periodontal therapy in female patients

1. Periodontal therapy in the female patients
Dr. Nikhat Fatima. Rama
Dental College and Hospital

2. • A woman is the full circle.
Within her is the power to
create, nurture and transform.
Diane Mariechild

3. Hormone connection
• From puberty, pregnancy and menopause a woman’s life
cycle is influenced by hormones. Reproductive hormones
play a major role which influence her physical, emotional
as well as oral health.
• When it comes to oral and periodontal health, dentists
have greater awareness of and better capabilities for
dealing with hormonal influences ,recognizing ,customizing
and appropriately altering the periodontal therapy
according to individual woman’s needs based on her stage
of her life cycle.

4. Female life cycle.
This can be studied under the following headings :
• Puberty
• Menses
• Periodontal manifestations of pregnancy
• Oral contraceptives
• Menopause

5. Puberty
• It occurs between the average ages of 11 to 14 in
most women.
• The production of sex hormones [estrogen and
progesterone] increases.
• Prevotella intermedia, an anaerobic organism is
associated with puberty gingivitis.
• This organism may use ovarian hormone as a
substitute for vitamin K growth factor.
• Other organisms involved are Prevotella
nigrescens and capnocytophaga species.

6. Manifestations
• The gingiva becomes inflamed,
erythematous, lobulated and
retractable, and tends to bleed easily.

7. Management
• Education of the parent or caregiver.
• Milder gingivitis-Scaling, Root planing.
• Severe cases of gingivitis --Microbial culturing,
antimicrobial mouth washes and local site delivery, or
antibiotic therapy.

8. • The clinician should recognize the intra oral
effects of chronic regurgitation of gastric contents
due to certain eating disorders like Bulimia and
Anorexia nervosa; Perimylosis (smooth erosion of
enamel and dentin) on the palatal surfaces of
maxillary anterior teeth.
• Enlargement of the parotid glands.

9. Menses
FEMALE REPRODUCTIVE CYCLE:
[1] Follicular phase
[2] Luteal phase
FOLLICULAR PHASE:
• Levels of FSH are elevated
• Estradiol[E2], major form of estrogen synthesized by the
follicle peaks 2 days before ovulation.
• Estrogen stimulates ovulation and proliferation of stroma
cells, blood vessels and glands of endometrium.

10. Luteal phase
• Corpus luteum synthesizes estradiol and
progesterone.
• The corpus luteum involutes, ovarian hormone
levels drops and menstruation ensues.
• Progesterone increases from the second week,
peaks at approximately 10 days, and dramatically
drops before menstruation.

12. Periodontal manifestations
• Tumor necrosis factor alpha, which fluctuates
during the menstrual cycle, elevated prostaglandin
E2 synthesis, and angiogenetic factors,
endothelial growth factors, and receptors may be
modulated by progesterone and estrogen,
contributing to gingival inflammation.

13. • Chemotaxis of polymorphonuclear leukocytes is
enhanced by progesterone but reduced by
estradiol.
• Gingiva appears edematous during menses and
erythematous before the onset of menses.

14. • There is an increase of gingival exudate,
associated with minor increase in tooth mobility.
• Incidence of post extraction osteitis is higher.
• During luteal phase, intra oral recurrent aphthous
ulcers, Herpes labialis lesions and candidal
infections occur.

15. • Progesterone relaxes esophageal sphincter and
women may be more susceptible to
gastroesophageal reflux disease (GERD) leading
to heart burn, regurgitation, chest pain, sore
throat, gingivitis etc
• About 7-10 days before menstruation,
Premenstrual Syndrome may occur.
• These patients have lower levels of
neurotransmitters such as Encephalin,
Endorphins, GABA and Serotonin.

16. Symptoms of PMS
• Depression, irritability,
mood swings, difficulty with
memory and concentration.
Fatigue, sweet and salty
food cravings, abdominal
bloating, heightened gag
reflex; more sensitive;
swollen hands or feet,
headache, nausea, GI
upset.

17. Management
• Clinician should aware that NSAIDS,
infection exacerbate GERD.
• Medical history is to be reviewed.
• Antidepressants like selective serotonin
reuptake inhibitors [SSRIS] are used.
• Fluoxetine, Fluvoxamine, Paroxetine and
Citalopram are used commonly.
• Gingival and oral mucosal tissues are
treated gently.

18. • Gauze pads or cotton rolls should be moistened
with a lubricant, chlorhexidine rinse before placing
them in the aphtha - prone patient.

19. • Because the hypoglycemic threshold is elevated,
the clinician should advise the patient to have a
light snack before her appointment.

20. • For a patient with a history of excessive post
operative hemorrhage or menstrual flow,
scheduling surgical visits after cyclic menstruation
is sensible.

21. Periodontal manifestations of
pregnancy
[A] PERIODONTAL
DISEASES:
PREGNANCY GINGIVITIS:
• Gingival inflammation initiated
by plaque and exacerbated by
these hormonal changes in the
2nd and 3rd trimester of
pregnancy, is referred to as
pregnancy gingivitis

22. • Gingival probing depth, bleeding on probing and
crevicular fluid flow were found to be increased.
• Gingival erythema, edema and hyperplasia are
seen, associated with transient tooth mobility.

23. • Mostly interproximal sites of anterior teeth are involved.
• Anterior site inflammation may be exacerbated by
increased mouth breathing, primarily in the 3rd trimester,
from pregnancy rhinitis.

24. Pyogenic granuloma or epulis
• A pedunculated, fibro-
granulomatous lesion
developing during
pregnancy is referred as
pregnancy granuloma.
• They are bright red,
hyperemic and edematous.
• They do not exceed 2 cm in
diameter.

25. • Occurs most often during 2nd or 3rd month of
pregnancy.
• Clinically, they bleed easily and become
hyperplastic and nodular.

26. • ROLE OF PREGNANCY HORMONES:
PERIODONTAL DISEASE AND
PRETERM, LOW – BIRTH –WEIGHT
INFANTS:
Untreated periodontal disease in pregnant
women may be a significant risk factor
for preterm [less than 37 weeks
gestation], low-birth-weight [less than
2500g ] infants

27. • This occurs as a result of infection and is
mediated indirectly by the translocation of
endotoxin [lipopolysaccharide ] and the action of
maternally produced inflammatory mediators.
• PGE2 AND TNF alpha which are involved in
normal parturition, are raised to high levels by the
infection process, which may foster premature
labor.

28. • ETIOLOGY OF GINGIVAL RESPONSES TO
ELEVATED ESTROGEN AND PROGESTERONE
DURING PREGNANCY:
• SUB GINGIVAL PLAQUE COMPOSITION :
• Increase in anaerobic / aerobic ratio.
• Higher concentrations of Prevotella intermedia,
Bacteroides melaninogenicus, Porphyromonas
gingivalis.

29. MATERNAL IMMUNORESPONSE:
• Depression of cell mediated immunity
• Decreased neutrophil chemotaxis
• Decrease in the ratio of peripheral T helper cells to T
suppressor cytotoxic cells [CD4 / CD8 ratio ]
• Decrease in absolute numbers of CD3+ ,CD4+ and CD
19+ cells in peripheral blood during pregnancy versus
postpartum.
Stimulation of prostaglandin production.

30. SEX HORMONE CONCENTRATION:
• [A] ESTROGEN- Increases cellular proliferation in blood
vessels
• Decreases keratinization.
• [B] PROGESTERONE: –Increases vascular dilation, thus
increases permeability resulting in edema and
accumulation of inflammatory cells.
• Increases proliferation of newly formed capillaries-
Increased bleeding tendency.

31. • Alters rate and pattern of collagen production.
Increased metabolic breakdown of folate [Inhibit tissue
repair ].
Decreases plasminogen activator inhibitor type –2 , thus
increases proteolysis.
[C] ESTROGEN AND PROGESTERONE:
Affect ground substance of connective tissue by increasing
fluidity.

32. OTHER ORAL MANIFESTATIONS OF
PREGNANCY
• 1.Xerostomia
• 2. Rarely ptyalism or Sialorrhea [excessive secretion of
saliva] usually begins at 2-3 weeks of gestation and may
diminish at the end of the first trimester.
• It occurs as a result of inability of nauseated gravid women
to swallow normal amounts of saliva.

33. Clinical management
• Because of immunologic alterations, increased blood
volume, fetal interactions, the clinician must monitor the
patient’s medical and periodontal stability.
• Medical history should include pregnancy complications,
previous miscarriages, recent history of cramping, spotting
or pernicious vomiting.

34. • The patient’s Obstetrician should be contacted if
necessary.
• PLAQUE CONTROL-Scaling, Polishing and Root planing
must be performed.
• Prefer to use non- alcohol – based oral rinses.

35. • Avoid elective dental care during 1st trimester and the last
half of 3rd trimester.
• Prolonged chair time may need to be avoided to prevent
SUPINE HYPOTENSIVE SYNDROME.
• In supine position, inferior vena cava is compressed by the
gravid uterus.
• By interfering with venous return, this compression causes
maternal hypotension, decreased cardiac output, and
eventual loss of consciousness.

36. • It can be reversed by turning the patient on her
left side [there by removing pressure on the vena
cava and allowing blood to return from the lower
extremities and pelvic area].
• A 6-inch soft wedge [rolled towel] should be
placed on the patient’s right side when she is
reclined for treatment.

37. • The 2nd trimester is the safest period for providing routine
dental care.
REASON-
Most medications cross the placental barrier and
organogenesis occurs in 1st trimester, hence to avoid the
occurrence of developmental defects.
Major oral or periodontal surgery should be postponed
until delivery.

38. • Pregnancy tumors that are painful, interfere with
mastication or continue to bleed or suppurate after
mechanical debridement may require excision and
biopsy before delivery.

39. Radiographs
• High speed film, filtration, collimation and lead aprons
are used.
In most cases, only bite-wing, panoramic, or selected
periapical films are indicated.
It is not desirable to have any irradiation during
pregnancy [especially 1st trimester] because the
developing fetus is susceptible to radiation damage.

40. Medications
•
Lidocaine
Prilocaine
Etidocaine
Acetaminophen

45. • BREAST FEEDING:
The amount of drug excreted in breast milk is
usually not more than 1% to 2% of the
maternal dose.
The mother should take prescribed drugs just
after breast feeding and then avoid nursing
for 4 hrs or more; if possible, to decrease the
drug concentration in breast milk.

46. Oral contraceptive
• These utilize synthetic
gestational hormones
[estrogen and
progesterone], to reduce
the likelihood of ovulation /
implantation.
• Progesterone promotes
tissue catabolism, resulting
in increased periodontal
attachment loss.

47. • Gingiva shows inflammation which may range
from mild edema and erythema to severe
hemorrhagic or hyperplastic tissues.
• More exudate is present in inflamed gingival
tissues of oral contraceptive users.

48. • The response may be caused by an altered
microvasculature, increased gingival permeability and
increased synthesis of PG E2.
• This inflammation may become chronic because of the
extended periods of exposure to elevated levels of
estrogen and progesterone.
• A decreased concentration of protein, sialic acid,
hexosamine fructose, hydrogen ions and total electrolytes
has been reported.

49. • OSTEITIS:
Localized osteitis after extraction of mandibular 3rd molars
may be attributed to the effects of OC on clotting factors.
Sometimes gingival melanosis occurs especially in fair
skinned individuals.

50. Management of osteitis
• Establishing low plaque levels by scaling and root planing.
• Periodontal surgery may be indicated if initial therapy is
inadequate.

51. • Perform extraction of teeth [3rd molars] on
nonestrogenic days [days 23 –28] of OC cycle to
reduce the risk of a post-operative localized
osteitis

52. • All women of child bearing age should be
informed of reduced efficacy of steroid OCs during
antibiotic therapy and advised to use additional
forms of contraception during short term therapy.
During long term antibiotic therapy, they should
consult their physician.

53. Menopause
• Estradiol levels fall gradually in the
years before menopause.
• Levels of FSH and LH begin to rise,
and levels of sex hormones begin to
fluctuate.
• This stage of PERIMENOPAUSE is
characterized by increasing ovarian
unresponsiveness, and thus sporadic
ovulation ensues.

54. • Thinning of the oral mucosa-DESQUAMATIVE
GINGIVITIS.
• Burning mouth.
• Gingival recession.
• Xerostomia.
• Altered taste sensation
• Alveolar bone loss
• Alveolar ridge resorption
• Gingival inflammation, hypertrophy or atrophy.
• More prone to Lichen planus.

55. Mechanism
• Estrogen affects cellular proliferation,
differentiation and keratinization of the gingival
epithelium.
• Sex steroids have a direct effect on the
connnective tissue, with estrogens increasing the
intracellular fluid content.

56. • OSTEOPENIA:
Reduction in bone mass caused by an imbalance between
bone resorption and formation, favoring resorption and
resulting in demineralization.
OSTEOPOROSIS:
It is characterized by low bone mass and fragility and a
consequent increase in fracture risk.

57. Clinical management
• Review the patient’s medical history.
• If gingival and mucosal tissue thinning occurs, soft tissue
augmentation may be performed.
• Brushing with an extra soft tooth brush prevents scrubbing.
• Dentifrices with minimal abrasive particles should be used.
• Low alcohol concentration rinses.

58. Clinical management
• During periodontal maintenance, root surfaces should be
debrided gently with minimal soft tissue trauma.
Oral pain resulting from xerostomia, thinning of tissues,
inadequate nutritional intake, or hormone depletion should
be relieved.
Symptoms may be significantly reduced by Hormone
Replacement therapy or Estrogen Replacement therapy.

59. • Sodium fluoride, biphosphonates [Ex:Alendronate],
Selective estrogen receptor modulators or parathyroid
hormone may be other therapies for the osteoporotic
patient.
• Consult the physician if required.

60. • RECOMMENDATIONS FOR OPTIMAL CALCIUM
INTAKE ACCORDING TO NIH [National Institute Of
Health]:
• Premenopausal women:1000 mg / day
• Postmenopausal women :
[estrogen therapy]: 1000 mg / day
[No estrogen therapy]: 1500 mg / day.

61. • Clinicians need to take the initiative and become familiar
with all these systemic relationships and to initiate
treatment co-ordination with the woman’s physician.
• Patients should be educated regarding the profound
effects of sex hormones on periodontal and oral tissues as
well as the consistent need for home and office removal of
local irritants.

62. • Research regarding female issues in periodontal
therapy is in process .
• In the near future information regarding specific
management and etiology of sex hormone related
infections will enhance our ability to provide
quality care to our female patients.

63. Thank you