Virtual 'knowledge explosion' has equipped dental healthcare professionals to enhance
appreciation and understanding of women's health issues from adolescence to her
senior years. A women's life is marked with hormonal changes from the time of adolescence,
motherhood to menopause. During these hormonal stages women need to give special
heed to oral hygiene in order to prevent gum disease and oral infections.
- Puberty
- Menstruation
- Pregnancy
- Menopause
Puberty is the time in life when physical changes occur by which a child's body
becomes an adult capable of reproduction. When young women enter puberty, the changes
in oestrogen levels are also reflected by changes in the gingival tissues. The relative
proportion of anaerobes in the sub-gingival plaque may change coinciding with the
menstrual cycle
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Gingivitis:
Hormone-influenced gingivitis appears in some adolescents before menstruation. Gingivitis
may flare up in some women a few days before they menstruate, when progesterone
levels are high, called erythematous gingiva. Gum inflammation may also occur during
ovulation. Progesterone dilates blood vessels causing inflammation and blocks the
repair of collagen, the structural protein that supports the gums. Certain micro-organisms
like Prevotella Intermedia and Capnocytophagia capitalise on the hormonal activity
and increase in number. These organisms cause increased gingival bleeding during
adolescence. The gums become red, swollen, tender and bleed on brushing and eating.
The sensitivity of the gums reduces in due course of time and gradually the problem
subsides.
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Herpes infection:
Other oral problems may be exacerbation of herpes infection, Aphthous ulcers, prolonged
haemorrhage following oral surgery, swollen salivary glands, particularly the parotids
and tooth mobility may also be observed.
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Eating disorders:
Bulimia nervosa\anorexia nervosa are characterised by abnormal eating habits that
involve either insufficient or excessive food intake, to the detriment of an individual's
physical and emotional health. Bulimia nervosa and anorexia nervosa share common
features, the most prominent being over-concem with body shape or weight. Bulimia
nervosa is characterised by recurrent episodes of binge eating, followed by self-induced
vomiting, laxatives or diuretics, fasting or exercise to prevent weight gain.
Anorexia nervosa is characterised by refusal to maintain body weight over a minimal
normal weight for age and height. Intense fear of gaining weight or becoming fat
and a distorted body image characterise anorectic individuals. Most bulimic patients
are in their late adolescent or early adult years. Anorexia nervosa affects young
women between ages 12 to 30. Women in certain occupations that focuses on body shape
and weight, such as modeling, gymnastics, wrestling, track or ballet dancing, may
be at greater risk. The typical features include:
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The self-induced vomiting causes erosion of the lingual surfaces of the upper teeth
or perimylolysis.
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Enlargement of the parotid (largest salivary) gland and occasionally the sub- lingual
and sub-mandibular glands is caused by the binge-purge cycle in people with eating
disorders. The occurrence and extent of parotid swelling is proportional to the
duration and severity of the bulimic behaviour. In the early stages of the disorder,
the enlargement is often intermittent and may appear and disappear for some time
before becoming persistent. When it persists this imparts a widened, squarish appearance
to the mandible, which then compels the individual to seek treatment. Parotid swelling
is soft to touch and generally painless. Intra-oral examination generally reveals
a patent duct, normal salivary flow and absence of inflammation. Minute examination
shows greater acinar size, increased secretary granules, fatty infiltration and
non-inflammatory fibrosis. The mechanisms may be cholinergic stimulation of the
glands during vomiting or autonomic stimulation of the glands by activation of the
taste buds.
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There has been reductions in salivary flow in patients who binge eat and induce
vomiting. Salivary flow may also be affected by abuse of laxatives and diuretics.
Dentist have noted xerostomia in their patients and have related it to this reduction
in flow, as well as to chronic dehydration from fasting and vomiting.
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Poor oral hygiene is more common in anorectic than bulimic patients. In such cases,
higher plaque indices and gingivitis are found. Dentists have observed that xerostomia
and nutritional deficiencies may cause generalised gingival erythema.
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The oral mucous membrane and the pharynx may be traumatised in patients who binge
eat and purge, both by the rapid ingestion of large amounts of food and by the force
of regurgitation. The soft palate may be injured by objects used to induce vomiting,
such as fingers, combs and pens. Dryness, erythema and angular cheilitis ( inflammation
of the lips) have also been reported.
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Gingivitis
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Gingival tissue or a tumour needs meticulous dental hygiene, a mix of professional
as well as home care.
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Mild cases of gingivitis may respond to scaling, but in severe cases anti- microbial
therapy may be needed.
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Herpetic infections
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The self-induced vomiting causes erosion of the lingual surfaces of the upper teeth
or perimylolysis. This results from the chemical effects caused by vomiting of the
gastric contents. When the posterior teeth are affected, there is often a loss of
occlusal anatomy. Perimylolysis occurs after the patient has been binge eating and
purging for at least two years. Destruction of tooth structure can be avoided by
adhering to oral hygiene practices after vomiting.
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Plans for dental restoration depend on the severity of the case. Milder cases of
erosion with minimal caries may require simple restorations to reduce sensitivity
and improve aesthetics. Occlusal rehabilitation and full reconstruction with fixed
prosthodontics may be required where enamel erosion has involved the posterior teeth
and vertical dimension of occlusion has been lost.
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Unfortunately, there is no recommended treatment to reduce the size of the parotid
gland. Only counseling with cessation of purging is recommended as a treatment,
resulting in spontaneous regression
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It is recommended that dental treatment begin with rigorous hygiene and home care
to prevent further destruction of tooth structure. Such measures include: Regular
professional dental care, in-office topical fluoride application to prevent further
erosion and reduce dentin hypersensitivity.
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Daily home application of either
1% sodium fluoride gel in custom trays or applied with a toothbrush to promote remineralisation
of enamel or daily application of 5000 parts per million fluoride prescription dental
paste.
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Daily home application of either 1% sodium fluoride gel in custom trays or applied
with a toothbrush to promote remineralisation of enamel or daily application of
5000 parts per million fluoride prescription dental paste.
- Artificial saliva for patients with severe xerostomia may be prescribed by the dentist.
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If possible rinse with water immediately after vomiting and followed by a 0.05 percent
sodium fluoride rinse to neutralize acids and protect tooth surfaces. It has been
noted that tooth brushing at this time might accelerate the enamel erosion.
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Definitive dental treatment may be delayed, with the exception of palliation of
pain and perhaps temporary cosmetic procedures, until the patient is adequately
stabilized psychologically. The rationale for this recommendation is that an acceptable
prognosis for dental treatment depends on cessation of the binge eating and vomiting
habit. Restoration of dental health and especially regaining a normal appearance
can be an important aspect of the patient's recovery. For this reason, it is optimal
for the dentist to be included in the patient's comprehensive care.
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Past use of the appetite suppressant phentermine and fenfluramine or Phen- fen,
may place the individual at risk for cardiac valvular disease. Those with a history
of Phen- fen use for at least four months should have an echocardiogram and cardiac
evaluation by a physician to determine the need for prophylaxis prior to dental
procedures that induce bleeding.
Occasionally, some women experience menstruation gingivitis. Women with this condition
may experience bleeding gums, bright red and swollen gums and sores on the inside
of the cheek. Menstruation gingivitis typically occurs right before menses and clears
up once it has started.
The effect of Oral Contraceptives on the oral cavity is a growing concern with the
increasing number of women.
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Gingivitis : Oral contraceptive pills can increase the swelling of the gums (Gingival
inflammation), apparently due to changes in the micro-circulation.
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Local alveolar osteitis : Apart from the gingival inflammation another concern is
that oral contraceptive pills causes local alveolar osteitis i.e. the non-healing
of an extraction socket. However, no additional preventive procedures are recommended
by dentists at the time of extractions and treatment for patients developing localised
osteitis .
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Salivary flow : Salivary flow may change with alteration in the rate of salivary
secretions, chronic dry mouth has been reported. These changes include a decrease
in concentrations of protein, sialic acid, hydrogen ions and total electrolytes.
IDA survey have shown both an increase and decrease in salivary flow. Oral contraceptives
contain the synthetic progesterone desogestrel (but not dienogest, another common
progesterone) increases the risk for periodontal disease.
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Heart attack : IDA study states that there is an increased risk of heart attack (myocardial
infarction) and strokes in women who constantly smoke and take oral contraceptives.
This precaution is for women older than 30 years. Women should under go regular
oral examinations, professional cleanings and plaque control to minimise the effects
of oral contraceptives.
Oral manifestations have been attributed to oral contraceptive use, it can be presumed
that the same effects could occur with the use of other contraceptive medications
(e.g., implants, transdermal patches).
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Gingival inflammation
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Periodontal surgery may be indicated if there is inadequate resolution after initial
therapy (scaling, root planing and curettage).
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Anti-microbial mouthwashes may be suggested by your dentist as part of the home
care regimen.
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Antibiotics & Oral Contraceptives
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The patient would be advised to maintain compliance with oral contraceptives when
concurrently using antibiotics.
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Patient must be told of the potential risk for
the antibiotic's reduction of the effectiveness of the oral contraceptive.
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Your
dentist may ask you to maintain compliance with oral contraceptives when concurrently
using antibiotics. A decrease of antibiotics may reduce the effectiveness of oral
contraception, you should discuss if it is necessary to take additional non- hormonal
contraception .
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Medical history
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A comprehensive medical history and assessment of vital signs, including blood pressure
is important.
A number of changes in the oral cavity have been associated with pregnancy, including
caries, perimyolysis, tooth mobility, xerostomia, pregnancy granuloma and ptyalism
/ sialorrhea.
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Pregnancy gingivitis : Hormonal changes during pregnancy can aggravate existing gingivitis,
which typically worsens around the second month and reaches a peak in the eighth
month. This is called pregnancy gingivitis. The gum tissues become tender, swollen
and bleed. Simple preventive oral hygiene can help maintain healthy gums. Any pregnancy-
related gingivitis usually resolves within a few months of delivery.
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Periodontal Disease & Preterm Low Birth Weight Infants (PLBW) : Recent studies have
indicated that women with periodontal disease have an increased risk of pre-term
births. A pre- term low-birth weight baby is defined as one born before the 37th
week of gestation weighing less than five pounds, six pounds. Maternal risk factors
for pre- term low birth weight (PLBW) include: age, low socio- economic status,
alcohol and tobacco use, diabetes, obesity, hypertension and genitourinary tract
infections. PLBW results in morbidity and mortality of infants. Research has demonstrated
an association between maternal oral infection and PLBW. Therefore, oral health
care for the pregnant woman should include an assessment of her periodontal status
and if diagnosed, one should go for prophylaxis or scaling and root planing to decrease
the infection and subsequent inflammation
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Pregnancy tumour : Pregnancy gingivitis
aggravates large, painless lumps in the mouth. These are red nodules, typically
found near the upper gum line but can also be found elsewhere in the mouth. They
are known as pregnancy tumours. They are not cancerous. This is a benign growth
of tissues, often happening due to plaque/calculus irritation. Generally seen in
the anterior region of the upper teeth, this tumour is a red, shiny growth that
happens generally from the interdental papillae. Sometimes it may bleed while mastication.
Though the growth is rapid it seldom grows larger than 2cm in size. Poor oral hygiene
is invariably present. The tumour generally regresses post partum. Sometimes if
the tumour is causing problems, like, exerting pressure on teeth and bleeding, then
dental help should be sought.
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Caries : Clinical studies suggest that pregnancy
does not contribute directly to the carious process. It can be attributed to an
increase in local cariogenic factors as pregnancy causes an increase in appetite
and often a craving for unusual foods. If these cravings are for cariogenic foods,
then the pregnant woman could increase her caries risk.
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Acid erosion of teeth
(perimylolysis) :
Acid erosion of teeth is the result of repeated vomiting associated
with morning sickness or esophageal reflux. This erodes the enamel on the back of
the front teeth. Women can be instructed to rinse the mouth with water immediately
after vomiting so that stomach acids do not remain in the mouth.
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Tooth mobility:
Generalised tooth mobility may also occur in the pregnant patient. Tooth mobility
can be defined as ' the degree of looseness of a tooth'.This change is probably
related to the degree of periodontal disease disturbing the attachment of the gum
and bone to the tooth. This condition usually reverses after delivery.
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Xerostomia:
Some pregnant women complain of mouth dryness. Hormonal alterations associated with
pregnancy are a possible explanation. More frequent consumption of water and sugarless
candy and gum may help alleviate this problem.
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Ptylism/Sialorrhea : A relatively rare finding among pregnant women is excessive
secretion of saliva, known as ptyalism or sialorrhea. It usually begins at two to
three weeks of gestation and may abate at the end of the first trimester. In some
instances, it continues until the day of delivery.
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Breastfeeding : There is a
risk of drugs prescribed by your dentist passing to the nursing infant through the
breast milk. Conclusive information about drug dosage and effects via breast milk
is lacking but still it poses an issue of concern.
The evaluation of patients history is must such as previous miscarriages, cramping
or spotting. This warrants consultation with the obstetrician prior to initiating
dental treatment. Optimum oral hygiene consists of nutritional counseling and rigorous
plaque control measures.
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Nutrition
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Nutritional guidance is given by the obstetricians and this may be reinforced by
the dental team
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It is imperative that the mother's diet supply sufficient nutrients,
including vitamins A, C and D; protein; calcium; folic acid; and phosphorus, as
the diet is also important for the developing dentition of the foetus.
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Patients
should select nutritious snacks, but avoid food that contain sugars and starches
that contribute to caries development and pregnancy gingivitis.
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It is advisable
to limit the number of snack taken between meals.
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Pregnancy gingivitis
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Oral hygiene techniques may be taught, reinforced and monitored throughout pregnancy
to control plaque to decrease the inflammation caused by the periodontal infection.
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Scaling, polishing and root planing may be performed whenever necessary throughout
the pregnancy to minimise the inflammation of the gingival tissues.
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Elective Dental Treatment
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Elective dental care should be timed during the second trimester and first half
of the third trimester.
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The first trimester is the period of organogenesis when the foetus is highly susceptible
to environmental influences.
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Avoid dental treatment in the last half of the
third trimester, as it is not comfortable to sit in the dental chair and there is
a possibility that supine hypotensive syndrome (dizziness and drop in blood pressure)
may occur.
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Extensive reconstruction procedures and major surgery should be postponed
until after delivery.
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Dental emergencies can be dealt with whenever they arise,
throughout the entire pregnancy, for elimination of pain, stress and infection for
the mother and endangerment of the foetus due to dental care.
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Emergency treatment
by dentist which involves sedation/general anaesthesia necessitates consultation
with the patient's obstetrician, as does any uncertainty about prescribing medication
or pursuing a particular course of treatment.
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Dental radiographs may be needed
for dental treatment or a dental emergency. Radiation exposure from dental radiographs
is extremely low. However, precaution should be taken to minimise exposure by use
of high speed film, filtration, collimation, protective abdominal and thyroid shielding.
Abdominal shielding minimises exposure to the abdomen and should be used when any
dental radiograph is taken.When possible, X-rays should be delayed until after the
pregnancy.
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Medications
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Drugs given to a pregnant woman can affect the foetus. A classification system to
rate foetal risk levels associated with many prescription drugs was established.
The commonly used drugs in dental practice can be safely given during pregnancy,
although there are a few important exceptions.
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Obviously, drugs in category A or B are preferred for prescribing. However, many
drugs that fall into category C are sometimes administered during pregnancy. Consulting
the patient's physician may be advisable prior to prescribing any medications during
pregnancy.
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Additionally, references such as ADA Guide to Dental Therapeutics,
Brijz 4s Drugs in Pregnancy and Lactation or Drugs Facts and Comparisons or Drug
Information Handbook for Dentistry are available for information on the prescription
drugs associated with pregnancy risk factors.
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Breastfeeding
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There is a risk of drugs prescribed by your dentist passing to the nursing infant
through the breast milk.
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The amount of drug excreted in breast milk is usually
not more than 1 to 2 percent of the maternal dose; however for some drugs used in
dentistry, such as metronidazole, the amount excreted can be up to one-third of
the maternal dose.
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In addition to choosing drugs carefully, it is also desirable
for the mother to take the drug just after breastfeeding and then avoid nursing
for four hours or more if possible
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If there is serious concern about the drug
passing to the child through the breast milk, particularly narcotics or anti- anxiety
agents, the mother can pump the breast milk and discard it after taking the medication.
This will decrease the drug concentration in breast milk that is consumed by the
child.
Menopause naturally occurs in women most often between the ages of 45 and 55. The
body produces less of the hormones estrogen and progesterone, leading to cessation
of menstrual periods.
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Menopausal gingivostomatitis : There may be alterations in the oral mucosa, as well
as in thinning of the epithelial lining. This has been identified as menopausal
gingivostomatitis, in which the gingiva becomes dry, bleeds easily and may experience
change in colour. Post menopause, incidence of periodontal disease rises, except
in women on hormone replacement therapy (HRT).
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Osteoporosis : It has been seen,
that oestrogen deficiency after menopause reduces bone mineral density, which leads
to bone loss. Bone loss is associated with both periodontal disease and osteoporosis.
Bone loss in the alveolar bone (which holds the tooth in place) may be a major predictor
of tooth loss in post- menopausal women. Periodontal disease is the main cause of
alveolar bone loss.
Osteoporosis is a reduction in bone mass with deformity, pathologic fractures and
sometimes associated pain. It results from decreased density or thinning of bone
related to the aging process. Osteoporotic bone is more porous and is weaker than
normal bone, thus it fractures more easily. Our study has indicated that loss of
bone mass associated with osteoporosis is somehow associated with the incidence
and severity of periodontitis.
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Burning Mouth Syndrome :
Burning mouth syndrome (stomatopyrosis) has been defined as burning pain in the
tongue or oral mucous membranes. While the oral cavity is clinically normal. The
disorder has been associated with a variety of other conditions including psychological
problems, nutritional deficiencies and disorders of the mouth, such as oral thrush
and dry mouth (xerostomia). Some researchers suggest dysfunctional or damaged nerves
as a possible cause. But little is known about the natural course of burning mouth
syndrome.
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Menopausal gingivostomatitis
The symptoms of menopausal gingivostomatitis usually regress in patients on hormone
replacement therapy.
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Salivary Dysfunction (Sjogren's Syndrome) & Dry mouth (xerostomia)
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Decreased salivary flow accompanies menopause causing dry mouth (xerostomia).
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Dry mouth or signs of salivary hypo- function (increased caries, mucosal dryness,
oral candidiasis), then the possibility of Sjogren's syndrome must be considered.
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Regular dental care is critical with frequent dental evaluations, supplemental fluorides
and impeccable oral hygiene. Stress must be on a low cariogenic (causing caries)
diet and sugar- free foods and snacks.
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Oral fungal infections may be recurrent
and necessitate lengthy treatment.
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Periodic salivary gland enlargement may occur
and become persistent. Dryness symptoms can be managed with frequent sips of water,
saliva replacement products and oral rinses and gels. Increased local humidification,
particularly at night, may be beneficial.
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Diagnosis is based on the presence
of signs and symptoms of salivary and lacrimal gland involvement and serologic markers.
The salivary biopsy is usually done on the minor salivary glands of the lower lip
and demonstrates a characteristic focal, periductal mononuclear cell infiltrate.
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Medical management focuses on symptoms and associated conditions, as there is no
specific treatment for Sjogren's syndrome. Face an increased risk of development
of B-cell lymphomas, often of the salivary glands.
Enlargement of the glands or lymphadenopathy in any area is aggressively investigated
by the dentist.
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Patients with Sjogren's syndrome complain of a dry mouth or
have signs of salivary hypofunction (increased caries, mucosal dryness, oral candidiasis).
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Regular dental care is critical to successful management of Sjogren's syndrome.
Patients require more frequent dental evaluations, supplemental fluorides and impeccable
oral hygiene. Diet counselling should stress a low cariogenic (causing caries)diet
and sugar- free foods and snacks. Oral fungal infections may be recurrent and necessitate
lengthy treatment. Dryness symptoms are managed with frequent sips of water, saliva
replacement products and oral rinses and gels. Systemic sialogogues (is a drug that
increases the flow of saliva)available by prescription such as pilocarpine (Salageng)
and cevimeline (Evoxace), will with time transiently increase salivary output and
relieve xerostomia. Many patients find these salivary stimulants helpful and these
agents are a significant advance in the management of dry mouth.
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Burning Mouth Syndrome (stomatopyrosis)
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The onset of pain is spontaneous with no precipitating factor. Once the pain starts,
it can last for years. In many patients, pain is absent during the night but occurs
at a mild to moderate level by middle to late morning. The pain is similar in intensity
to toothache.
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Treatment involves identifying an underlying cause and then treating
the cause. Conditions such as xerostomia, candidiasis, referred from the muscle
tissues of tongue (musculature), chronic infections, reflux of gastric acid, medications,
blood dyscrasias (pathological condition of the blood), nutritional deficiencies,
hormonal imbalances, allergic and inflammatory disorders need to be considered.
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The management of burning mouth depends on the aetiology. On the basis of history,
physical evaluation and laboratory studies, the practitioner should rule out all
possible organic causes.
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If burning persists after the management of systemic
and local factors, the diagnosis of burning mouth syndrome is made. Low doses of
clonazepam (Klonoping), chlordiazepoxide (Librium(g) and tricyclic antidepressants,
such as amitriptyline (Elavil(&). Anticonvulsants, such as gabapentin (Neuronting),
have also been used with some success.Topical capsaicin has been used as a desensitising
agent in patients with burning mouth syndrome. However, capsaicin may not be palatable
or helpful in many patients
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Osteoporosis
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A diagnosis of osteoporosis is made by a bone mineral density (BMD) test, which
uses small amounts of radiation to determine the bone density of the spine, hip,
wrist or heel.
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The most commonly used BMD test is DXA-dual energy x-ray absorptiometry. It is a
painless, noninvasive procedure.
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Serum and urine tests that assess biochemical markers may soon be available to determine
how rapidly bone resorption and bone formation is taking place, as well as to identify
possible causes of bone loss.
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Generalised bone loss from systemic osteoporosis may render the jaws susceptible
to accelerated alveolar bone resorption.
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The compromised mass and density of the maxilla or mandible in a patient with systemic
osteoporosis also may be associated with an increased rate of bone loss around the
teeth or the edentulous ridge.
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Recent studies support the hypothesis that systemic bone loss may contribute to
tooth loss in healthy individuals, and women with low bone mineral density tend
to have fewer teeth
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Your dentist may recommend calcium intake, weight- bearing exercise, tobacco cessation
and use of bisphosphonate medications to cure osteoporosis.
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Calcitonin is a naturally occurring hormone involved in calcium regulation and bone
metabolism. In women who are at least five years beyond menopause, calcitonin safely
slows bone loss. Calcitonin is administered by injection or as a nasal spray. Injectable
calcitonin may cause an allergic reaction and unpleasant side effects including
flushing of the face and hands, urinary frequency, nausea and skin rash. Side effects
reported with nasal calcitonin include a runny nose.
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Alendronate (Fosamax) is a bisphosphonate bone resorption inhibitor. It increases
bone mineral density in post-menopausal women with osteoporosis. All women over
age 50 are advised to maintain adequate calcium intake.
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Osteonecrosis of the jaw has been reported with bisphosphonate use. Most cases have
been in cancer patients treated with intravenous bisphosphonates (Zometa, Aredia),
but some have occurred in patients with post-menopausal osteoporosis. Osteonecrosis
of the jaw may occur spontaneously or more commonly, following extractions or other
trauma. While on treatment, these patients should avoid invasive dental procedures,
if possible.
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A concern for dentists, especially with regard to removable prosthodontics, is the
condition of the mandibular residual ridge. When patients exhibit rapid continuing
bone resorption under a well- fitting dental prosthesis, osteoporotic bone loss
may need to be considered as contributing to the aetiology and pathogenesis of the
resorptive process. Postmenopausal osteoporotic women may require new dentures more
often after age 50 than women without osteoporosis. The bone loss may become so
severe that fabrication of a functional prosthesis may become difficult.
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Bone regeneration techniques and dental implants may be of significant benefit to
an osteoporotic patient who has experienced decreased function of a denture. Most
dental implants depend on sufficient bone volume and density for success, bone regeneration
therapy may be necessary prior to implant placement. It appears that there is no
contraindication for osseointegrated implant therapy in the osteoporotic patient.
