For the most part, the loss of periodontal attachment and supporting bone is relatively uncommon in children but the incidence increases in adolescents aged 12 to 17 when compared to children aged 5 to 11, this may be due to hormonal changes related to puberty. Enhanced levels of gingival inflammation without increased levels of plaque accumulation occur in children at puberty. Increase in the levels of estrogen and progesterone in the gingival tissues result in vasodilatation and proliferation, increase in gingival vascularity, and increase in susceptibility of inflammation in the presence of local factors. Contrarily, the loss of estrogen during menopause also has an effect on periodontal health.
Puberty is a complex process of sexual maturation resulting in an individual capable of reproduction, induces changes in physical appearance and behavior that is the direct result of increases in sex steroid hormones, primarily testosterone in males and estradiol in females. These hormones exert their effects on different tissues wherever their receptors are present.
The relationship between elevated levels of circulating sex hormones and prevalence of gingivitis in puberty is strengthened by the observation that, during adolescent, gingivitis peaks earlier in girls (12-13 years) than in boys (13-14 years). The current periodontal disease classification describes Puberty-Associated Gingivitis as having susceptibility towards developing clinical signs of inflammation with relatively small amounts of bacterial plaque present during this period. Gingival inflammation during puberty is not related to increase in plaque levels. Normal and abnormal fluctuation in hormone levels, including changes in gonadotrophic hormone levels during the onset of puberty, can modify the gingival inflammatory response to dental plaque. The cytoplasm of gingival cells contains specific high affinity, low capacity receptors for both estrogens and testosterone. Estrogen receptors are found in the basal and spinous layers of the epithelium and in fibroblasts and endothelial cells of small vessels in the connective tissue. Thus, gingiva appears to be a target organ for some of the steroid hormones.
Pubertal gingivitis is characterized by swelling of the interdental papilla, with spontaneous gingival bleeding. The most common symptoms in young patients include bleeding and inflammation of the gums at the embrasure between two adjacent teeth. The gum tissue exhibits changes in color, size and consistency. Generally, the margin of the gum tissues shows a linear reddish coloration associated with the gum inflammation.
In most of the cases of enlargements associated with puberty, a conventional periodontal therapy comprising of scaling and root planing is sufficient to treat the condition.However, in some cases where there is more amount of fibrotic tissue along with the inflammatory component, the inflammation can get subsided with conventional scaling and root planing but the fibrotic component that persists after scaling has to be removed by surgical means. Gingivectomy is the treatment of choice in such cases, and it can be performed by a conventional method with a scalpel or periodontal knives, Electro surgery, LASER, etc.
Contrary to puberty, during menopause, the female cycle of hormone fluctuation of circulating estrogens ceases. Menopause refers to the permanent cessation of menstruation owing to loss of the ovarian follicular activity. A diagnosis of natural menopause is made retrospectively following 12 months of amenorrhea with no pathologic association. Menopause may however be artificially induced by radiation, surgery, and chemotherapy.
Women can experience a sudden bone loss increase in the first decade after the onset of menopause as estrogen levels decline. In fact, women can lose up to 20% of their bone mass in the 5–7 years after menopause. Lower estrogen levels affect bone metabolism and also affect the oral cavity, causing inflammatory changes in the body that can lead to gingivitis. Systemic osteoporosis leading to generalized bone loss may make the jaws susceptible to advanced alveolar bone loss, decreased bone mineral density (BMD) of alveolar crest/subcrestal alveolar bone and to a smaller extent ligamentous attachment loss.The exact relationship between osteoporosis, periodontal pathosis and edentulism remains however controversial.
Hyposialia, xerostomia or dryness of mouth is yet another symptom frequently manifested by menopausal women. Although few studies conclude that salivary flow decreases in menopausal women with increase in salivary IgA and total proteins, others have not been able to delineate any alterations in salivary volume/composition. Some studies further implicate decreased salivary flow as a cause for increased incidence of root caries, oral discomfort, taste alterations, oral candidiasis, and periodontal disease in menopausal women.
One other common oral manifestation in menopausal women is Burning Mouth Syndrome (BMS), although there is no proven correlation. Burning mouth syndrome also known as glossodynia, stomatodynia, stomatopyrosis, glossopyrosis, glossalgia represents a common oral abnormality that manifests as intense pain and spontaneous burning sensation affecting various areas of the oral cavity in the absence of any identifiable organic abnormalities. It is chiefly bilateral and affects the tongue, lips, palate, gingival, and areas of denture support.
Other oral mucosal changes, due to menopause, may thus range from a condition referred to as “menopausal gingivostomatitis” to an atrophic pale appearing mucosa.Menopausal gingivostomatitis is characterized by gingiva that bleed readily, with an abnormally pale dry/shiny erythematous appearance.
The postmenopausal symptoms may unfavorably affect oral health and the dental health care providers need to be aware of the symptoms and health care needs of menopausal/postmenopausal women. The oral changes observed at menopause are mostly related to hormonal changes although a physiological aging of the oral tissues also plays a contributing role in it.
The underlying etiology of BMS remains unclear with hormonal changes and small-fiber sensory neuropathy of the oral mucosa suggested as possible underlying causes . Variable results have been obtained following treatment of BMS in menopausal women with HRT and psychological counseling. Low dosages of clonazepam, chlordiazepoxide and tricyclic antidepressants have been found to be beneficial in management of BMS. Evidence also supports the utility of a low dosage of gabapentin. No benefit has been seen from treatment with selective serotonin reuptake inhibitors.
Xerostomia associated with postmenopausal women can be countered with frequent sipping of water, artificial salivary substitutes, sugar free-gums/lozenges, xylitol tablets and sialogogues such as pilocarpine, bromhexine, cevimeline, and bethanecol can be included in the management of xerostomia. Chlorhexidine rinses can also help reduce the incidence of caries.
Systemic bone loss may be a risk indicator for periodontal destruction, and augmented rates of bone mineral density loss after menopause are coupled with greater risk of tooth loss. A number of studies have shown that bone changes in osteoporosis are associated with loss of periodontal attachment, loss of teeth, and height of residual ridge. Based on these findings, it has been hypothesized that osteoporosis may be a risk factor for the progression of periodontitis. Both the entities, osteoporosis and periodontitis, in fact, are bone resorptive diseases sharing common etiologic agents/risk factor that may either modulate or alleviate the process of both diseases. Therefore, avoidance and management of osteoporosis after menopause could also have enhanced future oral health consequences.
Apart from regular oral hygiene recalls and strict and meticulous oral hygiene maintenance, it has been found that estrogen therapy can be helpful in building up mandibular bone mass and diminishing the severity of periodontal disease [33]. Bisphosphonates, particularly Risedronate and Alendronate, have been beneficial in preventing systemic bone resorption and decreasing the incidence of vertebral fractures in postmenopausal women, also they have been found effective in improving periodontal status. Recent study by Bhavsar et al., found that bisphosphonate therapy, when used as an adjunct to scaling and root planing, may have beneficial effects on periodontium of postmenopausal women with moderate or severe chronic periodontitis. Some cases have also been associated the use of bisphosphonates to occurrence of osteonecrosis of jaw, though the chances are rare as the dosage of bisphosphonates are administered orally as compared to its use intravenously in multiple myeloma or metastatic bone disease.