How does a women’s oral health change throughout her life?

Although on average, women visit the dentist more often than men, women are more likely to experience sudden spikes in oral health issues. As only women experience more concentrated changes in their hormones, especially during pregnancy and menopause, there are a number of oral health issues which may surface at different stages of a woman’s life.

Are you aware that hormones can make your weight — mood —sex drive —Oral health all go haywire. Female hormone (estrogen and progesterone) increases blood flow to the gums making them sensitive and vulnerable to disease. These hormonal changes not only affect the blood supply to the gum tissue, but also the body’s response to the toxins (poisons) that result from plaque buildup. Women are more sensitive to the presence of plaque and bacteria especially when the hormone levels are high.

Your gums will become inflamed, swell and bleed. If left untreated, ongoing inflammation in the gums can lead to bone loss around the teeth and eventual tooth loss. The five stages in a women’s life during which changes in hormone levels make them more susceptible to oral health problems are – puberty, the menstruation cycle; especially during pregnancy and menopause when using oral contraceptives.

Gum disease is preventable and reversible

Your hormones are a fact of life, but gum disease is not. But It’s preventable and in its early stages reversible. So women must pay extra attention and take care of mouth during puberty, at certain points in the monthly menstrual cycle, when using birth control pills, during pregnancy, and at menopause.

In any girl’s life puberty is a critical time. This is the time to remember that many hormonal changes (including a dramatic increase in estrogen and progesterone) you are going through at this age. Along with hormonal fluctuations, microbial changes in the mouth resulting in ‘destructive’ bacteria that can cause more plaque, cavities, gingivitis and bad breath, it’s also normal to experience light bleeding during brushing and flossing.

Oral Manifestations during this phase includes

  • Swollen erythematous gingival- bleeding, red and swollen gums in the days preceding the onset of menstrual flow, which usually resolves once the cycle begins.
  • Other Oral changes that may occur-
    • Activation of Recurrent Herpes Infection
    • Aphthous Ulcers
    • Prolonged hemorrhage following oral surgery
    • Swollen salivary glands particularly, Parotid gland

All this occurs due to the change in the increase in blood flow, which changes how gum tissue easily become irritated to foreign material (such as sugary foods or plaque). It’s a condition referred to as puberty gingivitis and leaving you with red, swollen gums that bleed more easily than usual.

Bulimia and anorexia nervosa is likely as you get conscious of your body during this period. Eating disorders cause nutritional deficiencies which affect the health and appearance of the mouth with evident symptoms like pale tissues, burning mouth, and painful cracks at the mouth corners. If binging involves sugary food and sweetened drinks cavities may increase. Women have a dry mouth and swollen facial glands if they binge and frequently vomit. The palate and throat may become red if vomiting is forced. Teeth are damaged due to self-induced vomiting. Acids from the stomach soften teeth and can erode enamel. This is usually seen on the insides of the front teeth with broken and painful teeth.

Oral health Care

The puberty gingivitis can be cured by brushing and flossing. If you’ve got braces, you need to make sure you’re spending extra time to properly brush your teeth by taking out the removable parts of your braces such as elastics and bands, clean carefully around the pins and wires. Regular professional cleanings by a dentist must also be considered for removal of plaque and calculus, with the frequency of such intervention based on the individual’s assessed risk for caries/periodontal. In some cases, your dentist may recommend periodontal therapy to help prevent damage to the tissues and bone surrounding the teeth. Topical analgesics may be suggested to relive discomfort associated with aphthous ulcerations and herpetic lesions.

Diet management must be considered as adolescents are exposed to and consume high quantities of refined carbohydrates and acid containing beverages.

As you probably know all too well, your monthly menstrual cycle can wreak havoc on your body and oral health due to increase in progesterone. Many women experience dry mouth and bad breath due to a loss of saliva the week before the period.

Oral Manifestations during this phase includes

  • Menstruation gingivitis or a temporary form of gingivitis accompanied by oral changes which include bright red swollen or bleeding gums,
  • Swollen salivary glands
  • Development of canker sores and cold sores - sores that appear on your tongue and inside cheeks.

This usually starts a day or two before the start of the period and fortunately clears up shortly after the period has started. All this is accompanied by build-up of plaque. On the other hand, some women may experience little to no ill-effects at all.

Oral health Care

The best advice is to keep brushing and flossing as normal in order to stay on the right track for excellent oral health. If you experience increased sensitivity or soreness, see your dentist who can suggest the best way to handle brushing and flossing during these hormonal fluctuations. Another advice IDA gives is that due to the increased gum puffiness and inflammation of your gums visit for a professional cleaning by your dentist about a week after your period ends. Similarly, you might find that the day’s right after your period is the least sensitive time for you to get a filling or have a tooth extracted. Schedule the checkup in order to get better results and comfortable experience.

Hormone levels of women using oral contraceptives, especially those containing progesterone, , may experience inflamed gingival tissues due to the body's exaggerated reaction to the toxins produced from plaque. Progesterone reduces corpuscular flow rate, causing accumulation of inflammatory cells; thus increased vascular permeability and proliferation.

Hormone connection to TMJ: Researchers also have evidence that the use of synthetic estrogens (birth control pills) can lead to decreased levels of natural estrogen. This is associated with the temporomandibular joint (TMJ) which joints connects the jaw to the side of head. TMJ disorders are caused due to problems in the jaw, jaw joint, surrounding muscles which help in chewing and jaw movement.

Women are more prone to temporomandibular disorders than men; which lead the researchers to think that it may be hormone-related. According to a recent research, there is a connection between birth control pills, decrease in natural estrogen and TMJ. There is increase in inflammation due to the compression caused by TMJ disorder and decreased levels of natural estrogen. And in some individuals, this inflammation also causes joint osteoarthritis.

Oral Manifestations during this phase includes

  • Increased blood flow to the gums results in hormonal gingivitis. Gingiva can be experienced due to gingivitis redness, swelling, and bleeding. The gum tissue becomes sensitive to irritants in the mouth, such as food or plaque
  • In the first few months after starting birth control pills that the most profound changes in the gums are seen.
  • Dry mouth, dry socket is a very painful condition in which the socket left behind after tooth extraction does not heal.

It’s important to tell your dentist if you are on birth control, as some antibiotics such as penicillin, tetracycline, metronidazole, etc., which can be used to treat periodontal problems may lessen the effect of oral contraceptive pills.

It appears that pregnancy does not have much to do with oral health. Pregnancy constitutes a physiological state characterized by a series of temporary adaptive changes in body structure, as the result of an increased production of estrogens and progesterone. Oral changes due to these complex physiological alterations will lead to an increase in oral vascular permeability and a decrease in host immune response, making the oral cavity more susceptible to infections.

The well-being and health of the pregnant mother and baby is dependent on oral health. A mother's oral health can affect the overall health of her baby, so pay close attention to dental care and any changes that may arise while pregnant.

Periodontal Disease and Preterm Low Birth Weight

Infants- There is an association between maternal infection and PLBW. Periodontal disease may represent a previously unrecognized risk factor for PLBW. Oral health care for the pregnant woman should include an assessment of her periodontal status and if diagnosed, at a minimum should include prophylaxis or scaling and root planning to decrease the inflammation and infection.

Oral Manifestations during this phase includes

Caries: Studies suggest that pregnancy does not contribute directly to the carious process. It is most probable that when an increase in caries activity is noted, it can be attributed to an increase in local cariogenic factors. Pregnancy often increases not just the appetite but also craving for unusual foods. If these are cariogenic foods, there would be an increase in the pregnant woman’s caries risk. Here, the mother’s untreated dental caries increases the risk of early childhood caries (ECG) among her children, due to natural maternal transmission of Streptococcus mutans to the offspring. Children are affected at an early age due to their mothers compromised oral health and high levels of cariogenic bacteria. Therefore, Indian Dental Association (IDA) strongly advocates in decreasing the mothers cariogenic bacterial by treatment to curb or prevent the infant developing ECC.

Gingival inflammation: Gingivitis is the most prevalent oral manifestation associated with pregnancy, reported to occur in 60 to 75 percent of all pregnant women due to an increased level of progesterone. This condition is also called a condition called pregnancy gingivitis. Gingival due to poor oral hygiene and local irritants – like plaque deteriorates, and during the hormonal and vascular changes accompanying pregnancy the inflammatory response exaggerates. Gingival changes are most noticeable from the second month of gestation, reaching a maximum in the eighth month. Gingiva becomes inflamed, fiery red in color with smooth shiny surface, loss of resiliency and a tendency to bleed easily.

Pregnancy gingivitis is temporary but it can seriously weaken the tissues that hold your teeth in place. Gingival response to plaque accumulation causes inflammation and leads to complications. The first being the transfer of Streptococcus bacteria from the mother to the fetus. During pregnancy, both gingivitis and periodontitis are a cause for concern as studies have proven that this is responsible for premature and low birth weight babies. Therefore, IDA stresses on periodontal evaluation as important during prenatal care. Treatment of periodontal diseases can reduce PLBW infant rates.

Swollen gingiva in pregnancy gingivitis may sometimes strongly react to irritants to form large lumps called pregnancy tumors (officially pyogenic granulomas). These are often found on the interdental areas of teeth which is along the gum line and between the teeth. These are painless, noncancerous and usually go away on their own after delivery or can be removed by a dental surgeon.

Acid erosion of teeth ( Perimylolysis ): Repeated vomiting associated with morning sickness or esophageal reflux can cause acid erosion; affecting the teeth as the acid in the vomit has an erosive effect.

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. During second trimester the lesion occurson the labial aspect of the maxillaryanterior region, however surgical excisionis often required for complete cure. Scaling and root planning should be initiated toreduce the plaque retention.

Tooth mobility: May also occur during pregnancy due to periodontal disease disturbing the attachment apparatus but it reverses after delivery.

Xerostomia: Hormonal alterations associated with pregnancy attribute to dryness of mouth; the problem can be resolved by frequent consumption of water and sugarless candy.

Ptyalism/Sialorrhea: Excessive secretion of saliva. It is a rare finding among pregnant women which may begin at 2-3 weeks of gestation and may cease at the end of first trimester. It may continue until the day of delivery.

Oral health Care

Indirectly dentist plays a major role in maintaining the systemic health of a pregnant woman by keeping her oral cavity healthy and gingivitis under control by frequent cleanings during your second trimester and early third trimester.

Further complications can be avoided by frequent dental visits, brushing, flossing, mouthwashes, and tongue scraping.

It is also essential that pregnant women receive key nutrients, such as calcium, protein, phosphorous and vitamins A, C and D because a baby's teeth develop in utero between the third and sixth month of pregnancy.

The unborn child is affected by the mothers diet during pregnancy, the best choice is well-balanced nutritious meals and snacks. Usually, craving for ice-creams, sweets and pickles are high on a pregnant women crave list and these can cause tooth decay or disturb the oral environment. We advise you to eat healthy, limiting sugary food, choose healthier options like fresh fruit, natural yoghurt; food which are rich in calcium to develop healthy bones and teeth, Vitamin B12, Vitamin C, etc.

Determine your oral health status and need for treatment by scheduling a dental cleaning and examination during early in pregnancy. Second trimester is the safest time for pregnant women to have any dental procedure or X-rays. Regularly visit the dentist to avoid the risk for serious, ongoing health issues.

Do not brush your teeth within an hour of vomiting as this can cause damage your teeth by stripping away the enamel. Instead of brushing, rinse your mouth with water immediately after vomiting so that stomach acids neutralizing food such as cheese or drink milk or chew sugar-free gum.

Avoid risk of a preterm baby or other pregnancy complications if you have periodontal disease by NOT using tobacco products. Babies are born with cleft lip or cleft palate if you smoke during pregnancy. Smoking is also a cause of sudden infant death syndrome (SIDS).

Routine X-rays will likely be postponed during pregnancy. However, if an X-Ray is must for dental treatment or a dental emergency, know that the radiations from X-rays are very low and precautions will be taken to minimize radiation exposure, because untreated dental infections are a risk to both mother and unborn child. However, prior to any X-ray or dental procedure let your dentist know your pregnant status.

It's important for women experiencing menopause to pay special attention to their oral health as there is overall decline in estrogen levels. It is normal to experience cessation of menses. It is not an illness or a deficiency and 30 to 50 percent of women have no symptoms as they transition through this phase of their life. On average, it occurs at the age of 50 ± 3 years, and is preceded by the postmenopausal phase. During the age related ovarian degeneration, ovarian estrogen production and secretion is reduced for 1 to 2 years and then stops.

Numerous oral changes happen due to old age, medicines taken to treat diseases, and hormonal changes as a result of menopause which alter taste, cause a burning sensation, greater sensitivity to hot and cold foods and beverages, and dry mouth due to decreased salivary flow.

Oral Manifestations during this phase includes

  • Sensitivity to hot and cold food and drinks, and that everything tastes a little odd, salty, peppery or sour, or bitter & metallic. This can be a by-product of what’s known as burning mouth syndrome (BMS), which is described the affected individual usually complains of moderate-to-severe, bilateral burning or cutting sensation of the tongue, lips, or other oral mucosal surfaces. This is a major complication in menopausal and postmenopausal women.
  • Accompanied inflamed gums which stem from a condition called menopausal gingivostomatitis. It’s hard to miss, marked by shiny, pale to deep red gums that bleed easily.
  • Dry mouth or xerostomia due to a decrease in saliva production can make eating and swallowing difficult, as well as increasing your risk of tooth decay and development of periodontal disease because saliva is not available to moisten and cleanse the mouth by neutralizing acids produced by plaque, fights germs and prevents bad breath. Certain medications can cause dry mouth commonly prescribed to older adults.
  • The decline in estrogen occurring during menopause causes bone loss or osteoporosis and tissue inflammation surrounding the teeth (called periodontitis); tooth loss can happen due to loss of bone, specifically in the jaw. Tooth surface can be exposed to tooth decay due to receding gums due to bone loss in the jawbone.

Oral health Care

Visit your Dentist regularly to effectively manage hormonal fluctuations during menopause. Women appear to experience from xerostomia will be recommended to increase intake of water, along with sugar-free sweets or chewing gum to induce salivation. Or suck on ice chips or sugar-free candy or use an over-the-counter dry mouth spray to reduce the dryness. Ask your dentist to recommend fluoride toothpaste which will reduce risk of tooth decay.

Avoid certain foods like salty, spicy, sticky and sugary foods or dry food as this would increase dryness. Even alcohol, tobacco and caffeine must be avoided as they make dry mouth worse. At night, sleeping sleep in a room with humidifier on will make it easier to deal with dryness.

Women can start using hormone replacement therapy (HRT) for improvement in their quality of life including less oral discomfort. Women opting for HRT protect themselves from not just osteoporosis but also cardiovascular diseases. Prevent bone loss in jawbone and skeletal muscles by estrogen therapy. Dental implants will improve your quality of life, if you’ve lost teeth as a result of osteoporosis or menopause.

Effects of HRT on the Periodontal tissues:

  • Minimal tooth loss
  • Reduced gingival bleeding
  • Less prone to edentulism
  • Reduction in the risk of edentulism

Women should follow nutritious eating habits that include plenty of calcium and vitamin D, avoiding smoking and excessive alcohol consumption to prevent oral health effects of osteoporosis.

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