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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 209-214

Assessment of awareness, experience, and attitude of Saudi women about oral health changes during the menstruation: A cross-sectional study


Department of Periodontology and Oral Medicine, College of Dentistry, Qassim University, Buraydah, Saudi Arabia

Date of Submission30-May-2022
Date of Decision03-Sep-2022
Date of Acceptance05-Sep-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Abdullah Saleh Almutairi
Department of Periodontology and Oral Medicine, College of Dentistry, Qassim University, Buraydah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_57_22

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  Abstract 


Background: One of the systemic conditions that lead to several changes in the oral cavity is hormonal changes which occur during puberty, menstruation, pregnancy, or menopause, so the awareness of women about these oral changes during the menstruation is important to motivate them toward maintaining good oral hygiene to prevent or reduce oral health changes during menstruation and to seek treatment if needed and not ignore them. Aims: This study aims to assess awareness, experience, and attitude of Saudi healthy menstruating women about oral health changes during menstruation. Setting and Design: This study was performed by distributing a questionnaire in the Arabic language to 401 healthy menstruating females between 18 and 45 years of age among the general population of Saudi Arabia. Methodology: A self-administered closed-end questionnaire was designed comprising 21 questions to assess the awareness, experience, and attitude of females about oral health changes during menstruation. Statistical Analysis Used: The frequency analysis and percentages for all answers were calculated. In addition, pairs of Chi-square analyses were conducted between the dependent and independent variables. Results: This study's results showed that halitosis was the oral change that the participants experienced most during their menstruation followed by a mouth burning sensation (36.4%), gingival bleeding (33.9%), alteration in taste sensation (31.2%), gingival swelling (30.2%), formation of oral ulcers (23.25), and increased tooth mobility (18.7%). 53.11% of the participants in this study were aware of the relationship between menstruation and oral health changes and 48.87% of them agreed that maintaining good oral hygiene can reduce these oral changes during menstruation. Conclusion: More than half of the participants in this study were aware of the relationship between menstruation and oral health changes and approximately half of them agreed that maintaining good oral hygiene can reduce these oral changes during menstruation.

Keywords: Health, menstruation, oral, periodontics, women


How to cite this article:
Almutairi AS. Assessment of awareness, experience, and attitude of Saudi women about oral health changes during the menstruation: A cross-sectional study. Saudi J Health Sci 2022;11:209-14

How to cite this URL:
Almutairi AS. Assessment of awareness, experience, and attitude of Saudi women about oral health changes during the menstruation: A cross-sectional study. Saudi J Health Sci [serial online] 2022 [cited 2023 Feb 7];11:209-14. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/3/209/362379




  Introduction Top


Oral health is important for overall general health; however, oral health can be affected by systemic diseases or conditions. One of the systemic conditions that lead to several changes in the oral cavity is hormonal changes. In females, hormonal fluctuations occur at different life stages during puberty, menstruation, pregnancy, or menopause. Hormonal fluctuations affect females throughout their lives.

The two main female sex hormones are estrogen and progesterone. Receptors for both have been found in human gingiva.[1] It has been noticed that there is a fluctuation in ovarian hormones during the menstrual cycle.[2]

In females, several oral changes due to fluctuations in estrogen/progesterone levels have been reported. Increased gingival bleeding, sensitivity, and tenderness have been reported in young females during puberty and 3–4 days before menstruation. These issues resolve once menstruation has begun.[3] In addition, increased gingival exudate during menstruation has been reported[4] which causes increased tooth mobility.[5]

The primary etiological factor of periodontal disease is microorganisms that form dental plaque. This microbial dental plaque induces tissue inflammation that may manifest and remain as gingivitis or proceed to periodontitis in certain patients.[6] The severity of this inflammatory condition is modified by systemic factors and environmental factors. Sex hormones are one of these systemic factors. There is strong evidence that sex hormone levels may alter the inflammatory response to plaque and, although this predominantly results in gingivitis alone, an increased risk of periodontitis.[6]

Activation of herpes labialis and oral aphthous ulcers is one of the complaints that is seen during menstruation, however, there is disagreement regarding the relationship between the menstrual cycle and either recurrent aphthous ulcers (RAUs) or recurrent herpes labialis (RHL) episodes. According to Segal et al.'s study, there is no consistent relationship between the menstrual cycle and either RAU or RHL episodes[7] whereas another study showed a relationship between RAU incidence and phases of the menstrual cycle.[8]

These hormonal fluctuations can impact women physiologically and psychologically. In addition, oral health can be affected by these hormonal fluctuations so the awareness of women about these oral changes during the menstruation is important to motivate them toward maintaining good oral hygiene to prevent or reduce oral health changes during menstruation and to seek treatment if needed and not ignore them. This study aims to assess awareness, experience, and attitude about oral health changes during menstruation among healthy menstruating women in Saudi Arabia.


  Methodology Top


Study design

The present cross-sectional closed-ended questionnaire-based study was conducted from April 2021 to June 2021. Ethical clearance to conduct the study was obtained from the Research Ethics Committee of the College of Dentistry Qassim University, ref no. ST/82/2021.

This study was performed by distributing a questionnaire in the Arabic language to healthy menstruating females between 18 and 45 years of age among the general population of Saudi Arabia. A self-administered closed-end questionnaire was designed comprising 21 questions to assess the awareness, experience, and attitude of females about oral health changes during the menstrual cycle. The study objectives were illuminated to the participants and those willing to participate were included in the study. The participants who were unwilling to participate were excluded from the study. Informed consent was taken with a detailed explanation in the Arabic language without harming the cultural and social values.

Sampling

The sample size was fixed at a 95% confidence level and an error margin of 5% was computed using Cochran's formula. To achieve a statistically significant result, the gauged sample size came to 326 participants (n = 326). Voluntary response sampling was utilized.

Description of the tool

All the participants who took part in the present study were elucidated about the study protocol and written informed consent was obtained before the completion of the questionnaire. As it is a web-based questionnaire study, a template provided by Google Forms (Google, Inc., USA) was used to gather the quantitative data. The setting of the response was set to be one response to avoid multiple entries from the same participant. A Google Forms link was sent to the participants through a survey agency.

Pilot study

A pilot study was conducted on 30 participants to recognize the variability and to verify its validity and standardization before the administration of the questionnaire. The feedback from the pilot survey was used for refining and clarifying the questionnaire.

Statistical analysis

The statistical analysis was executed on the data collected using a Statistical Package for the Social Sciences Software (Version 21: SPSS, Chicago, IL, USA). The frequency analysis and percentages for all answers were calculated. To determine if there was a relationship between the dependent variables (awareness and attitude) and the independent variables or predictors (age and education) a logistics regression was run. In addition, pairs of Chi-square analyses were conducted between the dependent and independent variables. The test results with P < 0.05 were considered statistically significant.


  Results Top


In this present study, 401 females of different age groups agreed to participate out of 500 females (response rate was 80.2%). Most participants (207) were in the age group 25–34 years (51.6%) followed by 105 in the age group 34–45 (26.18%), and then 89 in the age group 18–24 (22.19%).

Regarding education level, the majority (260) of the participants had a bachelor's degree (64.8%), 109 (27.2%) participants had a secondary school education, and 32 (8%) participants had a postgraduate degree. Two hundred and forty-six (61.3%) of the participants were married. Regarding occupation, 70 (17.5%) of the participants were students, 185 (46.1%) were employees, and 146 (36.4%) were homemakers. The participants' demographic data are shown in [Table 1].
Table 1: Sociodemographic characteristics of the study participants (n=401)

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The results showed that 46.6% of the participants experienced changes in their overall health during menstruation. Regarding the experiences of oral health changes during menstruation, 45.1% of the participants experienced oral changes and 42.4% did not experience oral changes. 12.5% of the participants were not sure about experiencing oral health changes during their menstrual cycle. 44.6% of the participants did not notice how many days before menstruation the changes occurred or they did not have oral changes. Eleven percent of participants noticed oral changes occurring more than 7 days before menstruation whereas 16.5% had changes <7 days before menstruation and 27.9% during menstruation [Table 2].
Table 2: Response to questionnaire

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Two hundred and thirteen (53.11%) of the participants in this study were aware of the relationship between menstruation and oral health changes whereas 188 (46.88%) of them were not aware of this relationship.

In this study, we assessed the awareness of the female participants about oral health changes during menstruation. These changes include the following: formation of oral ulcers, gingival bleeding, gingival swelling, alteration in taste, a mouth burning sensation, halitosis, and increased teeth mobility. The results showed that only 23.2% of participants experienced oral ulcer formation during menstruation, 17.5% of participants did not experience oral ulcer formation, and 59.4% of participants were not sure about the formation of ulcer during menstruation. 33.9% of participants experienced gingival bleeding during menstruation whereas 50.4% of participants did not experience it, and 15.7% of participants were not sure about it. 30.2% of participants experienced gingival swelling during menstruation whereas 53.1% of participants did not experience it and 16.7% of participants were not sure about it. 31.2% of the participants had altered taste sensations whereas 43.4% of the participants experienced halitosis and 18.7% experienced increased teeth mobility. 36.4% of the participants experienced a mouth burning sensation. 30.4% of the participants reported recurrences of these changes [Table 2].

21.4% of the participants had consulted a dentist about these changes while 9% of the participants had consulted physicians. 69.5% did not consult anyone about these changes. 27.7% of the participants received treatment for these changes while 72.3% did not [Table 2].

Regarding the participants' oral hygiene habits, the majority of them (73.6%) brushed their teeth twice a day or more, 62.1% used dental floss, and 59.4% of the participants used oral mouthwash daily. One hundred and ninety-six (48.87%) of the participants agreed that maintaining good oral hygiene can reduce these oral changes during menstruation [Table 2].

Regarding a relationship between the dependent variables (awareness and attitude) and the independent variables (age and education), we found that older adults (age group 35–45) were more likely to be unaware of the relationship between oral health changes and menstruation than younger adults (age group 15–24 and age group 25–34) (P = 0.0007) where the other Chi-square tests of independence were not statistically significant. This indicates that there is no relationship between awareness of the relationship and education level, attitude toward oral health and age group, and attitude and education level [Table 3] and [Table 4].
Table 3: Association between awareness of the relationship and age group and education level

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Table 4: Association between attitude toward oral health and age group and education level

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  Discussion Top


Menstruation is characterized by hormonal fluctuations which negatively impact oral health, especially in women who do not maintain good oral hygiene. In this study, we assessed the awareness and experience of Saudi menstruating females about oral health changes during the menstrual cycle. Furthermore, we assessed their attitude toward and practice of oral health.

We assessed the participants' experience with the development of gingivitis by asking them if they'd experienced any gingivitis signs and symptoms such as gingival bleeding and gingival swelling. The results showed that 30.2% to 33.9% of the participants had experienced at least one of these signs and symptoms. Kardalkar et al.[2] found in their study that 7.3% of the participants experienced gingival bleeding and no one experienced gingival swelling. This difference can be explained by the different populations because their study targeted Indian females whereas our study targeted Saudi females.

According to the new periodontal classification 2017, gingivitis during menstruation is diagnosed as dental plaque-induced gingivitis mediated by a systematic factor (sex steroid hormones–menstrual cycle).[9] In this disease, the elevated sex steroid hormones increase the gingival inflammatory response even to a relatively small amount of plaque so it is crucial for females to maintain good oral hygiene by brushing at least twice daily and using dental floss once a day to avoid gingivitis during menstruation.

23.2% of the participants had experienced ulcer development, however, there is disagreement regarding the relationship between menstruation and either RAU or RHL episodes.[7],[8] As with gingivitis, the development of an ulcer during menstruation may be explained by the effect of elevated sex hormones on the immune response.

Alteration in the taste sensation during menstruation has been documented.[10],[11] This alteration is caused by the effect of a high level of sex steroid hormones which increases the taste buds' sensitivity. In this study, 31.2% of the participants experienced an alteration in taste sensation during menstruation compared to 29% in the Indian study.[2]

An increase in halitosis in some females during menstruation has been reported.[12] Also, a high level of volatile sulphur compounds was found in the mouth air during and before menstruation.[13] 43.4% of the participants in this study had experienced halitosis during their menstruation compared to only 11.3% in Kardalkar et al.'s study.[2] However, this finding needs to be confirmed by a clinical study to determine the prevalence of halitosis during menstruation in Saudi women.

Teeth mobility may increase during menstruation due to increased gingival exudate.[4] Only 18.7% of the participants in this study had experienced increased teeth mobility.

Due to hormonal imbalances, a burning sensation is one of the oral changes that may be seen in women during menstruation. The reduced salivary flow rate during menstruation is the possible cause of mouth burning sensation. 36.4% of the participants in this study had experienced mouth burning sensation compared to 12% in Kardalkar et al.'s study.[2]

In general, when we compare our findings with another study that was conducted in India, we found a greater number of Saudi women who experienced oral changes (gingivitis, alteration in taste sensation, oral malodour, and mouth burning sensation) during menstruation than Indian women. This can be explained by the different populations and in our study, we excluded the participants who were not sure about experiencing oral changes during menstruation because we added a third answer (Not sure) to our questionnaire whereas, in Kardalkar et al.'s study,[2] they put just two answers (Yes or No).

More than half of the participants in this study were aware of the relationship between menstruation and oral health changes and approximately half of them agreed that maintaining good oral hygiene can reduce these oral changes during menstruation. Regarding oral hygiene measures, we found satisfactory results where the majority of them brush twice or more daily, and use dental floss and oral rinse. These measures are important in reducing the chance of the occurrence of these oral health changes during menstruation. However, an education campaign is required to educate those who are unaware of the relationship between oral health changes during menstruation about the importance of maintaining good oral hygiene to prevent and reduce these changes, especially because 51.12% of the participants did not agree that maintaining good oral hygiene can reduce these oral changes during menstruation.

This study's main limitation is the absence of similar national studies to compare our findings with. To the best of our knowledge, this is the first study to assess awareness, experience, and attitude about oral health changes during menstruation among menstruating females in Saudi Arabia.


  Conclusion Top


In this study, halitosis was the main oral change that the participants had experienced during their menstruation followed by a mouth burning sensation (36.4%), gingival bleeding (33.9%), alteration in taste sensation (31.2%), gingival swelling (30.2%), formation of oral ulcers (23.25), and increased teeth mobility (18.7%). 53.11% of the participants in this study were aware of the relationship between menstruation and oral health changes and 48.87% of them agreed that maintaining good oral hygiene can reduce these oral changes during menstruation.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vittek J, Hernandez MR, Wenk EJ, Rappaport SC, Southren AL. Specific estrogen receptors in human gingiva. J Clin Endocrinol Metab 1982;54:608-12.  Back to cited text no. 1
    
2.
Kardalkar S, Kardalkar S, Bhayya H. Assessment of attitude and awareness of oral health changes in females during menstrual cycle: A questionnaire-based survey. J Dent Res Rev 2021;8:194.  Back to cited text no. 2
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3.
Steinberg BJ, Minsk L, Gluch JI, Giorgio SK. Women's Oral Health Issues. In: Clouse AL, Sherif K. (eds) Women's Health in Clinical Practice. Current Clinical Practice: Humana Press; 2008. https://doi.org/10.1007/978-1-59745-469-8-14.  Back to cited text no. 3
    
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Lindhe J, Attsfröm R. Gingival exudation during the menstrual cycle. J Periodontal Res 1967;2:194-8.  Back to cited text no. 4
    
5.
Balan U, Gonsalves N, Jose M, Girish KL. Symptomatic changes of oral mucosa during normal hormonal turnover in healthy young menstruating women. J Contemp Dent Pract 2012;13:178-81.  Back to cited text no. 5
    
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Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Periodontol 2000 [Internet]. 2006;40:107-19.  Back to cited text no. 6
    
7.
Segal AL, Katcher AH, Brightman VJ, Miller MF. Recurrent herpes labialis, recurrent aphthous ulcers, and the menstrual cycle. J Dent Res 1974;53:797-803.  Back to cited text no. 7
    
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Dolby AE. Recurrent Mikulicz's oral apthae. Their relationship to the menstrual cycle. Br Dent J 1968;124:359-60.  Back to cited text no. 8
    
9.
Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS, et al. A new classification scheme for periodontal and peri-implant diseases and conditions – Introduction and key changes from the 1999 classification. J Clin Periodontol 2018;45 Suppl 20:S1-8.  Back to cited text no. 9
    
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Khobragade R, Wakode S, Tadas S, Wakode N, Kale A. Taste recognition threshold in different phases of menstrual cycle. Panacea J Med Sci 2014;4:45-8.  Back to cited text no. 10
    
11.
Alberti-Fidanza A, Fruttini D, Servili M. Gustatory and food habit changes during the menstrual cycle. Int J Vitam Nutr Res 1998;68:149-53.  Back to cited text no. 11
    
12.
Tangerman A. Halitosis in medicine: A review. Int Dent J 2002;52 Suppl 3:201-6.  Back to cited text no. 12
    
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Yaegaki K, Coil JM. Examination, classification, and treatment of halitosis; clinical perspectives. J Can Dent Assoc 2000;66:257-61.  Back to cited text no. 13
    



 
 
    Tables

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



 

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