|Year : 2015 | Volume
| Issue : 2 | Page : 116-120
Taos of late 50: A review on postmenopausal oral discomfort in women
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra, India
|Date of Web Publication||20-Apr-2015|
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra
Menopause, the cessation of menses, is a normal physiologic event experienced by women. It is not an illness or a deficiency. After a woman's reproductive years, there is a 5- to 10-year period of menopause-related alterations in hormone patterns. These patterns terminate in a sharp decline of female hormone levels. The lack of ovarian estrogens appears to be associated with the onset of several postmenopausal diseases, most notably osteoporosis and heart disease. Oral discomfort has been reported as a complaint among postmenopausal women. It includes occurrences of pain, burning sensations, altered taste perception and dryness of the mouth. On this background this paper presents a review on the postmenopausal discomfort in women.
Keywords: Discomfort, menopausal gingivostomatitis, overlooked
|How to cite this article:|
Brahmankar U. Taos of late 50: A review on postmenopausal oral discomfort in women. SRM J Res Dent Sci 2015;6:116-20
| Introduction|| |
The word menopause literally means the permanent physiological, or natural, cessation of menstrual cycles, and comes from the Greek "meno" (month) and "pausis" (a pause, a cessation). The World Health Organization (WHO) defines menopause as "the permanent cessation of menstruation resulting from the loss of ovarian follicular activity." WHO contends that natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea, for which there is no other obvious pathological or physiological cause. The mean age of menopause is 52 years.  Even though menopause is an unavoidable event for all women, several health complaints experienced by women, such as an increased risk of osteoporosis and coronary heart disease and a decreased quality-of-life can be linked to menopause.  Due to a lack of awareness regarding the management of menopause, some women are forced to spend one-third of their postmenopausal life battling associated problems and diseases.  According to the World Bank, the total population of postmenopausal women throughout the world was 476 million in 1990 and an analysis of the distribution of postmenopausal women revealed that 40% live in the industrialized world. It is predicted that the total number of postmenopausal women in 2030 will be approximately 1200 million and the proportion of those living in the developing world will increase to 76%.  It is imperative for health-care professionals to look at the various problems menopausal women may encounter, in order to inform and empower them in managing this phase.
| Oral health considerations in postmenopausal women|| |
These events induce major modifications in the genital system as well as in other areas of the body  . Earlier reports on the various oral manifestations of menopause emphasized on cytological studies of the oral mucosa, gingiva, and vagina of postmenopausal women and reported tissue
changes [Table 1]. , Additional studies, later supported correlations between estrogen deficiency and oral changes seen during menopause. , Oral mucosa resembles vaginal mucosa in its histology as well as its response to estrogens. Sex hormone receptors have been detected in the oral mucosa and salivary glands. ,,, Estrogen can affect the oral mucosa directly or through neural mechanism thus altering the periodontal health in menopausal women.  The oral problems may include a paucity of saliva leading to xerostomia, burning mouth syndrome (BMS), increase in incidence of dental caries, dysesthesia, taste alterations, atrophic gingivitis, periodontitis, and osteoporotic jaws. 
| Xerostomia|| |
Saliva plays an essential role in maintaining oral health. Salivary glands contain sex hormone receptors, and these hormones have been estimated in the saliva. ,,, Postmenopausal women have decreased unstimulated and stimulated submandibular and sublingual salivary gland flow compared with premenopausal women; a finding unrelated to any medication effect.  Although few studies conclude that salivary flow decreases in menopausal women with an increase in salivary IgA and total proteins, others have not been able to delineate any alterations in salivary volume/composition.  Alterations in salivary function may lead to impairment of oral tissues and have a large impact on the patient's quality-of-life.  A higher incidence of dental caries, oral mucositis, dysphagia, oral infections, and altered taste has been reported in individuals with reduced salivary flow. 
Dry mouth not only is annoying, but may lead to yeast infections, dental caries, mouth ulcers, and oral malodor because saliva functions to wash away food debris, plaque, carbohydrates, and helps prevent new plaque buildup along with remineralization of the teeth and combating harmful micro-organisms.  Dry mouth is not the only cause for oral malodor seen in postmenopausal women. Many menopausal women suffer changes in mood, especially depressive disorders, which have been associated with xerostomia, although the causal relationship between these two factors and dry mouth is unclear. With regard to depression and its relationship with the appearance of xerostomia, various studies have used different tests to evaluate the psychological condition, establishing a direct relationship between these variables, both with the appearance of the symptomatology and with its disappearance on the improvement of the depression. ,
Management includes frequent sipping of water, artificial salivary substitutes, sugar-free gums/lozenges, xylitol tablets and sialogogues such as pilocarpine, bromhexine, cevimeline, and bethanechol. ,, Use of toothpastes, gels/varnishes containing fluorides is advisable for the prevention of dental caries.  Chlorhexidine reduces plaque and enables prevention of root caries. 
| Burning mouth syndrome|| |
Burning mouth syndrome also known as glossodynia, stomatodynia, stomatopyrosis, glossopyrosis, glossalgia represents a common oral abnormality that manifests as intense pain and spontaneous burning sensation affecting various areas of the oral cavity in the absence of any identifiable organic abnormalities.  It is chiefly bilateral and affects the tongue, lips, palate, gingival, and areas of denture support. Menopause plays an important role in the incidence of glossodynia. Mean patient age for the onset of BMS is 50-60 years. The underlying etiology remains ambiguous with hormonal changes and small fiber sensory neuropathy of the oral mucosa suggested as probable underlying causes.  Certain microorganisms such as Candida albicans, Staphylococci, Streptococci, and various anaerobes have also been suggested as the etiological factor of BMS, along with xerostomia (associated to Sjogren's syndrome, anxiety and medication), anemia (pernicious or iron deficiency), nutritional disorders related to vitamin B complex or iron, diabetes mellitus, climacteric hypoestrogenemia per se, certain mechanical factors (abnormal oral habits, chronic denture-induced irritation) and other idiopathic factors. Psychological disorders, including depression, anxiety, phobia for severe illnesses such as cancer and other psychogenic alterations appear to play a fundamental role. During menopause, some women may experience neglect by their husband and children, or financial difficulties or a change in their role within the house. These problems may aggravate any psychological or sexual difficulties already being experienced, and are classified as psychosocial problems. , The diagnosis of BMS is based on the compilation of a detailed case history, the absence of findings in the physical examination and laboratory tests and the exclusion of other possible oral disorders. In general, a clinical diagnosis is established without difficulty though the factors underlying the symptoms are either difficult or impossible to identify. Treatment consists of low dose topical (without swallowing) or systemic clonazepam. The association of this drug to tricyclic antidepressants has afforded variable results. 
| Periodontal health|| |
The periodontium is composed of the supporting structures of teeth, namely; gingiva, periodontal ligament, cementum, and alveolar bone. Sex steroid hormones are responsible for health of the periodontium also. They can lead to changes in inflammatory mediators, vascular permeability, and growth and differentiation of fibroblasts. There are estrogen receptors in osteoblasts and fibroblasts of periodontal tissues, which respond to the varying levels of hormones in different stages of reproductive life and thus affect the health of the periodontium. ,, Female gender-related hormonal situations, such as pregnancy and puberty associated gingivitis are known as temporary periodontal diseases. , Women may demonstrate menopausal gingivostomatitis and the clinical signs of this disease are drying of the oral tissues, abnormal paleness of the gingival tissues, redness and bleeding on probing and brushing. In literature, there are very few studies that correlate only menopause or an estrogen deficient state to susceptibility to periodontal disease. , Endocrinal alteration induced bone resorption appears to be the principle pathogenic mechanism underlying accelerated bone loss in postmenopausal women with no direct relationship between the two phenomena. ,, Though, systemic bone loss may be a risk indicator for periodontal destruction, and augmented rates of bone mineral density (BMD) loss after menopause are coupled with greater risk of tooth loss. , Therefore, avoidance and management of osteoporosis after menopause could also have enhanced future oral health consequences. ,
Systemic osteoporosis leading to generalized bone loss may make the jaws susceptible to advanced alveolar bone loss, decreased BMD of the alveolar crest/subcrestal alveolar bone and to a smaller extent ligamentous attachment loss. , The exact relationship between osteoporosis, periodontal pathosis, and edentulism remains, however, controversial.  Methods of diagnosing systemic osteoporosis in postmenopausal women have been developed by oral and maxillofacial radiologists employing dental/panoramic radiographs. Postmenopausal women endure greater residual ridge resorption following dental extractions than premenopausal women making construction of conventional dentures and placement of implants difficult.  Apart from maintenance of a meticulous oral hygiene, several studies have indicated that estrogen therapy builds up mandibular bone mass and diminishes the severity of periodontal disease in postmenopausal women. Bisphosphonates prevent systemic bone resorption and decrease the incidence of vertebral and nonvertebral fractures in postmenopausal women. 
| Miscellaneous|| |
Other less common menopause-associated symptoms include mucosal disorders such as lichen planus, benign mucosal pemphigoid, and Sjogren's syndrome.  Nutritional status is also important during menopause as nutritional condition may have a direct effect on the chemosensory function, which in turn would induce changes in dietary habits. Individuals with loss of sensitivity to sweet tastes may sweeten foods with potentially serious consequences, especially for those with diabetes mellitus, cardiac disease or obesity. A significant reduction in sucrose perception and palatal sensitivity in postmenopausal women is also noted.  Psychological distress in menopausal women may lead to eating disorders. Oral changes may crop from self-induced vomiting and resultant regurgitation of gastric contents. Smooth erosion of enamel, perimolysis, enlarged parotid glands, trauma to oral mucous membrane and pharynx resulting from use of fingers, combs, and pen to induce vomiting, angular cheilitis, dehydration, and erythema may be observed in menopausal women suffering from eating disorders.  Trigeminal neuralgia is also known to occur frequently in postmenopausal women owing to compression of superior cerebellar artery on any one of the branches of the trigeminal nerve. The same is characterized by severe unilateral, lancinating, "electric shock" like pain usually in the middle and lower third of the face.  Apart from this, other neurological disorders such as Alzheimer's disease and atypical facial pain/neuralgia may affect postmenopausal women. Neurological disorders influence impression making procedures, jaw relation records, and denture retention. Thus, employment of anxiety and stress reduction protocols is suggested in menopausal women during treatment procedures. 
| Role of hormone replacement therapy|| |
Peri- or post-menopausal women take hormone replacement therapy (HRT) for relieving climacteric symptoms and increasing the quality-of-life [Table 2]  . A number of studies have shown that HRT can relieve this oral discomfort in postmenopausal women, further suggesting a role for female sex hormones in the maintenance of oral tissues.  One study showed that postmenopausal HRT protected against tooth loss and reduced the risk of edentulousim as well as reduced gingival bleeding. Norderyd et al.,  in a cross-sectional study, found less periodontal disease in postmenopausal women who were on estrogen therapy than in those who were not, although the difference was not statistically significant. The rate of bone loss in postmenopausal women predicts tooth loss for every 1%/year decrease in whole-body BMD, the risk of tooth loss increases more than four times. Estrogen replacement improves bone density in postmenopausal women. 
| Conclusion|| |
Research on interventions and treatments for diseases with differing prevalence in women, including diseases of the oral system, should be considered a priority in women's health research.  Physicians caring for postmenopausal women should be vigilant and encourage their patients to seek regular dental evaluation for prevention and early management of oral disorders. Conversely, dentists should be aware of the potential effects of menopause and its treatments on oral health. They should always exercise their own professional judgment in any given situation, with any given patient. Scientific advances, unique clinical circumstances, and individual patient preferences must be factored into clinical decisions. This requires the dentist's careful judgment. Balancing individual patient needs with scientific soundness is a necessary step in providing oral health care for the postmenopausal women.
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[Table 1], [Table 2]