A 

40-year-old man come to the dentist complaining of his gums bleeds easily whenbrushing
his teeth. The teeth has never been cleaned before since he is afraid to go to dentist. Patient
also has a bad habit of chewing food only on the right side. The examination showed that
many tartar (calculus) attached to the upper right molars. The surrounding gum of teeth
covered by tartar looked reddish and enlarged.

Setting Problem

1. How is tartar formed?

2. What is the causes of tartar?
3. Bleeding gums mechanism
4. What are the causes of bleeding gums?
5. What the indications of gingivitis/gums bleed?
6. What is the relation between tartar (calculus) attached to the upper right molars and
patient complaints of bleeding gums?
7. The impact of chewing only on the one side
8. The impact if tartar is allowed to continue?
9. How to prevent the bleeding gums?
10. How to prevent the tartar?
11. Why does the patient feel fear when the patient want to go to the dentist?

Analyzing Problem

1. How is tartar formed?

The first stage of dental plaque is the process attachment of the pallicle to the tooth
enamel. if u guys wondering what pallice is. Pallicle is a thin film of salivary protein that
firmly attached to the tooth surface only a few minutes after cleansing. The pallicle protect
the enamel from acid activity and acts as a double side adhesive to the tooth surface and
make a sticky surface on the other which make it easier for bacteria to stick to the tooth.

The second stages is that pallicle colonized by steptococcus mutans and streptococcus
saguins by converting glucose and carbohydrates in food into acid through the fermentation
process.

The last stage is when there is combination of bacteria, acid, food residue and saliva. That
will make yellowish substance that stick to the tooth surface called plaque. If we didn’t clean
the plaque properly, it can be harder or mineralize and become a tartar that stick to the
tooth surface.

It is formed when the bacteria that is naturally occurring in the mouth mixes with remnants
of food particles to form a sticky film known as plaque. When plaque is left untreated, it
hardens and discolors, forming into tartar.

Calcium and phosphate in saliva are important in the process of remineralizing enamel and
also play a role in the formation of tartar because Saliva is a liquid that is secreted directly
into the oral cavity by the salivary glands. Saliva contains calcium ions, combined with
phosphorus to form calcium phosphate, a solid material. Calcium phosphate which is
supersaturated in saliva will cause this compound to settle on the enamel, at first calcium
phosphate is a fine precipitate and adheres to the tooth surface as a soft layer, and over
time this material will harden and become increasingly difficult to remove. as much as 95%
of the mineral calcium hydroxyapatite. The tooth surface under physiological conditions has
a negative charge. Therefore, positively charged ions, such as calcium ions (Ca2+) and
salivary biopolymers (especially proteins) can be absorbed by the body. But negatively
charged biopolymers can only be absorbed through positively charged divalent ions.
Although the teeth have a self-cleansing system from the activity of the oral cavity, the
teeth can still be coated with calcium phosphate deposits, even if it is only a thin layer.
Tartar can cause several diseases, such as heart disease, menopause, and other oral
diseases and can affect Tartar formation is pH and oral hygiene. An acidic pH can stimulate
the mouth to secrete more saliva so that calcium is supersaturated in the saliva and
consequently accelerates the formation of tartar. Teeth that are not cleaned properly will
not remove the pellicle that is attached to the enamel, this pellicle gets thicker and hardens
over time to form tartar. Recent research states that tartar in smokers is more than non-
smokers due to increased calcium content in saliva, the higher the concentration of calcium
in saliva, the higher the concentration of calcium in saliva, the higher the concentration of
calcium in saliva.

2. What is the causes of tartar?

 When saliva, food, and fluids combine in your mouth they produce an environment
that allows the bacteria to grow and deposit which collect on teeth and gums and
especially where the teeth and gums meet. Common foods that contribute to plaque
formation and growth include those containing carbohydrates, or simple sugars,
such as sucrose and starches, found in soft drinks and candy. Eating those foods can
cause an increase in plaque bacteria. Plaque hides between teeth and under the
gum line. There’s no way to avoid it entirely so it’s important to maintain a good oral
routine to keep it from accumulating. Certain foods, especially carbohydrates (foods
containing sugars or starches), are big contributors to plaque growth such as milk,
soft drinks, cake, and candy. Plaque can be a pale yellow color, but it can also be
colorless making it difficult to see
 Physical environment, including the anatomy and position of the teeth.
In conditions of convexity of the tooth surface, malpositioned teeth, defective
enamel surface and others, it is seen that the amount of plaque formed will be more
than a good tooth position.
 As the bacteria begins to colonize the surface of the tooth, other species such as
Veillonella, Actinomyces, and Capnocytophaga, which are both gram positive and
negative bacteria, begin to contribute to the colonization and creation of the plaque.
Between the first and third week, if the plaque is not removed, an anaerobic
environment is created.
 in medical news, tartar or plaque is a combination of bacteria and an extracullar
matrix that adheres to the outer surface of the tooth
 proteolitycs bacteria, which breakdowns protein, mostly accumulated in subgingival
crevice. It results ammoniac compound as metabolite --> increase pH --> stimulating
precipitation of Ca Phosphate --> plaque calcification --> calculus/tartar
  Tartar formation is related with high saliva flow rate. calculus formation
predominantly occurred on the lingual surfaces of incisors and canines & buccal
surfaces of maxillary molar which is close to saliva gland.

3. Bleeding gums mechanism

Problems such as bleeding gums can be a sign that your gums are not being properly cared
for and need more attention. While you don’t need to panic if you notice bleeding gums,
you do need to take action to help prevent the progression to a more advanced form of gum
disease. Since so many people have gingivitis and bleeding gums, people often don’t take it
seriously enough.

The Most Common Cause

Bleeding gums are most often caused by harmful plaque – and the millions of bacteria in it –
found at or around the gum line being left to develop gingivitis. Gingivitis, a mild form of
gum disease, may require treatment and improved oral hygiene to help eliminate it. If left
untreated, bleeding gums and gingivitis can lead to a more serious form of gum disease
called periodontitis.
Other Causes
If you don’t have gingivitis, but still suffer from bleeding gums, don’t ignore the problem.
Bleeding gums can also be caused by bleeding disorders, leukemia, vitamin K deficiency,
hormonal changes, scurvy or the use of blood

The process of gingivitis is divided into several stages

 The first stage

Plaque found on the teeth near the gums causes the gums to be red (older than pink),
slightly swollen (rounded, and shiny, not thin and speckled like orange peel), easy to bleed
when brushed (due to a small wound in the gum pocket), no pain.

 Second stage

After several months or years this inflammation persists. Plaque can cause the uppermost
fibers between the jawbone and tooth root to decay, and this is followed by partial loss of
the jawbone at the site of attachment. The gum pocket also deepens with a decrease in
jawbone height, the gums remain red, swollen and bleed easily when brushed, but are not
painful.

 Third phase

After several months without proper plaque clearance, a third stage may occur. By this time
more jawbone will be damaged and the gums are dropping, although not as fast as the bone
is. The gums are getting deeper (more than six mm), as bone is lost, the teeth become sore,
loose and sometimes the front teeth start to move from return position. The redness,
swelling, and bleeding were still as before, and there was still no pain.

 Fourth stage
After a few more years without proper plaque removal and gum care, the final stage has
been reached, now most of the bone around the teeth has been damaged so some teeth
become very loose, and start to hurt, at this stage it is a stage of left gingivitis, Thus,
gingivitis progresses to the most acute stage, periodontitis.

 plaque that is not removed will harden into tartar. This will lead to increased
bleeding and a more advanced from of gum and jaw bone disease kwnon as
periodontist.

4. What are the causes of bleeding gums?

There are 2 factors that cause gums bleeding or gingivitis, namely local factors and systemic
factors

a. Local factors

1) Dental plaque
Dental plaque is a soft deposit that forms a biofilm that accumulates the surface of the teeth
or other hard surfaces in the oral cavity such as restorations loose and tight.
2) Dental calculus
Dental calculus is a calcified mass that adheres to the tooth surface natural or artificial
teeth. Usually the calculus consists of plaque of bacteria that has undergo mineralization.
Based on the location of the attachment associated with the edge

Gingival calculus can be divided into supragingival and subgingival calculus

3) alba material
Alba material is a soft deposit, adherent, yellow or grayish white, and its adhesion is lower
than plaque dental.
4) Dental stains are pigmented deposits on the tooth surface
5) Debris / food waste

b. Systemic factors

1) Endocrine (hormonal) factors include: puberty, pregnancy, and Menopause

2) Nutritional disorders and deficiencies include: vitamin deficiency
3) Protein deficiency and drugs include: drugs that cause non-inflammatory gingival
hyperplasia and hormonal contraception
4) Hematological diseases: leukemia and anemia
 vitamin deficient,
 dentures to tight and bleeding disorders such as hemophilia and leukemia.
 too little vitamin c, thrombocytopenia,leukemia,diabetes,periodontitis
 Gum Trauma, if you accidentally poke your gums with a sharp or abrasive object,
could lead to bleeding of the gums, and leave vulnerable to infections.
 Brush the teeth to hard may injure the gums

5. What the indications of gingivitis/gums bleed?

irritated, red, swollen and when brushing teeth, the gum would easily bleeds
 6. What is the relation between tartar (calculus) attached to the upper right molars and
patient complaints of bleeding gums?

Because the plaque found on the teeth near the gums causes the gums to become red and
slightly swollen, it bleeds easily when brushed (due to a small wound in the gum pocket).
And the case in the scenario above is stage 1 gingivitis

7. The impact of chewing only on the one side

limitation or difficulty on opening and closing of the mouth, felt pain on the joint, clicking or
popping sound, became tartar, gingivitis, digestive problem and jaw lock
facial asymmetry and periodontitis
Chewing on one side of the mouth can lead to strain, sensitivity and sometimes TMD
(temporomandibular disorders). This disorders can result in jaw problems such as locking
and pain in the jaw joints.

8. The impact if tartar is allowed to continue?

tartar impact allowed to continue too long can cause bleeding gums, bad breath, swollen
teeth, inflammation of the gums, to blockage of blood vessels.
These causes come from the deposition of coarse materials, saliva and blood, do to an
inflammation. Calculus has a rough surface so that food debris and saliva adhere to the
tooth surface
so, tartar will continue to form and increase in size so that it can cover part of the surface of
the teeth and can also be on the surface of the roots and of the teeth under the edge of the
gums. If this situation is allowed to continue, this tartar will cause periodontal tissue
abnormalities.
Plaque and tartar must be removed from your teeth promptly or they can cause serious
problems. Plaque is a sticky, clear film full of bacteria that builds up on teeth. Bacteria
produces acid that destroys a tooth's protective coating, called enamel. Over time, failing to
remove plaque can lead to tooth decay and cavities, and can lead to more serious health
problems.

Plaque that's allowed to remain on teeth can harden into a destructive substance called
tartar that forms along the gum line. The bacteria in plaque and tartar can promote
inflammation of the gums, known as gingivitis. This mild form of gum disease can
deteriorate into a more serious condition called periodontitis. Untreated periodontitis can
result in bone loss and lost teeth.

9. How to prevent the bleeding gums?

 by brushing your teeth with soft toothbrush, brushing your teeth with antigingivitis
toothpaste, do dental floss daily, and see a dentist regularly
 Keep your teeth and mouth clean
Because Bleeding gums can be a sign of poor oral and dental hygiene.
 Gargle with mouthwash
Gargle with a mouthwash containing hydrogen peroxide to remove plaque, improve gum
health, and stop bleeding gums
  Increase your intake of vitamin C
Eating foods rich in vitamin C can strengthen your immune system and help fight off the
gum infections that cause bleeding gums. Eat fewer carbs
has found that reducing your carbohydrate intake may also improve gum health and
prevent gum disease. Drink green tea
Drinking green tea on a daily basis may also reverse periodontal disease and stop bleeding
gums.

10. How to prevent the tartar?

 brushing teeth twice a day for 2 minutes, by brushing your teeth properly.use a
toothpaste that contains fluoride and a toothbrush with soft bristles.
 Use dental floss and mouthwash Also clean your teeth with dental floss at least once
a day after brushing your teeth. It aims to remove plaque and food residue
 Reduce sugar consumption It is proven that plaque-causing bacteria develop due to
the consumption of foods or drinks that contain a lot of sugar.
 Drink enough water Water serves to lift bacteria and dirt in the mouth that can
trigger the buildup of plaque that causes tartar.
 Avoid smoking and alcoholic beverages These bad habits can increase the risk of
dental and oral health problems, including the formation of tartar.
 Eat a healthy diet , The food you eat will either feed or starve the bacteria in your
mouth, so try to cut back on sugary foods and eat more vegetables

Efforts can be made to prevent and control the formation of dental plaque, including
regulating food patterns, chemical action against bacteria and extracellular polysaccharides
and mechanical action in the form of cleaning the oral cavity and teeth from all food
residues, bacteria and their metabolic products.

Regulating Diet (The first action that can be taken to prevent or control plaque formation is
to limit foods that contain lots of carbohydrates, especially sucrose. Foods that are soft and
easily stick to the teeth should be avoided as much as possible.)

11. Why does the patient feel fear when the patient want to go to the dentist?

Those who aren’t embarrassed or afraid of a dental visit itself might be facing another fear:
the fear of not being able to afford treatment. Many people don’t have dental insurance,
and even those that do will find that some treatments aren’t covered. With the average cost
of medical treatment in the world being so high, it’s natural to be afraid of ending up with a
huge bill

dental anxiety has many causes and factor such as:

 personality characteristic

 fear of pain

 past traumatic dental experiences

  the influence of dentally anxious family members or peers

 blood injury fears

management to reduce dental anxiety:

 allowing sufficient time for the dental appointment

 minimizing triggers

 introducing relaxation methods; by reducing physical muscle tension, so the patient

will have less fear and more aware of their stressed

 good communication; if we had good communication/manners. patient will enjoy

the treatment and has less anxiety to go to the dentist

 anxious patients who must undergo

 restorative procedures are often managed using the “4 S” rule

 which aims to reduce the triggers of stress

 Sights (e.g. needles, drills)

 Sounds (drilling)

 Sensations (high frequency vibrations – with a high annoyance factor)

 Smells (clinical odours, such as eugenol and bonding agents)

using alternative methods such as

• atraumatic restorative technique (ART)

• Ultra-low speed cutting

• Polymer bur cutting

• Chemo-mechanical caries removal

• Air abrasion

• Pulsed Er:YAG and Er,Cr:YSGG lasers

• Ultrasonic instruments with diamond-coated tips