How does the menopause affect oral health and the quality of life in female patients?

Abstract

Objective: To determine if a more supportive approach is required from dental professionals to the menopausal patient - peri, current and post-menopausal stage and to evaluate if this alteration impacts the oral health risk.

Introduction: The menopause is where a female does not menstruate for a consecutive 12 months, causing her hormone levels to reduce. Symptoms can occur from the age of 35 years and a female can still be menstruating but symptomatic, this is known as the perimenopause. After a female has reached the menopause, they can continue to have symptoms for many years, this is known as post-menopause. This literature review looks at the evidence of how the menopause, before and after, can be implicated in the oral health and quality of life (QOL) in the female patient.

Methodology: Various electronic databases were used to answer a PEO question [Patient/Population/Problem, Exposure and Outcome] using Boolean operators and truncators. Inclusion and exclusion criteria were utilised to screen papers that did not meet the criteria.

Nine papers met the criteria and were critically appraised.

Results: The reviewed literature showed that menopause affects the QOL of female patients, leading to depression and a lack of motivation towards oral care.

Hormone replacement therapy (HRT) can be considered as a benefit due to reduced xerostomia leading to patient comfort and reduced caries risk.

Burning Mouth Syndrome (BMS) appears more prominent in menopausal women, but with no definitive connection, this should be explored further.

Skeletal bone loss and vaginal dryness are also associated with menopause and, therefore, should not be ruled out as secondary risk factors to oral health and patient QOL.

Conclusions: The menopause should not be considered lightly when discussing this in a patient's medical history. Dental professionals need to understand the implications of menopause and the secondary risk factors that can affect the oral health and QOL within female patients who are experiencing the menopause at various stages.

By dental therapist and recent graduate Christine Lindsay

©DrAfter123/DigitalVision Vectors/Getty Images Plus

Introduction

The menopause, or secondary amenorrhoea, is when a female stops having a menstrual cycle for a consecutive 12 months.¹ This occurs when the female body naturally reduces its hormone levels, and it is anticipated that this transition usually occurs around the ages of 45-55 years but that the timing can be influenced by a woman's ethnicity and lifestyle.² The menopause can also be medically induced for reasons such as a hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), and cancer treatments.³

During the perimenopause, a fluctuation in oestrogen can develop, causing the onset of menopausal symptoms such as tiredness, hot flushes, vaginal dryness, and the risk of osteoporosis. Irregular periods may commence, and menstrual cycles can be longer or shorter, which can impact ovulation (egg release).⁴

Post-menopause is the stage when a female has experienced menopause for 12 months; it is predicted that females will undergo post-menopause around the age of 51. During this stage, a female no longer ovulates and may experience milder menopausal symptoms lasting up to ten years, and is considered at greater risk of osteoporosis.⁵

Psychological and physical changes occur throughout all three menopause stages, and it is common for a female to face sleep disturbances and depression, which can have an impact on QOL. Therefore, the impact of menopause on oral health and QOL throughout this process was explored.

Methodology

A literature search was carried out using University of the Highlands and Island's (UHI's) multi-search, PubMed, Medline, Web of Science, Google Scholar, CINAHL and Cochrane. Boolean logic and truncators were applied with various relative search terms. Hierarchy evidence was limited to cohort studies and case-control studies, due to the nature of the topic; all findings were critically appraised using the CASP tool.⁶ And an additional tool from AXIS was also used.⁷

Females over the age of 35 were included throughout the search. Medically induced menopause was excluded.

One paper included male participants, which was outside the original inclusion criteria. However, it was used to focus on the section which discussed BMS in menopausal women.

Results

Nine studies published after 2013 were included in this review: seven case-control studies and three cohort studies. Whilst this sits on the lower scale of the hierarchy of evidence, it was not viable to carry out a study for this question with the use of randomised control studies or systematic reviews.

Two papers showed that menopause affects the QOL in female patients due to factors such as depression, leading to a lack of motivation towards oral care.

Three papers discussed BMS to be more prominent in menopausal females but with no definitive connection. One paper stated that chokeberry juice could be a natural therapeutic treatment for patients suffering from BMS.

One paper discussed Hormone Replacement Therapy (HRT) and the benefits it can have on the oral health for the menopausal patient.

Two papers discussed skeletal bone loss in menopausal women, focusing on the association with osteoporosis and bone thickness in the maxilla.

One review discussed dental management in the menopausal patient.

Discussion

During the menopause stages, females are more susceptible to oral diseases due to changes in sex hormones such as oestrogen, progesterone, and testosterone.⁸ Emotional changes such as depression and mood fluctuations can also influence physical wellbeing, including sleep disruption, anxiety, sexual behaviours, and memory/concentration changes. These are all common menopausal symptoms which will have a direct impact on a person's QOL. Rabiei et al. discuss that the psychological disorders affect a patient's tolerance and understanding making them more susceptible to oral health diseases and therefore re-enforcement towards oral care is paramount to reduce the risk of invasive dental disease and tooth loss.⁹

Postmenopausal changes affect intraoral tissues, due to thinning of the oral mucosa, alterations of the oral flora, and decrease of alveolar bone mineral density.¹⁰ According to another source, the oral mucosa and periodontal tissues are more susceptible to inflammation due to changes in hormone levels.⁸ Periodontitis is a chronic inflammatory disease of supporting tissues around teeth that may lead to tooth loss due to alveolar bone resorption.¹⁰ However, Lee et al. discuss that bone resorption occurs during the menopause, due to the body experiencing many hormonal changes.¹¹ This leads a patient to be more susceptible to plaque, therefore increasing the risk of periodontal disease.¹² Whilst menopause does not directly impact oral health, its associations do affect the QOL, which can have a direct impact on oral health. Yakar et al. state that there is no consensus for an increased risk of periodontitis after menopause.¹⁰

Burning mouth syndrome

Burning mouth syndrome (BMS), also referred to as glossodynia or stomatodynia throughout some of the reviewed literature, is difficult to establish within the mouth. This is due to there being a lack of clinical signs during dental examination. BMS is a condition in which patients complain of the burning sensation of the tongue, lips or other oral mucosa surfaces.⁹ Other sources have mentioned xerostomia and the feeling of burning sensation on the palate and the pharynx. BMS can also increase the risk of dental diseases such as candidiasis,¹² which is a common side effect of the menopause and of post-menopause due to the hormone imbalance. Research carried out by Ślebioda and Szponar found that BMS is more evident in females and more likely to increase with age and suggested that this is due to the hormone changes which occur in women due to the menopause.¹³ Anxiety, depression and emotional stress were found to be associated with the BMS condition and that the feeling of BMS can extend up to a period of six months.⁹

Diagnosis and treatment for BMS should be carefully considered, if a patient reports pain due to BMS for a period of four to six months, or if it affects their eating and drinking habits due to sensitivity localised to the oral mucosa. Ślebioda and Szponar suggest the application of local gels containing lidocaine hydrochloride, benzocaine and benzydamine.¹³ They also suggest topical agents containing chamomile and linseed as well as highlighting that oral mouth rinses containing alcohol should be avoided, as this can dry the mucosa, increasing the irritation sensation which is associated with BMS. Whilst these suggestions fall beyond the remit of a dental therapist, a discussion with a dentist or general practitioner would be the encouraged option.

Research carried out in Serbia suggested the use of chokeberry juice as a natural therapy for menopausal women suffering with BMS.¹⁴ The required experiment requested that participants with the menopause and BMS had rinsed their mouth with 15 ml of chokeberry juice for five minutes before swallowing it, for three times a day for 28 days. They were required to do this after mealtimes and to avoid eating and drinking for up to one hour after the juice experiment. The results showed the sensation of pain and xerostomia to have reduced. The authors mentioned that this can improve peripheral circulation and has antioxidative properties, but that the study needed further intervention to confirm that the placebo effect did not compromise the experiment.¹⁴

Oestrogen deficiency can reduce saliva flow, leading to an increase in caries risk and potential infection, but it can also affect speech, chewing and swallowing which can impact on quality of life.

A cohort study carried out in Korea suggested that oestrogen replacement therapy can reduce BMS in patients.¹⁵ Although the suggestion and prescription of medication is out of the remit of a dental therapist, a patient can still be referred to other health care departments. The same study focused on the neuropathy to locate the oral sensation when considering BMS and found that oestrogen regulates nociceptive receptors, and that the reduced oestrogen caused by the menopause is a triggering factor for BMS. Seol and Chung also suggest that reduced oestrogen can increase the feeling of pain and sensitivity due to the nerve receptors in the sensory neurons.¹⁵

Hormone replacement therapy (HRT)

HRT is used to replace loss of oestrogen or progesterone in a female's body due to the occurrence of the menopause. Treatments come in variations to improve a woman's QOL.¹⁶ Research shows that post-menopausal women who received oestrogen therapy increased the density of the alveolar bone levels and that those taking HRT are less likely to develop periodontal disease as it has a positive effect on the alveolar bone density.⁸ However, it has no relationship with periodontal tissues or pocket depth and therefore HRT may be viewed as an option in reducing the periodontal risk status⁸ along with emphasis towards oral care.

A cross-sectional study carried out in Korea suggested that HRT should be considered to perimenopausal women for prevention.⁸ This is due to the increased risk of bone loss and periodontal disease caused by prolonged oestrogen deficiency.

Oestrogen deficiency can reduce saliva flow, leading to an increase in caries risk and potential infection, but it can also affect speech, chewing and swallowing which can impact on QOL. Wang et al. suggest that some post-menopausal women have reported the experience of less discomfort and dry mouth whilst taking HRT.¹⁷

Skeletal bone loss

A cross-sectional study showed that bone loss increased one to two years after the menopause but then stabilised. The study showed that periodontal disease is more evident in menopausal women due to the oestrogen deficiency and that menopausal women with osteoporosis were at a higher risk of bone loss compared to women without osteoporosis and concluded the menopause to be a risk factor towards periodontal disease.² However, Naghibi et al. found bone thickness in non-menopausal women to be higher than menopausal women when assessing the thickness of the buccal bone of the anterior maxilla but states that there was not a significant difference.¹⁸

Dental care professionals should be aware of the risks associated with menopause such as osteoporosis and skeletal bone loss, as these both have been proven to have a direct impact towards periodontal disease.

Ślebioda and Szponar discuss the hormonal imbalance in the body and the effects of receptors for sex hormones being the same for oral and genital epithelium.¹³ This leads to the question of whether xerostomia and genitourinary syndrome menopause (vaginal dryness due to the menopause) are associated. No evidence to discuss genitourinary syndrome menopause (GSM) towards oral health was found. Research for the association of GSM and QOL was found but did not meet the criteria.

Conclusion

The menopausal transition puts women at greater risk towards their oral health and a potential risk to bone loss. Individuals that present with depression are more likely to develop periodontitis and motivation to their oral health should be implemented.¹⁰ Dental care professionals should be aware of the risks associated with menopause such as osteoporosis and skeletal bone loss, as these both have been proven to have a direct impact towards periodontal disease.

Chokeberry juice as a natural therapy was shown to give relief for those who suffered with BMS during the menopause. HRT has a positive effect with reduced xerostomia and on alveolar bone density but has no relationship with periodontal tissues or pocket depth. Therefore, intervention with medical professionals in regard to HRT should be considered.

Clinical recommendations

Further research into BMS and chokeberry juice as therapeutic treatment is needed.

Genitourinary syndrome menopause (GSM) should be explored and if this has any impact on oral health and quality of life in the menopausal patient.

Author information

Christine says: I have recently graduated from the University of the Highlands and Islands (UHI) and have a history in dental nursing. I feel that dentistry has always been a passion and a big part of my life. I'm newly working as a dental hygienist and therapist in two separate practices and am looking forward to finding my feet in employment before deciding on my next step in my dental adventure.