Periodontology
HISTOPATHOLOGY OF MARGINAL SUPERFICIAL
PERIODONTIUM AT MENOPAUSE
1. Assist. Prof, Dept of Periodontology, Faculty of Med Dent, „Carol Davila” U.M.Ph., Bucure[ti
2. Prof. PhD., „Carol Davila” U.M.Ph., Bucure[ti, Corresponding member of the Academy of Medical Sciences of Romania
Corresponding author: Alexandru Georgescu alexg22@yahoo.com
Abstract
Premises: Sexual hormones may affect the general
health condition of women, as early as puberty, continu-
ing during pregnancy and also after menopause. Varia-
tions of the hormonal levels may cause different – either
local or general – pathological modifications. Sexual hor-
mones may also affect periodontal status, favourizing
gingival inflammations and reducing periodontal re-
sistance to the action of the bacterial plaque.
Scope: Establishment of the correlations between the
debut or the manifestation of menopause and the modifi-
cations produced in the superficial periodontium.
Materials and method: Clinical and paraclinical in-
vestigations were performed on female patients with ages
between 45 and 66 years, involving macroscopic, micro-
scopic and radiological recording of the aspect of the
superificial periodontium (gingiva).
Results: Analysis of the histological sections evidenced
atrophic and involutive modifications in the marginal
superficial periodontium of female patients at meno-
pause.
Conclusions: Sexual hormones intervene in the histo-
logical equilibrium of the marginal superficial periodon-
tium, influencing the periodontal health status, which
explains the correlation between the subjective sympto-
matology specific to menopause and the histopatological
aspect at epithelial level.
Keywords: sexual hormones,menopause, marginal super-
ficial periodontium
INTRODUCTION
Sexual hormones may affect the general
health condition of women, as early as puberty,
continuing during pregnancy and also after
menopause. Variations of the hormonal levels
may cause different pathological – either local or
general – modifications. Sexual hormones may
also affect periodontal status, as favourizing
gingival inflammations and reducing periodon-
tal resistance to the action of the bacterial plaque
[1].
In the women in whom menopause was not
still installed, the main circulating hormone is
International Journal of Medical Dentistry
A. Georgescu1 , H.T. Dumitriu2
17 – estradiole. As women approach the age of
menopause, the levels of estrogens are decreas-
ing, preponderently in the folicular and luteal
stages of the menstrual cycle, the result of such
physiological condition being the installation of
irregular cycles. Usually, the interval between
the occurrence of irregular cycles and their total
disappearance, lasting between 2-7 years, is
known as the perimenopause period. Along this
period, the concentration of circulating estrogen
decreases, while the FSH and LH concentrations
increase [2]. At the same time, the effects of
estrogens upon the periodontium, listed in the
table below, are quite reduced, which diminishes
the anti-inflammatory effect of this hormone
upon the periodontium [1.2]
EFFECTS OF ESTROGENS UPON PERIODONTIUM
Increased plaque amount, without subsequent
inflammation
Inhibition of pro-inflammatory cytokines’
release by the medular cells
Reduction of the inflammation mediated
by lymphokycites T
Inhibition of leukopoesis
Inhibition of PMN chemotactism
Stimulation of PMN phagocytosis
Progesterone is another sexual hormone playing
an important role in bone metabolism during
pre- and post-menopause periods. Literature
data [3,4] showed that the ovarian secretory defi-
cit and the related disorders are, more than the
age, the main causes of the bone mass losses
along the first two post-menopause decades. The
investigations made showed that progesterone
competes with the glucocorticoides for a certain
receiver from the osteoblaste surface, inhibiting
the osteoporosis induced by glucocorticoides.
That is why, DMO post-menopause reduction
may be the result of a combination between
63
A. Georgescu, H.T. Dumitriu
stimulation of osteoclastes’ activity, by the low
estrogen level, and inhibition of osteoblastes,
mediated by cortisole, through reduction of the
competition with progesterone.
EFECTS OF PROGESTERONE UPON PERIODONTIUM
Stimulation of prostaglandine synthesis
Stimulation of PMN and PGE2
Reduction of the anti-inflammatory effect
of glucocorticoides
Alteration of colagen and of non-colagenic
proteins’ synthesis
Alteration of fibroblastes’metabolism
Increase of vascular permeability
Menopause also affects the concentration of
circulating androgens. Prior to menopause, 50%
of the circulating androstendione is produced
by ovaries and 50% by the medulosuprarenal
gland [5]. When menopause is installed, as a re-
sult of the ovarian insufficiency characteristic to
this period, plasmatic concentration will de-
crease with 50%. It has been suggested that the
process of peripheric conversion of androgens
into estrogens might be the main factor of bone
protection, as long as it had been demonstrated
that estrogens have an inhibiting effect upon
osteoclastes. [5]
EFFECTS OF ANDROGENS UPON THE PERIODONTIUM
Stimulates the synthesis of the bone matrix
by osteoblastes
Stimulates the fibroblastes from the periodontal
ligament
Stimulates differentiation and proliferation
of osteoblastes
Reduces the synthesis of IL-6 in inflammations
Inhibits secretion of prostaglandines
Increases the concentration of osteoprotegerine (OPG)
Testosterone is also involved in the equilibrium
of bone density, as shown by the low concentra-
tion of this hormone in the blood of the patients
suffering from osteoporosis. [6-8]
MATERIALS AND METHOD
The experimental group was formed of
women at menopause, selected among the pa-
tients having addressed the Periodontology
Department of the ”Dan Theodorescu” Hospital
of Bucharest, for periodontal investigations and
64
treatment. The patients, with ages between 45 and
66 years, suffered of no other general associated
diseases, such as diabetes, hepatic or renal prob-
lems, metabolic bone maladies, cancer. Also, the
patients declared that they do not follow any
substitution hormonal treatment and gave their
consent for being included in the study.
After a detailed anamnesis, registering sev-
eral aspects on the debut and history of the dis-
ease, personal physiological and pathological
antecedents, as well as the heredo-colateral ones,
a minute clinical examination of the oral cavity
followed, for evidencing the signs related to the
installation of menopause and the manifestation
of some involutive and distrophic modifications.
Clinical (determination of the indices of peri-
odontal health, measurements of the degree of
gingival recession and depth of the periodontal
pockets, testing of dental mobility) and para-
clinical investigations (retro-alveoloary and pa-
noramic radiographies) were performed for a
correct establishment of the diagnosis and for
the elaboration of the treatment plan, including
registering of the macroscopic, microscopic and
radiological aspect of the superficial periodon-
tium (gingiva). Taking over of the bioptical
pieces was made during interventions of gin-
gival debridement and subgingival curettage at
the level of the inter-dental papillae. The sam-
ples were fixed in 10% buffered formaldehyde,
with neutral pH. After processing and inclusion
in paraffin, the samples were sectioned at micro-
tome, into 2m sections, and coloured.
The colourations presented below were em-
ployed for evidencing the epithelial morphology
specific to this period. Out of them, a representa-
tive case was selected for discussion.
Usual colorations Special colorations
Van Gieson, where
Hematoxyline – eosyne, colour  the nuclei appear black
 the nuclei – blue  collagene – red
 basophilic elements – red
 acidophilic elements – Gömöri- silver impregnation
orange nuclei appear oxidated
reticulin fibers – black
collagene – brown.
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 HISTOPATHOLOGY OF MARGINAL SUPERFICIAL PERIODONTIUM AT MENOPAUSE

RESULTS AND DISCUSSION

Gingivitis and gingivostomatitis induced by

menopause, or the ‘atrophic senile gingivitis’, as
also known, is not a normal pathological case of
the climacterium, as it is installed only in certain
cases of physiological or surgically-induced
(hysterectomy, ovarectomy) menopause. [9]
Subjectively, the patient complains of a sensa-
tion of dry mouth and burning at the level of the
oral mucous membrane, of painful sensations on Fig. 1. Clinical aspect frontal norm
contact with cold or hot aliments or beverages.
Another symptom is an altered perception of the
sour and salty tastes [10,11]. A systematization
of the oral manifestations accompanying meno-
pause is provided in Table 1 [12].

Table 1

ORAL MANIFESTATIONS AT MENOPAUSE

Oral disconfort

pain

burning sensations Fig. 2. Lateral clinical aspect

modification of the gustative sensations
(salty, hot, sour)

xerostomy
Modifications of the oral mucous membrane
1. gingival atrophy
2. menopause gingivostomatitis
Osteoporosis

accelerated bone atrophy

severe osteoporosis – rapid loss of teeth and
atrophy of the residual edentulous ridge

may affect the severity of the pre-existing
periodontopathy
Fig. 3. Vestibular aspect of the gingiva
Objectively, it was observed that the gin-
gival and oral mucous membrane had a smooth,
dry aspect, pale in colour, here and there – in the
zones in which additional inflammation was
visible – reddish. Also, some fissures were ob-
served here and there.
Figures 1-4 illustrate some objective aspects
of the fixed gingiva, of the free gingival margin
and of the inter-dental papillae, in frontal, la-
teral and horizontal plane. Mention should be
made of the characteristic aspect of the gingiva,
with signs of distrophy. Fig. 4. Palatinal aspect of the gingiva

International Journal of Medical Dentistry 65

A. Georgescu, H.T. Dumitriu
Figure 5 shows the situation of the deep peri-
odontium, especially of the alveolary bone, the
aspect of the interdental and inter-radicular
septum being flattened, resorbed, which indi-
cates a generalized horizontal atrophy.
The phenomenon may be especially observed
for the frontal maxillary teeth, yet suggestive
aspects may be also observed in the frontal man-
dibular region.
At levels 37, 38, as a consequence of the
involution process, some vertical demineraliza-
tion, vertical resorption and occurrence of a real
periodontal pocket of about 6mm may be no-
ticed.
Taking over of the bioptic sample during the
subgingival curettage performed at this level
was made from this area. The intervention was
justified by the presence of the inflammatory
pathology at this level, of the periodontal pocket
and of the subjective symptomatology.
Analysis of the biopsy punch is presented in
the following.
Fig. 5. Radiological aspect
Fig. 6. Histopathological aspect of
the gingival papilla
66
Fig. 7. Van Gieson colouration
Figure 6 presents a portion of an inter-dental
papilla, in HE colouration. One should observe
the microscopic architecture of the epithelium
with artrophic phenomena, and the presence of
an infiltrate with PMN in the chorione. The
inflammating infiltrate is better seen in the fol-
lowing image (fig. 7), being evidenced by the
specific Van Gieson colouration, where the
collegene fibers of the chorione appear in red,
intercalated with the cells migrated from the
vascular bed.
The reticulin fibers situated in the deep
chorione were evidenced through silver impreg-
nation (fig. 8)
The cell stroma appears poor, the amount of
basic substance is increased, fibroblastes are
atrophic, while the limphocytes show degenera-
tive lesions.
At the level of the gingival chorione, groups
of cells with deficit of cytoplasma with hetero-
chromatic nuclei may be observed.
Fig. 8. Silvery impregnation (Gömöry)
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 HISTOPATHOLOGY OF MARGINAL SUPERFICIAL PERIODONTIUM AT MENOPAUSE
CONCLUSIONS
1. Sexual hormones intervene in maintaining
the histological equilibrium of the marginal
superficial periodontium, influencing the
periodontal health condition and explain-
ing the correlation between the subjective
symptomatology specific to the menopause
and the histopatological aspect at epithe-
lial level.
2. At the same time, they play an important
role in the prevention or treatment of the
periodontal maladies caused by meno-
pause, by slowing down the advance of the
disease, thus favourizing its curing.
The clinician should be informed on the spe-
cific characteristics of this type of patients, for
the elaboration of a suitable treatment plan, in-
sisting upon the regenerative aspects and on the
prevention of distrophic phenomena.
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