Effects of oral contraceptives on the oral cavity.
If there are people around, then there are drug users around. It is simple as that, people have been using drugs since prehistoric times and they aren't going to stop any time soon. Drugs are used in treatment, cure, prevention or diagnosis of disease or to otherwise enhance physical and mental well being. However, drugs are also capable of inducing several adverse side effects, the most serious of which include blood dyscrasias, altered immune responses, immediate or delayed hypersensitivity reactions and predisposition to oncogenic changes. Adverse drug reactions can involve every organ and system of the body. The mouth and associated structures can also be affected by many drugs or chemicals. Drug reactions can be categorized as to the parts of the oral complex such as the oral mucosa and tongue, periodontal tissues, dental structures, salivary glands, muscles and nerves.
Oral contraceptive agents are one of the most commonly used classes of drugs. The number of women taking oral contraceptives has reached 50 million worldwide. As a result of such widespread use, many systemic and oral side effects have been identified. The systemic side effects include--nausea, vomiting, diarrhea, stomach cramps, acne, skin pigmentation, weight gain or loss, breast tenderness, changes in menstrual flow etc., Women taking Oral contraceptive pills (OCPs) are at an increased risk of developing breast, liver and cervical cancer. Also they are more likely to develop deep vein thrombosis and have an increased risk of heart attack and stroke. (1)
Hormonal fluctuations have a surprisingly strong influence on the oral cavity. Puberty, menses, pregnancy, menopause and use of contraceptive medications all influence women's oral health. Women on contraceptive medications have special oral health needs and considerations. (2)
Current oral contraceptives consist of low doses of estrogens (0.05mg/day) and progestins (1.5mg/day). However, the initial formulations contained higher concentrations of sex hormones (20-50|jg estrogen and 0.15-4mg progesterone). (3)
Two types of oral contraceptive pills are available.
1. The--progesterone only pill contains progestogen.
2. The combined oral contraceptive pill contains estrogen and progestogen.
Hormonal contraception is primarily used for the prevention of pregnancy, but it is also used for the treatment of polycystic ovary syndrome, dysmenorrhea, menorrhagia and hirsutism. This review highlights mainly the effects of OCP's on the oral cavity so as to aid in providing information for dental monitoring in women patients during these times of hormonal fluctuation. (3)
EFFECTS ON ORAL MUCOSA
Gingivitis and Periodontitis
The use of hormonal contraceptives by women has been considered to influence gingival and periodontal disease progression. The two possible factors influencing the effects of OCP's on periodontal condition include hormonal dosage and the total duration of intake. A continued exposure for a long period of OCP use results in a higher risk to periodontal disease development and progression because of increased production of pro-inflammatory cytokines and prostaglandins resultant from elevated levels of this hormones. (4)
Gingival tissues may have an exaggerated response to local irritants. Oral contraceptives can aggravate patients' inflammatory condition, causing erythema and an increased propensity to gingival bleeding. Inflammation may vary from mild edema, erythema to severe inflammation with hemorrhagic or hyperplastic gingival tissues. There is evidence that the presence of metabolic products of the sex hormones in gingiva is an essential factor in the pathogenesis of chronic gingivitis. (4)
It has been reported that there is a 50 percent increase in gingival fluid volume in women using oral contraceptives for a period of 12 months. Kalkwarf noted that this response might be due to change in microvasculature, increased gingival permeability and the increasing production of prostaglandins. (3)
Clinical studies reported higher prevalence of gingival inflammation, loss of attachment and gingival enlargement in woman taking hormone based oral contraceptives. However, recent studies based on large population samples suggested that as compared to the previously used medications, current combined oral contraceptives (COC) do not affect periodontal health, possibly related to their lower concentration of progesterone and estradiol. (5)
Brusca, et al. (2010), after investigating the influence of oral contraceptives, showed that women taking oral contraceptives specially smokers, showed significant prevalence of severe periodontitis. Also, these women had higher numbers of cultures positive for Candida sp., which were associated with P. gingivalis and P. intermedia. (5) Also it has been noted that there is a 16-fold-increase in Bacteroides species in the oral contraceptive user group versus a non-pregnant group. (3)
Oral contraceptives have been reported to induce gingival enlargement. (1) The incidence of gingival overgrowth by oral contraceptives is common and resolves when the drug is withdrawn. (4) Maintenance of adequate plaque control is essential for gingival health during the intake of oral contraceptives. (5)
Pigmentation of the oral mucosa
Pigmentation of the oral mucosa can be caused by the use of oral contraceptives, and withdrawing of the drug does not produce complete regression. Estrogens are well known to induce high levels of cortisol binding globulin which leads to a decrease in plasma free cortisol. This produces a hyper secretion of ACTH and melanocyte stimulating hormone. The later may cause the increased pigmentation of the oral mucosa. (5)
Oral contraceptive is the only medication associated with developing alveolar osteitis following extraction of teeth. The use of oral contraceptives has been related with a considerable increase in the frequency of dry sockets after removal of impacted lower third molars. Estrogen plays a significant role in the fibrinolytic process. It is believed to indirectly activate the fibrinolytic system, contributing to the premature destruction of the clot and the development of dry socket. Catellani et al. further concluded that the probability of developing AO increases with increased estrogen dose in the oral contraceptives. (6) Sweet and Butler also found that increase in the use of oral contraceptives positively correlates with the incidence of AO. (7)
Cohen et al even suggested that, to reduce the risk of AO hormonal cycles should be considered when scheduling elective exodontia. (8) Incidence of dry sockets can reduced by performing extractions during days 23-28 of the contraceptive tablet cycle. (5) However, no other preventive procedures are required at the time of extractions and treatment for patients developing localized osteitis is according to the clinician's dry socket protocol. (1)
Several changes have been observed in the salivary components and flow in women taking contraceptive medications. There is a decrease in concentrations of protein, sialic acid, hydrogen ions and total electrolytes. Studies have shown both an increase and decrease in salivary flow. (1)
A study has also shown that salivary buffer effect of OCP users is significantly higher than non users. (10)
Interaction between OCPs and antibiotics
Antibiotic interference with contraceptive medication levels is controversial. For most antibiotics, the mechanism of interference is at the level of the enterohepatic recirculation of the contraceptives. (11)
A recent report from the ADA Council on Scientific Affairs noted that, considering the possible consequences of an unwanted pregnancy, when prescribing antibiotics to a patient using oral contraceptives, the dentist should:
* Advise the patient to maintain compliance with oral contraceptives when concurrently using antibiotics.
* Advise the patient of the potential risk for the antibiotics reducing of the effectiveness of the oral contraceptives.
* Recommend that the physician discuss with the patient, use of an additional non hormonal means of contraception. (11)
Health necessities of women at all ages require special attention because of the distinct changes that occur over a women's lifetime. A comprehensive medical history and assessment of vital signs are extremely important in this group of patients. Treatment of gingival inflammation exaggerated by oral contraceptives should include establishing an oral hygiene program and removing all local predisposing factors. Periodontal surgery may be indicated if there is inadequate resolution after initial therapy. Antimicrobial mouthwashes may be indicated as part of the home care regimen.
(1.) American Dental Association. ADA.org: OHCS Women's Oral Health 2006:1-46.
(2.) Available at URL: http:// www.nlm.nih.gov/medline plus/ druginfo/meds/a60150.html
(3.) Guncu GN, Tozum TM, Caglayan F. Effects of endogenous sex hormones on the periodontium--Review of literature. Australian Dental Journal 2005;50(3):138-145.
(4.) Domingues RS, Ferraz BF, Greghi SL, Rezende ML, Passanezi E, Sant'Ana AC. Influence of combined oral contraceptives on the periodontal condition. J Appl Oral Sci 2012;20(2):253-259.
(5.) Abdollahi M, Rahimi R, Radfar M. Current Opinion on drug-induced oral reactions: A comprehensive review. J Contemp Dent Pract 2008;9(3):1-15.
(6.) Catellani JE, Harvey S, Erickson SH, Cherkin D. Effect of oral contraceptive e cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc. 1980 Nov;101(5):777-780.
(7.) Sweet JB, Butler DP. The relationship of smoking to localized osteitis. J Oral Surg. 1979 Oct;37(10):732-735.
(8.) Cohen ME, Simecek JW. Effects of gender-related factors on the incidence of localized alveolar osteitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995Apr;79(4):416-422.
(9.) Kolokythas A, Olech E, Miloro M. Alveolar osteitis: A comprehensive review of concepts and controversies. Int J Dent 2010;2010:249073.
(10.) Laina M, Pienihakkinen K, Ojanotko--Harri A, Tenovou J. Effects of low-dose oral contraceptives on female whole saliva. Arch Oral Biol. 1991;36(7):549-552.
(11.) American dental association. Council on scientific affairs. Antibiotic interference with oral contraceptives. JADA 2002;133:880.
Prakruthi Reddy , Saleha Jamadar , Chaitanya Babu N 
 Senior lecturer
 Professor & Head
Department of Oral & Maxillofacial Pathology The Oxford Dental College Bommanahalli, Hosur Road
Received: April 8, 2013
Review Completed: May 8, 2013
Accepted: June 7, 2013
Available Online: October, 2013 (www.nacd.in)
Email for correspondence:
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|Author:||Reddy, Prakruthi; Jamadar, Saleha; Chaitanya, Babu N.|
|Publication:||Indian Journal of Dental Advancements|
|Date:||Jul 1, 2013|
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