1. Periodontal therapy in female patients1 Dr. Nitika Jain8/31/2012

2. Contents2 Dr. Nitika Jain8/31/2012 3. Contents Hormone and types of hormones Female hormonal system Conditions clinical features andmanagement. Puberty Menstrual cycle Pregnancy Local anesthetic and analgesicadministration during pregnancy3 Dr. Nitika Jain 8/31/2012 Antibiotic administration during 4. Periodontal disease and Preterm lowbirth weight births Association of periodontal disease andpre eclampsia Oral contraceptives Menopause Osteoporosis Hormone replacement therapy Conclusion References4 Dr. Nitika Jain 8/31/2012 5. Hormones are specific regulatory molecules thatmodulate reproduction, growth and development,maintenance of the internal environment, as wellas energy production, utilization, and storage(Mariotti 1994). Hormonal effects reflectphysiological/ pathological changes Steroidsin almost all types of tissues of the body Glycoprotein Polypeptides Amines5 Dr. nitika jain 31 August 2012 6. FEMALEHORMONAL SYSTEM6 Dr. nitika jain 31 August 2012 7. The female hormonal system, consists ofthree hierarchies of hormones, as follows: 1. A hypothalamic releasing hormone, Gonadotropin-releasing hormone (GnRH) 2. The anterior pituitary sex hormones, follicle-stimulating hormone (FSH) and luteinizing hormone(LH), both of which are secreted in response to therelease of GnRH from the hypothalamus 3. The ovarian hormones, estrogen andprogesterone, which are secreted by the ovaries inresponse to the two female sex hormones from theanterior pituitary gland.7Dr. nitika jain 31 August 2012 8. Ovarian hormones EstrogenProgesterone8 Dr. nitika jain31 August 2012 9. Age PubertyMenstrual cyclePregnancy Menopause9 Dr. nitika jain 31 August 2012 10. Puberty10 Dr. Nitika Jain 8/31/2012 11. Pubertal changes It is the transitional phase when a sexually immature girl or boy becomes sexually mature. It lasts for 36 months. Ovarian cycle ovulation Accessory sex organs grow Bone and muscle growth takes place Hormones FSH, LH sex steroid secretion - all increase11 Dr. nitika jain31 August 2012 12. Effects on Periodontium Enhanced blood circulation in the end terminal capillary loops and associated increased prevalence of gingivitis/bleeding tendency (Muhlemann 1948, Massler et al. 1950, Curilovic et al. 1958, Sutcliffe 1972, Daniell 1983) Higher bacterial counts (especially Prevotella intermedia (Pi) and12 Capnocytophaga species)(Kornman & Dr. Nitika Jain8/31/2012 Loesche 1982, Mombelli et al. 1990, 13. 13 Dr. nitika jain 31 August 2012 14. Management Preventive care Milder gingivitis case scaling and root planing with frequent oral hygiene instructions. Severe gingivitis case microbial culturing, antimicrobial mouth washes and local site delivery, or antibiotic therapy.14 Supportive periodontal therapy Dr. Nitika Jain8/31/2012 15. Menstrual cycle15 Dr. Nitika Jain8/31/2012 16. Pre menstrual syndromeMenstrual cycle16 Dr. Nitika Jain 8/31/2012 17. Pre menstrual syndrome ( PMS) During the peak level of progesterone (about 7 10 days prior tomenstruation) PMS also occur. No significant differences in estrogen and progesterone levelsbetween women who suffer PMS and women who do not. Depression, irritability, mood swings, and difficulty with memoryand concentration due to reduced neuro transmitters PMS women have lower of certain neuro transmitters such as Enkaphalins Endorphins amino butyric acid(GABA) Serotonin17 Dr. Nitika Jain8/31/2012 18. Management of PMS PMS is often treated by antidepressants. Selective serotonin reuptake inhibitors are generally the first line choice of drugs. Increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. E.g. Fluoxetine, Sertraline, Fluvoxamine, paroxetine, and citalopram. Other antidepressants are selective serotonin, norepinephrine reuptake inhibitors( SNRIs) {increase the levels of two neurotransmitters in the brainthat are known to play an important part in mood,serotonin, and norepinephrine.}, tricyclics, trazodone,18mirtazapine, nefazodone, maprotilline. Dr. Nitika Jain 8/31/2012 19. Menstrual cycle Recurs at the interval of 28 days. 4 phases: Menstruation bleeding phase ; 1 4 days Proliferative phase follicular phase ; 5 13 days Phase of ovulation 14th day Secretive phase luteal phase ; 14 28 days19 Dr. nitika jain 31 August 2012 20. 20 Dr. nitika jain 31 August 2012 21. Two different clinical findings have been observedin the oral cavity: Gingival bleeding and Increased production of gingival exudate Kribbs & Chesnut1984, Kribbs et al. 1989, Kribbs1990,1992, Grodstein et al. 1996a, b). Ulcerations of the oral mucosa and vesicular lesionshave also been noted in the luteal phase of themenstrual cycle, although the incidence is low. (Segal et al. 1974, Ferguson et al. 1978, 1984).21 Dr. Nitika Jain8/31/2012 22. Tumor necrosis factor fluctuates during the menstrual cycle, PGE2 elevated, angiogenetic factors , endothelial growth factors, and receptors may be modulated by Progesterone and estrogen , contributing to increases in gingival inflammation during certain stages of the menstrual cycle.22 Dr. nitika jain31 August 2012 23. 23 Dr. nitika jain 31 August 2012 24. Management Women who have increased gingival bleeding associated with the menstrual cycle SPT for continuous 3 4 months is must. Antimicrobial mouth rinses prior to cyclic inflammation is indicated. The dentist should treat the gingival and oral mucosal tissues gently. Gauze pads or cotton rolls should be moistened with a lubricant, chlorhexidine rinse, or water before placing them in the aphtha-prone patient. Careful retraction of the oral mucosa, cheeks, and lips is necessary in patients prone to aphthous or herpetic lesions. Because the hypoglycemic threshold is elevated, the clinician should advise the patient to have a light24 Dr. Nitika Jain before her appointment. snack8/31/2012 25. Pregnancy25 Dr. Nitika Jain 8/31/2012 26. One Tooth Is Lost With Every pregnancy Myth..But Women Do Experience Some Changes in General and Oral Health During Pregnancy, Primarily Due to Hormonal Level Changes So They Characterize a Special Group for Whom Extra care and Special Care Need to Be Provided26 Dr. Nitika Jain8/31/2012 27. Pregnancy27Dr. nitika jain 31 August 2012 28. Stages of Pregnancy1st Trimester (1-12 weeks)Fetal organ formation anddifferentiation.Most susceptible to adverseeffects of teratogens.Avoid all elective care butprovide care as needed. 8/31/2012Dr. Nitika Jain 28 29. Stages of Pregnancy2nd Trimester (13-24 weeks)Fetal growth and maturation.Safest period to provide dentalcare.8/31/2012 Dr. Nitika Jain 29 30. Stages of Pregnancy3rd Trimester (25-40 weeks)Fetal growth continues.8/31/2012Dr. Nitika Jain 30 31. Increased tendency for gingivitis and larger gingival probing depths (Loe & Silness 1963,Silness & Loe 1964, Miyazaki et al. 1991, Robinson & Amar 1992, Machuca et al. 1999, Soory 2000) and periodontitis (Robinson & Amar 1992) Increased susceptibility to infection (Cohen et al. 1969, Brabin 1985) Decreased neutrophil chemotaxis and depressed antibody production (Sooriyamoorthy & Gower 1989b, Raber-Durlacher et al. 1991, Raber-Durlacher et al. 1993) Increased numbers of periodontopathogens (especially Porphyromonas gingivalis and Pi) (Kornman & Loesche 1980, Tsai & Chen 1995) Increased synthesis of PGE2 (ElAttar 1976)31 Dr. Nitika Jain8/31/2012 32. Tumor like enlargement/Pyogenic granuloma Incidence : 0.2 9.6 % Pregnancy tumor or pregnancy epulis is different from pyogenic granuloma which occur in non pregnant females 2nd or 3rd trimester Clinical features : Tumor like growth appear on inter dental papilla of maxillary anterior teeth Grow rapidly, bleed easily, and become hyperplastic, and nodular Sessile or pedunculated or may be ulcerated32 Dr. nitika jain Color purplish red to deep blue. 31 August 2012 33. 33 Dr. nitika jain 31 August 2012 34. Marginal gingival enlargement/ pregnancy gingivitis Extremely common Incidence: 30 75 % Clinical features: Erythema , edema, hyperplasia, increased bleeding. Mild inflammation, pain , bleeding Alteration in immunocompetency during pregnancy may create an exaggerated response on Periodontium. Mainly anterior region and inter proximal surfaces Dr. nitika jain 31 August 201234 Anterior site inflammation may be exacerbated by increased 35. Other oral manifestations of pregnancy Perimylolysis or acid production of teeth may occur due to excessive morning sickness or esophageal reflux Xerostomia 44% reported dryness ( El- Ashiry G. comparative study of the pregnancy and oral contraceptives on the gingiva. Oral Surg 1970.)35 Dr. nitika jain31 August 2012 36. 36 Dr. Nitika Jain 8/31/2012 37. Clinical management Plaque control oral hygiene techniques must be taught, reinforced, and monitored throughout the pregnancy. Scaling and root planing must be performed when ever necessary. Avoid the use of high alcohol content antimicrobial rinses in pregnant and prefer to use non alcohol based oral rinse. Prenatal fluoride acontroversial and inconclusive. Studies by Glenn FB(1977, 1982) claimed the benefitswhereas studies by reported by (Reference manual. Pediarrdent 1994) showed no clinical efficacy of prenatal fluoride. ADA does not recommend the use of prenatal fluoride.prenatal F administration may reduce the incidence ofcaries in the offspringCox & Okerse.37 Dr. Nitika Jain8/31/2012 38. Treatment for Acid ExposureDo NOT brush immediately after vomitingRinse Water with baking soda Antacid Plain waterEat some cheese38Dr. Nitika Jain8/31/2012 39. Elective dental treatment Prolonged chair time should be avoided because the woman is most uncomfortable at this time. Supine hypotensive syndrome may occur. In a semi reclined or supine position , the great vessels particularly inferior vena cava are compressed by the gravid uterus. and this compression will cause maternal hypotension,39 decreased cardiac output, and eventual Dr. Nitika Jain 8/31/2012 loss of consciousness. 40. How should the pregnant woman be positioned? Flat position may cause hypotension and hypoxia Place a small pillow under right hip - left lateral displacement Head above feet40 Dr. Nitika Jain8/31/2012 41. SUPINE HYPOTENSION SYNDROME (Vena Cava Compression) SUPINE POSITION AFTER 5TH MONTH UTERUS COMPRESSES THE INFERIORVENA CAVA VOL. BLOOD RETURN TO THE HEARTREDUCED PERFUSION OF UTERUS FETAL HYPOXIA41 Dr. Nitika Jain8/31/2012 42. Supine Hypotension Syndrome Obstruction of inferior vena cava and aorta from pressure of the large fetus. Symptoms: Sweating Nausea Weakness Sense of lack of air42 Dr. Nitika Jain 8/31/2012 43. Supine Hypotension Syndrome Other symptoms: Drop in blood pressure Bradycardia Possible loss of consciousness43 Dr. Nitika Jain8/31/2012 44. Prevention of Supine Hypotensive SyndromeElevate right hip 10-12 cm.Weight is taken off the majorvessels8/31/2012 Dr. Nitika Jain 44 45. Treatment of Supine Hypotensive SyndromeRoll patient onto herleft side. 8/31/2012 Dr. Nitika Jain 45 46. Use of Radiation on Pregnant Patient Dose given and time of gestation are important doses < 5-10 rads (Gy) not teratogenic fetus is most susceptible to radiation between the 2ndand 6th week of gestation single dental x-ray exposes patient to 0.01 millirads ofradiation. In relative terms, this amount is 40 times lessthan daily dose acquired from cosmic radiation.Therefore, diagnostic radiation should not be withheldduring pregnancy46 Dr. Nitika Jain 8/31/2012 47. Radiographs during Pregnancy Take as needed with optimal methods for reducingsecondary radiation and exposure time. Always use a lead apron. Exposure to fetus (with apron use) is .00001centiGray.(rad) Daily cosmic radiation - .0004 centiGray (rad)47 Dr. Nitika Jain 8/31/2012 48. Risks of Dental X-Rays X-ray only if necessary (i.e. root canal therapy, trauma) When x-rays are indicated, radiation exposure is extremely low Exposure can be limited by: Lead apron shielding Modern fast film Avoiding retakes48Dr. Nitika Jain8/31/2012 49. Drugs in pregnancy49 Dr. Nitika Jain8/31/2012 50. FDA drug classification for pregnancy Combines risk statements including congenital anomalies, fetal effects, perinatal risks, and therapeutic risk-benefit ratio Untreated disease or condition may pose more serious risks to both mother and fetus than any theoretical risks from the medication Category A thru D and X50 Dr. Nitika Jain 8/31/2012 51. Local anesthetic and analgesic administration during pregnancy51 Dr. Nitika Jain 8/31/2012 52. Antibiotic administration during pregnancy52 Dr. Nitika Jain8/31/2012 53. 53 Dr. Nitika Jain 8/31/2012 54. 54 Dr. Nitika Jain 8/31/2012 55. 55 Dr. Nitika Jain 8/31/2012 56. Periodontaldisease and Pretermlow birth weightbirths Dr. Nitika Jain8/31/201256 57. WHO defination Preterm birth as any live birth at less than 37 weeks of gestation. Delivery at less than 32 weeks is termed as very preterm Delivery at less than 28 weeks is termed as extremely preterm Birth weight to be considered low if < 2500g, very low if < 1500g and extremely low if 65 years old88 1500mg/day Dr. Nitika Jain 8/31/2012 89. Hormone replacement therapy It is based on the idea that the treatment mayprevent discomfort caused by diminishedcirculating oestrogen and progesteronehormones, or in the case of the surgically orprematurely menopausal, that it may prolong lifeand may reduce incidence of dementia. Itinvolves the use of one or more of a group ofmedications designed to artificially boosthormone levels. The main types of hormonesinvolved are oestrogens, progesterone orprogestins, and sometimes testosterone.89 Dr. Nitika Jain8/31/2012 90. CONVENTIONAL HORMONE REPLACEMENT DRUGS The most frequently prescribed estrogen product for HRT is conjugated equine estrogens (brand name Premarin). The most frequently prescribed progestin for HRT is medroxyprogesterone acetate (MPA). BIO-IDENTICAL HORMONES COMPOUNDED There are many alternatives to conventional drug products, including natural or bio-identical hormones, which are identical in chemical structure to the hormones naturally produced by our bodies. This type of HRT is referred to as natural hormone replacement therapy, or NHRT. NHRT is available both in brand-name products and from compounding pharmacies, which can supply any of the bio-identical hormones alone or combine them into one dose in the form desired (e.g, sublingual tablets, oil Dr. Nitika Jain90 caps, or cream). 8/31/2012 91. Dosages prescribed for ERT, HRT and NHRT vary and can be adjusted to meet a womans specific needs. Relatively low doses of estrogen and estrogen/progestin is effective for treating symptoms of menopause and can also maintain bone density. Low doses of estrogen, doses of conjugated equine estrogen (Premarin) as low as .3 mg (compared to the "standard" dose of .625 mg) alone or combined with a reduced dose of progestin; doses of oral estradiol as low as .25 mg; and a transdermal patch dose of .02591 micrograms. Using lower doses of estrogens8/31/2012 Dr. Nitika Jainand 92. Conclusion Female patients may present with periodontal and systemic considerations that alter conventional therapy. Patients should be educated regarding the profound effects of the sex hormone on periodontal and oral tissues as well as the consistent need for home and office removal of local irritants. Thorough medical history in the female patient should include questions regarding menstrual regularity, oral contraceptive use , hormone replacement therapy, fertility medications, Dr. Nitika Jain928/31/2012 pregnancy, breast feeding. 93. REFERENCES93 Dr. nitika jain31 August 2012 94. Clinical periodontology, Carranza 10th edition. Periodontal medicine. Rose, Genco, Mealey , Cohen. Mascarenhas P, Gapski R, Al-Shammari K, Wang H-L: Influence of sex hormones on the Periodontium. J Clin Periodontol 2003; 30: 671 681. rBlackwell Munksgaard, 2003. GN gnc, TF tzm, F aglayan: effects of endogenous sex hormones on the periodontium review of literature. Australian dental journal 2005;50:(3):138-145.94 Dr. nitika jain 31 August 2012 95. Concise medical physiology 5th edition, chaudhari Despopoulos, color atlas of physiology 5th edition. Text book of medical physiology, 11th edition. Guyton and hall. MARJORIE K et al. Post-menopausal bone loss and its relationship to oral bone loss. Periodontology 2000, Vol. 23, 2000, 94102.95 Dr. nitika jain 31 August 2012