Sex-Based Differences in Oral Health
Women and men have unique needs when it comes to the delivery of dental care and maintaining oral health.
Men and women have different dental care needs and factors that impact their oral health. When discussing these differences, the terms “sex” and “gender” must be clarified. The Institute of Medicine (IOM) defines sex as “the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement.”1 The IOM definition for gender is “a person’s self-representation as male or female, or how that person is responded to by social institutions based on the individual’s gender presentation.”1 This article takes a brief look at sex-based differences and their effects on oral health and the delivery of dental care.
Although largely preventable, periodontal diseases and dental caries are the two biggest threats to oral health. They are also among the most common chronic diseases in the United States.2 Due to the importance of oral health to overall health, the World Health Organization has made the development of accessible, cost-effective oral health systems for the prevention and control of oral diseases and the creation of oral health programs that will empower individuals to control determinants of their oral health key objectives in its Global Goals for Oral Health 2020.3
Periodontal diseases are highly prevalent in the US, with nearly half of Americans exhibiting some form of gum disease.4 Recent data from the National Health and Nutrition Examination Survey showed that men were more likely to develop periodontal diseases than women (56.4% vs 38.4%).4 This may be due to the fact that women tend to be more concerned about oral health than men.5 Research shows that women are more likely to receive professional dental care, comply with recommended oral health treatment, and have higher oral health literacy, as well as present with lower levels of plaque, calculus, and bleeding on probing than men.5 Additional research is needed to support men in oral health promotion and self-care.6
Assessing risk factors for periodontal diseases—such as plaque levels, bacterial composition, genetics, smoking, and stress—is pertinent to all patients, regardless of sex. This can be accomplished with a basic checklist or risk calculator.7–9 Testing of the pathogenic periodontal bacteria present and/or DNA testing to determine genetic susceptibility are available and may help with risk assessment and treatment planning.10
Preventing and effectively treating periodontal diseases are paramount to maintaining health. Cardiovascular disease, diabetes, and preterm/low-birthweight babies are all exacerbated by the inflammation caused by periodontal diseases. With men at increased risk for cardiovascular disease and women bearing the risk of preterm low-birthweight births, the maintenance of periodontal health is key.
Women are at greater risk for dental caries than men (92.66% vs 90.57%).11 Initial studies attributed higher caries prevalence among women to the earlier eruption of teeth in girls, hence, longer exposure to the cariogenic oral environment; better access to food supplies; and frequent snacking during pregnancy.11 More recent research indicates that genetics may play a role in women’s elevated caries rates.12 The mechanism of a genetic contribution may be rooted in the gene amelogenin, which resides on the p-arm of the X chromosomes. A deficient gene or a reduced hormone level may lead to a disruption in the formation of the enamel matrix, thereby increasing caries susceptibility.12 On the other hand, men seem to be at greater risk of root caries and gingival recession.13,14
Caries risk assessment is also important for patients of both sexes, as is preventive education, including nutritional counseling; oral hygiene instruction; and the implementation of individually based prevention and treatment plans. Toothbrushing instruction should focus on proper toothbrush angulation with a soft bristle toothbrush and the use of fluoride toothpaste. Emphasis should be placed on proper biofilm removal to prevent future incidence of decay. Male patients tend to consume more sugared beverages (eg, sports and energy drinks) than women; thus, they should be advised of the increased caries risk that is inherent to consuming these drinks. Tobacco use is a modifiable risk factor for both periodontal diseases and caries. Men are far more likely to smoke than women (40% vs 9% globally).15 Thus, tobacco cessation is necessary to maintaining oral health among both genders.
HORMONE FLUCTUATION IN WOMEN
The hormone fluctuations experienced by women during puberty, pregnancy, and menopause can exert oral health effects. The increased production of estrogen during puberty increases blood flow to the gingiva. During pregnancy, swollen erythematous gingival tissues may be present, as well as herpes labialis and aphthous ulcers. These transient changes are attributed to peak levels of estrogen and progesterone.16 Physiological changes during pregnancy may result in pregnancy gingivitis, benign oral lesions, tooth mobility, tooth erosion, dental caries, and periodontal diseases. Women with periodontitis who become pregnant experience higher risks of preeclampsia, preterm birth, gestational diabetes, and low-birthweight births than pregnant women with good oral health.17–22 Although studies have not determined a causal relationship between periodontitis and low birthweight, there is an association between oral inflammation and preterm and/or low-birthweight births.17–22
Pregnant women should be educated about these possible changes and encouraged to maintain excellent oral self-care.23 Regular dental care is also important for pregnant women. This population may need reassurance that dental care is safe and necessary. Optimal maternal oral hygiene during the perinatal period may decrease caries-producing oral bacteria transmitted to the infant during parenting behaviors, such as sharing spoons. Motivating and educating women to maintain good oral hygiene and seek preventive dental health care is paramount to reducing dental disease.
During menopause, menstruation stops and estrogen production is reduced. Women going through menopause may experience changes of the oral mucosa, xerostomia, pain in the temporomandibular joint, and increased caries risk.16 Burning mouth syndrome, which manifests as intense pain and spontaneous burning sensations in the oral cavity, frequently affects women during or after menopause. The underlying etiology is unknown, but it may be attributed to hormonal changes and small-fiber sensory neuropathy of the oral mucosa.24
Another oral health concern for menopausal women, as well as older men, is osteoporosis, which causes bones to weaken and break. Men may experience hypogonadism—a decrease in testosterone—which raises the risk of osteoporosis.25 This disease can result in jaw fractures and resorption of the alveolar bone. The use of bisphosphonates can prevent systemic bone loss, but they also exhibit significant side effects such as osteonecrosis of the jaw.25
Women floss more, are more embarrassed by tooth loss, and are more aware of the importance of oral health than men.5 As such, oral health professionals may want to target their prevention, education, and motivation strategies by sex to improve efficacy. Men frequently report lack of time as a barrier to oral hygiene. Suggesting alternative times, such as toothbrushing while watching television, or technique tips may help motivate male patients to make oral health a priority.
Sex differences do affect compliance with oral hygiene instructions. Men tend to have better motor and spatial abilities, while women may have superior memory and social cognition skills. These physiological differences warrant additional research due to their importance in human behavior.26
Understanding the relationship between sex differences and oral health may help clinicians increase the effectiveness of preventive and therapeutic measures with the goal of improving patients’ oral and overall health. Increased knowledge about the development and management of dental diseases emphasizes the important role of health behavior in preventing or arresting caries and periodontal diseases. Motivating individuals to consistently adhere to oral hygiene regimens in conjunction with regular professional oral health care are paramount to the prevention of dental disease. The scarcity of data regarding sex differences in oral self-care makes it difficult to identify and evaluate the determinants of this phenomenon for effective oral health promotion. Additional research is warranted.2
Achieving optimal oral and oral health requires a coordinated effort between dental and medical team members. Closer integration of dentistry and medicine will support general health advancement. Dental hygienists stand with other health care providers on the frontline of oral disease prevention for both genders.
- Niessen LC, Gibson G, Kinnunen TH. Women’s oral health: why sex and gender matter. Dent Clin N Am. 2013;57:181–194.
- Benjamin RM. Oral health: the silent epidemic. Public Health Rep. 2010; 125:158–159.
- Hobdell M, Petersen PE, Clarkson J, Johnson N. Global goals for oral health 2020. Int Dent J. 2003;53:285–288.
- Eke PI, Dye BA, Wei L, Slade GD, Thornton-Evans GO, Borgnakke WS, Taylor GW, Page RC, Beck JD, Genco RJ. Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015;86:611–622.
- Buunk-Werkhoven YAB, Buunk AP. Fear of social rejection and oral self-care in men versus women. Int Dent J. 2015;65(Suppl1):1–57.
- American Academy of Periodontology. Gum Disease Risk Factors. Available at: perio.org/consumer/risk-factors. Accessed November 29, 2016.
- National Institute of Dental and Craniofacial Research. Gum (Periodontal) Diseases. Available at: nidcr.nih.gov/oralhealth/topics/gumdiseases/periodontalgumdisease.htm. Accessed November 29, 2016.
- University of Maryland. Periodontal Disease. Available at: umm.edu/health/medical/reports/articles/periodontal-disease. Accessed November 29, 2016.
- Gurenlian J. Risk assessment for general and oral conditions. Dimensions of Dental Hygiene. 2010;8(5):68–71.
- Lukacs JR, Largaespada LL. explaining sex differences in dental caries prevalence: saliva, hormones and “life-history” etiologies. Am J Hum Biol. 2006,18:540–555.
- Ferraro M, Vieira AR. Explaining gender differences in caries: a multifactorial approach to a multifactorial disease. Int J Dent. 2010;2010:649643.
- Chi DL, Shyue C. Managing caries risk in adults. Dimensions of Dental Hygiene. 2014;12(6):36–40.
- Satheesh K. Managing gingival recession. Dimensions of Dental Hygiene. 2012;10(8):18–23.
- The World Health Organization. 10 Facts on Gender and Tobacco. Available at:?who.int/gender/documents/10facts_gender_tobacco_en.pdf. Accessed November 29, 2016.
- American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Health Care for Underserved Women. Committee Opinion No. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122:417–422.
- Michalowicz BS, Gustafsson A, Thumbigere-Math V, Buhlin K. The effects of periodontal treatment on pregnancy outcomes. J Clin Periodontol. 2013;40(Suppl 14):195–208.
- Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal, periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol. 2003;101:227–231.
- Offenbacher S, Lieff S, Boggess KA, et al. Maternal periodontitis and prematurity. Part I: obstetric outcome of prematurity and growth restriction. Ann Periodontol. 2001;6:164–174.
- Moore S, Ide M, Coward PY, et al. A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J. 2004;197:251–258.
- Mills LW, Moses DT. Oral Health during pregnancy. Am J Maternal Child Nurs. 2002;27:275–280.
- Brame J. Improve oral health during pregnancy. Dimensions of Dental Hygiene. 2016;14(03):52–57.
- Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 3rd ed. St. Louis: Saunders; 2010:1006-1020.
- Mutneja P, Dhawan P, Raina A, Sharma G. Menopause and the oral cavity. Indian J Endrocrinol Metab. 2012;16:548–551.
- National Institute of Health Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis in Men. Available at: niams.nih.gov/health_info/bone/osteoporosis/men.asp. Accessed November 29, 2016.
- Goldie MP. The influence of sex on health. Dimensions of Dental Hygiene. 2015;13(6):50–54.
From Dimensions of Dental Hygiene. December 2016;14(12):33–34.