CHAPTER I INTRODUCTION

1.1

Background Dental and oral health is something that should be viewed upon as something

of a significant matter, as they contribute to a persons overall health. Dental and oral problems could lead to unwanted pain and it can even interfere with ones social life. Pain in the teeth can be caused by a number of different factors, such as lack of hygiene in the oral cavity, lack of visits to the dentist, and lack of knowledge that can lead to bad habits. These factors are usually common among teenagers, especially teenage boys, who usually have plenty to do and have a high curiosity on things that can be detrimental to their health. Dental pain can be caused by several reasons, such as sensitive teeth (dentine hypersensitivity) and dental caries. Dental pain can usually be attributed to a sharp and painful feeling in the oral cavity that may be constant or not, sometimes the victim suffers from a fever or a headache that may be caused by the everlasting pain. Dental pain could be made worse due to complications in the periodontal tissue, periodontal issues can include gingivitis and periodontitis. Bad breath, or halitosis may also occur due to poor oral hygiene. All of these complications that happen within the oral cavity can easily be avoided just by taking simple measures that can maintain the homeostasis within the oral cavity. Diseases in the mouth area can also have an effect on someones social life, especially on a teens social life. Teenagers can be attributed with wanting a lot of friends, but when dental and oral problems occur, these problems can inhibit the teens social interaction. Problems that can be seen on a teen with poor oral hygiene is the yellowing of teeth or usually called tooth discoloration, and bad breath or sometimes called halitosis. These two problems can cause the teenager to have a low-self esteem since he or she will be shunned by his friends for having these dental/oral problems.

There are also habits that can exacerbate a persons overall dental/oral health. These so called bad habits can be lacking the common decency to have an occasional check-up to the dentist and picking up life-threatening choices, such as smoking. Teenagers whom are ignorant of their dental/oral health will usually not bother going to the dentist, this causes them to lack knowledge of what is going on within their own mouth. The teenager could have a high buildup of plaque, which is usually a source of many dental problems, and not even know it since he does not check-up with the dentist regularly. Smoking also worsens dental/oral health in that in can cause discoloration of the tooth, halitosis, and even receding gums due to alveolar bone loss. 1.2 The Purpose of Discussion The purpose of this discussion is to know what happens in the oral cavity of the 19 year old smoker boy whom feels pain when he consumes hot or cold drinks and/or hot or cold foods, also with all the boys friends avoiding him whenever he talks. The boy is also afraid of visiting the dentist, so he never or barely checks his oral hygine.

CHAPTER II REVIEW OF LITERATURE

2.1 Nineteen Years Old Boy Adolescence is the most critical time period for the human development. At this time, both teenage boys and girls experience growth in the form of physical and psychological changes. Adolescents also experience emotional changes which is apparent in the form attitude and behavior. Personality development during this period is affected by their parents and familys environment, as well as the schools environment. Other influences can stem from the rapid advances in information technology, both print and electronic media. Insight and knowledge of these things will affect the process of searching for these teenagers identity. Most women (95% of total population) reached puberty between the ages of 9-16 years, while the majority of men (95% of total population) reached puberty between the ages of 10-19 years (Brooks-Gunn & Reiter, 1990). 2.1.1 Physical Changes of Boys Men have testosterone which helps the growth of hairs around the armpits, male genitals, and the face (beard, moustache, goatee, etc), and also changes in their voices, acne formation, and sperm production at certain times that can come out as a wet dream. Other changes include: Weight and height increase Start to sweat more Skin becomes oily, sometimes with pimples and acne Hands, feet, arms, and legs become larger Hair grows under arms, pubic areas, legs, chest, and face Voice will break and deepen Shoulders and chest broaden Penis and testes continue to enlarge and lengthen Perspiration increases and body odor may appear 3

2.1.2

Psychological Changes in Boys Beside physical changes, boys also experience the psychological changes,

such as: Showing strong feelings Thinking more about right and wrong things Capable of thinking rationally and more complex Attracted or having relationship with girls Having mood swings Parents are no longer welcome to accompany in public More self-conscious

2.1.3

Social Changes in Boys These changes occur as a consequence of the effect of increasing maturity

and the way of thinking and acting upon others or the environment. However, these changes are sometimes plunged in the wrong direction.1 Some social changes experienced by men: 2.1.4 Searching for identity Boys will usually have more freedom than girls Looking for new experiences, especially when it turns to be a trend (Smoking, taking drugs, etc.) Seeking more independence Take and do risky or challenging things

Mens Periodontal Health Mens periodontal health may be poorer than that of women due to their

lack of action when it comes to oral hygiene. Research published in the Journal of Periodontology found that women are almost twice as likely as men to have received a regular dental check-up in the past year, and women were more likely than men to schedule suggested treatment following those dental check-ups. Furthermore, men have worse indicators of periodontal health than women, including higher incidence of dental plaque, tartar, and bleeding on probing. This may be because women are three times more likely to floss every day than men2 4

2.2 2.2.1

Smoking Habit Tobacco Smoking

Figure 2.2.1

It is well known that tobacco contributes to the development of health problem, including oral health. Tobacco contains chemicals that are harmful to the human body and the smoking or chewing of tobacco is the cause of 8090% of oral cancers. Other oral consequences of tobacco consumption include increased risk of periodontal disease, bad breath, tooth discoloration, an increased buildup of dental plaque, and delayed healing following tooth extraction, periodontal treatment or oral surgery. Smoking is a risk factor for several types of diseases, both locally and systemic. Tar, nicotine, and carbon monoxide are three kinds of the most dangerous chemicals in cigarette smoke. Tobacco usage produces harmful effects on every structure in the mouth such as staining teeth and slowing down dental restoration (healing), tooth decay, periodontal disease, hairy tongue, taste derangement, halitosis, premalignant lesion, oral cancer etc. The pathogenesis of these oral lesion most likely result from the many irritants of the tobacco, and also carcinogens from burning tobacco, but also arrive from the drying of the mucosa by the high intra oral temperature, pH change, alteration in immune response or altered resistance to infection. Most of these lesions are reversible after tobacco cessation. 5 Smoking can cause a decrease in the acidity of saliva, lower buffering capacity, also reduction of saliva which results in the increase of streptococcus cariogenic that may increase the incidence of dental caries. Smoking not only 5

causes systemic effects, but also can cause pathological conditions in the oral cavity. Teeth and soft tissue in the oral cavity, are parts that can be damaged by smoking. Periodontal disease, caries, tooth loss, gingival recession, pre-cancerous lesions, oral cancer, as well as implant failure, are cases that can arise from habitual smoking. The emergence of a variety of local and systemic pathological conditions in the oral cavity are caused by the decrease in the function of the molecule, including saliva.5 2.2.2. Oral Cavity The oral cavity is the easiest area that can be exposed by the effects of smoking, because it is the site of absorption of the main results of the burning cigarette. Toxic components in cigarettes can irritate the soft tissues of the oral cavity, cause mucosal infection, cause dry socket, cause slow-healing wounds, weaken the ability of phagocytosis, suppress the proliferation of osteoblasts, and can also reduce the intake of blood flow to the gingiva.6 2.2.3. Tooth Staining Smoking can cause an external tooth discoloration. At first, this stain was initially thought to be due of nicotine reaction. But actually, this was the effects of tobacco combustion products called tar. Nicotine itself is colorless and soluble. The stain is easily cleaned by a dentist because it just being in the outer surface of the teeth. But to a person who smokes cigarettes for a very long time, the stain could sink in the deeper part of the enamel layer and can be hard to clean permanently. 5

Figure 2.2.3

There are three main types of tooth discoloration: 1. Extrinsic discoloration, This occurs when the outer layer of the tooth (the enamel) is stained. Coffee, wine, cola or other drinks or foods can stain teeth. Smoking also causes extrinsic stains. 6

2. Intrinsic discoloration, This is when the inner structure of the tooth (the dentin) darkens or gets a yellow tint. The person can get this type of discoloration if: The person had too much exposure to fluoride during early childhood. The persons mother used tetracycline antibiotics during the second half of pregnancy. The person used tetracycline antibiotics when you were 8 years old or younger. The person had trauma that affected a tooth when you were a young child. A fall, for example, may damage the developing permanent tooth. The person had trauma in a permanent tooth, and internal bleeding discolored the tooth. The person were born with a rare condition called dentinogenesis imperfecta. This causes gray, amber or purple discolorations. 3. Age-related discoloration, This is a combination of extrinsic and intrinsic factors. Dentin naturally yellows over time. The enamel that covers the teeth gets thinner with age, which allows the dentin to show through. Foods and smoking also can stain teeth as people get older. Finally, chips or other injuries can discolor a tooth, especially when the pulp has been damaged. 2.2.4. Periodontal and Gum Disease Oral soft tissue abnormalities can happen due to toxic components and carcinogenic agent contained in cigarette smoke, these abnormalities include erythroplakia, leukoplakia, smokers keratosis, squamous cell carcinoma, and verrucous carcinoma. Smoker's keratosis is a white patch in the roof of the mouth (palate) of someone who is a smoker, these usually comes about from chronic contact with tobacco smoke. Smoking can stimulate melanocytes to produce melanin oral mucosa redundant. Melanin is then deposited on the basal cell layer of the mucosa, resulting in brown pigmentation of the buccal mucosa and gingiva, 7

known as smokers melanosis. Other pathological conditions in the oral cavity often found in smokers are root caries, halitosis, periimplantitis, impairment of taste, staining of the teeth or restorations, as well as periodontal disease. Periodontal diseases include the accumulation of plaque and calculus, periodontal pockets, gingival inflammation, gingival recession, and alveolar bone loss. Side effects of tobacco to periodontal tissue are related to the quantity of cigarette consumption per day and duration of smoking. Epidemiological study has proved that smoking is the main factor of periodontal disease.

Figure 2.2.4

Nicotine, as the result of cigarette combustion causes the abnormal condition of the blood vessel called vasoconstriction, although some form of vasoconstriction appear normally on the human body, vasoconstriction due to nicotine can be permanent. Blood vessels act as a nutrient and oxygen transporter, which is mainly responsible for wound healing process. Nicotine also causes the formation of periodontal pocket, reduces saliva production, causes halitosis, and can increase the risk of gingivitis. Periodontal tissue disease due to smoking begins with the accumulation of plaque on the teeth and gingiva. Tar buildup on the teeth, in addition to causing aesthetic problems, also causes tooth surface to become rough, making it easy for plaque to cling on. The accumulation of plaque on the gingival margin, exacerbated by conditions of poor oral hygiene, and the change of gingival vascularization caused by smoking causes gingival inflammation. Untreated gingivitis, can progress to periodontitis as a result of bacterial invasion of chronic plaque below the gingival margin, followed by accumulation of chronic inflammatory cells, causing loss of collagen in the 8

gingival connective tissue exposed. The loss of gingival attachment to the tooth, causes gingival recession, resulting in root caries risk. Alveolar bone and tooth loss is the most severe condition of periodontitis. 2.2.5 Tongue

Figure 2.2.5

Smoking also stimulates the filliformis papillae to become longer. The combustion of cigarette produce a brown colored substance which is easily deposited on the tongue papillae, that is why it is harder for smokers to taste sweet, bitter, and also salty foods because of the sensoric nerve ending dysfunction of the taste buds. This condition is called by black hairy tongue. Black hairy tongue is only found on the top of the tongue, and it usually starts in the back and progresses towards the tip of the tongue as it grows. The treatment of hairy tongue is variable. In many cases, simply brushing the tongue with a toothbrush or using a commercially available tongue scraper is sufficient to remove elongated filiform papillae and retard the growth of additional ones.ue is perfectly harmless and only temporary.4 2.2.6. Delayed Wound Healing Wounds result from many things such as burns, surgery, scraping your knee, or infections.When a wound occurs, the immune system sends out many healing factors through the blood vessels to the wound to help it heal. Oxygen we breath is also sent to the wound through our blood vessels to help the wound heal. When the wound healing process is complete, the new skin and/or scar tissue functions as a new covering to protect us from future injuries.5 Research shows that smoking can also cause vasoconstriction of blood vessels. This may be influenced by the degree of inhalation of cigarette smoke and 9

nicotine absorption into the tissues. Vasoconstriction of blood vessels can reduce blood flow and gingival sulcus fluid, resulting in reduced supply of oxygen and nutrients to the tissues, carbon monoxide in cigarettes can increase blood pressure that will have an effect on hemoglobin switching systems. Carbon monoxide have an affinity with hemoglobin around two hundred times stronger than the affinity of oxygen to hemoglobin, this can inhibit wound healing.5 2.2.7. Oral Cancer The changing condition in the mouth cavity is caused by the toxic contained within tobacco or because of constant irritation that comes from the burning of tobacco products that cause drying of the oral mucosa, intra oral temperature increases, change in pH in the mouth, change in the immune response, or change in resistance to infection, especially viral and fungal infections. Irritation from tobacco smoke invade mucosal epithelial cells that increased cellular activity, keratotic changes, the epithelium becomes thicker white and gray on the mucosa of the mouth buccal. Smoking is a predisposing factor, can increase the likelihood of oral cancer about 2-4 times. Tar carcinogenic substance chronic irritation causes changes in the basic structure of early oral mucosal epithelium, such as desquamation, atrophy, keratosis, and can even cause epithelial dysplasia that have a malignancy. Oral cancer begins with mucosal changes that are not accompanied by pain. 4,5

Figure 2.2.7

When signs and symptoms do appear, the typically include: Patches on the lining of the mouth or tongue, usually red or red and white in color. Mouth ulcers that do not go away. A sore that does not heal. 10

A swelling in the mouth that persists for over three weeks. A lump or thickening of the skin or lining of the mouth. Pain when swallowing. Loosening teeth (tooth) for no clear reason. Dentures don't fit properly. Jaw pain. Jaw stiffness. Sore throat. A sensation that something is stuck in your throat. Painful tongue. A hoarse voice. Pain in the neck that does not go away.

2.3

Toothache A toothache, also known as odontalgia or, less frequently, as odontalgy is

a painful feeling in or around the tooth.8It can be caused by a number of factors, such as: Tooth decay Abscess tooth Fractured tooth Damaged filling Infected gums Sensitive teeth

In most cases, a toothache is caused mostly by problems within the jaw. 2.3.1 Toothache Symptoms Symptoms of toothache may include the following: Tooth pain that may be sharp, throbbing, or constant. In some people, pain results when pressure is applied to the tooth (i.e, Sensitive Teeth) Swelling around the tooth A Fever or a headache Foul tasting drainage from the infected tooth 11

Because the symptoms of a toothache may resemble other medical conditions or dental problems, it can be difficult to diagnose the cause without a complete evaluation by a dentist.

Figure 2.3.1 A person with a toothache

2.3.2

Plaque Plaque is a soft, sticky film that builds up on your teeth and contains

millions of bacteria. The bacteria in plaque cause tooth decay and gum disease if they are not removed regularly through brushing and flossing.9 When you eat, the bacteria in plaque use the sugars in your food to produce acids that eat away at the tooth enamel. Repeated attacks cause the enamel to break down, eventually resulting in a cavity (or hole) in the tooth surface.Plaque that is not removed daily by brushing and flossing between teeth can eventually harden into tartar. Brushing and flossing become more difficult as tartar collects at the gum line. As the tartar, plaque and bacteria continue to increase, the gum tissue can become red, swollen and possibly bleed when you brush your teeth. This is called gingivitis, an early stage of gum (periodontal) disease. If plaque is allowed to remain on your teeth and harden, bigger problems to ones oral health can arise; this can happen after just 26 hours. When this happens, the plaque hardens into tartar, or dental calculus. Because it has mineralized onto your teeth, tartar is far more difficult to remove than plaque.Once tartar forms on teeth, it may be more difficult to brush and floss it off the teeth effectively. If this is the case, the acids released by the bacteria in your mouth are more likely to break down tooth enamel. That leads to cavities and

12

tooth decay. The CDC estimates that more than 90% of adults over the age of 40 have some form of tooth decay. Tartar that develops above the gum line can be especially serious. That's because the bacteria it harbors may irritate and damage gums. Over time, this inflammation can lead to progressive gum disease. Gum disease can have serious consequences if left untreated. According to the CDC, between 5% and 11% of adults are affected by advanced gum disease.9 Since plaque is constantly growing in your mouth, the best way to remove it and to prevent tartar build-up is to brush and floss ones teeth every day. Dental plaque is usually broadly classified as supra-gingival plaque, even though it can be divided into two categories; these two categories are, as mentioned before, supra-gingival plaque and sub-gingival plaque. Supra-gingival plaque is found at or above the gingival margin; the supra-gingival plaque in direct contact with the gingival margin is referred to as marginal plaque. Subgingival plaque is found below the gingival margin, between the tooth and the gingival sulcular tissue.10 The different regions of plaque are significant to different processes associated with diseases of the teeth and periodontium. For example, marginal plaque can lead to gingivitis. Supra-gingival plaque and tooth-associated subgingival plaque are critical in calculus formation and root caries. Sub-gingival plaque can lead to soft tissue destruction which will eventually lead to different forms of periodontitis.7 According to a study done by the Forsyth Institute in Boston, Porphyromonasgingivalis, Bacteroidesforsythus and Treponemadenticola could be detected in supragingival plaque samples of both healthy and periodontitis subjects. Actinomyces species were the dominant taxa in both supra- and subgingival plaque from healthy and periodontitis subjects.11 Actinomyces species accounted for 63.2%, of supragingival and 47.2% of subgingival plaque in healthy subjects and 48.% and 37.8% in periodontitis subjects respectively. Increased proportions of P. gingivalis, B. forsythus, and species of Prevotella, 13

Fusobacterium, Campylobacter and Treponema were detected subgingivally in the periodontitis subjects. P. gingivalis, B. forsythus and T. denticola were significantly more prevalent in both supra- and subgingival plaque samples from periodontitis subjects.The main differences between supra and subgingival plaque as well as between health and disease were in the proportions and to some extent levels of Actinomyces, "orange" and "red" complex species.11 2.3.3 Tooth Decay (Dental Caries) Tooth decay is the process that results in a cavity (dental caries). It occurs when bacteria in your mouth make acids that eat away at a tooth. If not treated, tooth decay can cause pain, infection, and tooth loss. Another definition of tooth decay is an infection, bacterial in origin, that causes demineralization of the hard tissues of the teeth; these include the enamel, dentin, and cementum. It is usually a result of the production of acid by bacterial fermentation of food debris accumulated on the tooth surface.7 Dental caries can come about in different ways, a persons mouth provides a vast ecology for bacteria to thrive, bacteria which combine with small food particles and saliva to form a sticky film known as plaque, which builds up on your teeth just minutes after brushing; bacteria in plaque survives by digesting the foods we eat, specifically the ones that are broken down into simple sugars (monosaccharides). When a person consumes food and drink that are high in carbohydrates (sugary or starchy), the bacteria in plaque turn the carbohydrates into energy they need, producing acid at the same time. Over time, the acid in plaque begins to break down the surface of your tooth. The plaque will first start to erode the enamel. Over time, a small hole known as a cavity can develop on the surface.11 This will cause a toothache. Once cavities have formed in the enamel, the plaque and bacteria can reach the dentine; as the dentine is softer than the enamel, the process of tooth decay speeds up as shown in figure 2.3.2.

14

Figure 2.3.2

Without treatment, plaque and bacteria will enter the pulp. At this stage, your nerves will be exposed to bacteria, making your tooth very painful. The bacteria can also infect tissue within the pulp, causing pulpitis. Pulpitis is the inflammation of dental pulp tissue. The pulp contains the blood vessels the nerves and connective tissue inside a tooth and provides the tooths blood and nutrients. Pulpitis is mainly caused by bacteria infection which itself is a secondary development of caries (tooth decay). It manifests itself in the form of a toothache. Increased sensitivity to stimuli, specifically hot and cold, is a common symptom of pulpitis. A prolonged throbbing pain may be associated with the disease. However, pulpitis can also occur without any pain.12 When pulpitis becomes worse, a necrotic pulp may form as seen in figure 2.3.3. Necrotic pulp is a finding in dentistry to describe dental pulp within a tooth which has become necrotic. It is a finding of interest to dentists as the process of pulp death may be painful causing, a toothache. Sequelae of a necrotic pulp include acute apical periodontitis, dental abscess or radicular cyst and discoloration of the tooth that may require tooth bleaching. Tests for a necrotic pulp include: vitality testing using a thermal test or an electric pulp tester. Discoloration may be visually obvious, or more subtle. Treatment usually involves endodontics or extraction. 15

Figure 2.3.3

Tooth decay typically occurs in teeth at the back of your mouth, known as molars and premolars. These are large flat teeth used to chew food. Due to their size and shape, it is easy for particles of food to get stuck on and in between these teeth. They are also harder to clean properly. It is more common for a front tooth to be affected by tooth decay when it is touching another tooth alongside it.10 Factors that increase your risk of tooth decay include diet, poor oral hygiene, smoking, and dry mouth. A diet that is high in carbohydrates increases the risk of tooth decay. Poor oral hygiene also exacerbates tooth decay as plaque develops and is not taken care of by brushing or flossing. Smoking interferes with the production of saliva, saliva helps balance the effects of the acid produced by plaque, wash away the bacteria in plaque, and also neutralizes the acid caused by plaque. Smoking also contributes to dry mouth, people with dry mouth produces lower levels of saliva. (Jamie Alexander, 2012) 2.3.4 Symptoms and Treatments of Tooth Decay As we mentioned before, tooth decay is caused by the acids produced by plaque, acids that can erode tooth enamel, dentin, and cementum. The symptoms that are associated with tooth decay usually do not occur until a cavity forms or a tooth becomes infected.14 When these occur, symptoms can include: Toothache, which is the most common symptom. An infection or irritation of the tooth pulp usually causes the pain. Bad breath or a foul taste in the mouth. White, gray, brown, or black spots on the teeth. 16

Loose fillings. A broken tooth or a tooth that is sensitive to pressure.

The pain may become worse, when someone: Eat sweets. Eat hot or cold foods or drink hot, cold, or acidic liquids, such as citrus drinks. Chew food or gum. Breathe in cold air. Brush your teeth. Treatment for tooth decay depends on how bad it is. One may be able to reverse slight tooth decay by using fluoride. To fix cavities caused by mild tooth decay, a dentist will fill the cavities with another substance (fillings) as seen in figure 2.3.4. For more severe tooth decay, one may need a crown or root canal. In extreme cases, your dentist may have to remove the tooth.

Figure 2.3.4

2.3.5

Sensitive Teeth: Causes and Treatments Sensitive teeth, or dentine hypersensitivity is similar to tooth decay in that

the victim feels pain, but it is different because the pain only arises when pressure is applied to the sensitive tooth/teeth (e.g hot/cold food and drinks). Although it can be said that tooth decay increases the sensitivity of the decayed tooth to its surroundings. Sensitive teeth usually occurs when the enamel is eroded, thus exposing the dentin, or because the roots of the tooth are exposed, which also 17

expose the dentin. The reason for this can be numerous, enamel can be eroded from too much bleaching; roots can be exposed by overaggressive brushing, gum recession, and periodontal disease.13 A layer of enamel, the strongest substance in the body, protects the crowns of the healthy teeth. A layer called cementum protects the roots of the tooth under the gum line. Underneath the enamel and the cementum is dentin, a part of the tooth that is less dense than enamel or cementum. The dentin contains microscopic tubules. When the dentin loses its protective covering, the tubules allow heat and cold or acidic or sticky foods to stimulate the nerves and cells inside the tooth as seen is figure 2.3.5. This causes hypersensitivity and occasional discomfort when you chew, drink cold or hot liquids, or when you breathe through your mouth.

Figure 2.3.5

Periodontal disease an infection of the gums and bone that support the teeth also may be responsible. If periodontal disease is left untreated, gum tissues can separate from the teeth and form spaces called pockets that provide a home for bacteria. Periodontal disease can progress until the bone and other toothsupporting tissues are destroyed, leaving the root surfaces of teeth exposed. Regular dental checkups are important so that tooth decay, periodontal disease and other problems may be detected and treated in the early stages.13

18

Sensitive teeth can be treated. Depending on the cause, dentists may suggest that patients try desensitizing toothpaste, which contains compounds that help block sensation traveling from the tooth surface to the nerve. Desensitizing toothpaste usually requires several applications before the sensitivity is reduced. If the desensitizing toothpaste does not ease the patients discomfort, dentists may also suggest in office treatments. A fluoride gel or special desensitizing agents may be applied to the sensitive areas of the affected teeth. When these measures do not correct the problem, your dentist may recommend other treatments, such as a filling, a crown, an inlay or bonding to correct a flaw or decay that results in sensitivity. The type of treatment will depend on what is causing the sensitivity. If gum tissue has been lost from the root due to gum recession, a dentist may recommend a surgical gum graft (figure 2.3.6) to cover the root, protect the tooth and reduce sensitivity. In cases in which hypersensitivity is severe and persistent and cannot be treated by other means, your dentist may recommend endodontic (root canal) treatment to eliminate the problem

Figure 2.3.6

2.3.6

Periodontal Disease (Gingivitis and Periodontitis) Gingivitis, also generally called gum disease or periodontal disease, begins

with bacterial growth in your mouth and may end -- if not properly treated -- with tooth loss due to destruction of the tissue that surrounds your teeth.15 19

Gingivitis (gum inflammation) usually precedes periodontitis (gum disease). However, it is important to know that not all gingivitis progresses to periodontitis.16 In the early stage of gingivitis, bacteria in plaque builds up, causing the gums to become inflamed and to easily bleed during tooth brushing. Although the gums may be irritated, the teeth are still firmly planted in their sockets. No irreversible bone or other tissue damage has occurred at this stage. The longer plaque and tartar are on teeth, the more harmful they become. Gingivitis is a mild form of gum disease that can usually be reversed with daily brushing and flossing, and regular cleaning by a dentist or dental hygienist. This form of gum disease does not include any loss of bone and tissue that hold teeth in place.16

Figure 2.3.7

When gingivitis is left untreated, it can advance to periodontitis as seen in figure 2.3.7. In a person with periodontitis, the inner layer of the gum and bone pull away from the teeth and form pockets. These small spaces between teeth and gums collect debris and can become infected. The body's immune system fights the bacteria as the plaque spreads and grows below the gum line. Toxins or poisons -- produced by the bacteria in plaque as well as the body's natural response enzymes involved in fighting infections -- start to break down the bone and connective tissue that hold teeth in place. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. If 20

not treated, the bones, gums, and tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed.Gum disease is the leading cause of tooth loss in adults. Plaque is the primary cause of gum disease.15 However, other factors can contribute to periodontal disease. These include: Hormonal changes, such as those occurring during pregnancy, puberty, menopause, and monthly menstruation, make gums more sensitive, which makes it easier for gingivitis to develop. Illnesses may affect the condition of your gums. This includes diseases such as cancer or HIV that interfere with the immune system. Because diabetes affects the body's ability to use blood sugar, patients with this disease are at higher risk of developing infections, including periodontal disease and cavities. Bad habits such as smoking make it harder for gum tissue to repair itself. Poor oral hygiene habits such as not brushing and flossing on a daily basis, make it easier for gingivitis to develop. Family history of dental disease can be a contributing factor for the development of gingivitis. Gum disease may progress painlessly, producing few obvious signs, even in the late stages of the disease. Although the symptoms of periodontal disease often are subtle, the condition is not entirely without warning signs. Certain symptoms may point to some form of the disease. The symptoms of gum disease include: Gums that bleed during and after tooth brushing Red, swollen, or tender gums Persistent bad breath or bad taste in the mouth Receding gums Formation of deep pockets between teeth and gums Loose or shifting teeth

Even if the symptoms are unnoticeable, some form of gum disease. In some people, gum disease may affect only certain teeth, such as the molars. Only a 21

dentist or a periodontist can recognize and determine the progression of gum disease. 2.4 Halitosis 2.4.1. Introduction Halitosis, oral malodor or fetor oris, commonly known as 'bad breath' is defined as an unpleasant smell on the breath when the patient breathes out or speaks, or when he or she wakes up in the morning.17 Halitosis term originates from the Latin "halitus" meaning "breath" and the Greek "osis" meaning "abnormal" or "diseased". The unpleasant smell of the breath mainly originates from VSCs, especially hydrogen sulfide ( important is dimethyl sulfide [ ), methylmercaptan ( ), and the most

]. However, when the saliva dries out on

the mucosal surfaces, other compounds in mouth air may also play role a role, for example diamines (putrescine & cadaverine), indole, skatole, and volatile organic acids (butyric or propionic acid). Most of these compunds are results from the proteolytic degradation by oral microorganisms of peptides present in saliva. Sulfur-containing or non-sulfur-containing amino acids, shed epithelium, food debris, gingival crevicular fluid (GFC), interdental plaque, postnasal drip, and blood. In particular, usually gram negative -- anaerobic bacteria poses such preteolytic activity) 2.4.2. The Category of Halitosis Halitosis can be divided into three categories, there are true halitosis, pseudohalitosis, and halitophobia18 1. True halitosis Real halitosis can be further subdivided into physiological and pathological halitosis. Physiologic halitosis includes halitosis caused by dietary components, deleterious habits, morning breath, secondary to xerostomia caused by physiologic factors. Pathologic halitosis occurs secondary to pathologic conditions or oral tissues like gingival and periodontal diseases like periodontitis, acute necrotizing ulcerative gingivitis, residual post-operative blood, debris under dental appliances, ulcerative lesions of the oral cavity, Halitosis may be associated 22

with a coated tongue, may occur due to xerostomia secondary to salivary gland diseases, tonsilloliths. 2. Pseudohalitosis Patients who suffer from pseudohalitosis complain of the existence of halitosis even though it is not perceived by others. This condition can be managed effectively by counseling (using literature support, education and explanation of examination results) and simple oral hygiene measures. 3. Halitophobia Some individuals continue to insist that they have halitosis even after they have been treated for genuine halitosis or pseudo-halitosis. Such individuals are categorized as halitophobic. Halitophobia may be considered when no physical or social evidence exists to suggest that halitosis is.20 2.4.3 The Causes of Halitosis The cause of halitosis are diveded into physiologic halitosis and pathologic halitosis. Physiologic halitosis caused by: a. Lack of salivary flow during sleep Saliva is very important to maintain the freshness of your breath. Production of saliva decreases during sleep, this may cause dry mouth and bad breath. b. The food

Oral malodor can occur due to the influence of food. Some types of foods that can cause bad breath (Halitosis), which are sulfur-containing foods 23

such as garlic, cabbage, broccoli and food that smells like MLA, in Curry, and durian. c. Drinks or alcohol

Alcohol can reduce saliva production and also irritate the mouth tissue, eventually making the drinker get aggravating bad breath. d. Smoking habit Smoking may aggravate the health status of oral hygiene that can trigger the onset of gingivitis and can result in the occurrence of bad breath. e. Women in Menstrual period Menstruation (menses) can make women experience bad breath (halitosis) due to the reduction of saliva secretion in the mouth. Pathologic halitosis can be caused by: a. Poor Oral Hygiene Poor oral hygiene can trigger the onset of halitosis, leftover foods stuck on the teeth can be very hard to clean, especially when using braces. b. Plaques Plaque is a soft deposits consisting of a collection of bacteria that breeds on a matrix that is formed and attached tightly on the surface of the teeth, plaque forms when someone ignores his or her dental/oral health. c. Caries that leads to necrosis Dental caries is a disease that may be caused by the interaction between 4 factors, there are: Hosts, Agent, Environment and Time, all of these factors damage the hard tissue of teeth, namely the enamel, dentin and 24

cementum. Caries may erode into the central of connective tissue core of a tooth or dental pulp.causing necrosis of the pulp and infection.26 This condition leads to gangren gass release that smells like corpse. 2.4.4. Plaque and Halitosis

Figure 2.5.4

Halitosis usually starts with plaque formation in teeth. Plaque formation is divided into three stages: pellicle formation, bacterial adhesion (colonization) and hardening. Pellicle formed when plaque, food debris and bacteria gather together. The first stage of the plaque formation is pellicles attachment on the tooth enamel. Pellicle is thin layer of saliva protein that attach immediately after we brush our teeth. Pellicle has a role to protect email from acid activity. But, pellicle makes the surface of tooth sticky, so the bacteria are easily attached to the tooth especially the Streptococcus mutans bacterium and aldo Streptococcus sangius. These bacteria produce a substance that stimulates the other free bacteria that gather in the tooth. If plaque is not cleaned, it will accumulate, harden, and then become tartar. Even though what triggers bad breath is not clear, yet, most of the smell comes from the food debris in the mouth. Actually in everybodys mouth well always find bacteria, but, if the bacteria multiply in a large scale, it is a problem. Most of these bacteria live between the teeth and are united with plaque and caries, and also in the back of tongue. The bacteria produce toxins or poisons, by outlining the leftovers and dead cells which are present in the mouth. These toxins cause bad breath during exhale as the result of metabolism by anaerobic

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decomposition of food waste. And this decomposition produces sulfide and ammonia compounds. 2.4.5 The Reduction of Saliva and Halitosis Saliva is a clear, watery liquid made by several glands in your mouth area. Saliva is an important part of a healthy body. Saliva is mostly made of water and it also contains important substances that ones body needs to digest food and keep his or her teeth strong.28 Saliva is important because it: Keeps the mouth moist and comfortable Helps chew, taste, and swallow Fights bacteria in plaque and prevents bad breath Has proteins and minerals that protect tooth enamel, prevent tooth decay and also prevents gum disease Helps keep dentures securely in place The glands that make saliva are called salivary glands. The salivary glands sit inside each cheek (Parotid Gland), at the bottom of your mouth (Sub-lingualis Gland), and near your front teeth by the jaw bone (Sub-Mandibularis gland). There are six major salivary glands and hundreds of minor ones. Saliva moves through tubes called salivary ducts. Normally, the body is always making saliva, up to 2 to 4 pints a day. Usually, the body makes the most saliva in the late afternoon. It makes the least amount at night. Certain diseases and medicines can affect how much saliva we can make. If we do not make enough saliva, our mouth can become quite dry. This condition is called dry mouth (xerostomia). Dry mouth causes the gums, tongue, and other tissues in the mouth to become swollen and uncomfortable. Anaerobic bacteria thrive in this type of setting. A high amount of anaerobic bacteria can leads to halitosis.28 Dry mouth also makes us more likely to develop rapid tooth decay and gum (periodontal) disease. That's because saliva helps clear food particles from our teeth. This helps reduce your risk for cavities.

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Dry mouth is common in older adults, although the reasons are unclear. Diseases that affect the whole body (systemic disorders), poor nutrition, and the use of certain drugs are thought to play a key role.28 Too little saliva and dry mouth can be caused by: 2.5 Certain diseases such as HIV/AIDS, Sjogren's syndrome, diabetes, and Parkinson's Blockage in one or more tubes that drain saliva (salivary duct obstruction) Chemotherapy and radiation therapy Dehydration "Fight or flight" stress response Structural problem with a salivary duct Smoking cigarettes Rarely Visit The Dentist Dental fear and anxiety (DFA) refers to the fear of and anxiety towards going to the dentist. It exists in a considerable proportion of children.24 Dental fear and anxiety are major contributors to the reluctance of people across the world to obtain dental services. The cost in human terms as a result of this fear and anxiety is staggering: pain, swelling, lack of function, lack of esthetics, missed time from work (and its attendant cost to business), lack of proper nutrition, and medical complications arising from dental problems to name just a few issues. While dental fear and anxiety are two of the foremost challenges clinicians face in treating patients, strategies for managing fearful patients are not widely agreed upon or considered standard, certainly not scientifically proven. Understanding the root causes of dental fear with a view toward providing management strategies short of sedation and general anesthesia has proven elusive. In other words, there are no universally agreed upon and taught standards that scientists are aware of for management of dental fear and anxiety short of pharmacological means. This study was undertaken to statistically compare the perceptions of doctors and patients with regard to very specific factors that might cause dental fear and anxiety in adolescents and is a major dilemma in pediatric dental practice.25 27

Fear of and anxiety towards going to dentists (ie, dental fear and anxiety, DFA) are major problems for a sizeable proportion of children and adolescents. The prevalence of DFA in children and adolescents ranges from 5-20% in various countries, with some cases being considered to be dental phobia (severe DFA). Children and adolescents with DFA are often uncooperative during dental visits, thus rendering treatment difficult or impossible. Such behavior compromises the treatment outcome, creates occupational stress among dental staff, and is often a cause of discord between dental professionals and patients or their parents. Fearful children and adolescents may try every possible means to avoid or delay treatment, resulting in deterioration of their oral health. Beyond its impacts on dental care, DFA may also cause sleep disorders, affect ones daily life and have a negative impact on ones psychosocial functioning. DFA acquired in childhood may persist to adulthood and is a significant predictor for avoidance of dental visits in adulthood. This pinpoints childhood as a critical stage for preventing and intercepting DFA, thereby assisting people to protect their oral health in the long term.24 Previous studies into DFA draw predominantly upon quantitative instruments such as questionnaires and psychometric scales. The development of these instruments, however, is largely based on professionals presumptions and thus may not capture the whole spectrum of respondents perceptions and views. Moreover, quantitative methods that focus on generating statistics and testing hypotheses may not be able to uncover complex mechanisms. Qualitative research approach is therefore considered an important complement to quantitative methods, especially for gathering in-depth information on human behavior and reasons for such a behavior. Although qualitative studies do not aim to provide data that are statistically extra-palatable to a wide population, they can delineate a wide range of views and experiences in peoples own words and rich contexts.24 To children and adolescents, a visit to the dentist may represent a tremendous challenge. Often seen in, their immediate physical reactions, such as crying piteously, screaming forcefully, and shivering uncontrollably. On the other hand, psychological responses to DFA appeared as an amalgamation of worry, upset, panic, feeling of helplessness, insecurity, resentment, and hatred towards 28

dentists. Some teenagers explicitly expressed worry and panic towards dental treatments by making a video and publishing it on social media. And then, in fearful pediatric patients often refused to sit in the dental chair or open their mouths for oral examination. Parents and dental teams have to struggle to convince or encourage them to cooperate.24

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CHAPTER III MIND MAPPING

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CHAPTER IV DISCUSSION
In the case that we have discussed, we know that this 19 old boy is a smoker, he has bad breath when he talks with his friends and feels pain in few of his teeth when he consumes cold/hot foods and beverages. He is also afraid to go to the dentist. So we can conclude that this boy had little knowledge about dental health education. According to our group, there are 2 main problems in this case which affect the condition of this boy. First is about his smoking habit; the materials contained in cigarettes are harmful ingredients. Smoking cigarettes is detrimental to dental/oral health, and also harmful to overall body health. The effect of the materials contained within cigarettes is of many kinds, one of which is contained in this issue. Second is because of his fear about the dentist, we know that this boy is rarely visiting the dentist. When he is rarely visiting the dentist, his teeth are lacking the proper checkup that they should have gotten, which means he will have a poor oral hygiene. Meanwhile, his knowledge about oral hygiene is also very miniscule. It will further aggravate his condition because he does not maintain his dental problem. From our discussion, we began by discussing about plaque. The plaque formation is likely because of the tar from the cigarette that exacerbates the buildup of plaque in his teeth and his poor oral hygiene; smoking also causes the reduction of saliva production, which causes more plaque to form since saliva washes away the bacteria within the plaque. In our group, we divided plaque formation into 2 groups, which are periodontal disease-causing bacteria in plaque and caries-causing bacteria in plaque. Because of periodontal disease bacteria, plaque on teeth can accumulate and become calculus (tartar). Since the boy rarely visits the dentist, the plaque will likely accumulate even further. Bacteria in plaque can cause the gums to inflame and bleed easily, thus leading to gingivitis. Since he is afraid to go to the dentist, his gingivitis will become more severe because it is not treated; when 31

gingivitis is not treated, it becomes a worse form of periodontal disease called periodontitis. Periodontitis causes the roots of the teeth to be exposed. Because the roots of the teeth do not contain any enamel, they are more susceptible to hot/cold foods and beverages, this is what mainly causes the pain. Periodontitis is a condition when the periodontal pocket gets deeper. Thus, the food debris becomes harder to clean just by brushing the teeth daily. Gram negative anaerobic bacteria breaks down the food debris that are left in periodontal pocket and then release VSC as the result. In many cases, the production of VSC in the mouth can be used as a unit of measurement for halitosis. So, besides pain, periodontal disease can produce an unpleasant smell in the mouth (halitosis). The bacteria of caries such as streptococcus kariogenik, streptococcus mutans, streptococcus sanguinis may lead to the formation of dental caries. Dental caries is a chronic infectious disease affecting the mineralized tissues of the teeth: enamel, dentine, and cementum. It occurs when microorganisms in bacterial dental plaque metabolizes sugars, resulting in the production of acid. The acid eats away at the hard tissues of the teeth (enamel, dentin, cementum), when the decay reaches the pulp of a tooth, it will cause inflammation of the pulp called pulpitis. Caries may erode into the central of connective tissue core of a tooth or dental pulp, causing necrosis of the pulp and infection.26 This condition leads to gangreene gas release, which smells like rotting corpse. So when the boy speaks to his friend, they can smell this unpleasant smell. Thus, besides periodontitis, dental caries is one of the factors that can cause bad breath or halitosis. In early pulpitis, the pulp will react painfully to hot, cold, and sweet stimuli but the pain does not last long and will cease whe the stimulus is withdrawn. So, the pain that happens to the boy is due to the exposure of the dentine and also due to pulpitis. This pain occurs just when he consumes hot and cold food or beverages. And the boys friends are avoiding him because of his bad breath. The cause of his bad breath are necrosis and periodontitis that he suffered. The most effective thing to be done by this boy is that he should not be afraid of the dentist. When he is afraid to go to the dentist, he will not get the good 32

dental care and good oral health that he should have gotten; he also will not know about the overall condition of his mouth. When he is ignorant about his dental/oral health, he will not look for any information that is beneficial to maintaining his dental/oral health, his dental/oral health will be compromised. His smoking activity will worsen his dental health. If he were to go to the dentist, he might have gotten a lot of information about his dental/oral health. The costs of which he pays would be even smaller if he diligently checks his teeth, rather than do a treatment or treatments after a severe toothache.

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