How Menopause affects Oral Health?

Menopause marks the end of the fertile span of a woman. Natural menopause has been defined by the World Health Organization (WHO) as at least 12 consecutive months of amenorrhea, not due to surgery or any other cause.

Menopause is not only associated with the cessation of monthly cycle and flow. It does affect the overall body of postmenopausal women, both physically and psychologically and the oral cavity is not an exception to this. Not only menopause but puberty, menses, pregnancy have a varied influence on women’s oral health. During the menopause women, sex steroid hormone production is drastically reduced, affecting their health. As oral mucosa and salivary glands also contain estrogen receptors, fluctuations in the hormone levels directly affect the oral cavity too.

Common Symptoms associated with Menopause

• Hot flashes (Most common)
• Irritation, Anxiety and mood swings
• Insomnia
• Fatigue
• Night Sweats
• Sleeping problems
• Emotional and cognitive symptoms
• Vaginal itching and dryness
• Urinary symptoms

Factors that affect the age at Onset of Menopause

Loss of fertility and journey toward the menopause goes slowly and steadily. Each month, some part of fertility is lost along with the monthly cycle.  Generally, menopause commences in the fourth decade of life, but there is no discrete age of menopause, after all, biology is the science of exceptions and when it comes to human body, it is under the influence of many factors which determine the cessation of monthly periods.

• Onset age of menopause is defined as “early menopause” when menopause commences before the age of 40.
• Early onset of menopause is associated with long-term health risks, including cardiovascular disease and premature death.

Body mass index

Overweight woman compared to thin woman, experience menopause later in life with fewer climacteric symptoms (symptoms before the actual arrival of menopause) due to the availability of estrogen in adipose tissues.

Dietary factors

High consumption of polyunsaturated fats accelerates the onset of menopause while high consumption of total calories, fruits and protein delays menopause.

Personnel and Family history

Women whose mothers entered menopause at an early age are at high risk of the early arrival of menopause.

Women with hypertension and low exposure to the sun throughout the life enter menopause at earlier ages.

Women who undergo a unilateral oophorectomy ( surgical removal of one ovary) enter menopause at an earlier age than women.

A high serum ferritin level and a low bone mineral density may be the causes of early menopause.

Parity

Women without any progeny experience early menopause. While women who bore multiple progenies are related to late menopause. Having the first pregnancy at a later age has been associated with a later menopause onset.

Menarche (beginning of the monthly cycle)

Girls who had their periods at an early age shall face early menopause. Irregular periods are also associated with early onset of menopause.

Previous oral contraceptive use

The use of oral contraceptives has been associated with late menopause.

Smoking, drinking alcoholic beverages

Smoking may cause early cessation of fertility period. As per studies, smoking 14 or more cigarettes a day enter menopause 2.8 years earlier than women who do not smoke. Immediate and long-term effects of alcohol are different in male and female. Females have a lower level of dehydrogenase enzymes – Alcohol breaking enzyme. Moreover, the female body has higher fat/water.

Physical activity

While heavy physical activity is associated with early menopause light physical activity delays menopause to later ages.

Blood heavy metals levels

Women with high blood levels of heavy metals – Lead and Arsenic experience the early onset of menopause.

Low socioeconomic status

Women from lower strata of society, with a lower level of education, have been found to enter menopause at earlier ages than women with higher levels of education.

What are the Various Oral Changes At Menopause?

Effects of hormonal changes accompanying menopause may take a toll on oral health too.

The following are the oral manifestations noted at menopause:

• The reduction of salivary secretion leading to xerostomia
• Burning mouth syndrome
• Increase in the incidence of dental caries
• Taste alterations of the four main
  tastes (sweet, salt, bitter and acid)
• Atrophic gingivitis
• Periodontitis
• Osteoporotic jaws

1. Burning mouth syndrome

Symptoms:

• The burning or stinging sensation seems to be like mouth burnt with hot coffee, but it does not go away.
• Alteration of the taste sensations may be present
• Intense pain and spontaneous burning sensation or cutting sensation of Tongue (in particular the back and the tip), palate, lips, gingiva, superficial tissue
  in a relationship with prosthesis and mouth’s floor are involved.

2. Xerostomia and dryness of mouth

Salivary glands contain sex hormone receptors, so salivary flow rates depend upon estrogen status, the salivary flow is reduced in postmenopausal women.

The decrease in saliva poses a threat to oral health. Saliva plays a protective role in the oral cavity. Salivary reduction compromises dental prostheses adhesion, reducing the possibility to chew, to taste the food and to facilitate the digestion.

In addition to above, paucity of saliva may breach the integrity of oral tissues, making them susceptible to caries particularly root caries, or gum or bone diseases, bad breath, candidiasis, bad taste and increase in dental plaque, which is again responsible for initiating gingivitis, thereby, providing a contributing factor for periodontitis in menopause. 

Postmenopausal women are at greater threat of  Sjogren’s syndrome,  an autoimmune disorder, the immune system attacks the body’s lubrication- secreting glands and tissues- lacrimal glands, salivary glands and mucous membranes in the nose and vagina, leading chiefly to dryness and itchiness.

How to relieve symptoms of xerostomia

• Do not dehydrate yourself. Keep sipping water at regular time intervals
• Chew artificial salivary substitutes
• Chewing Sugar free-gums/ lozenges Xylitol tablets
• Sialogogues, drugs increasing salivary secretion such as pilocarpine, bromhexine, cevimeline, and bethanechol, a physician’s prescription only

3. Mucosal changes

Like changes in vaginal mucosa, alteration in the hormonal secretion makes the oral cavity supersensitive to plaque build-up leading to increasing the susceptibility of gum disease and rapid bone loss, increasing teeth mobility which can lead to tooth loss eventually.

Gum tissues become dry and shiny that bleeds easily with the onset of menopause, specifically termed as “menopausal gingivostomatitis”. 

Postmenopausal women with dental prosthesis encounter frequent problems with the denture and may need frequent adjustments in order to relieve symptoms due to injuries to already fragile soft tissues. Oral ulcerations is also common following mechanical trauma from long-standing denture-induced irritation.

Menopause makes women susceptible to a plethora of oral mucosal disorders, both infectious or autoimmune. The list includes candidiasis, oral ulcerations, pemphigus vulgaris, benign mucosal pemphigoid, lichen planus.

4. Neurological disorders

Neuralgia is very frequent in postmenopausal women. Most common is the Trigeminal neuralgia owing to compression artery associated with the nerve. This neuralgia is very incapacitating, affecting half of the face and have trigger points around the face.

Even a slight feather touch or mild blow of air on the skin is sufficient to cause lancinating, excruciating, stabbing, “electric-shock” like pain.

Other neurological disorders which may affect postmenopausal women: Alzheimer’s disease and atypical facial pain/neuralgia. Neurological disorders may complicate the process of denture delivery owing to unstable jaw relations.

5. Loss of bone: Osteoporosis

Osteoporosis is a disease characterized by a low content of calcium in bones. Calcium deficient bones are prone to fracture. Both bone-forming cells (osteoblasts) and bone-resorbing cells (osteoclasts) express estrogen receptors.

Though Estrogen decrease is sensed by estrogenic receptors present on osteoclasts and osteoblasts both. However,  osteoclasts respond by enhancing their activity level and osteoblasts respond by decreasing their activity level. In nutshell, Menopause leads to overall bone loss (Osteoporosis), including jaw bones.

Loss of structural elements of gum tissue and jaw bones enhance tooth mobility and eventual tooth loss. Women with advanced osteoporosis are more susceptible to teeth loss than their healthy counterparts to loss of mineral content all over the body.

Also, postmenopausal women endure the greater loss of jaw bones following dental extractions than premenopausal women, making the construction of conventional dentures and placement of implants difficult task.

However, women receiving hormone replacement therapy has a similar rate of bone loss to premenopausal women.

6. Gingivitis and Periodontitis

Gingivitis, gum inflammation, characterized by swelling, reddening, and bleeding derived from an increase of plaque. The oral symptoms during the menopause and perimenopause include flush or swelling up of the gums, pain, uneasiness, bleeding, dryness and change in the sense of the taste.

Desquamative gingivitis is not a single and defined disease, but it’s also characterized from coughing of oral tissues,  redness, extreme bleeding, pain, erythema,  abraded gum tissues and sometimes ulcer formation. The gums are soft because the keratinocytes resistant to the food particles abrasion are absent.

Periodontitis is a chronic inflammatory disease characterized by gum inflammation and alveolar bone loss. The periodontal ligament is a fibrous structure, located between alveolar bone and cementum of tooth and anchor tooth to tooth socket. Osteoporosis is considered one of the risk factors for the periodontal disease and the loss of the teeth.

7. Eating disorders

Physical changes accompanied by menopause crop up psychological issues too, leading to eating disorders in postmenopausal women.

There are broadly two types of eating disorders 

• Anorexia Nervosa
• Bulimia

Dental effects may arise from self-induced vomiting and resultant regurgitation of gastric contents which may include:

• Smooth erosion of enamel
• Enlarged parotid glands
• Injury to mouth or  to  pharynx resulting from the use of fingers, combs, and pen to induce vomiting.
• Angular cheilitis
• Dehydration
• Redness of the oral cavity.

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