Knowledge and awareness about the influence of female sex hormones on periodontal health had been assessed so far only in specific groups like adolescent girls, the pregnant female population, and gynecologists. This was the first study to be conducted in the general female population of Western Maharashtra with a focus on assessing knowledge and awareness regarding the effects of female sex hormones on periodontal health.

Periodontal disease has been associated with self-reported signs and symptoms like swollen gums,’ ‘sore gums,’ ‘receding gums,’ ‘loose teeth,’ ‘drifting teeth,’ ‘and bad breath,’. Our study showed that most of the study participants were knowledgeable about these findings [8] which is in accordance with a study by Nada Alzammam, and Alaa Almalki in 2019 among Jordanian University students [9].

In the menstrual cycle of the luteal phase, there is an increase in the level of progesterone hormone. This causes a response in gingival tissue, which becomes more sensitive to the plaque on the teeth and produces inflammatory reactions [10]. A study done by Shiba et al. in 2019 showed only 4% of adolescent girls participants were aware of the possible association between gingival changes during menstruation. In our study, 34% of the general female population was aware of this possible association between gingival changes and menstruation.

During the pregnancy period, both progesterone and estrogen are elevated due to the continuous production of these hormones by the corpus luteum [11]. Susceptibility to infections increases during early gestation due to alterations in the immune system and can be explained by the hormonal changes observed during pregnancy [12], suppression of T-cell activity, decreased neutrophil chemotaxis and phagocytosis, altered lymphocyte response, and depressed antibody production [13] and even chronic maternal stress. Pregnancy gingivitis is an extremely common finding and affects 30-100% of all pregnant women [14]. The awareness of the participants of the relationship between Pregnancy and periodontal disease was 24.3% in a study by Olubunmi O. Onigbinde et al. in 2019 which was conducted in the general female population of Lagos state in Nigeria [15]. In our current study, 43% general female population knew about the possible correlation between pregnancy and periodontal health. However, our study reported that 62% of study participants were not aware of the gingival changes during pregnancy. These results are similar to a survey done by Fouzia Tarannum in 2013 [16].

High hormone levels when accompanied by periodontal diseases are known to cause many adverse pregnancy outcomes, such as preterm birth, low birth weight, and preeclampsia which are the major causes of maternal morbidity and mortality. These adverse outcomes can be successfully prevented by maintaining proper oral hygiene, and hence, maintenance of proper oral health during pregnancy plays a key role in the health of pregnant women [17]. Several authors have reported that importance should be given to oral health maintenance during pregnancy [18]. It is in accordance with our study where almost 65% of participants showed concern about maintaining good oral hygiene during pregnancy.

Changes in the body due to the effects of estrogen insufficiency are observed in many women during menopause. Osteoporosis is one of these changes [19]. A study by Manickavasagam in 2019 concluded that 60% of pregnant female participants had awareness of postmenopausal osteoporosis [20]. When compared to these studies our study reported better knowledge in a general female population about postmenopausal osteoporosis which was about 72%.

Polycystic ovary syndrome (PCOS) is a complex endocrine, reproductive and metabolic condition, characterized by hyperandrogenism and polycystic ovary [21]. It has a worldwide prevalence ranging from 5–15%. A meta-analysis by Vanessa Machado et al. in 2020 revealed that PCOS females have 28% more risk of periodontal diseases, and females with periodontitis have 46% more risk to have PCOS [22]. PCOS females with periodontal diseases had higher gum bleeding, periodontal pocket depth, and clinical attachment loss than non-PCOS females with periodontal diseases. Based on the available evidence, it is possible to assume a bidirectional link between PCOS and periodontal diseases. Also, Kellesarian et al. in 2017 suggested that women with PCOD are at increased risk of developing the periodontal disease [23]. Awareness level was reported to be 8% in our study regarding this relationship. 

Oral contraceptives (OCs) enhance periodontal breakdown by reducing the resistance to dental plaque and can induce gingival enlargement in otherwise healthy females. The long-term use of OC may cause clinical attachment loss (CAL), increased gingival inflammation, and gingival enlargement [24]. Castro et al. in their meta-analysis concluded that the use of hormonal contraceptives may be associated with the severity of periodontal diseases [25]. In a study by Al-Qahtani on gynecologists of hospitals across the five areas of Riyadh in 2019, 50% of gynecologists indicated that gingival changes could be induced by the long-term use of oral contraceptives [26]. Our study stated that the majority of the study population 78% were unaware of this association.

During menopause estrogen deficiency is one of the most frequent causes of osteoporosis in women and a possible cause of bone loss. A survey by Ergin A et al. in 2017 reported 90.5% awareness of osteoporosis in postmenopausal patients. In contrast to this study, awareness about postmenopausal osteoporosis was 70% in our study.

HRT plays an important role in preventing osteoporosis by reducing postmenopausal bone mass loss [27]. Since periodontal diseases are also affected by the state of the alveolar bone, various studies have attempted to demonstrate the association between HRT and periodontal disease [28].

The analysis of menopausal women aged between 45 and 74 years old showed that the HRT group was less likely to develop periodontal diseases than the non-HRT group. However, a study by Pizzo et al. evaluated 91 Italian menopausal women and reported that there was no difference in periodontal pocket depth between the group who underwent HRT and the group who did not, but the group who did not undergo HRT had a higher plaque level [29]. Our study revealed that the majority of the respondents had limited knowledge related to the association between HRT and periodontal disease.

Conclusion

Within the limitations of the study, it can be concluded that there is a lack of knowledge and awareness among women of Western Maharashtra about the relationship between female sex hormones and periodontal health. Therefore, creating awareness about this relationship is necessary to prevent periodontal diseases and improve systemic conditions affecting the female population. This can be achieved by coordinated efforts from general dentists, periodontists, and gynecologists which will ensure good periodontal health of a woman.

Future prospective

The results obtained would serve as baseline information for identifying areas of deficiency in the women’s knowledge regarding the effects of female sex hormones on periodontal health and to educate them about various modalities to reduce these effects. It would help plan oral health education programs aimed at improving the oral health of women.

Acknowledgments: None

Conflict of interest: None

Financial support: None

Ethics statement: Ethical clearance was obtained from The Institutional Ethical committee of Krishna Institute of Medical Sciences, Deemed to be University (KIMSDU), Karad, Maharashtra, India [Ref. No: KIMSDU/IEC/2XI/2021].