ADVERTISEMENT

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

Cleveland Clinic Journal of Medicine. 2009 August;76(8):467-475 | 10.3949/ccjm.76a.08095
August 1, 2009|Cleveland Clinic Journal of Medicine
Maria Clarinda A. Buencamino, MD;Leena Palomo, DDS, MSD;Holly L. Thacker, MD, CDD
Author and Disclosure Information

Maria Clarinda A. Buencamino, MD
Women’s Health Institute, Cleveland Clinic

Leena Palomo, DDS, MSD
Assistant Professor of Periodontology, Director of Predoctoral Periodontics, Case Western Reserve University School of Dental Medicine, Cleveland, OH

Holly L. Thacker, MD, CDD
Director, Center for Specialized Women’s Health, Women’s Health Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Maria Clarinda A. Buencamino, MD, Internal Diagnostic Department, E13, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail buen-cam@ccf.org

Dr. Palomo has disclosed that she has received honoraria for speaking and teaching from Procter and Gamble.

Dr. Thacker has disclosed that she has received honoraria for speaking and teaching from Bayer, Novartis, Procter and Gamble, Sanofi-Aventis, Ther-Rx, Upsher-Smith Laboratories, and Wyeth companies, and the Alliance for Better Bone Health.

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.

HORMONE THERAPY PRESERVES BONE IN THE JAW

Hormones have long been recognized as having some role in periodontal disease.

Payne et al19 reported that postmenopausal women who were estrogen-deficient had a higher frequency of sites with a net loss of alveolar bone density at follow-up. Furthermore, estrogen-deficient women undergoing supportive periodontal therapy following treatment of moderate to severe periodontitis had three times as many sites losing more than 0.4 mm of interproximal alveolar bone height. Patients who had sufficient estrogen levels did not lose bone during 1 year of follow-up.20

Estrogen replacement improves bone density in postmenopausal women. In a 3-year randomized trial in postmenopausal women with moderate or advanced periodontal disease, estrogen therapy significantly increased alveolar bone mass compared with placebo (P = .04), and it increased bone density in the femur but not the lumbar spine.21 Furthermore, women receiving hormonal therapy had significantly less gingival inflammation, lower plaque scores, and less loss of attachment.

On the other hand, a report by Albandar and Kingman22 suggested that women who comply with hormonal therapy also comply with oral hygiene instructions. This compliance could explain the lower gingival inflammation scores, lower plaque scores, and lesser loss of attachment.

Norderyd et al,23 in a cross-sectional study, found less periodontal disease in postmenopausal women who were on estrogen therapy than in those who were not, although the difference was not statistically significant.

In a 5-year longitudinal study of 69 postmenopausal women receiving estrogen, a moderate but significant relationship was found between bone mineral density of the lumbar spine and the mandible, and estrogen replacement therapy had a positive effect on the mandibular bone mass.24

In a longitudinal study of 24 postmenopausal women, estrogen-deficient women had a mean net loss of alveolar bone density over time, while estrogen-sufficient women had a mean net gain, suggesting that estrogen deficiency may be a risk factor for alveolar bone loss.20 More-recent studies had similar findings. A cross-sectional study by Meisel et al25 found that hormone therapy significantly reduced the extent of clinical attachment loss and, hence, periodontal disease.

The findings of these studies are generally consistent, suggesting that estrogen builds up mandibular bone mass and attenuates the severity of periodontal disease in postmenopausal women.26

DOES ESTROGEN THERAPY PROTECT THE TEETH?

Studies of the Leisure World,27 Framingham,28 and Nurses Health Study29 cohorts suggest that hormone therapy protects against tooth loss in postmenopausal women.

On the other hand, Taguchi et al30 evaluated more than 300 postmenopausal Japanese women and found no significant difference in the total number of teeth between estrogen users and nonusers. The population in this study was younger than in the other studies mentioned above,27–29 which may explain the negative finding. However, the duration of estrogen use was significantly associated with the total number of teeth remaining, independent of age.30 Meisel et al25 reported that women receiving hormonal therapy had more teeth, though the difference was not significant.

CYTOKINES, PERIODONTITIS, AND SKELETAL BONE LOSS

Studies suggest that low estrogen production after menopause is associated with increased production of interleukin 1 (IL-1), IL-6, IL-8, IL-10, tumor necrosis factor alpha, granulocyte colony-stimulating factor, and granulocyte-macrophage colony-stimulating factor, which stimulate mature osteoclasts, modulate bone cell proliferation, and induce resorption of both skeletal and alveolar bone.31–34

Based on Genco RJ, et al. Is estrogen deficiency a risk factor for periodontal disease? Compend Contin Educ Dent Suppl 1998; 22:S23–S29.
Figure 4. Proposed model for how estrogen deficiency contributes to severe periodontal disease.
Genco and Grossi26 have proposed a model for estrogen deficiency as a risk factor for periodontal disease (Figure 4). In this model, estrogen deficiency leads to more production of bone-resorbing cytokines produced by immune cells (monocytes and macrophages) and osteoblasts. When challenged by products related to periodontal bacterial plaque biofilm, by bone-resorbing factors such as lipopolysaccharides, and by toxins, the host immune system produces more inflammatory cytokines that activate osteoclasts, which reabsorb bone. The buildup of bacterial plaque biofilm made up of periopathogenic bacteria35 seems to be necessary for an estrogen-deficient woman to actually show changes such as loss of tooth attachment and alveolar bone. The host’s inflammatory response to this biofilm starts the inflammation cascade and may lead to constant activation of tissue proteinases and degradative enzymes, leading to connective tissue destruction, alveolar bone resorption, and ultimately tooth loss, which can explain the increased risk of periodontal disease in postmenopausal women.26,3

In this regard, osteoporosis and periodontitis appear to be mediated by common cytokines. Managing osteoporosis, removing bacterial plaque biofilm with good oral hygiene, and regular dental visits are important in avoiding periodontitis in susceptible women.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT