Midlife transitions and oral health

The endocrine system is a hard worker. It is a collection of glands that produce hormones regulating sleep, mood, metabolism, growth, tissue, and sexual function. Major glands of the endocrine system are the pineal gland, pituitary gland, thyroid and parathyroid glands, adrenal glands, pancreas, thymus, ovaries, and testes.

Common diseases of the endocrine system include type 1 and type 2 diabetes, Cushing’s and Addison’s diseases, osteoporosis, and thyroid disorders. A way to understand the endocrine system is to think of it like the nervous system. The nervous system uses neurotransmitters to communicate, and the endocrine system uses hormones.

For women, estrogen is considered the master regulator. Estrogen isn’t a single hormone. There are three subtypes: estradiol, estriol, and estrone. Estradiol is made by the ovaries during the reproductive years; estriol is mostly 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 nearly as potent as estradiol, which is what causes imbalances and symptoms.

Also by Anne O. Rice:

Salivary diagnostics: The 411

Do you really know what oral-systemic means?

Ask most women over 50 and they will share that during perimenopause and menopause, the decrease in hormones, estrogen, and progesterone causes an imbalance in the body that’s hard to miss. This includes hot flashes, night sweats, poor sleep, and a host of other alterations.

But female hormones do a whole lot more in a woman’s overall health than those 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 any connection with oral health?

Xerostomia

The most significant oral discomfort in women going through menopause is oral dryness or xerostomia. Some women also complain of burning mouth syndrome and altered taste buds. Occasionally bouts with oral lichen planus can rear their head.¹

Progesterone and estrogen levels seem to be associated with that oral dryness. Not only is there a reduction in salivary flow, but also in composition. When cortisol levels increase in the saliva, it changes the composition of the saliva; a 2012 study investigating salivary cortisol levels were checked against oral dryness in postmenopausal women and found a direct relationship.² It’s good for all patients to be on the lookout for symptoms of dry mouth, but it’s especially warranted for women in their menopausal years.

Burning mouth syndrome (BMS)

This syndrome is diagnosed by exclusion after ruling out 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. Medications used for high blood pressure and heart failure such as lisinopril or other ACE inhibitors can cause BMS. If it is suddenly happening three to 12 years after menopause, the cause may simply be that. Unfortunately, hormone replacement therapy doesn’t seem to help these patients. Antidepressants can be helpful with neuropathic pain as well as anticonvulsants such as gabapentin.

That’s a conversation you should suggest the patient have with their physician. BMS can arise with depression and anxiety, but the particulars of the relationship are unclear.³ Concerns with anxiolytics that calm nerve fibers include addiction and fall risk in the elderly, limiting their value. When cortisol levels are elevated as they are with stress, burning mouth is another issue that may occur.⁴

Mucosa

Menopausal gingivostomatitis is when the gums are dry, shiny, and bleed easily. Gums can range in color from pale to deep red. There also may be signs of candidiasis, pemphigus vulgaris, benign mucosal pemphigoid, and lichen planus. Autoimmune disorders 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 that the condition may be influenced by hormone changes.⁵ Low levels of estrogen during menopause predisposes the TMJ to degeneration and increases alveolar bone loss.⁶ The effects of estrogen and TMD have been contradictory. However, in recent years results suggest that low levels of estrogen may potentiate certain types of TMD. Menopause is the most common cause of osteoporosis, resulting in the reduction of bone quality—but the roles of osteoporosis and TMJ bone changes are wrought with controversy.^7-9

Periodontal disease and bone loss

The American Academy of Periodontology considers osteoporosis a risk factor for periodontal disease. Oral-systemic health isn’t just what pathogens can do to the body—it’s also what the body systems can do to the mouth. Osteoporosis affects both men and women of all races, but white and Asian women and older women who are past menopause are more prone. Bisphosphonates are a group of drugs that are prescribed to help women with their osteoporosis. A side effect is the loss of blood to the bone, which can cause necrosis.

Here is the double-edged sword: the administration of bisphosphonates in conjunction with scaling and root planing showed come clinical efficacy.¹⁰ Our immune system is one of the most complex systems we have, and as we age, immune activity declines. Estrogen, progesterone, and testosterone reduction have been attributed to some degree to a decline in immune function, and growing older gives us a larger susceptibility to infectious disease.^11,12 As an example, 10%-15% of women over 60 suffer from increased frequency of urinary tract infections, and this is partially due to the changes in the defense system of the urogenital tract. Low estrogen production postmenopause 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 immune system compromise that must fight the periodontal pathogens, and a perfect storm of disease awaits.

From puberty to postmenopause, every female patient’s oral health can be different. Women’s hormones and their effects can mark oral health transformations that clinicians need to know to differentiate treatment and recommendations. Six thousand women enter menopause every day—that’s two million per year. I would suspect there are a few in your practice, or perhaps in your own family, who would benefit from a greater understanding of their systemic health.

Editor's note: This article appeared in the November 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Mohan RP, Gupta A, Kamarthi N, Malik S, Goel S, Gupta S. Incidence of oral lichen planus in perimenopausal women: a cross-sectional study in Western Uttar Pradesh population. J Mid-life Health. 2017;8(2):70-74. doi:10.4103/jmh.JMH_34_17

2. Agha-Hosseini F, Mirzaii-Dizgah I, Mirjalili N. Relationship of stimulated whole saliva cortisol level with the severity of a feeling of dry mouth in menopausal women. Gerodontology. 2012;29(1):43-47. doi:10.1111/j.1741-2358.2010.00403

3. Tait RC, Ferguson M, Herndon CM. Chronic orofacial pain: burning mouth syndrome and other neuropathic disorders. J Pain Manag Med. 2017;3(1):120.
   

4. Amenábar JM, Pawlowski J, Hilgert JB, et al. Anxiety and salivary cortisol levels in patients with burning mouth syndrome: 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
   

5. Robinson JL, Johnson PM, Kister K, Yin MT, Chen J, Wadhwa S. Estrogen signaling impacts temporomandibular joint and periodontal disease pathology. Odontology. 2020;108(2):153-165. doi:10.1007/s10266-019-00439-1
   

6. Bueno CH, Pereira DD, Pattussi MP, Grossi PK, Grossi ML. Gender differences in temporomandibular disorders in adult populational studies: a systematic review and meta-analysis. J Oral Rehabil. 2018;45(9):720-729. doi:10.1111/joor.12661
   

7. Bäck K, Ahlqwist M, Hakeberg M, Björkelund C, Dahlström L. Relation between osteoporosis and radiographic and clinical signs of osteoarthritis/arthrosis in the temporomandibular joint: a population-based, cross-sectional study in an older Swedish population. Gerodontology. 2017;34(2):187-194. doi:10.1111/ger.12245
   

8. Jagur O, Kull M, Leibur E, et al. Relationship between radiographic changes in the temporomandibular joint and bone mineral density: a population based study. Stomatologija. 2011;13(2):42-48.
   

9. 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
   

10. Muniz FWMG, Silva BFD, Goulart CR, Silveira TMD, Martins TM. Effect of adjuvant bisphosphonates on 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

11. Gavazzi G, Krause KH. Ageing and infection. Lancet Infect Dis. 2002;2(11):659-666. doi:10.1016/s1473-3099(02)00437-1

12. Giefing-Kröll C, Berger P, Lepperdinger G, Grubeck-Loebenstein B. How sex and age affect immune responses, susceptibility to infections, and response to vaccination. Aging Cell. 2015;14(3):309-321. doi:10.1111/acel.12326
    

13. Pacifici R. Estrogen, cytokines, and pathogenesis of postmenopausal osteoporosis. J Bone Miner Res. 1996;11(8):1043-1051. doi:10.1002/jbmr.5650110802