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Oral Health Guide for Women

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
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Puberty
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

Oral problems & diagnosis

  • 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.
  • 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.
  • 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:

    • The self-induced vomiting causes erosion of the lingual surfaces of the upper teeth or perimylolysis.
    • 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.
    • 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.
    • 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.
    • 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.
Treatment & Care

  • Gingivitis
    • Gingival tissue or a tumour needs meticulous dental hygiene, a mix of professional as well as home care.
    • Mild cases of gingivitis may respond to scaling, but in severe cases anti- microbial therapy may be needed.
  • Herpetic infections
    • 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.
    • 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.
    • 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
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
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Menstruation

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.

Oral Contraceptives (OC) & Oral problems

The effect of Oral Contraceptives on the oral cavity is a growing concern with the increasing number of women.

Oral problems & diagnosis

  • Gingivitis: Oral contraceptive pills can increase the swelling of the gums (Gingival inflammation), apparently due to changes in the micro-circulation.
  • 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 .
  • 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.
  • 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.
Treatment & Care

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). ul class="sep">

  • Gingival inflammation
    • Periodontal surgery may be indicated if there is inadequate resolution after initial therapy (scaling, root planing and curettage).
    • Anti-microbial mouthwashes may be suggested by your dentist as part of the home care regimen.
  • Antibiotics & Oral Contraceptives
    • The patient would be advised to maintain compliance with oral contraceptives when concurrently using antibiotics.
    • Patient must be told of the potential risk for the antibiotic's reduction of the effectiveness of the oral contraceptive.
    • 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 .
  • Medical history
    • A comprehensive medical history and assessment of vital signs, including blood pressure is important.
Pregnancy & Oral problems

A number of changes in the oral cavity have been associated with pregnancy, including caries, perimyolysis, tooth mobility, xerostomia, pregnancy granuloma and ptyalism / sialorrhea. Oral problems & diagnosis

  • 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, swell and bleed. Simple preventive oral hygiene can help maintain healthy gums. Any pregnancy- related gingivitis usually resolves within a few months of delivery.
  • 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
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.

    • 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.
    • 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.
    • 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.
Treatment & Care

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.

  • Nutrition
    • Nutritional guidance is given by the obstetricians and this may be reinforced by the dental team
    • 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.
    • Patients should select nutritious snacks, but avoid food that contain sugars and starches that contribute to caries development and pregnancy gingivitis.
    • It is advisable to limit the number of snack taken between meals.
  • Pregnancy gingivitis
    • Oral hygiene techniques may be taught, reinforced and monitored throughout pregnancy to control plaque to decrease the inflammation caused by the periodontal infection.
    • Scaling, polishing and root planing may be performed whenever necessary throughout the pregnancy to minimise the inflammation of the gingival tissues.
  • Elective Dental Treatment
    • Elective dental care should be timed during the second trimester and first half of the third trimester.
    • The first trimester is the period of organogenesis when the foetus is highly susceptible to environmental influences.
    • 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.
    • Extensive reconstruction procedures and major surgery should be postponed until after delivery.
    • 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.
    • 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.
    • 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.
  • Medications
    • 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.
    • 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.
    • 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.
  • Breastfeeding
    • There is a risk of drugs prescribed by your dentist passing to the nursing infant through the breast milk.
    • 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.
    • 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
    • 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 & Oral problems

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.

Oral Problems And Diagnosis

  • 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).
  • 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.

  • 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.

Treatment & Care
  • Menopausal gingivostomatitis

    The symptoms of menopausal gingivostomatitis usually regress in patients on hormone replacement therapy.

  • Salivary Dysfunction (Sjogren's Syndrome) & Dry mouth (xerostomia)
    • Decreased salivary flow accompanies menopause causing dry mouth (xerostomia).
    • Dry mouth or signs of salivary hypo- function (increased caries, mucosal dryness, oral candidiasis), then the possibility of Sjogren's syndrome must be considered.
    • 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.
    • Oral fungal infections may be recurrent and necessitate lengthy treatment.
    • 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.
    • 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.
    • 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.
    • Patients with Sjogren's syndrome complain of a dry mouth or have signs of salivary hypofunction (increased caries, mucosal dryness, oral candidiasis).
    • 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.
  • Burning Mouth Syndrome (stomatopyrosis)
    • 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 intensely to toothache.
    • 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.
    • 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.
    • 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
  • Osteoporosis
    • 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.
    • The most commonly used BMD test is DXA-dual energy x-ray absorptiometry. It is a painless, noninvasive procedure.
    • 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.
    • Generalised bone loss from systemic osteoporosis may render the jaws susceptible to accelerated alveolar bone resorption.
    • 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.
    • 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
    • Your dentist may recommend calcium intake, weight- bearing exercise, tobacco cessation and use of bisphosphonate medications to cure osteoporosis.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
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