October 2009 | Modern Hygienist
Patients: menopause

Perio and the post-
menopausal patient

As women age, are you ready to respond?

by Eduardo R. Lorenzana, DDS, MS

Photo: Purestock/Getty Images

It is considered common knowledge amongst our female patient population that the onset of menopause is marked by deficiencies in estrogen levels, followed by a subsequent loss of bone mineral density.^1-4 While this knowledge leads many of our patients to seek help with the management of estrogen deficiency, osteopenia/osteoporosis and other associated complications, most of our patients are not aware that the onset of menopause also can mark the onset of certain potentially debilitating conditions in the oral cavity. Oftentimes it is at the routine prophylaxis or periodontal maintenance appointment that the first signs and symptoms are discovered and where early identification and intervention can preserve the quality of life for our patients.

Much of the research into the effects of menopause on the periodontium have revolved around tooth loss secondary to estrogen deficiency/osteopenia/osteoporosis.^5-9 Estrogen deficiency has been associated with accelerated tooth loss in postmenopausal women, and has been explained mostly by an increased severity of periodontal disease5,6 and decreased bone density due to estrogen deficiency.^{7, 8} In a recent long-term study of the periodontal status of postmenopausal women followed over 10-13 years, researchers found that for every millimeter of bone loss and attachment loss at baseline there resulted a 2.5- to 3-fold increase in risk for subsequent tooth loss.⁹ Finally, estrogen deficiency also has been found to negatively impact dental implant survival rates, with the underlying mechanism being a decrease in trabecular bone density and bone to implant contact.^10-12

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Estrogen deficiency and HRT

If estrogen deficiency is indeed a risk indicator or risk factor for periodontitis and subsequent tooth loss,¹³ then perhaps hormone replacement therapy (HRT) can have a protective or corrective effect on loss of attachment and tooth loss. Several recent studies have focused on that question, many with positive results. Reinhardt and coworkers found that estrogen supplementation was associated with reduced gingival inflammation and a reduced frequency of clinical attachment loss in osteopenic/osteoporotic women in early menopause.¹⁴ A much more recent study found the prevalence of periodontitis was higher in postmenopausal women not taking HRT (HRT-) vs. premenopausal women. In addition, postmenopausal women who were on HRT (HRT+) had no statistical differences in the prevalence of periodontitis to premenopausal women.¹⁵

Still other investigators have found HRT acts as a protective factor in dental pain and improves tooth mobility and depth of the probing of periodontal pockets.¹⁶ It is important to note, however, that no HRT regimen should be initiated without the cooperation of the patient’s physician. Given recent findings of the Women’s Health Initiative, where amongst the risks of prolonged HRT were significant increases in invasive breast cancer, coronary heart disease, stroke, and venous thromboembolism,^17,18 the use of HRT regimens has to be tailored on a case-by-case basis.

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