Female life expectancy is «S0+ years, therefore many women will live 40% of their lives in menopause. I bis cohort represents a large number of the patients that present in clinical practices. Therefore we must be aware of the implications that reduced hormones have on the periodontal tissues «is well as the systemic changes that may manifest.
Throughout a woman's lifetime, the number of oocytes steadily diminishes. Menopause is associated with symptoms of estrogen deficiency. Estradiol levels fall gradually in the years before menopause. Levels ol thegonadotophins ISII and I II begin to rise, and levels of sex hormones begin to fluctuate. I bis stage of "peri-menopause" is characterized by increasing ovarian unresponsiveness, therefore sporadic ovulation ensues. Anovulatory cycles indicate low estradiol and progesterone because ot absent corpus luteum function.
Important to the clinician is recognition ot the effec t ol hormonal alterations on the oral cavity as well as systemic and psychologic changes. Oral changes in menopause include thinning of the oral mucosa, oral discomfort ("burning mouth"), gingival recession, xerostomia, altered taste sensation, alveolar bone loss, and alveolar ridge resorption.
Fluctuations of sex hormones during menopause have been implicated as factors in inflammatory changes in the human gingiva, hypertrophy, or atrophy. Istrogen affects cellular proliferation, differentiation, and kera-tinization of the gingival epithelium. Hormone receptors have been identified in basal and spinous layers of the epithelium and connective tissue/ implicating gingiva and other oral tissues as targets to manifest hormone de-tidencies. Sex steroids are known to have a direct effect on connective tissue, with estrogens increasing the intracellular fluid content. I strogen deficiency can lead to a reduction in collagen formation in connective tissues, resulting in a decrease in skin thickness."' Alterations in collagen affect tissues such .is joints, hair, nails, and glands. In 1996, Mohammed et al noted significant increased recession in postmenopausal patients with low bone density. 1
Osteopenia and osteoporosis have been associated with the menopausal patient. Osteopenia is a reduction in bone mass due to an imbalance between bone resorption and formation, favoring resorption and resulting in deminerali/ation and osteoporosis. Osteoporosis is a disease characterized by low bone mass and fragility and a consequent increase in fracture risk."1 In most women, peak bone mass oii urs between 20 to AO years of age and declines from this point. Menopause accelerates declining bone mass.8" It is estimated that 25 million Americans are affected with osteoporosis, of whom .80% art.' female. Ongoing studies are examining the association of postmenopausal primary osteoporosis with mandibular/ maxillary bone mineral density, tooth loss, alveolar ridge atrophy, and clinical periodontal attachment loss, l he effects of hormone replacement therapy (IIK1 > or estrogen replacement therapy (UKD on the oral bone and tooth loss is under investigation. Much of the latest evidence points to an probable association between osteoporosis and tooth loss as well as alveolar hone loss/0"'
Clinical Management li is the clinician's responsibility to review the patient's medical history and keep information up to date. Due to possible alterations in oral soft and osseous tissues during perimenopause and postmenopausc. appropriate questioning regarding hormone changes should be performed and documented. A myriad of therapies lor IIKT/I KI lire available, from prescriptions to holistic approaches that need to be followed. Many medications may alter clotting times, prolong other medications, and interfere with absorption or effectiveness ol prescription medications.
If gingival and mucosal tissue thinning occurs, soft tissue augmentation may be performed. Brushing with «in extra-soft toothbrush using the toe or heal of the brush may prevent "scrubbing" the thinning gingiva. Dentifrices with minimal abrasive particles should be used. Rinses should have low alcohol concentrations During periodontal maintenance, root surfaces should be debrided gently with minimal soli tissue trauma. Oral pain may be from thinning tissues, xerostomia, inadequate nutritional intake, or hormone depletion. It has been noted that when patients with oral symptoms were placed on HUT. symptoms were significantly reduced.
II lhe patient is osteoporosis susceptible (menopausal, female, Caucasian or Asian, smoker, minimal physical activity, lowr calcium intake, thin build or low body weight 58 kg. systemic disease associated with predisposition, and genetic history), consult the patient's physician as to the risks versus benefits of I IK I/I K I and calcium/vitamin D supplementation lor the individual patient. Sodium fluoride, biphosphonates (alendronate),
524 PARTS " Treatment ofPeriodontal Disease
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