulate causing plaque salivary pH will drop and cause of the occurrence of gingivitis is also influenced by the hormones estrogen and progesterone. 3.2.3 Relationship Between Ph Saliva With Caries The relationship between the pH of saliva with caries is the case when the caries process. Where clean surfaces in contact with saliva, forming layer glycoprotein pellicle effect absorption of saliva on the tooth surface. Absorbption occurred cause the presence of gravity - attraction between salivary glycoprotein, then microorganisms stick above pellicle. With the presence of sucrose, forming an extracellular polysaccharide (dextran) and intracellular (levan) by Streptococcus mutans which dextran adhesives plaque on teeth and levan are nutrient reserves. Action of various types of microorganisms that ferment carbohydrates into acids that cause a reduction in pH immediately after 3-5 minutes consuming sucrose. The acid formed as a result of metabolism, microorganisms resulted in the process of demineralization of dental hard tissues and destruction of organic materials teeth.

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According to Stephan, plaque pH decrease was greater in individuals with active caries than caries-free. Patients with active caries found at pH 5, which is called the critical pH. At pH 6 to 6.5 all microorganisms can form acid, but the highest activity was kind of streptococci. Below pH 5 types of streptococci and lactobacillus can still produce acid to pH 4.5 and below pH 4.5 only type of Lactobacillus can survive and produce acids. Protection by way of saliva to prevent caries is 1. Forming a layer of mucus as a protective barrier against irritants and Prevent dryness. 2. With irrigation saliva, will help cleanse the mouth of food debris, cell debris and bacteria that would eventually inhibit plaque formation. 3. Adjust the pH balance of the mouth with the content of bicarbonate, phosphate and protein amfoter. Increased salivary secretion rate will raise the pH and buffer capacity of saliva. In a situation where there is decreasing pH, resulting from acidogenic organism metabolism, will be inhibited. 4. Able to help maintain the integrity of the tooth with the content of calcium and phosphate in saliva with caries remineralization road is still early to be increased if given fluorine. 5. Capable of antibacterial activity in the presence of specific antibodies, enzymes, lactoferrin and lactoperoxidase. Afonsky (1961) discuss the relationship between saliva with caries. According to individuals who have a lot of caries, will have a low pH of saliva. This is due to the increasing number of microorganisms will improve results in the form of acid metabolism. Newbrun (1978) and Rider (1982) believe that the pH of saliva affects to the works caries process. And according Newbrun (1983), the low pH of saliva, microorganisms can thrive. In contrast, at high pH can prevent dental caries. 3.2.4 Relationship Between Morning Sickness With Caries Complained of nausea and vomiting by about three-quarters of pregnant women, usually occurs during the first trimester. Usually accompanied by nausea and vomiting many complaints spit (hyper salivation), dizziness, abdominal

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bloating, and the body feel weak. Complaints are generally known as "morning sickness" because it was heavier in the morning. However, nausea and vomiting can last all day. The flavor and the intensity are often described like nausea and vomiting due to cancer chemotherapy. Hyper emesis gravidarum can be clinically classified into three levels, is a. Level I Hyper emesis gravidarum is characterized by a level I continued vomiting accompanied by intolerance to eating and drinking. There are weight loss and epigastric pain. First of all contents are regurgitated food, and mucus and a little bile, and when it's time to get out of blood. Pulse rate increased to 100 beats / min and systolic blood pressure decreased. Examination reveals sunken eyes, dry tongue, decreased skin turgor, and urine slightly reduced. b. Level II Hyperemesis gravidarum II levels, patient vomited everything eaten and drunk, rapid weight decreased, and there is a great thirst. Pulse rate 100140 beats / min and systolic blood pressure less than 80 mmHg. Patients seen apathy, pale, dirty tongue, sometimes jaundice, and found acetone and bilirubin in urine. c. Level III The condition is extremely rare with stage III, characterized by reduced or even stopped vomiting, but decreased consciousness (delirium to coma). Patients experienced jaundice, cyanosis, nystagmus, heart problems was found in the urine billirubin and protein. Nausea in the first months of pregnancy due to increased production of the hormone estrogen which provoke an increase in the acidity of the stomach. If the frequency of nausea and vomiting more often in the morning, it's because of the distance between dinner time with a long breakfast. As a result, an empty stomach secrete gastric acid that makes the mother feel more nauseous. This proves that excreation on a asam lambung or HCG hormone and also influenced by estrogen dan progesteron hormone can causes hypersalivation( secretion of much salivary) and happen nausea, can called

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morning sickness. After happened nausea, oral condition become acidic. So, can influence pH salivary become acid and impact of the demineralization or caries. 3.2.5 Relationship Oral Hygiene With Life Pattern Oral hygiene is an oral hygiene and is an act to clean your teeth and mouth and gums (Clark, 2005). According to Clark, 2005 aims to prevent oral hygiene for oral disease, prevents disease transmission through the mouth, increase endurance and improve the function of the mouth to enhance appetie. While the pattern of life of a pregnant woman is pregnant it's likely lazy to do an activity that they think is not important, for example, do not brush your teeth every day In addition, a pregnant woman usually likes to things that are able to snacking without rinsing and brushing his teeth . The relationship between oral hygiene with a lifestyle that is owned by pregnant women with such unnatural habits like snacking every day so make lazy to brush my teeth. This will affect the cleanliness of the mouth, if the continuous snacking without rinsing or brushing is not the mouth hygiene will be vulnerable to oral disease such as gingivitis. As a result of excessive snacking of these women it will gathering bacteria - bacteria that will happen and continue to accumulate plaque becomes tartar and get away in gingival and there such thing as gingivitis. 3.2.6 Relationship Plaque With Gingivitis Dental plaque is a soft deposit form biofilms, attached to the tooth surface or the surface of the cavity a soon scrambled hard, especially supragingival area a third of gingival and sub gingival especially on rough surfaces, holes or edges overhanging restorations. Dental plaque grayish white, yellow and has a globular surface. Dental plaque is seen on the surface of the tooth after 1-2 days did not do the cleaning of the mouth. Movement and shifting network of food material to the tooth surface during chewing mechanical plaque removal resulted in two-thirds of the coronal tooth so specific plaque seen in gingival third. Plaque is a cause of gingivitis. Plaque is also an irritant local and systemic factors that affect the occurrence of gingivitis. Once plaques appeared, pregnant

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women that will clean teeth, but at the time it, wrong to brush his teeth and the gingival. So based on the above description, it affects the occurrence of gingivitis is plaque, the most dominant factor in the occurrence of gingivitis due to plaque as a local irritant factor. 3.3 Eat Healthy Pregnant Women Pregnancy is an important event in the life of a woman and her family to obtain offspring. Pregnancy is a physiological process that can lead to changes the female body, both physically and psychologically (Hamilton, 1995). The changes that occur during pregnancy due to a change in the amount of estrogen and progesterone increase thus affecting the condition of the mother. Therefore, usually the mother during pregnancy had a variety of complaints such as pain, nausea, vomiting, including complaints and toothache mouth. The condition of the teeth and mouth pregnant women are especially visible in the gingival enlargement is often characterized by gums that bleed easily due to changes in the hormonal and vascular factors in conjunction with the local irritation in the oral cavity (Adyatmaka, 1992). Gingivitis is an inflammation of the gingival usually caused by the accumulation of plaque. Clinically gingivitis is often marked by a change in color, change shape, and consistency changes (plasticity), changes in texture, and bleeding of the gums. Gingivitis is a disease that often in the society, because it can strike all ages and genders. In women gingivitis can become more severe when the woman is pregnant or called Pregnancy Gingivitis during pregnancy. Hasibuan (2007), states that the term of pregnancy gingivitis is made to describe the clinical gingival inflammation that occurs in most pregnant women. Gingival changes seen in pregnancy usually begin two months of age, and will reach its peak in the eighth. It is caused due to an increase in the hormones estrogen and progesterone during pregnancy, as well as the vascular response that causes excess to local irritation factor. Manson (1993) says that many factors such as the cause of gingivitis, plaque, oral hygiene status, irregular arrangement of teeth, dental caries, use orthodontic wire, oral breathing habits, and smoking. Richard (2009) states Fusobacterium fusiformis are bacteria that are normally

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present in the mouth, but if allowed to proliferate, can cause gingivitis. Prevention of gingivitis should be done as early as possible by pregnant women to prevent gingivitis and the risk of LBW births. Setiono (2004), by maintaining proper oral hygiene, including regular brushing action, the use of dental floss to clean between teeth, rinse your mouth with antibacterial solution, and the removal of the remains of food stuck between the teeth, as well as regularly during their pregnancy KIA is to poly and poly teeth, to prevent gingivitis during pregnancy. As a precaution, pregnant women should gingivitis started paying attention to oral hygiene and consuming foods that contain high fiber, such as vegetables and fruits. The food should be consumed and avoided by pregnant women to prevent gingivitis is: 1. Avoid too much intake of sugar. This is not to say that one should avoid foods that naturally contain sugar. One may still continue consuming such foods because the sugar in them are easily digested and can be absorbed by the body easily. What one should avoid are foods wherein sugar is added. 2. When eating, choose crunchy foods over soft foods. Crunchy foods crumple when ground by the teeth, leaving little of the food particles to be caught in between teeth. Compared to soft foods, crunchy foods contribute little to having gingivitis. This is because soft foods tend to get caught in between teeth and promote bacterial growth. 3. Eat plenty of fruits and vegetables, especially those that are rich in fiber. Foods that are rich in fiber help boost the immune system of the body, making it more resistant to periodontal diseases. 4. Consuming a balanced diet helps prevent gingivitis and keep your gums and teeth healthy during pregnancy. Vitamin C, found in citrus fruits, bell peppers, strawberries and tomatoes, is especially important for preventing and treating gingivitis in pregnancy because it reduces bleeding and strengthens the gums. Contrary to popular belief, added calcium in the diet during pregnancy does not prevent tooth problems. The body does not take calcium out of teeth to give it to the baby, but it

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does take it from bones, so calcium intake is still important for that reason. 5. Avoid chewy sweets and dried fruit, since these can stick to your teeth and increase the chances of gum problems. 6. Brushing your teeth twice a day and using floss to clean between your teeth are necessary to keep your teeth and gums free of plaque. Visit a dentist before becoming pregnant to get any major procedures you need done completed at that time. 7. Also visit your dentist during your pregnancy so he can assess the state of your mouth and make sure that gingivitis or periodontitis has not taken hold. 3.4 Treatments During pregnancy, womens bodies undergo complex physicological changes that can adversely affect oral health. For this reason, health professionals need to ensure that the pregnant women they serve receive needed oral health care. 3.4.1 Prenatal Care Health Professionals 1. Assess Pregnant Womens Oral Health Status Ask the following questions during the first prenatal visit: a. Do you have bleeding gums, a toothache, cavities, loose teeth, teeth that dont took right, or other problems in your mouth? b. Have you had a dental visit in the last 6 months?

2.

Advise Pregnant Women about Needed Oral Health Care a. If the last dental visit took place more than 6 months ago or if any oral problems (e.g., toothache, bleeding gums) are identified, tell women to schedule an appointment with a dentist as soon as possible.

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b. Encourage women to improve or maintain good oral health during pregnancy and to attend prenatal classes. c. Counsel women to adhere to their dentists recommendations for treatment or follow-up. 3. Improve Access to Oral Health Services a. Provide information about oral hygiene and oral health care by including oral health topics in prenatal classes and making available educational materials that are written at appropriate reading levels. (See Resources.) b. On the patient intake form, include an oral health assessment that identifies problems and offers recommendations. c. Provide referrals as needed. (See Appendix A: Referral Form for Pregnant Women to Receive Oral Health Care.) d. Provide a list of dentists in the community, including those who accept Medicaid and other public insurance programs. 3.4.2 Oral Health Professionals 1. Improve Access to Oral Health Services a. Reduce practice-level barriers (e.g., long waits for available appointment dates, long waits in the dental force waiting room). b. Accept patients enrolled in Medicaid and other public insurance programs. c. Reduce system-level barriers (e.g., contact community based programs such as the Special Supplemental Nutrition Program for Women, Infants and Children [WIC] that serve pregnant women to create partnerships). 2. Conduct Health History, Risk Assessment, and Oral Examination a. Ask weeks of gestation (due date). b. Implement best practices (e.g., as presented in Caries Diagnosis, Risk Assessment, and Management Protocols) in caries risk assessment and management. (See Resources.) 3. Improve Access to Oral Health Services a. Integrate oral health topics into prenatal care classes.

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b. Make available educational materials that are written at appropriate reading levels. (See Resources.) c. Provide referrals as needed. (See Appendix A: Referral Form for Pregnant Women to Receive Oral Health Care.) d. Help women complete applications for insurance coverage or social services, or for securing other necessary services such as transportation. e. Help women access oral health care, as needed. a. Provide a list of dentists in the community, including those who accept Medicaid and other public insurance programs. b. Contact a dental clinic to facilitate care. f. Help women make decisions about oral health care and communicate information to their dentist. g. Perform a comprehensive gingival and periodontal examination, which includes a periodontal probing depth record. h. Take X-rays as needed. i. Consider the following when developing a treatment plan: j. Chief complaint (if any). Medical history.

History of tobacco, alcohol, and other substance use. periodontal examination.

k. Findings from the clinical evaluation, including the gingival and

4. Assist Pregnant Women with Disease Management a. Develop and discuss a comprehensive treatment plan that includes preventive and maintenance care based on an evaluation of the benefits, risks, and alternatives. b. Educate pregnant women about care that will improve their oral health. c. Complete all necessary dental procedures before delivery. d. Prioritize treatment for untreated caries. e. Consider recommending the following as strategies to decrease maternal cariogenic bacterial load: Use of fluoride toothpaste and mouth rinse.

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 5.

Use of chlorhexidine mouth rinse and fluoride varnish as appropriate. Use of chewing gum or mints that contain xylitol.

Use the Following When Clinically Indicated: a. X-rays with thyroid collar, and abdominal apron. b. Local anesthetic with epinephrine. c. Appropriate analgesics and/or antibiotics. d. Dental amalgam with proper isolation and high-speed evacuation.

6.

Position Pregnant Women Appropriately During Treatment a. Keep the head at a higher level than the feet. b. Place a small pillow under the right hip, or have women turn slightly to the left to avoid dizziness or nausea.

7.

Consult with the Prenatal Care Health Professional a. Consult with the prenatal care health professional when considering the following: Deferring treatment because of pregnancy. Co-morbid conditions or medication use (e.g., diabetes, hypertension, Heparin use) that may affect management of oral problems. Intravenous sedation or general anesthesia to complete dental Procedures.

8.

During Pregnancy: 1. Brush teeth with fluoridated toothpaste twice a day, and floss once a day. 2. Limit foods containing sugar to mealtimes only. 3. Drink water or low-fat milk. Avoid carbonated beverages (pop or soda). 4. Choose fruit rather than fruit juice to meet the recommended daily intake of fruit. 5. Obtain necessary oral treatment before delivery: a. Diagnosis (including necessary dental X-rays) and necessary treatment can be provided throughout pregnancy; however, the period between the 14th and the 20th week of pregnancy is the best time to receive treatment.

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b. Treatment for conditions requiring immediate attention is safe during the first trimester of pregnancy. Delaying necessary treatment could result in significant risk to you, and indirectly to your baby. 6. for frequent nausea and vomiting: a. Eat small amounts of nutritious foods throughout the day, if possible. b. Chew sugarless or xylitol-containing gum after meals. c. Rinse your mouth with a teaspoon of baking soda (sodium bicarbonate) in a cup of water after vomiting, to neutralize acid. d. Gently brush teeth with fluoridated toothpaste twice a day to prevent damage to demineralized tooth surfaces.

CHAPTER IV CONCEPTUAL MAPPING

4.1 Conceptual Mapping

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Pregnant Woman on The First Trimester

Matern al Conditi on Hormo nal Exchan ges Mornin g Sicknes s Increasi ng of Oral Acid

Behavio ur Lazy to Brushing Teeth

Life Patter n Snacki ng

Fluctuations in Estrogen and Progesteron e Levels

Bad Oral Hygine Bacterias metabolis m Pain and Swollen Gum, Easy Bleeding Gingiviti s Gravidar um Plaque Calculus

Carie s

Increased Depth of Periodo Pocket / teeth ntits regardless of the gums During pregnancy, there are fluctuations in estrogen and progesterone levels

in combination with changes in oral flora and a decreased immune response the increased level of progesterone in pregnancy causing bacteria to grow, as well as make gum tissue more sensitive to plaque and exaggerate the body's response to the toxins (poisons) that result from plaque http://www.webmd.com/oral-health/pregnancy-gingivitis-tumors
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The mechanism of dental caries starts with a plaque on the tooth surface. Sucrose (sugar) from food debris and bacteria attach to proceed given time turns into lactic acid which lowers the pH of the mouth becomes critical (5.5). This causes demineralization of dental caries continues to be email. PH decrease repetitive within a specified time will result in a susceptible tooth surface demineralization and caries process begins from the tooth surface (pits, fissure and interproximal areas) extends to the pulp. 4.2 Hypothesis We explain that disease is gingivitis especially gingivitis gravidarum,

because the symptoms from the scenario same with symptoms of gingivitis gravidarum there are morning sickness, swollen and bleeding gums, and also caries. And gingivitis gravidarum disease only happens on pregnant women. We not choose periodontitis disease because in the scenario no mention dislodged teeth symptom, so the symptoms of scenario different with the symptoms of periodontitis disease

CHAPTER V CONCLUSION AND SUGGESTION 5.1 Conclusion In the first trimester of pregnancy until the third period of pregnancy pregnant women often gingivitis disease. This situation is caused by the hormonal activity of the hormone estrogen and progesterone. Greater influence of

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progesterone on the inflammatory/inflammation. Enlarged gum will decline in the nine months of pregnancy and the few days after giving birth. The situation will return to normal as before pregnancy. Enlargement of the gums can be the / attack on all places or places (single/multiple) forms rounded, smooth shiny, bright-red, soft consistency, bleed easily when in contact with the touch Enlarged gum in the world of dentistry called gingivitis gravidarum/pregnancy or gravidarum / hyperplasia, gravidarum often appears in the first trimester of pregnancy. The above situation is not necessarily the same for every pregnant woman. In pregnant women are encouraged to keep the OH mouth to prevent gingivitis. Provision of dental hygiene is recommended for pregnant women and other therapies, but this does not heal completely because hormone fluctuations of pregnancy are uncertain. Gingivitis will decline in the nine months of pregnancy and the few days after giving birth. The situation will return to normal as before pregnancy. 5.2 Suggestion Pregnant women usually affected gingivitis disease especially gingivitis gravidarum, so they must keep their oral health during pregnancy with many treatment for prevent or to overcome gingivitis gravidarum. Treatment for prevent from this disease with methods : oral health education this method counseling and early intervention by healthcare providers such as physicians, nurses, and dentists to provide expectant mothers with the tools and resources necessary to understand the importance of oral health care during pregnancy. Oral hygiene this method removing the bacterial plaque, which researchers have connected to preterm birth and low birth-weight babies, is essential. Using the correct brushing and flossing methods greatly increase the amount of plaque that is removed from the teeth and gums. Fluoride this method from The American Dental Association recommends the use of toothpaste with fluoride by persons over the age of six. Echoing their sentiment, the AAP oral health guidelines advise the continued use of fluoridated

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toothpaste during pregnancy, and recommends the use of an over-the-counter alcohol-free fluoride rinse to help reduce the amount of plaque in the mouth. Then, nutrition this method educating expectant mothers about proper diet and nutrition during pregnancy will limit unnecessary sugar intake and in turn, prevent plaque build up. Treating existing tooth decay these methods expectant mothers are encouraged to have existing tooth decay treated during their pregnancy, which experts believe is a completely safe practice during pregnancy. Restoring decayed teeth will help achieve oral health by removing the bacteria associated with tooth decay. Transmission of bacteria these method expectant mothers are discouraged from sharing food and utensils in order to prevent the transmission of the bacteria known to cause tooth decay. And use of xylitol gum this method expectant mothers are encouraged to chew xylitol gum (four times a day) as research suggests that chewing this gum may decrease the rate of tooth decay in children. If pregnant women affected gingivitis gravidarum, they must overcome with talk to dentist, to discuss any concerns they may have with their dentist. Women who are thinking about becoming pregnant may want to consider their oral health before becoming pregnant as research suggests that treating existing gum disease in pregnant women does not reduce the instance of preterm birth. Despite this fact, experts insist that regular oral health care should continue throughout pregnancy. On the other hand, the visit to the periodontitis during pregnancy can prevent and identify and treat the signs and symptoms of gingivitis gravidarum in the case of necessary.

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tidak berkaries, USU e-Repository , page 6-9. McKinney BE. 2009. Host defense mechanisms in the oral cavity. InHarris NO, mediated disease.Vol. 25 no.1, p;9-14 Mese H, Matsuo R. 2007. Salivary secretion, taste and hyposalivation. J Oral Rehabil.; 34(10):711-23. Morning sickness (homepage on the internet). 2012 (cited 2012 Dec 15) http://www.answers.com/topic/morning-sickness Nausea and vomiting in early pregnancy. (homepage on the internet). 2010 (cited 2012 Dec 15) http://www.health.qld.gov.au/masters/copyright.asp Pardede, Ratna. 2004. Peranan Saliva dalam Melindungi Gigi terhadap (Skripsi). Repository : Medan. P 5- 16 Karies.

Salcetti JM, Moriarty JD, Cooper LF, Smith FW, Collins JG, Offen-bacher S. The clinical, microbial, and host response character-istics of the failing implant. Int J Oral Maxillofac Implants 1997;12;3242. Short MJ. Head, neckm and dental anatomy. 3rd ed. Canada : Thomson Delmar Learning, 2002 :220-2 Sickness and Vommiting of Pregnancy (homepage on the internet).2012 (cited 2012 Dec 16) http://www.patient.co.uk/health/Pregnancy-Sickness-andVomiting.html The Journal of the American Dental Association July 2001 vol. 132 no. 7 1009 1016 Journals AFPP Vol. 77/No. 8(April 15, 2008).

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