Elena Cantwell
Devon McClure
In terms of health care, the transgender population is underserved and experiences discrimination. These factors prevent patients from seeking care. Additionally, hormone therapy used during the transition process could have severe implications for dental health. The purpose of this literature review is to establish a link between the hormone therapy used during gender transitioning and the effects on oral health. Few studies have linked hormone replacement therapy and periodontal status, despite clinical evidence that sex hormones impact the periodontium. This knowledge must apply to the health-care needs of the transitioning population.
As society becomes increasingly aware and accepting, it becomes alarmingly evident that the transgender population experiences a wide disparity in health-care access. In 2015, the U.S. Transgender Survey reported that 27,715 individuals identified as transgender.1 Only a year later, 1.4 million people in the United States identified as transgender.2 This population often faces adversity, preventing them from receiving essential health care. The main deterrents that discourage this population from receiving routine dental care are stress, fear of discrimination, unequal treatment, and judgment.3,4 Unfortunately, many electing to delay routine oral health care do not understand the adverse consequences for oral and systemic health. Though more research must be conducted about the relationship between hormone therapy and risk for periodontal disease, many studies indicate a clinical correlation between osteoporosis, diabetes, bone loss, and periodontitis in the transgender population due to hormonal therapy.
The term transgender “is an umbrella term for persons whose gender identity, expression, or behavior does not conform with the sex they were assigned at birth.”5 To aid these individuals in their transitions from male to female (MTF) or female-to-male (FTM), physicians often provide hormone therapy. Those undergoing MTF transition are prescribed estrogen and progesterone, while those transitioning FTM are prescribed testosterone. These sex hormones affect facial hair development, vocal changes, body fat development and retention, and influence the oral cavity.6 According to a study by Jafri et al., hormones “may alter immunologic factors and responses, including antigen expression and presentation, cytokine production and the expression of apoptotic factors.”7 Altered immune responses may lead to difficulties fighting pathogenic bacteria that cause periodontal disease, putting a transgender patient at an increased risk for infection.
Estrogen and progesterone directly affect the gingiva, periodontal ligament, and osteoblasts.7 Periodontitis is an inflammatory disease that affects the soft and hard structures that support the teeth.8 Clinical research shows that estrogen deficiency is directly linked to periodontitis, causing inflammation, osteoporosis, and loss of alveolar bone in patients undergoing FTM transitions.8 Bone loss leads to clinical attachment loss, implicating periodontal disease.7 Also, testosterone receptors have been isolated from the periodontal tissues, indicating that these hormones directly affect the development of periodontal disease.9
Hormone therapy and periodontal disease
Sex steroid hormones play an essential role in the maintenance of skeletal integrity. Linked to periodontal pathogenesis and alveolar bone loss, estrogen and progesterone stimulate a decrease in male pattern hair growth and induce the formation of breast tissue.10 Estrogen receptors are found in osteoblast-like cells that have a direct action on the alveolar bone. These receptors can be found in periosteal fibroblasts, fibroblasts of the lamina propria, and periodontal ligament, proving the direct action of sex hormones on periodontal tissues.7 If estrogen levels are deficient, there will not be enough estrogen to bind to the receptors, and bone resorption will occur.7 Excess estrogen leads to inflammation, increasing the risk of developing periodontitis.
Testosterone is used in a female-to-male transition to allow for lowering of the voice, male pattern hair growth, atrophy of the ovaries, and muscle and fat redistribution.10 It is also associated with the maintenance of bone density. To examine the effect of androgens on bone metabolism, the bone remodeling marker osteoprotegerin, OPG, can be analyzed. OPG, a secreted receptor that inhibits osteoclast formation and activation by neutralizing its associated ligand function, can be used to determine whether bone resorption or deposition occurs.9 It was found that the OPG action associated with testosterone causes a reduction in bone mineral density that is also observed during periodontal disease progression.9 This evidence implicates that androgen hormones impact the progression of periodontal disease in those undergoing FTM transitions.
Fluctuations of hormone levels not only have adverse effects on the periodontium but also increase risks for diabetes and osteoporosis. For transgender men on testosterone, osteoporosis screening is a standard of care. Deficient estrogen levels lead to osteopenia.10 The alveolar bone of transgender patients should be included in this examination to determine whether any bone loss occurs, which could lead to clinical attachment loss and periodontitis. Another factor that could impact the periodontium is the high risk for diabetes due to hormonal changes. The severity of chronic periodontal disease can complicate metabolic control, which can aggravate diabetes. Diabetic patients are more likely to present with chronic periodontitis that may worsen over time if their A1c is not well controlled.10
Though the knowledge of the effects of sex steroid hormones on the periodontium has been established, little research has been performed on the transgender population’s exact implications. A study by Shewale et al. focused on the periodontal status of India’s transgender population. These individuals are denied general, oral, and psychological care.11 The study included 639 subjects comprising 207 transgender individuals, 218 cisgender males, and 214 cisgender females.11 The term cisgender refers to individuals who identify as their birth sex.12 It was noted that 56.9% of males had the highest prevalence of calculus, while the transgender population had the highest prevalence for bleeding (17.4%) and deep pocket depth (9.7%). It was also found that 92.8% of the transgender individuals surveyed suffered from various periodontal disease stages. The study identified that transgender individuals are at a higher risk of disease, infection, and inflammation due to hormone alterations, stress, anxiety, social isolation, and lack of care.
Stress and periodontal disease
Compared to the general population, transgender individuals are more prone to stress, including financial hardship, discrimination, and abuse. A study by Sivaranjani et al. assessed the direct effects of stress on the periodontium. Stress can impact the periodontium by disrupting “homeostasis and the immune system, which is one of the contributing factors to the severity of periodontal problems.”13 Stress levels were assessed with a questionnaire; cortisol levels were analyzed from serum and saliva samples. Cortisol is a steroid hormone released into the blood during times of stress.14 High levels of cortisol indicate significant levels of stress. Long-term psychosocial stress can lead to emotional disabilities resulting in neglect of oral hygiene, which could implicate periodontal disease development.13 Additionally, a correlation was established between high stress and increased probing depths, clinical attachment loss, and salivary cortisol levels. Based on this study’s results, stress is an additional risk factor for periodontal disease in the transgender population.
The stress the LGBTQ+ population faces is related to discrimination, harassment, and fear of judgment. According to a cross-sectional study, 33.1% of the transgender population surveyed experience discrimination on one or multiple occasions in their lifetime.15 Many transgender individuals are “very much” or extremely fearful of maltreatment in a dental office. 85.5% report experiencing maltreatment from an oral health provider in the past.16 According to Narayan et al., transgender patients often have more restorative and prosthetic needs due to poor oral health status.17 These dental needs are often not met, leading to discomfort and more severe dental concerns. To ensure that this population receives adequate care, these patients must perceive dental offices as safe spaces.
Overcoming barriers
The lack of knowledge about transgender health is the most significant barrier to their care; oral health-care professionals must strive to educate physicians and health-care providers about the implications on oral health in those undergoing a transition. Research about the specific health needs of the population must continue, while providers advocate against any forms of discrimination that prevent or inhibit their care.18
Additionally, cultural diversity and competence training should address all demographic aspects of our growing populations, including a focus on sexual identity and orientation.19 Individuals of sexual minorities must be treated with respect and provided access to health care to ensure that the transgender population receives the best oral care. Dental health providers must accommodate stress and fear while assessing the patient’s periodontal status throughout their transition process. Those prescribing hormone therapy must understand the impact of these hormones on oral health and encourage them to seek preventative dental care.
Conclusion
There is a clinical correlation between sex hormones and their effects on the oral cavity. Therefore, there is a possible correlation to the transgender population taking hormone replacement. For the health of those transitioning, a potential connection between the prevalence of periodontitis in transgender individuals must be made so those undergoing the transition process can receive the best dental care and ensure that all oral health providers can advocate for their health needs.
References
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