Women’s Oral Health Issues
Barbara J. Steinberg, DDS
Dr. Steinberg will present "Dental and Medical Considerations in
Treating the Mature Female Patient" at CDA’s Conference for the Woman
Dentist. Her presentation will be from 2:15 to 4:10 p.m. on Thursday,
Sept. 14, in Room 130 of the Moscone Convention Center.
Copyright 2000 Journal of the California Dental Association.
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Hormonal fluctuations affect more than a woman’s reproductive system. They have a surprisingly strong influence on the oral cavity. Puberty, menses, pregnancy, and menopause all influence women’s oral health and the way in which a dentist should approach their treatment. This paper will review aspects of a woman’s life when hormonal fluctuations may affect oral tissues. |
Because oral health is an integral part of general health, oral problems indigenous to the female population have to be addressed. Women have special oral health needs and considerations that men do not have.
Hormonal fluctuations affect more than a woman’s reproductive system. They have a surprisingly strong influence on the oral cavity. These changes are not necessarily the result of direct hormonal action on the tissue but are, perhaps, best explained as the effects of the local factors (e.g., plaque on tissues exacerbated by hormonal activity). Puberty, menses, pregnancy, and menopause all influence women’s oral health and the way in which a dentist should approach their treatment. Similar influences may also be seen in women taking oral contraceptives. This paper will review each of those parts of a woman’s life when hormonal fluctuations may affect oral tissues. It will also discuss the effects of eating disorders on the oral cavity.
Puberty
Gingival tissues and the subgingival microflora respond with a variety of changes to the increasing hormone level at the onset of puberty. Microbial changes have been reported during puberty and can be attributed to changes in the microenvironment seen in the gingival tissue response to the sex hormones as well as the ability of some species of bacteria to capitalize on the higher concentration of hormones present.1
Clinically, during puberty there may be a nodular hyperplastic reaction of the gingiva in areas where food debris, materia alba, plaque, and calculus are deposited, The inflamed tissues are deep red and may be lobulated, with ballooning distortion of the interdental papillae. Bleeding may occur when patients masticate or brush their teeth. Histologically, the appearance is consistent with inflammatory hyperplasia.
Menses
Oral changes that may accompany menses include swollen erythematous gingival tissues, activation of herpes labialis, apthous ulcers, prolonged hemorrhage following oral surgery, and swollen salivary glands.2,3
Some females are not aware of any gingival changes at all, while others complain of bleeding and swollen gums in the days preceding the onset of menstrual flow. These changes usually resolve once menses begin. In addition, an increase in gingival exudate caused by inflamed gingiva has been observed during the menstrual period and is sometimes associated with a minor increase in tooth mobility.4,5
Intraoral recurrent apthous ulcers and herpes labialis lesions occur in some women as a pattern that seems related to their menstrual cycle. The lesions appear during the luteal phase of the cycle and heal following menstruation.
In some women, postoperative hemorrhage occurs more frequently during menses than at other times. No significant hematologic laboratory findings accompany this other than a slightly reduced platelet count and a slight increase in clotting time.
Swelling of the salivary glands, particularly the parotid, occurs occasionally during menses. There may be an associated increase in gynecologic complaints, though the cause is unclear.2
Pregnancy
The popular notions that pregnancy causes tooth loss ("a tooth for every pregnancy") and that calcium is withdrawn in significant amounts from the maternal dentition to supply fetal requirements have no histologic, chemical, or roentgenographic evidence to support them. Calcium is present in the teeth in a stable crystalline form and, as such, is not available to the systemic circulation to supply a calcium demand. However, calcium is readily mobilized from bone to supply these demands.
Gingivitis is the most prevalent oral manifestation associated with pregnancy. It has been reported to occur in from 30 percent to 100 percent6,7 of all pregnant women, although it most frequently ranges from 60 percent to 75 percent. Gingival changes usually occur in association with poor oral hygiene and local irritants, especially bacterial flora of plaque. However, the hormonal and vascular changes that accompany pregnancy often exaggerate the inflammatory response to these local irritants.
Clinically, the appearance of inflamed gingiva during pregnancy is characterized by a fiery red color of the marginal gingiva and interdental papillae. The tissue is edematous, with a smooth, shiny surface; loss of resiliency; and a tendency to bleed easily There may also be increased pocket depth and minimal loss of attachment apparatus.8,9 Gingival changes are most noticeable from the second month of gestation, reaching a maximum in the eighth month. These changes occur earlier and more frequently in anterior than posterior areas. The severity of gingival disease is reduced after childbirth, but the gingiva does not necessarily return to a state of health.10 Patients with untreated gingival disease during pregnancy will most likely have gingival disease after pregnancy, although it may decrease in severity.11
A recent study12 suggests that maternal periodontal disease may be a risk factor for preterm low-birthweight babies. A preterm low-birthweight baby is one born before the 37th week of gestation who weighs less than five pounds, eight ounces. More studies are needed to substantiate these results as well as to determine whether intercepting maternal periodontal disease will reduce the risk of preterm delivery.
In addition to generalized gingival changes, pregnancy may also cause single, tumor-like growths, usually on the interdental papillae or other areas of frequent irritation. This localized area of gingival enlargement is referred to as a "pregnancy tumor," "epulis gravidarum," or "pregnancy granuloma." The histologic appearance is similar to the pyogenic granuloma. Its reported frequency ranges from 0 percent to 9.6 percent.1,13 The lesion occurs most frequently on the labial aspect of the maxillary anterior region during the second trimester. It often grows rapidly, although it seldom becomes larger then 2 cm in diameter. A pregnancy tumor classically starts to develop in an area of inflammatory gingivitis. Poor oral hygiene invariably is present, and often there are deposits of plaque or calculus on the teeth adjacent to the lesion. The gingiva becomes hyperplastic and enlarges in a nodular fashion to give rise to the clinical mass. The fully developed pregnancy granuloma is a sessile or pedunculated lesion that is usually painless. The color varies from purplish red to deep blue, depending on the vascularity of the lesion and the degree of venous stasis. The surface of the lesion may be ulcerated and covered by a yellowish exudate, and gentle manipulation of the mass easily induces hemorrhage. Bone destruction is rarely observed around pregnancy granulomas.
Generally, the lesion will regress somewhat postpartum; however, surgical excision is often required for complete resolution. It may be prudent to delay surgery until after the pregnancy. Before parturition, scaling and root planing, as well as intensive oral hygiene instruction, may need to be initiated to reduce the plaque retention.
There are situations, however, when the pregnancy granuloma will have to be excised during pregnancy, such as when it is uncomfortable for the patient, disturbs the alignment of the teeth, or bleeds easily on mastication. Pregnancy granulomas excised before term may recur; therefore, the patient should be advised that revision of the surgical procedure may have to be performed postpartum.10
An additional oral finding that may be seen in the pregnant patient is generalized tooth mobility.14 This change is probably related to the degree of gingival diseases disturbing the attachment apparatus, as well as to mineral changes in the lamina dura. This condition usually reverses after delivery.
Finally, some pregnant women complain of xerostomia; and, indeed, one study found this persistent dryness in 44 percent of the pregnant participants.15,16 Hormonal alterations associated with pregnancy are a possible explanation. More frequent consumption of water and sugarless candy and gum may help this problem.
Oral Contraceptives
One of the most common effects on the oral mucous membranes in individuals taking oral contraceptives is gingival inflammation. Many people have an exaggerated gingival inflammatory response to local irritants, characterized by fiery red, enlarged, and hemorrhagic gingival tissues.
Women taking oral contraceptives demonstrate a significant increase in the number of Prevotella species in the gingival microflora. Increased female sex hormones substituting for the naphthoquinones required by certain Prevotella species most likely are responsible for this rise.7
Measurable changes have also been observed in the salivary components of women taking sex hormones, including a decrease in concentrations of protein, sialic acid, hexosamine fucose, hydrogen, and total electrolytes. In some studies, changes in salivary flow have been reported. For example, both parotid and submandibular salivary secretion rates increased in women using oral contraceptives in one report,17 while another noted a persistent dryness of the mouth in 30 percent of subjects on oral contraceptives.16
The dental literature reports that women taking oral contraceptives experience a twofold to threefold increase in the incidence of localized osteitis following extraction of mandibular third molars.18 The higher incidence of osteitis in these patients may be attributed to the effects of oral contraceptives (estrogens) on blood-clotting factors. It may be advisable to perform extraction of teeth (especially of third molars) on non-estrogenic days (days 23 to 28) of the pill cycle, to reduce the risk of a postoperative localized osteitis.2
Menopause
Menopause, the cessation of menses, is a normal developmental event experienced by women around the age of 50. It has been said that the average women can expect to live one-third of her life after her last menstrual period.19 Menopause is accompanied by a number of physical changes, some which occur in the oral cavity. The most common oral problems of menopause are discussed below. Though menopause has long been associated with certain physical changes, the exact etiology and the mechanisms involved in the onset of these symptoms remain unknown.19
Oral Discomfort
Oral discomfort is a common complaint among menopausal and postmenopausal women. Occurrences of pain, burning sensations, altered taste perception (salty, peppery, or sour), and dryness of the mouth have been reported in approximately 20 percent to 90 percent of menopausal women.20-22 Most menopausal women who complained of oral discomfort were relieved after the administration of estrogens either systemically or topically.20,22,23
Oral Mucosal Changes
Changes in the oral mucosa occurring in menopausal women may vary from an atrophic and pale appearance to a condition known as menopausal gingivostomatitis. This condition is marked by gingiva that is dry and shiny, bleeds easily, and ranges from an abnormally pale color to tissue that is very erythematous.24 Other studies report menopausal women with oral discomfort had a clinically normal oral mucosal appearance,23,25 suggesting that oral discomfort may be due to other causes, such as psychological disturbances. It appears that hormonal replacement therapy is of benefit in reducing oral discomfort in those who have both abnormal and normal mucosal appearance. Woman on hormonal replacement therapy (i.e., estrogen and progestin) may experience gingival problems similar to those of oral contraceptive users.
Salivation
It has long been assumed that salivary flow decreases with age, but it is now generally accepted that major salivary gland output does not diminish with advancing age if the individual is otherwise healthy.26
Osteoporosis
Generalized bone loss from systemic osteoporosis may render the jaws susceptible to accelerated alveolar bone resorption.27 The compromised mass and density of the maxilla or mandible in a patient with systemic osteoporosis may also be associated with an increased rate of bone loss around the teeth or the edentulous ridge.28-30 Recent studies support the hypothesis that systemic bone loss may contribute to tooth loss in healthy individuals31 and women with low bone mineral density tend to have fewer teeth compared to controls.32 In fact, one study reports that women with severe postmenopausal symptoms were three times as likely as controls to be edentulous.33
Although it has been thought that residual ridge resorption was a local problem caused or promoted by disuse, inflammation, or mechanical factors, there now appears to be ample evidence to support the idea that it is principally a systemic problem.19 There have been numerous reports that show a relationship between residual ridge reduction and osteoporosis.34,35
When considering the relationship between osteoporosis and periodontitis, it is believed that osteoporosis is not an etiologic factor in periodontitis but may affect the severity of the disease in pre-existing periodontitis.1 A recent study suggests that severe osteoporosis that significantly reduces the bone mineral content of the jaws may be associated with less favorable attachment level in the case of periodontal disease.36 Some recent studies have suggested that estrogen replacement therapy protects against tooth loss and reduces the risk of edentulism.37-39
Eating Disorders
The most dramatic oral problems seen in eating-disordered individuals stem from self-induced vomiting. While this symptom is more characteristic of the syndrome of bulimia nervosa, a subgroup of anorectic individuals also engage in self-induced vomiting with or without prior binge eating.
The most common and dramatic effect of chronic regurgitation of gastric contents is smooth erosion of enamel or perimylolysis. This manifests as a loss of enamel and dentin on the lingual surfaces of the teeth as a result of chemical and mechanical effects caused mainly by regurgitation of gastric contents and activated by movements of the tongue. This erosion typically is seen on the palatal surfaces of the maxillary anterior teeth and has a smooth, glassy appearance. There are few, if any, stains or lines in the teeth; and when the posterior teeth are affected, there is often a loss of occlusal anatomy. Perimylolysis is usually clinically observable after the patient has been binge eating and purging for at least two years.40
There appears to be a relationship, albeit not a perfect correlation, between the extent of tooth erosion and the frequency and degree of regurgitation, as well as with oral hygiene habits.40 For example, some patients do not regurgitate all of the low pH stomach contents and thereby avoid severe enamel erosion. Destruction of tooth structure can also be avoided by adhering to scrupulous oral hygiene practices (with the exception of immediate toothbrushing) after vomiting.
Enlargement of the parotid glands and occasionally the sublinguals are frequent oral manifestations of the binge-purge cycle in eating disorder individuals.41 The incidence of unilateral or bilateral parotid swelling in patients who frequently binge eat and purge has been estimated at between 10 percent and 50 percent. The occurrence and extent of parotid swelling is proportional to the duration and severity of the bulimic behavior.40
The etiology of this salivary gland swelling is still not identified, but most investigators have associated it with recurrent vomiting. The mechanisms, in this case, may be cholinergic stimulation of the glands during vomiting, or autonomic stimulation of the glands by activation of the taste buds.41
The oral mucosa membranes and the pharynx may also be traumatized in patients who binge eat and purge, both by the rapid ingestion of large amounts of food and by the force of regurgitation.42 The soft palate may be injured by objects used to induce vomiting, such as fingers, combs, and pens. Dehydration, erythema, and angular cheilitis have also been observed.42
Author
Barbara J. Steinberg, DDS, is a professor of medicine and surgery at the MCP Hahnemann School of Medicine and a clinical associate professor of oral medicine at the University of Pennsylvania School of Dental Medicine.
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To request a printed copy of this article, please contact/Barbara Steinberg, DDS, Medical College of Pennsylvania Hospital, 3300 Henry Ave., Philadelphia, PA 19120.
