MODUL 1

CRITICAL THINKING

LEARNING SKILLS & EVIDENCE BASED LEARNING

PROBLEM BASED LEARNING

By :

LAILA FATMAWATI (021211131001)

DESY RISKA IMA KUSUMA PERDANI (021211131002)

BALQIS CHARISA AMANDA (021211131003)

YUNITA MARWAH (021211131004)

AMANDA PUJI DHARMA SAPUTRI (021211131005)

TRI DESIANA KURNIAWATI HARTONO (021211131006)

NUR ARISKA NUGRAHANI (021211131007)

ADAM BIMASAKTI (021211131008)

ERINA FATMALA YULI ANDARI (021211131009)

FITRIAH HASAN ZABA (021211131010)

AYU LARISSA PUTRI (021211131011)

ISNAINY NOVIANTARI ZULFAH HUSNAN (021211131012)

PUTRI ANDIKA S (021211131013)

SHUFIYAH NURUL AINI (021211131014)

RIZKI TRI HANDAYANI (021211131015)

FACULTY OF DENTISTRY

AIRLANGGA UNIVERSITY

SURABAYA 2012

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PREFACE

Praising to Allah, for completing of a paper on " Modul 1 Critical Thinking

Learning Skills & Evidence Based Learning, Problem Based Learning " well.

This scientific paper is written based on scientifical sources which includes

oral health in pregnant woman. So we believe the reader can use this paper as a

means of learning or studying.

Authors realize that this paper can be realized because the instructions,

guidance, criticism, encouragement, and assistance from various parties.

Therefore, on this occasion the authors thank to:

1. Thalca Hamid, drg., MhPED., PhD., Sp.Ort(K) as Lecturer PJMA in

charge of 1st modules

2. Dr. drg. Didik Hadi Mulyana, MS., Sp. Ort as mentors who have

supported and given guidance so that this paper can be arranged

3. Friends and all those who have supported directly or indirectly.

We wrote this paper to fulfill the scene 2 of first module of Critical

Thinking Learning Skills & Evidence Based Learning, Problem Based Learning.

We hope this module may be able to give great benefit to the reader, especially to

increase the knowledge of oral health in pregnant woman.

The authors recognize that this paper is far from perfection. Hopefully this

paper is beneficial to both the author and those who take advantage. We need

criticism and suggestions from the readers of this paper for improving it on the

future.

Surabaya, December 2012

Authors,

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ABSTRACT

Background : Pregnancy is a unique period in a woman's life and is

characterized by physiological and hormonal changes which are complex.

Pregnancy can cause physiological changes in all body systems including the

endocrine system, which is influenced by the hormones estrogen and

progesterone. Purpose: After completing this module, students first semester

Faculty of Dentistry, University of Airlangga will be able to apply the skills of

independent learning, critical thinking, and be able to trace scientific study that is

valid and relevant to the basic level of medical knowledge. Able to implement

independent learning skills in the learning process, apply critical thinking skills in

solving health problems, and use information technology to locate scientific

studies, assess the relevance and validity to be used in solving medical problems

according to the depth of knowledge. Result: We explain that disease is gingivitis

especially gingivitis gravidarum, because the symptoms from the scenario same

with symptoms of gingivitis gravidarum there are morning sicknes, swollen and

bleeding gums, and also caries. Conclusion: In the first trimester of pregnancy

until the third period of pregnancy pregnant women often gingivits gravidarum

disease / pregnancy gravidarum / hyperplas. This situation is caused by the

hormonal activity of the hormone estrogen and progesterone. Provision of dental

hygiene is recommended for pregnant women and other therapies, but this does

not heal completely because hormonal fluctuations’s condition. Gingivitis will

decline in the nine months of pregnancy and the few days after giving birth. The

situation will return to normal as before pregnancy.

Key words: pregnancy, gingivitis, therapies

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CONTENTS

TITTLE PAGE ......................................................................................... i

PREFACE.............. .................................................................................. ii

ABSTRACT. ............................................................................................ iii

CONTENTS.............................................................................................. iv

CONTENTS OF FIGURE ........................................................................ vi

CONTENTS OF TABLE ......................................................................... vii

CHAPTER 1 INTRODUCTION

1.1 Background ............................................................................ 1

1.2 Identification of the Problems................................................. 3

1.3 Purposes of Discussion........................................................... 3

1.3.1 General Purpose............................................................. 3

1.3.2 Specific Purpose............................................................ 3

1.4 Benefits of Discussion............................................................. 4

CHAPTER 2 LITERATURE REVIEW

2.1 Dental Caries ......................................................................... 5

2.1.1 Definition .............................................................................. 5

2.1.2 Etiology ................................................................................. 5

2.1.3 Mechanism ............................................................................ 6

2.1.4 Symptomps ........................................................................... 8

2.2 Gingivitis ................................................................................ 9

2.2.1 Definition .............................................................................. 9

2.2.2 Etiology ................................................................................. 9

2.2.3 Mechanism ............................................................................ 10

2.2.4 Symptoms .............................................................................. 11

2.3 Morning Sickness ................................................................... 11

2.3.1 Definition .............................................................................. 11

2.3.2 Etiology ................................................................................. 12

2.3.3 Mechanism ............................................................................ 12

2.3.4 Treatments ............................................................................. 14

2.3.5 Symptoms .............................................................................. 15

iv

2.3.6 Tips............. ........................................................................... 16

2.3.7 Other Tips .............................................................................. 18

2.4 Salivary ................................................................................ 18

2.4.1 Definition .............................................................................. 18

2.4.2 Salivary Glands ..................................................................... 18

2.4.3 Major Glands ......................................................................... 18

2.4.4 Minor Glands ........................................................................ 19

2.4.4.1 Labial Glands ............................................................ 19

2.4.4.2 Buccal Glands ........................................................... 20

2.4.4.3 Palatal Glands ........................................................... 20

2.4.4.4 Lingual Glands .......................................................... 20

2.4.5 Flowrate ................................................................................. 21

2.4.6 Viscosity ................................................................................ 21

2.4.7 Function ................................................................................. 21

2.4.8 Hyper-salivation .................................................................... 22

2.4.9 Hypo-salivation ..................................................................... 23

2.4.10 Conclusion ........................................................................... 24

2. 5 Hormone ............................................................................... 24

2.5.1 Estrogen ................................................................................. 24

2.5.2 Progesterone .......................................................................... 26

2.5.3 HCG....................................................................................... 27

2.5.4 Prostaglandin. ........................................................................ 27

2. 6 Behaviour ............................................................................. 27

2. 7 Oral Hygiene ......................................................................... 28

2. 8 Life Pattern ........................................................................... 28

CHAPTER 3 DISCUSSION

3.1 Oral Health during Pregnancy................................................. 30

3.2 Relationship between Pregnant Women & Oral Health Disease..32

3.2.1 Relationship between Pregnant Women & Gingivitis............ 32

3.2.2 Relationship between Saliva & Gingivitis............................. 34

3.2.3 Relationship between pH Saliva & Caries............................. 35

3.2.4 Relationship between Morning Sickness& Caries. ............... 37

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3.2.5 Relationship between Oral Hygiene & Life Pattern............... 38

3.2.6 Relationship between Plaque & Gingivitis. .......................... 38

3.3 Eat HealthyPregnancy Woman............................................... 39

3.4 Treatments............................................................................... 41

3.4.1 Prenatal Care Helath Professional ......................................... 41

3.4.2 Oral Health Professional........................................................ 42

CHAPTER 4 CONCEPTUAL MAPPING AND HIPOTESIS

4.1 Conceptual Mapping............................................................... 46

4.2 Hypothesis............................................................................... 47

CHAPTER 5 CONCLUSION AND SUGGESTION

5.1 Conclusion.............................................................................. 48

5.2 Suggestion. . ............................................................................ 48

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

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CONTENTS OF FIGURES

Figure 1. Sevee Adult Dental Caries....................................................... 6

Figure 2. Salivary Glands.........................................................................9

vii

CONTENTS OF TABLE

Table 1.Summary of Consumption during Pregnancy................................... 18

viii

CHAPTER I

INTRODUCTION

1.1 Background

Pregnancy is a unique period in a woman's life and is characterized by

physiological and hormonal changes. Pregnancy can cause physiological changes

in all body systems including the endocrine system, which is influenced by

hormone estrogen and progesterone (Sam A, 2008).

The effect of hormonal changes will affect almost every organ system,

including the oral cavity. Pregnant women who believe that every pregnancy will

cause the loss of the teeth. This opinion is wrong, because the tooth is not directly

caused by the pregnancy, but due to poor oral hygiene and lack of maintenance of

oral health.

Some studies suggest that the effects of hormonal changes will affect the

dental health of pregnant women by 60% with 10-27% have swollen gums(Diana

D, 2009).

According to the Household Health Survey (Household Health Survey,

2001), 60% of Indonesia's population suffers from gum disease, and one of them

is periodontal disease, amounting to 87.84% of the population in Indonesia.

Increased prevalence of this occurs with increasing age and the symptoms

observed in the whole population, and one of those most vulnerable to her

problem is a group of women who experienced pregnancy(Departmentof Health,

2001).

Periodontal disease is an infectious disease caused by the bacteria found in

dental plaque. Dental plaqueisa complex mass of bacteria and products containing

metabolites, toxins, viruses, food scraps and dead cells. Periodontal diseases

include gingivitis, periodontitis and other periodontal disease( LF

Rose&MealeyBL, 2004).

During pregnancy the most common disease is Gingivitis, with a prevalence

of 60% to 75%.Approximately one half of women with preexisting gingivitis have

significant exacerbation during pregnancy (Hey-Hadavi JH, 2002).

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And also in pregnant woman of 1st trimester, the oral cavity is exposed

more often to gastric acid that can erode dental enamel. Morning sickness is a

common cause early in pregnancy; later, a lax esophageal sphincter and upward

pressure from the gravid uterus can cause or exacerbate acid reflux. Patients with

hyper emesis gravidarum can have enamel erosions (ADA, 2006).

Sustainability increased acidity in the oral cavity (result from frequently

nausea), sugary dietary cravings, and limited attention to oral health in pregnant

women, causes demineralization or tooth decay. Caries are at higher risk in

pregnant women(Hey-Hadavi JH, 2002).

Dental caries is a disease of porous starting at a specific location on the

teeth, and followed the process of decay or tooth decay rapidly. Dental caries

begins with the erosion of minerals from the tooth enamel surface or organic acid

fermentation of carbohydrate foods, especially sugar and starch-patian that

remains attached to the parts and between teeth by lactic acid bacteria (Koswara,

2006).

Periodontal disease, namely inflammation and changes in the gingival and

periodontium recessive. Gingivitis is an inflammatory process limited to the

gingival (no attachment loss). Besides almost ubiquitous condition gingivitis

caused by plaque, gingival changes are also detected during the period of

hormonal imbalance, systemic disease, or as a side effect of medication. If the

network supporting alveolar bone is also affected by the inflammatory process in

periodontium, then it is called periodontitis. The term refers to the decrease in

gingival recession gingival or alveolar bone apical direction, which usually occurs

on the labial aspect of the teeth were clinically free of inflammation (Klaus H, et

al., 2004).

Periodontitis is an inflammatory disease of the supporting tissues of the

teeth caused by specific microorganisms, resulting in progressive destruction of

the periodontal ligament and alveolar bone with pocket formation, recession, or

both (Elisabetta C, et al., 2010). Periodontitis lesions showed gingival

inflammation and destruction of periodontal ligament and alveolar bone. This

leads to bone loss and apical migration of the junctional epithelium, resulting in

the formation of periodontal pockets (Li X, 2010).

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Periodontitis can progress from pregnancy gingivitis (inflammation or

infection of the gums) were not treated (Wiriawan&Elly, 2002). The infection will

spread from the gums to the bone under the teeth, causing greater damage to the

periodontal tissues (BM Eley JD & Manson, 2002).

Based on the research showed that 4% of pregnant women are lazy to brush

teeth because it can cause nausea and vomiting. If things are left unchecked, will

eventually lead to dental caries even with a very high prevalence (Diana, 2009).

Awareness of the importance of protecting pregnant women oral health is

very important. Knowledge, attitudes, and behavior of pregnant women on oral

health will determine the health status of the oral cavity. In addition, the health

behavior of pregnant women also have a huge influence for themselves and the

fetus (baby).

According to the 2002 National Health Survey which states that 67% of

pregnant women suffer from gingivitis gave birth prematurely (Santoso, 2003).

An acidic diet or high sugar levels can lower the pH of saliva and the

presence of nausea and vomiting that make pregnant women lazy to clean the oral

cavity. Therefore, actions such as brushing, flossing, and scaling highly

recommended.

Based on the above background, in this report we would like to discuss

more about the oral health in pregnant woman, so as a professional dentist in the

future we can solve the problems with every variant, such as in pregnant woman.

1.2 Identification Problems

1. Why does pregnant woman oftenly have oral health diseases?

2. Why do the therapies apllied to this pregnant woman don’t help her?

3. What is the relevation between the new caries showed up and the

pregnancy?

1.3 Purposes of Discussion

1.3.1 General Purpose :

After completing this module, students Semester 1 Faculty of Dentistry,

University of Airlangga will be able to apply the skills of independent learning,

3

critical thinking, and can trace scientific study that is valid and relevant to the

basic level of medical knowledge.

1.3.2 Specific Purpose :

1. Able to implement independent learning skills in the learning process.

2. Able to apply critical thinking skills in solving health problems.

3. Able to use information technology to locate scientific studies, assess the

relevance and validity to be used in solving medical problems according

to the depth of knowledge.

1.4 Benefit :

1. Able to apply self-learning skills and critical thinking.

2. Able trace scientific study that is valid and relevant to the basic level of

medical knowledge.

3. Able to solve health problems.

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CHAPTER II

LITERATURE REVIEW

2.1 Dental Caries

2.1.1 Definition

Dental caries is an infectious, communicable disease resulting in destruction

of tooth structure by acid-forming bacteria found in dental plaque, an intraoral

biofilm, in the presence of sugar. The infection results in the loss of tooth minerals

that begins with the outer surface of the tooth and can progress through the dentin

to the pulp, ultimately compromising the vitality of the tooth.(The Journal of the

American Dental Association July 2000 vol. 131 no. 7 887-899)

Dental caries is a bacterially based disease. When it progresses, acid

produced by bacterial action on dietary fermentable carbohydrates diffuses into

the tooth and dissolves the carbonated hydroxyapatite mineral—a process called

demineralization. Pathological factors including acidogenic bacteria (mutans

streptococci and lactobacilli), salivary dysfunction, and dietary carbohydrates are

related to caries progression. Protective factors—which include salivary calcium,

phosphate and proteins, salivary flow, fluoride in saliva, and antibacterial

components or agents—can balance, prevent or reverse dental caries. (The Journal

of the American Dental Association July 2000 vol. 131 no. 7 887-899)

2.1.2 Etiology

One fourth of women of reproductive age have dental caries, a disease in

which dietary carbohydrate is fermented by oral bacteria into acid that

demineralizes enamel (Figure 1). Pregnant women are at higher risk of tooth

decay for several reasons, including increased acidity in the oral cavity, sugary

dietary cravings, and limited attention to oral health. Early caries appears as

white, demineralized areas that later break down into brownish cavitations.

Fillings or crowns are a sign of previous caries. Untreated dental caries can lead to

oral abscess and facial cellulitis. Children of mothers who have high caries levels

are more likely to get caries.Pregnant patients should decrease their risk of caries

by brushing twice daily with fluoride toothpaste and limiting sugary foods.

5

Patients with untreated caries and associated complications should be referred to a

dentist for definitive treatment. (Journals AFPP April 15, 2008 vol. 77/No. 8)

Figure 1.Severe adult dental caries.

(Journals AFPP April 15, 2008 vol. 77/No. 8)

The presence of cariogenic bacteria, fermentable carbohydrates, and a

susceptible host are needed for the development of dental caries (Keyes 1960).

Cariogenic bacteria in dental biofilm produce organic acids during metabolism of

fermentable carbohydrates (Loesche 1986), and these organic acids dissolve

minerals in hard dental tissue. The main groups of bacteria needed in the caries

process are mutants streptococci and lactobacilli (Featherstone 2008). Frequent

consumption of fermentable carbohydrates increases the amount of these bacteria

(Marsh 1994). The progression of dental caries is a dynamic process since periods

of demineralization and remineralization alternate (Kidd and Fejerskov 2004).

Remineralization is achievable if fluoride, calcium, and phosphate are

present in saliva, and it may completely arrest the progression of a lesion (Nyvad

et al. 1999). Saliva has good buffering capacity, and salivary flow can clear

bacteria from the tooth surface. Dental caries is a transmissible infectious disease,

and the cariogenic bacteria mutants streptococci are usually transmitted to young

children from their mothers (Alaluusua et al. 1996).

2.1.3 Mechanism

Dental caries arises from an overgrowth of specific bacteria that can

metabolize fermentable carbohydrates and generate acids as waste products of

their metabolism. Streptococci mutants and Lactobacillus acidophilus are the two

principal species of bacteria involved in dental caries and are found in the plaque

biofilm on the tooth surface.2,3,4 When these bacteria produce acids, the acids

diffuse into tooth enamel, cementum, or dentin and dissolve or partially dissolve

6

the mineral from crystals below the surface of the tooth. If the mineral dissolution

is not halted or reversed, the early subsurface lesion becomes a cavity.(Lethbridge

Undergraduate Research Journal. 2007. Volume 2 Number 2).

Streptococcus mutans has been implicated most of all as the initiator of

dental caries. Streptococcus mutans such a potent initiator of caries because a

variety of virulence factors unique to the bacterium have been isolated that play an

important role in caries formation. First, S. mutans is an anaerobic bacterium

known to produce lactic acid as part of its metabolism. Then there is the ability

of S. mutans to bind to tooth surfaces in the presence of sucrose by the formation

of water-insoluble glucans, a polysaccharide that aids in binding the bacterium to

the tooth. Mutant strains developed to produce water-soluble glucans instead have

extremely diminished cariogenicity, especially on the smooth surfaces of the teeth

which require greater tenacity for binding to occur (Loesche 1986). Water-

insoluble glucan has also been found to lower the calcium and phosphate

concentration of saliva, decreasing its ability to repair the tooth decay caused by

bacterial lactic acid (Napimoga, Kamiya et al. 2004).

The most important virulence factor, however, is the acidophilicity

of Streptococcus mutans. Unlike the majority of oral microorganisms, S. mutans

thrives under acidic conditions and becomes the dominant bacterium in cultures

with permanently reduced pH. Additionally, unlike many species present in

plaque, whose metabolisms slow considerably at such a low pH, the metabolism

of S. mutans actually improves, as the proton motive system used to transport

nutrients through its cell wall in environments of low pH or high glucose

concentration is modulated by hydrogen ion content, which increases with acidity

(Hamilton and Martin 1982). In this way, S. mutans can actually continue to lower

or maintain the oral pH at an unnaturally acidic value, leading to conditions

favorable for its own metabolism and unfavorable for other species it once

coexisted with. It is this lowered pH that results in demineralization and cavitation

of the teeth, both of which increase with increased rates of S. mutans.

Under acidic conditions, S. mutans succeeds in creating a cycle that is

favorable for itself and unfavorable for others involved in the oral ecology –

7

becoming, in effect, a pathogen.(Lethbridge Undergraduate Research

Journal. 2007. Volume 2 Number 2)

2.1.4 Symptoms

Bacteria are normally found in your mouth. These bacteria change foods --

especially sugar and starch -- into acids. Bacteria, acid, food pieces, and saliva

combine in the mouth to form a sticky substance called plaque. Plaque sticks to

the teeth. It is most common on the back molars, just above the gum line on all

teeth, and at the edges of fillings.(Journals AFPP April 15, 2008 vol. 77/No. 8).

Plaque that is not removed from the teeth turns into a substance called tartar.

Plaque and tartar irritate the gums, resulting gingivitis and periodontitis. Plaque

begins to build up on teeth within 20 minutes after eating. If it is not removed,

tooth decay will begin.(Journals AFPP April 15, 2008 vol. 77/No. 8)

The acids in plaque damage the enamel covering your teeth, and create

holes in the tooth (cavities). Cavities usually do not hurt, unless they grow very

large and affect nerves or cause a tooth fracture. An untreated cavity can lead to

a tooth abscess. Untreated tooth decay also destroys the inside of the tooth (pulp),

which leads to tooth loss.(Journals AFPP April 15, 2008 vol. 77/No. 8)

Carbohydrates (sugars and starches) increase the risk of tooth decay. Sticky

foods are more harmful than non-sticky foods because they remain on the teeth.

Frequent snacking increases the time that acids are in contact with the surface of

the tooth.(Journals AFPP April 15, 2008 vol. 77/No. 8)

During pregnancy, the oral cavity is exposed more often to gastric acid that

can erode dental enamel. Morning sickness is a common cause early in pregnancy;

later, a lax esophageal sphincter and upward pressure from the gravid uterus can

cause or exacerbate acid reflux. Patients with hyper-emesis gravidarum can have

enamel erosions. Management strategies aim to reduce oral acid exposure through

dietary and lifestyle changes, plus the use of antiemetics, antacids, or both.

Rinsing the mouth with a teaspoon of baking soda in a cup of water after vomiting

can neutralize acid. Pregnant women should be advised to avoid brushing their

teeth immediately after vomiting and to use a toothbrush with soft bristles when

they do brush to reduce the risk of enamel damage. Fluoride mouthwash can

protect eroded or sensitive teeth. (Journals AFPP April 15, 2008 vol. 77/No. 8)

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2.2 Gingivitis Gravidarum

2.2.1 DefinitionPregnancy gingivitis is a common form of gum disease known to develop in

almost half of all pregnant women likely due to the change in hormones. When

kept at-bay, pregnancy gingivitis generally ends shortly after the birth of the child,

although it should be monitored by a dentist periodically during pregnancy in

order to prevent this form of gingivitis from progressing into more serious

periodontitis, an advanced and irreversible form of gum disease that has been

linked with preterm birth.

2.2.2 Etiology

The physiologic changes in the mouth that occur during pregnancy are well-

documented. Combined with lack of routine exams and delays in treatment for

oral disease, these changes place pregnant women at higher risk for dental

infections. Gingivitis is caused by a build up of dental plaque which, when left to

collect, will irritate and sometimes inflame your gums, causing them to bleed.

Gingivitis due to accumulation of plaque is the most common clinical periodontal

condition of women during pregnancy, occurring in 60-75% of women,81 which

speaks to the importance of establishing periodontal preventive and treatment

measures during pregnancy.

Gingival changes generally occur between three and eight months of

pregnancy and gradually decline after delivery. While gingival changes usually

occur in association with poor oral hygiene and local irritants, especially bacterial

flora of plaque, the hormonal and vascular changes that accompany pregnancy

often exaggerate the inflammatory response to these local irritants.82 The most

marked changes are seen in gingival vasculature. This type of gingivitis, known as

pregnancy gingivitis, is characterized by gingival that is dark red, swollen, smooth

and bleeds easily.

Gingival changes associated with pregnancy have been observed in women

who are taking oral contraceptive agents. In general, changes include an increase

in gingival inflammation that appears out of proportion to the amount of

supragingival plaque present. This condition clearly does not occur in all women.

Two mechanisms may cause this significant response:

9

1. There may be an increase in some pathogenic bacteria, such as

porphyromonas gingival is and Actinobacillus actinomycetemcomitans

2. There may be an increase in prostaglandin E, a mediator of inflammation

2.2.3 Mechanism

The hormonal changes during pregnancy change the body’s natural response

to dental plaque, and thus exaggerate the way the gum tissues react to the bacteria

in plaque, thus resulting in a higher chance of pregnant women getting gingivitis.

Generally, if extra care is taken of the teeth and possible plaque buildup, it can be

prevented. It is even more important to have a good oral hygienic routine during

this time.

It is very important for expecting mothers to take care quickly if they have

gum disease because they have a six times greater risk of having preterm and low-

birth weight babies! If expecting mothers had untreated tooth decay and/or

consumed a lot of sugar, their children had four times the risk of developing tooth

decay as opposed to children of other mothers.

As far as hormones are concerned, expecting mothers (and also women who

take oral contraceptives) generally experience elevated levels of estrogen and

progesterone. This is why pregnant women have a 65 to 70% chance of

developing gingivitis during the pregnancy. The risk of getting gingivitis

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

ninth month.

If you already have gingivitis going in to a pregnancy, it will likely get

worse during pregnancy if you do not get treatment. Keep in mind that it is the

bacteria in plaque that causes gingivitis by infecting the gum tissue and not the

hormonal changes.

The problem with gum disease (periodontal disease) is that the infected

gums are toxic reservoirs of disease-causing bacteria. The toxins released can

attack the ligaments, gums, and bones surrounding your teeth to create infected

pockets similar to large infected wounds in the oral cavity. These pockets,

unfortunately, can provide access to your bloodstream and allow bacteria to travel

throughout your body.

10

Since the bacteria that cause gingivitis can enter the bloodstream, the

bacteria can travel all the way down to the uterus. This triggers the body to

produce prostaglandins, which is a natural fatty acid that normally controls

inflammation and smooth muscle contraction. When a woman is pregnant, her

level of prostaglandins increases and peaks when she goes into labor. It is

possible that if extra prostaglandins are produced when the body is reacting to

infected gums, a pregnant women’s body may think it is a signal to go into labor

sooner than expected, thus causing a baby to be born too early or too small.

2.2.4 Symtomps

Plaque irritates the gum tissue, making them tender, bright red, swollen,

sensitive, and easy to make bleed. Gum tissue will appear red rather than pink,

may be swollen, and bleed easily. It is usually painless. The gums may be

moveable rather than tight against the teeth. Pregnancy gingivitis is typically seen

in the second month of pregnancy, being at its worst at the end of the pregnancy.

Gums may remain swollen for months after delivery. The severity of pregnancy

gingivitis depends upon the condition of the mouth before pregnancy. A woman

who has gum problems before pregnancy may see her gingivitis worsen dramatically

2.3 Morning Sickness

2.3.1 Definition

Morning sickness, also called nausea gravidarum, nausea, vomiting of

pregnancy (emesis gravidarum or NVP), or pregnancy sickness is a condition that

affects more than half of all pregnant women. Sometimes symptoms are present in

the early hours of the morning and reduce as the day progresses. However, in spite

of its common name, it can occur at any time of the day. For most women it may

stop around the 12th week of pregnancy.

Related to increased estrogen levels, a similar form of nausea is also seen in

some women who use hormonal contraception or hormone replacement therapy.

The nausea can be mild or induce actual vomiting, however, not severe enough to

cause metabolic derangement. In more severe cases, vomiting may cause

dehydration, weight loss, alkalosis and hypokalemia. This condition is known as

hyper-emesis gravidarum and occurs in about 1% of all pregnancies. Nausea and

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vomiting can be one of the first signs of pregnancy and usually begins around the

6th week of pregnancy (counting gestational age from 14 days before conception).

2.3.2 Etiology

Proximate causes of pregnancy sickness include:

a. An increase in the circulating level of the hormone estrogen. Estrogen

levels may increase by up to a hundredfold during pregnancy. However,

there is no consistent evidence of differences in estrogen levels and levels

of bilirubin between women that experience sickness and those that do

not.

b. Low blood sugar (hypoglycemia) due to the placenta's draining energy

from the mother, though studies have not confirmed this.

c. An increase in progesterone relaxes the muscles in the uterus, which

prevents early childbirth, but may also relax the stomach and intestines,

leading to excess stomach acids and gastroesophageal reflux disease.

d. An increase in human chorionic gonadotropin. It is probably not the

human chorionic gonadotropin itself that causes the nausea. More likely,

it is the human chorionic gonadotropin-stimulating the maternal ovaries

to secrete estrogen, which in turn causes the nausea.

e. An increase in sensitivity to odors, which over stimulates normal nausea

triggers.

f.An increase in bilirubin levels due to increased liver enzymes.

(Note that Gastro esophageal reflux disease can also be caused by pregnancy, and

may result in nausea and vomiting.)

2.3.3 Mechanism

Morning sickness is believed to be an evolved trait that protects the fetus

against toxins ingested by the mother. Many plants contain chemical toxins that

serve as a deterrent to being eaten. Adult humans, like other animals, have

defenses against plant toxins, including extensive arrays of detoxification

enzymes manufactured by the liver and the surface tissues of various other organs.

In the fetus, these defenses are not yet fully developed, and even small doses of

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plant toxins that have negligible effects on the adult can be harmful or lethal to the

embryo.

Pregnancy sickness causes women to experience nausea when exposed to

the smell or taste of foods that are likely to contain toxins injurious to the fetus,

even though they may be harmless to her.

There is considerable evidence in support of this theory, including:

a. Morning sickness is very common among pregnant women, which argues

in favor of its being a functional adaptation and against the idea that it is

a pathology.

b. Fetal vulnerability to toxins peaks at around 3 months, which is also the

time of peak susceptibility to morning sickness.

c. There is a good correlation between toxin concentrations in foods, and

the tastes and odors that cause revulsion.

Women who have no morning sickness are more likely to miscarry. This may be

because such women are more likely to ingest substances that are harmful to the

fetus.

In addition to protecting the fetus, morning sickness may also protect the

mother. Pregnant women's immune systems are suppressed during pregnancy, it is

presumed to reduce the chances of rejecting tissues of their own offspring.

Because of this, animal products containing parasites and harmful bacteria can be

especially dangerous to pregnant women. There is evidence that morning sickness

is often triggered by animal products including meat and fish.

If morning sickness is a defense mechanism against the ingestion of toxins,

the prescribing of anti-nausea medication to pregnant women may have the

undesired side effect of causing birth defects or miscarriages by encouraging

harmful dietary choices. On the other hand, many domestic vegetables have been

purposely bred to have lower levels of toxins than in the distant past, and so the

level of threat to the embryo may not be as high as it was when the defense

mechanism first evolved.

2.3.4 Treatments

13

There is no evidence to demonstrate the effectiveness of home treatments

for morning sickness. Suggested treatments typically aim to lessen the symptoms

of nausea, rather than attacking the root cause(s) of the nausea. Frequently

suggested treatments include:

If the vomiting/nausea is due to acid reflux, taking an antacid or two before bed

may help reduce the stomach acid and prevent morning vomiting.

a. If the vomiting/nausea is due to reduced stomach motility then reducing

fiber and fat intake may help. (For example, white bread instead of

brown bread, well cooked fruits and vegetables instead of raw, avoiding

high-fiber foods, removing skins from fruit or vegetables, avoiding fatty

meats and high-fat foods.) Also, walking after meals may help to increase

stomach motility.

b. If the vomiting/nausea is due to acid reflux or reduced stomach motility,

eating more small meals during the day (instead of several larger ones)

may help. This will also help to keep blood sugar levels more consistent.

c. If the vomiting/nausea is due to iron pills (or multivitamins containing

iron) a slower-release form or several lower-dose iron pills may help.

d. If the vomiting/nausea is due to low blood sugar, avoiding an empty

stomach may help (e.g. snacking throughout the day with several smaller

meals instead of a few large ones.)

e. Folk remedy: Lemons, in particular the smelling of freshly cut lemons.

f. Accommodating food cravings and aversions.

g. Ginger , in capsules, tea, ginger ale, or ginger snaps. Safety concerns have

been raised in the medical community due to the powerful

pharmacological activity of ginger, especially its anticoagulant action.

h. Eating dry crackers in the morning. Some women benefit from eating

crackers before rising out of bed in the morning. This may be because it

helps to absorb the stomach acid.

i. Drinking liquids 30 to 45 minutes after eating solid food.

j. If liquids are vomited, sucking ice cubes made from water or fruit juice

or trying lollipops.

14

k. Sucking on a hard candy seems to help with nausea due to morning

sickness. A doctor may prescribe anti-nausea medications if the

expectant mother suffers from dehydration or malnutrition as a result of

her morning sickness, a condition known as hyper-emesis gravidarum.

2.3.5 Symptoms

Remember, not all vomiting may be due to the pregnancy - you can still get

other illnesses such as a urinary tract infection. You should see a doctor urgently

if you develop any symptoms that you are worried about and particularly if you

develop any of the following:

a. Very dark urine or not passing any urine for more than 8 hours.

b. Stomach pains.

c. High temperature (fever).

d. Pain on passing urine.

e. Headache.

f.Diarrhea.

g. Jaundice (yellow skin).

h. Severe weakness or feeling faint.

i.Blood in your vomit.

j.Repeated, unstoppable vomiting.

k. Thirst

l.Dizziness or fainting.

1st Trimester 2nd Trimester 3rd Trimester

Fatigue, backaches, mood

swings

Gradually getting used to

changes

Definite physical

alterations

Nausea and vomiting /

morning sickness

Stabilizing of systemic

changes

Significant increase in

weight

Frequent urge to urinate

Dizziness

Physical changes begin

appearing

Difficulty in moving

around

15

Snacking binges Uterus becomes more

gravid

Danger of premature

labour

Fetal organogenesis

begins

Development of the fetal

systems

Almost completion of

fetal

Development

Table 1. Summary of maternal changes during pregnancy.

2.3.6 General tips for managing morning sickness

a. Eat small meals often. Skipping meals can make nausea worse.

b. Drink lots of fluid between meals.

c. Avoid foods with strong smells. Eating food at room temperature or cold

foods can help. (Note: remember to avoid the “at-risk” Listeria foods like

cold meats, smoked seafood, soft cheeses or left-overs that are cold or

more than 24 hours old).

d. Avoid spicy foods and fatty foods.

2.3.7 Other helpful tips

a. Avoid caffeine-containing drinks (tea, coffee, cola).

b. Ginger has been shown to help with morning sickness. Try ginger tablets,

ginger lollies or ginger ale.

c. Vitamin B6 may also help manage morning sickness. Speak with your

pharmacist about the correct dose as too much can be harmful.

d. 8. Iron supplements or iron in your pregnancy supplement may upset

your stomach.

In severe cases, your doctor may need to prescribe some medication

to help control your nausea and vomiting. You may lose a small amount of

weight because you can’t eat very much or from vomiting. Do not be too

concerned as this weight will usually return. However, if you are having

difficulty regaining this weight or you are struggling to eat a balanced diet

please speak to your doctor, midwife or dietitian. This table shows foods

and drinks to try if you have mild, moderate or severe morning sickness.

Stage of Morning Strategy Examples

16

Sickness

Severe Try sipping cold, clear fluids Flat lemonade/ginger ale

Sports drinks, cordial, sweet

jelly

Keep your mouth fresh Ice-blocks

Barley sugars, Boiled sweets

When feeling a little better,

increase the variety of drinks

Dilute fruit & vegetable

juices

Weak tea, soft drinks & soda

water

Bonox, clear soups & broths

Moderate Try to eat something plain as

soon as you wake in the morning

Plain dry biscuits or a slice of

toast

Eat small, frequent meals Eat/drink slowly & chew

foods well

Avoid having drinks with

meals

Rest after mealtimes

Choose high carbohydrate foods Plain, dry crackers or popcorn

Cereal or toast with spreads

Plain, boiled rice/pasta

Plain fruit & starchy

vegetables

Mild Avoid high fat, fried or spicy

foods

Use low-fat dairy foods

Limit butter, margarine, oils

Choose lean cuts of meat

Try to include some low-fat,

protein rich foods

Try plain lean meat, chicken

or fish

Try cooked eggs or baked

beans

You may need to use high

protein meal replacement eg:

17

Sustagen, Ensure

Before bed have a snack that

contains protein and

carbohydrate

Cheese & crackers, fruit &

yoghurt or custard

Table 1. Summary of consumption during pregnancy.

2.4 Salivary Flow rate and PH

2.4.1 Definition of Saliva

Saliva is a watery substance located in the mouths of organisms, secreted by

the salivary glands. Human saliva is composed of 99.5% water, while the other

0.5% consists of electrolytes, mucus, glycoproteins, enzymes, and antibacterial

compounds such as secretory IgA and lysozyme (Fejerskov, E; Kidd 2008).

2.4.2 Salivary Glands

Salivary glands are exocrine glands that have ducts empties into the oral

cavity and secrete saliva with many functions and introduction assist mastication

of food. Salivary glands can be distinguished according to the size and

composition of the secretory unit. There are 2 type of glands according to the size,

major and minor glands. And also 2 types according to composition of secretory,

mucus and serous (McKinney BE, 2009).

2.4.3 Major Glands

Three major glands that occur in pairs, located symmetrically on both sides

of the head: Parotids, Submandibulars (sometimes referred to as Submaxillarys),

and Sublinguals (Figure 2).

18

Figure 2. (1)Parotid Gland, (2)Subamndibular Gland, (3)Sublingual Gland

Adapted form Michelle Hurlbut

The parotid glands are the largest of the glands and are located

subcutaneously, below and in front of the ear. The saliva is carried into the oral

cavity from the parotid via the Stensen’s duct, opposite the maxillary second

molar. Although the parotid glands are the largest, they only produce a quarter of

the saliva volume.

The submandibular glands lie on the medial side (inside) of the mandible, in

the submandibular fossa, below the mylohyoid ridge. Each submandibular gland

has a duct that runs forward through the structures in the floor of the mouth and

opens via the Wharton’s ducts located at the lingual caruncles. The submandibular

glands are the most active glands, contributing the most saliva volume.

The sublingual glands are the smallest of the major glands and lie under

the tongue in the floor of the mouth and contribute the least to the total saliva

volume.

2.4.4 Minor Glands

Minor salivary gland is a small salivary glands, located on the cheeck

mucosa, lips, and palate. Some minor glands are labial, buccal , palatal, anterior

lingual glands, glands van Ebner and posterior lingual glands.

2.4.4.1 Labial Glands

labial glands located on the upper and lower lip sub mucosal and

abundant in midline areas. Labial gland is mixed gland seromucous,

where mucus is more dominant (Dubrul et al, 2000).

2.4.4.2 Buccal Glands

19

Buccal mucous glands located on the cheek, which a continuation of the

layers in the posterior labial glands. This gland is thin and irregular

distances on the cheek while the anterior posterior cheeks, glands more

numerous and widespread muscle reach buccinators. Buccal glands

contain seromucous where mucus is more dominant (Short MJ, 2002).

2.4.4.3 Palatal Glands

Palatal glands form a compact gland body lies in the sub mucosal layer of

the hard and soft palate. In the anterior part of the palate, the gland is thin

and sparse in the posterior palate, gland sub mucosal thickening and

expanding reach soft palate. Palatal glands is pure mucous glands (Short

MJ, 2002)..

2.4.4.4 Lingual Glands

Lingual glands is divided into three glands, the glands found on the

lingual anterior that is 2/3 anterior tongue and produces rich mucous

saliva, Von Ebner glands located near the papilla serous circumphalate

and produce saliva and lingual glands located in posterior the lingual

tonsil close to 1/3 posterior tongue and produces mucous saliva (Short

MJ, 2002).

Salivary secretions are classified as serous, mucous, or mixed. As the name

implies, serous secretions contain more water than mucous. Each gland produces a

different type of saliva (Table II). When salivary flow is unstimulated, such as in

resting saliva (RS); the parotid, submandibular, sublingual and minor salivary

glands contribute approximately 25%, 60%, 7%-8%, and 7%-8% respectively to

the whole saliva volume.38-39 The flow rate of RS for all three glands is very

low, approximately one-tenth of that during stimulated flow (McKinney BE,

2009)

The total amount of saliva secreted varies among individuals and

environmental factors. Salivary flow is greater standing vs. sitting as well as

during cool weather compared to hot weather. In addition, saliva is subject to a

circadian rhythm, with the highest flow in mid-afternoon and the lowest around

4:00 AM.40 Approximately 0.5 – 1.7 liters of saliva is secreted into the oral

cavity each day (Mese H, Matsuo R. 2007).

20

Mucous (slime) is a saccharide glycoprotein called mucin. With water it

makes the slippery lubricant used in many parts of the body, where it lines the

moving parts, surfaces and tubes. Here it lubricates the mouth, throat and

alimentary canal. The mucous also has antiseptic qualities: it contains lysozyme

and immunoglobulins. Mucous, with its antiseptic molecules and slime, traps

fungi, bacteria and viruses and prevent infections. The body produces about a liter

of mucous per day, in the mouth and other places.

The serous fluid contains the enzyme amylase which acts in the digestion of

carbohydrates. Minor salivary glands on the tongue secrete the amylase. The

parotid gland produces purely serous saliva. The other major salivary glands

produce mixed (serous and mucus) saliva. Another type of serous fluid is secreted

by the two layered serous membranes which line the body cavities. The serous

fluid between the two layers acts as a lubricant and reduces friction from muscle

movement

2.4.5 Flow rate

Salivary flow rate is determined by measuring the amount of stimulated

saliva (SS) produced in a given period of time. Usually, a patient is provided a

piece of unflavored wax which he or she chews for five minutes. All saliva

produced during this time is collected and measured. Dividing the amount of

saliva produced by the time provides the stimulated flow rate. A patient can

subjectively look or feel “xerostomic,” but until the flow rate is quantitatively

measured, a conclusion that the patient has salivary gland hypo function cannot be

made.

For a salivary gland hypo function diagnosis, one would have to have less

than 0.7 ml/min of flow. Since a sample of SS has been collected, it is an ideal

time to further test for saliva buffering capacity and use the saliva sample to

culture MS and LB.

2.4.6 Viscosity

Viscosity of the saliva relates to its thickness and is determined during the

intra-and extra-oral examination. Here the clinician should assess the patency

(unobstructed), consistency, and flow of the saliva. Saliva is 99% water and

should look like water; not thick and stringy or frothy and bubbly.

21

A low resting pH (less than 6.6) indicates lack of proper salivary quality and

demineralization of tooth structure could occur. Since most people do not

stimulate their saliva in-between meals, the resting pH becomes a valuable

tool in correcting the intra-oral chemistry of the individual patient.

2.4.7 Function

Saliva plays a critical role in the maintenance of optimal oral health and the

creation of an appropriate ecologic balance. The function of saliva includes:

a. Lubrication and protection of oral tissues

b. Buffering action and clearance

c. Maintenance of tooth integrity

d. Antibacterial activity

e. Taste and digestion

Saliva contains electrolytes such as sodium, potassium, calcium,

magnesium, bicarbonate, phosphate, as well as, immunoglobulins, proteins,

enzymes, mucins, urea, and ammonia. These components help to modulate: 1) the

bacteria attachment in oral plaque biofilm; 2) the pH and buffering capacity of

saliva; 3) antibacterial properties and; 4) tooth surface remineralization and

demineralization. These various components give saliva its overall quality and

character. With the recent emphasis on the extended ecological plaque hypothesis,

most noteworthy are saliva’s pH and buffering capacity. The pH can be either

acidic or basic, and the buffering capacity stabilizes the salivary pH.

In other words, as buffering capacity increases, the pH of the mouth

fluctuates less. When the pH of the mouth decreases (or becomes acidic),

cariogenic bacteria are likely to thrive(Humphrey SJ, Williamson RT. 2001).

2.4.8 Hyper salivation

Hyper salivation (also called ptyalism and sialorrhea ) is excessive

production of saliva. It has also been defined as increased amount of saliva in the

mouth, which may also be caused by decreased clearance of saliva. Hyper

salivation can contribute to drooling if there is an inability to keep the mouth

closed or in difficulty in swallowing the excess saliva. Hyper salivation also often

precedes emesis (vomiting), where it accompanies nausea (a feeling of needing to

vomit) (McKinney BE. 2009). Cause of hyper salivation include

22

a.Rabies

b.Gastroesophageal reflux disease, in such cases specifically called a water

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

mouth

c.Pregnancy

d.Excessive starch intake

e.Pancreatitis

f. Liver disease

g.Serotonin syndrome

h.Mouth ulcers

i. Oral infections

2.4.9 Hypo salivation

The salivary glands derive their fluid from the circulating blood. This fluid,

with its  electrolytes and small organic molecules, is modified by the glands and,

together with the macromolecules synthesized by the gland cells, secreted into the

oral cavity. Secretion occurs in response to neural stimulation. Disturbances of the

blood supply to the gland, of its secretory apparatus, or of the stimuli that

elicit secretion may lead to a decrease in the production of saliva. 

As mentioned earlier, a person experiences oral dryness when the volume of

saliva decreases to about half the normal flow rate; in xerostomia, the most

extreme form of dry mouth, the decrease is significantly greater. For the resting

flow of saliva to fall to such a level, more than one gland must be affected. The

loss of activity of a single gland, observed in patients with salivary gland tumors

and of sialoliths, does not result in oral dryness. Thus, xerostomia is the result of

multiglandular salivary hypo function, frequently as a result of the intake of

xerogenic drugs, therapeutic irradiation, or certain systemic conditions. Age and

decreased mastication may also contribute to the feeling of oral dryness. The most

common causes of salivary gland hypo fuction.

2.4.10 Conclusion

23

Saliva plays an important role in optimal oral health and new research

suggests that salivary pH is even more critical to the development and progression

of dental caries than once thought. Science suggests it is pH, rather than sugar,

which is the selective factor for cariogenic plaque biofilms. Low salivary pH

promotes the growth of aciduric bacteria which then allows the acidogenic

bacteria to proliferate creating an inhospitable environment for the protective oral

bacteria. This allows for a shift in the environmental balance to favor cariogenic

bacteria, which further lowers the salivary pH and the cycle continues.

Hyposalivation exacerbate oral health problems in pregnant women. Thick

viscosity, decreases buffer capacity of saliva dramatically allowing oral ph

reaches a low level, can lead to remineralization (caries), aggravating and

cleansing teeth can not be performed optimally. If serous secretion is reduced, it

will affect the maternal immune to infections that result as gingivitis and caries.

So, saliva has an important role in oral health.

2.5 Hormone

Hormonal changes that occur during pregnancy include increased

concentrations of the sex hormones estrogen and progesterone, HCG and

prostaglandin.

2.5.1 Estrogen

Estrogen (naturally) produced mainly by the theca interna cells of ovarian

follicles in the primary, and in much smaller amounts are also produced in the

adrenal gland through the conversion of androgen hormones. In men, also partly

produced in the testes. During pregnancy, also produced by the placenta. Serves as

the stimulation of growth and development (proliferation) in various female

reproductive organs. Estrogen levels increased slowly until the end of pregnancy.

In early pregnancy, estrogen and is produced by the corpus luteum. Then came the

turn of the function of the corpus luteum to the placenta, which occurred in the

sixth week until the eighth week of pregnancy, in which the placenta acts as a

novel endocrine organ.

At first trimester, estrogen has increased very significantly. Estrogen levels

are also increased in the state of ovulation, precocious puberty, gynecomastia,

24

testicular atrophy, ovarian tumors and adrenal tumors. Levels will decline in the

state of menopause, ovarian dysfunction, infertility, turner syndrome,

amenorrhoea due hipopituitari, anorexia nervosa, the state of stress, and testicular

ferninisasi syndrome in women.

Estrogens have important biological actions that can affect other organ

systems, including the oral cavity. For estrogen receptors can be found in the

periodontal tissues. As a result, endocrine system imbalances may be an important

cause in the pathogenesis of periodontal disease. Research conducted by

Mascarenhas P has shown that changes in periodontal conditions can be

associated with changes in sex hormone levels.

The increase in sex steroid hormones can affect vascularization gingiva,

subgingival microbiota, specific periodontal cells and local immune system during

pregnancy.

Several clinical and microbiological changes in periodontal tissues during

pregnancy are as follows:

a. Increased vulnerability of the occurrence of gingivitis and periodontal

pocket depth increased.

b. Increased susceptibility to infection.

c. Decrease in neutrophil chemotaxis and suppression of antibody

production.

d. Increased number of periodontal pathogens (Porphyromonas gingivalis in

particular).

e. Increased PGE2 synthesis.

Estrogen is produced by the placenta during pregnancy, may play a role in

regulating the local immune system and help protect the developing fetus from the

mother's reaction to rejection. Increased concentrations of sex hormones, namely

estrogen and progesterone are also utilized by periodontal pathogens such as

Porphyromonas gingivalis and Prevotella intermedia as their food source. These

bacteria generally increased in sulkular gingival fluid of pregnant women, a

condition that is positively associated with the severity of pregnancy gingivitis.

2.5.2 Progesterone

25

Progesterone is the primary sex hormone of pregnancy. Levels are elevated

up to the eighth month of pregnancy and become normal again after giving birth.

Progesterone (natural) produced mainly in the corpus luteum in the ovary, mostly

produced in the adrenal glands, and the pregnancy was also produced in the

placenta. Progesterone causes changes in the secretory (secretion phase) on

endometriumuterus, which prepares the uterine endometrium in a state of optimal

case of implantation. Progesterone together with estrogen plays an important role

in the regulation of female sex hormones.

In women, pregnenolone is converted into progesterone or 17a-

hidroksipregnenolone and this change depends on the ovulation phase in which

progesterone secreted by the corpus luteum in large numbers. Progesterone is also

a precursor to testosterone and estrogen, during the metabolism of 17 α-

hydroxyprogesterone into dehydroepiandrosterone were converted into 4

androstenedione 17α hydroxylase enzyme with the help of pregnenolone.

Whereas progesterone secreted by the corpus luteum and placenta

responsible for building the middle layer of the uterus during menstruation and

pregnancy. Increased concentrations of sex hormones begins at fertilization,

embryo implantation continues to occur and be maintained until the time of the

birth.

Progesterone is produced by the placenta during pregnancy, may play a role

in regulating the local immune system and help protect the developing fetus from

the mother's reaction to rejection. Lapp reported that high concentrations of

progesterone during pregnancy increases the incidence of gingival inflammation

by inhibiting the production of interleukin - 6 (IL-6). IL-6 stimulates the

differentiation of B lymphocyte function, cells activate T lymphocytes and

macrophages and NK cells, which are cells attacking role and memfagositosis

bacteria into the blood circulation, so that the inhibition of the production of IL-6

resulted in less efficient gingival inflammation against attacks of bacteria.

Progesterone also stimulates the production of prostaglandin (PGE2) where

PGE2 is a potent mediator in the inflammatory response. By PGE2 that acts as an

immunosuppressant, resulted in increased gingival inflammation when the

concentration of PGE2 and high mediator PGE2.

26

Levels are elevated in pregnancy, ovulation, ovarian cysts, adrenal tumors,

ovarian tumors, molahidatidosa. And decreases in state amonorea, abortion, and

fetal death. Factors affecting the examination is the use of steroid hormone

progesterone, progesterone, and oral contraceptives.

2.5.3 HCG (Human Chorionic Gonadotrophin)

Being produced since the age of 3-4 weeks gestation by trophoblastic tissue

(placenta). Levels increased up to 10-12 weeks of pregnancy (up to about 100,000

mU / ml), and then fell in the second trimester (around 1000 mU / ml), and then

rose back to the end of the third trimester (about 10,000 mU / ml). Works to

increase and maintain the function of the corpus luteum and the production of

steroid hormones, especially during periods of early pregnancy. It may also have

immunologic functions.

2.5.4 Prostaglandin

Prostaglandins are derivatives of cellular membrane fatty acids and exert

complex and multiple physiologic and pathologic effects. They are known to be

implicated in inflammation, including periodontitis and peri-implantitis.

Prostaglandin also can promote extracellular matrix destruction in the gingival

and stimulate bone resorption. The determination that periodontal tissue

destruction is primarily due to the host response.

2.6 Behaviour

A woman’s pregnancy is a thing that every spouse expecting of. This kind

of good news is something that they really want to happen, indeed. Unfortunately,

nowadays a woman who plans to have a baby is lack educated when it comes to

keep her oral stay health. The life pattern of her pre-pregnancy is definitely

important because it can impact the oral health when she hold a baby, otherwise

she will have any kind of oral disease, such as gingivitis and periodontal disease.

The habit of snacking a lot in pregnant woman causes a physical transformation,

including oral hygiene and life pattern.

27

2.7 Oral Hygiene

The pregnancy of a woman cause physically transformation of her body,

including the condition of her opening. The first and the most seen transformation

is the gingival. This happens due to the transformation of hormonal and vascular

system with the resembling of the factors of local irritation in the opening (Burket,

1971 :Barber and Graber, 1974; Sallis dkk,1995). The increasing amount of

estrogen and progesterone during the pregnancy affect the gingival, in which

proliferation of capillary, dilatation of blood vessel, the increase of vascular

permeability, edema, infiltration, leukocyte, and degeneration of epithelium cells

are microscopically visible (Mustaqimall, 1988).

The casual of a pregnant woman that has to undergo the morning sickness or

feeling queasy and followed by vomiting in the morning can make her oral health

becomes poor. This sickness makes the email of teeth erupted due to the acid

increasing of saliva and this condition also increasing the risk of caries.

2.8 Life Pattern

When a woman holds a baby, she usually snacks all the time. That one thing

that connects this with her oral health is the snacks are highly containing sugar

(Forest, 1995). The frequencies of queasiness and about to vomit make her too

lazy to keep her oral stay healthy. Due to this situation, the acid attack from

plaque be accelerated by the acid from saliva and simplified the process of caries

(Forest, 1995). The side effect of the acid situation of her mouth causes not only

caries, but also gingivitis and other periodontal diseases. Casually, a pregnant

woman will come to a dentist and tell him that her gingival inflamed. This is

normal due to the transformational hormone system.

On the other side, the lay pregnant woman will ignore this and keeps the

poor oral health. In fact, she will be lazier to brush her teeth because her gingival

will bleed. This will amass plaque and aggravating the situation in her mouth.

As a matter of fact, pregnancy is not directly cause caries to a woman. The

increasing risk of caries during pregnancy happens due to the transformation of

oral condition and lack of good treatment (Burket, 1971 ; Forest, 1995). If there

28

are no preventive actions pre-pregnancy, the grievance of oral diseases will

increase. The systemization of good life pattern for oral health is something

important. As an example, if a pregnant woman suffers from a gingival

gravidarum (gingivitis during pregnancy), the baby she holds will infected. A

study suggests that oral disease in a pregnant woman stimulates prostaglandin, a

hormone in which stimulates activity of uterus to contract and makes the risk of

premature baby born.

During pregnancy, it is necessary to make an optimal and good condition of

oral health. Doing a plaque control is a good thing to do to prevent gingivitis of

local irritation, unstable hormonal trouble, and another mouth disease during

pregnancy.

There are some important things for a pregnant woman to know to keep her

oral stay healthy due to avoiding from oral disease during pregnancy, such as:

a. Right after a pregnant woman vomits, clean the inside of the mouth with

brushing teeth or gargling.

b. Make a good food and life pattern by consuming fruits and vegetables

and avoiding cariogenic foods.

c. Brush the teeth regularly with the right method.

d. A pregnant woman must have her oral condition examined by a dentist.

This is not a contra-indication thing.

e. It is suggested that right after a pregnant woman meals, she better

chewing a gum with the amount of 67% xylitol for about a minute. By

chewing a gum, the condition of the oral will be refreshed and become

healthier.

CHAPTER III

DISCUSSION

29

3.1 Oral Health During Pregnancy

In the first month of pregnancy due to increased production of the hormone

estrogen which provoke an increase in the acidity of the stomach. If the frequency

of nausea and vomiting more often in the morning, it's because of the distance

between dinner time with a long breakfast. As a result, an empty stomach secrete

gastric acid that makes the mother feel more nauseous.

In addition it is a factor of HCG (Human chorionic gonodotropin). This

hormone produced by the placenta (afterbirth) during early pregnancy. Changes in

the mother’s body are then triggered by hormones cause nausea. Placental

function as circulating and giving food to the fetus will grow to a maximum when

the age of 12-14 weeks gestation. At this time usually nausea, vomiting will stop.

The cells of the placenta attached to the uterine wall was initially rejected by the

body because it is considered as foreign. Immunological reactions that trigger

reactions.

Changes in liver glycogen metabolism due to pregnancy are also considered

as a cause of nausea and vomiting. However, after adjusting for placental cells and

occurs compensation glycogen metabolism in the body, then the nausea goes

away.

The cause of hyper-emesis gravidarum is one of them, the hormone HCG

excessive. It may also be due to maternal adaptation in hormones that occurs

during pregnancy is not good. Adaptability of pregnant women, in fact it is very

idiviudal as well as allergic reactions. Enzyme disorder also expected to cause

nausea, vomiting excessively. Ulcer, for example, can aggravate the condition of

nausea and vomiting in pregnancy. This may be contrary to the theory that if

mothers with mag, then during pregnancy pain will disappear.

The assumption, pregnancy making bowel movements slow to follow gastric

emptying was so slow. Such a situation is in some mothers can create pain

magnya no recurrence during pregnancy, but there is also a permanent ulcer. This

is due to the wrong diet. For example, pregnant women often eat salad when the

stomach is empty. As a result, increases stomach acid.

The hormones that seem to have the most to do with this process include the

pregnancy hormone human chorionic gonadotropin (HCG), estrogen, and

30

progesterone. Abnormal levels of thyroid hormones have also been reported in

women with severe vomiting, although a cause-and-effect relationship remains

unclear. Some studies have shown that nausea is worse when your blood sugar

level is low. Women who are more likely to have nausea from birth control pills,

migraines, or motion sickness are at higher risk for nausea and vomiting in

pregnancy.

Thyroid function in early normal pregnancy was evaluated with reference to

morning sickness using a newly developed free thyroxin (T4) radioimmunoassay

and a highly sensitive TSH immunoradiometric assay. A significant increase in

serum free T4 and a decrease in serum TSH were observed in early pregnancy

relative to the levels in non-pregnant controls. The increased free T4 and HCG

and decreased TSH correlated with the severity of morning sickness, and these

changes were especially marked in subjects with nausea and vomiting. The

individual serum levels of HCG in the pregnant group correlated significantly,

directly with the levels of free T4 and inversely with those of TSH. The increased

free T4 and decreased TSH in subjects with emesis returned to the normal ranges

of non-pregnant controls after improvement of emesis. These data indicate that the

thyroid gland is physiologically activated in early pregnancy, possibly by HCG or

a related substance, which may induce gestational emesis. On the other hand, an

increased level of free T4 and a reduced level of TSH in early normal pregnancy

are not indications of thyrotoxicosis and may not necessitate anti-thyroid drug

treatment.

Hyper salivation occurs frequently in pregnant women, where as the

incidence of duodenal ulcers in such cases is very low. The nature of the "oral

regression" in ulcer patients and in pregnant women is discussed. In the first

instance, the regressive intensification of oral-instinctual impulses results from

unsuccessful mastery of interpersonal conflicts and is thus interpreted as a

pathologic phenomenon. In pregnant women, however, oral regression is the

result of primarily internal physiologic changes and is interpreted accordingly as a

normal concomitant of pregnancy. This difference in the nature of the oral

regression may account for the very low incidence of duodenal ulcers in pregnant

women.

31

3.2 Relationship between Pregnant Women and Oral Health Disease

3.2.1 Relationship Between Pregnant Women With Gingivitis

The relationship between gingival changes with pregnancy experts say

pregnancy usually manifests towards an increased incidence and severity of

gingivitis. But pregnancy itself is not causes gingivitis. Gingivitis in pregnancy is

caused by plaque bacteria, similar to the non-pregnant state. Therefore, no change

in the gingival during pregnancy when there is a cause local factor. In addition, a

significant factor during pregnancy, it is an increase in the hormone estrogen and

especially progesterone, which can lead to high degrees of severity of gingivitis.

Clinical features of gingivitis in pregnant women, gingival inflammation

and the color will experience will vary between red till bright bluish red. Marginal

and interdentally areas having edema, hyper plastic, smooth and shiny surface,

some fruits such as mulberry, common inflammation of the gingival when

brushing your teeth or chewing food thoroughly can change and local.

Gingivitis occurs during the first trimester of pregnancy, when it happens

over and gonadtrophin production in the third trimester it will happen increased

estrogen and progesterone. This hormone factors exacerbate the gingival response

to local factors. The interaction of bacteria with hormones can alter the

composition of the plaque, which causes gum inflammation. Increased hormone

progesterone was associated with gingival vasodilatation of blood vessels, static

circulation and increased susceptibility to mechanical irritation. The hormone

progesterone causes pronounced effects on micro vascular gingival, capillary

permeability changes and additions krevikuler fluid flow.

The degree of severity of gingival inflammation during pregnancy also

influenced the development of anaerobic microbial flora krevikuler fluid.

Microbial changes that occur because the hormones estrogen and progesterone

hormone affects growth factor pathogenic bacteria in periodontal tissues. So the

relationship between pregnant women with gingivitis caused by local factors and

hormones, namely estrogen and progesterone hormone.

1. Hormonal changes during pregnancy

32

Hormonal changes that occur during pregnancy include increased

concentrations of sex hormones, namely estrogen and progesterone.

Progesterone is the primary hormone of pregnancy sex. Levels are

elevated up to the eighth month of pregnancy and normal until become

the baby was born. In early pregnancy, estrogen and progesterone

produced by the corpus luteum. Then came the turn of the function of the

corpus luteum to the placenta that occurs in the sixth week until eighth

week of pregnancy, in which the placenta acts as a novel endocrine

organ. At the end of the third trimester, progesterone and estrogen

reaches its peak of 100ng/ml and 6ng/mg which are 10 and 30 times

higher than the concentration at the time of menstruation.

Estrogen is secreted by the ovaries and placenta plays an important

role in the development and maintenance of secondary sex characteristics

and uterine growth. Whereas progesterone secreted by the corpus luteum

and placenta, responsible for building the middle layer of the uterus

during menstruation and pregnancy. Increased concentrations of sex

hormone begin at fertilization, embryo implantation continues to occur

and be maintained until the time of birth.

Estrogen and progesterone have important biological actions can

affect other organ systems, including the oral cavity. Receptors for

estrogen and progesterone can be found in the periodontal tissues. As a

result of endocrine system imbalances may be an important cause in the

pathogenesis of periodontal disease. Research has shown that changes in

periodontal conditions may be associated with changes in sex hormone

levels. The increase in sex steroid hormones can affect vascularization

gingival, sub gingival microbiota, specific periodontal cells and local

immune system during pregnancy (Mascarents P, et al, 2000). Several

clinical and microbiological changes in periodontal tissues during

pregnancy are as follows:

a. Increased vulnerability of the occurrence of gingivitis and periodontal

pocket depth increased.

b. Increased susceptibility to infection.

33

c. Decrease neutrofil chemotaxis and antibody production emphasis.

d. Increased number of periodontal pathogens (especially Porphyromonas

gingivitis)

e. Increased synthesis of PGE.

3.2.2 Relationship Between Saliva Ph With Gingivitis

The flow of saliva can reduce the accumulation of plaque on the tooth

surface as well increasing ability cleaning action of the oral cavity. When the

amount of salivary secretion decreases, it will cause the frequency of dental caries

will increase. The degree of salivary pH and buffer capacity is always affected by

the changes caused by:

a. Rhythm of day and night

High buffer capacity immediately after waking up, but then quickly

dropped, high quarter of an hour after a meal (mechanical stimulation)

but usually within 30-60 minutes down again, slightly up until tonight,

after it went down.

b. Diet

Carbohydrate diet for example, lowering the capacity of the buffer

while ainterdiet rich in vegetables and protein-rich diet has the effect of

increasing the capacity of the buffer.

c. Stimulation of secretion rate

Salivary secretion regulated by the nervous system. Stimulation of

the sympathetic nerve that would cause the glandular salivary secreation

vascontruction bit and organic components in saliva increases.

Stimulation of the parasympathetic nerve will cause vasodilatation so that

secretion of salivary glands into lots, and dilute organic components in

saliva slightly.

d. Plaque

34

Plaques were in contact with dietary sugars (carbohydrates) will be

fermented by bacteria that produce lactic acid Palk which can lower the

salivary pH to reach critical point.

The relationship between salivary pH with gingivitis is due to the

presence of plaque, plaque is the organism or a layer of software that

deposits on the tooth surface, which includes the substances interbacterial

extracellular polysaccharides, enzymes, endotoxins and antigens. Antigen

on these plaques stimulate an immune response and cause tissue damage.

Dental plaque microorganisms that release the active biology

components lipopolysaccharide, chemotactic peptide and fatty acids.

These components stimulate gingival epithelial cells produce a variety

for active biological mediators dominated by citoxin. Gingival epithelium

also responds to the components of plaque microorganisms by inducing

the body's defense system by producing antimicrobial peptides. In

addition, salivary defense system works to limit the growth of bacteria

through saliva flow flushing action that cleans bacteria from the surface

of the oral, factor bacteria, antimicrobial proteins, and others.

While a woman is having an unusual habit with it because of his

habit of snacking and do not want to brush my teeth, so that it will

accumulate causing plaque salivary pH will drop and cause of the

occurrence of gingivitis is also influenced by the hormones estrogen and

progesterone.

3.2.3 Relationship Between Ph Saliva With Caries

The relationship between the pH of saliva with caries is the case when the

caries process. Where clean surfaces in contact with saliva, forming layer

glycoprotein pellicle effect absorption of saliva on the tooth surface. Absorbption

occurred cause the presence of gravity - attraction between salivary glycoprotein,

then microorganisms stick above pellicle. With the presence of sucrose, forming

an extracellular polysaccharide (dextran) and intracellular (levan) by

Streptococcus mutans which dextran adhesives plaque on teeth and levan are

nutrient reserves. Action of various types of microorganisms that ferment

carbohydrates into acids that cause a reduction in pH immediately after 3-5

35

minutes consuming sucrose. The acid formed as a result of metabolism,

microorganisms resulted in the process of demineralization of dental hard tissues

and destruction of organic materials teeth.

According to Stephan, plaque pH decrease was greater in individuals with

active caries than caries-free. Patients with active caries found at pH 5, which is

called the critical pH. At pH 6 to 6.5 all microorganisms can form acid, but the

highest activity was kind of streptococci. Below pH 5 types of streptococci and

lactobacillus can still produce acid to pH 4.5 and below pH 4.5 only type of

Lactobacillus can survive and produce acids.

Protection by way of saliva to prevent caries is

1. Forming a layer of mucus as a protective barrier against irritants and

Prevent dryness.

2. With irrigation saliva, will help cleanse the mouth of food debris, cell

debris and bacteria that would eventually inhibit plaque formation.

3. Adjust the pH balance of the mouth with the content of bicarbonate,

phosphate and protein amfoter. Increased salivary secretion rate will raise

the pH and buffer capacity of saliva. In a situation where there is

decreasing pH, resulting from acidogenic organism metabolism, will be

inhibited.

4. Able to help maintain the integrity of the tooth with the content of

calcium and phosphate in saliva with caries remineralization road is still

early to be increased if given fluorine.

5. Capable of antibacterial activity in the presence of specific antibodies,

enzymes, lactoferrin and lactoperoxidase.

Afonsky (1961) discuss the relationship between saliva with caries.

According to individuals who have a lot of caries, will have a low pH of saliva.

This is due to the increasing number of microorganisms will improve results in

the form of acid metabolism. Newbrun (1978) and Rider (1982) believe that the

pH of saliva affects to the works caries process. And according Newbrun (1983),

the low pH of saliva, microorganisms can thrive. In contrast, at high pH can

prevent dental caries.

3.2.4 Relationship Between Morning Sickness With Caries

36

Complained of nausea and vomiting by about three-quarters of pregnant

women, usually occurs during the first trimester. Usually accompanied by nausea

and vomiting many complaints spit (hyper salivation), dizziness, abdominal

bloating, and the body feel weak. Complaints are generally known as "morning

sickness" because it was heavier in the morning. However, nausea and vomiting

can last all day. The flavor and the intensity are often described like nausea and

vomiting due to cancer chemotherapy.

Hyper emesis gravidarum can be clinically classified into three levels, is

a. Level I

Hyper emesis gravidarum is characterized by a level I continued

vomiting accompanied by intolerance to eating and drinking. There are

weight loss and epigastric pain. First of all contents are regurgitated food,

and mucus and a little bile, and when it's time to get out of blood. Pulse

rate increased to 100 beats / min and systolic blood pressure decreased.

Examination reveals sunken eyes, dry tongue, decreased skin turgor, and

urine slightly reduced.

b. Level II

Hyperemesis gravidarum II levels, patient vomited everything eaten and

drunk, rapid weight decreased, and there is a great thirst. Pulse rate 100-

140 beats / min and systolic blood pressure less than 80 mmHg. Patients

seen apathy, pale, dirty tongue, sometimes jaundice, and found acetone

and bilirubin in urine.

c. Level III

The condition is extremely rare with stage III, characterized by reduced

or even stopped vomiting, but decreased consciousness (delirium to

coma). Patients experienced jaundice, cyanosis, nystagmus, heart

problems was found in the urine billirubin and protein.

Nausea in the first months of pregnancy due to increased production of the

hormone estrogen which provoke an increase in the acidity of the stomach. If the

frequency of nausea and vomiting more often in the morning, it's because of the

distance between dinner time with a long breakfast. As a result, an empty stomach

secrete gastric acid that makes the mother feel more nauseous.

37

This proves that excreation on a asam lambung or HCG hormone and also

influenced by estrogen dan progesteron hormone can causes

hypersalivation( secretion of much salivary) and happen nausea, can called

morning sickness. After happened nausea, oral condition become acidic. So, can

influence pH salivary become acid and impact of the demineralization or caries.

3.2.5 Relationship Oral Hygiene With Life Pattern

Oral hygiene is an oral hygiene and is an act to clean your teeth and mouth

and gums (Clark, 2005). According to Clark, 2005 aims to prevent oral hygiene

for oral disease, prevents disease transmission through the mouth, increase

endurance and improve the function of the mouth to enhance appetie. While the

pattern of life of a pregnant woman is pregnant it's likely lazy to do an activity

that they think is not important, for example, do not brush your teeth every day In

addition, a pregnant woman usually likes to things that are able to snacking

without rinsing and brushing his teeth .

The relationship between oral hygiene with a lifestyle that is owned by

pregnant women with such unnatural habits like snacking every day so make lazy

to brush my teeth. This will affect the cleanliness of the mouth, if the continuous

snacking without rinsing or brushing is not the mouth hygiene will be vulnerable

to oral disease such as gingivitis. As a result of excessive snacking of these

women it will gathering bacteria - bacteria that will happen and continue to

accumulate plaque becomes tartar and get away in gingival and there such thing as

gingivitis.

3.2.6 Relationship Plaque With Gingivitis

Dental plaque is a soft deposit form biofilms, attached to the tooth surface

or the surface of the cavity a soon scrambled hard, especially supragingival area a

third of gingival and sub gingival especially on rough surfaces, holes or edges

overhanging restorations. Dental plaque grayish white, yellow and has a globular

surface.

Dental plaque is seen on the surface of the tooth after 1-2 days did not do

the cleaning of the mouth. Movement and shifting network of food material to the

38

tooth surface during chewing mechanical plaque removal resulted in two-thirds of

the coronal tooth so specific plaque seen in gingival third.

Plaque is a cause of gingivitis. Plaque is also an irritant local and systemic

factors that affect the occurrence of gingivitis. Once plaques appeared, pregnant

women that will clean teeth, but at the time it, wrong to brush his teeth and the

gingival. So based on the above description, it affects the occurrence of gingivitis

is plaque, the most dominant factor in the occurrence of gingivitis due to plaque

as a local irritant factor.

3.3 Eat Healthy Pregnant Women

Pregnancy is an important event in the life of a woman and her family to

obtain offspring. Pregnancy is a physiological process that can lead to changes the

female body, both physically and psychologically (Hamilton, 1995). The changes

that occur during pregnancy due to a change in the amount of estrogen and

progesterone increase thus affecting the condition of the mother. Therefore,

usually the mother during pregnancy had a variety of complaints such as pain,

nausea, vomiting, including complaints and toothache mouth. The condition of the

teeth and mouth pregnant women are especially visible in the gingival

enlargement is often characterized by gums that bleed easily due to changes in the

hormonal and vascular factors in conjunction with the local irritation in the oral

cavity (Adyatmaka, 1992).

Gingivitis is an inflammation of the gingival usually caused by the

accumulation of plaque. Clinically gingivitis is often marked by a change in color,

change shape, and consistency changes (plasticity), changes in texture, and

bleeding of the gums. Gingivitis is a disease that often in the society, because it

can strike all ages and genders. In women gingivitis can become more severe

when the woman is pregnant or called Pregnancy Gingivitis during pregnancy.

Hasibuan (2007), states that the term of pregnancy gingivitis is made to

describe the clinical gingival inflammation that occurs in most pregnant women.

Gingival changes seen in pregnancy usually begin two months of age, and will

reach its peak in the eighth. It is caused due to an increase in the hormones

estrogen and progesterone during pregnancy, as well as the vascular response that

39

causes excess to local irritation factor. Manson (1993) says that many factors such

as the cause of gingivitis, plaque, oral hygiene status, irregular arrangement of

teeth, dental caries, use orthodontic wire, oral breathing habits, and smoking.

Richard (2009) states Fusobacterium fusiformis are bacteria that are normally

present in the mouth, but if allowed to proliferate, can cause gingivitis. Prevention

of gingivitis should be done as early as possible by pregnant women to prevent

gingivitis and the risk of LBW births. Setiono (2004), by maintaining proper oral

hygiene, including regular brushing action, the use of dental floss to clean

between teeth, rinse your mouth with antibacterial solution, and the removal of the

remains of food stuck between the teeth, as well as regularly during their

pregnancy KIA is to poly and poly teeth, to prevent gingivitis during pregnancy.

As a precaution, pregnant women should gingivitis started paying attention

to oral hygiene and consuming foods that contain high fiber, such as vegetables

and fruits. The food should be consumed and avoided by pregnant women to

prevent gingivitis is:

1. Avoid too much intake of sugar. This is not to say that one should avoid

foods that naturally contain sugar. One may still continue consuming

such foods because the sugar in them are easily digested and can be

absorbed by the body easily. What one should avoid are foods wherein

sugar is added.

2. When eating, choose crunchy foods over soft foods. Crunchy foods

“crumple” when ground by the teeth, leaving little of the food particles to

be caught in between teeth. Compared to soft foods, crunchy foods

contribute little to having gingivitis. This is because soft foods tend to get

caught in between teeth and promote bacterial growth.

3. Eat plenty of fruits and vegetables, especially those that are rich in fiber.

Foods that are rich in fiber help boost the immune system of the body,

making it more resistant to periodontal diseases.

4. Consuming a balanced diet helps prevent gingivitis and keep your gums

and teeth healthy during pregnancy. Vitamin C, found in citrus fruits, bell

peppers, strawberries and tomatoes, is especially important for

preventing and treating gingivitis in pregnancy because it reduces

40

bleeding and strengthens the gums. Contrary to popular belief, added

calcium in the diet during pregnancy does not prevent tooth problems.

The body does not take calcium out of teeth to give it to the baby, but it

does take it from bones, so calcium intake is still important for that

reason.

5. Avoid chewy sweets and dried fruit, since these can stick to your teeth

and increase the chances of gum problems.

6. Brushing your teeth twice a day and using floss to clean between your

teeth are necessary to keep your teeth and gums free of plaque. Visit a

dentist before becoming pregnant to get any major procedures you need

done completed at that time.

7. Also visit your dentist during your pregnancy so he can assess the state of

your mouth and make sure that gingivitis or periodontitis has not taken

hold.

3.4 Treatments

During pregnancy, women’s bodies undergo complex physicological

changes that can adversely affect oral health. For this reason, health professionals

need to ensure that the pregnant women they serve receive needed oral health

care.

3.4.1 Prenatal Care Health Professionals

1. Assess Pregnant Women’s Oral Health Status

Ask the following questions during the first prenatal visit:

a. Do you have bleeding gums, a toothache, cavities, loose teeth, teeth that

don’t took right, or other problems in your mouth?

b. Have you had a dental visit in the last 6 months?

2. Advise Pregnant Women about Needed Oral Health Care

41

a. If the last dental visit took place more than 6 months ago or if any oral

problems (e.g., toothache, bleeding gums) are identified, tell women to

schedule an appointment with a dentist as soon as possible.

b. Encourage women to improve or maintain good oral health during

pregnancy and to attend prenatal classes.

c. Counsel women to adhere to their dentist’s recommendations for

treatment or follow-up.

3. Improve Access to Oral Health Services

a. Provide information about oral hygiene and oral health care by including

oral health topics in prenatal classes and making available educational

materials that are written at appropriate reading levels. (See Resources.)

b. On the patient intake form, include an oral health assessment that

identifies problems and offers recommendations.

c. Provide referrals as needed. (See Appendix A: Referral Form for Pregnant

Women to Receive Oral Health Care.)

d. Provide a list of dentists in the community, including those who accept

Medicaid and other public insurance programs.

3.4.2 Oral Health Professionals

1. Improve Access to Oral Health Services

a. Reduce practice-level barriers (e.g., long waits for available appointment

dates, long waits in the dental force waiting room).

b. Accept patients enrolled in Medicaid and other public insurance

programs.

c. Reduce system-level barriers (e.g., contact community based programs

such as the Special Supplemental Nutrition Program for Women, Infants

and Children [WIC] that serve pregnant women to create partnerships).

2. Conduct Health History, Risk Assessment, and Oral Examination

a. Ask weeks of gestation (due date).

b. Implement best practices (e.g., as presented in Caries Diagnosis, Risk

Assessment, and Management Protocols) in caries risk assessment and

management. (See Resources.)

42

3. Improve Access to Oral Health Services

a. Integrate oral health topics into prenatal care classes.

b. Make available educational materials that are written at appropriate

reading levels. (See Resources.)

c. Provide referrals as needed. (See Appendix A: Referral Form for

Pregnant Women to Receive Oral Health Care.)

d. Help women complete applications for insurance coverage or social

services, or for securing other necessary services such as transportation.

e. Help women access oral health care, as needed.

a. Provide a list of dentists in the community, including those who accept

Medicaid and other public insurance programs.

b. Contact a dental clinic to facilitate care.

f. Help women make decisions about oral health care and communicate

information to their dentist.

g. Perform a comprehensive gingival and periodontal examination, which

includes a periodontal probing depth record.

h. Take X-rays as needed.

i. Consider the following when developing a treatment plan:

Chief complaint (if any).

Medical history.

j. History of tobacco, alcohol, and other substance use.

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

periodontal examination.

4. Assist Pregnant Women with Disease Management

a. Develop and discuss a comprehensive treatment plan that includes

preventive and maintenance care based on an evaluation of the benefits,

risks, and alternatives.

b. Educate pregnant women about care that will improve their oral health.

c. Complete all necessary dental procedures before delivery.

d. Prioritize treatment for untreated caries.

43

e. Consider recommending the following as strategies to decrease maternal

cariogenic bacterial load:

• Use of fluoride toothpaste and mouth rinse.

• Use of chlorhexidine mouth rinse and fluoride varnish as

appropriate.

• Use of chewing gum or mints that contain xylitol.

5. Use the Following When Clinically Indicated:

a. X-rays with thyroid collar, and abdominal apron.

b. Local anesthetic with epinephrine.

c. Appropriate analgesics and/or antibiotics.

d. Dental amalgam with proper isolation and high-speed evacuation.

6. Position Pregnant Women Appropriately During Treatment

a. Keep the head at a higher level than the feet.

b. Place a small pillow under the right hip, or have women turn slightly to

the left to avoid dizziness or nausea.

7. Consult with the Prenatal Care Health Professional

a. Consult with the prenatal care health professional when considering the

following:

• Deferring treatment because of pregnancy.

• Co-morbid conditions or medication use (e.g., diabetes, hypertension,

Heparin use) that may affect management of oral problems.

• Intravenous sedation or general anesthesia to complete dental

Procedures.

8. During Pregnancy:

1. Brush teeth with fluoridated toothpaste twice a day, and floss once a day.

2. Limit foods containing sugar to mealtimes only.

3. Drink water or low-fat milk. Avoid carbonated beverages (pop or soda).

4. Choose fruit rather than fruit juice to meet the recommended daily intake

of fruit.

5. Obtain necessary oral treatment before delivery:

a. Diagnosis (including necessary dental X-rays) and necessary

treatment can be provided throughout pregnancy; however, the

44

period between the 14th and the 20th week of pregnancy is the

best time to receive treatment.

b. Treatment for conditions requiring immediate attention is safe

during the first trimester of pregnancy. Delaying necessary

treatment could result in significant risk to you, and indirectly to

your baby.

6. for frequent nausea and vomiting:

a. Eat small amounts of nutritious foods throughout the day, if

possible.

b. Chew sugarless or xylitol-containing gum after meals.

c. Rinse your mouth with a teaspoon of baking soda (sodium

bicarbonate) in a cup of water after vomiting, to neutralize acid.

d. Gently brush teeth with fluoridated toothpaste twice a day to

prevent damage to demineralized tooth surfaces.

CHAPTER IV

CONCEPTUAL MAPPING

45

4.1 Conceptual Mapping

During pregnancy, there are fluctuations in estrogen and progesterone levels

in combination with changes in oral flora and a decreased immune response the

46

Pregnant Woman on The First Trimester

Pregnant Woman on The First Trimester

Maternal Condition

Life Pattern

Behaviour

Hormonal

Exchanges

Morning Sickness

Lazy to Brushing Teeth

Snacking

Increasing of Oral

Acid

Fluctuations in Estrogen and Progesterone

LevelsBad Oral Hygine

Bacteria’s metabolism

PlaquePain and

Swollen Gum, Easy Bleeding

Calculus

Increased Depth of Pocket / teeth regardless of the gums

CariesGingivitis Gravidaru

m

Periodontits

increased level of progesterone in pregnancy causing bacteria to grow, as well as

make gum tissue more sensitive to plaque and exaggerate the body's response to

the toxins (poisons) that result from plaque

http://www.webmd.com/oral-health/pregnancy-gingivitis-tumors

The mechanism of dental caries starts with a plaque on the tooth surface.

Sucrose (sugar) from food debris and bacteria attach to proceed given time turns

into lactic acid which lowers the pH of the mouth becomes critical (5.5). This

causes demineralization of dental caries continues to be email. PH decrease

repetitive within a specified time will result in a susceptible tooth surface

demineralization and caries process begins from the tooth surface (pits, fissure

and interproximal areas) extends to the pulp.

4.2 Hypothesis

We explain that disease is gingivitis especially gingivitis gravidarum,

because the symptoms from the scenario same with symptoms of gingivitis

gravidarum there are morning sickness, swollen and bleeding gums, and also

caries. And gingivitis gravidarum disease only happens on pregnant women. We

not choose periodontitis disease because in the scenario no mention dislodged

teeth symptom, so the symptoms of scenario different with the symptoms of

periodontitis disease

CHAPTER V

CONCLUSION AND SUGGESTION

47

5.1 Conclusion

In the first trimester of pregnancy until the third period of pregnancy

pregnant women often gingivitis disease. This situation is caused by the hormonal

activity of the hormone estrogen and progesterone. Greater influence of

progesterone on the inflammatory/inflammation. Enlarged gum will decline in the

nine months of pregnancy and the few days after giving birth. The situation will

return to normal as before pregnancy.

Enlargement of the gums can be the / attack on all places or places

(single/multiple) forms rounded, smooth shiny, bright-red, soft consistency, bleed

easily when in contact with the touch

Enlarged gum in the world of dentistry called gingivitis

gravidarum/pregnancy or gravidarum / hyperplasia, gravidarum often appears in

the first trimester of pregnancy. The above situation is not necessarily the same

for every pregnant woman. In pregnant women are encouraged to keep the OH

mouth to prevent gingivitis.

Provision of dental hygiene is recommended for pregnant women and other

therapies, but this does not heal completely because hormone fluctuations of

pregnancy are uncertain. Gingivitis will decline in the nine months of pregnancy

and the few days after giving birth. The situation will return to normal as before

pregnancy.

5.2 Suggestion

Pregnant women usually affected gingivitis disease especially gingivitis

gravidarum, so they must keep their oral health during pregnancy with many

treatment for prevent or to overcome gingivitis gravidarum. Treatment for prevent

from this disease with methods : oral health education this method counseling and

early intervention by healthcare providers such as physicians, nurses, and dentists

to provide expectant mothers with the tools and resources necessary to understand

the importance of oral health care during pregnancy. Oral hygiene this method

removing the bacterial plaque, which researchers have connected to preterm birth

and low birth-weight babies, is essential. Using the correct brushing and flossing

methods greatly increase the amount of plaque that is removed from the teeth and

48

gums. Fluoride this method from The American Dental Association recommends

the use of toothpaste with fluoride by persons over the age of six. Echoing their

sentiment, the AAP oral health guidelines advise the continued use of fluoridated

toothpaste during pregnancy, and recommends the use of an over-the-counter

alcohol-free fluoride rinse to help reduce the amount of plaque in the mouth.

Then, nutrition this method educating expectant mothers about proper diet

and nutrition during pregnancy will limit unnecessary sugar intake and in turn,

prevent plaque build up. Treating existing tooth decay these methods expectant

mothers are encouraged to have existing tooth decay treated during their

pregnancy, which experts believe is a completely safe practice during pregnancy.

Restoring decayed teeth will help achieve oral health by removing the bacteria

associated with tooth decay. Transmission of bacteria these method expectant

mothers are discouraged from sharing food and utensils in order to prevent the

transmission of the bacteria known to cause tooth decay. And use of xylitol gum

this method expectant mothers are encouraged to chew xylitol gum (four times a

day) as research suggests that chewing this gum may decrease the rate of tooth

decay in children.

If pregnant women affected gingivitis gravidarum, they must overcome

with talk to dentist, to discuss any concerns they may have with their dentist.

Women who are thinking about becoming pregnant may want to consider their

oral health before becoming pregnant as research suggests that treating existing

gum disease in pregnant women does not reduce the instance of preterm birth.

Despite this fact, experts insist that regular oral health care should continue

throughout pregnancy. On the other hand, the visit to the periodontitis during

pregnancy can prevent and identify and treat the signs and symptoms of gingivitis

gravidarum in the case of necessary.

REFERENCES

Agueda, A., Acheverria, A. & Manau, C. (2008). Association between

49

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