Management to increase patient's self-esteem

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Management to increase patient's self-esteem

1. - gingival overgrowth

Gingival overgrowth can cause patient to have poor appearance of the gingiva. Gingival appearance is one of the components of the harmony of the smile, which is seen as one of the most important physical characteristics of the development of self-image and self-esteem.

There are several causes of gingival overgrowth such as plaque-induced, hormonal influence, hereditary gingival fibromatosis, granulomtaous condition ( eg. Crhn's disease), Scurvy, neoplasia,drug-induced or mouth- breathing.

There is an association between oral hygiene and gingival inflammation. Poor oral hygiene can also increase the severity of drug-induced gingival hyperplasia. This is because, enlargemenr of gingiva causes difficulty to clean the area and it becomes plaque retentive sites.

Management of gingival overgrowth must be according to the aetiological factor identified. The management is organised into:

- initial therapy including improvised technique of plaque control .

Clorhexidine mouthrinse can be a useful adjunct to the management of gingival overgrowth. In severe cases of drug-induced gingival overgrowth, liaison with the general medical practitioner and any specialists may be associated when prescribing alternative drugs. Tacrolimus has been given to renal and cardiac transplant patients as an alternative to ciclosporin

- corrective therapy includes surgical reduction as required ( eg. gingivectomy)

- supportive therapy including monitoring for recurrence.

This is important because recurrence of gingival overgrowth , particularly where it is drug-induced , is common. Supportive therapy is important but repeated surgical reduction may be required.

2. - discoloured tooth

Tooth discolouration can affect self-esteem especially if it involves anterior teeth. Management of discoloured teeth depend on causes of discolouration which need to be investigated prior to treatments. The causes of tooth discolouration can be classified into 2 groups which are extrinsic staining and intrinsic staining. Intrinsic staining includes dental caries, blood pigments, tetracycline staining, fluorosis, amelogenesis imperfecta, dentinogesis imperfecta, regional odontodysplasia and chronological hypoplasia and age change.

Treatment options include vital bleaching agents using carbamide peroxide, nonvital bleaching, direct composite, indirect composite or porcelain veneers and crowns.




Vital bleaching agents using carbamide peroxide

Works best with extrinsic stains and quite well for many intrinsic stains.

Can also be used to mask severe staining before a veneer is placed. This prevents dark enamel showing through and allows a more translucent veneer to be used, improving final appearance.

Only appropriate when there are minimal or no restorations in the teeth.

Unpredictable effectiveness with tetracycline staining.

Non-vital bleach

Allows bleaching of deeper dentine , producing greater effect.

Only possible in non-vital teeth

Direct composite, indirect composite or porcelain veneers

Good appearance possibe, can be as good as crowns, but much less destructive.


Very darkly stained teeth are best crowned.

Porcelain are thicker than veneers, so opaque materials are not required.

The best alternative if the teeth contain extensive restoration.

Destructive of tooth tissue

3. Foul breath (halitosis)

Foul breath may be due to several factors. In this patient, gingival enlargement tends to be more severe in areas where plaque accumulates. In the same time, gingival enlargement impedes effective plaque control and regularly traps plaque or food, producing halitosis. Management of gingival enlargement could reduce the halitosis.

Halitosis may also be caused by dry mouth (also called xerostomia) . Saliva is necessary to moisten and cleanse the mouth by neutralizing acids produced by plaque and washing away dead cells that accumulate on the tongue, gums, and cheeks. If not removed, these cells decompose and can cause bad breath. Dry mouth may be caused by the side effects of various medications, salivary gland problems, or continuous breathing through the mouth. In this case, amlodipine taken by patient is a calcium-channel blocker ( an anti-hypertensive drug) can cause dry mouth. management of dry mouth could reduce halitosis such as chewing sugarless chewing gum.

Poor oral hygiene can also lead to foul breath. Although patient brushes two times daily, floss and mouthrinse regularly, the plaque score is high making patient having high risk caries. Ineffective plaque control can cause food particles to remain in mouth, which promotes bacterial growth between teeth, around the gums, and on the tongue. This causes bad breath. Therefore, effective plaque control management could reduce the halitosis. Antibacterial mouth rinses can also help reduce bacteria.

4. malocclusion

It is accepted that dentofacial anomalies and severe malocclusion can give negative effect on self-esteem of the individual. A patient's perception of the impact of dental variation upon his or her self-image is subjective and modified by cultural and racial influences. The Index of Orthodontic Treatment Need (IOTN) was used to try and quantify the impact of a particular malocclusion upon long-term dental health and aesthetic handicap that a particular arrangement of teeth poses for a patient.

Methods for reducing increased overbite (deep overbite) include removable appliance (eg. anterior bite plane), fixed appliance, orthognathic surgery or restorative treatment (eg. Dahl appliance).

Increased overjet reduction could benefit by improving dento-facial aesthetic, reducing risk of traumatic dental injuries, relieving deep traumatic overbite.

The treatment depends on patient's motivation ,age, severity of skeletal discrepancy and the facial profile.

Skeletal pattern

Mixed dentition

Early permanent dentition



Await permanent dentition

Fixed appliance (camouflage)

Fixed appliance ( camouflage)


Functional, +

fixed appliance (secondary dentition)

Mouthguard if no treatment

Functional, +

fixed appliance

Fixed appliances (consider partial Overjet reduction only)


Functional, +

fixed appliance (secondary dentition)

Mouthguard if no treatment

Functional, +

fixed appliance

Functional appliance

(consider partial Overjet reduction only)

Await completion of growth and consider orthognathic surgery.

Fixed appliances (consider partial Overjet reduction only)

Orthognathic surgery

5. -size of tooth

Macrodontia means a condition whereby a tooth or a group of teeth is abnormally larger than usual.

Macrodontia can be divided into:

i)  True generalized macrodontia

This is a condition where the jaws/head of a person is of normal size, but all the teeth are abnormally large. It is a rare condition, and can occasionally be seen in people with pituitary giantism, or excess growth hormones.

ii) Relative generalized macrodontia

This is a condition where the teeth are normal sized, but the jaws are small, hence the teeth are generally relatively larger in comparison. This is a result of inheritance from 2 parents, where the size of teeth can be inherited from one parent, while the size of the jaw is inherited from the other parent. Hence it is not uncommon for parents who each has straight, even teeth, to give birth to children who have crooked teeth.

iii) Macrodontia affecting a single tooth

Macrodontia can also affect only a single tooth, though it is rather uncommonly seen.

macrodontia affecting a single tooth

iv) Localized macrodontia affecting one side of the arch

Large teeth affecting only one side of the arch (either right or left side) can be seen in patients with facial hemihypertrophy, which is enlargement of one side of the face, with associated enlarged teeth on the involved side.


Macrodontia can give adverse effects on:

1. Appearance

Having a single large tooth or an entire dentition of large teeth can be an unpleasant sight.

2.  Lack of space of eruption

Having large teeth in a normal or relatively smaller jaw will result in lack of space of eruption, leading to problems of crowding, impaction, and even cyst formation in unerupted teeth

Management of macrodontia include:

1. Stripping/trimming

Stripping can be done on affected tooth, removing about 0.5mm from each side of a tooth.  The dental practitioner may also trim the entire tooth almost like he would in preparation of a tooth receiving a crown, with the aim of maintaining the anatomical form of the tooth. However, he should practice caution not to remove too much tooth substance to avoid the risk of exposing pulp.

2. Orthodontic treatment

Teeth that are crowded or crooked can first be stripped to create space, or have some tooth extracted, followed by orthodontic appliances to straighten the teeth.


Microdontia is a condition in which a tooth or a group of teeth is abnormally smaller than usual.

This condition can also be divided into:

i) True generalized microdontia

This is when all teeth are smaller than normal. It is very rare, but can be seen in pituitary dwarfism.

ii) Relative generalized microdontia

When an individual inherits the jaw size from one parent(large jaw) and the teeth size from the other parent (small teeth), the teeth appear relatively small.

A peg lateral

iii) Microdontia affecting a single tooth

This is the most common form of microdontia, whereby only a single tooth is affected. This can be seen in supernumerary tooth like mesiodens, cleft lip and palate ( small conical shaped teeth can sometimes be seen on each side of the cleft in the tooth-bearing region), can peg laterals (upper lateral incisors that are smaller and shaped like pegs, hence the name)

Consequences of microdontia:

1. Generalized spacing-poor appearance

2. Decreased ability to chew food

This is not a major problem, but with generalized small teeth, one would not be able to chew on tough food.


1. Accepting

If the person can accept the appearance and the disadvantage in ability to chew tougher foods, no treatment is necessary.

2. Crowns

For single small teeth, a crown can be placed on it. It may be harder to prepare such a small tooth, but only minimum preparation is necessary if there is already sufficient space around it for the crown. In generalized microdontia, the patient can opt for full mouth crownings.

3. Orthodontics

Another option is to push the teeth together, and placing fake teeth in the resultant space that is created. This is rather unstable and has a high chance of relapse, hence this option is not commonly recommended.


1. Edward. W. Clinical problem solving in dentistry. Churchill livingstone.2006.

2. Management of drug-induced gingival . enlargement. Available from:

3. Abnormalities in size of tooth/ teeth. Available from:

4. Valerie C. Periodontology at glance. Blackwell.

5. Daijit S. Orthodontic at glance. Blackwell

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