A study to evaluate mobility of teeth during menstrual cycle using Periotest.

BACKGROUND AND
OBJECTIVE: Over a century, an increased prevalence of gingival disease associated with increasing plasma sex steroid hormone levels has been reported. These situations present unique challenges to the oral health care professional. It is believed that hormonal fluctuations such as those associated with pregnancy, menstruation, and use of hormonal contraceptives lead to an increase in tooth mobility. However, this effect of female sex hormones on periodontal ligament and tooth supporting alveolar bone has rarely been investigated. So this study was undertaken to understand the effect on tooth mobility because of hormonal changes during the menstrual cycle.
MATERIALS AND METHODS: The mobility of index teeth 16, 13, 21, 23, 24, 36, 33, 41, 43, and 44 was measured with Periotest in 50 females at menstruation, ovulation, and premenstruation time points. Simplified oral hygiene index, plaque index, gingival index, and probing depth were also evaluated during the different phases of menstrual cycle for each subject participating in the study. STATISTICAL ANALYSIS: The results of the study were subjected to statistical analysis. Data analysis was done by applying Z test for comparing difference between two sample means. RESULT: The stages of menstrual cycle had no significant influence on the Periotest value. Despite no significant change in plaque levels, GI was significantly higher during ovulation and premenstruation time points.
CONCLUSION: No change in tooth mobility was seen during the phases of the menstrual cycle. However, an exaggerated gingival response was seen during ovulation and premenstruation time when the entire menstrual cycle was observed.

INTRODUCTION

The homeostasis of the periodontium involves complex multifactorial relationship in which endocrine system plays an important role.[1] Physiological events due to hormonal influences have long been recognized as an important influencing, predisposing, or ‘risk factor’ in periodontal diseases. Currently accepted periodontal classification also recognizes the influence of endogenously produced sex hormones on the periodontium.[2]

Changes in woman's hormonal milieu have surprisingly strong influence on oral cavity and are reflected in her periodontal tissues as well. The data available from previous studies,[3] strongly suggest that female sex steroid hormones may alter periodontal tissue response to microbial plaque and thus indirectly contribute to periodontal disease. It is believed that hormonal fluctuations associated with pregnancy, menstruation, and use of hormonal contraceptives lead to increase in the mobility of teeth, presumably because of physicochemical changes in periodontium. However, the literature to support this belief is very scanty.[45]

A better understanding of the periodontal changes in response to hormonal changes can help a dental practitioner in the diagnosis as well as in providing appropriate treatment. Thus, this study intends to understand the effect of menstruation on tooth mobility and gingival condition.

MATERIALS AND METHODS

This study was conducted in the Department of Periodontics (Rural Dental College, Loni), in 2006 (February–October). After obtaining consent, a total of 50 females in the age group of 17-25 years were examined. Each subject was asked to record the dates of her menstrual period. Depending on the dates that can be observed in different phases of menstrual cycle such as leutal/premenstruation (PM) (24th-26th day), follicular/menstruation (M) (2nd-3rd day), and ovulation (OV) (12th-14th day), specific time points were selected for each visit as 25th day for PM, 2nd day for M, and 13th day for OV for recording the parameters.

Inclusion criteria

Subjects chosen were nonperiodontitis patients with probing depth ≤3 mm

Subjects with steady menstrual cycle

Permanent dentition.

Exclusion criteria

Presence of any systemic disease that could influence the responses of periodontal tissues to the accumulation of plaque

Presence of gross caries or inadequate restorations interfering with removal of dental plaque

Use of oral contraceptives

Teeth restored with crown or fillings

Orthodontic treatment during the last 3 years.

Clinical examination

Simplified oral hygiene index (OHIS),[6] plaque index (PI),[7] gingival Index (GI),[8] probing depth (PD), and tooth mobility[9] were evaluated for each subject participating in the study.

Mobility of teeth 16, 13, 21, 23, 24, 36, 33, 41, 43, and 44 was measured with Periotest [Figure 1a and b].

Figure 1

(a) Armamentarium used for clinical examination; (b) Periotest® used for measuring tooth mobi

The device consists of a hand piece connected by a cable to a unit that controls functions and analyzes measurements. Inside the hand piece, a metal rod is accelerated until it reaches its nominal speed and contacts the tooth. Upon impact, the tooth is slightly deflected and rod is decelerated. The faster the deceleration, higher will be the stability and greater the damping of periodontal tissues. The contact time between tooth and tapping head is the signal used for analysis by the system. During each measurement, the device delivers 16 impacts in 4 s to the object.

The duration of contact of the tapping head on the tooth surface measured by the instrument that calculates the Periotest valve (PTV), indicates tooth mobility. An average of three PTVs obtained was calculated. PTVs are based on a numerical scale from −8 to +50 [Table 1].

Table 1

PTV and it's correlation to clinical mobility

Periotest device has many applications. It can be used in the diagnosis and assessment of healing of traumatized teeth in children. It offers great potential for use in implant dentistry to evaluate the bone implant interface. Since it offers an objective parameter even slight change in tooth as well as implant mobility can be evaluated. This device can also help in assessing even the most initial changes of progression from gingivitis to periodontitis.[510]

Statistical analysis

Mean and standard deviation were calculated. Data analysis was done by applying the Z test to compare the difference between two sample means.

OBSERVATIONS AND RESULTS

Table 2 shows distribution of PTV values at M, O, and PM time points. No significant difference was observed in the PTV values. Table 3 shows comparison of mean values of OHIS, PI, and GI whereas Table 4 shows the comparison of mean values of the probing depth (PD) at M, OV, and PM time points. GI was high at OV time point followed by PM whereas no significant difference was seen in PD scores. When the mean values of the PD were compared during the three phases of menstrual cycle, it was seen that there was no significant difference in PD scores.

Table 2

Distribution of periotest values at menstruation, ovulation and premenstruation phase

Table 3

Comparison of mean values of various parameters under study

Table 4

Comparison of mean values of probing depth at M, OV, and PM

DISCUSSION

Measuring the degree of tooth mobility is an important part of any thorough periodontal examination. Tooth mobility is the measurement of horizontal and vertical tooth displacement created by examiners force.[11] Even a tooth with significant alveolar bone support reveals physiologic tooth mobility. This is due to the syndesmotic mechanism by which teeth are supported within the alveoli and the elasticity of entire alveolar process. Stability of a tooth is dependent upon the resistance of its supporting structure and the character of forces directed against it. When either changes so does mobility.[12]

It is believed that hormonal fluctuations such as those associated with pregnancy, menstruation, and use of hormonal contraceptives lead to an increase in tooth mobility. It is undoubtedly possible that these structures react to changes in endocrine activity in a similar way the connective tissue does in other parts of the body.[5] It is believed that this increase occurs in patients with or without periodontal disease presumably because of physiochemical changes in periodontium.[513] The tooth-supporting structures, under the influence of hormones would offer less resistance to the forces acting on them and accordingly a reduction in the capacity to dissipate forces and increased tooth mobility.[514]

Rateitschak[4] explained that mobility during periods of hormonal changes is increased mainly because of an increase in the initial free intrasocket movement of the roots (initial mobility) and not because of increased elastic bone distortion. Initial mobility is among other factors dependent on the degree of vascularization and the vascular volume of the periodontal membrane. Experimental vasoconstriction and vasodilatation of periodontal vessels have been shown to decrease or increase initial movement respectively. Female sex hormones may have a hyperemic- and permeability- increasing action on the periodontal vascular system as shown for other parts of the body. With respect to the periodontal membrane, slight edema has a tooth extruding effect, increasing by this mechanism the horizontal mobility. Additionally, under the influence of sex hormones, changes in the viscosity of interstitial fluid and in the degree of ground substance polymerization and perhaps alterations of collagen fibers could also reduce resistance against intrasocket movements of roots.

This study was undertaken to understand the possible association between the effects of female sex hormones during the menstrual cycle and tooth mobility. Females in the age group of 17-25 years with stable menstrual cycle were examined.

Measuring tooth mobility and especially assessing changes in mobility is rather difficult. Luxation is the most commonly used method to detect tooth mobility. This is because the recommendations for evaluating tooth mobility are insufficient, nonscientific, and highly subjected to individual variation. Since there was need for a numerical assessment of tooth mobility to help assess changes during the different phases of menstruation, a Periotest (Siemens AG, Bensheim, Germany) was used. It is an electronic device that measures the damping characteristics of the periodontium and provides an objective measurement.

The result of this study showed that the stages of the menstrual cycle, which are menstruation (M), ovulation (OV), and premenstruation (PM) had no significant influence on the Periotest value (PTV). Our results are in accordance with those of Steenberghe et al.[5] and Friedman[15] who found no significant change in tooth mobility during the menstrual cycle. However, some authors have reported a minor increase in horizontal tooth mobility during the fourth week of menstrual cycle.[16]

Menstrual cycle is an important hormonal milieu in a woman's life. Dynamic relationship exists between the hormones and reproductive system. During the follicular phase follicular stimulating hormone (FSH) in conjunction with luteinizing hormone (LH) activates the secretion of estrogen. The maximum peak of estrogen secretion is seen about 48 h before ovulation. Ovulation is triggered by the rapid rise in estradiol elaborated by preovulatory follicle. The LH surge occurs 24-36 h before ovulation. This stimulates the synthesis of progesterone within the follicle. After ovulation at approximately 14th day of the cycle, the secretory or luteal phase begins. This phase is characterized by the synthesis and release of both estrogen and progesterone by follicular cells.[17]

Due to these events, several women report oral symptoms just before or during menses that include erythema, slight burning sensation, minor apthous, bleeding with minor irritation, and general pain and discomfort in gums.[18] Gingival manifestations of bleeding and swollen gingiva during menstrual cycle have been reported by Lindhe and other researchers.[19202122] Muhlemann over 64 years ago described a case of gingivitis intermenstrulis, which he observed as consisting of bright red hemorrhagic lesions of interproximal papillae identified prior to menstruation.[23]

Nevertheless, most women with a clinically healthy periodontium experience few significant periodontal changes as a result of menstruation.[1] In a longitudinal study, Holm-pederson and Loe[20] found no effect of hormonal variations during the menstrual cycle on clinically healthy gingiva whereas significant deterioration of pre-existent gingivitis was observed during days of menstruation. Lindhe and Attstrom[19] noted that during their menstrual cycles, women without clinical gingivitis showed no increase in gingival fluid whereas those with gingivitis showed an increase in gingival crevicular fluid flow.

The gingiva can thus be considered a target tissue for estrogen and progesterone. Elevated levels of progesterone affect gingival microvasculature enhancing capillary permeability and dilatation. Their high concentration also affects the host defense mechanism such as neutrophil chemotactic response and also enhances production of prostaglandins. Elevated levels of estrogen cause decrease in the keratinization of gingiva with an increase in epithelial glycogen and thus results in decreased effectiveness of epithelial barrier. Estrogen and progesterone reduce glycosaminoglycans synthesis and thus may affect ground substance of connective tissue.[24]

Miyagi et al.[25] found that sex hormones significantly enhanced synthesis of prostaglandin (PGE2) that plays an important role in periodontal inflammation. They also studied the effects of these hormones on PGE2 synthesis by pheripheral monocytes. Both estradiol and progesterone resulted in elevated PGE2 production that could turn up the inflammatory process. Another finding which was reported was that estradiol reduces the chemotactic ability of Polymorphonuclear neutrophils (PMNs) while progesterone significantly enhances it.[26] Thus, these hormones present as important influencing factors in the pathogenesis of periodontal diseases.[23] Hence, in this study, an attempt was also made to determine the gingival condition during various stages of the menstrual cycle.

In this study, gingival inflammation was assessed by the gingival index (GI). The findings revealed that GI scores were lower during the M phase than at OV and PM time points [Figures 2 and 3]. Our findings are similar to that reported by Macheti et al.[10] who found that despite no significant change in plaque levels, GI was significantly higher during OV and PM time points. This difference primarily maybe attributed to the increase in serum estradiol levels that peak during OV and a second peak that occurs just before menstruation.

Figure 2

Gingival condition at ovulation time point of menstrual cycle (Gingival index score = 2); (a) Lateral view and (b) frontal view

Figure 3

In the same patient gingival condition at menstruation time point of the menstrual cycle (Gingival index score = 1); (a) Lateral view and (b) frontal view

Serum estradiol levels peak at OV (150-600 pg/mL) and drop immediately after. A second peak is observed during PM (40-300 pg/mL). However, progesterone levels are initially low (0.06-0.37 ng/mL) to a peak a few days before M (4.3-19.4 ng/mL) with a sharp decline thereafter.[17] It is therefore suggested that the above-reported phenomenon of increase in GI at OV and PM maybe primarily attributed to the increase in estradiol levels. The increased levels of these hormones also influence the regulation of inflammatory mediators such as Tumor Necrosis Factor (TNFα) and Prostaglandins that could turn up the inflammatory process responsible for the heightened GI scores.[2627]

Gornstein et al.[28] and Lapp et al.[29] reported that Interleukin (IL-6) was down regulated by progesterone and hence could modulate the development of localized gingival inflammation rendering the gingival less efficient at resisting the inflammatory challenges produced by bacteria. They also found increased amount of gingival exudate during the ovulation phase of the menstrual cycle.

The periovulatory rise of IL-6 and late leutal rise of IL-6 and TNF-α may act as cofactors in rise in basal temperature or the premenstrual syndrome.[30] Studies have also shown that menstrual cycle irregularity maybe a marker of metabolic abnormalities predisposing to increased risk for immune-system-related diseases.[3132] Hence, precautions to strengthen immune system during this phase will be appropriate.

Probing depth during the three phases was also evaluated, but it showed no significant change. Hence, it can be inferred that the high concentration of circulating hormones has an effect only on gingiva and are insufficient to cause significant periodontal breakdown. Machtei et al.[16] did not find any change in mean probing depth during different phases of menstrual cycle. Our findings are similar to the aforementioned study.

CONCLUSION

Our investigation showed that there was no change in tooth mobility during the phases of menstrual cycle. Exaggerated gingival response was seen during ovulation and premenstruation time points when the entire menstrual cycle was observed. This increase in gingivitis was apparently the result of heightened tissue response to irritation, which suggests that the cause was related to the concentration of circulating sex hormones. However, tooth mobility may not be under the influence of hormonal changes occurring during the period of menstruation.

Much research is needed to address the increasing number of patients who present to our periodontal practices with sex-hormone-mediated infection. Studies regarding correlation of hormonal levels with specific tooth mobility and detailed microbiologic investigation would help us gain further insight and knowledge about issues regarding female health and periodontal therapy. Also, a better understanding of periodontal changes to varying hormone levels throughout life can help dental practitioner in diagnosis and treatment.