A need to educate postmenopausal women of their periodontal health.

BACKGROUND: Postmenopausal women have shown proactive willingness to take responsibility for their changing health care needs. The example of osteoporosis is a model that when educated of their bone health status, this cohort follows through with prevention and treatment regimens. Postmenopausal status is considered to be a risk factor for periodontitis. It is known that up to 50% of periodontal disease goes undiagnosed. The goal of periodontal therapy is to prevent tooth loss.
OBJECTIVE: Is there a need, then to educate and inform postmenopausal women of their periodontal status? Can dentists provide a greater service to this cohort by increasing education and information?
MATERIALS AND METHODS: The current study compares patient perception to actual clinical findings in 94 postmenopausal women. Patients are informed of their diagnosis, and educated about the disease, its risk factors and preventive and treatment modalities. Detailed interviews examine the patient intentions to follow up on preventive and treatment regimens suggested.
RESULTS: Although 97.8% of participants reported having "healthy gums", 36.2% had severe periodontitis in at least one site. Interviews reveal that patients associated disease with abscess, and would be likely to follow prevetive and treatment regimens when they were informed of their diagnosis and educated on the topic.
CONCLUSION: The findings suggest a need to make education a priority when treatment postmenopausal women.

INTRODUCTION

Postmenopausal women are vigilant in seeking prevention and treatment for osteoporosis. This stands as a testament to how driven this cohort is when properly educated and advised. This medical model can show dentists that when made aware of their osteoporosis status and when educated of the risks of osteoporosis, postmenopausal women follow through with preventive and treatment measures not only with physicians who are bone-specific-specialists but also with non-specialists.[1] By educating women about bone-health risks after menopause, medicine has empowered them to seek out prevention and treatment. As a result, this cohort reliably seeks out care from medical professionals regardless of their “specialty”. Medical professionals intervene either by suggesting simple daily changes like weight bearing exercise, calcium/vitamin D supplements, or, when indicated, more intense therapy like medications. Driven largely by esthetics demands, and less so by overall wellbeing, this postmenopausal cohort, makes up a large share of general dental practices.[2] Additionally, it is recognized that this same cohort of postmenopausal women is at risk for progressing periodontitis and tooth loss.

This begs the question, could periodontists provide a greater service to postmenopausal women, by providing them with a greater awareness of their oral health status and education of the risks associated with oral disease, in a fashion similar to what physicians have done with osteoporosis. Like periodontitis, osteoporosis is a painless condition until the point of irreversible damage. In osteoporosis, this damage occurs at the point of fracture, in periodontitis, this damage occurs in the form of abscess or tooth loss.

This study focused on periodontal oral health and aimed to identify if postmenopausal women are aware of their periodontal status, risks for progressing periodontal disease, systemic disease risks associated with periodontitis, and tooth loss.

MATERIALS AND METHODS

Ninety-four postmenopausal women receiving regular medical care and having some type of private medical and dental insurance coverage were recruited from the Center for Specialized Women's Health at the Cleveland Clinic Foundation, and participated in this Institutional Review Board-approved observational study. Participants responded to questionnaire assessing perception of oral health, awareness of risks for progressing periodontitis, and impacts of periodontitis on systemic health; they received a comprehensive periodontal exam, including radiographic exam, from a calibrated examiner. Plaque score percentage (PS) for each participant, periodontal probe depth, and clinical attachment level (CAL) in mm on six sites per tooth were measured. Bleeding on probing, and furcation involvement were noted when present. Based on the CALs, the participants were classified as mild (1-2 mm CAL), moderate (3-4 mm CAL), or severe (>5 mm CAL on greater than 30% of sites) periodontitis.[3] Perception of periodontal health status was compared to actual diagnosis from clinical exam outcome.

Following the clinical exam, all participants received a 30-45 min “awareness and education session”. The clinical examiner made each participant aware of their periodontal status. During this session, the patient reviewed her own clinical and radiographic evidence (existence of any and all periodontal defects including areas of clinical attachment loss, furcation involved teeth, and recession), risk factors for progression of these defects (in the scope of overall risks for periodontitis), systemic risks associated with untreated oral inflammation, and she was educated about the role of bacterial plaque in inflammation. Plaque-coated surfaces were pointed out to each participant and each was made aware that poor oral hygiene is related to gingival inflammation and is noted to be not only a risk factor for progressing periodontitis, but also reportedly related to risk for infective endocarditis-related bacteremia,[4] poorer glycemic control,[5] and is associated with stroke, and adverse cardiovascular outcomes.[6] Each participant was told that supragingival bacterial plaque deposits are visible within a few hours of a professional dental cleaning, and progresses to subgingival bacterial plaque infection. Bacterial plaque calcifies within a week if proper and effective oral hygiene is not completed by the patient. Hence, removal of these deposits during more frequent maintenance visits is a preventive measure. Participants were also educated of the role of bacterial species in subgingival plaque and oral bone loss; this biofilm has long been recognized, and in postmenopausal women, linked to alveolar bone loss and tooth loss.[789] Furcation involvement was explained to those patients who presented with that condition. They were educated about the fact that when furcation is reportedly involved, up to one-third of the tooth's attachment apparatus is already lost and that the presence of furcation involvement is a risk factor for the adjacent site of the neighboring tooth.[10]

Twenty of these 94 participants were randomly selected for in-depth one-on-one interview. Qualitative data gathered from the interview included information on whether or not now, after becoming aware of periodontal status, they would increase their usage of dental services and change preventive home-care behavior after becoming aware of periodontal status, risks to progressing disease, systemic disease risks associated with periodontitis, and tooth loss. Discussion included whether or not participants would more actively seek preventive care including more frequent maintenance, and altered oral hygiene practices at home. Since all participants had dental insurance, during interviews, coverage for such measures was assumed to be present; a discussion of coverage for preventive care and treatment measures was not included in the discussion.

RESULTS

97.8% of participants reported having “healthy gums”, 2.1% reported having had “history of gum disease, but currently healthy gums”, and 0% reported having gum disease [Figure 1]. Based on clinical exam findings, 36.2% had severe, 26.6% had moderate, and 34.0% had mild periodontitis in at least one site [Figure 2]. 3.2% had no sites with periodontal attachment loss. Average PS was 67.5% of sites in the mouth covered with bacterial plaque biofilm. 23.4% had at least one vertical/angular radiographic defect; 30.8% had some degree of furcation involvement. When asked about frequency of dental visits to maintain the current periodontal conditions, 86.2% reported “every 6 months”, 3.2% reported “every 3 months”, and 10.6% did not know. When asked if they “could be at risk for tooth loss”, 98.9% answered no. When asked if they were aware of any risks, or unchecked conditions which could lead to health of their gums to get worse over time, 95.7% said no. No abscess or acute conditions were noted.

Figure 1

Questionnaire results – Self report on disease awareness

Figure 2

Clinical examination for attachment loss

DISCUSSION

Although 97.8% of participants believed they had “healthy gums”, clinical examination revealed that 62.8% had at least one moderate to severe site of attachment loss, 23.4% had at least one vertical/angular defect radio graphically, and 30.8% had at least one site of furcation involvement. The contrast between self-report of awareness and clinical examination reveals that participants had a very little awareness of periodontal defects. This is not surprising, as periodontal defects are often not painful. However, the lack of awareness that the condition is present is clear.

Despite 86.2% of participants reported meeting regular (6 month) dental exam and prophylaxis visits, an average PS of 67.5% of sites in each participant were coated with bacterial plaque biofilm, the primary cause of periodontitis. Recognizing that self-report involves some inherent bias, and probably over-estimates the percentage of participants who report following a true 6-month-recall; but considering that all the participants had adequate access to dental care, it is reasonable to infer that despite the access to regular maintenance, the average PS (an objective measurement), is considerably high. The average PS of the participants is considered to be poor.[11] Since no abscess was identified in any participant, and 92 out of 94 participants reported “healthy gums”, it seems that abscess is more closely related to what participants in this cohort identified as problematic versus actual loss of attachment, cementum, periodontal ligament, and bone. It is clear from these results that oral health education in postmenopausal women is lacking. This underscores the need for more in-depth awareness of the benefit of more frequent maintenance visits and importance of daily oral hygiene in this cohort. Results of the 20 interviews made it clear that participants had little or no knowledge about the role of bacterial plaque in oral inflammation and ensuing destruction of structures that support the teeth. Although the majority of participants were able to identify that “improper/inadequate brushing” and sugary foods are associated with “cavities”, overall, the group was unclear about what causes gum diseases.

During in-depth interviews, it became evident that very few participants knew the potential systemic risks associated with oral inflammation. Several participants reported reading or hearing that “flossing can add years to life”; but none were able to connect the presence of bacterial plaque and oral inflammation with systemic health. Interview results shed light on the fact that none of the participants knew of furcation-involved teeth, or of its implication. Furthermore, interviews reveal that when participants were told of their periodontal defects, and risks for progression of these defects, they unanimously were interested in more prevention (in the form of frequent maintenance visits and improved home care) and treatment measures.

The media empowers postmenopausal women to “take charge” of their overall health and well-being. This has held true for medical well-being, particularly when related to osteoporosis prevention and treatment. Articles in popular magazines and commercial spots during television programs inspire women to seek out preventive measures and early treatment when risks for developing systemic disease are present. Medical counterparts have, through education and clear communication, developed this empowerment to include preventive and treatment action – as with the case of osteoporosis after menopause. Medical counterparts already acknowledge the potential of patient empowerment in oral health for postmenopausal women.[12] The results of this study suggest that periodontics may be able to do the same. Judging from their vigilant response to prevent and treat osteoporosis, our profession could provide the means to better oral health through a greater investment in educating this cohort. The implications of this study underscore the need for outreach to postmenopausal women. There is a knowledge gap in this cohort which our profession should address. A potential strategy to address this is to charge a taskforce or working group, comprised of periodontists, generalists, communications experts, and women at large, to develop informational guidelines.

CONCLUSION

Postmenopausal women are not aware of their periodontal health, the risks for progressing disease, or the risks of progressing disease to their systemic health. A detailed sampling from this cohort strongly suggests increased usage of preventive and treatment regimens if they were more aware and better educated about periodontal status. By making education a priority when treating postmenopausal women, periodontists may be able to provide a greater service to this cohort.