Dental management of thefemale patient

JO A N OT O M O-CO R G E L

The female patient presents with unique therapeutic

challenges that vary throughout her life�s continuum.

Hormonal influences may appear in oral tissues be-

fore other systemic manifestations are apparent.

Periodontal tissues can reflect the need to alter con-

ventional therapy. Therefore, it is the clinician�sresponsibility to recognize, customize and vary peri-

odontal therapy based on the individual female and

the stage of her life cycle (43).

This article reviews the clinical management of the

female patient during the life cycle from puberty

through menopause. The clinician should recognize

the periodontal manifestations and ⁄ or intra-oral le-

sions caused by systemic diseases. For example, the

clinical signs and symptoms of diabetes and auto-

immune disorders may be exaggerated by hormonal

fluctuations. A thorough review of the patient�smedical and psychological history is required as part

of the periodontal examination.

Puberty

An exaggerated periodontal tissue response to peri-

odontal risk factors may occur during puberty in

male subjects and female subjects. In the pubertal

female patient, the tissues are likely to present with

inflammatory responses as a result of elevated sex-

steroid hormone levels, which are irregular until

postpubertal hormones stabilize. An enlargement of

the gingiva may occur in areas where food debris,

materia alba, plaque and calculus are deposited. The

inflamed tissues can become erythematous, lobu-

lated and retractable. Bleeding may occur easily upon

mechanical debridement of the gingival tissues,

especially interproximally.

During puberty, education of the parent or care-

giver is an integral part of successful periodontal

therapy. Preventive care, including vigorous imple-

mentation of oral hygiene, is vital for maintaining

periodontal health. Milder cases of gingivitis in pub-

erty respond well to scaling and deplaqueing, along

with frequent oral hygiene reinforcement (5). Severe

cases of this type of gingivitis may require microbial

culture, antimicrobial mouthwashes and local site

delivery of an antiseptic. Periodontal maintenance

appointments may need to be more frequent when

there is an apparent risk of periodontal disease pro-

gression (42).

The clinician should also recognize that the inci-

dence of asthma and ⁄ or mouth breathing may be

higher in pubertal female and male subjects. The

incidence of asthma also increases after puberty in

female subjects. This may cause gingival enlarge-

ment, especially in the anterior area of the dentition,

possibly as a result of surface dehydration. The cli-

nician should recommend meticulous home care and

increase the frequency of periodontal maintenance

appointments and dental caries evalution. Topical

application of an occlusive barrier (lubricant) over

the inflamed gingiva after home-care procedures and

immediately before bedtime may aid in the reduction

of soft-tissue edema.

Female adolescents (11–14 years of age) are sus-

ceptible to problems associated with eating disorders.

The clinician should examine for intra-oral signs and

symptoms of anorexia nervosa and bulimia nervosa

in a suspect patient. Chronic regurgitation of gastric

contents will appear as perimylosis (i.e. smooth ero-

sion of enamel and dentin), typically on the lingual

surfaces of maxillary anterior teeth, and the duration

and frequency of the behavior will determine the

degree of perimylosis (9). Also, enlargement of the

parotid glands (occasionally sublingual glands) has

been estimated to occur in 10–50% of patients who

�binge and purge� (36). Therefore, a diminished

219

Periodontology 2000, Vol. 61, 2013, 219–231

Printed in Singapore. All rights reserved

� 2013 John Wiley & Sons A/S

PERIODONTOLOGY 2000

salivary flow rate may also be present, which will

increase oral mucous membrane sensitivity, gingival

erythema and caries susceptibility. Oral healthcare

providers are often the first to recognize eating dis-

orders. After consultation with the patient and ⁄ or

parent, a referral to a physician, psychologist or

nutritional consultant is advised. Patients with diag-

nosed eating disorders also demonstrate an increased

susceptibility to low bone mass. Many will report

cessation of menses, even before significant weight

loss is apparent, as a result of altered endocrine

function, especially low plasma-estrogen levels.

These patients need nutritional and vitamin supple-

mentation, especially calcium and vitamin D. Other

laboratory abnormalities include mild normochromic,

normocytic anemia, mild to moderate leukopenia

and a reduction in the number of polymorphonuclear

leukocytes (57). Blood urea nitrogen and creatinine

are increased in cases of dehydration, frequently

along with a low blood sugar level.

Menstrual cycle

The monthly reproductive cycle can be separated into

two phases (Fig. 1). During the luteal phase (the sec-

ond stage of the menstrual cycle), increased gingival

sensitivity and bleeding have been reported. Women

who present with increased periodontal inflammation

and tenderness should receive periodontal mainte-

nance therapy every 3–4 months. During the luteal

phase, an increased incidence of intra-oral recurrent

aphthous ulcers has also been reported (22), but is

probably independent of hormone levels (37).

The possibility of anemia as a result of iron loss

during menstruation can influence treatment (19,

51). Iron-deficiency-related anemia has been esti-

mated to affect almost 20% of women of childbearing

age, and the possibility of anemia must be considered

for women of reproductive age with lower than

average body weight or with a history of heavy

menstrual flow (51). Severe anemia may result in

angular cheilitis, atrophic glossitis and ⁄ or oral

mucosal atrophy (12). Patients with anemia should

be referred to a physician for appropriate laboratory

tests and treatment.

During the luteal phase, the lower esophageal

sphincter may relax, and thus the gag reflex may well

be heightened more than at other times during the

normal menstrual cycle. As a result, normal intra-oral

procedures can become more difficult. For example,

it may be more difficult for the dental professional to

retract the tongue, place radiographic films or use

aerosols in the mouth. If a patient does present with

oral problems during this state of the cycle, it would

be prudent to schedule surgical therapy until after

menstruation. The relaxed esophageal sphincter may

also make women more susceptible to gastroesoph-

ageal reflux disease, with heartburn, regurgitation

and chest pain, and some patients with severe reflux

disease may develop unexplained coughing, hoarse-

ness, sore throat, gingivitis and asthma (47). Fluoride

therapy is recommended for patients with gastro-

esophageal reflux disease as a result of increased

caries susceptibility and acid erosion (Figs 2 and 3).

The patient should also be advised to use alcohol-free

mouthrinses and to shorten the time intervals be-

tween periodontal ⁄ dental maintenance visits.

The premenstrual syndrome consists of physical

and emotional symptoms that are associated with the

menstrual cycle. The diagnosis of premenstrual syn-

drome is limited to symptoms that develop during

the luteal phase of the menstrual cycle and symp-

toms may be severe enough to impede some aspects

Fig. 1. Monthly female hormonal cycle. Diagramatic

illustration of changes in concentration of the gonado-

tropins (FSH and LH) and ovarian hormones (estrogens

and progesterone) during one reproductive cycle. FSH,

follicle-stimulating hormone; LH, luteinizing hormone.Fig. 2. Acid erosion of maxillary teeth from gastroesoph-

ageal reflux.

220

Otomo-Corgel

of life. Many patients with premenstrual syndrome

also receive antidepressants because of lower levels

of neurotransmitters such as enkephalins, endor-

phins, c-aminobutyric acid and serotonin. Selective

seratonin reuptake inhibitors are often prescribed for

neurotransmitter deficiency. Sertraline is the drug of

choice for premenstrual syndrome (24), but floxetine

is commonly prescribed owing to a reported 70%

response rate in the reduction of depression. Patients

taking fluoxetine have altered absorption, increased

side effects with highly protein-bound drugs (e.g.

aspirin) and an increased half-life of diazepam and

other central nervous system depressants (56). Other

common selective seratonin reuptake inhibitors are

fluvoxamine, paroxetine and citalopram, and an-

tidepressants that may be prescribed are the selective

serotonin and norepinephrine reuptake inhibitors,

tricyclics, trazodone, mirtazapine, nefazodone and

maprotiline. It is important to recognize that an-

tidepressants are associated with an increased inci-

dence of xerostomia. Depression, irritability, mood

swings and difficulty with memory and concentration

may be symptoms of neurotransmitter reduction.

Patients are more sensitive to and less tolerant of

therapeutic procedures while using selective serato-

nin reuptake inhibitors and may have an exaggerated

response to pain.

The premenstrual syndrome patient may be diffi-

cult to treat because of emotional and physiologic

sensitivity. The dentist should treat the gingival and

oral mucosal tissues gently. Gauze pads or cotton

rolls should be moistened with a lubricant, chlorh-

exidine rinse or water before placing them in the

�aphthous ulcer-prone� patient. Careful retraction of

the oral mucosa, cheeks and lips is necessary, espe-

cially in patients prone to aphthous or herpetic

lesions. Because the hypoglycemic threshold is

elevated, the clinician should advise the patient to

have a light snack before her appointment. Seventy

per cent of menstruating women have premenstrual

syndrome symptoms, but only 5% meet the strict

diagnostic criteria of premenstrual syndrome.

Oral contraceptives

Early studies examining the effects of oral contra-

ceptives on the periodontium have shown that the

periodontal response to these agents is similar to that

seen in pregnant women (37). The studies reported

an exaggerated gingival response to local factors.

Inflammation can range from mild edema and ery-

thema to severe inflammation with hemorrhagic or

enlarged gingival tissues (37). More exudate was also

present in inflamed gingival tissues of oral contra-

ceptive users than in pregnant women (63). Some

investigators reported that the inflammation in-

creased with the prolonged use of oral contracep-

tives, but Kalkawarf (31) did not find that duration of

use made a significant difference to inflammation;

however, the brand of contraceptive used resulted in

different gingival responses. It should be noted that

the concentration of female sex hormones in current

oral contraceptives is significantly lower than in the

earlier formulations (1970–1990) and current data

examining contemporary formulations suggest that

oral contraceptives do not have a significant effect on

the inflammatory composition of the periodontium

(45).

Similarly to the early reported effects of oral con-

traceptives on gingival inflammation, studies from

the 1970s found that the salivary composition chan-

ged notably in patients taking oral contraceptives. A

decreased concentration of protein, sialic acid,

hexosamine fucose, hydrogen ions and total electro-

lytes was reported. Salivary flow rates were increased

in one report (35) and were decreased in 30% of

subjects in another report (20). More recent studies

have shown no difference in salivary flow rates

between patients on oral contraceptives versus indi-

viduals not using oral contraceptives (48).

Oral contraceptives have also been reported to

cause a two- to threefold increase in the incidence of

localized osteitis after extraction of mandibular third

molars (52). The higher incidence of osteitis may be

attributed to the effects of oral contraceptives (i.e.

estrogens) on clotting factors. However, others refute

this finding (14), especially in light of the contem-

porary formulation of contraceptives. At this time,

evidence is inconclusive on osteitis after third-molar

extraction in patients on oral contraceptives.

In regard to the skin around the lips, a spotty

melanotic pigmentation of the skin may occur with

Fig. 3. Acid erosion of mandibular teeth from gastro-

esophageal reflux.

221

Therapeutic challenges through female continuum

oral contraceptive use. This suggests a relationship

between the use of oral contraceptives and the

occurrence of gingival melanosis (27), especially in

fair-skinned individuals.

Medical history should include oral contraceptives

under the heading of �medications�, and the dialog

with women of childbearing age should include

questions regarding the use of oral contraceptives.

For those rare patients who are sensitive to the ad-

verse effects of oral contraceptives and exhibit an

exaggerated gingival response while using an oral

contraceptive, treatment should include careful

mechanical debridement and the establishment of an

effective oral hygiene program. Periodontal surgery

may be indicated if the gingival response is inade-

quate after initial scaling and root planing.

Pregnancy

The importance of providing oral health care for

pregnant women is undisputable. Data suggest that

maternal oral health is associated with pregnancy

health, and further research on the nature of this

association is ongoing to determine if there is a

causal relationship (6). Despite conflicting clinical

trial results regarding the effectiveness of periodontal

therapy to improve pregnancy outcomes, preventing

and reducing periodontal inflammation in pregnant

women is safe (29, 41) and reduces the bacterial load.

Early studies indicated that pregnancy was associated

with a subgingival increase in certain bacterial spe-

cies, especially those belonging to the group known

as black-pigmented Bacteroides, and that this in-

crease may play an etiological role in the increased

incidence of gingivitis (37). Recent evidence does not

corroborate these early findings, and several investi-

gators have found little or no association between

periodontal black-pigmented Bacteroides and states

of hormonal surges in women during pregnancy,

puberty or menstruation (33). Pregnancy is also an

opportunity to educate parents on preventive care for

their offspring. Providing counseling to women of

childbearing age regarding the need for periodontal

heath should be offered, especially to individuals who

are planning to become pregnant.

A thorough medical history is an imperative com-

ponent of the periodontal examination, especially in

the pregnant woman. Because of immunologic

alterations, increased blood volume, cardiac consid-

erations and fetal interactions, the clinician must

diligently and consistently monitor the patient�smedical and periodontal status. The medical history

dialog should include previous pregnancy complica-

tions, previous miscarriages and any recent history of

cramping, spotting or pernicious vomiting. The pa-

tient�s obstetrician should be contacted to discuss the

patient�s medical status, periodontal or dental needs

and the proposed treatment.

Establishing a healthy oral environment and

maintaining optimal oral hygiene levels are primary

objectives in the pregnant woman. The periodontal

tissues, which contain hormonal receptors, can be

affected by pregnancy hormones and may reflect an

over-exuberant response, such as pregnancy-associ-

ated pyogenic granulomas (Figs 4 and 5). Pregnant

women with underlying systemic diseases may ex-

hibit exaggerated periodontal responses, as seen in

the periodontitis that occurs in HIV-positive women

during pregnancy (Fig. 6) or excessive gingival

enlargement, pain and bleeding as a result of treat-

ment with cyclosporine medication (Fig. 7). Other

types of gingival pathosis, such as central giant cell

granulomas or underlying systemic diseases that

Fig. 4. Pregnancy granuloma.

Fig. 5. Pregnancy granuloma (courtesy of Dr P War-

shawsky).

222

Otomo-Corgel

resemble pregnancy-associated pyogenic granuloma

must be ruled out for a correct diagnosis. A pre-

ventive periodontal program consisting of nutritional

counseling and rigorous plaque-control measures

should be reinforced. The increased tendency for

gingival inflammation during pregnancy should be

clearly explained to the patient so that acceptable

oral-hygiene techniques may be taught, reinforced

and monitored throughout pregnancy. With ade-

quate home care and periodontal intervention,

inflammation may resolve postpartum. Scaling and

root planing may be performed, whenever necessary,

during pregnancy. Some practitioners avoid the use

of high-alcohol-content antimicrobial rinses in

pregnant women and prefer to recommend the use of

nonalcohol-based oral rinses (42).

The prescription of prenatal fluoride supplements

has been an area of controversy. Although two stud-

ies have claimed beneficial results (24, 25), others

suggest that the clinical efficacy of prenatal fluoride

supplements is uncertain, and that the mechanism

by which prenatal fluoride supplements impart car-

iostasis is unclear (2). As such, the American Dental

Association and The American Academy of Pediatric

Dentistry do not recommend treatment with prenatal

fluoride supplements because of their unproven

efficacy.

Trimester periodontal care

Pregnancy alone is not a reason to defer routine

periodontal therapy. In fact, the pregnant woman is

more susceptible to periodontal inflammation during

this time of her life. The California Dental Association

Foundation, in collaboration with the American

College of Obstetrician and Gynecologists, produced,

in 2010, guidelines that state �prevention, diagnosis,

and treatment of oral diseases, including needed

dental radiographs and use of local anesthesia, is

highly beneficial and can be undertaken during

pregnancy without additional fetal or maternal risk

when compared to the risk of not providing care� (11).

Good oral health and control of oral disease protects

a women�s health and quality of life and has the po-

tential to reduce the transmission of pathogenic

bacteria from mothers to their children (11).

During the first trimester, therapy should include

preventive therapy, creating indiviudalized home-

care instruction. If there is periodontal inflammation,

it is �safe and effective to provide periodontal care to

reduce periodontal disease and periodontal patho-

gens during pregnancy� (11). It is recommended for

the pregnant woman to have a full clinical peri-

odontal examination and to understand the in-

creased susceptiblity to periodontal disease. It is

prudent, however, to avoid elective dental care if

possible during the first trimester and the last half of

the third trimester. The first trimester is the period of

organogenesis, when the fetus is highly susceptible to

environmental influences.

Early in the second trimester (14–20 weeks of ges-

tation) is the safest period for providing routine

dental care (23). The emphasis during this trimester

is to control active disease and eliminate potential

problems that could arise in late pregnancy. Peri-

odontal debridement should be performed during

this trimester. Major elective oral or periodontal

surgery should be postponed until after delivery.

Pyogenic granulomas that develop during pregnancy

(i.e. �pregnancy tumors�) that are painful, interfere

with mastication or continue to bleed or suppurate

after mechanical debridement, may require excision

and biopsy before delivery.

In the last half of the third trimester, a hazard for

premature delivery exists because the uterus is very

Fig. 6. HIV periodontitis in pregnancy.

Fig. 7. Gingival enlargement with cyclosporin treatment

during pregnancy.

223

Therapeutic challenges through female continuum

sensitive to external stimuli. Prolonged chair time

should be avoided because the woman is most

uncomfortable at this time. Furthermore, supine

hypotensive syndrome may occur. In a semi-reclining

or supine position, the great vessels, particularly the

inferior vena cava, are compressed by the gravid

uterus. By interfering with venous return, this com-

pression will cause maternal hypotension, decreased

cardiac output and eventual loss of consciousness.

Supine hypotensive syndrome can usually be reversed

by turning the patient on her left side, thereby

removing pressure on the vena cava and allowing

blood to return from the lower extremities and pelvic

area. A preventive 15 to 24-cm soft wedge (rolled to-

wel) should be placed on the patient�s right side when

she is reclined for clinical treatment (42). A periodontal

maintenance visit should also be performed during the

early- to mid-third trimester as a result of increased

periodontal inflammation associated with pregnancy.

Pre-eclampsia occurs when hypertension is asso-

ciated with proteinuria during pregnancy and is a

challenging condition in the management of the

pregnant woman. The presence of pre-eclampsia is

not a contraindication to dental care (11). Although

maternal periodontal infection has been associated

with a risk for pre-eclampsia, the research results

have been conflicting (28, 50) and further investiga-

tion is warranted (6).

Radiographs

The safety of dental radiography during pregnancy has

been well established, especially when features such

as high-speed film, filtration, collimation and lead

aprons are used. When radiographs are needed for

diagnosis, one of the most important aids for the pa-

tient is the protective lead apron with a thyroid collar

(4). Studies have shown that when an apron is used

during contemporary dental radiography, gonadal

and fetal radiation is virtually immeasurable (7, 38). To

put into perspective the safety of dental radiography,

the number of dental X-ray films needed to reach the

maximum accepted safety limit for radiation to the

fetus would be approximately half a million exposures

(60). With the obvious safety of dental radiography,

X-ray films should be taken when necessary and

appropriate to aid in diagnosis and treatment.

Medications

Drug therapy in the pregnant woman is controversial

because drugs can affect the fetus by diffusion across

the placenta. Presciptions should be kept to as brief a

duration as possible to support the pregnant patient�swellbeing and drugs should only be administered

after careful consideration of potential side effects.

The classification system established by the US Food

and Drug Administration in 1979 to rate fetal risk

levels associated with prescription drugs provides

safety guidelines. The prudent practitioner should

consult references such as Briggs Drugs in Pregnancy

and Lactation (8) and Olin�s Drug Facts and Com-

parisons (18) for information on the US Food and

Drug Administration pregnancy risk associated with

prescription drugs. Ideally, no drug should be

administered during pregnancy, especially in the first

trimester (34). However, it is virtually impossible

always to adhere to this rule. Fortunately, most

commonly used drugs in dental practice can be given

during pregnancy with relative safety, although there

are a few important exceptions. Tables 1, 2 and 3

present general guidelines for the use of anesthetic

and analgesic, antibiotic and sedative-hypnotic

drugs, respectively (5, 57).

Antibiotics, in particular, are often needed in

periodontal therapy. The effect of a particular medi-

cation on the fetus depends on the type of antimi-

crobial, dosage, trimester and duration of the course

of therapy (8, 18). Research regarding subgingival

irrigation and local site delivery in relation to the

developing fetus is limited at the time of writing.

Usually, there is a risk that the drug can enter

breast milk and be transferred to the nursing infant,

in whom drug exposure could have adverse effects

(Tables 4 and 5). Unfortunately, there is minimal

conclusive information on drug dosage in the mother

and level of drug in the breast milk, and the effect on

the infant; however, retrospective clinical studies and

empiric observations, coupled with known pharma-

cologic pathways, allow recommendations to be

made. The amount of drug excreted in breast milk is

usually not more than 1–2% of the maternal dose;

therefore, it is highly unlikely that most drugs have

any pharmacologic significance for the infant (8, 18,

58). When possible, the mother should take pre-

scribed drugs just after breastfeeding and then avoid

nursing for 4 h or more, if possible, to allow the drug

concentration in breast milk to decrease.

Menopause

The patient�s medical history during menopause

requires continual review, and changes in the medi-

cal and oral status should be recorded routinely

and updated. Hormonal changes alter a patient�s

224

Otomo-Corgel

Table 1. Local anesthetic and analgesic administration during pregnancy

Drug Food and Drug

Administration category

Use ⁄ risks during pregnancy

Local anesthetics*

Articaine B Yes; no nerve blocks

Etidocaine B Yes

Lidocaine B Yes

Prilocaine B Yes

Bupivacaine C Use with caution; consult physician

Mepivacaine C Use with caution; consult physician

Procaine C Use with caution; consult physician

Analgesics

Acetaminophen B Yes

Hydrocodone� B Use with caution; consult physician

Ibuprofen B ⁄ D Caution in first and second trimester;

avoid in third trimester

Oxycodone� B Use with caution; consult physician

Aspirin C ⁄ D Caution in first and second trimester;

avoid in third trimester

Codeine� C Use with caution; consult physician

Propoxyphene C Use with caution; consult physician

*Can use vasoconstrictors if necessary.�Avoid prolonged use.

Table 2. Antibiotic administration during pregnancy

Drugs Food and Drug

Administration category

Use during pregnancy Pregnancy risk

Cephalosporins B Yes Limited information

Clindamycin B Yes with caution Drug concentrated in fetal

bone, spleen, lung, liver

Erythromycin B Yes; avoid estolate form Intrahepatic jaundice in

mother

Metronidazole B Avoid Carcinogenic data from

animals

Penicillins B Yes Diarrhea

Ciprofloxacin C Avoid Cartilage erosin

Gentamicin C Caution; consult physician Limited information but

possible ototoxicity

Vancomycin C Caution; consult physician Limited information

Clarithromycin D Avoid; consult physician Adverse effects on pregnancy

outcomes and embryonic;

fetal development in animals

Tetracycline D Avoid Depression of bone growth;

enamel hypoplasia; gray-

brown tooth discoloration

225

Therapeutic challenges through female continuum

systemic, as well as psychologic, wellbeing. The

major cause of death in the menopausal female is

cardiovascular disease (32). The stage for osteope-

nia ⁄ osteoporosis is set at perimenopause. It is

recommended that the patient should be asked when

her last menstrual cycle occurred. If the patient has

had a hysterectomy, the date of the surgery and the

length of postoperative hormone replacement ther-

apy (if prescribed) will allow the clinician to note the

onset of estrogen deprivation. Patients who have not

had a hysterectomy are considered to be menopausal

if there has not been a cycle for one full year. The

median age for menopause is approximately

50 years, with 10% of women becoming menopausal

before 40 years of age and 10% after 60 years.

In women, two stages of primary bone loss occur.

The first stage is rapid trabecular bone loss caused by

estrogen deficiency; it is initiated with the onset of

menopause and continues for approximately 4–

8 years. This stage exhibits high bone resorption and

reduced bone formation. There is a second stage that

occurs in men and women in which slower trabecular

and cortical bone loss occurs as a result of decreased

bone formation.

Because of the possible alterations in oral soft and

osseous tissues during perimenopause and after men-

opause, appropriate questioning regarding hormone

changes should be performed and documented.

There are a myriad of hormone replacement ⁄ estro-

gen replacement therapies available, from prescrip-

tions to holistic approaches, which need to be

assessed. Many medications may alter clotting times,

prolong the effects of other medications and interfere

with absorption or effectiveness of prescription

medications. Estrogen depletion has also been

associated with xerostomia. To compound the prob-

lem of xerostomia, many postmenopausal patients

will be on antidepressants, which also reduce saliva

secretion.

Gingival and mucosal tissue thinning often occurs.

It is generally safe to perform soft-tissue augmenta-

tion procedures if needed. Brushing with an extrasoft

toothbrush using the �toe� or �heel� of the brush may

prevent �scrubbing� the thinning gingiva. Dentifrices

with minimally abrasive particles should be consid-

Table 3. Sedative-hypnotic drug administration duringpregnancy

Drugs Food and Drug

Administration

category

Use during

pregnancy

Barbituates D Avoid

Benzodiazepines D Avoid

Nitrous oxide Not assigned Avoid in first

trimester,

otherwise use

with caution;

consult physician

Table 4. Local anesthetic and analgesic administrationduring breastfeeding

Drug Use during breastfeeding

Local anesthetics

Lidocaine Yes

Mepivacaine Yes

Prilocaine Yes

Bupivacaine Yes

Etidocaine Yes

Procaine Yes

Analgesics

Aspirin Avoid

Acetaminophen Yes

Ibuprofen Yes

Codeine Yes

Hydrocodone No data

Oxycodone Yes

Propoxyphene Yes

Table 5. Antibiotic administration during breastfeeding

Drug(s) Use during breastfeeding

Antibiotics*

Penicillins Yes

Erythromycin Yes

Clindamycin Yes, with caution

Cephalosporins Yes

Tetracycline Avoid

Ciprofloxacin Avoid

Metronidazole Avoid

Gentamicin Avoid

Vancomycin Avoid

Sedative-hypnotics

Benzodiazepines Avoid

Barbiturates Avoid

Nitrous oxide Yes

*Have the risk of diarrhea and sensitization in the mother and infant.

226

Otomo-Corgel

ered. Mouthrinses should have a low alcohol con-

centration. During periodontal maintenance, root

surfaces should be debrided gently with minimal soft

tissue trauma. Oral pain may result from thinning

tissues, xerostomia, inadequate nutritional intake or

hormone depletion (42). In patients with oral symp-

toms who receive hormone replacement therapy,

symptoms may be significantly reduced. Studies

indicate improved periodontal status in women on

hormone replacement therapy or estrogen replace-

ment therapy, as well as increased alveolar bone mass

with associated improved alveolar crestal height, and

reduced clinical attachment loss (13, 46, 53). Consul-

tation with the patient�s physician as to the risks versus

benefits of hormone replacement therapy ⁄ estrogen

replacement therapy and calcium ⁄ vitamin D sup-

plementation for the individual patient may be

needed when periodontal disease occurs.

It has been suggested that the postmenopausal

woman who is susceptible to osteoporosis (e.g. Cau-

casian, Asian, smoker, minimal physical activity, low

calcium intake, thin build or low body weight, genetic

history) may also be more susceptible to periodontal

bone loss (30). Alveolar crestal height loss and max-

illary tooth loss have been associated with decreased

bone mineral density (15, 17, 26, 62); however, studies

evaluating the association of clinical attachment loss

and osteoporosis have produced equivocal results

(21, 39, 44, 49, 61). At the time of writing there were

no overwhelming data to link osteoporosis to peri-

odontal disease, and long-term studies are required

to assess the impact of these chronic problems on

one another (37). Furthermore, there are no scientific

data available to contraindicate the use of osseoin-

tegrated implants in osteoporotic patients, despite

articles indicating osteoporosis as a risk factor.

Bone-sparing drugs

Biphosphonates (e.g. alendronate, risendronte, iban-

dronate and zoledronic acid) are one of the primary

medications prescribed for osteoporosis. Bisphosph-

onate therapy studies have shown a positive effect on

reducing fracture risk, and reports have indicated a

reduction of periodontal disease progression (54, 55).

A rare side effect associated with bisphosphonate use

is osteonecrosis of the jaw. Osteonecrosis of the jaw

associated with bisphosphonates is defined as

exposed or necrotic bone in the maxillofacial region

that is present for at least eight continuous months in

patients who are using (or have used) bisphospho-

nates and have no history of radiation therapy to the

jaws (1, 3).

To date, no data are available regarding success or

failure with periodontal procedures in osteoporotic

versus nonosteoporotic individuals, with or without

bisphosphonate therapy. The best current peri-

odontal therapy is prevention and working in col-

laboration with the treating physician. Radiographic

evaluation of the alveolar bone and a thorough

periodontal examination assessing periodontal

attachment loss is necessary. The medical consulta-

tion conducted by the physician should include the

periodontal status and the periodontal ⁄ implant

treatment plan for the patient, as well as treatment

options. Patients should be asked about the length of

time they have been taking bisphosphonate medica-

tion, if the medication was taken reliably, noted side

effects and the date of the last bone-density scan.

If a patient taking an oral bisphosphonate presents

with osteonecrosis of the jaw, the prescribing physi-

cian needs to be consulted. Current recommenda-

tions for treating patients with osteonecrosis of the

jaw related to oral bisphosphonate use are found in

the 2011 American Dental Association recommen-

dations �Managing the Care of Patients Receiving

Antiresorptive Therapy for Prevention and Treatment

of Osteoporosis� (3). Thorough, but gentle, peri-

odontal debridement should be performed. The pa-

tient may be placed on appropriate antibiotics (as

determined in the medical consultation), stringent

home care and an antimicrobial (chlorhexidine)

mouthrinse. Exposed necrotic, sequestrated bone can

be gently debrided.

In addition to bisphosphonates, clinicians must

also weigh the effect of a myriad of medications that

may induce secondary osteoporosis (Table 6). In

patients taking this type of medication it is advisable

to monitor the patient�s periodontal status closely, to

perform titrated periodontal maintenance care, to

inform the patient about potential risks of hormone

depletion on the oral tissues and to consult the

treating physician.

The National Institutes of Health 1994 Conference

on Optimal Calcium Intake recommended 1,000 mg

of elemental calcium per day for premenopausal

women and 1,200 mg ⁄ day of elemental calcium for

postmenopausal women (Table 7) (40). Vitamin D

uptake has been determined to be suboptimal in 90%

of our elderly population. Currently, recommenda-

tions are 400 IU ⁄ day for premenopausal women and

800 IU ⁄ day for postmenopausal women. The new

consensus, however, is that 800–1,000 IU ⁄ day is the

minimal dose for the elderly, but 1,000-IU pills will

not be adequate for most elderly individuals during

the winter months and many people may consider up

227

Therapeutic challenges through female continuum

to 2,000 IU ⁄ day (16). Many physicians now propose

2,000 IU ⁄ day of vitamin D as the upper allowable

limit. Patients may also be given 50,000 IU ⁄ week of

vitamin D for 4–12 weeks if extremely low serum

levels of vitamin D are noted.

Patients who are prescribed intravenous bis-

phosphonates may be at risk for osteonecrosis of the

jaw. A systematic review by Woo et al. (59) reported

on 368 cases of osteonecrosis of the jaw. The primary

medical diagnoses of multiple myeloma, metastatic

breast cancer and metastatic prostatic cancer con-

stituted 91.5% of the reported cases. Over 94% of the

patients were on intravenous zoledronic acid,

pamidronate, or both. Of the osteonecrosis cases,

60% had received dentoalveolar surgery, but 40% of

cases of osteonecrosis appeared spontaneously, often

in denture wearers, in whom 39% were associated

with exostoses. Osteonecrosis of the jaw was more

common in the mandible (e.g. 65% prevalence) than

in the maxilla (e.g. 26% prevalence) and occurred

only 9% of the time in both mandible and maxilla.

The important predisposing factors for development

of osteonecrosis of the jaw were the type and dose of

the bisphosphonate, plus a history of trauma, dental

surgery or dental infection (59). Patients should have

dental clearance before starting therapy with intra-

venous bisphosphonates, similarly to protocols for

patients anticipating radiation to the head and ⁄ or

neck. Consultation with the treating physician is

important and the physician should be notified about

the status of the periodontal ⁄ dental tissues. Teeth

with a poor or hopeless prognosis should be ex-

tracted. Healthy periodontal tissues should be

established, individualized home-care procedures

developed and the possible oral effects of the medi-

cation should be explained to the patient. The ratio-

nale for closer periodontal monitoring and debride-

ment should also be explained to the patient. Sharp

or irregular bony prominences (e.g. lingual tori,

maxillary tori and the mylohyoid ridge) should be

reduced and removable prostheses should be as-

sessed for accurate fit.

Similarly to patients taking oral bisphosphonates, if

a patient presents with osteonecrosis of the jaw and

with a history of intravenous bisphosphonate therapy

or subcutaneous RANKL inhibitor therapy, the

treating physician should be contacted as soon as

possible. The following recommendations by the

American Academy of Oral and Maxillofacial Surgery

for the various stages of osteonecrosis of the jaw in-

clude informed consent, use of antibacterial mouth-

rinses and, when needed and depending on the

severity of the osteonecrotic lesion, the use of anal-

gesics, antibiotics, gentle debridement of the affected

area and, at times, surgical resection (1).

Surgical resection of lesions associated with

osteonecrosis of the jaw generally is not recom-

mended because more severe sequellae can develop.

However, a recent publication that evaluated surgical

resection of osteonecrosis of the jaw in patients tak-

ing an oral bisphosphonate concluded that resection

Table 6. Medications ⁄ drugs associated with secondaryosteoporosis

Glucocorticoids

Immunosuppressants i.e. cyclosporine A ⁄ tacrolimus

Cytotoxic drugs, i.e. methotrexate

Aromatase inhibitors i.e. anastrozole, exemestane,

letrozole

Lithium

Antisconvulsants, i.e. phenytoin, phenobarbital

Blood thinners i.e. warfarin ⁄ heparin therapy (long term)

Aluminum-containing antacids

Gonadotropin-releasing hormone agonists

Thyroid hormone (in excess)

Proton pump inhibitors (63)

Selective serotonin reuptake inhibitors

Thiazolidenediones i.e. pioglitazone ⁄ roziglitazone

Excessive alcohol

Table 7. Calcium recommendations

Age National academy of

sciences

Calcium intake

recommendations

mg ⁄ day

Birth to 6 months 210

7 months to 1 year 270

1–3 years 500

4–8 years 800

9–18 years 1,300

19–50 years 1,000

51 years or older 1,200

Pregnant ⁄ lactating

14–18 years

1,300

Pregnant ⁄ lactating

19–50 years

1,000

228

Otomo-Corgel

of the osteonecrosis can yield acceptable healing in

the maxilla or mandible (10). In patients with

necrosis after intravenous bisphosphonate therapy,

the healing outcome after surgical resection was

predictably good in the maxilla, but was variable in

the mandible (10). We are just beginning to under-

stand the process of osteonecrosis of the jaw, and

treatment modalities are in their infancy. Additional

research is needed to address the increasing number

of patients who may present to periodontal practices

with osteonecrosis of the jaw.

Conclusions

The female patient presents unique complexities that

vary along her life�s continuum. The cyclic nature of

the female sex hormones is often reflected in the

gingival tissues as initial signs and symptoms. Med-

ical history and dialogs should include thoughtful

investigation of the individual patient�s needs. Hor-

monal fluctuations differ from patient to patient. The

dental professional should explore hormonal stability

and medications associated with hormone regula-

tion. Patients should be educated regarding the

profound effects that sex hormones may play on

periodontal and oral tissues as well as the need for

proper oral self-care and a frequent professional

intervention.

It is apparent that dentists will be treating increasing

numbers of female patients with diseases associated

with longevity. The world population older than

80 years of age is increasing dramatically, with women

assuming the majority in the USA. In 2009, 101.9 mil-

lion octogenarians and older populated the world. By

2050, the projection by the United Nations Depart-

ment of Economic and Social Affairs predict this seg-

ment of the population will rise to 394.7 million.

Clinical periodontal therapy includes an under-

standing of the clinician�s role in the total health and

wellbeing of female patients. Dentists do not treat

localized oral infections without affecting other sys-

tems of the body. Female patients may present with

periodontal and systemic considerations that alter

conventional periodontal therapy.

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