The Saudi Dental Journal (2012) 24, 99–104

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
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ORIGINAL ARTICLE

Female sex hormones and periodontal health-awareness

among gynecologists – A questionnaire survey
Sonali N. Patil a, Nagaraj B. Kalburgi a, Arati C. Koregol a,*
, Shivaraj B. Warad a,
Sandeep Patil a, Mahesh S. Ugale b

a
Department of Periodontics, P.M.N.M Dental College and Hospital, Bagalkot, India
b
Department of Anatomy, S.N. Medical College and Hospital, Bagalkot, India

Received 16 March 2011; revised 3 November 2011; accepted 5 December 2011

Available online 8 January 2012

KEYWORDS Abstract Sex hormones play an important role in periodontal health and disease. For example,
Periodontal health; puberty, menses, pregnancy, menopause, and oral contraceptive use influence a woman’s periodon-
Pregnancy; tal health. Periodontal infection has also been associated with adverse pregnancy outcomes. Subse-
Periodontal disease; quently, it is important that gynecologists are educated about hormonal effects on women’s oral
Preterm low birth weight; health. The current study assessed gynecologist’s awareness regarding the effect of female sex hor-
Gynecologist; mones on periodontal health, preterm delivery, and maternal periodontal disease.
Questionnaire Methods: Gynecologists from the Bagalkot district of the Karnataka state, India, completed a
questionnaire regarding female hormonal and periodontal health. Respondents were divided into
two groups: Group A (doctors that practiced at a medical college or hospital) and Group B (doctors
that practiced at private hospitals). Out of 73 gynecologists, 62 (85%) completed the survey, with 19
(30.6%) participants in Group A and 43 (69.4%) participants in Group B. Survey responses were col-
lected in the presence of the investigator, and data between the groups were statistically compared.
Results: Our findings showed that most gynecologists were aware and concerned about female
patient’s oral health during various hormonal phases. However, gynecologists practicing at medical
colleges and hospitals (Group A) had significantly greater health awareness than doctors practicing
at private hospitals (Group B).

* Corresponding author. Address: Department of Periodontics,

P.M.N.M Dental College and Hospital, Bagalkot, Karnataka 587
101, India. Fax: +91 8354 221960.
E-mail address: aratikperio@yahoo.co.in (A.C. Koregol).

1013-9052 ª 2012 King Saud University. Production and hosting by

Elsevier B.V. All rights reserved.

Peer review under responsibility of King Saud University.

doi:10.1016/j.sdentj.2011.12.001

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100
Conclusion: Women have special periodontal health care considerations, and there is a need for
better oral health education among caregivers. Our results suggest that increasing dental health
awareness among gynecologists would significantly improve women’s health and pregnancy out-
comes.
ª 2012 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction
Periodontal disease results from a complex interplay between
host susceptibility and oral cavity micro flora. Various sys-
temic factors and conditions of the host may affect the preva-
lence, progression, and severity of the disease (Kinane and
Marshall, 2001). Among these variables, sex hormones likely
influence the pathogenesis of periodontal diseases (Apoorva
and Suchetha, 2010; Parker et al., 1998b; Hofbauer and
Hedfelder, 2001), as hormonal variation affects the physiology
of host parasite interactions in the oral cavity (Amar and
Chung, 1994).
Hormones are specific regulatory molecules that modulate
reproduction, growth, and development. In addition, hormones
maintain homeostasis, energy production, utilization and stor-
age (Mariotti, 1994). Androgen, estrogen, and progesterone
receptors are also localized in periodontal tissues (Gornstein
et al., 1999). In women, estrogen and progesterone contribute
to physiological changes at specific life phases. For example,
estrogens can influence the cytodifferentiation of stratified squa-
mous epithelium, as well as the synthesis and maintenance of
fibrous collagen (Eleni et al., 2009). Progesterone exerts direct
effects on the periodontium and may play an important role in
the coupling of bone reabsorption and bone formation
(Mascarenhas et al., 2003; Gallagher et al., 1991). Taken to-
gether, hormones influence a variety of tissues and may influence
an individual’s health.
Puberty, menstrual cycle, pregnancy, and menopause are all
phases that specifically influence oral and periodontal health in
women. Increased hormonal levels during puberty affect gingi-
val tissues and the subgingival micro flora (Steinberg et al.,
2008). For example, during puberty, Prevotella intermedia
and Capnocytophaga bacteria species emerge (Yokoyama
et al., 2005; Gusberti et al., 1990). Clinically, there may be a
hyperplastic reaction of the gingiva in those areas where local
bacteria deposits are present. The inflamed tissues become deep
red and may be lobulated, with ballooning distortion of the
interdental papillae. Histologically, tissue appearance is consis-
tent with inflammatory hyperplasia (Steinberg et al., 2008).
Moreover, bleeding may occur when patients masticate or
brush their teeth. In addition to puberty-induced changes, gin-
gival tissues are more edematous during the menstrual cycle
and erythematous before its onset. Consequently, increased
gingival bleeding and exudation (Machtei et al., 2004) has been
observed during the menstrual period and is sometimes associ-
ated with slight increases in tooth mobility (Otomo-Corgel,
2007). During pregnancy, progesterone and estrogen levels
are continuously elevated and, by the end of the third trimester,
peak at 100 and 6 ng/ml, respectively. These hormone levels are
10 and 30 times greater than the levels observed during the
menstrual cycle (Grodstein et al., 1996a). It is not surprising,
then, that gingivitis is the most prevalent oral manifestation
associated with pregnancy and occurs within 30–100% of all
S.N. Patil et al.
pregnant women (Zachariasen, 1989; Ferris, 1993). In addition
to generalized gingival changes, localized gingival enlargements
like ‘‘pregnancy tumor,’’ ‘‘epulis gravidarum’’ or ‘‘pregnancy
granuloma,’’ are also observed. The histological appearance
is similar to a pyogenic granuloma, and the enlargement is
found in up to 9.6% of women (Gornstein et al., 1999). Similar
types of gingival changes are also seen in women that are taking
oral contraceptives (Otomo-Corgel, 2007). Even during meno-
pause, when hormonal levels decline, women experience
changes in the oral mucosa, which may result in burning sensa-
tions, altered taste perception, dryness of the mouth, or meno-
pausal gingivostomatitis (Amar and Chung, 1994).
Several clinical and experimental studies have concluded
that subclinical infections in pregnant women are likely the
most frequent cause of low births (Gibbs, 2001; Moreu et al.,
2005). In the presence of periodontal disease, lipopolysaccha-
ride exposure, inflammatory mediators, and cytokine produc-
tion in the maternal serum increase patient risk for poor
pregnancy outcomes. Periodontal infection, as a chronic reser-
voir of lipopolysaccharides, may even target the placental mem-
branes via the bloodstream (Offenbacher et al., 1996, 1998).
Therefore, periodontal disease not only influences women, it
also affects pregnancy outcomes.
The emergence of ‘‘periodontal medicine’’ addresses dental
health and its connection with systemic diseases. Importantly,
data suggest that periodontal disease contributes to morbidity
and mortality of individuals with systemic diseases, such as
premature delivery, diabetes, atherosclerosis, stroke, and myo-
cardial infarction (Paquette et al., 1999). Unfortunately, the
concepts surrounding periodontal status and its influence on
health are not commonly addressed in day-to-day practice.
Therefore, dental and medical school curricula should place
greater emphasis on systemic medicine and better integrate
information across health disciplines and clinical applications
(Mouradian et al., 2005). Since periodontal disease is both
preventable and curable, early intervention may reduce the
microbial challenge and improve periodontal health in hor-
monal-sensitive tissue. Moreover, the integration of periodon-
tal care with obstetric management may improve pregnancy
outcomes (Shenoy et al., 2009).
Research clearly demonstrates that puberty, menstrual cy-
cle, pregnancy, oral contraception use, and menopause affect
gingival tissue. Since gynecologists assess and treat women
across their lifespan and during these hormonal changes, it is
important that these doctors understand the influence of hor-
monal fluctuations on a woman’s periodontal health. Unfortu-
nately, there are few data assessing gynecologists’ awareness in
this area. Therefore, the current study assessed gynecologists’
knowledge regarding the relationship between female sex hor-
mones and periodontal health. We hope our results will better
educate doctors in obstetrics and gynecology, as well as
encourage female patients to maintain their oral and systemic
health.
Female sex hormones and periodontal health-awareness among gynecologists – A questionnaire survey
2. Materials and methods
A cross-sectional survey was conducted among 73 gynecolo-
gists in the Bagalkot district in India. Survey responses were
divided into two groups based upon institutional practice:
Group A included doctors practicing at a medical college
and/or hospital (Siddanahalli Nijlingappa Medical College
and Hospital Bagalkot, Karnataka State, India); Group B in-
cluded doctors practicing at private hospitals. After obtaining
informed consent from all participants, the questionnaire was
individually distributed and answers were collected in the pres-
ence of the investigator. Respondents’ data were statistically
analyzed using Statistica 6.0 system. The Chi square test and
Fisher’s exact test were used to determine statistically signifi-
cant differences between Groups A and B (p < 0.05 for all sta-
tistical analyses).
3. Questionnaire design
The survey comprised of 12 questions, and the last question
was open-ended for the participant to comment about the
study. A pilot study was previously conducted with five gyne-
cologists and assessed question understanding and completion
time. According to the pilot study, doctors completed the ques-
tionnaire within 8–10 min. Following the results, we made sev-
eral changes to the survey in order to simplify technical words
and increase participant’s understanding of the questions. The
reliability analysis of the questionnaire showed a Cronbach
full-scale alpha value of 78%, with good internal consistency,
a split-half reliability, and validity (Shenoy et al., 2009).
4. Results
Sixty-two out of the 73 gynecologists (85%) completed the
questionnaire. The remaining 11 doctors did not participate
in the study due to personal interests and/or scheduling con-
flicts. Of the 62 participants, 19 (30.6%) doctors belonged to
Group A and 43 (69.4%) doctors belonged to Group B.
The results showed that Group A doctors believed it was
more important to refer patients for dental care compared to
Table 1 Opinions of the respondents on hormonal change cause change in gingival tissue.
Q. No. 1 Group-A % Group-B
Yes 18 94.74
No 1 5.26
Do not know 0 0.00
Total 19 100.00
Fishers exact test, p = 0.3061, NS.
Table 2 Opinions of the respondents on whether observed gingival changes need treatment or not.
Opinion Group A % Group B
Yes 10 52.63
Subside automatically 9 47.37
Do not know 0 0.00
Total 19 100.00
Chi-square = 0.3780, df = 1, p = 0.5389, NS.
101
Group B doctors. In fact, 52.63% of Group A gynecologists
would refer cases of gingival tissue changes to a periodontist
for further dental health, compared to only 27.91% of Group
B gynecologists (p < 0.01; Table 3).
Groups A and B expressed similar beliefs on all other sur-
vey questions. For example, institutional practice failed to
influence general knowledge regarding periodontal health
and female hormones (Table 1). Between the two groups,
94.74% of gynecologists in Group A and 100% of the doctors
in Group B agreed that hormonal fluctuations may change gin-
gival tissue across a women’s reproductive phases (p =
0.3061). A total of 73.68% respondents from Group A and
51.16% respondents from Group B believed that hormonal
fluctuations preceded alterations in oral micro flora, which
was also similar among the two groups (Chi-square value
2.74, p = 0.25). Moreover, 52.63% of Group A doctors and
44.19% of Group B doctors felt that observed gingival changes
needed treatment, whereas the remaining doctors in both
groups believed that symptoms would subside automatically
(Chi-square value 0.37, p = 0.53; Table 2). Both Group A
(78.95%) and Group B (53.49%) gynecologists agreed that
periodontal disease was a risk factor for ‘Preterm Low Birth
Weight’ (PLBW) deliveries (Chi-square value 3.73, p = 0.15;
Table 4).
Both Group A (26.32%) and Group B (13.95%) doctors
would advise their patients for prenatal oral health check up
(Table 5).
On the question, whether long term use of oral contracep-
tive pills can induce gingival changes; 26.32% from Group A
and 13.95% from Group B gynecologists were aware of gingi-
val tissue changes induced by contraceptive pills. There was
not much difference found in their views (Chi square value
1.00, p value 0.60).
On the demand of patient 61.29% of total doctor’s pre-
scribed mouthwash, antibiotics and analgesics whereas, rest
of them prescribed Vitamin supplements. 68.42% of doctors
from Group A and 58.14% of doctors from Group B were
in support of prescribing antibiotics, analgesics and mouth-
wash. Disparity in their opinions was not significant (Table 6).
After answering the questionnaire, more than one third of
the gynecologists felt the need to emphasize on regular dental
% Total %
43 100.00 61 98.39
0 0.00 1 1.61
0 0.00 0 0.00
43 100.00 62 100.00
% Total %
19 44.19 29 46.77
24 55.81 33 53.23
0 0.00 0 0.00
43 100.00 62 100.00
102 S.N. Patil et al.

Table 3 Opinions of the respondents on reported case, you refer it to.

Opinion Group A % Group B % Total %
Dentist 7 36.84 30 69.77 37 59.68
Periodontist 10 52.63 12 27.91 22 35.48
Do not refer 2 10.53 1 2.33 3 4.84
Total 19 100.00 43 100.00 62 100.00
Fishers exact test, p = 0.0000, S.

Table 4 Opinions of the respondents on periodontal disease is a risk factor in ‘Preterm Low Birth Weight’ deliveries according to
groups.
Opinion Group A % Group B % Total %
Yes 15 78.95 23 53.49 38 61.29
No 1 5.26 6 13.95 7 11.29
Do not know 3 15.79 14 32.56 17 27.42
Total 19 100.00 43 100.00 62 100.00
Chi-square = 3.6260, df = 2, p = 0.16315, NS.

Table 5 Opinions of the respondents on do you insist pregnant/planning to be pregnant woman for oral health check-up.
Opinion Group A % Group B % Total %
Yes 5 26.32 6 13.95 11 17.74
No 7 36.84 25 58.14 32 51.61
Advice, but not insists 7 36.84 12 27.91 19 30.65
Total 19 100.00 43 100.00 62 100.00
Chi-square = 2.6360, df = 2, p = 0.26763, NS.

Table 6 Opinions of the respondents on prescription to patients who complain of gingival enlargement/bleeding gums.
Q. No. 13 Group-A % Group-B % Total %
Mouthwash and antiseptic gel; antibiotics & analgesics 13 68.42 25 58.14 38 61.29
Vitamin supplements 6 31.58 18 41.86 24 38.71
Total 19 100.00 43 100.00 62 100.00
Chi-square = 0.5871, df = 1, p = 0.4435, NS.

checkups for optimum oral health not only during pregnancy
but also during all the reproductive phases of the female life
cycle.
5. Discussion
Although several studies have investigated doctors’ attitude
and awareness of the association between oral health and preg-
nancy outcomes, the present study is unique because it assessed
gynecologists’ awareness of pregnancy outcomes in addition to
knowledge about hormonal-induced gingival changes through-
out a woman’s reproductive phases. We found that most gyne-
cologists were well educated and concerned about a female
patient’s oral health during different hormonal phases (Eleni
et al., 2009). Our findings contribute to the literature regarding
gynecologists’ knowledge of oral health, particularly periodon-
tal health, for female patients (Apoorva and Suchetha, 2010).
Interestingly, our data showed that gynecologists from Group
A demonstrated greater awareness of the need for dental fol-
low-ups compared to gynecologists from Group B. This differ-
ence in awareness may be explained by the fact that doctors in
medical colleges or hospitals (Group A) are continually up-
dated with current research for teaching and research purposes.
Almost all respondents agreed that hormonal fluctuations
may induce gingival tissue changes across the female life cycle.
Although not statistically significant, a greater number of
Group A respondents felt that alteration in oral micro flora
was a primary cause for gingival tissue changes. Moreover,
the survey question regarding referrals and reports of gingival
tissue changes was also answered more positively by Group A
(52.64% would report changes to a periodontist) compared to
Group B (27.91% would report changes to a periodontist).
Perhaps the data represent the availability of a general dentist,
compared to a specialist, near the institutional area. In addi-
tion, fewer Group B gynecologists, although statistically simi-
lar participants compared to Group A, reported awareness
that periodontal disease was a risk factor for PLBW. These re-
sults were similar to a study done by Shenoy et al. (2009),
Female sex hormones and periodontal health-awareness among gynecologists – A questionnaire survey
which concluded that the respondent’s knowledge regarding
the oral manifestations of periodontal disease could be high,
while the application of periodontal disease as a risk factor
for PLBW could be low. Awareness about periodontal disease
as a risk factor for ‘PLBW’ may be gained through continuous
medical education programs.
The present study also showed that while 98% of the gyne-
cologists knew about hormonal influences on the periodon-
tium, they were less aware of the importance of a regular
dental checkup. Moreover, only 47.3% of participants would
refer their female patient for a prenatal dental checkup during
her reproductive years. These findings are supported by Wilder
et al. (2007), who concluded that obstetricians were well aware
of periodontal disease as a potential risk factor for PLBW but
showed limited incorporation of this knowledge into clinical
practice. Similar results were also found by a survey done by
AI Habashneh et al. (2008) in Northern Jordan. In this study,
the authors reported that approximately 68% of the gynecolo-
gists refrained from advising periodontal evaluation as a part
of their antenatal care for pregnant women or for those plan-
ning pregnancy.
In 2004, the American Academy of Periodontology released
recommendations that all pregnant women, including those
planning a pregnancy, should undergo periodontal examina-
tion and, if needed, should be provided with the appropriate
preventive and/or therapeutic services (American Academy
of Periodontology, Academy Report, 2004). Gynecologists
routinely refer pregnant women for blood tests, thyroid level
testing, anomaly testing, and sonography scans; the report rec-
ommended that a routine dental checkup also be included.
Risk identification factors, and the confirmation of periodon-
tal infection as an independent risk factor, for adverse preg-
nancy outcomes are of significant public value because
periodontal infection is both preventable and curable (Boggess,
2008). Since gynecologists are the primary caregivers during a
woman’s reproductive years, it makes sense that they have the
opportunity to detect oral health problems at an early stage,
and can then direct a patient to a periodontist for further eval-
uation. Thus, gynecologists should be receiving a higher level
of education in this area. In addition, prenatal care providers
should also be educated regarding the reported association be-
tween dental health and pregnancy outcomes, as they may be
able to refer patients for periodontal health checkups.
Gynecologists from both Group A and Group B group
were less educated about the gingival changes induced by the
long term use of oral contraceptive pills. This finding is not
surprising, as there are a limited number of studies focusing
on oral hormone administration and dental health. However,
gynecologists from both groups prescribed antibiotics, analge-
sics, mouthwash, and vitamin supplements to their patients,
which indicated that they were attentive toward a patient’s oral
health.
6. Conclusion
Research clearly demonstrates that women have exceptional
oral health considerations. Consequently, the incorporation
of periodontal care with obstetric management may improve
pregnancy outcomes and overall periodontal health in women.
It is of paramount importance that primary healthcare profes-
sionals address these gender-specific oral health concerns. We
suggest that continuing medical and dental education pro-
103
grams, and scientific intercommunication between medical
professionals, may provide better quality healthcare services
to the community.
Ethical Statement
There is no ethical issue regarding this study.
Conflict of interest
No conflict of interest declared.
Acknowledgment
The author(s) wish to acknowledge all the participant
gynecologists.
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