Introduction
The periodontium can be affected by several factors that illicit an immune response, which in turn, causes destruction of the supporting periodontal structures. Oral-systemic health is a continually evolving topic that demonstrates the bidirectional relationship between numerous conditions and oral health. The influence of hormones-specifically those found in oral contraceptives-on periodontal health has been evaluated for years and with evolving research, has recently identified a few definitive correlations. Studies are concluding that women on oral contraceptives present with worse periodontal and gingival health than their counterparts not on this medication.1 This article looks to current literature to gain an understanding of the changes hormones can have on a patient’s vasculature, immune system, and periodontium so that clinicians can educate patients on the oral health risks of hormonal contraceptives.
Overview of Hormonal Contraceptives
With varying purposes and components that have evolved to meet the specific needs of women, hormonal contraceptives have been used for decades. Whether the contraceptive is oral, intrauterine, or intramuscular, each are based on synthetic combinations of hormones estrogen and progesterone, progesterone alone, or levonorgestrel to mimic a state of pregnancy to prevent ovulation.2 Estrogen’s role in contraception is to inhibit ovulation, regulate bleeding, and keep the endometrial lining thin, while progesterone inhibits ovulation and thickens cervical mucus.2 When discussing oral contraceptives, the amount of hormones present can vary as well. Some oral contraceptives deliver a consistent amount of hormones throughout the month, while others can increase once or twice throughout an individual’s menstrual cycle.2 This is important to consider when evaluating the effects of hormones on oral health. In the event that estrogen and progesterone levels become elevated, vasodilation of blood vessels and capillary permeability is induced, which results in migration of fluid and white blood cells out of blood vessels. This leads to increased blood flow to gingival tissues along with sensitivity, irritation, and inflammation.3,4,5 These inflammatory changes appear synonymous with symptoms experienced by pregnant women as well.6 Hormonal contraceptives have played a substantial role in empowering women to have a say in their fertility, however as dental professionals, it is critical to have an understanding of how these hormones can be contributing to tissue destruction at the microbial level.
Risks to Oral Health
Healing Capabilities
Collagen is an important protein that most dental professionals are familiar with, as the periodontal ligament is made up of collagen fiber bundles that suspend the tooth into the alveolar bone. Considering the aforementioned effects of elevated progesterone and estrogen on the vasculature, changes in these hormones also negatively influence the immune system and collagen production by reducing the body’s ability to repair and maintain gingival tissues.3 In a meta-analysis that evaluated alveolar osteitis occurrence in oral contraceptive users, the average rate of alveolar osteitis in oral contraceptive users was 13.9% in comparison to 7.5% in non-oral contraceptive users.2 In addition to estrogen’s impact on the body’s ability to heal, it also effects one’s ability to coagulate and has been shown to cause changes in fibrinolytic factors. These factors play a large role in keeping clots stable, however without adequate fibrinolytic factors, there is greater incidence of clots breaking down and occurrence of inadequate healing.2,6
Another study looked to the effects of women taking systemic steroids, hormone replacement therapy, or oral contraceptives on implant success rate.5 In this study, 777 implant failure rates of women taking hormone replacement therapy or oral contraceptives, and women not taking these medications were evaluated.6 After excluding patients that smoked and had diabetes, the results provided statistically significant and indicated that the implant failure rate was 8.62% for the implants of patients taking hormone replacement therapy or oral contraceptives, compared to 1.53% of patients not taking these medications.5 How an implant osseointegrates into the bone could be largely dependent on systemic medications and hormonal influences.
Periodontal Health
In regard to gingival and periodontal health, even low-dose contraceptives have been shown to have increased gingival bleeding, which is correlated to the effects of elevated estrogen and progesterone on the vasculature that was discussed earlier.2 Estrogen receptors are found within the fibroblasts and osteoblasts of the PDL. Considering the effects of elevated estrogen levels covered thus far, these receptors bind to specific hormones that accumulate within tissues and can influence an inflammatory response in the gingiva.2,5,6 This leads to destruction of the periodontium, increased probing depths, clinical attachment loss, and bleeding. Many clinical studies have also demonstrated that the concentrations of C-reactive protein (CRP) in patients taking oral contraceptives is higher than those who are not.5 CRP is a protein that becomes activated in response to acute and chronic inflammation. This protein recognizes that injury to periodontal tissues is occurring and plays a pivotal role in the host’s defense against infection that is eliciting the inflammatory response.7
In a systematic review evaluating oral health and oral contraceptive use, it was determined that duration of contraceptive use was correlated with worsening gingival parameters. Women on oral contraceptives for more than one and a half years had greater clinical attachment loss compared to those using a contraceptive for a shorter duration of time.3,6 For all of these reasons alone, studies have correlated women taking hormonal contraceptives with worse gingival and periodontal health.1-3,6
Conclusion
Understanding the influence a patient’s medical history has on oral health conditions goes far beyond simply updating medications at every appointment. Prescriptions patients may be taking could be the contributing factor as to why changes in inflammation are being seen or alveolar osteitis occurred despite the patient following strict post-operative instructions. The conditions listed in this article are certainly multifactorial, with the effects of systemic medications being just part of a patient’s oral and systemic health. However, it is critical to shed light on the impact these hormones are having on the oral health of our patients, as many studies are concluding a positive correlation between patients taking these medications and worse periodontal outcomes. It is our responsibility as oral health care providers to make our patients aware of the possible effects that hormonal medications could be having on their vasculature, immune system, and periodontal health.
References
1. Bienek DR, Filliben JJ. Risk Assessment and Sensitivity Meta-Analysis of Alveolar Osteitis Occurrence in Oral Contraceptive Users. J Am Dent Assoc. 2016;147(6): 394-404.
2. Rojo GM, Lloret MRP, Gironés JG. Oral Manifestations in Women Using Hormonal Contraceptive Methods: a Systematic Review. Clin Oral Invest. 2024;28(184): 1-13.
3. Ali I, Patthi IAB, Singla A, et al. Oral Health and Oral Contraceptive- Is it a Shadow Behind Broad Day Light? A Systematic Review. J Clin Diag Res. 2016;10(11): 1-6.
4. Boyapati R, Cherukuri SA, Bodduru R, et al. Influence of Female Sex Hormones in Different Stages of Women on Periodontium. J Mid-life Health. 2021;12: 263-266.
5. Zou MY, Cohen RE, Ursomanno BL, et al. Use of Systemic Steroids, Hormone Replacement Therapy, or Oral Contraceptives is Associated with Decreased Implant Survival in Women. Dent J. 2023;11: 1-9.
6. Lamichange M, Salehi N, Ahmadjee A, et al. (2018). Pathology of Aterial Thrombosis: Characteristics and Thrombus Types. Cardiovascular Thrombus (pp.15-30). Elsevier. https://doi.org/10.1016/C2016-0-03582-9
7. Bansal T, Pandey A, Asthana A, et al. C-Reactive Protein (CRP) and its Association with Periodontal Disease: A Brief Review. J Clin Diagn Res. 2014;8(7): 21-24
