DEFINITION
Gingivitis can be defined as inflammation of the gingival tissue without loss of tooth attachment. It occurs commonly in the 2nd to 8th months of pregnancy.
ETIOLOGY
Pregnancy causes hormonal changes that increase the risk for developing oral health problems like gingivitis (inflammation of the gums) and periodontitis (gum disease). As a result of varying hormone levels, between 50%-70% of women will develop gingivitis sometimes during their pregnancy – a condition called pregnancy gingivitis.
PATHOPHISIOLOGY
Many studies have shown that the oral mucosa and salivary glands are sensitive to estrogen action. However, the expression of estrogen receptors (ERs) within these tissues is an area of controversy. ERs exist as two subtypes (ERalpha and ERbeta).
ERalpha was not detected in oral buccal and gingival epithelium or in salivary glands. In contrast, ERbeta was widely expressed at high levels in all oral tissues studied.
Importantly, these results suggest that estrogens may act via ERbeta in oral tissues and explain the effect of hormonal changes on the oral mucosa as well as on saliva secretion and composition.(1)
The hormonal changes that occur during pregnancy ,especially the level of progesterone, increase the blood flow to the gum tissue and causes gums to be more sensitive and vulnerable to irritation and swelling.
The gingival tissues respond to increased levels of estrogen and progesterone by undergoing vasodilation and increased capillary permeability. Consequently, there is an increased migration of fluid and white blood cells out of blood vessels.
Also associated with increased progesterone levels are alterations in the existing microbial populations. The levels of Gram-negative anaerobic bacteria, such as Prevotella intermedia, increase as a result of the high concentration of hormones available as a nutrient for growth.
In pregnancy the maternal immunological system presents some particular modifications (high IDO); these allow to avoid the immunological rejection between mother and fetus, but reduce the reactivity of gingival tissues against local irritating factors.
The anterior region of the mouth is more commonly affected by gingivitis and the interproximal sites tend to be the most involved areas.
Sex steroid hormones have been shown to have effects on cellular growth, proliferation and differentiation in target tissues including keratinocytes: and fibroblasts in the gingiva. Sex steroid hormones may also modulate production of cytokines, and progesterone has been shown to down regulate IL-6 production by human gingival fibroblasts. This down-regulation can affect the development of localized inflammation, and gingiva becomes less efficient at resisting the inflammatory challenges produced by bacteria.
Pregnant women saliva presents lower pH and higher sIgA than non-pregnant women, but no significant difference was found for secretion rate of saliva or concentrations of calcium and phosphate. The values of the tested salivary parameters have been shown to be within the international references of normality.
Changes in salivary composition and flow rates may compromise the integrity of the soft and hard tissues in the oral cavity, because saliva functions include food and bacteria clearance, mastication and digestion, lubrication, antimicrobial defense, and buffering effect. Saliva is composed of water and organic and inorganic molecules, but a large intra- and inter-subject variability in composition is reported.
Most studies focusing on the influence of pregnancy and hormonal alterations on salivary characteristics were performed in European countries, and some reference standards for normality are derived from data obtained in specific populations.
Finally an alteration of folate metabolism: is noted in response to both estrogen and progesterone.
Folate is essential for normal functioning and differentiation of many tissues, including epithelial cells.
Patients treated with oral folate and folate rinses have shown significant reduction of pregnancy gingivitis.
Folate:
The risk of gingivitis is increased by misaligned teeth, the rough edges of fillings, and ill fitting or unclean dentures, bridges, and crowns. This is due to their plaque retentive properties.
SYMPTOMS
The symptoms of gingivitis are as follows:
• Swollen gums
• Mouth sores
• Bright-red, or purple gums
• Shiny gums
• Swollen gums that emit pus
• Severe oral odor
• Gums that are tender, or painful to the touch.
• Gums that bleed easily, even with gentle brushing, and especially when flossing.
• Gums that itch with varying degrees of severity.
PREVENTION AND TREATMENT
Pregnancy Gingivitis can be prevented if the expectant mother can effectively brush her teeth with fluoride toothpaste in the morning and before bed at night and floss her teeth daily to thoroughly remove dental plaque. This oral hygiene habit can also promote healing of mild gingival inflammation.
BIBLIOGRAPHY
(1) Female hormones and oral health, 1998 pubmed
Meijer van Putten JB.
Ned Tijdschr Tandheelkd. 1998 Nov;105(11):416-8. Dutch.
PMID: 11928463 [PubMed - indexed for MEDLINE]
Hormonal factors in periodontal disease.
Soory M.
Dent Update. 2000 Oct;27(8):380-3.
PMID: 11218530 [PubMed - indexed for MEDLINE]
Expression of estrogen receptors in desquamative gingivitis.
Yih WY, Richardson L, Kratochvil FJ, Avera SP, Zieper MB.
J Periodontol. 2000 Mar;71(3):482-7.
PMID: 10776938 [PubMed - indexed for MEDLINE]
