Female Hormones and Oral Health: Part II - Pregnancy, Contraceptives and Menopause
The intricate interplay between hormonal fluctuations and oral health in people assigned female at birth (AFAB) has long been recognized, yet the depth of understanding continues to evolve. While we explored the influence of hormones on oral health during puberty and menstruation in Part I, we will now delve into the effects of pregnancy, contraceptives, and menopause on oral health in Part II.
Pregnancy and oral health
Poor oral health including chronic periodontitis is associated with increased time to conception in people assigned female at birth. Pregnancy may increase susceptibility to gum, periodontal disease, and dental caries. Salivary glands and gingival tissues have receptors for both estrogen and progesterone, suggesting that these tissues respond to hormonal influences.
Progesterone alters the rate and manner in which collagen is produced in the gingiva, consequently diminishing the body's capacity to effectively repair and sustain gingival tissues. Furthermore, both progesterone and estrogen induce folate deficiency, which hinders gingival repair processes, and they also suppress the immune system.
During pregnancy, hormonal changes can lead to gingival alterations characterized by highly vascularized, hyperplastic, and edematous gums. Untreated gingivitis can damage tooth support as bacterial plaque progresses under the gums. This destroys the supporting connective tissue fibers causing periodontitis and eventually tooth loss. Periodontal infection during pregnancy has been associated with preterm birth, low birth weight, and pre-eclampsia.
During pregnancy, progesterone also functions to suppress the maternal immune response, crucial for preventing the rejection of 'foreign' fetal antigens. This reduced natural immunity may elevate susceptibility to bacterial infections, with an increase in cariogenic bacterial strains. There is mounting evidence linking estrogen to a heightened incidence of dental caries. Estrogen has been shown to impact both the composition and the flow rate of saliva. This also predisposes the pregnant individual to increased bacterial growth and caries. There is an increased risk for caries during pregnancy due to changes in behaviors, such as eating habits. Nausea and vomiting during pregnancy can contribute to enamel erosion.
A bidirectional relationship exists between periodontal disease and gestational diabetes mellitus (a condition of carbohydrate intolerance detected during pregnancy). Inflamed periodontal tissues release cytokines known as insulin antagonists, potentially affecting blood glucose control and contributing to disease progression. On the other hand, gestational diabetes mellitus increase the risk of periodontitis and tooth loss in people assigned female at birth.
Pyogenic granuloma (pregnancy tumor), is a common benign inflammatory lesion that may appear on the gums, tongue, lips, or buccal mucosa, typically during the second month of pregnancy. It usually resolves within 12 weeks postpartum. It should be removed only if it causes pain and chewing difficulties.
All pregnant people should undergo dental consultations to assess their oral health.
At the initial prenatal visit, they should be advised to see a dentist, emphasizing the importance of dental care for both maternal and fetal health. Pregnancy gingivitis can be avoided or at least minimized by establishing low plaque levels at the beginning of pregnancy. In the postpartum period, vertical transmission of the cavity causing bacteria (Streptococcus mutans) from mother to child is very common. So, clinicians should encourage mothers to resume their own dental care if it was postponed during pregnancy.
Contraceptives and oral health
Hormonal contraceptives, used to prevent pregnancy, also serve various purposes such as family planning, regulating menstrual cycles, and reduction of ovarian cyst occurrence. These contraceptives include pills, patches, implants, injections, and intrauterine devices. Oral contraceptive pills are widely utilized by people assigned female at birth, with an estimated 50 million users worldwide. Despite their popularity, oral contraceptives have been associated with various systemic and oral side effects. The presence of estrogen and progesterone levels in contraceptive formulations can modulate biological responses.
The use of oral contraceptives causes gingivitis as well as peridontitis by the increase of oral microbes like P. gingivalis, P. intermedia, and A. actinomycetemcomitans or Candida species. These contraceptives can exacerbate periodontal degradation by diminishing resistance to dental plaque and may induce gingival enlargement in otherwise healthy individuals. People using oral contraceptives exhibit a higher prevalence of gingival inflammation, loss of attachment (connective tissue attachment loss around the tooth), and progression of periodontal disease.
The adverse changes usually appear after a few months of oral contraceptive therapy. They gradually increase with dosage and duration of therapy. Prolonged use of oral contraceptives has been linked to a heightened risk of periodontal disease due to increased production of pro-inflammatory cytokines and prostaglandins triggered by elevated hormone levels. Local factors also play a vital role in patients using oral contraceptives. Hormonal contraceptive users often undergo changes in saliva composition and reduced saliva production. They are also at higher risk of experiencing dry socket after tooth extraction.
Women should inform their dentists about their hormonal contraceptive use. This is because some medications prescribed by dentists can potentially reduce the effectiveness of birth control. Additionally, it's important to do so before undergoing dental procedures to prevent any potential complications.
Oral health examination which includes proper periodontal assessment and treatment is essential for the women who use oral contraceptives. The negative influence of the changes in estrogen and progesterone levels can be controlled by additional plaque control and strict oral hygiene measures. It should be followed up routinely to avoid any future dental complications for oral contraceptive users. Current combined oral contraceptives (COCs) may not significantly affect periodontal health, possibly attributed to lower levels of progesterone and estradiol compared to earlier formulations.
Menopause and oral health
The World Health Organization defines three age stages for women during midlife:
Menopause is the year of the final physiological menstrual period retrospectively designated as one year without flow (unrelated to pregnancy or therapy) in women aged ≥ 40 years.
Premenopause begins at ages 35-39 years, with reduced fertility despite regular menstruation.
Perimenopause refers to the years immediately preceding menopause and the first year following menopause.
Estrogen receptors are observed in the oral mucosa, gingiva, and salivary glands. The decrease in estrogen contributes to the change in the composition and quantity of saliva and drying of the oral mucosa. This can lead to menopausal gingivostomatitis, and the gingiva bleeds readily, with an abnormally pale, dry/shiny erythematous appearance.
Estrogen decreases osteoclast activity and enhances apoptosis. In the menopause stage, when the estrogen levels decline rapidly, there is the upregulation of immune cells (macrophages and monocytes) and osteoclasts. These are responsible for the greater production of bone-resorbing cytokines. This contributes to the destruction of connective tissue, and alveolar bone resorption.
Menopausal individuals suffer from osteoporosis which involves reduced bone density, leading to fractures and deformities. Periodontitis in menopausal women often progresses silently until advanced stages marked by tooth mobility, abscesses, and loss. While osteoporosis isn't directly linked to periodontitis, it may worsen existing cases. Edentulous women face denture fitting issues due to significant bone loss and changes in jawbone morphology.
Oral manifestations of menopause also include burning mouth syndrome, xerostomia, lichen planus, and stomatodynia (painful mouth). Neurological disorders like trigeminal neuralgia, atypical facial pain/neuralgia and Alzheimer's disease may affect postmenopausal individuals. These tend to impact dental procedures such as impression-making, recording jaw relations, and denture retention.
Menopausal individuals suffer from eating disorders due to psychological stress. Self-induced vomiting or regurgitation of gastric contents in the oral cavity leads to perimolysis (intrinsic dental erosion), enlarged parotid glands, angular cheilitis, dehydration, erythema, and trauma to the oral mucosa and pharynx resulting from the use of fingers.
Women taking hormone therapy may not experience oral problems but it also depends on the oral systemic health of each individual. Estrogen therapy protects against mandibular bone loss and diminishes the severity of periodontal disease in postmenopausal individuals.
During dental check-ups, a detailed clinical history should be obtained from the patient. A complete evaluation of the oral mucosal membranes, periodontal health, other dental conditions, and salivary flow should be done. Other examinations like radiographs, periodontal probing, and sialometry (measure of salivary flow) should also be done. Proper oral hygiene measures, such as brushing, interproximal brushes, and dental floss, together with the use of mouth washes are recommended. This lowers the dental plaque levels and improves the oral health.
Certain hormonal fluctuations are natural and inevitable in a woman's lifetime like menarche, pregnancy, and menopause. I would encourage them to visit their dentists and follow strict oral hygiene routine that caters to their diagnosis. This will help reduce the negative effects of hormonal changes on their oral health. There is extensive research being done in the area of female hormones and oral health. I, myself was part of a survey team, wherein we interviewed ASHA workers on the knowledge they had about pregnancy affecting the gums of a woman. I have also come across research correlating burning mouth syndrome and hormonal changes which seems intriguing.
Dr. Yogeeta V H, BDS, Bapuji Dental College and Hospital, Davangere, Karnataka, India.
As National Women's Health Month is commemorated in May, it's essential to recognize the intricate relationship between female hormones and oral health. Hormonal fluctuations, including those during puberty, menstruation, pregnancy, and menopause, exert a significant impact on the oral health of people assigned female at birth. By understanding these connections, healthcare providers can tailor interventions and preventive strategies to support the individual's oral health across their lifespan. Further research and awareness are key to ensuring comprehensive healthcare for women, addressing the often-overlooked aspect of oral health. As we advocate for the health of people assigned female at birth, let's not forget the crucial role of oral health in overall well-being, promoting a holistic approach to healthcare for all.
References
https://www.cdc.gov/oralhealth/publications/features/pregnancy-and-oral-health.html
Kessler JL. A Literature Review on Women’s Oral Health Across the Life Span. Nursing for Women’s Health [Internet]. 2017 [cited 2024 May 12]; 21(2):108–21. Available from: https://www.sciencedirect.com/science/article/pii/S1751485117300570
https://www.efp.org/publications/perio-insight/women-and-oral-health-views-from-periodontology-and-gynaecology/
Prachi S, Jitender S, Rahul C, Jitendra K, Priyanka M, Disha S. Impact of oral contraceptives on periodontal health. Afr Health Sci [Internet]. 2019 [cited 2024 May 12]; 19(1):1795–800. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531981/.
Castro MML, Ferreira MKM, Prazeres IEE, Oliveira Nunes PB de, Magno MB, Rösing CK, et al. Is the use of contraceptives associated with periodontal diseases? A systematic review and meta-analyses. BMC Women’s Health [Internet]. 2021 [cited 2024 May 12]; 21(1):48. Available from: https://doi.org/10.1186/s12905-021-01180-0.
https://www.ida.org.in/Public/Details/Community-Focus
Grover CM, More VP, Singh N, Grover S. Crosstalk between hormones and oral health in the mid-life of women: A comprehensive review. J Int Soc Prev Community Dent [Internet]. 2014 [cited 2024 May 13]; 4(Suppl 1):S5–10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247552/.
SB
