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Similar to PERIODONTAL THERAPY IN FEMALE PATIENTS Presented by- Dr. Himanshu gorawat
PERIODONTAL THERAPY IN FEMALE PATIENTS Presented by- Dr. Himanshu gorawat
- 1. PERIODONTAL THERAPY IN FEMALEPATIENTS Presented by- Dr. Himanshu gorawat Dental surgeon
- 2. CONTENTS • INTRODUCTION • PUBERTY •MENSES • PREGNANCY • ETIOLOGY OF GINGIVAL RESPONSES TO ELEVATED ESTROGEN AND PROGESTERONE DURING PREGNANCY • OTHER ORAL MANIFESTATIONS OF PREGNANCY • CLINICAL MANAGEMENT • TREATMENT • BREAST FEEDING • DENTAL RADIOGRAPHS • MEDICATIONS • ORAL CONTRACEPTIVES • MENOPAUSE • CONCLUSION
- 3. INTRODUCTION • Throughout ahuman life cycle hormonal influences affect therapeutic decision making in periodontics. Historically therapies have been gender biased. • Oral health care professionals have greater awareness and capabilities of dealing with hormonal influences associated with reproductive process. • Periodontal and oral tissue responses may be altered, creating diagnostic and therapeutic dilemmas. • Therefore it is imperative that the clinician recognizes customize and appropriately alter periodontal therapy according to the individual woman’s needs based on the stage of her life cycle.
- 4. PUBERTY • It occursbetween the average ages of 11 to 14 in most women. An increase in the production of sex hormones (estrogen and progesterone) occurs, which then remains relatively constant during the remainder of the reproductive phase. • The prevalence of gingivitis increases without an increase in the amount of plaque. The organisms involved in causing puberty gingivitis. Prevotella intermedia, capnocytophaga species. The organisms have been implicated in the increased bleeding tendency observed during puberty.
- 5. • During puberty,periodontal tissues may have an exaggerated response to local factors. A hyperplasic reaction of the gingival may occur in areas where food debris, material Alba plaque and calculus are deposited. The inflamed tissues become erythematous, lobulated and retractable. Bleeding may occur easily with mechanical debridement of the gingival tissues. Histologically, the appearance is consistent with inflammatory hyperplasia.
- 6. MANAGEMENT DURING PUBERTY •Education of the patient parent • Milder gingivitis cases respond well to scaling and root planning with frequent oral hygiene reinforcement. • Severe cases of gingivitis may require microbial culturing, antimicrobial mouthwashes and local site delivery or antibiotic therapy.
- 7. MENSES Periodontal Manifestations:-- • Ovarianhormones may increase inflammation in gingival tissues and exaggerate the response to local irritants. Gingival inflammation seems to be aggravated by an imbalance and/or increase in sex hormones. • Progesterone has been associated with increased permeability of the microvasculature, altering the rate and pattern of collagen production in the gingiva. Prostaglandins E2 (PGE2) is one of the major secretary products of monocytes and is higher in inflamed gingival.
- 8. • Gingival tissueshave been reported to be more edematous during menses and erythematous preceding the onset of menses in some individuals. In addition, an increase in gingival exudates has been observed during the menstrual period and is sometimes associated with a minor increase in tooth mobility. The incidence of postextraction osteitis has also been reported to be higher during the initiation of menses. • When progesterone is highest (during the luteal phase of the cycle), intraoral recurrent apthous ulcers, herpes labialis lesions and candida infections occur in women as a cyclic pattern. Because the esophageal sphincter is relaxed by progesterone, women may be more susceptible to gastroesophageal reflux disease (GERD) during this time of cycle as well. Symptoms of GERD include heart burn, regurgitation and chest pain and when reflux is severe, some people develop unexplained coughing hoarseness, sore throat, gingivitis or asthma.
- 9. MANAGEMENT DURING MENSES •Closer periodontal monitoring. • Periodontal maintenance should be titrated to the individual patients need and, if problematic, 3 to 4 months intervals should be recommended. • An antimicrobial mouth rinse. • Maintain oral hygiene. • For the patients with a history of excessive postoperative hemorrhage or menstrual flow, scheduling surgical visits after cyclic menstruation is prudent.
- 10. • During PMSmany exhibit physical symptoms including fatigue, sweet and salty food, abdominal bloating, swollen hands or feet, headaches, breast tenderness, nausea and gastrointestinal upset. • nonsteroidal anti-inflammatory medication, infection and acidic foods exacerbate GERD. • Fluoride rinses and/or trays, frequent periodontal debridement, and avoidance of high-alcohol-contest mouthwashes may reduce the associated gingival and caries sequela. • PMS is often treated by antidepressants selective serotonin reuptake inhibitors (SSRIS) are generally the first line choice because they have fever side effects than other antidepressants, do not require blood monitoring and are safe in overdose.
- 11. PREGNANCY Periodontal manifestations:- The linkbetween pregnancy and periodontal inflammation has been known for many years. In 1978, vermecren discussed “tooth pains” in pregnancy. In 1918, pitcarin described gingival hyperplasia in pregnancy.
- 12. Pregnancy gingivitis • Itis extremely common in 30% to 100% of all pregnant women. • Characterized by-- erythema, edema, hyperplasia and increased bleeding. • Mild to severe inflammation. • Can progress to severe hyperplasia, pain and bleeding. • The anterior region of the mouth is more commonly affected, and interproximal site tend to be most involved. • Increased tissue edema may lead to increased pocket depths and relate to transient tooth mobility. • Anterior site inflammation may be exacerbated by increased mouth breathing, primarily in the third trimester from pregnancy rhinitis.
- 13.
- 14. • Gingivitis ismore common site involved followed by tongue and lips, buccal mucosa and palate. • Pyogenic granulomas, pregnancy tumors, or pregnancy epulides occur 0.2% to 9.6% of pregnancies. • The lesion classically occurs in an area of gingivitis and is associated with poor oral hygiene and calculus.
- 15.
- 16. Etiology of gingivalresponses to elevated estrogen and progesterone during pregnancy 1. SUBLINGUAL PLAQUE COMPOSITION 2. MATERNAL IMMUNORESPONSE 3. SEX HORMONE CONCENTRATION
- 17. SUBLINGUAL PLAQUE COMPOSITION ▫Intermedia (substitute’s sex hormone for vit-K anaerobic to aerobic ratio increases). ▫ Higher concentration--- 1. prevotella growth factor 2. bacteroides melaninogerium 3. porphyromonas gingivalis
- 19. MATERNAL IMMUNORESPONSE ▫ Depressionof cell mediated immunity ▫ Depression neutrophil chemotaxis ▫ Depression of antibody and T Cell responses ▫ Decrease in the ratio of peripheral T helper cells to T suppressor – cytoxic cells (CD4/CD8 ratio) ▫ Cytotoxicity directed against macrophages and B cells may result in diminished ▫ Decrease in absolute number or CD3, CD4 and CD19 positive cells in peripheral blood during pregnancy versus postpartum ▫ Stimulation of the production of prostaglandin.S
- 20. SEX HORMONE CONCENTRATION •a. Estrogen • i) Increases cellular proliferation in blood vessels (known in the endometrium) • ii) Decreases keratinization, while increases epithelial glycogen. • iii) Specific receptors are found in gingival tissues.
- 21. • b. Progesterone •i) Increases vascular dilation, thus increasing permeability (result in edema and accumulation of inflammatory cells) • ii) Increases proliferation of newly formed capillaries in gingival tissues (increased bleeding tendency) • iii) Alters rate and pattern of collagen production • iv) Increased metabolic breakdown of folate (a deficiency can inhibit tissue repair) • Specific receptors are formed in gingival tissues • vi) Decreases plasminogen activator inhibitor factor type 2, thus increases tissue proteolysis
- 22. • c. Estrogenand progesterone • i) Effect ground substance of connective tissue by increasing fluidity. • ii) Concentration increases in saliva and fluid with increased concentration in serum.
- 23. OTHER ORAL MANIFESTATIONSOF PREGNANCY • Perimolysis or acid erosion of teeth may occur if “morning sickness” or esophageal reflux is severe and involves repeated vomiting of the gastric contents. • The severe reflux may cause scarring of the esophageal sphincter and the patient may become a more likely candidate for GERD later in life. • Xerostomia is a frequent complaint among pregnant women.
- 24. • A rarefinding in pregnancy is ptyalism or sialorrhea. This excessive secretion of saliva usually begins at 2 or 3 weeks of gestations and abates at the end of the first trimester. • Because pregnancy places the women in an immunocompromised state, the clinician must be aware of the total health of the patient.
- 25. CLINICAL MANAGEMENT • Athrough medical history is an imperative component of the periodontal examination especially in the pregnant patient. Due to immunologic alteration, increase in blood volume, and fetal interactions, the clinician must diligently and consistently monitor the patient’s medical and periodontal stability.
- 26. PLAQUE CONTROL • Theheightened tendency for gingival inflammation should be clearly explained to the patient so that acceptable oral hygiene techniques may be taught, reinforced, and monitored throughout pregnancy. • Scaling and polishing and root planning may be performed whenever necessary throughout the pregnancy. • Some avoid the use of high-alcohol-content antimicrobial mouth rinses in pregnant women and prefer to use that are non-alcohol based.
- 27. PRENATAL FLUORIDE • Theprescribing of prenatal fluoride supplements has been an area of controversy for quite some time. Although studies have suggested that the clinician efficacy of prenatal fluoride supplement is uncertain and the mechanism which prenatal fluorides might impart cariostasis is unclear. • The ADA does not recommend the use of prenatal fluoride because it efficacy has not been demonstrated.
- 28. TREATMENT Elective dental treatment •Other than good plaque control, it is prudent to avoid elective dental care if possible during the first trimester and the last half of the third trimester. • Prolonged chair time may need to be avoided because the woman is most uncomfortable at this time. Supine hypotensive syndrome may possibly occur. • A preventive soft 6-inch wedge (rolled towel) should be placed on the patient’s right side when she is reclined for clinical treatment.
- 29. • The secondtrimester is the safest period for preventing and providing dental care. The emphasis at this time is on controlling active disease and eliminating potential problems that could arise in late pregnancy. • Major oral and periodontal surgery should be postponed until after delivery. Pregnancy tumors that are painful, interfere with mastication or continue bleeding or suppurate after mechanical debridement may require excision and biopsy before delivery.
- 30. BREAST FEEDING • Usually,there is a risk that the drug can enter breast milk and be transferred to the nursing infant, in whom exposure could have adverse effects. • The amount of drug excreted in breast milk is usually hot more than 1% and 2% of the maternal dose; therefore it is highly unlikely that most drugs have any pharmacologic significance for the infant. • The mother should take prescribed drugs just after breastfeeding and then avoid nursing for 4 hours or more.
- 31. DENTAL RADIOGRAPHS • Thesafety of dental radiography has been well established, provided features such as high- speed film, filtration, collimation and lead aprons are used. • However it is most desirable not to have any irradiation during pregnancy, especially during the first trimester, because the developing fetus is particularly susceptible to radiation damage.
- 32. MEDICATIONS • Drug therapyin the pregnant patient is controversial because drugs can affect the fetus by diffusion across the placenta. • Prescriptions should be only the duration absolutely essential for the pregnant patient’s well being and only after careful consideration of potential side effects. • The classification system established by the FDA in 1979 to rate fetal risk levels associated with any prescription drugs provide safety guidelines.
- 33. ORAL CONTRACEPTIVES • Oralcontraceptives may have similar responses to those witnessed in pregnant patients. • An exaggerated response to local irritants occurs in gingival tissues. • Inflammation ranges from mild edema and erythema to severe inflammation with hemorrhagic or hyper plastic gingival tissues. • Exudate is present in inflamed gingival tissues. • Gingival inflammation may become chronic due to the extended periods of time that women are exposed to elevated levels estrogen and progesterone. • Spotty milanotic pigmentation of the skin may occur with use of oral contraceptives.
- 34. MANAGEMENT • Inform patient--oral and periodontal side effects of oral contraceptives and the need for meticulous home care and compliance with periodontal maintenance. • Establishing an oral hygiene programmed • Eliminating local pre disposing factors. • Periodontal surgery may be indicated if resolution after initial therapy is inadequate. • Extraction of teeth.
- 35. MENOPAUSE • Menopause isassociated with symptoms of estrogen deficiency. • Estradid levels fall gradually in the years before menopause. • Levels of the gonadotrophins, TSH and LH begin to rise, and levels of sex hormones begin to fluctuate.
- 36. ORAL CHANGES • Thinningof the oral mucosa • Oral discomfort (“burning mouth”) • Gingival recession • Xerostomia altered taste sensation • Alveolar bone loss • Alveolar ridge resorption. • Estrogen affects cellular proliferation differentiation and keratinization of the gingival epithelium. • Osteopenia and osteoporosis have been associated with the menopausal patients
- 37. CLINICAL MANAGEMENT • Itis the clinician’s responsibility to review the patient’s medical history and keep information upto date. • If gingival and mucosal tissue thinning occurs, soft tissue augmentation may be performed. • Brush with an 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.
- 38. CONCLUSION • Clinical periodontaltherapy includes an understanding of our role in the total health and well-being of our patients. • The cyclic nature of the female sex hormones often reflects in the gingival tissues as the initial signs and symptoms. • Medical histories and dialogues should include thoughtful investigations of the individual patient’s problem and needs. • Questioning should reflect hormones stability and medications associated with regulation. • Patient should be educated. • Information regarding specific management and etiology of sex hormone-mediated infections will enhance their ability to provide quality care to our patients.