This course was published in the February 2021 issue and expires February 2024. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Identify the various types of contraceptives and prevalence of use among United States women.
- Describe the oral health effects associated with different methods of contraception, as well as therapeutic indications other than birth control.
- Discuss the clinical benefits of understanding contraceptive therapies and recognizing the potential adverse oral health effects.
According to the United States Centers for Disease Control and Prevention, 66.2% of women in the United States visited the dental office in 2016.1 Additionally, 64.9% of the 72.2 million women ages 15 to 49 in the US were using hormonal or nonhormonal contraceptives between 2015 and 2017.2 In light of these figures, oral health professionals should understand the oral effects that may present in women who use contraceptives. Familiarity with the different forms of contraceptives—and potential reasons for their use other than birth control—is important for comprehensive patient care.
Hormonal contraceptives are categorized as long-acting reversible contraceptives or short-acting reversible contraceptives.3,4 The former category includes intrauterine devices (IUDs) and hormonal implants,3,4 while short-acting agents include contraceptive pills, vaginal rings, skin patches, and injectable contraceptives (eg, medroxyprogesterone acetate).3,4 Limited research indicates contraceptive pills and injectable agents raise the levels of estrogen and progesterone in the body. These elevated levels are linked to periodontal diseases, decreased bone mineral density, dry socket and temporomandibular disorders (TMD).5,6 Studies demonstrate nonoral contraceptives (such as levonorgestrel implants and medroxyprogesterone acetate) and traditional estrogen/progestin oral contraceptives are linked to periodontal diseases.5–7 Additionally, the administration of medroxyprogesterone acetate for more than 2 years may put women at risk for osteoporotic fractures due to the inverse relationship between medroxyprogesterone acetate and loss of bone mineral density in the hip and/or spine.5,8
Research has yet to be conducted on the possible adverse oral health effects of using hormonal forms of the intrauterine system (IUS).9 Accounting for bone density and periodontal diseases while assessing a patient helps create a complete health history, which can be used to tailor treatment plans and educational services. As such, research to determine if the method of contraceptive therapy can impact the relationship between osteoporosis, overall bone density, and periodontal health would be beneficial.
ORAL HEALTH EFFECTS
While commonly used to prevent pregnancy, oral contraceptives can also be used for treating acne, hormonal-balance issues, and premenstrual syndrome.10 Typically, traditional oral contraceptives are a combination of two hormones: estrogen and progestogen.10,11 Evidence indicates that women taking traditional forms of oral contraceptives have increased risk for gingival inflammation, dry socket, TMD, clinical attachment loss, and gingival hyperplasia. In contrast, recent research suggests combined oral contraceptives do not effect periodontal health. This may be related to lower levels of progesterone and estradiol found in the new combined oral contraceptives, compared to earlier formulations.6
Prostaglandins are a major component in the inflammatory response. When there is an infection, prostaglandins create the reactions that cause pain, fever, and inflammation, which support the healing process.12 Prostaglandins are present in the inflammatory response that is seen in gingivitis and periodontitis. As this is a natural reaction to disease and infection, it is difficult to distinguish this response from an exacerbated inflammatory response due to contraceptive use. This should be considered when studying the effects of contraceptives in women who may already have experienced disease and infection in gingival tissue prior to contraceptive use.
An investigation by Mullally et al11 found that women actively using oral contraceptives displayed increased probing depths during six-site periodontal charting. Periodontitis was seen in 60% of women actively using oral contraceptives. Based on this clinical study, there was a higher retention rate for biofilm, and increases in gingivitis and bleeding on probing in subjects using oral contraceptives, as compared to those not currently taking an oral contraceptive.11 The investigation showed that 41.7% of women demonstrated increased probing depths ranging from 4 mm to 6 mm.11 Additionally, women taking oral contraceptives experienced increased susceptibility to advanced periodontal disease if they had preexisting gingivitis.10,11
In a study by Collins et al,13 subgingival samples were collected to evaluate which bacteria were present in patients diagnosed with periodontal diseases. Of the 29 subjects, 17 were diagnosed with generalized periodontitis, and 12 with localized periodontitis. Prevotella intermedia was the most prevalent bacterial species.13 With early detection, progression could be arrested with the addition of oral hygiene instructions and scheduling periodontal maintenance appointments at 3-month to 4-month intervals to help stabilize the patient’s periodontal health.
Medroxyprogesterone acetate was first approved by the US Food and Drug Administration (FDA) in 1992 as a contraceptive injection containing progestin.4,5,14,15 Research shows users experience a decrease of 5.7% to 7.5% bone mineral density at the hip and spine; as a result, premenopausal users are at increased risk for osteoporotic fractures.5,8,14,15 In 2004, the FDA assigned a black box label to medroxyprogesterone acetate listing the possible risk of osteoporosis.15
Research suggests traditional oral contraceptives containing progestin and estrogen negatively affect oral health.10,11 Although the medroxyprogesterone acetate injection does not contain estrogen, there is evidence of reduced natural estrogen serum levels caused by the injection due to the absence of synthetic estrogen.5 This decrease in estrogen has led to reduced bone mineral density due to estrogen’s association with overall bone health.5 According to Clark et al,8 substantial bone loss can occur in women receiving the medroxyprogesterone acetate injection. Moreover, medroxyprogesterone acetate causes negative oral health effects, including increased probing depths, bleeding on probing, clinical attachment loss, and gingival inflammation.5 It is suspected the contraceptive injection may exacerbate a patient’s periodontal condition.
Taichman et al5 identified a significant increase in probing depths, bleeding points, and clinical attachment loss among women who received the medroxyprogesterone acetate injection. The authors surmised that progestin may promote tissue destruction. As this injection only contains progestin, the absence of estrogen in the contraceptive agent can potentially increase the susceptibility to loss of clinical attachment levels, alveolar bone, and teeth. The contraceptive injection of progestin may also stimulate the production of prostaglandins, contributing to gingival inflammation.5
In addition to the effects on physiology of the tooth and surrounding structures, the temporomandibular joint is also affected.16 TMD—which presents as stiffening of the jaw, limited opening, and pain—is more common in women than men.17 Among the possible reasons for this correlation are the hormonal changes the body goes through as aging progresses.17 The decrease in natural estrogen that occurs with medroxyprogesterone acetate use could alter the hormonal balance, giving rise to TMD.5,16 Contraceptives known to decrease natural estrogen amplify the effects of inflammation and bone loss,16 thus suggesting a possible link with TMD.16,18 If women are taking medroxyprogesterone acetate injections for prolonged periods, they need to be educated on the possible risk for oral diseases—and what can be done in terms of prevention. Further research is needed to determine if the alteration in hormones from contraceptive injections can be linked to periodontal health and TMD in women.
Additional vulnerable populations, such as those of low socioeconomic status that choose this method of contraception and have limited access to dental care, should be considered. As noted, Taichman et al5 investigated the effects of contraceptive injection on women’s periodontal health. The results suggest nonwhite women of low socioeconomic status are at highest risk for negative effects on the periodontium from contraceptive therapy. Compared to other groups, they found this population also tends to have poor oral hygiene and is less likely to receive regular professional oral healthcare. Further research is needed to determine if any other potentially vulnerable populations exist, and what clinicians can do to support these groups. Oral health professionals play an important role in educating vulnerable populations about the need to follow an effective self-care regimen to reduce the risk of periodontal diseases.
The first contraceptive implant, which contained levonorgestrel, a synthetic progestogen, was approved by the FDA in 1990.4,19 The implant is placed subdermally in the brachium, and releases hormones to prevent pregnancy for up to 5 years.4,19 Discontinuation of the original levonorgestrel implant was partially attributed to negative media coverage.19 Consequently, etonogestrel (also a form of synthetic progestogen) was used as a replacement,19,20 and, in 2010, a modified version of the etonogestrel implant was released.21 There are limited studies on the effects of the etonogestrel implant in the oral cavity. Both etonogestrel-containing implants protected women against pregnancy; however, there were only two differences between the new and previous implant.21 The new etonogestrel implant is radiopaque, which allows it to be seen in radiographs easier than the older implant. Furthermore, it contains more hormones than the original implant.21
In 2008, Kazerooni et al7 conducted a clinical study to evaluate the effects of levonorgestrel in the periodontium of women 6 months after receiving the implant. Approximately 75% of subjects used barrier forms of contraceptives, such as condoms, compared to 25% who received the implant. Women with the levonorgestrel implant exhibited increased probing depths. With almost all teeth affected by periodontitis, the women with the levonorgestrel implant continued to demonstrate deeper periodontal pockets after 6 months.7 Although this study evaluated the effects of levonorgestrel on the periodontium, the ambiguous sample included in the investigation also warrants discussion. The researchers failed to mention several limitations, including the use of convenience sampling, undisclosed age groups, and whether other forms of contraceptive therapies were used.
Etonogestrel is similar to levonorgestrel, as they are both synthetic progestogen hormones; while not known, it is possible they may have similar side effects in the oral cavity.20 Although the levonorgestrel implant was discontinued, levonorgestrel is still used as a contraceptive agent, so its effects on the periodontium may still be relevant.9 As such, clinical studies are needed to evaluate etonogestrel’s impact on the periodontium, and if the effects are similar to levonorgestrel. Healthcare providers who participate in the decision-making process with patients considering contraceptive therapy should educate patients about all risks.
In the US, three levonorgestrel-releasing intrauterine systems (LNG-IUS)9 are available. They work by releasing this synthetic progestogen hormone into the uterus. These LNG-IUS are approved for treating heavy or prolonged menstrual bleeding, and serve as a source of progestin in post-menopausal estrogen therapy.9 They can also be used to prevent pregnancy for up to 5 years.9 It is important to note the different indications for use, as patients have their own reasons for choosing a particular form of therapy.
As previously stated, Kazerooni et al7 examined the effects of levonorgestrel implant contraception on oral health. They noted probing depths, clinical gingival index, bleeding on probing, and papillary bleeding were all elevated in patients using this therapy. Although levels of levonorgestrel differ between these two forms of contraceptives, it allows room to question the side effects. As this study focused on the levonorgestrel implant,7 it would be beneficial if further research was done to determine if the levonorgestrel that is used in LNG-IUS contraceptives may also show adverse effects to the periodontium.
IMPLICATIONS FOR PRACTICE
Recognizing adverse oral side effects in women taking oral or nonoral contraceptives is essential for comprehensive care, and will allow providers to tailor treatment plans to meet the patient’s individual needs. One of the many responsibilities in clinical practice is to educate patients. Oral health professionals can inform patients about the signs and symptoms to look for when taking a new medication—which may include increased bleeding when brushing or flossing.7
When caring for women of childbearing age, focusing on the potential oral impacts of contraceptives is important in discussions with those who use these therapies. Keeping abreast of the latest scientific evidence—including the different forms of contraceptive therapies, why they are prescribed, and who is likely to use a given method—will make it easier to talk about this subject.
Women have many options when considering contraceptive therapy; thus, it is important to consider the possible effects of various contraceptives on the periodontium. Traditional oral contraceptives present an elevated risk of gingival inflammation, dry socket, TMD, clinical attachment loss, gingival hyperplasia, increased probing depths, and elevated levels of the Prevotella pathogen. Women who received medroxyprogesterone acetate injections have an increased risk for periodontal diseases, bone density loss, osteoporotic fractures, and gingival inflammation. In addition, further investigation is needed to assess the possible link between medroxyprogesterone acetate and TMD.
Although investigations of contraceptive implants and IUS therapies are limited, research into levonorgestrel contraceptive implants demonstrates that all or most teeth of users were affected by periodontitis. Additional studies into contraceptive implants and IUS therapy would be beneficial in clarifying their potential negative effects on oral health.
In conclusion, patients and practitioners will both benefit from understanding the various forms of contraceptive therapy, their mechanisms of action, and potential impact on periodontal health.
- National Center for Health Statistics. Health, United States, 2017: With Special Feature on Mortality. Available at: cdc.gov/nchs/data/hus/2017/078.pdf. Accessed December 3, 2020.
- Daniels K, Abma JC. Current contraceptive status among women aged 15–49: United States, 2015–2017. Available at: cdc.gov/nchs/products/databriefs/db327.htm. Accessed December 3, 2020.
- Tibaijuka L, Odongo R, Welikhe E, et al. Factors influencing use of long-acting versus short-acting contraceptive methods among reproductive-age women in a resource-limited setting. BMC Womens Health. 2017;17:25.
- U.S. Food and Drug Administration. Birth Control. Available at: fda.gov/consumers/free-publications-women/birth-control. Accessed December 3, 2020.
- Taichman LS, Sohn W, Kolenic G, Sowers M. Depot medroxyprogesterone acetate use and periodontal health in 15- to 44-year-old U.S. females. J Periodontal. 2012;83:1008–1017.
- Prachi S, Jitender S, Rahul C, Jitendra K, Priyanka M, Disha S. Impact of oral contraceptives on periodontal health. Afr Health Sci. 2019;19:1795–1800.
- Kazerooni T, Ghaffarpasand F, Rastegar N, Kazerooni Y. Effect of levonorgestrel implants on the periodontium. Int J Gynaecol Obstet. 2008;10:255–256.
- Clark M, Sowers M, Levy B, et al. Bone mineral density loss and recovery during 48 months in first time users of depot medroxyprogesterone acetate. Fertil Steril. 2006;86:1466–1474.
- Nelson A, Massoudi MN. New developments in intrauterine device use: focus on the U.S. Open Access J Contracept. 2016;7:127–141.
- Saini R, Saini S, Sharma S. Oral contraceptives alter oral health. Ann Saudi Med. 2010;30:243.
- Mullally BH, Coulter WA, Hutchinson JD, Clarke HA. Current oral contraceptive status and periodontitis in young adults. J Periodontal. 2007;78:1031–1036.
- Hormone Health Network. What is Prostaglandins? Available at: hormone.org/your-health-and-hormones/glands-and-hormones-a-to-z/hormones/prostaglandins. Accessed December 3, 2020.
- Collins JR, Chinea S, Cuello RJ, et al. Subgingival microbiological profile of periodontitis patients in Dominican Republic. Acta Odontol Latinoam. 2019;32:36–43.
- National Women’s Health Network. Depo Provera and Bone Mineral Density. Available at: nwhn.org/depo-provera-and-bone-mineral-density/. Accessed December 3, 2020.
- U.S. Food and Drug Administration. Highlights of Prescribing Information, Depo-Provera CI. Available at: accessdata.fda.gov/drugsatfda_docs/label/2010/020246s036lbl.pdf. Accessed December 3, 2020.
- Cleveland Clinic. Hormones and Oral Health. Available at: my.clevelandclinic.org/health/articles/11192-hormones-and-oral-health. Accessed December 3, 2020.
- National Institutes of Health. TMJ Disorders. Available at: nidcr.nih.gov/sites/default/files/2017-12/tmj-disorders.pdf. Accessed December 3, 2020.
- Birth Control Side Effects and Oral Health. Available at: colgate.com/en-us/oral-health/adult-oral-care/birth-control-side-effects-oral-health. Accessed December 3, 2020.
- Rosenfield A, Harrison PF. Appendix B: Norplant: historical background. Contraceptive research, introduction, and use: lessons from Norplant. Available at: nap.edu/read/5946/chapter/6. Accessed December 3, 2020.
- Implanon product insert. Available at: accessdata.fda.gov/drugsatfda_docs/label/2009/021529s004lbl.pdf. Accessed December 3, 2020.
- Family Planning Association. Contraception: past, present and future factsheet. Available at: fpa.org.uk/factsheets/contraception-past-present-future. Accessed December 3, 2020.
From Dimensions of Dental Hygiene. February 2021;19(2):36-39.