HORMONAL

IMBALANCE
Learning outcomes

Appreciate the role of hormones in the oral health of the female

patient
Describe physiological actions of estrogen and progesterone

Relate systemic effects of hormones to oral health

Identify clinical anifestations of female hormonal changes

Develop appropriate preventive and therapeutic dental hygiene care

plans for female patient

Relate female life stages to clinical oral manifestations

FEMALE SEX HORMONES

CLINICAL MANIFESTATIONS

HORMONE REPLACEMENT THERAPY

OSTEOPOROSIS
DENTAL HYGIENE SUPPORTIVE CARE
PLAN
HORMONES
ORAL
HEALTH

? SEX

Effects of hormones on gingivitis

during puberty and pregnancy

showed an exacerbated gingival

response in the presence of bacte

plaque

Role of dental hygienist

Recognizing hormonal effects

Educating the patient regarding management of clinical

manifestations related to hormonal release or hormonal thera

the form of oral contraceptives or hormones replacement

therapy
FEMALE SEX HORMONE-HORMONA
IMBALANCE
Menstrual cycle
• The most common condition associated with hormon
imbalances
Pregnancy
• The female body undergoes many changes duri

result in significant & oral effects

contracep
• Hormonal imbalances similar to those in pregnancy

MENSTRUATION
• Puberty: 9-16 yo
• Cycle 28 days, variation 22-34 days
Secretory
Menstrual phase (days period 15-28)

(days 1-5)
 Ovulation (day 14)
Proliferative phase (days 6-13)

ESTROGEN &
PROGESTERONE
ESTROGEN

The estrogens are steroidal hormones synthesized from cholesterol and produced prima
ovaries, placenta and corpus luteum

Maturation growth and development of the reproductive organs

Stimulation of normal physiological processes of the tubular reproductive tract

Growth of the uterine muscle

Development of the endometrial lining of the uterus

Increase the vascularity of the uterus

Dilation of the cervix, liquefaction of mucous plug

Under the influence of the estrogens the uterus is less susceptible to infection

• Progesterone plays a
role in the maintenance of
PROGESTERON pregnancy (and
E pseudopregnancy) by
• Steroid hormone which is
synthesized from providing a favorable
cholesterol and environment for survival
produced by the corpus of the embryo
luteum
• Progesterone causes growth of the glandular system of the endom
of the uterus, and the secretions from the endometrial glands fo

nutrition of the ovum and the attachment of the embryo

• Progesterone causes growth of the alveolar system of the mamm

gland

• Progesterone inhibits the smooth muscle activity of the uterus - re

it less sensitive to oxytocin.

Effect on oral flora

Changing the microfloraof the gingival sulc

and altering the types of bacteria that g

in plaque
Plaque that is more likely to produce gingiv

disease
Cont’

Dilated capillaries, regulated cellular proliferation,

decreased keratinization, increased vascular permeab
and increased production of gingival crevicular fluid

Increased bleeding response and gingivitis in the abs

of large amounts of bacteria plaque

Cont’ Estrogen & progesterone shown to influence the immune

by
depressing neutrophil chemotaxis and phagocytosis as well as antibody and
responses
Progesterone alters both the rate and the pattern of collagen production alters b
rate and pattern of collagen production in the gingiva, resulting in a reduced abi
repair and maintain the structure of the gingiva

Microbes that allowed to multiply as a result of this effect include gram negative
anaerobes such as Prevotella intermedia, which has the ability to substitute est
progesterone for vitamin K, thereby affecting the individual’s blood clotting activ

An increase in gram negative Capnocytophaga has been documented along wi

intermedia as increasing the bleeding tendency during puberty

CLINICAL MANIFESTATIO
 Bacteria in the
gingival sulcus act
to increase the
bleeding tendency
and result in an
PUBERTY exaggerated
Increased incidence
of gingivitis response to
apparently minor
local irritants

Puberty gingivitis decreases in severity over time bu

does not disappear until local irritants are removed
Chaitra et al.,2012
MENSTRUATION

Patients may not be aware of the correlation between the me

cycle and their periodic episodes of these manifestatio

Evidenced by erythematous swollen gingival tissues, herpes labial

aphthous ulcers (RAS), prolonged hemorrhage after oral surge

swollen salivary glands

reported in 30-100% all
pregnant women,
frequently in the range of
60- 75%

PREGNANC
Y During pregnancy, as
levels of estrogen and
Gingivitis has been progesterone increase,
the periodontal P. increase
intermedia bacteria also
Pregnancy gingivitis manifests in the presence of local irritants with
exaggerated response

Gingival changes are most evident between the second and eight m

Clinically the gingival tissues appear bright red and edematous at the
gingiva and interdental papilla, with an increased bleeding tendency
PREGNANCY
Some women develop a pyogenic granuloma during pregn

This benign lesion sometimes is referred to as a pregnancy

and should be removed surgically so that the tissue can re
health

Pregnancy gingivitis decreases in severity after childbirth, h

gingival inflammation remains until irritants are removed

Khaitan et al., 2018 Rosa et al., 2018

Pyogenic granuloma

Degree of inflammation may

be associated with the

ORAL duration of HRT with more

CONTRACEPTIVES periodontal destruction

Oral effects of these evident if OCs are taken
hormones include two longer than 1,5 years

distinct areas of concern The second effect is an

increased incidence of
localized osteitis after
extraction of mandibular
third molars
The most common effect is an increase in gingival inflammation, simi
seen in puberty and pregnancy gingivitis
This attributed to the effects of esterogen on blood clotting factors

The recommended that extractions be performed between days 23-28

OC cycle because of the lack of estrogen delivered during this time

altered taste sensation,
bone loss, tissue
atrophy, pain, and
sensitivity to hot and
cold

Menopause
Burning mouth A combination of these
syndrome, dry mouth, symptoms has been
menopausal reported in 20-90% of
gingivostomatitis, menopausal and
postmenopausal women

Estrogen replacement therapies appears to alleviate most sym

HORMONES REPLACEMENT THERAP

• Decrease amount of estrogen released by ovarie

puts the individual at risk for osteoporosis &

cardiovascular diseases

• HRT has been used to decrease these risk

• HRT mimics the normal release of hormones

OSTEOP
OROSIS
Effect on maxilla & and eventual tooth
mandibular bone loss
Loss of attachment

DENTAL HYGIENE
SUPPORTIVE CARE PLAN

Patient should be
informed of possible
Must be prepared to symptoms and the role of
develop effective care hormones in the disease
plans to meet these process
special needs Must assess for an
Thorough periodontal
exaggerated response
examination must be
completed, including to local irritants with
gingival assessment, resulting gingivitis
evaluation of bleeding Must assess for an
response, and periodontal
probing exaggerated response

to local irritants with

 resulting gingivitis the patient taking OC as
well as during certain
times in the menstrual
cycle
The scheduling of oral
23-28 to avoid osteitis
surgery procedures is
23-28 to avoid osteitis
important to consider for

DENTAL HYGIENE SUPPORTIVE CARE PLAN

Dental hygienist must recognize the systemic cond

and educate patient about the oral effect

Protheses → proper fit an d prevention of sore spo

Identifying causative factors for a wide range of or

manifestations → educate the patient