INTRODUCTION:

Contents of review: The present review contains information about

1. Meaning of good oral hygiene

2. Mouth as a window

3. Role of saliva

4. Poor oral hygiene and associated problems

5. Vicious circle- Relation between poor oral hygiene and systemic diseases

6. Importance of good oral hygiene

7. Mouth as source of infection

8. Plaque as a source of infection

9. Clinical research study reports

10. Major oral diseases and disorders: a view

11. Major oral diseases, epidemiology and causative factors

12. Diseases and disorders affecting oral hygiene

13. Drugs affecting oral hygiene

14. Habits affecting oral hygiene

15. Food affecting oral hygiene

16. Conditions or practices affecting oral hygiene

17. Protective factors for maintaining good oral hygiene

18. Ten important steps for good oral hygiene

1. Meaning of Good Oral hygiene:

Good oral hygiene results in a mouth that looks and smells healthy. This means, Teeth are clean and free of debris, Gums are pink and do not hurt or bleed when you brush or floss and Bad breath is not a constant problem.¹ Oral hygiene care consists of proper brushing and flossing daily.² The purpose of oral hygiene is to minimize any etiologic agents of disease in the mouth. The primary focus of brushing and flossing is to remove and prevent the formation of plaque; which consists mostly of bacteria.³

Oral hygiene is of most importance as it contributes in aesthetic expectations ⁴ of individual; and of society. Negligence, carelessness and unawareness of some people towards maintaining good oral hygiene; and increased popularity of fast food, cold drinks, smoking and tobacco-chewing which again contributes in disturbing oral hygiene lead to development of gum and dental diseases.

2. Mouth as a window:

i) What's in mouth reveals much about health^{5, 6}:

What does the health of mouth have to do with overall health? In a word, plenty. A look inside or a swab of saliva can tell to doctor volumes about what's going on inside the body.

ii) Many conditions cause oral signs and symptoms:

Mouth is a window into what's going on in the rest of the body, often serving as a helpful vantage point for

Fig. 1. Poor oral hygiene and associated problems

↓ed means decreased, ↑ed means increased, MI- Myocardial Infarction

Fig. 2. Vicious circle

Detecting the early signs and symptoms of systemic disease — a disease that affects or pertains to entire body, not just one of its parts. Systemic conditions such as AIDS or diabetes, for example, often first become apparent as mouth lesions or other oral problems. In fact, according to the Academy of General Dentistry, more than 90 percent of all systemic diseases produce oral signs and symptoms like HIV/AIDS, Diabetes, osteoporosis, Sjogren's syndrome, certain cancers, eating disorders, syphilis, gonorrhea and substance abuse.

3. Role of saliva:

i) Saliva: Helpful diagnostic tool:

Routine saliva testing can also measure illegal drugs, environmental toxins, hormones and antibodies indicating hepatitis or HIV infection, among other things.

ii) Protection against harmful invaders: How saliva disables bacteria and viruses:

Saliva is also one of body's main defenses against disease-causing organisms, such as bacteria and viruses. It contains antibodies that attack viral pathogens, such as the common cold and HIV. It contains proteins called histatins, which inhibit the growth of a naturally occurring fungus called Candida albicans. When these proteins are weakened by HIV infection or other illness, candida can grow out of control, resulting in a fungal infection called oral thrush. Saliva also protects against disease-causing bacteria. It contains enzymes that destroy bacteria in different ways, such as by degrading bacterial membranes, inhibiting the growth and metabolism of certain bacteria, and disrupting vital bacterial enzyme systems.

4. Poor oral hygiene and associated problems:

Unbalanced diet, or lack of diet containing natural abrasives like fruits, cereals, leafy vegetable, fibers etc; which polishes the surfaces of teeth, gums and the oral cavity; leads to bad breath, development of plaque and local as well as systematic infections.

Fig. 4. Oral bacteria develops infective endocarditis

Smoking has been identified as a significant dose-related risk factor in periodontal disease, as both increasing susceptibility and prejudicing treatment outcome. The strong positive association that exists between poor oral hygiene and gingival and periodontal diseases; makes poor hygiene the primary etiologic agent. Poor oral hygiene is prominent risk factor for dry socket, a well-recognized post tooth extraction complication.⁷ Mouth ulcer is a very common and most frequently seen disease in the different population.

Table 2. Diseases affecting oral hygiene

DISEASE

ORAL EFFECTS

Blood Disorders:

Neutropenia:

It means low levels of white blood cells called neutrophils.

Neutrophils provide the first line of defense against bacterial infections.

1) Bacterial infections in mouth.

2) Periodontal (gum) disease and oral ulcers can get worse rapidly.

Polycythemia Vera:

People with polycythemia vera have abnormally high numbers of red blood cells.

1) More likely to form blood clots.

2) Purplish or red discoloration of the tongue, cheeks, lips and gums.

Anemias:

Reduction of oxygen-carrying element hemoglobin in the blood.

1) Pale tissue in mouths. 2) Tongue can become smooth.

3) Bony changes in jaws.

4) More susceptible to infection.

Hemophilia:

People with hemophilia have lack of clot forming proteins in their blood.

1) More oral bleeding than healthy people.

2) More dental problems.

3) Develops poor oral hygiene.

Platelet Disorders:

Platelets help the blood to clot. People without enough platelets have a higher risk of uncontrolled bleeding.

1) More cavities.

2) More teeth that need restoring.

3) More severe gum disease.

4) All because of poor oral hygiene.

Bulimia:

People with bulimia may have chronic sore throat and small bruises on the skin of the roof of the mouth (palate). Frequent vomiting leads to swelling of salivary glands and the tissues of the mouth and tongue to become dry, red and sore.

1) Frequent vomiting can erode tooth enamel.

2) Teeth sensitive to cold or heat.

3) Changes in bite

4) Tooth loss.

5) Poor healing

6) Increase the overall risk of periodontal (gum) disease.

Leukemia:

It is a white blood cell cancer

1) Gingival hypertrophy.

2) Petechie, ecchymosis.

3) Ulcers and hemorrhage.

Langerhans cell histiocytosis:

A condition of unknown etiology and pathogenesis characterized by abnormal proliferation of histocytes and eosinophils.

1) Large ulcerations

2) Ecchymosis.

3) Narcotizing gingivitis

4) Periodontitis

5) Subsequent tooth loss

Kawasaki disease (Mucocutaneous lymph node syndrome):

It is a vasculities that affects medium and large arteries with a corresponding cutaneous lymph node syndrome.

1) Strawberry tongue

2) Erythema of mucosal surface

3) Labia are cracked, cherry red, swollen and hemorrhagic.

Cardiovascular: Myocardial Infarction (Heart Attack)

1) Pain starting in the chest and radiating to the lower jaw.

Bacterial endocarditis:

Life threatening infection of the heart valves.

1) Bacteria enter to blood from bleeding gums and infect valves of the heart.

High Blood Pressure (Hypertension) :

Anti-hypertensive medications cause

1) Dry mouth.

2) Altered sense of taste (dysgeusia).

3) Gum overgrowth

Stroke : Stroke is a leading cause of long-term disabilities

1) Difficulty in speaking and swallowing.

2) Paralysis of the face and tongue.

Congestive Heart Failure:

Many medications used to treat congestive heart failure may cause

1) Dry mouth (xerostomia).

Oral Cancer:

Only about half of people diagnosed with oral cancer survive more than five years. That because cancer in the neck and mouth spreads quickly, and it often isn't found until it's very advanced.

1) Oral cancer includes cancer of the throat, lips, mouth, tongue, gums and salivary glands.

2) Although smoking increases the risk of oral cancer, more than 25 percent of oral cancer cases occur in people who never smoked.

Diabetes:

It is a syndrome characterized by disordered metabolism and abnormally high blood sugar.

Diabetes can affect the entire body.

1) Periodontal (gum) disease 2) Gum inflammation (gingivitis)

3) Dry mouth (xerostomia)

4) Poor healing of oral tissues

5) Oral candidiasis (thrush)

6) Burning mouth and/or tongue

Thyroid Disease:

Radioactive iodine used to assess and treat various forms of thyroid disease — can damage salivary gland tissue and cause swollen salivary glands and changes in salivation.

1) Children with hypothyroidism may have upper and lower teeth that do not come together correctly (malocclusion).

2) Delayed tooth eruption.

3) A protruding tongue, and thick lips.

4) Adults with hypothyroidism may have an enlarged tongue and a hoarse voice.

5) Hyperthyroidism may cause tooth decay.

6) Rapid and severe periodontal disease.

Pituitary Tumors:

People of pituitary gland tumors may have an increased production of growth hormone (GH).

1) Lead to gradual growth changes in facial structures containing cartilage, including the nose, ears and jaw.

2) The lower jaw and/or the tongue may become progressively enlarged.

3) Affect denture fit.

Paget's Disease of Bone:

It is increased bone metabolism that may be associated with a virus; result in deformities and fractures in one or several bones.

1) Disease involves the upper or lower jaw.

2) Extensive bleeding after a fracture or dental surgery.

Dry Socket:

It is a complication of having a tooth extracted. When the blood clot gets washed away, the bone is exposed to air and food. This is called a dry socket, and it can be extremely painful.

1) Extreme pain

2) Radiating pain.

3) Pain in the ear on that side. 4) The pain is severe and usually not relieved by over-the-counter painkillers.

5) Bad breath and a bad taste in the mouth.

Gastrointestinal (GIT): Peptic Ulcer:

It is defined as mucosal erosions equal to or greater than 0.5 cm of an area of GIT that is usually acidic and thus extremely painful.

1) Tooth erosion.

2) Anti ulcer drugs cause dry mouth.

3) Changes in taste

4) Black hairy tongue.

Gastro esophageal Reflux Disease (Heartburn) :

It is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus

1) Foul taste in the mouth.

2) A burning sensation in the mouth

3) Tooth erosion.

4) Black hairy tongue.

Inflammatory Bowel Disease:

(Crohn's disease or ulcerative colitis): It is a group of inflammatory conditions of the large intestine and, in some cases, the small intestine.

1) Ulcers, sores and overgrowths of tissue in their mouths.

2) Oral fungal infections (thrush)

Head and Neck Cancer:

Head and neck cancers commonly develop in the mouth, nose, brain, throat or sinuses.

This type of cancer typically is treated with a combination of radiation therapy, surgery and chemotherapy.

Each of these treatments can affect your oral health

Radiation cause-

1) Permanent destruction of salivary gland tissue.

2) Oral sores and muscle stiffness.

3) A permanent decrease in blood flow.

4) Tissue inflammation.

Chemotherapy:

It is the use of chemical agents or antibiotics to treat the infectious diseases.

1) Activation of herpes infections.

2) Sores in the mouth.

3) Dry mouth.

4) Change in taste.

5) Increased risk of infection.

6) Increased risk of bleeding.

7) Loss of appetite

Surgery:

Surgery for head and neck cancer often involves the removal of bone.

1) Reconstruction of jaw requires more than a year.

2) Depending on the type and location of the cancer certain salivary glands may be removed.

3) Tongue cancer causes difficulties with speech and eating after surgery.

HIV and AIDS:

The oral effects of HIV and AIDS occur because your immune system is weakened and less able to fight off infection.

These effects also are found in other people with weakened immune systems.

1) Dry mouth (xerostomia)

2) Enlarged lymph nodes

3) Thrush (oral candidiasis)

4) Hairy leukoplakia

5) viral infection (Epstein-Barr virus)

6) Kaposi's sarcoma

7) Oral bacterial infections.

8) Periodontal (gum) disease

9) Swollen salivary glands

10) Herpes simplex virus lesions

11) Human papilloma virus lesions

12) Canker sores (aphthous ulcers)

Immune Disorders:

Rheumatoid Arthritis (RA)

Rheumatoid arthritis is a disease characterized by inflammation of joints.

1) Affected jaw joint.

2) Difficulty brushing and flossing.

3) Dryness of the mouth and eyes.

4) Plaque deposits on your teeth.

5) Tooth decay and gum disease.

6) Problems wearing dentures.

Lupus Erythematosus:

Lupus is an autoimmune disease that affects multiple organs, including the mouth.

1) Sores on their lips, palate and cheeks.

2) Burning of the mouth

3) Dry mouth

4) Tooth decay.

Scleroderma (Progressive Systemic Sclerosis) :

Scleroderma is a disease that causes hardening of the skin, especially on the hands, face, lips and tongue.

1) The lips and tongue can become rigid and the mouth narrows.

2) Mask like appearance.

3) Damage the lower jaw.

4) Dry mouth (xerostomia)

5) Gum overgrowth and an increased susceptibility to cavities and periodontal disease.

Selective Immunoglobulin (IG) Deficiencies:

IG deficiencies are a group of disorders that affect a type of white blood cell called a B cell.

The most common deficiency is of immunoglobulin A, which normally appears in secretions, such as saliva.

1) They are more prone to bacterial infection.

2) IG A deficiency causes chronic sinusitis, chronic pulmonary infections and digestive problems.

3) More prone to lupus and rheumatoid arthritis.

Ataxia Telangiectasia:

Ataxia or difficulty controlling voluntary muscles.

Telangiectasias or lesions of the skin or eyes.

Immune system malfunction.

1) The immune system doesn't function properly in people with this disease because of abnormalities in two types of white blood cells — T cells and B cells.

2) More prone to bacterial, fungal and viral infections.

Kidney Disease:

People whose kidneys do not function properly occasionally receive dialysis, a process that uses a machine to "clean" the blood.

1) Halitosis because the kidneys fail to remove urea from the blood and the urea breaks down to form ammonia, which is a foul-smelling substance.

2) As body cannot absorb calcium properly, leads to lose bone from the jaws

3) Teeth may become loose and painful.

4) Anorexia , anemia , high blood pressure and heart disease,

5) Dry mouth, periodontal disease, loose teeth, and inflammation of the mouth and salivary glands.

Neuromuscular Diseases and Conditions:

Bell's palsy is a temporary paralysis of certain facial muscles.

It comes on very quickly, sometimes overnight.

1) It usually affects only one side of the face. So frequent and careful dental hygiene is important.

2) Reduced saliva secretion.

3) Loss or decrease in the sense of taste.

Epilepsy:

It is a common chronic neurological disorder that is characterized by recurrent unprovoked seizures.

1) Phenytoin (Dilantin) or other anti-seizure medications may cause overgrowth of gums.

2) Overgrowth will need a type of gum surgery called gingivectomy.

3) Gum overgrown leads to tooth loss.

4) Carbamazepine causes dry mouth, bleeding of the gums, and osteoporosis.

Multiple Sclerosis:

Because multiple sclerosis affects muscle control, it may be more difficult for you to maintain a good oral-hygiene routine.

1) Complete or partial paralysis of face. 2) Severe tooth, jaw, chins or lip pain or numbness.

3) Inadequate oral hygiene and difficulty swallowing can lead to tooth decay and gum disease.

4) Difficult or impossible to wear dentures.

Cerebral Palsy:

Cerebral palsy refers to a group of body movement (motor) disorders that result from brain injury and do not worsen over time.

Anti-seizure medication, which can cause gum overgrowth. Good oral hygiene can help prevent the overgrowth or reduce its severity.

1) Cerebral palsy causes defects in their tooth enamel, stained a greenish color.

2) Malocclusion

3) Severe grinding of teeth (bruxism).

4) Damage to front teeth.

5) Tooth decay and periodontal (gum) disease

6) Excessive salivation or drooling

7) Underdeveloped tooth structure (enamel hypoplasia)

Muscular Dystrophy:

Muscular dystrophy is a genetic disease that causes severe and progressive muscle weakness.

1) People with myotonic dystrophy may have trouble chewing, moving their lips and turning their head. Other types usually do not involve facial muscles.

2) Malocclusion

3) Trouble brushing, flossing or rinsing.

Parkinson's Disease:

People with Parkinson's disease have involuntary muscle tremors and stiffness.

1) Difficult or impossible to wear dentures.

2) Parkinson’s disease can cause dry mouth (xerostomia). This can increase your risk of tooth decay.

Huntington's Disease:

People with Huntington's disease have involuntary muscle movements, including muscles in the face and tongue.

1) They can have trouble swallowing as well.

2) Difficult to practice good oral hygiene.

3) Good oral hygiene is important in order to minimize infection and tooth loss.

Myasthenia Gravis:

People with myasthenia gravis may have expressionless faces because they cannot move their facial muscles.

1) Difficulty in chewing food.

2) Their muscles may be so tired that they cannot keep their mouths closed after eating.

3) They may also have weakened tongue and palate muscles.

Spina Bifida:

It is a developmental birth defect involving the neural tube

1) If arms or chest are paralyzed, it may be difficult for you to brush and floss without assistance.

2) Medications that cause oral side effects (e.g. gum overgrowth).

Cold sores:

It is caused by the herpes simplex virus type 1 (HSV-1), Virus passes from person to person by infected skin or secretions, including saliva.

1) Nearly 70% of Americans ages 12 and older test positive for (HSV-1)

3) Nausea, vomiting, painful swelling and open sores on the gums and inside the cheeks. 4) Painful throat infection

Respiratory Diseases

Asthma:

Many drugs used to treat asthma have effects on the mouth and throat.

1) Rescue inhalers can cause dry mouth.

2) More susceptible to oral fungal infections

3) Cromolyn causes nausea, cough, a bad taste and dry or irritated sensation in mouth or throat.

Chronic Obstructive Pulmonary Disease (COPD), Bronchitis and Emphysema:

1) A long-term use of steroids may cause oral Candida infections (thrush).

Tuberculosis:

It is a common and deadly infectious disease caused by mycobacteria, mainly Mycobacterium tuberculosis

1) Enlarged lymph nodes.

2) Painful ulcer or sore in your mouth.

Sinusitis:

It is an inflammation of the paranasal sinuses, which may or may not be as a result of infection, from bacterial, fungal, viral, allergic or autoimmune issues.

1) Pain in the upper teeth. 2) Medications cause dry mouth.

3) Tooth decay

Wegener granulomatosis:

It is a necrotizing vasculitis of small to medium arteries and veins associated with necrotizing granulomas of the upper and lower airways and necrotizing glomerulonephritis.

1) Ulceration

2) Gingival enlargement

Sarcoidosis:

It is an idiopathic systemic disease.

1) Multiple, nodular, painless ulcerations of the gingival, buccal mucosa and palate.

STDs and Related Conditions:

Herpes Simplex Virus:

There are two major types of herpes simplex virus (HSV). HSV-1 usually results in oral and skin infections.

1) Sore mouth.

2) Red and inflamed gums

3) Oral ulcers and a sore throat.

4) Sore throat or tonsillitis

5) Cold sore or fever blister.

Gonorrhea:

It is the most common sexually transmitted diseases in the world, caused by Neisseria gonorrhoeae.

1) Sore throat.

2) Red and swollen tissue in their mouths.

Hepatitis:

Inflammatory disorder of liver due to viral infection.

1) Hepatitis rarely causes oral effects.

Syphilis:

It is sexually transmitted disease caused by the Treponema pallidum spirochete.

1) Painless sores that appear ulcerated and gray (necrotic) in the mouth tend to occur during the second stage of syphilis.

Epstein-Barr Virus: Most common disease associated with Epstein-Barr virus (EBV) infection is infectious mononucleosis, or "kissing disease."

1) Fever, fatigue, enlarged glands and sore throat.

2) Easy transfer of virus.

3) Hairy leukoplakia.

4) Cancer of the nasopharynx.

Cytomegalovirus: Cytomegalovirus (CMV) is a type of herpes virus.

1) Sore throat.

2) Salivary-gland enlargement and mouth sores.

Vitamin Deficiencies and Your Mouth:

Vitamin B:

Vitamin B deficiencies are one of the most common deficiencies with consequences for your mouth and teeth.

1) Burning sensation in mouth, and on tongue.

2) Trouble in swallowing.

3) Angular cheilitis — A painful inflammation and cracking in the corners of the mouth, usually related to a fungal infection. 4) Recurrent aphthous stomatitis

5) Chronic oral mucosal candidiasis.

6) Atrophic glossitis — taste buds of the tongue degenerate, making the tongue look "bald." and affects the sense of taste.

Iron:

Potential oral effects of iron deficiency are similar to those of vitamin B deficiency:

1) Burning sensation in the mouth and tongue.

2) Fungal infections in the mouth.

3) Tongue redness and swelling.

4) Oral sores and pale oral tissues.

Vitamin C:

It contributes to the synthesis of collagen, the main building block for many tissues.

1) Bleeding gums

2) Gingivitis,

Vitamin A:

It helps skin cells grow and maintain themselves.

1) Delayed healing in the mouth.

Vitamin D:

Vitamin D works with calcium to maintain bone quality and strength.

1) Jaw fracture.

2) Periodontal disease.

3) Affect the formation of teeth.

Vitamin K:

It is common vitamin deficiency that affects the mouth. Vitamin K is made by bacteria in your intestines.

1) Blood clotting problems.

2) Excessive bleeding after a tooth is extracted, or even after a simple teeth cleaning.

Table 3. Drugs affecting oral hygiene

Oral disease	Responsible drugs
Xerostomia	Antihistamines, Decongestants, Pain Killers, Diuretics, Antihypertensive, Antidepressants, antiasthmatics
Gum tissue overgrowth	Anti-seizure, immunosuppressant, calcium channel blockers
Oral sores, inflammation or discoloration	Antihypertensive, immunosuppressive agents, oral contraceptives and some chemotherapeutic agents
Abnormal bleeding	Aspirin and anticoagulants like heparin or warfarin
Tooth discoloration	Tetracycline

6. Importance of good oral hygiene:

Taking good care of mouth, teeth and gums is a worthy goal in and of itself. Good oral and dental hygiene can help prevent bad breath, tooth decay and gum diseases. An unhealthy mouth, especially gum disease may increase the risk of serious health problems such as Heart attack, Stroke, Poorly controlled diabetes and Preterm labor.

7. Mouth as source of infection:

i) Acute Necrotizing Ulcerative Gingivitis:

More than 500 species of bacteria thrive in mouth at any given time. These bacteria constantly form dental plaque a sticky, colorless film that can cling to teeth and cause health problems. If we don't brush and floss regularly to keep our teeth clean, plaque can build up along our gumline, creating an environment for additional bacteria to accumulate in the space between gums and teeth. This gum infection is known as gingivitis. Left unchecked, gingivitis can lead to a more serious gum infection called periodontitis. The most severe form of gum infection is called acute necrotizing ulcerative gingivitis, also known as trench mouth. (See Fig. 3.)

ii) Infective endocarditis:

Bacteria from mouth normally don't enter bloodstream. However, invasive dental treatments sometimes with just routine brushing and flossing if you have gum disease can provide a port of entry for these microbes. Medications or treatments that reduce saliva flow and antibiotics that disrupt the normal balance of bacteria in mouth can also compromise mouth's normal defenses, allowing these bacteria to enter bloodstream. If immune system is weakened, for example because of a disease or cancer treatment, oral bacteria in the bloodstream (bacteremia) may cause to develop an infection in another part of the body. Infective endocarditis, in which oral bacteria enter the bloodstream and stick to the lining of diseased heart valves, is an example of this phenomenon. (See Fig. 4.)

8. Plaque as a source of infection:

Long-term gum infection can eventually result in the loss of teeth. But the consequences may not end there. Recent research suggests that there may be an association between oral infections primarily gum infections and poorly controlled diabetes, cardiovascular disease and preterm birth. More research is needed to determine whether oral infections actually cause these conditions, which include: Poorly controlled diabetes, Heart attack and stroke, Low weight baby and premature labor and birth.

i) Poorly controlled diabetes:

Diabetic person is already at increased risk of developing gum disease. But chronic gum disease may, in fact, make diabetes more difficult to control, as well. Infection may cause insulin resistance, which disrupts blood sugar control. (See Fig. 5.)

ii) Heart attack and stroke:

Oral inflammation due to bacteria (gingivitis) may also play a role in clogged arteries and blood clots. It appears that bacteria in the mouth may cause inflammation throughout the body, including the arteries. This inflammation may serve as a base for development of atherosclerotic plaques in the arteries, possibly increasing the risk of a heart attack or stroke.

Some research suggests that people with gum infections are also at increased risk of heart attack and stroke. The more severe the infection, the greater the risk appears to be. Gum disease and tooth loss may contribute to plaques in the carotid artery. In one study, 46 percent of participants who had lost up to nine teeth had carotid artery plaque (CAP); among those who'd lost 10 or more teeth, 60 percent of them had such plaque. (See Fig. 6.)

Fig.6. Relationship between tooth loss and carotid artery plaque (CAP)

Table 4. Habits affecting oral hygiene

Habit	Oral effects
Smoking	1)Oropharyngial cancer 2) Periodontal disease 3) Dental implant failure 4) Discoloration of teeth 5) Halitosis 6) Diminished taste and smell 7) More prone candidiasis 8) Leucoplakia 9) Palatal keratosis 10) Stomatitis 11) Gingival recession 12) Smokers palate
Tobacco chewing	1) Oropharyngial cancer 2) Development of plaque 3) Periodontal disease 4) Gingival recession 5) Halitosis 6) Leucoplakia
Gutkha and Panmasala	1)Orapharangial cancer 2) Periodontal disease 3) Development of plaque 4) Dental staining 5) Gingival recession 6) Halitosis
Fast food	1) Development of plaque 2) Dental caries 3) Periodontal diseases 4) Halitosis 5) Dental erosion

iii) Low weight baby and premature labor and birth:

Severe gum disease may increase the risk of preterm delivery and giving birth to a low birth weight baby. The National Institute of Dental and Craniofacial Research, in fact, estimates that as many as 18 percent of preterm, low birth weight babies born in the United States each year may be attributed to oral infections.

The theory is that oral bacteria release toxins, which reach the placenta through the mother's bloodstream and interfere with the growth and development of the fetus. At the same time, the oral infection causes the mother to produce labor-triggering substances too quickly, potentially triggering premature labor and birth. (See Fig. 7.)

Fig.7. Poor oral hygiene and low weight baby and premature birth

9. Clinical research study reports ^{14, 15}:

Dental diseases are recognized as major public health problem throughout the world. Numerous epidemiological studies shown that the diseases such as tooth decay and diseases of the periodontum are among the most common afflictions of mankind. The studies conducted through the world indicated a high correlation between poor oral hygiene, dental plaque, prevalence and the severity of periodontal diseases.

Fig. 8. Effect of variables on and Periodontal Index Score (PIS)

i) Age, sex and oral hygiene ¹⁶:

The research study has been carried out in 752 South Vietnamese older than 15 years of age to evaluate importance of oral hygiene relative to other demographic variables like age, sex and oral hygiene to periodical index scores.

Study reveals that statically 67% (two third) of variance was attributed to oral hygiene (O H), approximately 31% was attributed to age and only 2% with sex. (See Fig. 8.)

ii) Relation between Periodontal disease and Tooth loss ^17-21:

Periodontal diseases are believed to involve anaerobic bacterial infections. Periodontal disease affects the periodontum, which is the investing and supporting tissues surrounding a tooth (i.e. periodontal ligament, the gingival and the alveolar bone). Gingivitis and periodontosis are more severe conditions involving degenerative disorders of the tissue. Combination of inflammatory and degenerative conditions are termed Periodontitis complex.

Fig. 9. Relation between tooth loss and periodontal disease (PD)

Periodontal disease is a major cause of tooth loss in adults. Tooth loss from periodontal disease is a significant problem beginning at age 35, but even by age 15 it is estimated that about 4 out of 5 persons already have gingivitis and 4 out of 10 have periodontal disease. Approximately 16.70% tooth loss in United States after age 40 is caused by periodical diseases. Where as in India the disease is responsible for 80% the teeth extracted after age30. (See Fig. 9.)

11. Major oral diseases, epidemiology and causative factors ^22-38:

Some important oral diseases and their causative factors are listed in table 1.

12. Diseases and disorders affecting oral hygiene^{40, 41}:

Most of the systemic diseases produces oral signs and symptoms and thus disturbs oral hygiene. The severity and magnitude of the disease widely vary and mostly depends on type of infection and part of oral cavity involved are listed in table 2.

Table 5. Dental erosive acid and their dietary sources

Type of acid	Dietary source
Acetic	Vinegar containing food, pickles, sauces.
Ascorbic	Chewable vitamin C tablets, some drinks.
Carbonic	Carbonated drinks.
Citric	Citrus juices and fruits.
Malic	Apple and apple juice.
Oxalic	Rhubarb.
Phosphoric	Soft drinks (eg. Cola drinks).
Tartaric	Grapes and grape juice, wine.

Table 6. Potential erosive foods and drinks⁴⁹

Potential erosive drinks	Potential erosive foods
Soft drinks: sweetened and nonsweetened, carbonated and non-carbonated, fruit flavored, fruit juices, sport drinks and energy drinks.	Fresh acidic fruit (e.g. Grapes, apples and citrus fruits) when consumed in high quantities and high frequencies.
Some herbal teas	Vinegar and vinegar containing foods and sauces (such as salt and vinegar potato chips and pickled foods).
Alcoholic drinks	Tomato ketch-up, Fruit base candy, Spicy food (e.g. fast food)

Table 7. Conditions or practices affecting oral hygiene

1. Vomiting

2. Reflux or chronic regurgitation associated with GIT problems

3. Regular or high intake of acidic medication

4. Regular intake of chewable vitamin C tablets

5. Professional wine testing

6. High consumption of acidic foods and drinks

13. Drugs affecting oral hygiene ⁴²:

It has been observed and clinically proved that many of the medication have side effects that disturb oral hygiene. The severity and type of adverse reaction depends upon the medication used and effects ranging from oral sore to abnormal bleeding. Some known lists of drugs that are responsible for development of oral disease are listed in table 3.

14. Habits affecting oral hygiene^43-48:

Life style and nature of habits have been known to produce long lasting effect on physical and mental health. Some important bad habits that are the primary cause of oral diseases are listed in table 4.

15. Food affecting oral hygiene ⁴⁹:

Most of the food material or drinks contain various acids, which leads to erosion of tooth surface due to its acidic nature. The most known erosive acids and its dietary source are listed in table 5 and potential erosive foods and drinks are listed in table 6.

10. Major oral diseases and disorders: a view

16. Conditions or practices that affecting oral hygiene⁴⁹:

Various medicinal conditions, practices or daily job profile, increases the chances and severity of dental erosion. Some important conditions are listed in table 7.

17. Protective factors for maintaining good oral hygiene ⁵⁰:

Food is a well known and self sufficient factor to maintain good oral hygiene. Food is important source of vital elements like nutrients, minerals, vitamins and fibers. Fibers are also known as nature’s tooth-brushes. Some important protective food, factor responsible, mechanism and supportive evidence are listed in table 8.

18. Ten important steps for good oral hygiene:

It is rightly said that prevention is better than cure. Routine oral hygiene practices helps to maintain good oral hygiene and also reduces the chances of development of local or systemic diseases to a great extent.

So it is better to follow ten important steps for good oral hygiene and bright smile.

1. Use good quality brush and fluoride toothpaste for cleaning teeth, gums and tongue.

2. Brush at least two times a day, for sufficient period of time preferably before breakfast and after dinner.

3. Use fluoride mouth wash for healthy gums and strong teeth.

4. Regularly floss your teeth.

5. Regularly massage gums, tongue, palate and buccal mucosa; it will increase blood circulation and salivary secretion.

6. Quit tobacco, gutkha, misery, smoking, alcohol and cold-drinks.

7. Don’t use sharp pins or needles to remove entrapped food debris.

8. Maintain regular dental check-up at least twice a year and avoid self diagnosis and self medication.

9. Take diet containing lots of minerals, vitamins and fibers. Limit high sugar containing diet, chocolates and candies.

10. Use mouth-guard/ face-guard during sports.

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Received on 13.03.2009 Modified on 15.04.2009

Research J. Pharm. and Tech.2(2): April.-June.2009,;Page 262-273

Food	Cariostatic factor	Mechanism	Supportive evidence
Cow’s milk	Calcium, phosphate, casein	Promote remineralization and prevent demineralization. Casein forms stable calcium- phosphate complex. Enamel absorbs milk protein and protect against acid dissolution.	Experimental studies Animal studies
Cheese	Calcium, phosphate, casein, casein-phosphopeptides	Increases salivary flow-rate and pH. Promote remineralization.	Clinical studies Animal studies
Apples	Flavonoids	Inhibit bacterial adherence. Antibacterial.	Preclinical studies
Cranberries	Flavonoids	Inhibit bacterial adherence. Antibacterial.	Experimental studies in vitro.
Tea (green and black)	Flavonoids Fluoride	Inhibit bacterial adherence. Antibacterial.	Clinical studies and Animal studies.
Peanuts		Gustatory flow and Increases salivary flow.	Experimental studies
High-fiber foods	Fibers are natural toothbrushes.	Increases salivary flow and removes plaque.	Epidemiological observational studies.
Others like: Cocoa butter, Licorice, Honey, Xylitol.	Cocoa factor Glychirizinic acid Esters	All contains cariostatic factors.	Experimental studies