STRONG INFLUENCE OF SEX HORMONES IN FEMALE’S ORAL HEALTH

INTRODUCTION

The production of estrogens changes drastically at menopause (menopause could be a physiological process, generally occurring within the fifth decade of life in women, indicating the end of the phase of a woman) leading to pathology in skeletal bones, characterised by the loss of bone mass and reduction of bone density, and with a subsequent increase in bone fragility and susceptibleness to fracture.

INFLUENCE OF FEMALE SEX HORMONE IN ORAL HEALTH

IN PROGRESSION OF PERIODONTAL DISEASE

Sex hormones are thought-about to play a big role in periodontal tissues and disease progression from an extended time. 

Chronic periodontitis is a disease initiated by microorganism pathogens that elicit a bunch response with sequent loss of animal tissue attachment and supporting alveolar bone. 

Though microorganism are the causative agents of periodontitis but estrogen deficiency even have received increasing attention in regard to susceptibleness to chronic periodontitis in postmenopausal women. 

Estrogen reduces the bone cell activity and will increase their apoptosis. within the menopause stage, the oestrogen levels decline rapidly, and result in general bone loss. 

Estrogen might have an repressing effect on gingival inflammation by 

• Inhibiting mediators 
• IL-1
• TNF-α
• IL-6
• IL-1β
• IL-8 
• Cellular mechanism of inflammation 
• PMN recruitment
• lymphocyte activation 

Lipopolysaccharide-released by-products regarding periodontal tissues and plaque biofilm stimulate the assembly of inflammatory cytokines that additionally activate the osteoclasts that absorb the bone. 

Inflammatory cytokines embody 

• Interleukin 1 (IL-1), IL-8, IL-6, IL-10
• Growth necrosis factor alpha
• Granulocyte-macrophage colony-stimulating factor (GM-CSF)
• Granulocyte colony stimulating factor

which stimulate mature osteoclasts, alter bone-cell proliferation, and activate reabsorption of both the skeletal and alveolar bones, by triggering tissue proteinases and degradative enzymes, resulting in destruction of the connective tissue, alveolar bone resorption, and eventually tooth loss.

Estrogen affects cellular proliferation, differentiation, and biological process of the gingival epithelial tissue. hormone receptors are known within the basal and acanthoid layers of the epithelium and conjointly in the connective tissue implicating the gingiva and oral tissue.

IN MICROVESSELS

Estrogen and progesterone also has effect on the microcirculatory system, manufacturing the subsequent changes: 

• Swelling of epithelium cells and pericytes of the venules
• Adherence of granulocytes and platelets to vessel walls, 
• Formation of microthrombi
• Disruption of perivascular mast cells
• Increased vascular permeability 
• Vascular proliferation.

IN SALIVARY FLOW

Saliva acts as a defense for prevention of caries and reduced salivary flow can encourage oral microbic organization therefore affecting the dental health. 

Salivary glands contain sex hormone receptors and these hormones are calculable within the saliva. 

Xerostomia is outlined because of the subjective sensation of oral xerotes and is typically related to hyposalivation. 

The composition of saliva and decreased saliva flow appear to be steroid hormone-dependent, typically deed menopausal and postmenopausal ladies with a persistent feeling of dry mouth, as there's reduction of estrogen at the menopause stage. 

This could be among bitter tastes and bad breath (Halitosis). 

Medications are thought of as a significant reason for impaired secretion function. 

Steroid hormones will be assessed within the saliva samples and their salivary concentrations are shown to correlate well with those in the blood serum.  

Salivary progesterone in menopausal ladies with oral dryness feeling showed that subjects with xerostomia had remittent un-stimulated saliva flow and salivary progesterone compared with those while not dry mouth. 

Thus, salivary progesterone level seems related to oral dryness feeling in menopause. 

Decrease in salivary flow is liable for a rise in 

• Dental caries
• Candidiasis
• Increase in dental plaque, that is once more responsible for initiating gingivitis

 thereby, providing a contributing issue for periodontitis in menopause.

Dry mouth

Photo credit: scientificanimations.com (wikipedia commons)

IN GINGIVA

Hyperplastic reaction resulting in gingival enlargement and onset of exuberant inflammation of the gingiva. 

Gingivostomatitis that is characterised by gingivae that are dry and shiny, bleed easily and direct color from abnormally pale to erythroderma and signs and symptoms of postmenopausal gingivostomatitis are somewhat equivalent to those of chronic desquamative gingivitis.

Bacterial species such as 

• Prevotella intermedia (Pi) 
• Capnocytophaga. 

Prevotella intermedia has been shown to possess the power to substitute sex hormone and progestogen for menadione (Vitamin K) as a necessary growth factor. 

This could justify the association between exaggerated estrogen concentrations and also the elevated counts of Prevotella intermedia. 

Together, estrogen touching gingival vasculature and Capnocytophaga species which frequently will increase during puberty, are related to the exaggerated injury tendency determined throughout this period. 

Pregnant girls are additionally susceptible to inflammation and gingival bleeding. 

Pregnant women can also expertise localized gingival enlargement resembling pathology granulomas. 

These lesions also called maternity neoplasm have been delineated as a painless, exophytic mass that has either a sessile or pedunculated base extending from the gingival margin or, from the interproximal tissues within the jaw anterior region predominantly. 

The levels of sex steroid hormones in saliva will increase during pregnancy leading to alterations in the microorganism populations which can contribute to those pathologic changes. 

The increased synthesis of prostaglandin E2 determined once oestrogen and progestogen are present in higher concentrations, happens throughout maternity can also contribute to those pathologic changes. 

Effect of those hormones on microvasculature is liable for marked hurt tendency during pregnancy. 

Some girls develop senile atrophic gingivitis during which an abnormal paleness of gingival tissue develops. 

Reduction in epithelial keratinisation and albuminoid formation in animal tissue ends up in thinning of the oral tissue layer and difficulty with removable partial prosthesis.

ONE OF THE CAUSATIVE AGENT FOR BURNING MOUTH SYNDROME

BMS, also called glossodynia or stomatodynia(painful mouth has been accompanied with a reduced secretion flow rate) mainly affects women within the fourth or fifth decade of life. 

Mandibular dysfunction and also diffuse gingival atrophy or oral ulcerations may be present with oral dryness, inflicting pain in the mouth. 

Patients usually describe the burning pain as having a bilateral symmetrical distribution, most often involving the 

• Anterior two-thirds of the tongue
• The dorsum
• The lateral borders of the tongue
• The anterior arduous palate
• The mucosa of the lower lip, often in addition to one oral site.

The related symptoms might embrace dryness sensation or alterations in taste sensation. The underlying causes stay unclear. 

It's been advised that female sex hormones and neuropathic factors is also implicated, probably through small-fiber sensory neuropathy of the mucosa oral. 

Traditional clinical tests and explorations distinguish primary BMS from secondary stomatodynia. 

Oral tissue layer changes vary from a symptom pale look to menopausal gingivostomatitis, that is characterised by dry and glossy gingiva that bleeds easily, and a reduced secretion flow within the presence of the disease. 

The burning sensation looks to be like a mouth burnt with hot coffee, however it doesn't go away. it always happens in the tongue and is related to the bitter taste sensation. 

The bitter taste ability set at the tip of the tongue inhibits the pain, and once it's gone, it results in pain that's taken as burning mouth syndrome. 

Treatment consists of low-dose topical (without swallowing) or systemic clonazepam. 

The association of this drug to tricyclic antidepressants has afforded variable results. 

The symptom usually gets worse over the day and it will reach months or perhaps years. 

The explanation why burning mouth syndrome is common in post menopause ladies is directly regarding the reduced sex hormone production. 

There's additionally a relationship between anxiety and depression and burning mouth syndrome, though it's difficult to state that the precursor is the psychological changes or the pain.

HORMONES INFLUENCE IN GENERAL HEALTH

These hormones could alter immunologic factors and responses, together with matter expression and presentation, protein production in addition because of the expression of apoptotic factors and cell death. 

Progesterone, in particular, has been shown to stimulate the assembly of the Inflammatory mediator, prostaglandin E2 and enhances the buildup of polymorphonuclear leukocytes within the gingival sulcus and down regulates interleukin 6 production by human gingival fibroblasts.

HORMONE INFLUENCE IN BRAIN FUNCTION

Estrogen promotes neurotrophin synthesis; modulates cholinergic and dopaminergic neurochemical systems and protects the brain against stress and inflammation.

Estrogens and progesterones are thought to act along to boost neuronal function through mechanisms equivalent to conjunction formation and reduction, enhancing junction transmission and exerting neuroprotective impacts. 

Progesterone receptors have conjointly been known in cognitively relevant brain regions, together with the frontal cortex, hypothalamus, thalamus, hippocampus, amygdala, and cerebellum and also there may be a lack of proof supporting the timing hypothesis for enhancing cognition in postmenopausal women and most of the reserch urged that there have been no adverse cognitive outcomes related to hormone therapies.

HORMONE INFLUENCE IN BONE FUNCTION

Osteoporosis is most typically investigated in women, particularly when menopause, and it's rarely thought of in men, who additionally present important risk factors. 

Some of the important changes are 

• Inhibit generation and activity of osteoclasts
• Upregulation of osteoprotegerin
• Decrease T lymphocyte activation
• Decrease IFN-γ release by T cells
• Increase enteric calcium absorption

Estrogens inhibit generation and activity of osteoclasts through an upregulation of osteoprotegerin, decrease T-cell activation and consequently also interferon-γ release by T-cells, and increase intestinal calcium absorption.

Estrogen decline is abrupt at the start of the menopausal period, whereas in males the decline in T and consequently in estrogen is low and constant with aging, so it is clear how sex variations in osteoporosis exist. 

A rise in each bone formation marker and bone biological process marker are determined in biological time females, suggesting an increase within the rate of bone remodeling as confirmed by histomorphometry.

HORMONE INFLUENCE IN MUSCLE FUNCTION

Sarcopenia is an age-related syndrome outlined by the 

• Loss of muscle mass 
• Strength and/or performance
• Typically related to chronic diseases
• Obesity
• Prolonged immobilization. 

However, it additionally represents a physiological state of aging. 

Some of the important changes are

• Increase levels of pro anabolic factors
• Scale back muscle inflammation
• Decrease muscle damage
• Increase post exercise muscle satellite cell activation and proliferation
• Increase intrinsic contracted muscle function.

During menopause, females show a marked decrease in muscle mass and strength, whereas in males this loss is constant and takes place a lot of slowly. 

HORMONE INFLUENCE IN OBESITY

Females typically have a higher proportion of fat mass and are a lot of seemingly to deposit fat subcutaneously and on their lower extremities whereas men are more likely to deposit visceral fat within the abdominal region. 

Fatty tissue will increase with pubescence and early pregnancy, suggesting that endocrine steroids will influence body fat. 

Following menopause-induced sex hormone loss, a shift towards visceral adiposity occurs, that is sensitive to estrogen therapy. 

In postmenopausal females, adrenergic receptor ratio is reversed therefore probably explaining the discriminatory accumulation of fat within the visceral depot. 

Therefore, at the adipocyte levels, estrogens and their receptors could have the capability to extend the accumulation of fat cells in the subcutaneous deposit and to inhibit it in the visceral deposit.

Some of the important changes are

• Increase gynoid fat deposition
• Decrease postprandial carboxylic acid reaction 
• Increase fat oxidation throughout submaximal exercise
• Decrease energy intake; increase energy expenditure
• Reduce tissue inflammation

SEX HORMONE INFLUENCE IN OTHER ENDOCRINE HORMONE 

Thyroid cancer is more common in females however pathophysiological reasons explaining this distinction are unknown, but it's been planned that estrogens could play a fundamental role. 

This hypothesis is supported by proof that thyroid cancer includes a higher incidence in fertile women. 

Type 1 diabetic patients, in whom women showed worse metabolic control.

Furthermore, diabetic women, notwithstanding menopausal state, present considerably higher risk of ischaemic heart condition than diabetic men and additionally diabetic women have a worse prognosis when myocardial infarction and a better rate from cardiovascular disease.

MANAGEMENT OF ORAL DISEASE

Whenever a girl attends menopausal clinic she ought to be asked regarding complaints like dry mouth, discomfort within the mouth, tongue and pain in the teeth and so forth elaborate history of general diseases and use of medication should be elicited. 

A open-eyed and comprehensive analysis of the oral membrane membranes, the periodontal, dental conditions, and secretion flow, at the side of an in depth clinical history is imperative all told postmenopausal women, at the side of alternative pertinent tests, adore, radiographs, dentistry probing, and sialometry. 

A referral to the dentist should be created just in case of great symptoms. 

A dentist should examine the oral mucosa, dental and dentistry status thoroughly. 

Periodontitis should be treated relying upon the cause and microflora. 

The role of bisphosphonates within the management of dentistry disease is recommended by few workers. 

Patients should be educated concerning the profound effects of the endocrine on periodontal tissues and oral tissues furthermore because the consistent would like for home and workplace removal of local irritants. 

TREATMENT OF ORAL DISEASE

Dental treatment consists of hindrance of dental caries and treatment of existing conditions. 

Oral hygiene measures in the sort of smart brushing technique, use of flossing, antiseptic rinses and halide containing dentifrices should be advised. 

The use of toothpastes, varnishes or gels containing fluorides is additionally suggested for the hindrance of dental caries.

Utilization of mouth washes, such as, antiseptic or Listerine to lower the bacterial plaque levels, that improves the general periodontal health and prevents caries. 

Many oral liquids ought to be suggested and native applications of bound medication could facilitate burning mouth syndrome. 

It is crucial to maintain low levels of dental plaque by introducing adequate oral hygiene aids (interproximal brushes, dental floss, brushing frequency and technique), together with the use of therapy agents such as chlorhexidine digluconate. 

These substances reduce the buildup of dental plaque, improves periodontal disease and prevents dental caries (elimination of a lot of the presence of eubacteria mutans), significantly root caries, that are more frequent in old individuals. 

To cut back the incidence of hormone influenced dentistry diseases all native irritants ought to be removed, and meticulous plaque management be maintained. 

There's an uncertain role of psychotherapy and antidepressants also. hormone-replacement therapy is also advised for a brief term in cases of persistent symptoms. 

Given in low dosages, benzodiazepines, tricyclic or anticonvulsants are also effective in patients with burning mouth syndrome.

Medicine and risedronate are shown to enhance periodontal status.

Variety of studies have prompt that the symptoms of biological time gingivitis and risk of postmenopausal tooth loss is reduced by steroid hormone replacement, however largely patients fail to adjust to the therapy due to the concern of cancer, irregular bleeding, and alternative minor side-effects. 

Milder sort of periodontitis cases respond well to scaling and root planing. 

Severe cases, wherever enlargement occurs, needs surgical excision. 

For menopausal gingivitis hormone, replacement medical care is often included. 

CONCLUSION

Dentists ought to conduct an intensive examination of the oral cavity and rule out alternative general illness before incoming at any definitive diagnosing concerning secretion changes. 

Today the quality of dental treatment permits folks to retain their own teeth however it appears that a lot of periodontic issues still occur. 

Strict oral hygiene maintenance is of prime importance for the patient as a result of it's the plaque that results in incidence and prevalence of disease whereas the amount of secretion modifies the response. 

Effect of secretion replacement medical care in alleviating symptoms and up oral health is once more controversial. 

Massive randomised controlled studies are required to document vital results of hormone replacement therapy and alternative interventions in menopausal ladies with oral symptoms. 

There ought to be definite pointers for menopausal women relating to sensible oral health and lifestyle practices. 

The risk exists that the remittent oestrogen levels related to the biological time amount could contribute to the progression of disease by affecting the oral bone mass. 

In future, a lot of randomised controlled trial studies should be conducted to know the association between change of life and oral health.

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