I J Pre Clin Dent Res 2015;2(4):36-40 International Journal of Preventive &

Oct-Dec Clinical Dental Research

All rights reserved

Hormonal effect on the Periodontium: A Brief

Review
Abstract
Periodontitis is a chronic bacterial infection of the supporting structures Manu Sharma1, Bhavna Jha Kukreja2,
of the teeth. The host response to infection is an important factor in Pankaj Kukreja3, Anuja Agarwal4,
determining the extent and severity of periodontal disease. Periodontitis Avnish Singh5
is now seen as resulting from a complex interplay of bacterial infection 1
Senior Resident, Department of Dentistry,
and host response, often modified by behavioral factors. Systemic
Lala Lajpat Rai Medical College, Meerut, Uttar
factors modify periodontitis principally through their effects on the Pradesh, India
2
normal immune and inflammatory mechanisms. These systemic Senior Lecturer, Department of Periodontics,
disorders have been documented as capable of affecting the ITS Centre for Dental Studies and Research,
Ghaziabad, Uttar Pradesh, India
periodontium and/or treatment of periodontal disease. In order to 3
Associate Professor, Department of Oral and
rationally treat and prevent periodontal disease, we need to know the Maxillofacial Surgery, ITS Centre for Dental
etiologic agents for specific patients, and the mechanism of bacterial Studies and Research, Ghaziabad, Uttar
pathogenesis in periodontitis. In systemic diseases in which the Pradesh, India
4
Professor, Department of Oral and
periodontal tissues are affected as well, early detection and carefully
Maxillofacial Surgery, ITS Centre for Dental
managed therapeutics with the physician and periodontist working Studies and Research, Ghaziabad, Uttar
together may prove beneficial to the patient's general health and quality Pradesh, India
5
of life. In this article, we attempt to outline the effect of systemic Reader, Department of Community Dentistry,
ITS Centre for Dental Studies and Research,
hormones and body changes on the periodontium.
Ghaziabad, Uttar Pradesh, India
Key Words
Hormone; disease; periodontium

INTRODUCTION production of pro-inflammatory cytokines,

Periodontal diseases include a group of prostaglandins, and matrix metalloproteinases in
inflammatory diseases characterized by progressive periodontal connective tissue. Therefore, systemic
destruction of the periodontium. Dental plaque is diseases and genetic disorders that affect immune
the initiator of periodontal disease, but disease function, inflammatory response, and tissue
severity and response to treatment are determined organization are considered major determinants of
predominantly by host-based risk factors. When susceptibility and severity of periodontitis.[4]
dealing with periodontal problems, particularly in Periodontal diseases and cardiovascular diseases
children and adolescents, it is advisable to establish Cardiovascular diseases (CVD) are a group of
a differential diagnosis of periodontal disease due to diseases that include congestive heart failure,
systemic conditions.[1] Although specific cardiac arrhythmias, coronary artery disease
microorganisms have been identified as putative (including atherosclerosis and myocardial
periodontal pathogens, it has become apparent that infarction), valvular heart disease and stroke. CVD
pathogens are necessary, but not sufficient, for and periodontitis are both chronic and multifactorial
tissue breakdown to occur.[2] Their presence, in fact, diseases, and share some of their risk factors: age,
is a crucial factor in the onset of periodontitis, but male gender, lower socioeconomic status, smoking
disease susceptibility, progression, and severity as and psychosocial factors such as stress.[5] Recently,
well as response to treatment is determined periodontal disease (PD) has been investigated as a
predominantly by host-based risk factors.[3] These potential factor contributing to the onset and
factors operate by affecting primary host defense development of CVD.[6] Several mechanisms that
mechanisms at the microbial-host interface could explain this association have been
(humoral immune response, polymorphonuclear investigated. The host response to the presence of
leukocyte phagocytosis and killing) and the periodontal pathogens may trigger the production of
 37 Hormone & Periodontium Sharma M, Kukreja BJ, Kukreja P, Agarwal A, Singh A

inflammatory mediators such as C-reactive protein, the infection is installed, it exacerbates the systemic
TNF-α, PGE2, IL-1β and IL-6, which can accelerate disease.[16] The interrelationship between diabetes
the progression of pre-existing atherosclerotic and periodontal disease is established through a
plaques7 and are related to an increased number of number of pathways[27] and is bidirectional.[28]
adverse cardiovascular events.[8] Also, several Diabetes is a risk factor for gingivitis and
studies demonstrated the ability of periodontal periodontitis.[29,30] Blood sugar control is an
pathogens to induce platelet aggregation and the important variable in the relationship between
formation of atheromas.[9,10] diabetes and periodontal disease. Individuals who
Pregnancy and Periodontal Diseases have poor control over glycemia have a greater
The first study to report the influence of poor oral prevalence and severity of gingival and periodontal
health on the birth of low weight and preterm inflammation.[31-33] It has been suggested that
infants was performed by Offenbacher and hyperglycemia promotes periodontitis and its
colleagues.[11] The etiology of preterm birth is progression.[28,34-39]
multifactorial, but inflammation is the common Periodontal Diseases and Respiratory Diseases
pathway that leads to uterine contractions and Respiratory diseases is the term for diseases of the
cervical changes with or without premature rupture respiratory system, including lung, pleural cavity,
of membranes. Biological plausibility of the link bronchial tubes, trachea, and upper respiratory tract.
between both conditions, periodontal disease and There is increasing evidence that a poor oral health
preterm birth, does exist and can be summarized in can predispose to respiratory diseases, especially in
three potential pathways.[12,13] One of them refers to high-risk patients (nursing home residents, older
the hematogenous dissemination of inflammatory subjects, intensive care unit patients and
products from a periodontal infection, while the hospitalized individuals requiring mechanical
second potential pathway involves the fetomaternal ventilation). The oral cavity is contiguous with the
immune response to oral pathogens. The third trachea and may be a portal for respiratory pathogen
pathway proposed to explain the theoretical causal colonization. Dental plaque can be colonized by
relationship between periodontal disease and respiratory pathogens,[40] which may be aspirated
preterm birth involves bacteremia from an oral from the oropharynx into the upper airway and then
infection. There appears to be an association reach the lower airway and adhere to bronchial or
between both conditions, but whether periodontitis alveolar epithelium.[41] There is fair evidence of an
is a confounding factor, a marker or one of the association of pneumonia with oral health, but there
causes of preterm birth remains unclear.[14] is poor evidence of a weak association between
Diabetes and Periodontium COPD and oral health. Improved oral hygiene and
Diabetes is a group of metabolic diseases professional oral health care reduces the progression
characterized by hyperglycemia and results from or occurrence of respiratory diseases among high-
either a deficiency in the secretion of insulin and/or risk elderly adults.
reduced insulin action.[15] Chronic periodontal Oral contraceptives and Periodontium
disease and diabetes mellitus are common chronic Hormones are specific regulatory molecules that
conditions in adults throughout the world.[16] Severe have potent effects on the major determinants of the
periodontal disease often coexists with diabetes and development and the integrity of the skeleton and
is considered the sixth most common complication oral cavity including periodontal tissues. It is clear
of the disease.[17] A number of studies have that periodontal manifestations occur when an
demonstrated that poor blood sugar control may imbalance of these steroid hormones take place.
contribute to poor periodontal health[18-24] and that Women using hormonal contraceptives can be
such individuals have a 2.8-fold greater chance of considered to be a 'risk group' for periodontal
developing destructive periodontal disease[19] as disease, due to prolonged, sustained serum levels of
well as a 4.2-fold greater chance of having oestrogens and progesterone.[42] It is clear that
progressive alveolar bone loss.[25] The increased risk endogenous sex steroid hormones play significant
of developing periodontal disease cannot be roles in modulating the periodontal tissue responses.
explained by age, gender or hygiene.[26] The A better understanding of the periodontal changes to
interrelationship between periodontal disease and varying hormonal levels throughout life can help the
diabetes provides an example of a systemic disease dental practitioner in diagnosis and treatment. The
predisposing individuals to oral infection and, once women under contraceptive seem to set up a group
 38 Hormone & Periodontium Sharma M, Kukreja BJ, Kukreja P, Agarwal A, Singh A

at risk for developing a periodontal disease, it is 6. Weidlich P, Cimões R, Pannuti CM,

thus necessary to systematise periodontal appraisal Oppermann RV. Association between
before and during contraceptive use period.[43] periodontal diseases and systemic diseases.
CONCLUSION Braz Oral Res 2008;22(1):12-14.
The connection between systemic diseases and 7. Lalla E, Lamster IB, Hofmann MA,
chronic destructive periodontitis (CDP) has received Bucciarelli L, Jerud AP, Tucker S, et al. Oral
increasing attention in recent years. A major infection with a periodontal pathogen
unanswered question is how disease in one part of accelerates early atherosclerosis in
the body (e.g., the joints and skeletal tissues) can apolipoprotein E-null mice. Arterioscler
transmit signals to the periodontium. Current Thromb Vasc Biol 2003;23(8):1405-11.
treatment approaches available to the periodontist 8. Scannapieco FA, Bush RB, Paju S.
and dentist include: (i) antimicrobial therapy, Associations between periodontal disease and
including mechanical debridement and surgical risk for atherosclerosis, cardiovascular disease,
reduction of probing depth to reduce the bacterial and stroke. A systematic review. Ann
"load" in the periodontal pocket, combined (as Periodontol 2003;8(1):38-53.
needed) with topical and systemically administered 9. Khader YS, Albashaireh ZS, Alomari MA.
antimicrobials; and (ii) host-modulation therapy Periodontal diseases and the risk of coronary
(using FDA-approved, MMP-inhibitor sub- heart and cerebrovascular diseases: a meta-
antimicrobial-dose doxycycline by itself or, after analysis. J Periodontol 2004;75(8):1046-53.
confirmation by additional research, using other 10. Meurman JH, Sanz M, Janket SJ. Oral health,
pharmaceuticals, such as non-steroidal anti- atherosclerosis, and cardiovascular disease.
inflammatory drugs [NSAIDs] and Crit Rev Oral Biol Med 2004;15(6):403-13.
bisphosphonates, or combinations of these). There 11. Offenbacher S, Katz V, Fertik G, Collins J,
appears to be more than a casual relationship Boyd D, Maynor G, et al. Periodontal
between serum lipid levels and systemic health infection as a possible risk factor for preterm
(particularly cardiovascular disease, diabetes, tissue low birth weight. J Periodontol
repair capacity, and immune cell function), 1996;67(10):1103-13.
susceptibility to periodontitis, and serum levels of 12. Pretorius C, Jagatt A, Lamont RF. The
pro-inflammatory cytokines. In terms of the relationship between periodontal disease,
potential relationship between periodontitis and bacterial vaginosis, and preterm birth. J Perinat
systemic disease, further research is warranted for Med 2007;35(2):93-9.
the better treatment of the patients. 13. Goldenberg RL, Hauth JC, Andrews WW.
REFERENCES Intrauterine infection and preterm delivery. N
1. Pizzo G, Lo Re D, Piscopo MR, Pizzo I, Engl J Med 2000;342(20):1500-7.
Giuliana G. Genetic disorders and periodontal 14. Klebanoff M, Searle K. The role of
health: a literature review. Med Sci Monit inflammation in preterm birth/ - focus on
2009;15(8):167-78. periodontitis. BJOG 2006;113(3):43-5.
2. Socransky SS, Haffajee AD: The bacterial 15. Almas K, Al-Lazzam S, Al-Quadairi A. The
etiology of destructive periodontal disease: effect of oral hygiene instructions on diabetic
current concepts. J Periodontol 1992;63:322- type 2 male patients with periodontal diseases.
31. J Contemp Dent Pract. 2003;4(3):24-35.
3. Kinane DF, Peterson M, Stathopoulou PG: 16. Kiran M, Arpak N, Unsal E, Erdogan MF. The
Environmental and other modifying factors of effect of improved periodontal health on
the periodontal diseases. Periodontol 2000 metabolic control in type 2 diabetes mellitus. J
2006;40:107-19. Clin Periodontol. 2005;32(3):266-72.
4. Hart TC, Atkinson JC. Mendelian forms of 17. Loe H. Periodontal disease. The sixth
periodontitis. Periodontology 2000 complication of diabetes mellitus. Diabetes
2007;45:95-112. Care 1993;16(1):329-34.
5. Paquette DW, Brodala N, Nichols TC. 18. Cianciola LJ, Park BH, Bruck E, Mosovich L,
Cardiovascular disease, inflammation, and Genco RJ. Prevalence of periodontal disease in
periodontal infection. Periodontol 2000 insulin-dependent diabetes mellitus (juvenile
2007;44:113-26.
 39 Hormone & Periodontium Sharma M, Kukreja BJ, Kukreja P, Agarwal A, Singh A

diabetes). J Am Dent Assoc 1982;104(5):653- 30. Mealey BL. Periodontal implications:

60. medically compromised patients. Ann
19. Emrich LJ, Shlossman M, Genco RJ. Periodontol 1996;1(1):256-321.
Periodontal disease in non-insulin-dependent 31. Tervonen T, Oliver RC. Long-term control of
diabetes mellitus. J Periodontol diabetes mellitus and periodontitis. J Clin
1991;62(2):123-31. Periodontol 1993;20(6):431-5.
20. Jones JA, Miller DR, Wehler CJ, Rich SE, 32. Ervasti T, Knuuttila M, Pohjamo L, Haukipuro
Krall-Kaye EA, McCoy LC, et al. Does K. Relation between control of diabetes and
periodontal care improve glycemic control? gingival bleeding. J Periodontol
The Department of Veterans Affairs Dental 1985;56(3):154-7.
Diabetes Study. J Clin Periodontol 33. Campus G, Salem A, Uzzau S, Baldoni E,
2007;34(1):46-52. Tonolo G. Diabetes and periodontal disease: a
21. Novaes Jr AB, Gutierrez FG, Novaes AB. case-control study. J Periodontol
Periodontal disease progression in type II non- 2005;76(3):418-25.
insulin-dependent diabetes mellitus patients 34. Taylor GW. The effects of periodontal
(NIDDM). Part I - Probing pocket depth and treatment on diabetes. J Am Dent Assoc
clinical attachment. Braz Dent J 1996;7(2):65- 2003;134:41-8.
73. 35. Taylor GW. Bidirectional interrelationships
22. Safkan-Seppala B, Ainamo J. Periodontal between diabetes and periodontal diseases: an
conditions in insulin-dependent diabetes epidemiologic perspective. Ann Periodontol
mellitus. J Clin Periodontol 1992;19(1):24-9. 2001;6(1):99-112.
23. Taylor GW, Burt BA, Becker MP, Genco RJ, 36. Taylor GW. Periodontal treatment and its
Shlossman M, Knowler WC, et al. Non-insulin effects on glycemic control: a review of the
dependent diabetes mellitus and alveolar bone evidence. Oral Surg Oral Med Oral Pathol
loss progression over 2 years. J Periodontol Oral Radiol Endod 1999;87(3):311-6.
1998;69(1):76-83. 37. Iacopino AM. Periodontitis and diabetes
24. Unal T, Firatli E, Sivas A, Meric H, Oz H. interrelationships: role of inflammation. Ann
Fructosamine as a possible monitoring Periodontol 2001;6(1):125-37.
parameter in non-insulin dependent diabetes 38. Heitz-Mayfield LJ. Disease progression:
mellitus patients with periodontal disease. J identification of high-risk groups and
Periodontol 1993;64(3):191-4. individuals for periodontitis. J Clin
25. Taylor GW, Burt BA, Becker MP, Genco RJ, Periodontol 2005;32(6):196-209.
Shlossman M. Glycemic control and alveolar 39. Almas K, Al-Qahtani M, Al-Yami M, Khan N.
bone loss progression in type 2 diabetes. Ann The relationship between periodontal disease
Periodontol 1998;3(1):30-9. and blood glucose level among type II diabetic
26. Rodrigues DC, Taba MJ, Novaes AB, Souza patients. J Contemp Dent Pract
SL, Grisi MF. Effect of non-surgical 2001;15;2(4):18-25.
periodontal therapy on glycemic control in 40. Didilescu AC, Skaug N, Marica C, Didilescu
patients with type 2 diabetes mellitus. J C. Respiratory pathogens in dental plaque of
Periodontol 2003;74(9):1361-7. hospitalized patients with chronic lung
27. Tan WC, Tay FB, Lim LP. Diabetes as a risk diseases. Clin Oral Investig 2005;9(3):141-7.
factor for periodontal disease: current status 41. Scannapieco FA. Role of oral bacteria in
and future considerations. Ann Acad Med respiratory infection. J Periodontol
Singapore 2006;35(8):571-81. 1999;70(7):793-802.
28. Grossi SG, Genco RJ. Periodontal disease and 42. Tilakaratne A, Soory M, Ranasinghe AW,
diabetes mellitus: a two-way relationship. Ann Corea SM, Ekanayake SL, de Silva M. Effects
Periodontol 1998;3(1):51-61. of hormonal contraceptives on the
29. Papapanou PN. Periodontal diseases: periodontium, in a population of rural Sri-
epidemiology. Ann Periodontol 1996;1(1):1- Lankan women. J Clin Periodontol
36. 2000;27(10):753-7.
43. Seck-Diallo A, Cissé ML, Benoist HM, Diouf
A, Ahnoux-Kouadio A, Diallo T, et al.
40 Hormone & Periodontium Sharma M, Kukreja BJ, Kukreja P, Agarwal A, Singh A

Periodontal status in a sample of Senegalese

women using hormonal contraception.
Odontostomatol Trop. 2008;31(121):36-42.