Juliette Reeves discusses how clinicians can support patients during a difficult life change.

Women experience hormone deficiency during menopause. These hormone fluctuations affect the periodontal tissues directly. Oestrogen and progesterone are anti-inflammatory, and so the decline of these hormones during menopause means that women don’t have the same protective factors. As a result, there can be a heightened inflammatory response to the same levels of plaque they may have previously experienced. You may look at the patient’s mouth, and their oral hygiene hasn’t changed, but their periodontal condition is no longer stable. Patients may have extra sensitivity to plaque levels than they would have previously tolerated.

Furthermore, bacterial levels of biofilm change during this life stage. As oestrogen and progesterone reduce, there is a greater concentration of anaerobic bacteria in the biofilm. This also increases the risk of periodontal disease and exaggerated inflammation. Both hormones also impact bone density, which can lead to a reduced bone density of the jaw, which increases the risk of periodontal disease.

Menopause can also impact the oral tissues themselves. We know that the mucous membrane lines the whole mouth. For patients who are experiencing declining oestrogen and progesterone levels, the mucous membrane thins. The keratinised layer on the gingiva starts to become thinner, which leads to gingival thinning, and immune changes in the gingiva. As a clinician, it’s unlikely you will see any thinning yourself, and the effect doesn’t impact patients overnight. However, patients may complain of sensitivity. If the keratinised layer sloughs off, it can be painful. I would recommend advising peri or menopausal patients to investigate their hormone balance with their GP if they have tooth or gingival

sensitivity. Your patient may also want to look into other hormonal conditions – thyroid health and oestrogen and progesterone are related. Declining levels of the latter will affect thyroid levels.

As clinicians, we need to take any complaints like sensitivity seriously, even if clinically we can’t see why the patient may be experiencing issues. For example, saliva production reduces during menopause, as there are oestrogen and progesterone receptors in the salivary glands. As oestrogen declines, so can saliva production. The quality of salvia also changes – there are fewer protective enzymes such as lysozyme in the saliva. We may look at a patient’s mouth and see saliva pooling in the floor, even as the patient is complaining of having a dry mouth. As clinicians it’s unlikely we’ll be able to identify a reduction of saliva just by looking, but the patient will certainly feel a difference - saliva pooling isn’t the full picture. We need to identify these symptoms and address them before they become significant. The most common oral manifestations of menopause are oral discomfort, including pain, a burning sensation, taste disturbance, dry mouth, dry, cracked lips, bleeding on brushing, mouth ulcers, and a sore tongue.

Minimising the effects

It’s vital that the patient has good oral hygiene at this life stage. Biofilm removal and disruption will always be the most important way to support oral health. If your patient is experiencing sensitivity due to thinning tissues or a reduction of anti-inflammatory protection, which can lead to desquamative gingivitis, mouth ulcers, or lichen planus, the mouth will be sore. To help patients, we can guide them to appropriate products to help. Some menopausal patients may not use an electric toothbrush, because they find the vibration uncomfortable while they are experiencing increased sensitivity. However, an electric toothbrush will be much more effective in removing biofilm compared with a manual toothbrush or relying on mouthwash alone. It may feel more comfortable, but it will exacerbate issues later on.

Instead, I would recommend patients try a power toothbrush with a sensitive brush head and different brushing modes. The Philips Sonicare 6500 and 7100 brushes both have a sensitive mode, which reduces the level of vibration through the brush, making it gentler and more comfortable for patients, without compromising effectiveness. Philips sensitive brush head has over 3000 extra fine bristle filaments, ensuring it offers an extra soft yet effective brushing experience.

Patients also need to think about the food they are eating. There is evidence that ultra-processed foods and sugar increases the inflammation in both the mouth and gingival tissues. If your patient is already experiencing sensitivity in their tissue, it’s important to advise them to adopt or maintain a healthy diet. Patients should focus on eating omega-3 fatty acids, vitamin D, calcium, magnesium, and zinc. This will help to balance blood sugar levels too, which is important as our blood sugar levels impact all other hormones.

References available on request.

For more information visit: https://www.perio-nutrition.com/menopause and https://www.b2bshop.philips.com/philipsb2bstorefront/gb11-04/en_GB/GBP/login

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