Impact of oral contraceptives on periodontal health

Background Oral contraceptives pills (OCPs) are common and a convenient form of contraception. The use of hormonal contraceptives by women has been considered to influence gingival and periodontal disease progression. Aim This study was conducted to assess the effect of oral contraceptive pills on the periodontal health. Materials and method A cross-sectional comparative study was conducted among 200 females aged 18 years and above of Jaipur city. The study subjects were divided into two groups i.e. contraceptive users and non-contraceptive users, each group consisted 100 females. Data was collected using Modified WHO Performa (1997). Periodontal status was examined using Community Periodontal Index (CPI) and Loss of Attachment (LOA). Chi-square test and one sample t-test was used for statistical analysis and P value was set (p< 0.05) as significant. Results Mean CPI score in subjects and non-contraceptive users was 2.34+ 0.81 and 1.16+ 0.89 respectively. Mean LOA score in each group was 0.28+ 0.45 and 0.19+ 0.50 respectively. Conclusion Oral Contraceptive pills had adverse effects on periodontal health.


Introduction
Oral cavity is the mirror of general health and the target organ for number of adverse reactions that arise due to side effects of medications 1 . The initiation of contracep-tives created interest in their effect on oral and periodontal tissues in the late 1960's and 1970's 2 . Many studies had linked the use of oral contraceptive (OC) to increased gingival inflammation 3,4 and some suggested that periodontal attachment loss is likely to occur in contraceptive users 5,6 .
Women are more sensitive to oral health problems because of the hormonal changes they experience during their lifetime. These hormonal changes not only affect the general health but also the oral health. There are five stages in a women's life during which changes in hormone levels make them more susceptible to oral health African Health Sciences Vol 19 Issue 1, March, 2019 problems -puberty, monthly menstruation cycle, use of oral contraceptives, pregnancy, and menopause 7 . Current oral contraceptives consist of low doses of estrogens (0.05mg/day) and progestin (1.5mg/ day). Oral contraceptive agents are one of the most commonly used classes of drugs by females. The number of women on oral contraceptives has reached approximately 50 million worldwide, as a result of such widespread use; many systemic and oral side effects have been identified. 1 The systemic side effects include-nausea, vomiting, diarrhea, stomach cramps, weight loss, acne, breast tenderness, skin pigmentation changes in menstrual flow etc 8 .
There are many Studies which show the negative effects of oral contraceptives on periodontal health 9-10 . The two possible factors influencing the effects of oral contraceptive pills (OCP's) on periodontal condition include dosage and the duration of intake of the pills. A continued exposure of OCP use results in a higher risk of periodontal disease, it can be due to increased production of pro-inflammatory cytokines and prostaglandins from elevated levels of these hormones 11 .
Studies have shown that females who use oral contraceptives have higher prevalence of gingival inflammation, loss of attachment and periodontal disease progres-sion3-5,9-10. However, recent studies based on large or small population suggested that current combined oral contraceptives (COC) do not affect periodontal health, possibly related to lower level of progesterone and estradiol than previously used medications [12][13][14] .
However, there is a need to reassess the impact of contemporary oral contraceptives on periodontal health. The present study was an attempt to assess the impact of oral contraceptives on periodontal health.

Materials and method
This comparative cross-sectional study was conducted among 200 females aged 18 years and above. The study subjects were selected by convenient sampling technique and categorized into two groups. Group A included 100 female subjects who were taking OC pills while group B includes 100 females who had no history of taking OC pills. During the period of two months out of all the females visiting the health centers, sub-centers and hospitals, females fulfilling the inclusion and exclusion criteria were selected. The subject's selection was done till the desired sample size was reached Inclusion criteria 1. Subjects who were above 18 years of age. 2. Subjects who were married 3. Subjects who had no history of pregnancy Exclusion criteria 1. Those who consumed alcohol and tobacco in any form 2. Medically compromised. 3. Those who were under any type of medications other than OCP. 4. Those who had periodontal problem 5. Those who had undergone any periodontal treatment prior to 6 months of study.
Visits to the selected health centers, sub-centers and hospitals were made after obtaining the permission from concerned authorities. Ethical approval was obtained from the institutional ethical committee to carry out the study. Informed verbal consent was obtained prior to the data collection. Data was collected using modified WHO proforma (1997) which includes demographic details and Community Periodontal Index (CPI) and Loss of Attachment (LOA) index. The information regarding oral hygiene habits and duration of oral contraceptive pills was also recorded. Oral examination was carried out using Mouth mirror, and CPITN probe.

Statistical analysis
Data thus obtained was entered in Microsoft excel sheet 2007 and subjected for statistical analysis using SPSS 20.0.0 version. Chi-square and one sample t-test were used for statistical analysis. Level of significance was set at p< 0.05 as significant.

Results
The present comparative cross-sectional study was con-ducted among randomly selected 200 females aged 18 years and above.   Table II depicts the association of periodontal status (CPI) and duration of intake of oral contraceptive pills. Bleeding on probing was observed highest (62.5%) in 8 months while calculus was observed highest (100%) in 9 and 15 months. Periodontal pocket (4-5mm) was found highest (100%) in 18 months while periodontal pocket (6-8 mm) was observed highest (18.75%) in 36 months. A Highly significant association was observed among CPI and duration of intake of OCP (P=0.000) which shows that more the duration of OC intake, poorer is the periodontal health of the subjects.  Table III shows the association of periodontal status (LOA) and duration of intake of oral contraceptive pill. Loss of attachment (0-3mm) was observed highest (100%) in 6, 8,9,15 and 18 months. Loss of attachment (4-5 mm) was observed highest (68.75%) in 36 month. A highly significant association was observed between LOA and duration of intake of OCP (P=0.000).

Discussion
There have been several studies concerning the effect of oral contraceptives on the gingiva and periodontal tissues. The elevated ovarian hormones could predispose women to increased gingival inflammation and periodontal destruction. Both estrogen and progesterone are known to cause increased gingival exudates, edema and inflammation 15 .
Oral contraceptives (OCs) enhance periodontal breakdown by reducing the resistance to dental plaque and can induce gingival enlargement in otherwise healthy females 15 Oral contraceptives have pronounced effects on gingival microvasculature and it has been shown that human gingiva contains receptors for progesterone and estrogen. Hormonal dosage and duration of intake are the possible factors which influence the effect of OC on the periodontal condition. A continued exposure of OCP for longer duration results in higher risk of periodontal disease development due to increased production of pro-inflammatory cytokines and prostaglandins as a result of elevated levels of the hormones 7, 9,21 .
In the study we found that among the females who are non-contraceptive users ,some of them had good periodontal health while some of them had poor periodontal health this can be due to various other reasons such as inadequate knowledge about oral hygiene aids, inadequate oral hygiene practices and improper diet.

Conclusion
Females on contraceptives for longer duration had higher pocket depth, gingival bleeding and attachment loss as compared to the non-contraceptive user group. Contraceptive users had poor periodontal and gingival health. A comprehensive medical history and assessment of vital signs are extremely important in this group of patients. Treatment of gingival and periodontal inflammation exaggerated by oral contraceptives should include establishing an oral hygiene program. As OC pills have poor effect on oral health, females should use other measures of birth control.

Financial support
Nil