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How menopause affects oral health, and what we can do about it

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ABSTRACTAfter menopause, women become more susceptible to periodontal disease. We believe the problem is due in large part to estrogen deficiency with resulting bone loss and inflammatory processes. Osteoporosis and periodontal disease are best diagnosed early so that treatment can be started sooner and fractures and tooth loss can be prevented.

KEY POINTS

  • Physicians should be vigilant for dental problems and should encourage their patients to practice good oral hygiene and to seek regular dental care.
  • Available information suggests that hormone therapy and bisphosphonate drugs may be developed to protect against alveolar bone loss and perhaps slow the progression of periodontal disease.
  • Bisphosphonate-associated osteonecrosis of the jaw is rare, and most of the reported cases have been in cancer patients who received high doses of bisphosphonates intravenously and who had other risk factors for it.


 

References

Menopause can bring oral health problems that physicians ought to keep in mind. The same processes that lead to loss of bone in the spine and hips can also lead to loss of the alveolar bone of the jaws, resulting in periodontal disease, loose teeth, and tooth loss. Although the mouth is traditionally the dentist’s responsibility, patients may need encouragement from their physicians to practice good oral hygiene and to see their dentists, and should be referred to a periodontist at the first sign of periodontal disease.

Moreover, bisphosphonates, the class of drugs most often prescribed for osteoporosis, have been linked by case reports (unfairly, we believe) to osteonecrosis of the jaw. This low-evidence-level information, its far-reaching interpretation, and misinformation in the lay media about hormonal changes associated with menopause have led to confusion among women; for clarification and reliable information, they are driven to ask their physicians challenging questions related to oral health.

This article reviews the published studies of the association between menopause and periodontal disease, specifically, the effects of hormonal changes, osteoporosis, and bisphosphonate use on the periodontal status of postmenopausal women. We will highlight the interrelationship of dental health and postmenopausal health and underscore the need for cross-communication and patient referral between physicians and dentists.

GINGIVITIS CAN PROGRESS TO PERIODONTITIS

Figure 1. Red swollen gums of gingivitis.

Gingivitis is a reversible inflammatory response to bacterial plaque buildup that is limited to the gingiva (Figure 1).

Figure 2. Healthy gums and bones (left) vs periodontal disease (right). Note the lower bone height and resulting deeper pockets in periodontal disease.

If unchecked, gingivitis progresses to periodontitis, an inflammation of the supporting tissues of the teeth, including the gingiva, alveolar bone, and periodontal ligament (Figure 2). Periodontitis leads to progressive and irreversible loss of bone and periodontal ligament attachment, as inflammation extends from the gingiva into adjacent bone and ligament. Signs and symptoms of progressing periodontitis include red, swollen gums that may appear to have pulled away from the teeth, persistent bad breath, pus between the teeth and gums (Figure 3), loose or separating teeth, and the common complaint that “my teeth don’t fit together anymore.”

AS ESTROGEN DECLINES, SO DO THE BONES AND, MAYBE, THE TEETH

Figure 3. Red swollen gums with pus in periodontitis.

In menopause, estrogen levels decline rapidly, which can lead to systemic bone loss.1

The rate of bone loss in postmenopausal women predicts tooth loss—for every 1%-per-year decrease in whole-body bone mineral density, the risk of tooth loss increases more than four times.2 In fact, Kribbs3 found that women with severe osteoporosis were three times more likely than healthy, age-matched controls to be edentulous (ie, to have fewer teeth).

Although a number of studies have found that the density of the alveolar bone in the mandible correlated with the density of the bone in the rest of the skeleton and that generalized bone loss may render the jaw susceptible to accelerated alveolar bone resorption,3–11 these findings are not universal. In a longitudinal study, Famili et al12 found no association between systemic bone loss, periodontal disease, and edentulism. This shows that the relationship between alveolar bone loss and systemic bone loss is multifactorial and not yet fully understood.13

Nevertheless, the American Academy of Periodontology considers osteoporosis to be a risk factor for periodontal disease.10 In fact, alveolar bone loss has been related not only to osteoporosis but also to osteopenia.14

Bone mineral density has also been studied in relation to the loss of periodontal ligament—the collagenous attachment of tooth to bone. Klemetti et al15 found that healthy postmenopausal women with high bone mineral density seemed to retain teeth more readily than those with low bone density or those with osteoporosis, even if they had deep periodontal pockets (a sign of periodontal disease). These findings were reiterated when osteoporotic women were found to have significantly greater loss of attachment compared with nonosteoporotic women.7

However, Hildebolt16 reported that loss of tooth attachment correlated with tooth loss but not with the density of the vertebrae or the proximal femur. This study called into question the findings of the previous studies and provoked debate.

Tezal et al17 found that low bone mineral density was related to the loss of interproximal alveolar bone (the alveolar bone between adjacent teeth) and, to a lesser extent, ligamentous attachment loss. These data implicated osteoporosis as a possible risk indicator for periodontal disease in white women. (This study was limited to white women because of different demographics in the incidence of osteoporosis.)

Another study showed only a weak correlation between changes in alveolar bone height (in periodontal disease, bone height decreases) and attachment levels. Although a correlation might be present, the relationship was complex and required further examination. The authors found no clear association between clinical attachment levels and bone mineral density in the lumbar spine, but they recognized that attachment loss often precedes the loss of alveolar bone by a significant time period.13

Several studies have found a possible relationship between the bone density in the jaw and the density in the rest of the skeleton. It appears that loss of bone mineral density in the hip, wrist, and lumbar areas is correlated with low density in the mandible. Taguchi et al18 reported that the density in the lumbar spine correlated with the density of the mandibular cortex in early menopause, and with the density of both the cortex and cancellous bone in later menopause.

But whatever the statistical measurement, the susceptibility to progressive periodontitis increases after menopause, and the primary cause is bacterial plaque. The best hedge against this increased susceptibility is regular dental care to remove bacterial plaque biofilm under the gum-line.

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