Gingival changes by hormonal oscillations in female patients

Ilma Robo Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania
Saimri Heta Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania
Elsaida Agrushi Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania
Sonila Kapaj Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania
Eduart Kapaj Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania
Vera Ostreni Albanian University, Departamenti i Stomatologjisё, Tiranё, Albania

Abstract

Introduction

Cyclic hormonal fluctuations are known from the literature to have clinically visible effects on gingival tissue reactions and processes of inflammation.

Materials and methods

A total of 47 female patients were recruited at the University Clinic of Tirane (Albania), data on the effect of hormonal oscillations before and after periodontal treatment protocol were recorded. Oral examination was performed on gingival soft tissues and the oral mucous membrane, using the air-drying procedure and then clinically checking the differences in oral mucosa.

Results

Out of a total of 47 patients, 13 were diagnosed under the gingivitis classification, and 24 patients under the periodontal classification. Patients included in the study are divided by age, week of menstrual cycle (respectively 1,2,3 and 4). The younger the age of female patients the more prone the patient is to the appearance of gingivitis, which is further aggravated by the effects of sexual hormones and of their controlled or non-regulated fluctuations.

Conclusions

The healing process is more effective in the absence of high hormone levels, as they are pro-inflammatory hormones, both in or near the oral cavity, mainly in the gingiva.

 

Key words

Female patients, Gingiva, Hormonal oscillations, Mucosa, Periodontal non-surgical treatment.

 

 

Introduction

Gingival inflammation involves a lack of balance or increase of sexual hormone concentration (1,2,3). Most in vitro and in vivo studies have shown that sexual hormones modify the action of immune system cells (4,5,6,7). Interaction between estrogen and immune system cells may have unusual effects (8,9,10).

The study aims at presenting a macroscopic clinical view of female patients in the hormonal contraction, which has certain cycle periods that maximally express their effects. Estrogen act on gingival tissue proliferation, while progesterone on vasodilation and the creation of new blood vessels, which is expressed in gingivitis quite noticeably in adolescence (11,12,13,14,15). In the teenage form of gingivitis, especially in the area of incisors, where the gingival contact with air and drought is higher, the hormonal action is more apparent in the appearance of gingivitis, cervical spots, as a result of pigmented bacteria from minimal gingival bleeding. Stabilization of hormonal secretions, by cyclic adjustment, makes the actions of each hormone without a great duration of action, showing macroscopic clinical consequences, particularly in adolescence (16,17,18,19,20,21,22,23). Estrogen and progesterone show the effect of their action on the mouth, gingiva, and, depending on which stage of the cycle the female patient is, on periodontal treatment. These hormones not only affect the appearance of oral cavity, but also have a significant effect on the gingival healing process, which begins in the dental pulp, which can be evaluated in the mobility of marginal gingiva by the air stream, expression of mechanical activity of stimulation (24,25,26,27,28,29).

 

 

Materials and methods

In the study female patients were recruited at the periodontology department of the University Dentistry Clinic, Albanian University, for the routine scaling treatment. Regardless of the periodontal diagnosis, the periodontal disease from which the female patient suffers, was evaluated before and after periodontal treatment, by means of photo and clinical examination (30,31,32,33).

Data collected (34,35,36,37,38,39) were the following.

  • Demographic data.
  • Cycle phase, divided into 4 weeks, 1 week period.
  • Periodontal diagnosis, separating the patients suffering from gingivitis and periodontitis.
  • Periodontal post-treatment data were recorded, indicating whether the gingival tissues were prone to initiating the healing process at the initial post-scaling stage or if gingival bleeding was present.
  • Gingival mobility.
  • Bacterial plaque retentive factors were recorded for maxillary and mandibular incisors.
  • All lesions present in the oral cavity were photographed, based on the literature on systemic hormonal oscillations.

The study was conducted on a total of 47 patients, of which 13 had gingivitis, and 24 periodontitis. Patients included in the study were divided by age and cycle week (respectively 1,2,3 and 4). Each patient involved in the study was well informed about the study protocol, the purpose of the study and the ongoing procedure, and when full verbal consensus was reached to become part of the study, then the established protocol could start. Based on the basic principles of the literature on gingivitis and periodontitis (40,41,42,43,44), female patients were classified according to which group of diseases they suffered, i.e. gingivitis or periodontitis, according to the following criteria.

  1. Lack of orange-peel texture of fixed gingiva and the presence of subgingival calculus.
  2. Supragingival calculus and gingival recession.
  3. Lack of interdental papilla (except in diastema cases) and gingival recession.

The presence of all these three criteria classified the patient as affected by periodontitis, whereas the absence of one criterion meant diagnosis of gingivitis (45).

Hormonal fluctuations in female patients is also associated with the presence of bacterial plaque in the highest amount due to the existence of retentive factors causing more pathogen proilferation, where healing is more difficult (1, 45).

At the selected retentive factors, in the area of maxillary and mandibular incisors, include the following.

  • Crowded teeth, malocclusion.
  • Ill-fitting dental filling, operative dentistry.
  • Bridge, crowns, fixed prosthodontics.
  • Total, partial prosthesis, movable prosthesis.
  • Orthodontic appliances such as wires, brackets, retainers.
  • Pearls of enamel, dental morphology.

 

 

Results

Data were collecting at baseline (Table 1, Figure 1).

Table 1 Data on the week of sexual cycle of the patients recruited at the University Clinic (period between November 2018 and April 2019).
Figure 1 Numerical and in percent data of the patients recruited at the University Clinic.

Patients were classified according to the basic principles of the literature on gingivitis and periodontitis (Table 2, Figure 2).

Table 2 Distribution of patients, according to age-groups, regarding gingivitis and periodontitis susceptibility.
Figure 2 Distribution of patients, according to age ranges, regarding gingivitis and periodontitis susceptibility.

Patient's data regarding gingivitis or periodontitis susceptibility and about the weekly cycle and the ability of tissue healing were recorded  (Table 3, 4, Figure 3, 4).

Table 3 Distribution of patients, according to the week of cycle, regarding gingivitis and periodontitis susceptibility.
Table 4 Data on the week of cycle and tissue healing.
Figure 3 Distribution of patients according to week of cycle regarding gingivitis and periodontitis susceptibility.
Figure 4 Data on the week of cycle and tissue healing.

Retentive factors in the area of maxillary and mandibular incisors include the following (Table 5, Figure 5).

Table 5 Relationship between retentive factors and gingivitis/periodontitis.
Figure 5 Retention factors and appearance of gingivitis and periodontitis.
  • Crowded teeth, malocclusion.
  • Ill-fitting dental filling, operative dentistry.
  • Bridge, crowns, fixed prosthodontics.
  • Total, partial prosthesis, movable prosthesis.
  • Orthodontic appliances such as wires, brackets, retainers.
  • Pearls of enamel, dental morphology.

Figures 6-10 show some of the patients involved in the study.

Figure 6 Color changes in marginal gingiva and lateral hypertrophy on left mandibular incisors before and after treatment in a 25 years old patient.
Figure 7 Images before and after treatment with scaling in a 20 year old patient after the cycle, showing bleending on the vestibular side of mandibular teeth.
Figure 8 Different stages of the healing process showing: gingival mobility, tissue adhesion on the tooth surface, bleeding.
Figure 9 Bleeding in patients with fixed prosthesis at the maxillary incisors before and after periodontal treatment.
Figure 10 Oral lesions from hormonal changes in female patients.

Discussions

Gingiva is a target site for estrogen and progesterone, as estrogen receptors are present in periosteal and lamina fibroblasts, as well as in periodontal ligament fibroblasts and osteoblasts. This determines visible, clinically distinct macroscopic effects (13,14,15,16,17). In females, the stimulus on gingival fibroblasts is mainly expressed by uncontrolled indole production, mainly expressed during adolescence, when both estrogen and progesterone hormones still do not regulate their balance (3,5,8,13). During pregnancy these hormones do not have a natural and well-controllable balance, with increased production quantities (15,17,27,35,38,44). The increase in the production, indicated by the phase in which the female patient is, results in an increase in indium proliferation, which can be clinically evaluates in the form of pregnancy-related tumors (48,49). Estrogen and progesterone hormones inhibit the production of prostaglandin (50) and reduce IL-6 production (51). Severe reduction of T lymphocytes(52) reduces inflammation, while progesterone promotes folate metabolism, important for tissue preservation (53). These data are reported in the literature, in epidemiological and review studies. The lack of estrogen in menopause appears clinically with consequences on the stability of the alveolar bone structure, accompanied by the anti-inflammatory effect of the same hormone, so macroscopically the clinical appearance in the oral cavity of female patients becomes even more complicated (54).

Based on published studies (54), patient response is not always the same, also with the same amount of female sexual hormones. The response of premenopausal women to non-surgical periodontal therapy is better than in postmenopausal women, an element that can be reduced by controlling oral hygiene. The pro-inflammatory response of the gingiva to the local factor, bacterial plaque, is added to the hormonal fluctuations in female patients. These conditions also occur in hormone therapy with oral contraceptives and the effects of postmenopausal age (55). This element in our study is presented in the evaluation of the healing process, related to the weekly stages of menstrual cycle. The increased hormonal level is expressed by the pro-inflammatory effect on a minimal amount of bacterial plaque, presenting the highest percentage in the area of mandibular incisors and molars. Also during pregnancy, the effect of sexual hormones on periodontal tissues can be controlled by maintaining good oral hygiene (56). This is the advice that is appropriate for this stage of life.

The evaluation of the bacterial plaque index was not the purpose of the study and therefore it has not been recorded in the clinical evaluations of the patients involved in the study. The side effects of hormonal therapy may be more visible in presence of periodontal disease, the latest generations of oral contraceptives are better tolerated by the organism.

Based on the results of the present study, the following can be stated.

The highest percentage of patients included in the study, 47%, were in the first post-cycle week. This was the highest value in the 35-44 age group, the pre-menopause period.

According to the age group of the patients included in the study, 34% were in the age range of 15-34 years.

For prevalence of gingivitis, the highest value was 28%, in the age group 15-34 years, while for periodontitis the highest value was 30% in the age group of 35-44 years. These values divided into age groups, have on the whole almost the same prevalence in total patients for both diseases. In relation to gingivitis according to the week menstrual cycle, it was 19% in week 1 and week 4; periodontitis was 28% week 1. The induration process is displayed at 47% in week 1, mainly on the appearance gingival tissue adhesion to teeth after scaling. On the 4th week, healing shows as the air-testing phase. In total, irrespective of the menstrual cycle, the air-testing showed recovery process in 49%, followed by tissue adhesion, 34%, and the presence of bleeding at 17%. This is a good indicator, as periodontitis appears at 45%, regardless of the menstrual cycle. The most frequent retention factors are mainly covered by operative dentistry, prosthetics and orthodontics, respectively: 11%,  9% and 9%.

 

 

Conclusions

Young age exposes female patients to the appearance of gingivitis, which is further aggravated by the effects of sexual hormones and of their controlled or non-regulated fluctuations. The healing process of soft tissues is more stimulated in the absence of high hormone levels, as these hormones are commonly present in conjunction with pro-inflammatory effects, which in the oral cavity are mainly located in the gingiva.

Regardless of sex, the aim of non-surgical periodontal therapy is to restore tissue adhesion to the treated tooth surface, as a sign of long duration and successful non-surgical periodontal therapy.

Any uneven surface present in the oral cavity for iatrogenic causes causes the accumulation of bacterial plaque. which causes periodontal diseases that in female patients, at high levels of sexual hormones, are clinically expressed by the severe manifestations of these diseases. The main recommendation based on the results of the study, once again emphasizes that the response of the oral structures to bacterial plaque is higher and more sensitive in cases where the hormonal levels are higher.

 

Conflicts of Interest: The authors declare that there is no conflict of interest.

 

 

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