Sex hormones affect females starting from puberty, peaking in pregnancy, and persisting up to and even after menopause. During these periods of fluctuating hormone levels many medical and dental problems may arise. Sex hormones may alter the female's periodontium (producing, for example, gingival inflammation) and reduce her resistance to dental plaque (i.e., bacteria).1 In addition, researchers have recently attempted to find a link between osteopor-osis/osteopenia and loss of bone surrounding the teeth in postmenopausal women.2
Studies have shown a possible link between oral inflammation and pregnancy complications and preterm, low-birthweight babies.3 Various biological immune markers present in the blood as a result of periodontal infection may serve as a risk factor for premature labor. This article will review factors related to women and oral health and discuss the role of the pharmacist in counseling female patients during these vulnerable life stages.
Hormones and Periodontal Diseases
As females go through certain stages in their reproductive life cycle, alterations arise in the level of sex (steroid) hormones circulating in their bloodstream. Specifically, variations in levels of progesterone and estrogen in women may adversely affect the periodontal tissues in the mouth. Extensive research suggests a relationship between periodontal diseases, which are subclassified as gingivitis and periodontitis, and puberty, menstruation, pregnancy, oral contraceptive use, and menopause.
|A 13-year old girl complained of bleeding when she brushed. Clinical examination revealed severe gingival inflammation characterized by enlarged and swollen (puffy) gingiva around the teeth. Puberty is notable for higher levels of sex hormones, which may produce transient gingival inflammation.|
Gingivitis: Gingivitis is defined as inflammation of the gingiva (gums) surrounding the teeth, with no radiographic evidence of bone loss. It is caused primarily by bacterial plaque, a sticky substance composed of bacteria and other deposits that then accumulates on the teeth. While a "plaque-free" mouth is an ideal that cannot be achieved, plaque build-up must be minimized to maintain healthy gums. If plaque is allowed to accumulate beyond threshold levels, the gingiva reacts by becoming inflamed. This process is similar to the events incurred when a splinter lodges in the skin. Vascularity increases, causing the blood vessels in the underlying connective tissue to become engorged and increase in number. This results in redness, bleeding and enlargement (overgrowth) of the gingiva. Associated with this inflammation is an increase in the flow of tissue fluid and a change in the immune response. This type of gingivitis is called "dental plaque-induced gingivitis" and is caused by the accumulation of dental plaque on the teeth due to inadequate oral home care.
Gingival diseases can also be modified by systemic factors, such as sex hormones. In these cases, the elevated levels of hormones cause an exaggerated response to the dental plaque on the teeth and gums, resulting in gingival inflammation. Unique to gingival diseases associated with sex hormones is that the gingival inflammation is elicited by relatively small amounts of dental plaque.4
Estrogen and progesterone affect the entire body, including the oral tissues. The gingival tissues respond to increased levels of estrogen and progesterone by undergoing vasodilation and increased capillary permeability. Consequently, there is an increased migration of fluid and white blood cells out of blood vessels.
Also associated with increased progesterone levels are alterations in the existing microbial populations. The levels of Gram-negative anaerobic bacteria, such as Prevotella intermedia, increase as a result of the high concentration of hormones available as a nutrient for growth.5,6
Gingival diseases can also be drug induced. Phenytoin, calcium channel blockers (especially nifedipine) and cyclosporine are widely reported in the literature to cause gingival enlargement. Of particular importance due to the large number of fertile women is the fact that oral contraceptive use is also reported to cause gingival disease.7 Oral contraceptives act to mimic pregnancy; thus, all of the dramatic hormonal changes seen in pregnancy also occur in women taking oral contraceptives. Why does hormonal-induced gingivitis occur in some individuals and not others? The answer to this question is not completely understood. Most likely, individual variability in the immune response to the various irritants and stimulants is responsible.
Periodontitis: Periodontitis involves the loss of supporting bone around the tooth. While changes in hormonal levels do not directly cause this loss of bone, it may occur as a result of a generalized osteoporosis in the body.
Puberty and Menstruation
Puberty, which marks the beginning of sexual maturation of an individual, involves reproductive changes. Gingival inflammation and enlargement can occur in both males and females, but it is more prevalent in females. Changes in levels of estrogen and progesterone and in gingival inflammation are transitory and will revert to normal levels in the post-circumpubertal period. Most females who are systemically healthy, with healthy gingiva, will not develop significant periodontal changes due to puberty or menstruation. However, some females who initially have gingivitis even with relatively little accumulation of dental plaque will likely develop signs of puberty- or menstrual cycle-associated gingivitis (FIGURE 1 and TABLES 1 and 2).
Pregnancy-associated gingivitis describes gingivitis that occurs during pregnancy. Clinical features of pregnancy-associated gingivitis are mainly limited to gingival changes (TABLE 3). These changes are temporary and will improve postpartum, when progesterone levels return to normal.
During pregnancy, gingivitis results from elevated serum progesterone and bacteria in plaque that affect the gingival microvasculature. Often, it is an exaggerated response to a small amount of plaque and most likely would not have developed in a nonpregnant woman. The condition does not occur in all pregnant women, but when it does, it is evident in the second or third trimester. The prevalence and severity of gingivitis may be higher in pregnant than nonpregnant women and in women with pre-existing gingivitis yet low plaque levels.8
|Table 1: Clinical Features of|
?Accumulation of dental plaque on teeth
?Pronounced inflamed gingiva
?Redness of gingiva
?Swelling of gingiva
?Bleeding of gingiva upon stimulation
?Reversible following puberty
?No radiographic bone loss
|Table 2: Clinical Features of Menstrual Cycle-Associated Gingivitis|
|? Accumulation of plaque on teeth|
?Modest inflammatory response of gingiva prior to ovulation
?No radiographic bone loss
?Reversible following ovulation
|Table 3: Clinical Features of|
|? Increased accumulation of plaque on teeth|
?Onset in the second or third trimester
?Pronounced redness of gingiva
?Edematous (swollen) gingiva
?Bleeding of gingiva upon stimulation
Oral contraceptives act by elevating hormonal levels to simulate pregnancy and prevent ovulation. Hence, it is expected that the same gingival changes seen during pregnancy will also be seen in women taking oral contraceptives. Gingival changes include inflammation and enlargement with increased amount of fluid flow into the tissue.9 As with pregnancy-associated gingivitis, gingival inflammation in women on oral contraceptives occurs in the presence of very little plaque. The most profound gingival changes are seen in the first few months after starting the contraceptive. If the condition worsens, a different formulation may be tried. Once the woman discontinues the contraceptive, the gingival condition will reverse.
Since the inception of oral contraceptives, the newer formulations contain lower concentrations of hormones. Unfortunately, most of the clinical studies investigating oral contraceptive use were performed in the 1960s. One more recent report suggests that because of the lower concentrations in the current oral contraceptive formulations, the inflammatory response of the gingiva to dental plaque was not affected in the study participants, so no gingival changes were found.10 More research is needed to evaluate these current formulations.
During menopause there is a decrease in the levels of progesterone and estrogen circulating in the bloodstream. The most common oral manifestations of menopause are oral discomfort and bone loss due to osteoporosis.11,12 Oral discomfort has been described as pain, burning, dryness, and a bad taste in the mouth.11
At this phase of life, many women may be taking estrogen supplements, which will most likely bring hormonal levels back to normal rather than to the elevated levels reached in pregnancy and in women taking oral contraceptives. Therefore, gingival inflammation will not be a major factor in menopausal and postmenopausal women.13 Women who have good oral (gingival) health are not at increased risk for the development of periodontal disease during and after menopause.1 Estrogen supplementation may also reduce the risk of osteoporotic fractures.
Osteoporosis is characterized by a loss of bone mass and density. Specifically, this disorder entails a reduction in cortical bone (outer compact bone) thickness and in the number and size of trabeculae of cancellous bone (inner bone). Osteoporosis results either from increased resorption of bone, decreased formation of bone, decreased estrogen levels, decreased calcium levels, excessive corticosteroids, hyperthyroidism or age-related changes.
Since the teeth are embedded in bone that comprises the maxilla and mandible (jaw), osteoporotic changes affect these structures.2,14 More current studies confirm previous studies finding that the systemic bone loss seen in osteopenia/osteoporosis is associated with loss of bone surrounding the teeth.15 Further investigation is needed to determine whether modification of bone mineral density will be helpful in the treatment of periodontal diseases.
Several risk factors are documented relating to the high incidence of preterm delivery (<37 weeks) of low-birthweight (<2,500-g) babies,16 including poor prenatal care, alcohol and drug use, and microbial infections of the genital area.
Prostaglandins are produced and released during inflammation. Specifically, prostaglandin E2 (PGE2) is involved in bone resorption and in stimulating the uterus to contract during pregnancy. Both inflammation and progesterone significantly increase the formation of prostaglandins in the gingival tissue of pregnant women. Thus, it has been postulated that women with periodontal disease who give birth to preterm, low-birthweight babies versus normal-birthweight babies have significantly increased PGE2 levels. These prostaglandins found in the serum originate in the fluid of the underlying gingival tissues and flow out into the pocket between the tooth and the gingiva.16 Additionally, four bacteria types (Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Bacteroides forsythus, and Treponema denticola) were detected at higher levels in mothers of preterm, low-birthweight babies than in mothers who delivered normal-birthweight babies.17 Given these data, pharmacists and other healthcare professionals should stress to their patients the role of oral health in preventing pregnancy complications.
Role of the Pharmacist
Pregnant women may come into the pharmacy requesting a medication to help with their "bleeding gums." Educating the pregnant patient regarding the etiology of gum inflammation and explaining that the gingival condition will reverse postpartum will help allay her fears of having some kind of debilitating disease. When counseling women on oral contraceptive use, the pharmacist should inform them of the possibility of gingival bleeding and enlargement and stress that these gingival changes will regress once the drug is discontinued. A patient in any stage of fluctuating hormone levels should be advised to keep meticulous oral home care, which includes brushing with a soft-bristled toothbrush and flossing. If bleeding occurs, the patient should not stop oral hygiene measures because then the inflammation would only get worse. The pharmacist should also emphasize the importance of regular visits to the dentist/periodontist to monitor periodontal status and to have plaque professionally removed.18
Throughout the reproductive life cycle of women, fluctuating levels of sex hormones may have direct and indirect effects on oral health, in the form of inflammation, gingivitis, periodontitis, and altered populations of microorganisms. Pregnancy is a particularly vulnerable time, and poor oral health may even be correlated with low-birthweight babies. Since there are many times in which women will visit a pharmacist for dental-related diseases, pharmacists are in a prime position to counsel women on the effects of hormones on oral health, to reassure patients of the often transitory nature of these effects, and to advise patients how to maintain good home oral care.
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