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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 11  |  Issue : 6  |  Page : 388-392

Gingival Inflammation in 2 Phases of Menstrual Cycle and its Relation to Oral Hygiene of Female Dentistry Students


Department of Dental Public Health, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Date of Web Publication26-Nov-2019

Correspondence Address:
Dr. Raden Darmawan Setijanto
Mayjend Prof Moestopo No. 47, Surabaya, East Java.
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_232_18

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  Abstract 

Aims and Objectives: Hormonal changes in women that occur in the menstrual cycle is one of the systemic factors that causes gingivitis, namely the menstruation gingivitis. Women with this condition will experience the same signs and symptoms as gingivitis in general. This study observed the description of the occurrence of gingivitis as well as its correlation to the level of dental and oral hygiene at female dental students, in which they have knowledge about how to keep dental and oral hygiene properly. The purpose of this study was to determine the profile of the occurrence of gingivitis as well as its correlation to the level of oral hygiene in female students of dentistry program. Materials and Methods: This was a descriptive analytic study with 318 samples, which were divided into three groups according to the menstrual cycle. Gingivitis examination was performed with the gingival index and oral hygiene examination with Oral Hygiene Index-Simplified. The statistical analysis was carried out for this study using Statistical Package for the Social Sciences (SPSS), version 17 software. Results: In the premenstrual period group, 94.3% had good oral hygiene and 24.5% had gingivitis. In the menstrual period group, 88.7% had good oral hygiene and 4.7% experienced gingivitis. In the postmenstrual period group, 88.7% had good oral hygiene and 100% of the samples had normal gingiva without inflammation. Conclusion: Menstruation gingivitis occurs higher in the premenstrual period (proliferative phase) although with good oral hygiene conditions.

Keywords: Gingivitis, menstruation, oral hygiene, women


How to cite this article:
Setijanto RD, Rahayu MV, Bramantoro T, Wening GR, Rudhanton RA, Ramadhani A. Gingival Inflammation in 2 Phases of Menstrual Cycle and its Relation to Oral Hygiene of Female Dentistry Students. J Int Oral Health 2019;11:388-92

How to cite this URL:
Setijanto RD, Rahayu MV, Bramantoro T, Wening GR, Rudhanton RA, Ramadhani A. Gingival Inflammation in 2 Phases of Menstrual Cycle and its Relation to Oral Hygiene of Female Dentistry Students. J Int Oral Health [serial online] 2019 [cited 2020 Aug 12];11:388-92. Available from: http://www.jioh.org/text.asp?2019/11/6/388/271780


  Introduction Top


The gingiva is the outermost part of the periodontium that serves to protect the underlying tissues. This function is carried out in the presence of gingival connective tissue that has a strong response when it gets dangerous stimuli in the form of inflammatory response.[1]

The process of inflammation of the gingiva is called gingivitis. The definition of gingivitis is an inflammation, where junctional epithelium is still intact on the teeth in their normal position.[2] Gingival inflammation is considered as a primary form of pathological changes in gingiva tissue, as a secondary form of systemic condition related to gingival health, and as a lesion from the systemic condition.[3]

The data from a survey conducted by the National Health and Nutrition Examination Survey III (NHANES III) 1988–1994 in the United States showed that the prevalence of gingivitis is highest (63%) in the age group of 13–17 years, the prevalence decreases in the age group of 35–44 years but increases again in the age group of 45–55 years, and is relatively stable in the older age groups. The prevalence of gingivitis in women in the age group of 18–24 years is 55%. From these data, it is known that there is a considerable prevalence of gingivitis in women in the age group of 18–24 years who are of productive age, followed by hormonal fluctuations.[4]

Gingivitis can be caused by various factors. The main factor is usually the bacteria from the plaque in the gingival margin, which causes gingivitis. Another factor is systemic factors, one of which is the presence of a hormonal change.[1]

Systemic factors may play a role in the gingivitis process but they could not specifically cause gingivitis without the presence of local factors. Systemic factors could reduce tissue resistance in the mechanisms against invasive plaque bacteria. The most common gingivitis is caused by the local factors, which is the accumulation of plaque in the gingival margin. The inflammation could get more severe if there is a systemic (hormonal) factor involved.[5]

Hormonal changes in women that occur during the menstrual cycle is one of the systemic factors that could cause gingivitis. The menstrual cycle takes place in two phases: the proliferative phase (during menstruation to the ovulation phase) and the luteal phase (after the ovulation phase until the onset of menstruation). In the menstrual cycle of luteal phase, there is an increase in the level of progesterone hormone. This causes a response in gingival tissue, which becomes more sensitive to the plaque on the teeth and produces inflammatory reactions. Therefore, gingivitis may occur despite relatively small amounts of plaque.[6]

Gingivitis that occurs due to hormonal changes in women during the menstrual cycle is called menstruation gingivitis. Women with this condition will experience the same signs and symptoms as gingivitis in general.[7],[8]

The progesterone hormone which released during the luteal phase may increase the permeability of the microvascular and affect the pattern of gingival collagen tissue production. It also increased the folic acid metabolism, increased the chemotaxis of PMN (Polymorphonuclear) cells, and stimulate the prostaglandin production. In the menstrual cycle, gingival tissue is likely to be more oedematous and erythematous during the pre-menstrual period.[9]

Also, there is a higher gingival index score during ovulation and before menstruation compared with the gingival index score during menstruation.[3]

The purpose of this study was to observe the description of the occurrence of gingivitis as well as its correlation to the level of oral hygiene in the female dental students, in which they should have knowledge about how to keep oral hygiene properly. On the basis of preliminary survey we conducted, the result showed that of 20 female dentistry students, only six had gingivitis. Thus, the possibility of female dentistry students to experience gingivitis was relatively small.


  Materials and Methods Top


This was an analytic cross-sectional study with 6 months of research. The population of this study constituted female students of the Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia. The sample included female students with healthy criteria, no systemic abnormality, regular menstrual cycle, and not using fixed orthodontic appliance. The sample size in this study was 318 female students. All the respondents who were the subjects in this study had filled the informed consent that stated their willingness for an intraoral examination and direct interview. The samples were then divided into three groups based on the menstrual cycle period, that is, the period before menstruation, menstruation period, and the period after menstruation. The distribution of the sample was 106 people in each group.

Ethical approval for performing this study was obtained from the Research Ethics Committee of Faculty of Dental Medicine, Universitas Airlangga, with the ethical clearance number: Ref No. 82/KKEPK.FKG/VI/2016). This research was approved by the head of Public Health Centre and the regent in Surabaya City, East Java Province.

The variables observed in this study were gingivitis, the level of oral hygiene, and the menstrual cycle, which included the premenstrual, menstrual, and the postmenstrual period. Samples were grouped according to the menstrual cycle that was being experienced, that is, premenstrual, menstrual, and postmenstrual period. The data were obtained from direct interview with each sample of study.

Dental and oral hygiene tests were measured using the Oral Hygiene Index-Simplified (OHI-S), which had two measurement indicators: Debris Index-Simplified (DI-S) and Calculus Index-Simplified (CI-S). Six teeth were examined, that is, the buccal portion of the teeth 16 and 26 (first left right maxillary molars), lingual portion of the teeth 36 and 46 (first left mandibular right molar), and the labial portion of the teeth 31 and 41 (first mandibular left incisor). The score criteria for DI-S were 0 (no debris or stain), 1 (soft debris < 1/3 cervical crown of tooth), 2 (soft debris > 1/3 but < 2/3 cervical dental crown), and 3 (soft debris > 2/3 cervical dental crown).[10]

The DI-S score was obtained by summing up the debris score of each tooth surface divided by the amount of tooth surface examined. As for CI-S, the scores were 0 (no calculus), 1 (supragingival calculus covers not > 1/3 of the tooth surface), 2 (supragingival calculus covers > 1/3 but not < 2/3 tooth surface and or there is subgingival calculus around the cervical portion of the tooth), and 3 (the supragingival calculus covers 2/3 of the tooth surface and/or the band formation of the subgingival calculus surrounding the cervical portion of the tooth). The individual score was obtained by summing the calculus score of each tooth surface and by the number of tooth surfaces examined.[11]

OHI-S score is the amount of DI-S added with CI-S. From this score, the degree of oral hygiene with the following provisions can be determined: good category (0.0–1.2), moderate category (1.3–3.0), and bad category (3.1–6.0).[12]

The gingivitis examination was performed by measuring the gingival index score on the 16, 21, 24, 36, 41, 44 mesial, distal, buccal/labial, and lingual/palatal with following criteria: 0= Normal gingiva; 1= Mild inflammation – slight change in color and slight edema but no bleeding on probing; 2= Moderate inflammation – redness, edema and glazing, bleeding on probing; 3= Severe inflammation – marked redness and edema, ulceration with tendency to spontaneous bleeding. Scores of each tooth obtained from the total score of each section was divided by four, whereas the score of each individual was calculated from the number of scores per tooth divided by the number of teeth examined. From this score, the following gingival health status was obtained: mild gingivitis (0.1–1.0), moderate gingivitis (1.2–2.0), and severe gingivitis (2.1–3.0).

After all the data were collected, the data were analyzed using multivariate analysis (P = 0.05, confidence interval = 95%). The statistical analysis for this study used the Statistical Package for the Social Sciences (SPSS) software, version 17 (SPSS, Chicago, Illinois). The result is presented in a form of distribution table and cross-tabulation. The data were also analyzed by using Z-score test.


  Results Top


From the results of the dental and oral hygiene examination as a whole, it was found that 288 samples (90.6%) had good oral hygiene with a score of 0.0–1.2; and the rest, as many as 30 samples (9.4%) had poor oral hygiene with a score range of 1.3–3.0 [Table 1], whereas on examination of gingival index, it was found that 287 samples (90.3%) had normal gingiva without inflammation and 31 samples (9.7%) had mild gingivitis [Table 2].
Table 1: Levels of oral cavity hygiene

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,
Table 2: Levels of gingivitis severity

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On examination of the severity of gingivitis, it was found that gingivitis was experienced by 24.5% of the sample in the premenstrual period and 4.7% in the menstrual period, whereas in the period after menstruation group, no samples were found with gingivitis [Table 2].

In the premenstrual period group, 20.7% of the samples had gingivitis with good oral hygiene levels and as many as 3.8% of samples had mild gingivitis. In the menstrual period, 2.8% of the samples had gingivitis with good oral hygiene and 1.9% had mild gingivitis with a moderate oral hygiene level [Table 3]. In the premenstrual period group, the number of samples that had gingivitis with good oral hygiene level was 22, whereas the samples experiencing gingivitis with the moderate level of oral hygiene were four. The total number of gingivitis samples in the premenstrual period was 26. From these data, the value of p1 = 22/26, q1 = 1 − 22/26, p2 = 4/26, q2 = 1 − 4/26, n1 = 26, and n2 = 26 was determined. The data were then inserted in Z calculation formula with the hypothesis that there are no differences in gingivitis that occur in good oral hygiene levels and gingivitis occurring at the moderate level of oral hygiene during the premenstrual period. The result of Z count was 7 (Z count > 1.96 then H0 was rejected). This explains that there is a difference between gingivitis that occurs in good oral hygiene levels and moderate oral hygiene level in the premenstrual period group.[13]
Table 3: Cross-tabulation between the oral hygiene level and level of gingival health in the premenstrual period group

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In the menstrual period group, the number of samples that had gingivitis with good oral hygiene level was 3 (2.8%), whereas the samples experiencing gingivitis with moderate level of oral hygiene were 2 (1.9%) [Table 4]. From these data, p1 = 3/5, q1 = 1 − 3/5, p2 = 2/5, q2 = 1 − 2/5, n1 = 5, and n2 = 5 can be determined. Test was carried out on the menstrual period group using the Z-score statistic test with the hypothesis that there are no differences in gingivitis that occur in good oral hygiene levels and in gingivitis that occur in moderate level of oral hygiene during the menstrual period. The aforementioned data were then inserted in Z calculation formula and the result of Z count obtained was 0.65 (Z count <1.96 then H0 was accepted). This explains that there is no difference between gingivitis that occurs in good oral hygiene levels and in moderate oral hygiene level in the premenstrual period.
Table 4: Cross-tabulation between the oral hygiene level and level of gingival health in the menstrual period group

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Finally, the data were then analyzed using the Z-score statistic test with the hypothesis that there is no difference of gingivitis occurrence between the premenstrual period and the menstrual period. The result of Z count was 4.25 (if Z count >1.96 then H0 was rejected). This explains that there is no difference between gingivitis that occurs in the premenstrual period and in the menstrual period.[13]

From the advanced statistical analysis using a multivariate test [Table 5], we found that in this study, menstrual cycle did not have a significant effect on the OHI-S conditions of the respondents. However, menstrual cycle does affect the gingival index of the respondents significantly, but only in the premenstrual phase (P = 0.00).
Table 5: Multiple comparisons of menstrual phase toward Oral Hygiene Index-Simplified and gingival index

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  Discussion Top


This explains there is no difference in gingivitis occurring at the level of good oral hygiene and at the level of oral hygiene during menstruation. This is in accordance with the research that has been conducted by Shourie et al.,[14] which examined the effect of menstrual cycle on periodontal health. The results of that study showed that women with clinically healthy gingiva showed negligible changes throughout the menstrual cycle, whereas women with gingivitis showed aggravated inflammation during ovulation and premenstruation as compared to those during menstruation. However, no alteration was observed in subgingival microbiota. After treating gingivitis, the next menstrual cycle following 4 weeks after periodontal therapy was monitored, and no periodontal changes were detected.[14]

In this study, we found that gingivitis was more prevalent among the samples in pre-menstrual period group with the number of 24.5% if compared to the samples in menstrual period group with only 4.7%.

The oral hygiene status showed that samples with good level of oral hygiene were more prevalent compared to the samples with the moderate oral hygiene level in all three groups. The presence of gingivitis in the premenstrual period was thought to be caused by a hormonal imbalance that occurs in the menstrual cycle that can lead to gingivitis despite the small number of plaque. In the menstrual cycle, there is an increase in the level of progesterone hormone that causes a response that is too sensitive to plaque on the teeth and gums, which produces inflammatory reactions. The rise in the progesterone hormone level may increase the permeability of the microvascular and affect the pattern of gingival collagen tissue production. It also increased the folic acid metabolism, increased the chemotaxis of PMN (Polymorphonuclear) cells, and stimulate the prostaglandin production.[15]

Menstruation cycle is divided into two phases: proliferation phase and luteal phase. In proliferation phase, follicle-stimulating hormone (FSH) is elevated and gets higher until 2 days before ovulation. In this research, this phase is grouped as “postmenstrual” group. Meanwhile in the luteal phase, there is a decrease in the progesterone hormone. Respondents in this phase are grouped as “menstrual” group. In this phase, where the level of progesterone is low, then it is not considered as a factor that can cause gingivitis. The gingivitis occurred in this phase is due to the low body immunity that causes the decrease of cells’ resistance to the irritation.[16]

The etiology of gingivitis as described previously is divided into two kinds of factors. The main factor is usually the bacteria and plaque and calculus-depositing irritant material, which when crossing the threshold limit, causes gingivitis. Another factor is the systemic factor, one of which is hormone.[17],[18]

The result of this study showed that gingivitis can still occur even in a subject with good oral hygiene levels, this can happen due to a more influential systemic factor. In woman, one of the most common systemic factors is the presence of hormonal changes during the menstrual cycle, mainly in the premenstrual period when there is an increase in the progesterone hormone level, whereas in gingivitis that occurs at the good level of oral hygiene, the etiology is more due to local factors. Given the accumulation of plaque and calculus, it can lead to gingivitis exacerbated by the presence of hormonal factors involved.[3],[18],[19]

Therefore, it is important to provide knowledge about risk factors of gingivitis, besides plaque and calculus. Compared with the previous study that observed the effect of menstrual cycle on periodontal health, which followed the next menstrual cycle, this study showed that women with clinically healthy gingiva showed negligible changes throughout the menstrual cycle, whereas women with gingivitis showed aggravated inflammation during ovulation and premenstruation as compared to those during menstruation period. However, although the finding of this study has explained the difference between gingival health status in three phases of menstrual cycle, the next menstrual cycle was not followed and monitored, so we cannot observe whether there is a periodontal change or not.[14]

In woman, gingivitis can arise due to hormonal changes, mainly in premenstrual period when there is an increase in the progesterone hormone. Gingivitis could be exacerbated by the presence of hormonal factors involved. Therefore, it is important to provide knowledge about risk factor of gingivitis, besides plaque and calculus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Shourie V, Dwarakanath CD, Prashanth GV, Alampalli RV, Padmanabhan S, Bali S. The effect of menstrual cycle on periodontal health—A clinical and microbiological study. Oral Health Prev Dent 2012;10:185-92.  Back to cited text no. 14
    
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Hosadurga R, Nabeel Althaf MS, Hegde S, Rajesh KS, Arun Kumar MS. Influence of sex hormone levels on gingival enlargement in adolescent patients undergoing fixed orthodontic therapy: A pilot study. Contemp Clin Dent 2016;7:506-11.  Back to cited text no. 15
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Nirola A, Batra P, Kaur J. Ascendancy of sex hormones on periodontium during reproductive life cycle of women. J Int Clin Dent Res Organ 2018;10:3-11.  Back to cited text no. 16
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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