MODULE 1 Content

8/12/2019 MODULE 1 Content

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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.


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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.


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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 schoolsenvironment. 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 BoysMen 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


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2.1.2 Psychological Changes in BoysBeside 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 BoysThese 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:

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

2.1.4 Mens Periodontal HealthMens 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


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2.2 Smoking Habit

2.2.1 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, periodontaltreatment 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


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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 oftobacco 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.


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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 earlychildhood.

The persons mother used tetracycline antibiotics during the secondhalf of pregnancy.

The person used tetracycline antibiotics when you were 8 years oldor younger.

The person had trauma that affected a tooth when you were ayoung child. A fall, for example, may damage the developing

permanent tooth.

The person had trauma in a permanent tooth, and internal bleedingdiscolored the tooth.

The person were born with a rare condition called dentinogenesisimperfecta. This causes gray, amber or purple discolorations.

3. Age-related discoloration, This is a combination of extrinsic andintrinsic 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,


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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


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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


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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 andwhite in color.

Mouth ulcers that do not go away. A sore that does not heal.


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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 SymptomsSymptoms 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


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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 PlaquePlaque 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


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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 progressivegum 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. Sub-

gingival 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 sub-

gingival 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.11Actinomyces 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,
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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 acavity (dental caries). It occurs

when bacteria in your mouth make acids that eat away at a tooth. If not treated,

tooth decay cancause 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.
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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 ofdental 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 tostimuli,specifically hot and cold, is a common symptom

of pulpitis. A prolonged throbbingpain 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 describedental pulp within atooth which has

becomenecrotic.It is a finding of interest todentists as the process of pulp death

may be painful causing, a toothache. Sequelae of a necrotic pulp includeacute

apical periodontitis,dental abscess orradicular cyst and discoloration of the tooth

that may requiretooth bleaching. Tests for a necrotic pulp include:vitality

testing using athermal test or anelectric pulp tester. Discoloration may be

visually obvious, or more subtle. Treatment usually involvesendodontics or

extraction.
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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 withthe 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 DecayAs 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 ofthe toothpulp usually causes the pain.

Bad breath or a foul taste in the mouth. White, gray, brown, or black spots on the teeth.
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Loosefillings. Abroken 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 acrown orroot canal.In

extreme cases, your dentist may have to remove the tooth.

Figure 2.3.4

2.3.5 Sensitive Teeth: Causes and TreatmentsSensitive 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
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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 tooth-

supporting 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


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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 calledgum 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
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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 inplaquebuilds 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
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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 duringpregnancy,puberty,menopause, and monthlymenstruation,make gums more sensitive, which

makes it easier for gingivitis to develop.

Illnesses may affect the condition of your gums. This includes diseasessuch ascancerorHIV that interfere with the immune system.

Becausediabetes 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 assmoking 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 thedevelopment 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 Persistentbad 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
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dentist or a periodontist can recognize and determine the progression of gum

disease.

2.4 Halitosis2.4.1. 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 ( ), methylmercaptan ( ), and the most

important is dimethyl sulfide [ ]. 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 halitosisReal 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


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with a coated tongue, may occur due to xerostomia secondary to salivary gland

diseases, tonsilloliths.

2.

PseudohalitosisPatients 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. HalitophobiaSome 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 sleepSaliva 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


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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 habitSmoking 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 periodMenstruation (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 HygienePoor 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. PlaquesPlaque 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 necrosisDental 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


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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 HalitosisSaliva 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 herteeth strong.28Saliva is important because it:

Keeps the mouth moist and comfortable Helps chew, taste, and swallow

Fights bacteria in plaque and preventsbad breath Has proteins and minerals that protect tooth enamel, preventtooth

decay and also prevents gum disease

Helps keepdentures securely in placeThe 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.28Dry 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 forcavities.
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Dry mouth is common in older adults, although the reasons are unclear.

Diseases that affect the whole body (systemic disorders), poornutrition,and the

use of certaindrugs are thought to play a key role.28

Too little saliva and dry mouth can be caused by:

Certain diseases such asHIV/AIDS, Sjogren's syndrome,diabetes, andParkinson's

Blockage in one or more tubes that drain saliva (salivary duct obstruction) Chemotherapy andradiation therapy Dehydration "Fight or flight" stress response Structural problem with a salivary duct Smoking cigarettes

2.5 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
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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 providedata 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


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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 alsovery 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


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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 iswithdrawn.

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


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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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