Hormones play a crucial role in various health aspects of people assigned female at birth (AFAB), including reproductive, bone health, cardiovascular health, mood regulation, metabolism, and immune function. However, their influence doesn't stop there, it also extends to impact oral health. From puberty to menopause, these hormonal fluctuations can significantly affect oral soft tissues and teeth. Understanding this connection is essential for individuals of all ages to maintain optimal oral health and overall well-being.

The main hormones of the reproductive system in people assigned female at birth (AFAB) are estrogen and progesterone. Puberty (a process where adolescents reach sexual maturity and become capable of reproduction) begins between 8 and 13 in people assigned female at birth. During puberty, the luteinizing hormone (LH) and follicle-stimulating hormone (FSH) produced in the pituitary gland increase. This in turn stimulates the sex hormones — especially estrogen.

Estrogen is responsible for the development and regulation of the reproductive system of people assigned female at birth. It regulates the menstrual cycle and secondary sex characteristics. Progesterone regulates the condition of the inner lining (endometrium) of the uterus to prepare it for a potential pregnancy. There are fluctuations (rise and fall) in the estrogen and progesterone levels during the different phases of the menstrual cycle.

Levels of these hormones increase significantly during pregnancy to support fetal development and maintain pregnancy. Additionally, the placenta produces Human Chorionic Gonadotropin (HCG) during pregnancy. Oral contraceptives can also affect these hormone levels. During menopause, estrogen levels decline sharply as ovarian function decreases, leading to a reduction in progesterone production. Similarly, post-menopause, both estrogen and progesterone levels remain consistently low.

Immature permanent tooth enamel, malocclusions, freedom for risk-taking behavior which leads to increased risk for traumatic orofacial injuries, poor nutritional habits, dental phobia, the potential use of tobacco, alcohol, and other drugs, eating disorders, independence to seek personal care or avoid it, a low priority for oral hygiene, and unique social and psychological needs may contribute to oral health problems in adolescents. Hormonal fluctuations can exacerbate these issues, further complicating oral health during this developmental stage.

During puberty, children may experience heightened levels of gingival inflammation even in the absence of increased plaque accumulation. Gingival cells contain specific receptors with high affinity but low capacity for estrogen. The gingiva is a target organ for these hormones. The puberty-associated gingival enlargement peaks earlier in people assigned female at birth. It is characterized by

• Pronounced inflammation

• Deep red or bluish-red discoloration

• Edema

• Nodular hyperplastic reactions leading to enlargement (ballooning or distortion of interdental papillae)

• Bleeding on slight provocation (mastication or tooth brushing)

The gingival enlargement is accompanied by deposits of food debris, material alba, plaque, and calculus.

The surge of sexual hormones at this stage significantly alters the composition of subgingival bacterial flora, leading to higher levels of Gram-negative bacteria compared to other life stages. Prevotella intermedia, identified as one of the prominent bacteria in this age group, thrives on estrogen and progesterone as growth factors. Similarly, Porphyromonas intermedius, bacterium is reliant on these hormones. It contributes to dental discoloration by leaving a noticeable black stain on the teeth's surface. 

A meticulous oral hygiene and nonsurgical approach are considered as the initial treatment options for puberty-induced gingival enlargement. Surgical procedures, such as gingivectomy or periodontal flap surgery should only be contemplated when gingival enlargement becomes fibrotic and resistant to nonsurgical therapy.

The influence of the menstrual cycle extends beyond the endometrium, impacting the microbial balance in the oral cavity. Salivary estradiol (type of estrogen) levels reach their peak during ovulation, coinciding with changes in the composition of uterine endocervical gland secretions.

Four bacterial genera exhibited varying abundance levels throughout the menstrual cycle: Campylobacter, Haemophilus, Prevotella, and Oribacterium. The higher abundance of Prevotella species' in saliva may elevate pH levels and stimulate gingival crevicular fluid flow. This favors the growth of acid-intolerant bacterial species associated with gingival inflammation.

Despite maintaining good oral hygiene practices, fluctuations in female hormones can lead to temporary changes in oral microbial composition, potentially contributing to deteriorating oral health. Decreased salivary flow and oral ulcers are the other most frequently observed oral manifestations during menstruation. High consumption of dietary sugar and smoking are identified as risky lifestyle factors that impact oral microbial function and exacerbate oral health issues during the menstrual cycle.

Individuals with gingivitis may experience swollen gingival tissues, activation of herpes labialis, aphthous ulcers (canker sores), prolonged hemorrhage after oral surgery, and swollen salivary glands because hormones may exaggerate preexisting inflammation.

While hormones can sometimes cause unexpected changes in the oral cavity, understanding this connection helps to take charge of one's oral health. Oral hygiene routine, regular dental checkups, and a healthy diet are the best allies in maintaining a healthy oral cavity throughout these hormonal shifts.

Stay tuned for Part II of the article!

References:

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By Dr. Nirainila Joseph