Hormonal changes occur throughout the entire life cycle of women. This presentation enlightens us about the impact of the endocrine influences on the oral and periodontal tissues. It thus becomes important for the clinician to identify and modify the periodontal therapy according to the hormonal stages of women.

1. DENTAL MANAGEMENT OF
THE FEMALE PATIENT
D R . S H R A D D H A K O D E

2. INTRODUCTION
• Alter periodontal therapy according to the individual woman’s needs based on the
stage of her life cycle

3. PUBERTY
• Average ages of 11 to 14 yrs
• ESTROGEN PROGESTERONE Later remains relatively constant
• Prevalence of gingivitis without an increase in the amount of plaque
• Association with P. intermedia
• Substitute for Vitamin K growth factor (KORNMAN & LOESCHE 1979)

4. • Association with Capnocytophaga Increased bleeding tendency
• Other organisms – Motile rods
Spirochetes
P. nigrescens
F. nucleatum
A. actinomycetemcomitans

5. • Periodontal tissues have exaggerated response to local factors
• Inflamed tissues become erythematous, lobulated and retractable
• Bleeding occurs easily
During reproductive years, women tend to have a vigorous and
strong immune response.
Allergy, sensitivity, and asthma occur more often in young men,
but after puberty, women become more susceptible than their
male counterparts.

6. MANAGEMENT
MILDER
GINGIVITIS:
Respond well to
SRP with
frequent OHI
reinforcement
SEVERE
GINGIVITIS:
•May require
microbial culturing,
antimicrobial
mouthwashes,
LDD or antibiotic
therapy
CHRONIC
REGURGITATION
OF GASTRIC
CONTENTS:
Perimolysis
Enlargement of
parotid glans
(occassionally
sublingual glands)
BULLIMIA &
ANOREXIA
NERVOSA:
•Referral to
physician
•Nutritional and
vitamin
supplements req
DIMINISHED SALIVARY FLOW RATE:
Increased oral mucous membrane sensitivity, gingival erythema and caries risk

7. MENSES
ANTERIOR
PITUITARY
FSH & LH
ESTROGEN &
PROGESTERONE
PREPARE UTERUS FOR
IMPLANTATION OF EGG
FOLLICULAR PHASE
FSH elevated
Estradiol peaks 2 days before
ovulation
Stimulates egg to move down
fallopian tubules and proliferation
of endometrium
LUTEAL PHASE
Corpus luteum synthesises
estradiol and progesterone
Rebuilding of endometrium for
implantation of egg
CORPUS LUTEUM INVOLUTES
HORMONE LEVELS DROP
MENSTRUATION ENSUES

8. BASED ON A 28 DAY CYCLE PROGESTERONE
INCREASES FROM SECOND WEEK AND DROPS
BEFORE MENTRUATION

9. • Ovarian hormones exaggerate the response to local irritants
• Fluctuation of TNF-α, elevated PGE-2 synthesis, angiogenetic and growth factors
• Increase gingival inflammation
PROGESTERONE
INCREASED PERMEABILITY
ALTERED COLLAGEN PRODUCTION &
IMMUNE RESPONSE
ESTROGEN
INCREASED PROLIFERATION,
DIFFERENTIATION AND
KERATINISATION OF ENDOMETRIUM

10. • Gingival tissues appear to be more edematous during menses and erythematous
before the onset of menses
• Increase in gingival exudate and bleeding
• Minor increase in tooth mobility
• Lab findings Slightly reduced platelet count and slight increase in clotting time
• Highest progesterone level (luteal phase) intraoral recurrent aphthous
ulcers,herpes labialis lesions and candidal infections occur in cyclic pattern
• Progesterone relaxes esophageal sphincter GERD

11. • Peak level of progesterone 7 to 10 days before menstruation
• No significant levels of estrogen progesterone
• But, lower levels of neurotransmitters enkephalins, endorphins,
GABA and serotonin
• Depression, irritability, mood swings, difficulty with memory and concentration,
heightened gag reflex, exaggerated response to pain
PRE MENSTRUAL
SYNDROME
70% have
PMS symptoms, but
only 5% meet the strict
diagnostic criteria.

12. • Periodontal maintenance titrated to individual patient’s needs
• Antimicrobial oral rinse before cyclic inflammation
• For patient with history of excessive postoperative hemorrhage or menstrual flow
Schedule surgical visits after cyclic menstruation
• Anemia is common Appropriate consultation req
• Fluoride rinses and trays, frequent periodontal debridement and avoidance of
mouthwashes with high alcohol content may reduce the associated gingival and caries
sequelae.
MANAGEMENT

13. • PMS is often treated by antidepressants
• SSRIs are generally the first-line choice because they have fewer side effects than
other antidepressants, do not require blood monitoring, and are safe in overdoses
• The PMS patient may be difficult to treat because of emotional and physiologic
sensitivity
• Treat the gingival and oral mucosal tissues gently. Gauze pads or cotton rolls should
be moistened with a lubricant, chlorhexidine rinse or water before placing them in the
aphtha-prone patient
• Careful retraction of the oral mucosa, cheeks, and lips is necessary in patients prone
to aphthous or herpetic lesions
• Because the hypoglycemic threshold is elevated, the clinician should advise the patient
to have a light snack before her appointment

14. • GERD may make it more uncomfortable for the patient to lay fully supine, especially
after a meal and the woman may have a more sensitive gag reflex
• Clinician should be aware that NSAIDs and acidic foods exacerbate GERD and
interact with some antibiotics and antifungals

15. PREGNANCY
• 1778 Vermeeran Tooth pains in pregnancy
• 1818 Pitcarin Gingival hyperplasia in pregnancy
• Current research Periodontal disease may alter the systemic health - Risk
for low birth weight, pre-term infants
• 1877 Pinard First case of “pregnancy gingivitis”
• Occurence 30 – 100% (HASSON 19966 & LUNDGREN ET AL 1973)

16. • ANTERIOR INTERPROXIMAL (DE LIEFDE 1984)
• Erythema, edema, hyperplasia, increased bleeding, increased pocket depths and
transient tooth mobility
• Gingiva 70% followed by tongue, lips, buccal mucosa and palate
• Anterior site inflammation may be exacerbated by increased mouth breathing in the
third trimester from pregnancy rhinitis

17. • PYOGENIC GRANULOMAS = PREGNANCY TUMOR = PREGNANCY EPULIS – 0.2
TO 9.6%
• Second or third month of pregnancy
• Clinically bleed easily, hyperplastic and nodular
• Purplish red to deep blue
• Sessile or pedunculated and ulcerated
• Associated with poor oral hygiene and calculus
• Alveolar bone loss is usually not associated with it

18. • Associated with increase in B.melaninogenicus and P.intermedia (2.2 to 10.1%)
• Offenbacher et al Untreated periodontal disease in pregnant women may be a
significant risk factor for preterm (<37 weeks of gestation), low birth weight (<2500g)
infants
• TRANSMISSION
• Pre-eclampsia Late pregnancy Associated with hypertension and excess
urine protein

19. • MATERNAL IMMUNORESPONSE Supressed during pregnancy so fetus is
allowed to grow as an allograft
• High concentrations of sex hormones found in gingival tissues (due to specific
receptors), saliva, serum and GCF
Cell mediated immunity
Neutrophil chemotaxis
Antibody and T cell responses
CD4/CD8 ratio
Prostaglandins
SUSCEPTIBILITY TO GINGIVAL
INFLAMMATION

20. • OTHER ORAL MANIFESTATIONS
PERIMOLYSIS
Due to morning
sickness and
esophageal reflux
XEROSTOMIA
El-Ashiry G et al
1970: Persistent
dryness in 44% of
pregnant patients
PTYALISM OR
SIALLORRHOE
A
Begins at 2 to 3
weeks of gestation
and ends at 1st
trimester
Etiology: Inability
to swallow normal
amounts of saliva
IMMUNOCOMPROMISE
D STATE
Gestational
diabetes, leukemia
or other conditions
may appear

21. MANAGEMENT
• A thorough medical history is prudent
• Maintaining optimal oral hygiene, nutritional counselling and rigorous plaque control
measures
• Increased gingival inflammation tendency during pregnancy should be explained to the
patient
• Non- alcohol based oral rinses to be preferred
• ADA does not recommend use of prenatal fluoride because its efficacy has not been
demonstrated

22. TREATMENT
• ELECTIVE DENTAL TREATMENT
• AVOID dental care during 1st and last half of 3rd trimester
• Prolonged chair time to be avoided
• Early in 2nd trimester (14-20 weeks of gestation) is the safest period for routine dental
care
• Major oral or periodontal surgery to be postponed after delivery
• Pregnancy tumours that are painful, interfere with mastication, continue to bleed or
suppurate after mechanical debridement may require excision and biopsy before
delivery

23. • SUPINE HYPOTENSIVE SYNDROME
• Preventive 6 inch soft wedge placed on patient’s right side

24. • DENTAL RADIOGRAPHS
• No irradiation during pregnancy especially 1st trimester because developing foetus is
susceptible to radiation damage
• When radiograph needed Protective lead apron to be used since gonadal and
fetal irradiation is immeasurable

25. • MEDICATIONS
• Ideally no drug should be administered during pregnancy. But it is virtually impossible
to adhere to this rule
• Drug therapy in pregnant patients is controversial because drugs can affect fetus by
placental diffusion
• According to FDA Drug Classification 1979 Category A and B drugs can be
prescribed, Category C drugs are given with caution, Category D drugs are avoided
and Category X drugs are contraindicated

26. CATEGORYB
• LIDOCAINE
• PRILOCAINE
• ARTICAINE
• ACETAMINOPHEN
• PENICILLIN -
Diarrhoea
• ERYTHROMYCIN –
Avoid estolate form.
Intrahepatic jaundice
in mother
• CLINDAMYCIN –
Drug concentration in
fetal spleen, bone,
lung, liver
• CEPHALOSPORINS
• METRONIDAZOLE
CATEGORYC
• MEPIVACAINE
• BUPIVACAINE
• PROCAINE
• CODEINE
• CIPROFLOXACIN
– Cartilage
erosion
• GENTAMICIN –
Possible
ototoxixity
• VANCOMYCIN
CATEGORYD
• BENZODIAZEPINES
• BARBITURATES
• TETRACYCLINE –
Bone growth
depression, enamel
hypoplasia, gray
brown tooth
discoloration
• ERYTHROMYCIN

27. BREAST-FEEDING
• Risk that the drug can enter breast milk and transferred to nursing infant in whom
adverse effects may appear
• But, little conclusive information
• Amount of drug excreted in breast milk 1% to 2% of maternal dose
• Hence most unlikely that most drugs can have pharmacologic effects on infant
Mother should take drugs just after breast-
feeding and avoid nursing for 4 hours or more to
decrease drug concentration in breast milk

28. MENOPAUSE
• No. of oocytes reduce steadily throughout a woman’s life
• Estrogen progesterone deficiency due to absent corpus luteum function
• PERIMENOPAUSE FSH LH
• OVARIAN UNRESPONSIVENESS
• SPORADIC OVULATION
• Median age for menopause is 50 years

29. • ORAL CHANGES
• Thinning of oral mucosa (Estrogen deficiency causes decrease in collagen formation in
CT. Hence decrease in skin thickness)
• Oral discomfort (Burning mouth)
• Altered taste sensation
• Xerostomia
• Gingival recession
• Alveolar bone loss
• Alveolar ridge resorption

30. • OSTEOPENIA OSTEOPOROSIS
• Peak bone mass in women occurs during 20 to 30 years of age. Menopause
accelerates the declining bone loss
• Association between post-menopausal primary osteoporosis with bone loss, tooth loss,
ridge atrophy is probable and inconclusive. Also effect of HRT on oral bone loss and
tooth loss is under investigation
• KRALL ET AL 1998 Odds of being edentulous were reduced by 6% for each 1
year increase in duration of HRT use
• KAYE EK 2007 Research supports that osteoporosis independantly influences
alveolar bone loss and that strategies for reducing osteoporosis may help retard
alveolar bone loss

31. MANAGEMENT
• Review patient’s medical history and questioning regarding hormonal changes should
be performed and documented
• Many available therapies for HRT/ERT from prescriptions to holistic approach should
be performed
• In cases of gingival or mucosal thinning soft tissue augmentation should be done
• Brushing with extra-soft toothbrush using toe/heel of brush prevents scrubbing of
thinned gingiva
• Dentrifices with minimal abrasive particles to be used

32. • Low alcohol concentration mouthrinses
• Root surfaces to be debrided gently with minimal soft tissue trauma
• Oral pain may occur due to thinning tissues, xerostomia, inadequate nutritional intake
or hormone depletion
• Close monitoring of periodontal tissues and maintenance and consultation of physician
advised

33. • BONE SPARING DRUGS Reduces fracture risk
• Primary medication for osteoporosis – BISPHOSPHONATES Reduces perio disease
progression
• Rare side effect associated with bisphosphonates OSTEONECROSIS OF JAW
• Mandible 65% prevalence Maxilla 26%
• Exposed or necrotic bone present in the maxillofacial region for atleast 8 continuous months
in patients with no h/o radiation therapy
• PREDISPOSING FACTORS Type and dose of bisphosphonates, h/o dental trauma,
dental surgery or dental infection

34. • Consult the physician in such cases
• 2011 ADA RECOMMENDATIONS
• Thorough but gentle debridement
• Appropriate antibiotics, stringent home care, antimicrobial mouthrinse
• Exposed necrotic and sequestered bone can be gently debrided. (Surgical resection is
questionable. Healing predictability is good in maxilla variable in mandible. It may lead
to severe sequelae)

35. • Patients should have dental clearance before starting with bisphosphonate therapy
• Teeth with poor or hopeless prognosis should be extracted and healthy periodontal
tissues to be established
• Sharp or irregular bony prominences should be removed and prostheses should be
assessed for accurate fit

36. • Physicians have raised the upper allowable limit to 2000mg/day
• VITAMIN D RECOMMENDATION:
• Premenopausal women – 400IU/day
• Postmenopausal women – 800IU/day
• Extremely low serum VIT D levels: 50000 IU/week for 4 to 12 weeks

37. ORAL CONTRACEPTIVES
• MULLALLY ET AL 2007 Use of OC’s had poorer periodontal health
• Exaggerated response of gingival tissues to local irritants ranging from mild edema
and erythema to severe inflammation with hemorrhagic or hyperplastic gingiva
• KALKWARF 1978 Response due to altered microvasculature, increased gingival
permeability and increased synthesis of prostaglandin (PGE2)

38. • JENSEN ET AL 1981 Significant microbial changes in pregnant and OC group
compared to non-pregnant group. 16 fold increase in Bacteriodes species (Increased
female sex hormones substitute for naphthoquinone requirement)
• PRESHAW PM 2013 Earlier formulations (1970-1990) had more concentration
of female sex hormones than the current. Current data suggests that OC’s do not have
significant effect on inflammatory component of periodontium
• SWEET JB, BUTLER DP 1977 Women taking OC’S experience 2 to 3 fold
increase in incidence of localised osteitis after mandibular third molar extraction. Other
studies refute these findings. So, results are inconclusive

39. MANAGEMENT
• Medical history should include OC’s under medication
• Patient should be informed about the oral and periodontal side effects of OC’s and
need for periodontal maintenance
• Treatment of gingival inflammation should include establishing oral hygiene program
and elimination of local predisposing factors
• It is advisable to perform extraction of teeth especially 3rd molars on nonestrogenic
days (days 23 to 28) to reduce the risk of post-operative localised osteitis

40. • ADA REPORT OF 1991 All women of childbearing age should be informed of
possible reduced efficacy of steroid OC’s during antibiotic therapy and advised to use
additional forms of contraception during short term antibiotic therapy

41. CONCLUSION
• Clinical periodontal therapy includes an understanding of the clinicians role in the total
health and wellbeing of female patients
• Dentists do not treat localized oral infections without affecting other systems of the
body
• Female patients may present with periodontal and systemic considerations that alter
conventional periodontal therapy
• Patients should be educated regarding the profound effects that sex hormones may
play on periodontal and oral tissues as well as the need for proper oral self-care and a
frequent professional intervention.

42. REFERENCES
• CARRANZA 12TH EDITION
• JOAN OTOMO-CORGEL; DENTAL MANAGEMENT OF THE FEMALE PATIENT
;PERIO 2000 VOL 61
• GARY C. ARMITAGE; Bi-directional relationship between pregnancy and periodontal
disease; PERIO 2000 VOL 61
• PHILIP M. PRESHAW; Oral contraceptives and the periodontium; PERIO 2000 VOL 61
• G. WRIGHT BATES & MEAGHAN BOWLING; Physiology of the female reproductive
axis; PERIO 2000 VOL 61