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131]

Original Article

A study to evaluate mobility of teeth

during menstrual cycle using Periotest
Poonam Mishra, P. P. Marawar1, Girish Byakod2, Jyoti Mohitey4, Sunil S. Mishra3

Department of
Periodontics, Bhabha
Dental College,
Bhopal, Madhya
Pradesh, 1Department
of Periodontology,
Rural Dental College,
Loni, 2Rangoonwala
Dental College, Pune,
3
Department of Oral
Medicine and Radiology,
CSMSS Dental
College, Kanchanwadi,
Aurangabad, 4AP
School of Dental
Sciences, Karad,
Maharashtra, India

Abstract:
Background and Objective: Over a century, an increased prevalence of gingival disease associated with
increasing plasma sex steroid hormone levels has been reported. These situations present unique challenges to
the oral health care professional. It is believed that hormonal fluctuations such as those associated with pregnancy,
menstruation, and use of hormonal contraceptives lead to an increase in tooth mobility. However, this effect of
female sex hormones on periodontal ligament and tooth supporting alveolar bone has rarely been investigated.
So this study was undertaken to understand the effect on tooth mobility because of hormonal changes during
the menstrual cycle. Materials and Methods: The mobility of index teeth 16, 13, 21, 23, 24, 36, 33, 41, 43, and
44 was measured with Periotest in 50females at menstruation, ovulation, and premenstruation time points.
Simplified oral hygiene index, plaque index, gingival index, and probing depth were also evaluated during the
different phases of menstrual cycle for each subject participating in the study. Statistical Analysis: The results
of the study were subjected to statistical analysis. Data analysis was done by applying Z test for comparing
difference between two sample means. Result: The stages of menstrual cycle had no significant influence on
the Periotest value. Despite no significant change in plaque levels, GI was significantly higher during ovulation
and premenstruation time points. Conclusion: No change in tooth mobility was seen during the phases of the
menstrual cycle. However, an exaggerated gingival response was seen during ovulation and premenstruation
time when the entire menstrual cycle was observed.
Key words:
Gingival condition, hormonal changes, menstruation, periotest value, tooth mobility

INTRODUCTION
Access this article online
Website:
www.jisponline.com
DOI:
10.4103/0972-124X.113078
Quick Response Code:

Address for
correspondence:
Dr.Poonam Mishra,
Flat No.404, Building No. F,
Surobhi Township,
Vishrantwadi,
Pune411015,
Maharashtra, India.
Email:drpoonam81@
gmail.com
Submission: 08122011
Accepted: 27022013

he homeostasis of the periodontium involves

complex multifactorial relationship in which
endocrine system plays an important role.[1]
Physiological events due to hormonal influences
have long been recognized as an important
influencing, predisposing, or risk factor
in periodontal diseases. Currently accepted
periodontal classification also recognizes
the influence of endogenously produced sex
hormones on the periodontium.[2]
Changes in womans hormonal milieu have
surprisingly strong influence on oral cavity
and are reflected in her periodontal tissues
as well. The data available from previous
studies, [3] strongly suggest that female sex
steroid hormones may alter periodontal tissue
response to microbial plaque and thus indirectly
contribute to periodontal disease. It is believed
that hormonal fluctuations associated with
pregnancy, menstruation, and use of hormonal
contraceptives lead to increase in the mobility of
teeth, presumably because of physicochemical
changes in periodontium. However, the literature
to support this belief is very scanty.[4,5]
A better understanding of the periodontal changes
in response to hormonal changes can help a
dental practitioner in the diagnosis as well as in

Journal of Indian Society of Periodontology - Vol 17, Issue 2, Mar-Apr 2013

providing appropriate treatment. Thus, this study

intends to understand the effect of menstruation
on tooth mobility and gingival condition.

MATERIALS AND METHODS

This study was conducted in the Department
of Periodontics(Rural Dental College, Loni),
in 2006(FebruaryOctober). After obtaining
consent, a total of 50females in the age group
of 17-25years were examined. Each subject was
asked to record the dates of her menstrual period.
Depending on the dates that can be observed
in different phases of menstrual cycle such as
leutal/premenstruation(PM)(24 th-26 thday),
follicular/menstruation(M)(2nd-3rdday), and
ovulation(OV)(12th-14thday), specific time points
were selected for each visit as 25thday for PM,
2ndday for M, and 13thday for OV for recording
the parameters.
Inclusion criteria
Subjects chosen were nonperiodontitis
patients with probing depth3mm
Subjects with steady menstrual cycle
Permanent dentition.
Exclusion criteria
Presence of any systemic disease that could
influence the responses of periodontal tissues
to the accumulation of plaque
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Mishra, etal.: Menstruation and tooth mobility

Presence of gross caries or inadequate restorations

interfering with removal of dental plaque
Use of oral contraceptives
Teeth restored with crown or fillings
Orthodontic treatment during the last 3years.
Clinical examination
Simplified oral hygiene index (OHIS),[6] plaque index (PI),[7] gingival
Index(GI),[8] probing depth(PD), and tooth mobility[9] were
evaluated for each subject participating in the study.
Mobility of teeth 16, 13, 21, 23, 24, 36, 33, 41, 43, and 44 was
measured with Periotest [Figure1a and b].
The device consists of a hand piece connected by a cable to a unit
that controls functions and analyzes measurements. Inside the
hand piece, a metal rod is accelerated until it reaches its nominal
speed and contacts the tooth. Upon impact, the tooth is slightly
deflected and rod is decelerated. The faster the deceleration,
higher will be the stability and greater the damping of periodontal
tissues. The contact time between tooth and tapping head is the
signal used for analysis by the system. During each measurement,
the device delivers 16 impacts in 4 s to the object.
The duration of contact of the tapping head on the tooth
surface measured by the instrument that calculates the Periotest
valve(PTV), indicates tooth mobility. An average of three PTVs
obtained was calculated. PTVs are based on a numerical scale
from8 to+50 [Table 1].
Table 1: PTV and its correlation to clinical mobility
Values

Mobility
0

8 to+9
+10 to+19

+20 to+29

II

+30 to+50

III

Table2: Distribution of periotest values at menstruation,

ovulation and premenstruation phase

16
13
21
23
24
36
33
41
43
44
Total

Menstruation
(n=50)
MeanSD

Ovulation
(n=50)
MeanSD

Premenstruation
(n=50)
MeanSD

3.442.18
1.901.97
1.172.88
1.801.33
4.111.55
1.122.13
2.120.89
3.992.41
0.851.21
1.620.81
2.211.88

3.522.09
1.921.93
1.232.81
1.891.41
4.131.64
1.201.81
2.180.87
4.082.35
0.801.31
1.721.67
2.261.79

3.601.61
1.982.03
1.182.80
1.881.45
4.152.12
1.171.75
2.140.96
3.972.41
0.791.14
1.681.25
2.251.77

(P>0.05; Not significant)

Periotest device has many applications. It can be used in the

diagnosis and assessment of healing of traumatized teeth in
children. It offers great potential for use in implant dentistry to
evaluate the bone implant interface. Since it offers an objective
parameter even slight change in tooth as well as implant
mobility can be evaluated. This device can also help in assessing
even the most initial changes of progression from gingivitis to
periodontitis.[5,10]
Statistical analysis
Mean and standard deviation were calculated. Data analysis
was done by applying the Z test to compare the difference
between two sample means.

OBSERVATIONS AND RESULTS

Table2 shows distribution of PTV values at M, O, and PM
time points. No significant difference was observed in the PTV
values. Table3 shows comparison of mean values of OHIS, PI,
and GI whereas Table4 shows the comparison of mean values
of the probing depth(PD) at M, OV, and PM time points. GI was
high at OV time point followed by PM whereas no significant
difference was seen in PD scores. When the mean values of the
PD were compared during the three phases of menstrual cycle,
it was seen that there was no significant difference in PD scores.

DISCUSSION
Measuring the degree of tooth mobility is an important part of
any thorough periodontal examination. Tooth mobility is the
measurement of horizontal and vertical tooth displacement
created by examiners force.[11] Even a tooth with significant
alveolar bone support reveals physiologic tooth mobility.
This is due to the syndesmotic mechanism by which teeth
are supported within the alveoli and the elasticity of entire
alveolar process. Stability of a tooth is dependent upon
the resistance of its supporting structure and the character
of forces directed against it. When either changes so does
mobility.[12]
It is believed that hormonal fluctuations such as those
associated with pregnancy, menstruation, and use of hormonal
contraceptives lead to an increase in tooth mobility. It is
undoubtedly possible that these structures react to changes in
endocrine activity in a similar way the connective tissue does in
other parts of the body.[5] It is believed that this increase occurs
in patients with or without periodontal disease presumably
because of physiochemical changes in periodontium.[5,13] The
toothsupporting structures, under the influence of hormones
would offer less resistance to the forces acting on them and
accordingly a reduction in the capacity to dissipate forces and
increased tooth mobility.[5,14]
Rateitschak [4] explained that mobility during periods of
hormonal changes is increased mainly because of an increase

Table3: Comparison of mean values of various parameters under study

Simplified oral hygiene index
Plaque index
Gingival index
220

Menstruation MeanSD

Ovulation MeanSD

Premenstruation MeanSD

0.470.41
1.580.82
O.130.10

0.450.39
1.570.79
0.480.20

0.520.68
1.560.81
0.210.12

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Mishra, etal.: Menstruation and tooth mobility

Table4: Comparison of mean values of probing depth at

M, OV, and PM

Probing depth

Menstruation
MeanSD

Ovulation
MeanSD

Premenstruation
MeanSD

2.161.78

2.261.78

2.201.69

(P>0.05; Not significant)

in the initial free intrasocket movement of the roots(initial

mobility) and not because of increased elastic bone distortion.
Initial mobility is among other factors dependent on the degree
of vascularization and the vascular volume of the periodontal
membrane. Experimental vasoconstriction and vasodilatation
of periodontal vessels have been shown to decrease or increase
initial movement respectively. Female sex hormones may
have a hyperemicand permeabilityincreasing action on the
periodontal vascular system as shown for other parts of the
body. With respect to the periodontal membrane, slight edema
has a tooth extruding effect, increasing by this mechanism the
horizontal mobility. Additionally, under the influence of sex
hormones, changes in the viscosity of interstitial fluid and in
the degree of ground substance polymerization and perhaps
alterations of collagen fibers could also reduce resistance
against intrasocket movements of roots.
This study was undertaken to understand the possible
association between the effects of female sex hormones
during the menstrual cycle and tooth mobility. Females in
the age group of 17-25years with stable menstrual cycle were
examined.
Measuring tooth mobility and especially assessing changes
in mobility is rather difficult. Luxation is the most commonly
used method to detect tooth mobility. This is because the
recommendations for evaluating tooth mobility are insufficient,
nonscientific, and highly subjected to individual variation.
Since there was need for a numerical assessment of tooth
mobility to help assess changes during the different phases of
menstruation, a Periotest(Siemens AG, Bensheim, Germany)
was used. It is an electronic device that measures the damping
characteristics of the periodontium and provides an objective
measurement.

of the cycle, the secretory or luteal phase begins. This phase

is characterized by the synthesis and release of both estrogen
and progesterone by follicular cells.[17]
Due to these events, several women report oral symptoms
just before or during menses that include erythema, slight
burning sensation, minor apthous, bleeding with minor
irritation, and general pain and discomfort in gums.[18] Gingival
manifestations of bleeding and swollen gingiva during
menstrual cycle have been reported by Lindhe and other
researchers.[1922] Muhlemann over64years ago described a case
of gingivitis intermenstrulis, which he observed as consisting
of bright red hemorrhagic lesions of interproximal papillae
identified prior to menstruation.[23]
Nevertheless, most women with a clinically healthy
periodontiumexperience few significant periodontal changes as a
result of menstruation.[1] In a longitudinal study, Holmpederson
and Loe[20] found no effect of hormonal variations during the
menstrual cycle on clinically healthy gingiva whereas significant
deterioration of preexistent gingivitis was observed during days
of menstruation. Lindhe and Attstrom[19] noted that during their
menstrual cycles, women without clinical gingivitis showed no
increase in gingival fluid whereas those with gingivitis showed
an increase in gingival crevicular fluid flow.
The gingiva can thus be considered a target tissue for estrogen
and progesterone. Elevated levels of progesterone affect
gingival microvasculature enhancing capillary permeability
and dilatation. Their high concentration also affects the host
defense mechanism such as neutrophil chemotactic response
and also enhances production of prostaglandins. Elevated
levels of estrogen cause decrease in the keratinization of
gingiva with an increase in epithelial glycogen and thus results
in decreased effectiveness of epithelial barrier. Estrogen and
progesterone reduce glycosaminoglycans synthesis and thus
may affect ground substance of connective tissue.[24]

The result of this study showed that the stages of the menstrual
cycle, which are menstruation(M), ovulation(OV), and
premenstruation (PM) had no significant influence on the
Periotest value(PTV). Our results are in accordance with those
of Steenberghe etal.[5]and Friedman[15] who found no significant
change in tooth mobility during the menstrual cycle. However,
some authors have reported a minor increase in horizontal
tooth mobility during the fourth week of menstrual cycle.[16]

Miyagi etal.[25] found that sex hormones significantly enhanced

synthesis of prostaglandin(PGE2) that plays an important role
in periodontal inflammation. They also studied the effects of
these hormones on PGE2 synthesis by pheripheral monocytes.
Both estradiol and progesterone resulted in elevated PGE2
production that could turn up the inflammatory process.
Another finding which was reported was that estradiol
reduces the chemotactic ability of Polymorphonuclear
neutrophils(PMNs) while progesterone significantly enhances
it.[26] Thus, these hormones present as important influencing
factors in the pathogenesis of periodontal diseases.[23] Hence, in
this study, an attempt was also made to determine the gingival
condition during various stages of the menstrual cycle.

Menstrual cycle is an important hormonal milieu in a womans

life. Dynamic relationship exists between the hormones and
reproductive system. During the follicular phase follicular
stimulating hormone(FSH) in conjunction with luteinizing
hormone(LH) activates the secretion of estrogen. The
maximum peak of estrogen secretion is seen about 48h before
ovulation. Ovulation is triggered by the rapid rise in estradiol
elaborated by preovulatory follicle. The LH surge occurs 24-36h
before ovulation. This stimulates the synthesis of progesterone
within the follicle. After ovulation at approximately 14thday

In this study, gingival inflammation was assessed by the

gingival index(GI). The findings revealed that GI scores
were lower during the M phase than at OV and PM time
points[Figures2 and 3]. Our findings are similar to that
reported by Macheti et al. [10] who found that despite no
significant change in plaque levels, GI was significantly higher
during OV and PM time points. This difference primarily
maybe attributed to the increase in serum estradiol levels that
peak during OV and a second peak that occurs just before
menstruation.

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Mishra, etal.: Menstruation and tooth mobility

b
Figure1:(a) Armamentarium used for clinical examination;(b) Periotest used for measuring tooth mobility

b
Figure2: Gingival condition at ovulation time point of menstrual cycle (Gingival index score=2);(a) Lateral view and(b) frontal view

b
Figure3: In the same patient gingival condition at menstruation time point of the menstrual cycle(Gingival index score=1);(a) Lateral view and(b) frontal view

Serum estradiol levels peak at OV(150-600pg/mL) and drop

immediately after. Asecond peak is observed during PM(40300pg/mL). However, progesterone levels are initially low(0.060.37ng/mL) to a peak a few days before M(4.3-19.4ng/mL)
with a sharp decline thereafter.[17] It is therefore suggested that
222

the abovereported phenomenon of increase in GI at OV and

PM maybe primarily attributed to the increase in estradiol
levels. The increased levels of these hormones also influence
the regulation of inflammatory mediators such as Tumor
Necrosis Factor(TNF) and Prostaglandins that could turn up
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Mishra, etal.: Menstruation and tooth mobility

the inflammatory process responsible for the heightened GI

scores.[26,27]
Gornstein etal.[28] and Lapp etal.[29] reported that Interleukin(IL6)
was down regulated by progesterone and hence could modulate
the development of localized gingival inflammation rendering
the gingival less efficient at resisting the inflammatory
challenges produced by bacteria. They also found increased
amount of gingival exudate during the ovulation phase of the
menstrual cycle.

5.

6.

7.

8.

The periovulatory rise of IL6 and late leutal rise of IL6 and
TNF may act as cofactors in rise in basal temperature or
the premenstrual syndrome. [30] Studies have also shown
that menstrual cycle irregularity maybe a marker of
metabolic abnormalities predisposing to increased risk for
immunesystemrelated diseases. [31,32] Hence, precautions
to strengthen immune system during this phase will be
appropriate.

9.

Probing depth during the three phases was also evaluated, but it
showed no significant change. Hence, it can be inferred that the
high concentration of circulating hormones has an effect only
on gingiva and are insufficient to cause significant periodontal
breakdown. Machtei etal.[16] did not find any change in mean
probing depth during different phases of menstrual cycle. Our
findings are similar to the aforementioned study.

12.

CONCLUSION

16.

Our investigation showed that there was no change in

tooth mobility during the phases of menstrual cycle.
Exaggerated gingival response was seen during ovulation
and premenstruation time points when the entire menstrual
cycle was observed. This increase in gingivitis was apparently
the result of heightened tissue response to irritation, which
suggests that the cause was related to the concentration of
circulating sex hormones. However, tooth mobility may not
be under the influence of hormonal changes occurring during
the period of menstruation.
Much research is needed to address the increasing number
of patients who present to our periodontal practices with
sexhormonemediated infection. Studies regarding correlation
of hormonal levels with specific tooth mobility and detailed
microbiologic investigation would help us gain further
insight and knowledge about issues regarding female health
and periodontal therapy. Also, a better understanding of
periodontal changes to varying hormone levels throughout
life can help dental practitioner in diagnosis and treatment.

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How to cite this article: Mishra P, Marawar PP, Byakod G, Mohitey

J, Mishra SS. A study to evaluate mobility of teeth during menstrual
cycle using Periotest. J Indian Soc Periodontol 2013;17:219-24.
Source of Support: Nil, Conflict of Interest: None declared.

Journal of Indian Society of Periodontology - Vol 17, Issue 2, Mar-Apr 2013