By Wendy S. Hupp, DMD
THE MOST OBVIOUS differences between men and women are in the reproductive areas. We discussed dental treatment for pregnant and breast-feeding patients in the January 2007 issue of WDJ, and there are other hormone-related periodontal changes that we learned about in dental school. Certain diseases and conditions, such as the autoimmune disease Sjogren’s disease and temporo-mandibular dysfunction, have clear female predilections. Still, the past 15 years have produced some interesting studies showing many other sex differences.
In the early 1990s, the National Institutes of Health and Congress created the Office of Women’s Health Research. With this came the mandate that any U.S. government-supported health research must include an analysis of sex as well as demographic data. Results have shown that sex* differences may exist for many processes and interventions, including those not related to reproductive systems.
The Institute of Medicine released the report “Exploring the Biological Contributions to Human Health: Does Sex Matter?” in 2001. This report concluded that “the study of sex differences is evolving into a mature science,” and that “barriers to the advancement of knowledge about sex differences in health and illness exist and must be eliminated.”
What’s new?
Every day new studies show that sex does matter. Some of this information relates directly to how we practice dentistry, and some of it affects the orofacial region indirectly. It’s important to consider the person attached to the mouth that we’re treating, as we may be able to intercept a problem before it progresses too far. Referral to a physician is within the ethical and competent practice of dentistry.
- Heart disease kills 500,000 women in the United States each year - 60,000 more than U.S. men - however, women are often about 10 years older when they show symptoms of heart disease, and many are misdiagnosed or mistreated. Symptoms of myocardial infarction in women are characterized by nausea and vomiting, indigestion, abdominal or mid-back pain, and dizziness instead of the crushing pain that men commonly describe.
- New evidence shows that well-established procedures such as angioplasty and coronary artery bypass graft are not as effective in women because the changes to coronary arteries are different. Sudden death (no previous symptoms) occurs in 68 percent of women compared to 50 percent of men who have heart attacks.
- Women are two to three times more likely to suffer depression. Female brains make less serotonin per weight. Selective serotonin reuptake inhibitors, or SSRI, stay in the blood longer. Female brains are physically smaller as a percentage of body weight, but have a greater percentage of gray-to-white matter. Women are more able to remember faces and recognize landmarks, and have a tendency to be more verbal than spatial. Alzheimer’s disease affects women at a higher rate than it does men.
- Eighty percent of osteoporosis patients are women, and the rate of hip fracture is two to three times higher than in men; however, the associated mortality is two times higher in men. Total joint replacements are less likely to be prescribed for women, and recently prosthetic joints were manufactured specifically for women (size and angle of femur to tibia or pelvis). Osteoarthritis and rheumatoid arthritis are more common in women.
- Women are twice as likely to contract a sexually transmitted disease, and 10 times more likely to get HIV, probably as a result of anatomic structures. In the beginning stages of HIV infection, the viral load is lower in women, but AIDS develops at a higher rate and opportunistic infections occur at higher CD4 cell counts. Women metabolize medications slower, especially AZT.
- Women are more likely to get lung cancer at the same level of exposure, i.e., one pack a year for a woman is more risky than one pack a year for a man - even figuring for body size. Environmental or secondhand tobacco smoke affects more women because of occupational exposure (waitresses, bartenders, flight attendants). More women get the more aggressive small-cell type of lung cancer.
- Women wake up faster from general anesthesia, are three times more likely to be awake during surgery, and are more likely to suffer side effects. Serious side effects and lethal arrhythmias are more common.
- Seventy-five percent of autoimmune disease patients are women, including diabetes type 1, multiple sclerosis, systemic lupus erythematosis, rheumatoid arthritis, scleroderma, thyroiditis, and Sjogren’s disease. Women have a stronger, more exuberant immune system; men have more NK (natural killer) cells and the IL-1-receptor II that lowers inflammatory response.
- Women produce less alcohol dehydrogenase that breaks down alcohol (even allowing for size). Nicotine enhances alcohol’s sedative effect in women while it dilutes the effect in men. Nicotine causes calming effects in women but enhances aggression in men.
- Some pain medications work much better in women (kappa opiates) than men, while ibuprofen is less effective.
Oral health studies show these differences:
- Periodontal disease in pregnant mothers may lead to preterm, low-birth-weight babies.
- Hormonal changes occur during the menstrual period.
- Women’s teeth are smaller than men’s, especially in dentin thickness.
- Rate of root caries is less in women.
- Eighty percent to 90 percent of Sjogren’s syndrome patients are women.
- Ninety percent of TMD patients are women.
- Osteoporosis may affect the jaw; bisphosphonate medications may lead to osteonecrosis (80 percent of osteoporosis patients are women).
- Eating disorders occur much more frequently in women.
- Bone healing rates are different after implant placement.
- Socioeconomic status influences dental care more for women.
Curriculum changes
The 1999 report from the American Association of Dental Schools (now the American Dental Education Association) Women’s Health in the Dental School Curriculum identified that women’s health and oral-health issues are covered “to a certain degree. However, there still is a lack of conscious or studied inclusion of gender in many dental school curricula.” The report was optimistic that most dental schools were aware of the importance of women’s issues and were willing to include these topics in the future.
Curriculum guidelines for women’s health are being established so that understanding biological, psychological, and socioeconomic factors will lead to better treatment modalities, medications, and access to care. The goals are better preventive, diagnostic, and therapeutic practices for all patients.
WDJ and your practice
It is often assumed that as a woman, one must have this knowledge already. While many of us are well-versed in these new findings, we still have to catch up for dentists (men and women) who graduated before this information was available in the dental school curricula. Articles such as this one in WDJ help keep us informed. I encourage all dental health care providers to stay current.
There are many sources to get this knowledge, including the Harvard Women’s Health Watch newsletter (www.health.harvard.edu/women), the Society for Women’s Health Research e-Newsletter (www.womenshealthresearch.org), and the American Medical Women’s Association’s AMWA NEWSFlash (www.amwa-doc.org).
It will take some time, but it will be a great accomplishment to have these sex differences published in all types of journals - not just those focusing on women. Keep your eyes open for the American Dental Association’s position paper on women’s health, due to be published this year.
Please share this information with your male colleagues, as more than half of all dental patients are women. Vive la différence!
“Gender” is often used interchangeably in this area, but “sex” is a more appropriate term for the genetic makeup while “gender” has societal implications.
