CHAPTER 4

DISCUSSION

Dental caries is the most common and widespread disease in parts of the

world population. According to the results of research in the countries of Europe,

America and Asia, including Indonesia, it turns out that 90-100% of children

under 18 years old of developing dental caries. The WHO target index for DMFT

score in 2010 is 1, 0. Based on Household Health Survey in 2004, the prevalence

of caries investment reached 90,05% and this is higher than the developing other

country.

There is relationship between consumption of carbohydrates with the

occurrence of dental caries to the formation of plaques on the surface of the tooth.

It is because some kind of the carbohydrate in foods, like sucrose and glucose, can

be fermented by several bacteria if it is not cleaned properly. The residue of less-

precise cleaned foods can be change as plaque and its plaque will affects oral

hygiene. The plaque would be overgrown by bacteria that can change glucose

into acids so that the pH of the mouth cavity is decreased up to 4.5 in 1-3 minutes

later. Repeated substraction of pH in a several time will be resulting

demineralization of dental surface, On the State structure of the teeth so then the

email will be dissolved. The repetition of the consumption of carbohydrates that

are too often leads to the production of acid by bacteria become more frequent

again so that the acidity of the mouth cavity becomes more acidic and is getting a

lot of emails that are dissolved.

In accordance with that stated in the British Nutrition Foundation 2004,

communities in developing countries such as Indonesia, are likely to consume the

soft food. In contrast to developed countries, such as America and Japan that its

people consume a lot of fibrous foods, so the number of caries incidence is lower

than developing countries. Sugar consumption is setting worth noting because it

can produce acid by bacteria.

The eating habits of children at school who are often found in General that

is consuming foods that are sweet or contains pure sugar such as candy, chocolate

and doughnuts. According to the Dietary Guidebook Moestopodalam Children,

cited by the Damanik on modern times, many of us encounter these kinds of this

food are sweet, tender and easy to attach to such as candy, chocolate, biscuit and,

etc. Usually the food is very well liked by children due to its soft, then there

needs to be easy, sweety, and having a good taste so that Mastication attached to

the teeth and if not cleaned immediately it will be continued in dental caries in

some mechanism. The mechanism of dental caries is shown by this circle of caries

agent.

In addition, the habit of gargle-gargle after consuming sugary foods as

well as rarely performed by children at school.

Most be a problem in this case is how long such foods, located in the

mouth moreover, food containing high sucrose and coincidence lagging long

enough on the teeth. So if all sugar sucrose consumed immediately ingested get

into the belly without any left on the teeth, then it will not cause of dental caries.

Various kinds of sugar and relation as the cause of dental caries been assessed on

the basis of the order emergency against an onset of carious, namely sucrose,

glucose, followed by maltose, lactose, fructose, sorbitol and xylitol.

The development of caries requires sugars and bacteria to occur but this

influenced by the susceptibility of the tooth, the bacterial profile, quantity and

quality of the saliva, and the time for which fermentable dietary carbohidrates or

available for bacterial fermentation. Streptococcus mutans and streptococcus

sorbrinus are important bacteria in the development of dental caries. Both these

bacteria readily aciduric bacteria can synthesise insoluble plaque matricks

polymers (extracellular dextran) from dietary sugar-a factor that aids bacterial

colonization of the tooth surface. Growth of these streptococci requires the

presence of fermentable monosaccharides. Mutansstreptococcal invertase splits

sucrose into glucose and fructose, which can be metabolised to produce mainly

lactic but also other acids including acetic and formic acids. The resulting low pH

alters the plaque ecology. A low pH in plaque is ideal for aciduric bacteria such as

streptococci, lactobacilli, and bifidobacteria as these are more competitive at low

pH than bacteria not associated with dental caries.

Beside that some mistake in brushing teeth can make bad oral hygiene. In

the oral mucosa plaque will not be pathogenic when there is no pathogenic species

such as lactobacilli and streptococci. Both of these bacteria are cariogenic equally,

but the bacteria streptococci in oral flora, particularly S. mutans is the main cause

of caries, while Lactobacilli more deeply involved if the formation of the lesion

has occurred (Badet and Thebaud, 2008; Hurlbutt, 2010).

If the plaque is located in the oral mucosa or teeth are not cleaned

immediately, it can cause the emergence of dental caries. Generally Caries is

caused by specific types of acid-producing bacteria that cause damage in the

presence of fermentable carbohydrates such as sucrose, fructose, and glucose. The

mineral content of teeth is sensitive to increases in acidity from the production of

lactic acid. Specifically, a tooth (which is primarily mineral in content) is in a

constant state of back-and-forth demineralization and remineralization between

the tooth and surrounding saliva (Konig and Navia, 1995; Ash & Nelson,2003)

Email caries is an early symptom of caries, which are macroscopic known

as white spot. These white spots will be clearly visible on the teeth scraped the

dry and will appear as small lesions, opaque and a white area that is located

slightly towards the cervix from the point of contact. The color of these lesions

will be very different compared with the surrounding email are still healthy.

Detection sonde with this stage cannot be performed because of an email that

surrounds it is still hard and shiny. Sometimes these lesions can be brown because

of the surrounding material is absorbed into the pores. In the picture rongent will

appear radiolucent lesion with clear striae Retzius with radiopaque image

(Fejerskov and Kidd 2003).

The development of these lesions cannot be prevented but can be

inhibited, if these lesions that had developed surface will experience cavitations,

forming a cavity. This resulted in plaque cavity formed be protected from cleanup

efforts such as brushing teeth or flossing. Lesions at this stage it is possible to

grow more quickly, despite the partial remineralization. The spread of these

lesions is determined by the direction of prism email (Moeller, 2009).

If email caries not inhibited immediately, it will get worse and will

develop into dentin caries. Dentine caries is a further development of caries email.

Given the dentin is the layer that is under the email, then email cavity occurs

when bacteria will reach the dentin there will be demineralization, organic matrix

degeneration, and damage and the death of odontoblast. When you continue the

more deep will result in pulpitis.

Chronic pulpitis, open-form, usually requires endodontic treatment,

since, generally, the prognosis for capping an exposed, chronically inflamed pulp

is poor. Recovery is possible but unlikely. Instead, the entire pulp may become

acutely inflamed, or total necrosis may ensue. If left untreated, the pulpitis may

become painful as a result of food packing or pressure, or chronic pulpitis may

gradually involve the entire pulp and, consequently, the periapical tissues as well.

Thus, breakdown of the pulp from caries results in the formation of an abscess

directly beneath the region of the invading microorganisms (Taichman, 1970).

Furthermore, this abscess is called periapical abscess.

The periapical (dentoalveolar) abscess is the result of pulpal infection

that extends through the apical foramen to the periapical tissues. Such abscesses

may develop fistulous tracts that communicate with the oral cavity. They may also

develop a communication with the periodontal pocket or the gingival sulcus. It is

possible for the pulpal infection to reach these periodontal tissues through an

aberrant canal, a root fracture, or a perforation. Of all the dental abscesses, the

periapical is the most common type.

The cytologic characteristics of the abscess are typical.

Polymorphonuclear leukocytes predominate close to the bottom of the pocket and

are massively congregated in the area of the abscess and in ulcerated areas. These

cells migrate from dilated blood vessels in an attempt to protect the tissues from

invading organisms by their phagocytic and enzymatic action. The more violent

the injury and virulent the bacteria, the greater the leukocytic migration in the

affected tissue area and through the epithelium into the pocket. The presence of

pus in a pocket is an indication of this leukocytic activity.

CHAPTER 2

LITERATURE REVIEW

2.1 Carries

Dental Caries is a disease of dental hard tissues, namely in the email,

dentin and cementum caused by the activities of a microorganism through a

process of fermentation of carbohydrates. The sign is the presence of

demineralization of dental hard tissue which is then followed by damage to

organic materials. As a result, bacterial invasion and pulpal death and the spread

of infection to the periapical tissue that can cause pain. tooth loss, infection, and,

in severe cases, death. Dental caries is a process that may take place on any tooth

surface in the oral cavity where dental plaque is allowed to develop over a period

of time. (Konig 1990; Kidd and Bechal,1992; Kleter,2003)

Plaque formation is a natural. Plaque is an example of a biofilm, which

means it is not a haphazard collection of bacteria but a community of

microorganisms attached to a surface. (Konig,1990). This community works

together, having a collective physiology. The bacteria in the biofilm are always

metabolically active. Some of the bacteria are capable of fermenting a suitable

dietary carbohydrate substrate (such as the sugars sucrose and glucose), to

produce acid, causing the plaque pH to fall to below 5 within 1–3 minutes.

Repeated falls in pH may in time result in demineralization of the tooth surface.

However, the acid produced is neutralized by saliva, so the pH increases and

mineral may be regained. This is called remineralization. The cumulative results

of the deand remineralization processes may be a net loss of mineral and a carious

lesion that can be seen.

Which plaque bacteria cause caries?

There are a number of possibilities, each of which has consequences:

• The specific plaque hypothesis proposed that only a few organisms out of the

diverse collection in the plaque flora were actively involved in the disease.

Preventive measures targeting specific bacteria (e.g. immunization) would be a

logical consequence of this hypothesis.

• The non-specific plaque hypothesis considered the carious process to be caused

by the overall activity of the total plaque microflora. A consequence of this

approach is that all plaque should be disturbed by mechanical plaque control

(toothbrushing).

• The ecological plaque hypothesis proposes that the organisms associated with

disease may be present at sound sites. Demineralization will result from a shift in

the balance of these resident microflora driven by a change in the local

environment. Frequent sugar intake (or decreased sugar clearance if salivary

secretion is low) encourages the growth of acidogenic

and aciduric species, thus predisposing a site to caries. The consequence of this

hypothesis is that both mechanical cleaning and some restriction of sugar intake

are important in controlling caries progression.

Where does caries occur?

Bacterial plaque is the essential precusor of caries and for this reason sites on the

tooth surface which encourage plaque retention and stagnation are particularly

prone to progression of lesions. These sites are:

• enamel in pits and fissures on occlusal surfaces of molars and premolars (Figure

1.2), buccal pits of molars, and palatal pits of maxillary incisors

• approximal enamel smooth surfaces just cervical to the contact point (Figure

1.3)

Figure 1.2. Occlusal caries in molars showing stained fissures. Cavities were

present

Figure 1.3. A carious lesion is present on the distal aspect of the upper first

premolar. The lesion is shining up through the marginal ridge which shows a

pinkish-grey discolouration.

• the enamel of the cervical margin of the tooth just coronal to the gingival margin

(Figure1.4a–c)

• in patients where periodontal disease has resulted in gingival recession, the area

of plaque stagnation is on the exposed root surface (Figure 1.5)

• the margins of restorations, particularly those that are deficient or overhanging

• tooth surfaces adjacent to dentures (Figure 1.5) and bridges which make

cleaning more difficult, thus encouraging plaque stagnation.

a. b.

c.

Figure 1.4. Caries of the enamel at the cervical margin of the

lower molars:

(a) The white spot lesions covered with plaque. (b) A red dye has

been used to stain the plaque so that the patient can see the plaque

clearly. (c) The patient has now removed the stained plaque with a

toothbrush: the white spot lesions are now very obvious. Note they

have formed in an area of plaque stagnation and this can been

shown to the patient to demonstrate the importance of plaque

removal.

Classification of Dental Caries

Classification : Caries can be classified according to -

1. Affected hard tissue

2. Location (smooth surface and pits and fissures , GV Black classification is

based according to the location on the tooth)

3. Rate of progression

4. Etiology

1. According to Affected Hard Tissues

Depending on which hard tissues are affected, it is possible to describe caries as

involving -

enamel

dentin or

cementum

Early in its development, caries may affect only enamel.

Once the extent of decay reaches the deeper layer of dentin, “dentinal caries” is

used. Since cementum is the hard tissue that covers the roots of teeth, it is not

often affected by decay unless the roots of teeth are exposed to the mouth.

Although the term “cementum caries” may be used to describe the decay on roots

of teeth, very rarely does caries affect the cementum alone. Roots have a very thin

layer of cementum over a large layer of dentin, and thus most caries affecting

cementum also affects dentin.

  2. According to Location

There are 6 classes involved in Location.

Class 1 Class 2 Class 3 Class 4 Class 5 Class 6

Class 1:

All pit and fissure restorations are Class I and They are assigned to three groups

Restorations on occlusal surface of premolars and molars. Restorations on occlusal two thirds of the facial and lingual surfaces of

molars Restorations on lingual surface of maxillary incisors.

Class 2:

Restorations on the proximal surfaces of posterior teeth are class II

Class 3:

Restorations on the proximal surfaces of anterior teeth that do not involve the incisal edge.

Class 4:

Restorations on the proximal surfaces of the anterior teeth that do involve the incisal edge are class IV

Class 5:

Restorations on the gingival third of the facial or lingual surfaces of all teeth.

Class 6:

Restorations on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth

3. According to Rate of Progression

Acute Chronic Arrested recurrent Incipient.

1. “Acute” signifies a quickly developing condition, whereas “chronic” describes a condition which has taken an extended time to develop.

2. Recurrent caries, also described as secondary, are caries that appears at a location with a previous history of caries. This is frequently found on the margins of fillings and other dental restorations.

3. incipient caries describes decay part of the tooth in which the lesion is just coming into existence

4. Arrested caries describes a lesion on a tooth which was previously demineralized but was remineralized before causing cavitations.

4. According to Etiology

1. Baby bottle caries2. Rampant caries

In some instances, caries are described in other ways that might indicate the cause. “Baby bottle caries”, “early childhood caries”, or “baby bottle tooth decay” is a pattern of decay found in young children with their deciduous (baby) teeth.

The teeth most likely affected are the maxillary anterior teeth, the name for this type of caries comes from the fact that the decay usually is a result of allowing children to fall asleep with sweetened liquids in their bottles or feeding children sweetened liquids multiple times during the day.

Another pattern of decay is “rampant caries”, which signifies advanced or severe decay on multiple surfaces of many teeth. Rampant caries may be seen in individuals with xerostomia, poor oral hygiene, due to drug-induced dry mouth and/or large sugar intake. If rampant caries is a result of previous radiation to the head and neck, it may be described as radiation-induced caries.

http://www.neuronarc.com/classification-of-dental-caries.html

Good oral health is important for a person's sense of well being and quality

of life (Fiske, 2001).   Inadequate oral hygiene can lead to pain, tooth loss, oral

disease, dehydration and speech impediments. It can also affect self-esteem and

the ability to eat and talk comfortably (Chalmers, Carter & Spencer, 2004).  

The main purpose of dental hygiene is to prevent the build-up of plaque, the

sticky film of bacteria that forms on the teeth. Bacterial plaque accumulated on

teeth because of poor oral hygene is the causative factor of the major dental

problems.

Poor oral hygiene allows the accumulation of acid producing bacteria on

the surface of the teeth. The acid demineralizes the tooth enamel causing tooth

decay (cavities). Dental plaque can also invade and infect the gums causing gum

disease and periodontitis.

In both conditions, the final effect of poor oral hygiene is the loss of one

or more teeth. You should not wait until a tooth is lost, just then to understand the

importance of oral hygiene and preventive care.

Many dental health problems, such as oral thrush, trench mouth, bad

breath and others are considered as effect of poor dental hygiene. Most of the

dental and mouth problems may be avoided by maintaining good oral hygiene.

Gingivitis

Definition

Gingivitis is inflammation of the gums (gingiva).

Causes

Gingivitis is a form of periodontal disease. Periodontal disease involves

inflammation and infection that destroys the tissues that support the teeth,

including the gums, the periodontal ligaments, and the tooth sockets (alveolar

bone).

Gingivitis is due to the long-term effects of plaque deposits. Plaque is a sticky

material made of bacteria, mucus, and food debris that develops on the exposed

parts of the teeth. It is a major cause of tooth decay. If you do not remove plaque,

it turns into a hard deposit called tartar that becomes trapped at the base of the

tooth. Plaque and tartar irritate and inflame the gums. Bacteria and the toxins they

produce cause the gums to become infected, swollen, and tender.

Injury to the gums from any cause, including overly vigorous brushing or flossing

of the teeth, can cause gingivitis.

The following raise your risk for developing gingivitis:

General illness

Poor dental hygiene

Pregnancy (hormonal changes increase the sensitivity of the gums)

Uncontrolled diabetes

Misaligned teeth, rough edges of fillings, and ill-fitting or unclean mouth

appliances (such as braces, dentures, bridges, and crowns) can irritate the gums

and increase the risk of gingivitis.

Medications such as phenytoin and birth control pills, and heavy metals such as

lead and bismuth are also associated with gingivitis.

Many people have gingivitis to a varying degree. It usually develops during

puberty or early adulthood due to hormonal changes and may persist or recur

frequently, depending on the health of your teeth and gums.

Symptoms

Bleeding gums (blood on toothbrush even with gentle brushing of the teeth)

Bright red or red-purple appearance to gums

Gums that are tender when touched, but otherwise painless

Mouth sores

Swollen gums

Shiny appearance to gums

Treatment

The goal is to reduce inflammation. The teeth are cleaned thoroughly by the

dentist or dental hygienist. This may involve various instruments or devices to

loosen and remove deposits from the teeth.

Careful oral hygiene is necessary after professional tooth cleaning. The dentist or

hygienist will show you how to brush and floss. Professional tooth cleaning in

addition to brushing and flossing may be recommended twice per year or more

frequently for severe cases. Antibacterial mouth rinses or other aids may be

recommended in addition to frequent, careful, tooth brushing and flossing.

Repair of misaligned teeth or replacement of dental and orthodontic appliances

may be recommended. Any other related illnesses or conditions should be treated.

Outlook (Prognosis)

The removal of plaque from inflamed gums may be uncomfortable. Bleeding and

tenderness of the gums should lessen within 1 or 2 weeks after professional

cleaning and careful oral hygiene. Warm salt water or antibacterial rinses can

reduce the puffiness. Over-the-counter anti-inflammatory medications will ease

any discomfort from a rigorous cleaning.

Healthy gums are pink and firm in appearance. Strict oral hygiene must be

maintained for your whole life or gingivitis will recur.

Possible Complications

Recurrence of gingivitis

Periodontitis

Infection or abscess of the gingiva or the jaw bones

Trench mouth

When to Contact a Medical Professional

Call your dentist if symptoms of gingivitis are present, especially if you have not

had a routine cleaning and examination in the last 6 months.

Call your health care provider if the dentist recommends medical treatment of

underlying conditions that contribute to the development of gingivitis.

Prevention

Good oral hygiene is the best prevention against gingivitis because it removes the

plaque that causes the disorder. The teeth should be brushed at least twice daily

and flossed gently at least once per day. For people who are prone to gingivitis,

brushing and flossing may be recommended after every meal and at bedtime.

Consult the dentist or dental hygienist for instructions on proper brushing and

flossing techniques.

Special appliances or tools may be recommended by the dentist for use by people

who are particularly prone to plaque deposits. The use of supplements does not

replace thorough brushing and flossing. Appliances and tools may include special

toothpicks, toothbrushes, water irrigation, or other devices.

Antiplaque or antitartar toothpastes or mouth rinses may be recommended by the

dentist or dental hygienist.

Regular professional tooth cleaning is important to remove plaque that may

develop even with careful brushing and flossing. Many dentists recommend

having the teeth professionally cleaned at least every 6 months.

For more information, visit the Franciscan Health Library at

www.FHSHealth.org/Health_Education.aspx