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HUMANS AND THE ENVIRONMENT

GROUP : K TUTOR : Bambang Surjanto, drg., MS. 1. Arinil Haque 2. Cornelia Johana C. 3. Reno Andrey S. 4. Luluk Rahmawati 5. Amelia Sinta M. 6. Dita Dwi Firza Putranto 7. Indira Ika Christianti 8. Valita Aulia Andari 9. Diyang Mahiswari 10. Nathania Astria 11. Christopher 12. Eghia Laditra A. 13. Intan Ayu Rizki P. 14. Ainani Dwi Hapsary 021211133050 021211133051 021211133052 021211133053 021211133054 021211133055 021211133056 021211133057 021211133058 021211133059 021211133060 021211133061 021211133062 021211133063

FACULTY OF DENTISTRY AIRLANGGA UNIVERSITY 2012

PREFACE Firstly, we would like to thank God Almighty for His presence and blessings so we could finish this problem based learning scientific paper which is named Humans and The Environment on time. We also thank many people who helped us on this project with an honour : 1. Bambang Surjanto, drg., MS, as a director of Modul 3 : Humans and The Environment, who helped, gave lecture to us and always monitored about what we were discussing in small class. 2. Taufan Bramantoro, drg., MKes, as our best instructor and guide, who helped us with the discussion and his guidance to enrich our knowledge and paradigm. 3. All lecturers who have given lectures that could help us when discussing the issue. 4. All members who have contributed ideas in group discussion and paper-making. Arinil, Cornelia, Reno, Luluk, Amelia, Dita, Indira, Valita, Diyang, Nathania, Christoper, Eghia, Intan, and Ainani . Keep the good teamwork. 5. All people who have helped and given support to us. We realize this paper is still far to be said as a perfect paper, so a lot of suggestions and constructive criticism are very welcome expected. In the end, we hope this paper can be useful for all the readers.

Surabaya, May 2013

Author

ABSTRACT

We were given a case where a 45 years old female patient is diagnosed with oral cancer. The patient has denture applied in her mouth by Tukang Gigi. Our analysis suggests that the oral cancer is caused by the wrong technique of denture appliance by the Tukang Gigi. Factors such as root fragments and genetic also contribute to the formation of oral cancer. We also consider environmental factors such as social, economical, and educational factors to affect the patients decision to apply the denture in the hands of Tukang Gigi. This scenario can be avoided by giving the society dental education about certain diseases.

Keywords: oral cancer, acrylic denture, residual monomer, denture stomatitis, root fragments, Tukang Gigi.

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CONTENT

PREFACE........................ ii ABSTRACT .................... iii CONTENT ...................... iv CHAPTER 1. INTRODUCTION .............. 1 1.1. Background................... 1 1.2. Problems............................................................................................ 2 1.3. Objectives.......................................................................................... 2 1.4. Hypothesis......................................................................................... 2 1.5. Benefits.............................................................................................. 3 CHAPTER II. REVIEW OF LITERATURES .................... 4 2.1. Oral Cancer .................. 4 2.2. Candida albicans and Denture Stomatitis........................................ 13 2.3. Root Fragments................................................................................. 19 2.4. Denture Base Polymers .................... 21 2.5. Residual monomer............................................................................ 33 2.6. Illegal Dental Practice ...................... 35 CHAPTER III. CONCEPT MAPPING.... 38 CHAPTER IV. DISCUSSION........................ 39 4.1. Scenario......................... 39 4.2. Analysis.................................................................................... 39 CHAPTER V. SUMMARY........................ 42 5.1. Conclusion........................ 42 5.2. Suggestions....................................................................................... 42 REFERENCES....................... 43

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CHAPTER 1 INTRODUTION

1.1. Background The environment is a vital component to the human health. Every aspect of the environment, be it the physical, social, cultural, or economical aspect, greatly influences our lives. That is why the society should pay more attention to their environment in order to create a healthy living. The situation right now, however, is still far from how a good environment should be. Many environment-related diseases are still widely spread among the society. Physical factors such as pollution still contribute greatly to many kind of diseases. Lack of education about the importance of health also causes a lot of communities to have unwanted health problems. Furthermore, the social aspect and lifestyle can also be a very influential factor in the spreading of diseases. Among those many health problems, the oral cavity is one of the most important points to look at since many dangerous diseases are originated from there. A good example would be the oral cancer, otherwise known as squamous cell carcinomas. This is one disease that should not be overlooked, since this disease may cause mortality in some cases. The best way to counteract problems like this is by preventing the exposure from the related agents. This can be done by creating a healthy and safe environment for the people to live in. For example, by giving necessary information about the dangers of disease and the basic symptoms to the society, an early diagnosis can be performed. Unfortunately, right now many people are still unaware of the importance in keeping a healthy environment. To make it even worse, there are still a lot of unlicensed dental practitioners that perform dental services without considering the risk of certain diseases. A clear example would be the application of dentures without the proper techniques which leads to a variety of oral health problems such as denture stomatitis or the oral cancer. This condition makes it harder for the society to live

in a disease-free environment. This kind of problem should be dealt quickly, otherwise the spreading of diseases might get worse from time to time. Based on the problems stated above, it is important for us to stay aware of our environment. There are many ways for us to be exposed to diseases form the environment, especially those that affects the oral cavity. Understanding the dangers of certain aspects in the environment will help us in avoiding unwanted diseases.

1.2. Problems From the background stated above, we formulate the problems as follows. 1. 2. What is the relationship between human and environment? What is the relationship between social, politic and economic aspect with utilization of environment? 3. What are the factors of environmental pollution based on system approach? 4. What is the relationship between genetic and microorganism aspect?

1.3. Objectives The objectives of this paper are: 1. 2. To explain the relationship between human and environment. To explain the relationship between social, politic and economic aspect with utilization of environment. 3. To explain the factors of environmental pollution based on system approach. 4. To explain the relationship between genetic and microorganism aspect.

1.3.

Hypothesis The main cause of the patient's oral cancer is the wrong appliance of

denture by Tukang Gigi. The Tukang Gigi uses a wrong type of denture base material without any retention. The denture itself is not removes for three years, resulting in a condition known as denture stomatitis. Supporting factors of the oral cancer formation includes the root fragments and the passed down cancer gene from the patient's mother.

1.4.

Benefits From the creation of this paper, we hope that readers can understand the

relationship between human and environment. We would also like to inform the readers the effects of denture self-cured acrylic and appliance of denture by Tukang Gigi. From these understandings, we expect that people would be more aware in applying denture and maintaining oral health. Finally, from the materials written in this paper, we hope that this paper can provide a great learning issue to both readers and writers.

CHAPTER 2 REVIEW OF LITERATURES

2.1. Oral Cancer Oral cancer, a subtype of head and neck cancer, is any cancerous tissue growth located in the oral cavity. It may arise as a primary lesion originating in any of the oral tissues, by metastasis from a distant site of origin, or by extension from a neighboring anatomic structure, such as the nasal cavity. Alternatively, the oral cancers may originate in any of the tissues of the mouth, and may be of varied histologic types: teratoma, adenocarcinoma derived from a major or minor salivary gland, lymphoma from tonsillar or other lymphoid tissue, melanoma from the pigment-producing cells of the oral mucosa (Werning, 2007). There are several types of oral cancers, but around 90% are squamous cell carcinomas, originating in the tissues that line the mouth and lips. Oral or mouth cancer most commonly involves the tongue. It may also occur on the floor of the mouth, cheek lining, gingiva (gums), lips, or palate (roof of the mouth). Most oral cancers look very similar under the microscope and are called squamous cell carcinoma. Age is frequently named as a risk factor for oral cancer, as historically it occurs in those over the age of 40. The age of diagnosed patients may indicate a time component in the biochemical or biophysical processes of aging cells that allows malignant transformation, or perhaps, immune system competence diminishes with age (Oral Cancer Foundation, 2012). Shah & Kaur (2013) explains that the carcinogenesis is a process by which normal cells are transformed into cancer cells and is characterized by a progression of changes on cellular and genetic level that ultimately reprogram a cell to undergo uncontrolled cell division, thus forming a malignant mass. Mutations in DNA that lead to cancer (only certain mutations can lead to cancer and the majority of potential mutations will have no bearing) disrupt these orderly processes by disrupting the programming regulating the processes. Carcinogenesis is thus, caused by this mutation of the genetic material of normal cells, which

upsets the normal balance between proliferation and cell death. This results in uncontrolled cell division and the evolution of those cells by natural selection in the body. Cancers are caused by a series of mutations. Each mutation alters the behavior of the cell somewhat. The mutations of cancer cells are shown in the following figure.

Figure 1. Series of mutations causing cancer from normal cells. Silverman (2003) states that the tongue is the most common site for oral cancer in both American men and women. This is also true of developed countries. However, in some developing countries, site prevalences differ, owing to different habits. Oral cancer incidence has remained stable, relative to the occurrence of newly diagnosed cancers of all sites, with absolute numbers only slightly increasing each year. The only oral site contrary to this trend was the lip, in which a reduction occurred over the past 10 years. This trend may reflect the public education regarding the dangers of ultraviolet light exposure and the use of sunscreens and hats outdoors. Comparing the past two decades, the greatest increase in oral cancer sites occurred in the tongue. Oral cancer malignancies accounted for 53% of tongue cancers. Patient profiles are further illustrated by findings in 595 oral cancer patients from the Oral Medicine Clinic, University of California, as seen in the following table.

Table 1. Characteristics of oral carcinomas in 595 patients: association of site, stage, and diagnostic patterns. First Mean delay time Pain as first complaint consultation with a dentist (%) 4.2 3.0 3.4 3.5 3.4 5.0 4.5 66 56 59 64 52 27 50 36 16 44 52 50 46 57

Localized Site stage at diagnosis (%) Tongue Oropharynx Mouth floor Gingiva Buccal Lip Hard palate 51 43 64 56 79 88 75

2.1.1. Symptoms The most common symptom of oral cancer is a nonhealing ulcer in the mouth followed by persistent pain. Other common symptoms include a mass in the mouth, persistent halitosis, or bleeding. Trismus; loose teeth; neck mass; and difficulty with speech, swallowing, or breathing are later symptoms, usually indicating more advanced disease. When these symptoms persist longer than 3 weeks, a focused examination for oral cancer is imperative. The lesion may present as an irregular ulcer, a thickened white or red patch, friable mucosa, or a submucosal mass. Oral cancer is often very curable when detected at an early stage. The same is not true of later stage disease. The ease of examination and access for biopsy make late recognition of disease particularly regrettable (Fischer, 2007). Oral cancer patient should be assessed for tissue changes that may include a red, white, or mixed red-and-white lesion; a change in the surface texture producing a smooth, granular, rough, or crusted lesion; or

the presence of a mass or ulceration. The lesion may be flat or elevated and ulcerated or nonulcerated and may be minimally palpable or indurated. Loss of function involving the tongue can affect speech, swallowing, and diet. The figure below shows the appearance of altered tissues caused by cancer (Glick et al, 2008).

Figure 2. Symptoms of oral cancer including irregular erytholeukoplakia, indurated and ulcerated lesion. Oral cancer occasionally arises from other oral conditions such as erythoplakia, which begins with a velvety red patch of tissue inside the mouth. This is always considered precancerous. Leukoplakia is marked by whitish tissue and is occasionally precancerous. Suspicious tissue changes may signal orla cancer. Symptomps of oral cancer are: a swollen lymph node in the neck, a whitish or velvety red patch of tissue (instead of normal pink membrane) in the oral cavity (may indicate a potential precancerous condition). If left untreated, the discolored patch may grow and begin to feel like canker sore, discomfort when swallowing, eating, or drinking, toothache, loose teeth, or an earache that wont respond to normal treatment. Advanced oral cancer symptoms include pain in the ear or roof of the mouth, unexplained spasms in facial or neck muscles, or continual bad breath (Wall, 2002).

2.1.2. Etiology According to Kravchenko et al (2009), cancers are primarily an environmental disease with 9095% of cases attributed to environmental factors and 510% due to genetics. Environmental, as used by cancer researchers, means any cause that is not inherited genetically, not merely pollution. Common environmental factors that contribute to cancer death include tobacco (2530%), diet and obesity (30 35%), infections (15 20%), radiation (both ionizing and non-ionizing, up to 10%), stress, lack of physical activity, and environmental pollutants. Known risk factors include smoking tobacco and drinking alcohol, which account for around 75 percent of mouth cancers, but the practice of chewing tobacco, paan, areca nut and gutkha favored by some ethnic groups is even more dangerous and ignorance of the risks are very high. A number of local authorities with large Asian populations are running public health campaigns to raise awareness of the dangers of chewing tobacco, and the benefits of stopping its use. There is also evidence from recent US studies that relates the human papilloma virus (HPV) to more than 20,000 oral cancer cases in the past five years, leading experts to predict that HPV could overtake tobacco and alcohol as a major risk factor within the coming decade. Poor diet is linked to around a third of cases. While it is clear there are many contributory factors and also o great need for sensitive and empathetic advice, the biggest single factor in the rampage of mouth cancer is ignorance - about symptoms and causes, which in turn leads to delays in diagnosis and treatment with the resultant unnecessary and tragically high death toll (Warnakulasuriya & Cook, 2012). The incidence of oral cancer increases with age in all parts of the world. In the west, in 98% of cases the patients are over 40 years of age. In the high-prevalence areas of the world, however, in many cases patients are less than 35 years old, owing to heavy abuse of various forms of tobacco. Furthermore, it is now clear that in many Western countries there

has been an alarming rise in the incidence of oral cancer (particularly among younger man), a trend that appears to be continuing. It is also clear that a number of cases of oral mucosal squamous cell carcinoma occur in both young and old patients, often in the absence of traditional alcohol and tobacco risk factors, and in which the disease may pursue a particularly aggressive course (Shah et al, 2003). Gorenchtein et al (2012) explains how genetics, in this case the microRNAs, contribute to the formation of oral cancer. MicroRNAs (miRNAs) represent a large family of ~22-nucleotide-long, non-coding, single-stranded RNA molecules that are endogenous to mammalian cells. They are believed to serve as crucial post-transcriptional regulators of gene expression. Given this pivotal function, miRNAs affect almost every cellular process and significantly have been implicated in numerous disease types, including cancer. Alterations in miRNA expression are now known to be a common feature across human malignancies. Both tumorsuppressive and oncogenic miRNAs have been uncovered, with the former down-regulated in disease and the latter up-regulated. The mechanisms that underlie miRNA expression changes in cancer are similar to those controlling the expression of protein-coding genes. For a summary of these miRNA regulatory mechanisms and their impact on tumorigenesis, please refer to the following figure.

Figure 3. Schematic review of cancer formation via miRNA deregulation. For OSCC, aberrantly expressed miRNAs have been shown to contribute directly to many cancer phenotypes and have been implicated in specific clinical outcomes. Furthermore, it has been shown that miRNA expression can be used for stratification of disease in several contexts (site of origin, chemo-response, patient survival, etc.). Once validated in larger trials, biomarkers based on these findings have the potential to guide detection, risk assessment, and treatment decisions of OSCC patients. miRNA targeting therapies may also have utility for OSCC (given the pivotal role emerging for these small RNAs in disease processes), though this remains a long-term objective at this time (Gorenchtein et al, 2012). 2.1.3. Diagnosis Goodson et al (2005) suggests that an examination of the mouth by the health care provider or dentist shows a visible and/or palpable (can be felt) lesion of the lip, tongue, or other mouth area. As the tumor enlarges,

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it may become an ulcer and bleed. Speech/talking difficulties, chewing problems, or swallowing difficulties may develop. A feeding tube is often necessary to maintain adequate nutrition. This can sometimes become permanent as eating difficulties can include the inability to swallow even a sip of water. There are a variety of screening devices that may assist dentists in detecting oral cancer, including the Velscope, Vizilite Plus and the identafi 3000. There is no evidence that routine use of the VELscope in general dental practice saves lives. However, there are compelling reasons to be concerned about the risk of harm this device may cause if routinely used in general practice. Such harms include false positives, unnecessary surgical biopsies and a financial burden on the patient. While a dentist, physician or other health professional may suspect a particular lesion is malignant, there is no way to tell by looking alone - since benign and malignant lesions may look identical to the eye. A non-invasive brush biopsy (Brush Test) can be performed to rule out the presence of dysplasia (pre-cancer) and cancer on areas of the mouth that exhibit an unexplained color variation or lesion. The only definitive method for determining if cancerous or precancerous cells are present is through biopsy and microscopic evaluation of the cells in the removed sample. A tissue biopsy, whether of the tongue or other oral tissues and microscopic examination of the lesion confirm the diagnosis of oral cancer or precancer. There are six common species of bacteria found at significantly higher levels in the saliva of patients with oral squamous cell carcinoma (OSCC) than in saliva of oral-free cancer individuals. Three of the six, C. gingivalis, P. melaninogenica, and S. mitis, can be used as a diagnostic tool to predict more than 80% of oral cancers. Schmidt (2012) explains the available methods and devices for the evaluation of suspicious oral lesions: 1. Toluidine blue: Toluidine blue is a vital stain that binds to nuclear material and preferentially stains tissues with high rates of cellular

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proliferation. Toluidine blue is an effective adjunctive screening tool for identifying premalignant lesions or oral cancer recurrences in those who have already been diagnosed with oral dysplasia or oral cancer. 2. Tissue fluorescence: Certain cellular molecules, especially those within mitochondria and lysosomes, absorb the energy from light of specific wavelength. When these molecules move back to their unexcited state, the absorbed energy is released. This energy is referred to as fluorescence emissions. 3. Tissue reflectance: Chemiluminescence, or tissue reflectance, is an adjunctive screening tool that is used to detect cervical premalignant or malignant developed lesions. for Two the systems cavity using are

chemiluminescence

oral

ViziLitePlus and MicroLux DL. The increased nuclear to cytoplasmic ratio characteristic of squamous cell carcinoma increases light reflectance relative to normal epithelium. 4. Brush cytology: The brush biopsy (Oral CDx from CDx Laboratories) is intended for oral lesions that appear innocuous and would not normally be biopsied by the provider. The brush biopsy is intended to be an adjunct diagnostic tool and not a screening tool. 5. Genomics: The human genome project, completed in 2002, was to revolutionize surgery and medicine. Scientists predicted that once the entire human genome sequence was known that many cancers, including oral cancer, would be curable. However, our

comprehensive understanding of the human genome has not cured cancer. The high mortality rate for oral cancer is due to several factors, but unquestionably it is believed that the most important reason is a delay in diagnosis. Oral lesions are easily accessible; therefore, OSCC should be identified early because early diagnosis is also important for effective treatment. However, patients are often diagnosed with advanced-stage

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disease. In most cases, diagnosis is delayed because the patient does not seek treatment or does not have easy access to professionals to diagnose the disease. The oral cytopathology method is a simple, noninvasive, relatively painless, and rapid diagnostic technique. Therefore, it is suitable for routine application in screening programs, early analysis of suspicious lesions, and post-treatment monitoring of malignant lesions. The real value of this technique for the early detection of OSCC is controversial. Although many studies have demonstrated the value of oral cytopathology as a diagnostic tool for OSCC, other professionals disagree with its application (Fondes et al, 2013).

2.2. Candida albicans and Denture Stomatitis The human oral cavity is known to harbor a multitude of organisms. Among them, Candida albicans has lately become a cause of great concern to the dental profession. Coexistence of Candida species, either as a commensal and/or as a pathogen has attracted the attention of many investigators. Candida albicans has been termed as a notorious opportunistic pathogen amongst similar species (Devarhubli et al, 2011). Candida albicans is an innocuous commensal of the microbial communities of the human oral cavity. Its primary location is the posterior tongue and other oral sites as the mucosa, while the film that covers the dental surfaces is colonized secondarily. Frequently, when the host defense system suffers because of any alterations, like immunodeficiency, C. albicans become virulent and generates candidiasis, that can be manifested through various clinical forms, involving one or more oral sites, up to affect the whole oral cavity and to disseminate into invasive forms. Candida-associated denture stomatitis is a very common inflammatory process affecting about 60% of the subjects carrier of a prosthesis (Salerno et al, 2011). Candida infections are common and often recurrent, and represent a significant clinical problem. Host factors play a more important role than

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organism virulence in the pathogenesis of oral candidosis, and intraoral environment conditions, such as the presence of dentures, also play a crucial role in the disease. Candidosis is most commonly caused by Candida albicans. Other species including C. tropicalis, C. glabrata, C. parapsilosis and C. krusei have also been isolated from denture wearers. In these patients, an important infection described as Candida-associated denture stomatitis (DS) occurs in about 50-60% of them (Rabelo et al, 2011). The word stomatitis means inflammation of oral mucosa. Denture stomatitis is a term used in the literature to indicate an inflammatory state of denture bearing mucosa. Denture stomatitis is also known as denture-induced stomatitis, denture sore mouth, inflammatory papillary hyperplasia and chronic atrophic candidiasis. It is one of the most common problems in elders wearing complete or partial dentures. Incidence occurrence is 11-67% of complete denture wearers and is more common in women than men. Palatal mucosa is the most common site for the fungi to grow where it is covered by the denture base (Pattanaik et al, 2010). According to Hoshing et al (2011), fungi normally live as innocuous commensals and colonize various habitats in humans, notably skin and mucosa. Commensal existence of oral Candida species varies from 20 to 50% in a healthy dentulous population. As growth on surfaces is a natural part of the Candida lifestyle, one can expect that Candida colonizes denture. There is a large body of evidence indicating that Candida is able to adhere to acrylic resin dentures. This is the first step that may lead to the development of the infectious process and that may ultimately result in varying degrees of denture stomatitis of the adjacent mucosa. Candida adheres directly or via a layer of denture plaque to denture base (polymethylmethacrylate). The pathogenesis of the Candida-associated denture stomatitis is elaborate and multifactorial. It includes local and systemic factors related to the host and to the Candida capability to adhere and proliferate in the host epithelial tissues. Candida-associated denture stomatitis is able to rise up when the conditions of the micro oral environment are favorable for the growth and the adhesion of the yeast

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and also when systemic factors of the host bring to a depression of the mechanisms of defense (Salerno et al, 2011). Pattanaik et al (2010) explains that denture stomatitis can be classified according to its clinical appearance (Newton classification) as: 1. Type I: A localized simple inflammation or pinpoint hyperemia. 2. Type II: An erythematous or generalized simple type seen as more diffuse erythema involving a part or the entire denture-covered mucosa. 3. Type III: A granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and the alveolar ridges. It should be noted that type III often is seen in association with type I or type II. The following figure shows the clinical appearance of each denture stomatitis type (Pattanaik et al, 2010)

Figure 4. Clinical appearance of denture stomatitis: type I (top-left), type II (top-right), and type III (bottom).

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2.2.1. Etiology Numerous studies have been done in the past to study the causes of the disease, but the main cause has not been agreed upon. Studies have pronounced different factors causing denture stomatitis like traumatic occlusion, poor oral and denture hygiene, microbial factors, age of the denture, allergy to the denture base materials, residual monomer, thermal stoppage below the denture, smoking, various types of irradiation, dryness of mouth, systemic conditions, diabetes mellitus and immunodeficiency, nutritional deficiencies, and medications. Plaque on the inner surface of the denture harbors microorganisms causing inflammation of the mucosa (Naik & Pai, 2011). Demographic factors include increasing age of denture wearers, female gender, smoking, and concurrent illnesses that compromise immune function. Factors related to denture use itself include poor-tting dentures, which exacerbate oral mucosal trauma and irritation, increasing age of the denture, use of maxillary versus mandibular dentures, lack of appropriate denture care and hygiene, the presence of pathogenic microbial infection (primarily Candida), and continual wearing of dentures. These factors have been considered in prior reviews. Past reviews also suggest a potential role of contact allergy from denture materials in denture stomatitis. While an allergic response may have been a signicant contributory factor in denture stomatitis in the past, use of modern denture materials have virtually eliminated allergic response as a signicant risk factor in denture stomatitis. The current view is that the etiology of denture stomatitis is multifactorial, and has a number of associative factors rather than a single cause. Poor denture hygiene, pathogenic Candida infection, and continual wearing of dentures appear to be the predominant associated etiological factors for denture stomatitis and represent likely targets for interventions using a combination of pharmacological therapy provided by healthcare professionals and improved denture hygiene by denture users (Gendreau & Loewy, 2010).

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Hoshing et al (2011) explains that denture stomatitis is associated with various local factors, including: 1. Traumas: Traumas are considered as the main liable to determine Candida-associated denture stomatitis with none association with the microbial communities and the presence of denture. 2. Role of Salivary Properties on Candida: The role of human saliva in the Candida adhesion process is still controversial. Saliva shows a physical cleaning effect and innate defence molecules, including lysozyme, hystatin, lactoferrin, calprotectine and IgA. Other components in whole saliva, including mucins, statherin and proline-rich-proteins have been reported to adsorb to Candida albicans, thereby facilitating adherence to saliva coated acrylic resins. 3. pH of the Oral Cavity: Low levels of pH can favor the adhesion and the proliferation of Candida yeast. In fact, a pH equal to 3 is optimal not only for the adhesion of the yeasts, but also for the enzymatic activity of the proteinases that together with the lipases, are the most important factors of virulence of permeability of the acrylic resins. In presence of poor oral hygiene, Candida can penetrate, stick and aggregate with the bacterial communities, as Streptococcus sanguis, Streptococcus gordonii, Streptococcus oralis and Streptococcus anginosus by the interactions between proteins and carbohydrates. Systemic factors that can potentially contribute to the formation of denture stomatitis includes (Naik & Pai, 2011): 1. Diabetes: The saliva of diabetics favors the growth of Candida albicans in vitro and it has been shown that on the denture surfaces of diabetic there are more elevated counts of colonies of the yeast by comparison with the nondiabetic subjects.

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2. Deficiency of Nutritional Factors: Some authors report the sideropenic anemia and high levels of cholesterol as causes of candidiasis. 3. Xerostomia: Qualitative and quantitative alterations of the salivary flow in elderly patients is probably secondary to the assumption of drugs, above all the antihypertensive ones, rather than a primary functional deficit. Such reduction has been shown to act as predisposing factor to the virulence of the Candida species. 2.2.2. Prevention Proper routine cleaning of a denture is necessary to prevent denture stomatitis and maintain healthy supporting tissues. Effective plaque removal requires a degree of manual dexterity that is often lacking especially among elderly patients. The use of chemical denture cleaning agents produces more effective results, especially in geriatric patients and in people who have problems with wearing dentures. A variety of experimental approaches have been tested in attempt to examine the efcacy of denture cleaning agents. A variety of chemical denture cleansing products are commercially available and these can be divided into ve groups: alkaline peroxides, alkaline hypochlorite, diluted organic and inorganic acids, disinfectants and enzymes. Immersion-type denture cleansers marketed mainly in the form of tablets that are used most commonly due to their easy application (Isseri et al, 2011). A study by Devarhubli et al (2011) indicated that brushing the test specimens with the help of denture brush, decreased the number of adherent candidial cells. Furthermore, it was evident that specimens that were cleaned after 24 hours showed less adherent candidial cells than that were cleaned after 48 hours. However, brushing did not completely eliminate the adherent candidial cells. Above findings suggest that the metallic denture bases are far better than acrylic denture bases in terms of incidence of denture stomatitis due to candidial infection. Further, they are seemed to be more biocompatible with the oral tissues with minimal tissue

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reactions if any. However, usage of these base metal alloys as denture bases may not be practicable in regard to their cost, difficulty in relining the necessary set up for their fabrication. Thus, acrylic resins still remain the materials of choice answering the requisites of economy and ease of fabrication. However, patients oral hygiene should be given prime importance irrespective of the denture base materials used.

2.3. Root Fragments Not infrequently a root or roots break during an extraction. If the retained root is very small and therefore deeply placed and not associated with any periapical pathology then it is acceptable to leave the fragment in situ, having informed the patient. If the root fragment is large or associated with infection, then it should be removed and this will involve surgical exposure and removal. If a tooth or root suddenly disappears it is most important that its whereabouts is identified. X-rays may be necessary to confirm the site of the displaced root. If it cannot be identified within the oro-facial region than a chest X-ray is mandatory (Yates, 2000). In order to preserve the alveolar crestal bone, old root tip fragments should be surgically removed by means of apical ostectomy. The indication for removal of root fragments must be determined on a case-by-case basis. Basically, root fragments showing signs of inflammation should be removed before any dental reconstructive treatment is performed in the area. Since root fragments represent potential foci of infection, it is imperative to remove them before radiotherapy of immunosuppressive therapy (Sailer & Pajarola, 2003). According to Datarkar (2007), tooth fracture is an inconvenience, but need not be a disaster, and it happens to the most experienced dentists. Several causes of root fracture are: 1. Excessive force applied to the tooth. 2. A tooth weakened by caries or large restorations.

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3. Inappropriate application of force resulting from failure to grasp enough of the root mass or using forceps with blades too wide to make two point contacts on the root. 4. Haste due to impatience or frustration. 5. Unfavorable root anatomy. Fragments of root should be removed as soon as they are found. However, small pieces of roots may be left as such in the socket as long as it does not cause any problem. But with advancing age, it is always risky to leave the fragments, hence should be removed. In edentulous patients, fractured segments present under the mucosa constantly get irritated from the overlying denture resulting in chronic ulcers which may sometimes undergo neoplastic changes. The root fragment may themselves undergo cystic or other pathological changes (Balaji, 2007). When the root itself has fractured, retrieval of the retained portion normally requires a surgical approach. The operator must assess whether this surgical task is feasible cooperation of the patient, the facilities available and his or her level of experience. Ideally all roots should be removed but some apical fragments may be difficult or hazardous to pursue because of the proximity of the inferior dental nerve or the antral floor. Such small apices are best left in situ and rarely cause any symptoms. In general, a root fragment of a vital tooth, less than 5 mm in length, can normally be safely left in the jaws of healthy patients. Larger root fragments and those with necrotic pulps or periapical radiolucent areas should be removed, unless the risk of so doing outweighs the potential gain. If it is decided that the root can be safely retained, then the patient must be informed of this eventuality along with a suitable explanation, and both the retention of the root apex and the information given to the patient should be recorded in the clinical notes (Datarkar, 2007).

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2.4. Denture Base Polymers The denture base is that part of the denture which rests on the soft tissues and so does not include the artificial teeth. Prior to 1940 vulcanite was the most widely used denture base polymer. This is a highly cross-linked natural rubber which was difficult to pigment and tended to become unhygienic due to the uptake of saliva. Nowadays acrylic resin is used almost universally for denture base construction (McCabe & Walls, 2008).

Figure 5. The appearance of typical acrylic denture base. According to Annusavice (2003), synthetic resins are used in a variety of dental applications. Typical uses include the following: 1. Dentures (bases, liners, and artificial teeth). 2. Cavity-filling materials (composites) 3. Sealants 4. Impression materials 5. Equipment (mixing bowls) 6. Cements (resin-based) Dental resins are used mainly to restore and replace tooth structure and missing teeth. These resins can be bonded with other resins directly to tooth structure or to other restorative materials. If all teeth are missing, a denture base (the part of the denture that rests on the soft tissues overlying the maxillary and

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mandibular jawbone in the mouth) with attached denture teeth can be made to restore chewing ability. The acrylic denture base is normally fabricated in a two-part gypsum mould. The mould is produced by investing wax trial dentures on which the artificial teeth have been mounted. After boiling out of the wax the gypsum mould is treated with an alginate mould-sealing agent. This is a viscous solution of sodium alginate which is rapidly converted to calcium alginate on contact with the gypsum. It forms a thin skin over the surface of the mould, preventing monomer in the acrylic dough from entering the gypsum. The space remaining after removal of wax is filled with acrylic dough which may be heat cured or allowed to cure at room temperature depending on the material being used. During curing the acrylic resin denture base becomes attached to the artificial teeth. The formation of the denture base by this technique is known as the dough moulding method. Acrylic denture bases may also be produced by injection moulding or by using a pourable resin technique, although the latter methods are not commonly used (McCabe & Walls, 2008). Dental resins solidify when they polymerize. Polymerization occurs through a series of chemical reactions by which the macromolecule, or the polymer, is formed from large numbers of molecules known as monomers. Synthetic resins are often called plastics. A plastic material is a substance that, although dimensionally stable in normal use, was plastically reshaped at home stage of manufacture. Resins are composed of very large molecules. The particular form and morphology of the molecule determine whether the resin is a fiber, rigid material, or a rubberlike product. Polymers have had an enormous impact on dentistry, and they are now used as sealants, bonding materials, restorative materials, veneering materials, denture bases, denture teeth, and impression materials (Annusavice, 2003) Because many of the undesirable properties of polymers are due to weak bonds between polymer chains, it would seem that a way to improve them would be to link chains together with primary chemical bonds. In fact, this method, called cross-linking, is widely used to improve strength, resistance to water

22

absorption, abrasion resistance, and other properties of polymers. Because of the small number of primary bonds in a given volume of polymer material as compared to ceramics or metals, however, polymer properties remain generally inferior even with cross-linking (OBrien, 2002). The most significant features of polymers are they consist of very large molecules and that their molecular structure is capable of virtually limitless configurations and conformations. Polymerization is a repetitive intermolecular reaction that is functionally capable of proceeding indefinitely. Because any chemical compound possessing a molecular weight in excess of 5000 is considered to be a macromolecule, most polymer molecules can be considered as macromolecules. In some instances, the molecular weight of the polymer can be as high as 50 million (Annusavice, 2003). Polymeric denture base materials are classified into five groups (or types). Types 1 and 2 are the most widely used products and are described in more detail in the table below (McCabe & Walls, 2008). Table 2. Classification of denture base polymers according to ISO 1567. Type 1 Class 1 2 1 2 1 Description Heat-processing polymers, powder and liquid Heat-processed (plastic cake) Autopolymerised polymers, powder and liquid Autopolymerised polymers (powder and liquid pour type resins) Thermoplastic blank or powder Light-activated materials Microwave-cured material

3 4 5

Annusavice (2003) explains that methacrylate polymers have earned great popularity in dentristy because:

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1. They can be processed easily using relatively simple techniques. 2. They are aesthetics 3. They are economical Because of their biological, physical, aesthetic, and handling properties, methacrylate polymers are capable of providing an excellent balance of performance features and characteristics needed for use in the oral cavity. 2.4.1. Composition Annusavice (2003) states that in dentistry, most resins are based on methacrylates, particularly methyl methacrylate. However, because the field is dynamic and new types of resins are being developed on a regular basis, a dentists knowledge must include basic concepts of resin chemistry so that new developments in the field can be critically evaluated. Most materials are supplied as a powder and liquid, details of the composition of which are given in the following table (McCabe & Walls, 2008). Table 3. Composition of acrylic denture base materials. Polymer Powder Initiator Pigments Monomer Cross-linking agent Liquid Inhibitor Activator Polymethylmethacrylate beads A peroxide such as benzoyl peroxide Salts of cadmium or iron or organic dyes Methylmethacrylate Ethyleneglycoldimethacrylate Hydroquinone (trace) N N-dimethyl-p-toluidine (only in self curing materials)

The

major

component

of

the

powder

is

beads

of

polymethylmethacrylate with diameters up to 100 m. These are produced by a process of suspension polymerization in which methylmethacrylate

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monomer, containing initiator, is suspended as droplets in water. Starch or carboxymethylcellulose can be used as thickeners and suspension stabilizers, but have the disadvantage of potentially contaminating the polymer beads. The temperature is raised in order to decompose the peroxide and bring about polymerization of the methylmethacrylate to form beads of polymethylmethacrylate which, after drying, form a freeflowing powder at room temperature. Polymethylmethacrylate is a clear, glass-like polymer and is occasionally used in this form for denture base construction. The major component of the liquid is methylmethacrylate (MMA) monomer. This is a clear, colourless, low-viscosity liquid with a boiling point of 100.3C and a distinct odour exaggerated by a relatively high vapor pressure at room temperature. MMA is one of a group of monomers which are very susceptible to free radical addition polymerization. Following mixing of the powder and liquid components and activation by either heat or chemical means, the curing of the denture base material is due to the polymerization of MMA monomer to form

polymethylmethacrylate. The liquid normally contains some cross-linking agent. The substance most widely used is ethyleneglycoldimethacrylate. This compound is used to improve the physical properties of the set material (McCabe & Walls, 2008). 2.4.2. Biological properties (biocompability) The resin should be tasteless, odorless, nontoxic, nonirritating, and otherwise not harmful to the oral tissues. To fulfill these requirements, a resin should be completely insoluble in saliva or in any other fluids taken into the mouth and should be impermeable to oral fluids to the extent that the resin does not become unsanitary or disagreeable in taste or odor. If the resin is used as a filling or cementing material, it should set fairly rapidly and bond to tooth structure to prevent microbial ingrowth along the toothrestoration interface (Annusavice, 2003).

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In the unmixed or uncured states the denture base material should not be harmful to the technician involved in its handling. The set denture base material should be nontoxic and non-irritant to the patient. In the previous section it was mentioned that the base should, ideally, be impermeable to oral fluids and this would certainly be an ideal property. If a degree of absorption occurs however, the base should not be able to sustain the growth of bacteria or fungi (McCabe & Walls 2008). 2.4.3. Mechanical properties Although opinion varies slightly, most clinicians consider that the denture base should be rigid. A high value of modulus of elasticity is therefore advantageous. A high value of elastic limit is required to ensure that stresses encountered during biting and mastication do not cause permanent deformation. A combination of a high modulus and high value of elastic limit would have the added advantage that it would allow the base to be fabricated in relatively thin section. Fractures of upper dentures invariably occur through the midline of the denture, due to flexing. The denture base should have sufficient flexural strength to resist fracture (McCabe & Walls, 2008).

Figure 6. Diagram illustrating how an upper denture may flex about the midpoint of the palate. This fatigue process may eventually cause fracture. Denture base materials should also have sufficient abrasion resistance to prevent excessive wear of material by abrasive denture

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cleansers or foodstuffs. Wear is a complex phenomenon which may depend on many material properties. For abrasive wear it is thought that surface hardness of the substrate is of primary importance. 2.4.4. Physical properties An ideal denture base material should be capable of matching the appearance of the natural oral soft tissues. The importance of this requirement varies considerably, depending on whether the base will be visible when the patient opens his mouth. The base should have good dimensional stability in order that the shape of the denture does not change over a period of time. In addition to distortions which may occur due to thermal softening, other mechanisms such as relief of internal stresses, continued polymerisation and water absorption may contribute to dimensional instability. A high value of thermal conductivity would enable the denture wearer to maintain a healthy oral mucosa and to retain a normal reaction to hot and cold stimuli. If the base is a thermal insulator it is possible that the patient may take a drink which he would normally detect as being too hot to bear, and undergo a painful experience as the drink reaches the throat and gut. The denture base should, ideally, be radiopaque. It should be capable of detection using normal diagnostic radiographic techniques. Patients occasionally swallow dentures and may even inhale fragments of dentures if involved in a violent accident, such as a car crash. Early radiological detection of the denture or fragment of denture is of immense help in deciding the best course of treatment (McCabe & Walls, 2008). OBrien (2002) states that t he increase of the temperature of a material as the result of increased atomic vibration within it is a familiar concept. This atomic vibration is limited by the bonds between atoms in a material such that when strong bonds are present between atoms, the atoms vibrate over a small amplitude, and when weak bonds are present, the atoms vibrate over a large amplitude. Ceramics and metals are characterized by strong bonds between atoms, and the secondary bonds

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play an insignificant role in their properties. As a result, most ceramics and metals expand relatively little when heated that is, their coefficients of thermal expansion are relatively low. Polymers, however, are

characterized by strong bonds within polymer chains and weak bonds between polymer chains. Thus, the vibration of carbon atoms within the polymer chain is restricted in the directions parallel to the long axis of the chain, but the atoms are free to vibrate in the two directions perpendicular to the long axis of the polymer chain. As a result, when a polymer is heated, the chains must move farther apart to allow for the largeramplitude vibration, which occurs perpendicular to the long axes of the polymer chains. This phenomenon accounts for the large coefficient of thermal expansion exhibited by polymers. The figure below illustrates the different thermal expansion behaviors of a polymeric material and a crystalline material. The resin should possess adequate strength and resilience, as well as resistance to biting or chewing forces, impact forces, and excessive wear that can occur in the oral cavity. The material should also be dimensionally stable under all conditions of service, including thermal changes and variations in loading. When used as a denture base for maxillary dentures, the resin should have a low specific gravity (Annusavice, 2003). The low strength of polymers when compared to ceramics and metals can also be understood in terms of the strong bonds within polymer chains and the weak bonds between polymer chains. If the rule-of-thumb value for theoretical strength, 0.1E, is applied to the oriented polyethylene fiber, a value of 3 million psi is obtained for the theoretical strength of polyethylene. Typical bulk polymers, however, seldom have tensile strengths of more than 10,000 psi. The weak secondary bonds between polymer chains allow these chains to slide past one another at much lower stresses than those required to break the bonds within the chains (OBrien, 2002).

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2.4.5. Manipulation (heat cured material) McCabe & Walls (2008) explains that the manipulation of acrylic denture base materials involves the mixing of powder and liquid to form a dough which is packed into a gypsum mould for curing. The ratio of powder to liquid is important since it controls the workability of the mix as well as the dimensional change on setting. MMA monomer undergoes a volumetric polymerization shrinkage of 21% on conversion to polymer. This shrinkage is considerably reduced by using a mix with a high powder/ liquid ratio. If the powder/liquid ratio is too high however, the mix becomes dry and unmanageable and the mixture will not flow when placed under pressure in the gypsum mould. In addition, there is insufficient monomer in a dry mix to bind all the polymer beads together. This may produce a granular effect on the denture surface which is normally referred to as granular porosity. Proportioning is normally carried out by placing a suitable volume of liquid into a clean, dry mixing vessel followed by slow addition of powder, allowing each powder particle to become wetted by monomer. The mixture is then stirred and left to stand until it reaches a consistency suitable for packing into the gypsum mould. During this standing period a lid should be placed on the mixing vessel to prevent evaporation of monomer. Loss of monomer during this stage could produce granular porosity in the set material. This is characterized by a blotchy, opaque surface. Immediately after mixing, a material of rather sandy consistency is produced. After a short period of time this becomes a sticky mass which forms strings of material sticking to the spatula, if an attempt is made to carry out further mixing. The next stage is the dough stage. Here, the material is more cohesive and has lost much of its tackiness. It can be moulded like plasticine and does not adhere to the sides of the mixing vessel. The material should be packed into the mould at this stage. If packing is delayed the material may become quite tough and rubbery and eventually becomes quite hard. The transitions from sandy to

29

stringy to dough and eventually rubbery and hard stages are due to physical changes occurring within the mix. Smaller polymer beads dissolve in monomer causing a gradual increase in viscosity of the liquid phase. Larger beads absorb monomer and swell, thus depriving the liquid phase of monomer and causing a further increase in viscosity. During this period the monomer remains unpolymerized (McCabe & Walls, 2008). The dough is packed into a two-part gypsum mould, which has previously been treated with a mould-sealing compound.

Figure 7. Diagrammatic representation of two-part split mould used for acrylic denture construction. Excess dough is used and a trial closure is performed causing excess material to form a flash at the point where the two halves of the flask meet. The flask is opened and the flash removed. The fl ask is then closed again under pressure using a threaded bench press and maintained under pressure during curing using a springloaded clamp. The applied pressure has three important functions. It ensures that dough flows into every part of the mould. It enables excess dough to be used, thus causing an effective reduction in the polymerization shrinkage and it prevents the formation of a raised bite on the denture by giving a base which is too thick. The use of insufficient dough to create an excess in the mould or the application of insufficient pressure during curing can lead to porosity

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voids dispersed throughout the whole mass of the denture base. This is known as contraction porosity (McCabe & Walls, 2008). Having filled the mould with dough, the next stage is to polymerize the monomer to produce the final processed denture. Curing is normally carried out by placing the clamped flask in either a water bath or an air oven. Whichever type of system is used, many curing cycles are available. The boiling point of the monomer is 100.3C and if the temperature of the dough is raised significantly above this, the monomer will boil, producing spherical voids in the hottest part of the curing dough. These will be apparent as gaseous porosity in the cured denture base.

Figure 8. Diagram illustrating the normal sites of gaseous porosity in an upper denture. Before deflasking the processed denture the fl ask is cooled to room temperature. This may lead to the setting up of internal stresses within the denture base since the coefficient of thermal expansion of acrylic resin is about ten times greater than that of the gypsum mould material. These internal stresses may be compounded with those caused by polymerization shrinkage, although the latter are normally eliminated by plastic flow when the polymerization takes place at elevated temperatures. Internal stresses may lead to warpage of the denture base at a later stage if the denture is placed in warm water for cleaning. The magnitude of the

31

stresses can be reduced by allowing the flask to cool slowly from the curing temperature (McCabe & Walls, 2008). 2.4.6. Self-cured acrylics Generally, these materials reach the dough stage quite quickly and remain workable for only a short period of time. Within a few minutes of attaining a dough consistency, the rate of polymerization increases rapidly causing a large temperature rise and the material becomes hard and unmanageable. The time available for carrying out a trial closure of the processing flask is minimal and, if the viscosity has increased beyond a certain point at the time of final closure, there is a danger of increased vertical height in the denture. These problems, coupled with the inferior mechanical properties and higher residual monomer content of the cold curing resins, generally restrict their use to repairing and relining of dentures. For repairing, a very fluid mix of cold cure resin is used. The large excess of monomer ensures adequate wetting of the fragments being repaired (McCabe & Walls, 2008). Soratur (2002) describes the many differences between heat-cured and cold-cured acrylics which are shown in the table below. Table 4. Characteristics differences of heat-cured and self-cured acrylic resins. Properties Activator Molecular Residual monomer Strength Strong Less strong but gain strength gradually Stress and strains More internal stresses and strains Less strains Heat High molecular wt-30,000 0,5% residual monomer Heat-cured Cold-cured Tertiary amine Low molecular wt.3,000 5% residual monomer

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Dimensional stability Surface hardness

More possibility of dimensional instability More surface hardness (KHN 20)

Negligible polymerization and thermal shrinkage Less surface hardness (KHN 17) Less porosity Repairs and additions, relining/rebasing, special

Porosity Uses

More chances of porosity Complete and partial dentures, artificial teeth,

special trays, record bases, trays, orthodontic obturators appliances, record base

2.5. Residual monomer The polymerization by chemically activated method remains incomplete as residual monomer is more in chemically activated cured resin, which may irritate the tissues and also result in decreased transverse strength (Chandra, 2000). In an experimental clinical study, Austin and Basker documented a clear association between irritation of the mucosa beneath dentures and the release of residual monomers. Three cases of denture stomatitis were examined. The residual monomer concentration of all analyzed dentures exceeded the normal levels by 611-fold. It was reported in 1962 that dentures with a residual monomer concentration of 0.63% a year after insertion did not cause mucosal irritations. In addition to released substances, mainly MMA and formaldehyde, microorganisms (e.g., Candida albicans) may significantly contribute to the development and severity of a denture stomatitis. This was especially observed on dentures with a permanently soft relining, but both effects should interact in most cases because various leaching substances may promote microbial proliferation. A clinical study of 22 patients who suffered from burning mouth syndrome revealed an allergy to MMA in five cases, as well as a high residual monomer concentration in their dentures. Three of these five patients were free of symptoms after they received new dentures with low residual monomer content. This was

33

corroborated by findings on four further patients in this investigation who suffered from an irritation (not an allergy) of the mucosa caused by residual monomers (Schmalz & Arenholt-Bindslev, 2009). Methyl methacrylate monomer has been implicated as a primary irritant and a sensitizer that can cause an allergic eczematous reaction on both the skin and oral mucosa. The residual monomer in the acrylic resin denture base might leach out and contact the oral mucosa, especially the denture bearing mucosa, and may cause adverse reactions, such as redness, swelling, and pain in the oral mucosa (Yilmaz et al, 2003). The components released are biologically active and their use has occasionally been associated with necrosis and irritation of the pulp. Apart from bio-compatibility issues, monomers trapped in the set composite may reduce the clinical serviceability of the restoration (Sharma et al, 2012). The residual monomer, approximately 0.4% in a well-processed denture, is the usual component singled out as an irritant. A true allergy to acrylic resin can be recognized by a patch test. Direct contact of the monomer over a period of time may provoke dermatitis. The high concentration of monomer in the dough may produce a local irritation and a serious sensitization of the fingers. Inhalation of monomer vapor is avoided. During the polymerization process the amount of residual monomer decreases first rapidly and later more slowly. The highest residual monomer level is observed with chemically activated denture base resins at 1-4% shortly after processing. When they are processed for less than one hour in boiling water the residual monomer is 1-3%. If it is processed for 7 hours at 70C and then boiled for 3 hours the residual monomer content may be less than 0.4%. to reduce the residual monomer in heat cured dentures it should be processed for a longer time in boiling water. The temperature should be raised to boiling only after most of the polymerization is completed otherwise porosity may result (Manappallil, 2003). According Basker et al (2011), high levels of residual monomer in the denture base have been reported and the tissue damage produced is considered to be the result of a chemical irritation rather than a true allergy. It is possible that high levels of residual monomer, which have ranged from three to ten times the

34

normal value, are due to errors inadvertently introduced into the short curing cycles which are popular with manufacturers and dental laboratories. This content can be measured by specialized analytical techniques such as gas chromatography. Recent work has confirmed that higher levels of residual monomer are found in cold-curing as opposed to heat-curing resins. The cold-curing materials release significant amounts of residual monomer in the first few weeks of storage in water.

2.6. Illegal Dental Practice Illegal practice cases include dentists who have been erased or removed from the register but continue to practice, unregistered dental technicians who practice dentistry, and beauty salons that offer tooth whitening. Dental technicians can, of course, repair dentures but sometimes they can go beyond what the law allows. Consequently a variety of approaches is required in order to apprehend the miscreant and persuade, prevent and even prosecute them in the process of stopping their illegal activities (Mathewson & Rudkin, 2008). To locate illegal practitioners it frequently relied on licensed dentists reports about the illegal dentists in their regions. Often it required these licensed dentists to prosecute the unlicensed themselves. Dental students who attempted to practice dentistry before they graduate were variously dealt with. Typically they were merely warned not to do it again. Having met the education requirements established by the dental board, dental students were more easily forgiven than were other illegal practitioners. Viewing these students as future responsible colleagues, professional leaders wanted to make them stop their illegal practice, without going as far as to prosecute them (Adams, 2000). Criminal law involves offenses against society, which must be proven beyond a reasonable doubt. For example, the practice of dentistry without license is a violation of state criminal law. Dental personnel must be careful to perform only the functions that are legally allowable within the jurisdiction in which they work. Performing illegal dental procedures places the allied dental professional in

35

the situation of practicing dentistry without license, a serious criminal offense. If the dentist permits an auxiliary to perform illegal functions, both are held responsible in a court of law for the performance of an illegal act. Because dentists hold a unique position of trust in the society and are self-regulatory, the process of peer review may require a report to the jurisdictions regulatory agency. If the violation is relatively serious, licensure may be suspended temporarily or revoked permanently. Any licensed individual can be punished, including the dental assistant and dental hygienist. When a licensed individual is convicted for violation of criminal law, licensure may be revoked permanently, rendering the individual unable to practice his or her occupation (Andrews, 2007). Dentures provided by laboratory technicians had a signicantly higher occurrence of having unacceptable characteristics compared with those provided by dentists or denturists. The laboratory technicians educational curriculum does not include any patient management. Instead it contains only mechanical work. Both from a legal point of view and also in the light of present studys ndings, laboratory technicians role as denture providers is certainly questionable (Tuominen, 2003). 2.5.1. Tukang gigi as controversial dental practitioners in Indonesia. According to Kemenkes RI (2011), the service of Tukang Gigi, sometimes referred as ahli gigi, has been appearing in many places to practice independently while exceeding their professional authority. The illegal practice of Tukang Gigi may include mounting braces, tooth extraction, or fillings. In order to keep Tukang Gigi within the boundaries of governmental law, a restriction for Tukang Gigi has been made by using the Permenkes 339 Tahun 1989. According to this law, every Tukang Gigi is forbidden to: 1. Perform dental restorations using any kind of restorative materials. 2. Produce and/or apply permanent dentures. 3. Use any drugs that are associated with temporary or permanent dental fillings.

36

4. Perform tooth extraction. 5. Perform any medical act including the appliance of drugs. 6. Deputize his/her work to anyone. Mahkamah Konstitusi (MK) had set their decision regarding the petition of dentistry practice submitted by Tukang Gigi. MK states that the deviation and/or violation done by Tukang Gigi in their practice can be solved by the act of educating, licensing, and monitoring by the government. This guidance are done in order to give Tukang Gigi basic dentistry knowledge. Control on Tukang Gigi is intended to monitor the works of Tukang Gigi and keep them within the governments standards, while prosecuting those who violate or misuse their profession. Licensing is done in order to give Tukang Gigi legal rights to do their works according to their abilities and skills. According to MK, the profession of Tukang Gigi can be categorized as Indonesias traditional medical techniques that must be preserved within certain rules (PDGI, 2013).

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CHAPTER III CONCEPT MAPPING

38

CHAPTER 4 DISCUSSION

4.1. Scenario

In a dental hospital, a 45 years old female patient, referred from the Puskesmas, is diagnosed with oral cancer. According to intraoral checkup, the patient is using denture from acrylic, without taking it off since using it 3 years ago. The denture is attached very tightly against the gingiva and teeth, and successfuly removed by the dentist, root fragments are found in 45 & 46 teeth. The denture itself was not applied by a dentist.

4.1.1 Additional information 1. The denture is made of self-cured acrylic without retention. 2. The patients mother died because of breast cancer. 3. The denture is attached on the 44 & 47 teeth.

4.2. Analysis Based on our analysis of the case, we believe that the patients oral cancer is influenced by several factors. First, the patient is using a denture made of selfcured acrylic. The dent ure is applied by Tukang Gigi without using any kind of retention. The self-cured acrylic produces a lot of residual monomer which leads to irritation in oral mucosa. Methyl methacrylate monomer the usual component singled out as an irritant. Secondly, the denture itself has not been removed for 3 years since it was applied. This causes the patients oral hygiene to worsen and forms bacterial plaque. Among the many species of microorganisms in the plaque, the most dominant species is Candida albicans. The Candida albicans is an innocuous commensal of the microbial communities of the human oral cavity. This microorganism is the main cause of denture stomatitis which is the

39

inflammatory state of denture bearing mucosa. The untreated denture stomatitis leads to heavy irritation and inflammation. Third, the appliance of denture without retention causes the denture to be attached directly to the gingiva, thus causing the blood vessels to be blocked. This also causes the remains of food to be stucked and rot. The accumulation of food debris leads into an infection on the gingiva. These conditions are the main cause of the patients oral cancer. It can be safely assumed that the reason why such conditions are experienced by the patient is the lack of knowledge in dental safety from the Tukang Gigi. There are several environmental factors that influenced the patients decision in choosing Tukang Gigi to apply her denture. We have decided to break down the environmental factor into 3 parts: economical factor, social factor, and educational factor. The economical factor can be seen on the price which the operator charges after the appliance of denture. Compared to the price of denture provided by a professional dentist, Tukang Gigi offers a way cheaper fee, which leads the patient into choosing Tukang Gigi as her operator. The social factor is the presence of Tukang Gigi practices everywhere. It is undeniable that denture appliance by Tukang Gigi has become some sort of trend in the society. Finally, the educational factor relates to the patients knowledge of dental safety. It is most likely in this scenario that the patient is unaware of the dangers that reside in denture appliance by Tukang Gigi. These factors affect the patients choice of operator in applying denture, which turns out to be endangering for her own dental health. During the checkup, root fragments were found in the location of 45 & 46 teeth. Although this might seem simple, root fragments that are left behind after extraction is a serious problem. Fractured segments present under the mucosa constantly get irritated from the overlying denture resulting in chronic infection on the oral mucosa. The infection becomes one of the influential factors of the oral cancer. Fragments of root should be removed as soon as they are found. However, in this case, it seems that the operator (Tukang Gigi) is not aware of this importance and ends up endangering the patient.

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Furthermore, it is known that the patients mother died because of breast cancer. The mothers miRNA experienced an alteration and then get carried down to her daughter. Alterations in miRNA expression are now known to be a common feature across human malignancies. The altered miRNA becomes one of the influential factor in the formation of the patients oral cancer. This happens because the expressed miRNAs contributes directly to cancer phenotypes, in this case, the oral cancer. So, our analysis suggests that the oral cancer that is experienced by the patient is an accumulating result of multiple factors. We believe that the main cause of this problem is the patients unawareness of the dangers in applying denture by unlicensed dental practitioners, in this case the Tukang Gigi. Social and economic factors play a vital role in this problem. Wrong type of acrylic denture base material, the appliance of denture without retention, and the fact that the denture isnt removed for 3 years become the main reasons why the patient experiences oral cancer. Other factors include the root fragments that are left behind after extraction and the passed down cancer phenotype (via miRNA) by the patients mother.

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CHAPTER 5 SUMMARY

5.1. Conclusion It can be concluded from our discussion that the main cause of the patients oral cancer is the wrong appliance of denture by Tukang Gigi. The Tukang Gigi uses a wrong type of denture base material without any retention. The denture itself is not removed for three years, resulting in a condition known as denture stomatitis. Supporting factors of the oral cancer formation includes the root fragments and the passed down cancer gene from the patients mother. Environmental factors such as social, educational, and economical factor play a vital role in this scenario. These environmental fac tors affect the patients decision in choosing Tukang Gigi as her operator in applying denture.

5.2. Suggestions It is important for the society to learn about dental health. Underestimating dental health may cause many kinds of dental problem. Education by professionals is needed in order to give public awareness about dental health and diseases. Dental patients should not trust unlicensed dental practitioners, such as Tukang Gigi, to treat their dental problems.

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