Midlife transitions and oral health
The endocrine system is a hard worker. It is a set of glands that produce hormones regulating sleep, mood, metabolism, growth, tissues and sexual function. The main glands of the endocrine system are the pineal gland, pituitary gland, thyroid and parathyroid glands, adrenal glands, pancreas, thymus, ovaries and testicles.
Common diseases of the endocrine system include type 1 and type 2 diabetes, Cushing’s and Addison’s disease, osteoporosis, and thyroid disorders. One way to understand the endocrine system is to think of it as the nervous system. The nervous system uses neurotransmitters to communicate and the endocrine system uses hormones.
For women, estrogen is considered the main regulator. Estrogen is not a single hormone. There are three subtypes: estradiol, estriol and estrone. Estradiol is made by the ovaries during the reproductive years; estriol is mainly produced during pregnancy; and estrone is the most predominant estrogen in postmenopausal women. Estrone is made by adipose fat rather than the ovaries. Estrone is not as potent as estradiol, which causes imbalances and symptoms.
Also by Anne O. Rice:
Salivary diagnosis: The 411
Do you really know what oral-systemic means?
Ask most women over 50 and they’ll tell you that during perimenopause and menopause, the decrease in hormones, estrogen, and progesterone causes an imbalance in the body that’s hard to ignore. This includes hot flashes, night sweats, lack of sleep, and a host of other alterations.
But female hormones do much more for a woman’s overall health than these inconvenient truths. The biochemical function of hormones promotes good cardiovascular health, protects bone density and regulates respiratory function. With all the relationships between hormones and overall health, are we missing a connection to oral health?
The most prominent oral discomfort in postmenopausal women is dry mouth or xerostomia. Some women also complain of burning mouth syndrome and altered taste buds. Occasionally, episodes of oral lichen planus may arise.1
Progesterone and estrogen levels seem to be associated with this dry mouth. Not only is there a reduction in salivary flow, but also in its composition. When cortisol levels increase in saliva, it changes the composition of saliva; a 2012 study looking at salivary cortisol levels was checked against dry mouth in postmenopausal women and found a direct relationship.2 It is good for all patients to be on the lookout for symptoms of dry mouth, but it is especially warranted for women going through menopause.
Burning mouth syndrome (BMS)
This syndrome is diagnosed by exclusion after excluding a pathological lesion, vitamin deficiencies, systemic disease such as type 2 diabetes, anemia or hypothyroidism, and autoimmune conditions such as lichen planus or Sjögren’s disease. Medications used for high blood pressure and heart failure such as lisinopril or other ACE inhibitors can cause WNS. If it happens suddenly three to 12 years after menopause, the cause may be just that. Unfortunately, hormone replacement therapy does not seem to help these patients. Antidepressants can be useful for neuropathic pain as well as anticonvulsants such as gabapentin.
This is a conversation you should suggest the patient have with their doctor. BMS can occur with depression and anxiety, but the details of the relationship are unclear.3 Concerns about anxiolytics that calm nerve fibers include dependence and the risk of falling in the elderly, which limits their value. When cortisol levels are high as they are with stress, burning mouth is another problem that can occur.4
Menopausal gingivostomatitis occurs when the gums are dry, shiny and bleed easily. Erasers can vary in color from pale red to dark red. There may also be signs of candidiasis, pemphigus vulgaris, benign mucous pemphigoid, and lichen planus. Autoimmune diseases increase after menopause. Topical antifungal agents such as nystatin may provide relief, depending on the mucosal disorder.
Temporomandibular Joint Disorder (TMD)
Women are twice as likely to develop TMD, and some research suggests the condition may be influenced by hormonal changes.5 Low estrogen levels during menopause predispose TMJ to degeneration and increase alveolar bone loss.6 The effects of estrogen and TMD have been contradictory. However, findings from recent years suggest that low estrogen levels may potentiate certain types of TMD. Menopause is the most common cause of osteoporosis, resulting in reduced bone quality, but the roles of osteoporosis and TMJ bone changes are controversial.7-9
Periodontal disease and bone loss
The American Academy of Periodontology considers osteoporosis a risk factor for periodontal disease. Oral-systemic health is not only what pathogens can do to the body, it is also what the body’s systems can do to the mouth. Osteoporosis affects both men and women of all races, but white and Asian women and older women past menopause are more prone. Bisphosphonates are a group of drugs that are prescribed to help women with their osteoporosis. A side effect is blood loss to the bones, which can cause necrosis.
Here is the double-edged sword: the administration of bisphosphonates in conjunction with scaling and root planing has been shown to be clinically effective.ten Our immune system is one of the most complex systems we have, and as we age, immune activity decreases. Reduced estrogen, progesterone, and testosterone have been attributed to some extent to a decline in immune function, and aging makes us more susceptible to infectious disease.11.12 For example, 10-15% of women over 60 suffer from an increased frequency of urinary tract infections, and this is partly due to changes in the defense system of the urogenital tract. Low estrogen production after menopause has been associated with increased production of interleukin 1 (IL-1), IL-6, IL-8, IL-10, and tumor necrosis factor alpha (TNF1α).13 Then add the compromise of the immune system to fight off periodontal pathogens, and a perfect storm of disease awaits you.
From puberty to postmenopause, each patient’s oral health may be different. Female hormones and their effects can mark transformations in oral health that clinicians need to be aware of to differentiate treatment and recommendations. Six thousand women go through menopause every day, or two million a year. I suspect there are a few in your practice, or perhaps in your own family, who would benefit from a better understanding of their systemic health.
Editor’s note: This article originally appeared in the November 2022 print edition of HDR magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.
- Mohan RP, Gupta A, Kamarti N, Malik S, Goel S, Gupta S. Incidence of oral lichen planus in perimenopausal women: a cross-sectional study in the population of western Uttar Pradesh. J Quarantine health. 2017;8(2):70-74. doi:10.4103/jmh.JMH_34_17
- Agha-Hosseini F, Mirzaii-Dizgah I, Mirjalili N. Relationship between stimulated whole salivary cortisol level and severity of dry mouth sensation in postmenopausal women. Gerodontology. 2012;29(1):43-47. doi:10.1111/j.1741-2358.2010.00403
- Tait RC, Ferguson M, Herndon CM. Chronic Orofacial Pain: Burning Mouth Syndrome and Other Neuropathic Disorders. J Pain Management Med. 2017;3(1):120.
- Amenábar JM, Pawlowski J, Hilgert JB, et al. Anxiety and salivary cortisol levels in patients with burning mouth syndrome: a case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(4):460-465. doi:10.1016/j.tripleo.2007.10.002
- Robinson JL, Johnson PM, Kister K, Yin MT, Chen J, Wadhwa S. Estrogen signaling impacts temporomandibular joint pathology and periodontal disease. Odontology. 2020;108(2):153-165. doi:10.1007/s10266-019-00439-1
- Bueno CH, Pereira DD, Pattussi MP, Grossi PK, Grossi ML. Gender differences in temporomandibular disorders in adult population studies: a systematic review and meta-analysis. J Oral rehabilitation. 2018;45(9):720-729. doi:10.1111/joor.12661
- Bäck K, Ahlqwist M, Hakeberg M, Björkelund C, Dahlström L. Relationship between osteoporosis and radiographic and clinical signs of osteoarthritis/osteoarthritis in the temporomandibular joint: a population-based cross-sectional study in a Swedish population old. Gerodontology. 2017;34(2):187-194. doi:10.1111/ger.12245
- Jagur O, Kull M, Leibur E, et al. Relationship between radiographic changes of the temporomandibular joint and bone mineral density: a population-based study. Stomatology. 2011;13(2):42-48.
- Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(3):349-356. doi:10.1016/j.tripleo.2005.04.010
- Muniz FWMG, Silva BFD, Goulart CR, Silveira TMD, Martins TM. Effect of adjuvant bisphosphonates on the treatment of periodontitis: systematic review with meta-analyses. J Oral Biol Craniofac Res. 2021;11(2):158-168. doi:10.1016/j.jobcr.2021.01.008
- Gavazzi G, Krause KH. Aging and infection. Lancet Infect Dis. 2002;2(11):659-666. doi:10.1016/s1473-3099(02)00437-1
- Giefing-Kröll C, Berger P, Lepperdinger G, Grubeck-Loebenstein B. How gender and age affect immune responses, susceptibility to infection, and response to vaccination. aging cell. 2015;14(3):309-321. doi:10.1111/acel.12326
- Pacifici R. Estrogen, cytokines and the pathogenesis of postmenopausal osteoporosis. J Bone Miner Res. 1996;11(8):1043-1051. doi:10.1002/jbmr.5650110802