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 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 39-44

Detrimental consequences of women life cycle on the oral cavity

1 Department of Periodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
2 Department of Conservative and Endodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India

Date of Web Publication2-Feb-2018

Correspondence Address:
Jammula Surya Prasanna
Department of Periodontics, Panineeya Institute of Dental Sciences and Research Center, Road No 5, Kamala Nagar, Dilshuknagar, Hyderabad - 500 060, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jorr.jorr_33_17

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The majority of us visit a dentist only when we experience a toothache, as visiting the dentist regularly is the last thing that strikes our mind. Many clinical studies have concluded that oral bacteria can lead to a genre of health conditions which may sometimes be very serious. 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 and puberty, menstruation, pregnancy, oral contraceptive use, and menopause. Estrogen and progesterone affect the entire body, including the oral tissues. The gingival tissues respond to this increased level of estrogen and progesterone by undergoing vasodilatation 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. This article discusses the plethora of causes which affect the oral health of women as they undergo the different life cycles.

Keywords: Dental health, hormonal fluctuation, hygiene, inflammation, women's health

How to cite this article:
Prasanna JS, Karunakar P, N. Sravya M V, Madhavi B, Manasa A. Detrimental consequences of women life cycle on the oral cavity. J Oral Res Rev 2018;10:39-44

How to cite this URL:
Prasanna JS, Karunakar P, N. Sravya M V, Madhavi B, Manasa A. Detrimental consequences of women life cycle on the oral cavity. J Oral Res Rev [serial online] 2018 [cited 2021 Dec 1];10:39-44. Available from: https://www.jorr.org/text.asp?2018/10/1/39/224540

  Introduction Top

Omen may be more susceptible to oral health problems because of the hormonal changes they experience. Hormones do not only affect the blood supply to the gingival tissue but also the body's response to the toxins that result from plaque buildup. As a result of these changes, women are more prone to develop periodontal disease and other health problems in certain stages of their lives. There are five situations in a woman's life during which hormone fluctuations make them more susceptible to oral health problems during puberty, at certain points in the monthly menstrual cycle, when using birth control pills, during pregnancy, and at menopause.

  Puberty Top

The surge in production of the female hormones estrogen and progesterone that occurs during puberty can cause an increase in blood flow to the gingiva which alters the gingival response to plaque and calculus.[1],[2],[3]

Kornman and Loesch postulated that anaerobic organisms may use ovarian hormone as a substitute for Vitamin K growth factor. During puberty, periodontal tissues may have an exaggerated response to local factors. A hyperplasic reaction of the gingiva may occur in areas where food debris, material-Alba, plaque, and calculus are deposited. The inflamed tissues become erythematous, lobulated, and retractable. During puberty, education of the parent or the caregiver is a part of successful periodontal therapy.[4],[5],[6]

Bulimia and anorexia nervosa are more likely to be developed during this period as girls get conscious of their body during this period.[7] Eating disorders may lead to nutritional deficiencies that might affect the health and appearance of the mouth. Some symptoms may include, pale tissues, burning mouth, and cracks at the corners of the mouth. If binging involves sugary food and sweetened drinks cavities may increase. Women who binge and vomit frequently, often have a dry mouth and swollen glands around their face. The palate and throat may become red if vomiting is forced. Self-induced vomiting can cause damage to the teeth. Acids from the stomach soften teeth and can erode enamel. This is usually seen on the insides of the front teeth. This can cause pain and breaking of teeth.[8]

Pubertal gingival changes are also seen in boys, but more severe and more destructive nature in the female because of estrogen and progesterone.[9] The proper oral-hygiene regimen should be followed at home, including regular brushing, flossing, and regular dental care. Professional periodontal therapy may be recommended in some cases in the prevention of damage to the tissue and bone surrounding the teeth.

  Menstruation Top

Due to the monthly fluctuation of hormones, some women experience oral changes that can include bright red hypertrophic gingiva and salivary glands, development of canker sores, or gingival bleeding. This condition is termed as menstruation gingivitis, which usually occurs a day or two before the start of the period and clears up shortly after the period has started. In this case, dentist plays a major role in diagnosing and treating the condition.[10],[11]

  Oral Contraceptives Top

Women who take certain oral contraceptive pills that contain progesterone, increases the level of that hormone in the body, may experience inflamed gingival tissues due to the body's exaggerated reaction to the toxins produced from plaque.[12] Progesterone has been shown to reduce corpuscular flow rate, allowing for accumulation of inflammatory cells, increased vascular permeability, and proliferation. Dry mouth, dry socket, and gingivitis are the most common side effects of oral contraceptives. Dry socket is a very painful condition in which the socket left behind after extraction does not heal. In case of gingivitis redness, swelling, and bleeding in the gingiva can be experienced.[13] Women on oral contraceptives should inform the dentist about this before the treatment. Hence, women should be aware of these side effects.

Women on oral contraceptives and pregnant women are susceptible to similar oral health conditions. Women on these pills should be aware of the fact that antibiotics such as penicillin, tetracycline, metronidazole, etc., which can be used to treat periodontal problems may lessen the effect of oral contraceptive pills.[14],[15],[16]

  Pregnancy Top

Hormone levels change considerably during pregnancy. An increased level of progesterone, in particular, can cause gingival diseases anytime, during the second to 8th month of pregnancy, a condition called pregnancy gingivitis. Estrogen, progesterone, and chorionic gonadotropin, during pregnancy, affect the microcirculatory system by producing the following changes: swelling of endothelial cells and periocytes of the venules, adherence of granulocytes and platelets to vessel walls, the formation of microthrombi, disruption of the perivascular mast cells, increased vascular permeability, and vascular proliferation. Consequently, systemic endocrine imbalances may have an important impact on periodontal pathogenesis.[13] The symptoms of pregnancy gingivitis include swelling, bleeding, redness, and tenderness of the gingiva. The dentist may recommend more frequent professional cleaning during this period to help reduce the chances of developing gingivitis. Swollen gingiva in pregnancy gingivitis may sometimes strongly react to irritants to form large lumps called pregnancy tumors.[13] They are often found on the interdental areas of teeth. They are painless, noncancerous and usually go away on their own after delivery. If persists can be removed by a dental surgeon.

The destructive periodontal disease affects up to 15% of the population of childbearing age, with a relatively high proportion of pregnant women demonstrating some degree of periodontal disease.[17] Gingival response to plaque accumulation exaggerates the inflammation and can lead to complications. Studies have shown that Streptococcus bacteria pass from the cavity of the mother to the fetus.[18] During pregnancy, any oral infections, including gingivitis and periodontitis, is cause for concern. Many studies have proven that pregnant women with periodontal disease may be more likely to have premature and low birth weight babies. Periodontal evaluation is important for every woman as a part of prenatal care.[19],[20],[21] In contrary, a case–control study conducted in London, Davenport et al. have failed to demonstrate, the association between maternal periodontal disease and preterm birth. Surprisingly, they found that deeper pockets during delivery were associated with a reduction in the risk of delivery of preterm low birth weight (PLBW) infants. Although Moore et al. found no association between maternal periodontal disease and preterm birth, there was an increase in 2nd-trimester fetal loss rates in women with periodontal disease.[22],[23] Many studies had suggested that treatment of periodontal diseases during pregnancy could reduce PLBW infant rates.[24],[25]

It is not yet clear whether the relationship between periodontal disease and adverse pregnancy outcome is casual or is a surrogate for another maternal factor. However, many published studies of ante partum versus delayed (postpartum) treatment of maternal periodontal disease demonstrate and promise for the intervention for preterm birth prevention. The PLBW rate was lower among women who received periodontal treatment compared to those who did not.[26]

If treatment of periodontal disease is going to impact pregnancy outcomes, then it is likely that the therapy will be of greatest benefit before or in very early pregnancy. The science supporting interventions before, during, and after pregnancy to reduce risk is much stronger.

The production of increased levels of inflammatory mediators may shorten the gestational age. It is also plausible that microorganisms may gain direct access to the amniotic fluid and fetus through a hematogenous route.[27] The 1996 study by Offenbacher et al. suggested that maternal periodontal disease could lead to a sevenfold increased risk of delivery of a PLBW infant. Moreover, it has been observed that infection with Gram-negative periodontitis-associated microorganisms may adversely affect pregnancy outcomes. As pointed out by Offenbacher et al.,[28] the prevalence of periodontal disease and the possibility of preterm birth prevention by treatment of oral infection make this a novel approach to improve the health and well-being of mothers and their soon to be born children.[24],[25],[26] About 5% of pregnant women are affected by preeclampsia, a hypertensive disorder of pregnancy accountable for noteworthy maternal and fetal morbidity and mortality. Generalized intravascular hyper inflammation may be the basic pathology. Some investigators have hypothesized a potential role of maternal periodontal disease as a risk factor for preeclampsia.[29] In a retrospective analysis, Boggess et al. reported that women with the severe periodontal disease at delivery were at higher risk of preeclampsia.[30]

Indirectly dentist plays a major role in maintaining the systemic health of a pregnant woman by keeping her oral cavity healthy. Frequent visits to a dentist, twice brushing, flossing, using antibacterial mouthwashes, and tongue scraping avoid further complications.[31] Not only this but also diet is an important factor in maintaining oral health.[32] Usually, pregnant women crave for pickles, ice-creams, sweets etc., which lead to tooth decay and disturbs the normal oral environment.[33] The healthy diet should include calcium for healthy bones and teeth, Vitamin B12, Vitamin C, etc.[34]

During 1st and 3rd trimester, radiographs and anesthesia are contraindicated as they are not considered safe.[35] In case of emergency, lead aprons will be provided to shield mother and baby from a lower dose of radiation. As the vital organs develop in the 1st trimester, it is considered to be risky. During 3rd trimester, it may be uncomfortable to sit in the same position for a long time due to weight gain. The uterus also puts pressure on the inferior vena cava which may lead to premature labor. The second trimester of pregnancy is the best time to receive regular dental care. Pregnant women these days are concerned about silver filling toxicity. One should avoid its removal/replacement as nothing has been proven and other alternatives filling materials are available.[36]

Certain drugs such as penicillin, clindamycin, and amoxicillin thought accepted, but better to be avoided. Drugs like tetracycline and narcotic pain relievers, aspirin, and ibuprofen must be avoided. For some unavoidable circumstances, paracetamol is the safest drug.[37],[38],[39],[40] Elective procedures such as cosmetic surgery should be postponed till delivery.

Pregnant women with periodontal disease that use tobacco products are at greater risk of a preterm baby or other pregnancy complications. Smoking during pregnancy has been linked to babies being born with cleft lip or cleft palate. Smoking is also a risk factor of sudden infant death syndrome.[41],[42]

Losing a tooth with every pregnancy is an old wives tale. Getting proper dental care and maintaining good oral hygiene throughout the pregnancy can be vital to both the mother and the health of the unborn baby.

  Lactation and Nursing Top

When the baby is born, the oral cavity is free of bacteria. Bacteria start transferring at the point of kissing and cuddling from the mother, through the salivary transmission. Supportive diet, earlier transmissions are the other factors which too can influence the levels of bacteria in maternal saliva. Susceptibility of caries increases with frequency and child's receptivity. If the mother is having extensive tooth decay, it harbors high titers of mutans streptococci, with an increased risk of vertical transmission and thereby the development of early childhood caries of their young ones. Caries is perhaps the most prevalent of infectious diseases in every nation's children. A newly published study linking breastfeeding for the past 2 years to tooth decay may cause mothers concern.[43]

Nursing caries is caused by fermentation of sugars present in liquids fed to the infant by the bacteria present in the mouth. In studies, comparison of bottle fed to breast-fed babies, bottle-fed babies have been found to have a higher incidence of dental caries overall. This has attributed to bottle propping and giving the baby a bottle of formula milk or juice to sleep with at night. Tooth decay speeds up the most at night. That's because saliva flow slows down at night and during sleep. Saliva helps to protect teeth against decay. Any food or drink, including breast milk, consumed just before sleep or during sleep can stimulate the decay process.[44],[45]

Breast milk inhibits the growth of several bacteria, which are contributors of dental caries. The key factors which influences are high p H, IgA, IgG, and IgM, which are readily available in human milk have potential to retard streptococcal growth and streptococcus mutans. Lactoferrin is an active component of breast milk that has bactericidal actions. The presence of numerous growth factors (IgF-1), cytokines, and gastric hormones enhance the development of protective barriers. Human milk also actively strengthens teeth by depositing calcium and phosphorus in them. However, some studies have shown that, if infants are nursed night long, are more prone to nursing caries.[46] In contrary, the longer the duration of breastfeeding, the lower the incidence of malocclusion.[47] Human milk rarely contributes to decay and actually has tooth-strengthening properties. Human oral flora is antiseptic, and an infant will not develop stable oral flora until the eruption of primary teeth at approximately 6–30 months of age. Breastfeeding a child throughout the night “should be avoided after the first primary tooth begins to erupt.” The first primary tooth can appear at any point from 3 to 12 months of age. About 6 months of age are typical.[46]

The main risk associated with breast-fed infants appears to be deficient in the dental enamel. Early childhood caries affect the primary molars, maxillary incisors most frequently since they first erupt and have long exposure to cariogenic challenge and nursing liquid always pools around these teeth. This has been variously termed nursing caries, baby bottle tooth decay, and early childhood caries. Caries in primary teeth can affect a child's growth, resulting in significant pain and serious infection, and diminish the overall quality of life. This early decay also can set up a child for a lifetime of dental woes.[48]

If a mother's prenatal diet and/or antibiotics received during pregnancy have an effect on the quality of a child's tooth enamel and resistance to cavities. Diet and oral hygiene are also factors.[34],[37]

The best way to aid dental health is to wipe or brush child's teeth thoroughly at least twice a day. Encourage the child to swish, or at least sip, water after eating might be useful for a certain extent. Brushing before going to sleep and not offering any carbohydrates during the bedtime, keeps the teeth healthy. The children of mothers with high caries rates have an increased risk of caries. Therefore, it is very much important that the mother maintains good oral habits and schedule regular dental visits for herself. USBC (United States Breastfeeding Committee) also recommends that parents take their infant to a dentist beginning, ideally at 7–9 months of age or at the time of first tooth eruption, and no later than 1 year of age, to receive an assessment of their child's risks for tooth decay and information on preventive measures.[49]

  Menopause Top

The menopause is a physiological change in women that gives rise to adaptive changes at both systemic and oral levels. As we all begin to reach an older age, dental health and hygiene become a major concern. The dentist is often the first person to appreciate numerous changes that are experienced in the oral cavity during menopause. The teeth and gingiva are extremely susceptible to any hormonal changes that take place just before menopause and readily decrease the body's ability to fight off minor infections or to maintain a healthy balance of useful and harmful bacteria within the oral environment.[50] Menopause can also affect bones throughout the body, reducing the relative anchorage that the jaw has on one's teeth.[51]

Burning mouth syndrome (BMS) is described as a burning sensation affecting different areas of the oral cavity. BMS is one of the major complications seen in menopausal and postmenopausal women. It is a chronic condition characterized by a burning sensation of the oral mucosa, with or without dysgeusia (the distortion of the sense of taste) and xerostomia, in the setting of no identifiable clinical lesions, laboratory abnormalities, or cause systemic disease. The affected individual usually complains of moderate-to-severe, bilateral burning or cutting sensation of the tongue, lips, or other oral mucosal surfaces. Women appear to experience from xerostomia more often than men.[52],[53] In these patients ample water intake must be recommended, along with sugar-free sweets or chewing gum to induce salivation. In some cases, sialogogues such as Pilocarpine may be indicated. Several authors (up to 45%) have shown that women who start using hormone replacement therapy report improvement in their quality of life including less oral discomfort. They further propose 'increased saliva secretion' as the main reason behind such positive finding.[54],[55],[56]

  Conclusion Top

Female sex steroid hormones may alter periodontal tissue response to microbial plaque and thus indirectly contribute to periodontal disease. Research clearly demonstrates that women have exceptional oral health considerations. Consequently, the incorporation of periodontal care with obstetric management may improve pregnancy outcomes and overall periodontal health in women. It is of paramount importance for primary health-care professionals to address these gender-specific oral health concerns. We suggest that continuing medical and dental education programs and scientific intercommunication between medical professionals may provide better quality health-care services to the community.

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