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The Impact of Oral Contraceptives
on Women’s Periodontal Health and
the Subgingival Occurrence of
Aggressive Periodontopathogens
and Candida Species
Marı
´a Isabel Brusca,* Alcira Rosa,* Olatz Albaina,
†
Marı
´a D. Moragues,
‡
Fernando Verdugo,
†§
and Jose
´Ponto
´n
†
Background: The purpose of this study is to evaluate the influence
of oral contraceptive (OC) use on the subgingival occurrence of spe-
cific periodontopathogens and the host’s periodontal status.
Methods: Ninety-two females aged 19 to 40 years were included in
the study. They were divided into two groups, OC users and non-users,
and subgrouped according to the most severe periodontal condition
and duration of OC usage. A pooled subgingival sample from each
subject was cultured to investigate the presence of Candida
species, Porphyromonas gingivalis,Aggregatibacter actinomycetem-
comitans (previously Actinobacillus actinomycetemcomitans), and
Prevotella intermedia.
Results: OC users, particularly smokers, show a statistically signif-
icant increase in the prevalence of severe periodontitis. OC users had
deeper probing depths (‡5 mm) than non-users. Moreover, OC users
had higher gingival index scores and clinical attachment loss, ‡2and
‡5 mm, respectively, than non-users (P<0.01). Patients taking OCs
had significantly higher numbers of cultures positive for Candida.
Seven Candida species were isolated. Subgingival Candida was asso-
ciated with P. gingivalis and P. intermedia in 82.9% and 85.4%, respec-
tively, in patients taking OCs. A. actinomycetemcomitans was isolated
in patients with moderate and severe periodontitis and was associated
with subgingival P. gingivalis,P. intermedia,andCandida.
Conclusions: OC use may increase the risk of severe periodontitis
and seems to cause a selection of certain Candida species in periodon-
tal pockets. OC users showed a higher prevalence of P. gingivalis,P.
intermedia,andA. actinomycetemcomitans compared to non-users.
C. albicans,C. parapsilosis,C. krusei,C. tropicalis,andC. glabrata
were the species with the ability to survive in the conditions created
by the sex hormones after 3 years. J Periodontol 2010;81:1010-1018.
KEY WORDS
Actinobacillus actinomycetemcomitans;Candida; oral
contraceptives; periodontitis; Porphyromonas gingivalis;
Prevotella intermedia.
Hormonal contraceptive us-
age by females of child-
bearing age has been
suggested as a potential risk fac-
tor for the progression of destructive
periodontitis.
1-6
However, recent
data from large cross-sectional
studies (National Health and Nutri-
tion Examination Surveys I and III)
failed to validate this hypothesis.
7
Gingival inflammation seems to
be associated with high concen-
trations of sex steroids in females
taking birth control pills.
8,9
The
new generations of oral contra-
ceptives (OCs) containing 30 to
35mg of estradiol present fewer
associated vascular systemic
risks.
10
Other authors support
the notion that increased gingival
inflammation depends on the du-
ration of OC use.
9,11
Variations i n female endogenous
sex hormones during menstrua-
tion or pregnancy or use of OCs
have long been associated with
gingivitis.
1-6,8-11
An in vitro study
showed that polymorphonucleo-
cyte chemotaxis was enhanced by
progesteroneandreducedby estra-
diol. Such polymorphonucleocyte
* Department of Microbiology and Parasitology, School of Dentistry, University of Buenos Aires,
Buenos Aires, Argentina.
† Department of Immunology, Microbiology and Parasitology, School of Medicine and Odontology,
University of Basque Country, Leioa, Spain.
‡ Department of Nursing I, University of Basque Country.
§ Veterans Affairs Hospital, Greater Los Angeles Healthcare System, Los Angeles, CA.
doi: 10.1902/jop.2010.090575
Volume 81 • Number 7
1010
hormonal-induced impairment may translate into gin-
gival inflammation.
12
A recent study
13
could not con-
firm a specific cyclic pattern of bacterial colonization
in a group of 20 systemically and periodontally healthy
females who were not taking OCs during one full men-
strual cycle. Interestingly, the levels of Aggregatibacter
actinomycetemcomitans (previously Actinobacil-
lus actinomycetemcomitans) reportedly increased
between the onset of menstruation and 2 weeks
(P<0.05). These differences were not significant at
the P<0.001 level set in the aforementioned study.
13
Adriaens et al.
14
recently showed in a group of
20 pregnant females (mean age, 31.5 years),
that total bacterial counts decreased between week
12 and postpartum. Although the counts of Capnocy-
tophaga ochracea,Capnocytophaga sputigena,
Fusobacterium spp., Parvimonas micra (previously
Peptostreptococcus micros or Micromonas micros),
and Prevotella intermedia decreased, A. actinomyce-
temcomitans,Porphyromonas gingivalis,Tannerella
forsythia (previously T. forsythensis), and Treponema
denticola did not change for this specific population
between week 12 of pregnancy and postpartum. Fur-
thermore, Dinas et al.
15
reported that from a pool of
425 pregnant females, 47% presented symptoms of
gingivitis.
The importance of smoking as a risk factor asso-
ciated with periodontal disease progression is un-
derscored in different studies.
16
Kamma et al.
17
compared the microbial profiles of smokers and
non-smokers in a group of patients with early onset
periodontitis and reported that smokers harbored
a greater number of bacteria in total and presented
deeper pockets (>5 mm). The study also showed that
a number of oral bacteria and fungi, including Candida
albicans, were more frequently isolated in smokers.
The pathogenesis of Candida species in the pro-
gression of periodontal disease has not been fully
addressed. On the contrary, the bacterial role of com-
mon periodontopathogens, such as P. gingivalis,A.
actinomycetemcomitans, and P. intermedia, has been
studied for decades. More studies are needed to under-
stand the putative role of yeast as periodontopatho-
gens. A number of studies recently reported that
Candida species are isolated in subgingival samples
of patients with periodontal disease.
18-20
C. albicans
is usually the most frequently isolated species of
yeast in patients with periodontal disease. Yet,
C. dubliniensis, a recently described oral pathogen
very similar structurally to C. albicans, has also been
associated with periodontitis.
21
There are specific receptors within the periodontal
tissues for estrogens and progesterone.
22
Some re-
searchers
23,24
have shown specific patterns of bacte-
rial colonization in the presence of estrogens and
progesterone in periodontal pockets, whereas a differ-
ent group
25
found no association between low-dose
OCs and gingivitis. It is also reported that sex hor-
mones (estrogens and progesterone) could alter the
gingival vasculature and local immune response, re-
ducing the capacity of the periodontium to repair.
26
A limited number of animal studies also show that
sex hormones have the ability to alter the gingival
microvasculature, increasing its permeability and cel-
lular immune response, which could predispose to
periodontitis.
27-29
A recent human study on 27 non-
smoking, healthy females without signs of peri-
odontitis showed that the fluctuation of sex steroid
hormones during menstruation had an impact on gin-
gival inflammation. Bleeding on probing (BOP) and
interleukin-1bwere significantly increased under
good plaque control.
30
Thereseemstobeevidence
suggesting that sex hormonal therapy may modify
the gingival inflammatory response and alter the
subgingival microbiota.
8-13,22-29
Little is known about the influence of OCs on the
patterns of subgingival colonization, severity and
extent of periodontal disease, and its potential asso-
ciation with duration of use. Furthermore, scarce sci-
entific data are available regarding the presence of
Candida species in subgingival tissues. The purpose
of this study is to determine the influence of OC
usage on the distribution of specific periodontopath-
ogens (Candida spp., P. gingivalis,A. actinomyce-
temcomitans,andP. intermedia) in females of
child-bearing age. Moreover, a further aim is to find
associations between OC use, age, and duration of
the drug administration and severity of the disease.
MATERIALS AND METHODS
The study was approved by the School of Odontology,
University of Buenos Aires Ethical Committee, Bue-
nos Aires, Argentina. All patients signed informed
consent forms. Ninety-two females with an average
age of 30 years (range, 19 to 40 years) were included
in the study. Patients were recruited between March
2007 and February 2009 from the university and pri-
vate clinic offices. They were divided into those taking
OCs (n =41) and an age-matched control group not
taking OCs (n =51). Moreover, the test and control
groups were matched for socioeconomic characteris-
tics and oral habits without variations in ethnicity,
occupation, or educational level. Subjects were ex-
cluded from the study if they presented with a meta-
bolic or systemic disorder (e.g., diabetes, epilepsy,
hypertension, or metabolic syndrome) that could
affect the periodontium, had taken antibiotics in the
6 months previous to the study, or were pregnant.
Therefore, all subjects were systemically healthy
and had not received antibiotic therapy or profes-
sional cleaning in the 6 months previous to the study.
A detailed questionnaire was completed by each
J Periodontol • July 2010 Brusca, Rosa, Albaina, Moragues, Verdugo, Ponto
´n
1011
patient recording a full medical history, smoking
habits, and contraceptive pill usage before clinical ex-
amination. Specifically, the type of OC and the dura-
tion of the medication were recorded. All patients were
examined by an experienced periodontist (MIB). The
medical history data were withheld from the examin-
ing clinician to prevent potential influence of bias. At
the beginning of the study, the examining clinician un-
derwent a period of training to achieve a reproducibil-
ity of 98% for probing depths and 96% for attachment
level measurements to within £1 mm.
Clinical Parameters
Plaque and gingival inflammation were measured for
each site using the indices proposed by Silness and
Lo
¨e
31
and Lo
¨e and Silness,
32
respectively. The data
for these measurements are presented as the percent-
age of sites for each patient exhibiting plaque (i.e.,
plaque index ‡1 and ‡2) and gingival inflammation
(gingival index [GI] ‡1 and ‡2).
After a comprehensive periodontal examination in-
cluding probing depths (six sites per tooth), number of
teeth, and radiographic evaluation, the study popula-
tion was grouped according to the most severe peri-
odontal condition at any one site and the usage of
OCs. Full-mouth radiographs were analyzed by one
experienced periodontist (MIB) to assess interproxi-
mal bone loss and confirm clinical measurements.
The following criteria were used: healthy/gingivitis
subjects presented no radiographic bone loss and
probing depths ranging from 2 to 4 mm. Mild chronic
periodontitis exhibited radiographic bone loss and
clinical attachment loss (CAL) of 1 to 2 mm. Moderate
chronic periodontitis described patients with CAL of 3
to 4 mm and severe chronic periodontitis with CAL
‡5 mm. Clinical attachment levels were calculated us-
ing the cemento-enamel junction or margin of a crown
as the reference landmark. For instance, whenever
a gingival recession was present, CAL was measured
by adding the probing depth to the distance from
the cemento-enamel junction to the free gingival
margin.
Specimen Collection
Each subject provided a pooled subgingival sample
from the deepest pockets in each quadrant using
a minimum of four and a maximum of eight sterile pa-
per points per patient. After supragingival scaling, pa-
per points were inserted into the gingival sulcus/
pockets for 20 seconds and placed thereafter in 0.5
ml of reduced transport Go
¨teborg, anaerobically pre-
pared III (VMGA III) medium. After homogenization,
a serial dilution was performed and aliquots of 20
mL of each dilution were placed into different media
(anaerobic blood agar supplemented with vancomy-
cin and kanamycin, trypticase soy agar with bacitra-
cin and vancomycin,
33
and a medium for Candida
i
).
Anaerobic incubation was performed
¶
at 36C for 7
days. Candida agar plates were incubated at 37C
for up to 7 days. Identification of the periodontopatho-
genic species P. gingivalis,A. actinomycetemcomi-
tans, and P. intermedia was performed by means of
morphologic and biochemical properties.
#
Candida
species were identified by colony color and morphol-
ogy in a medium for Candida and carbohydrate as-
similation.** Isolates yielding green colonies on
agar for Candida were further characterized to differ-
entiate C. albicans from C. dubliniensis. Definitive
identification of C. dubliniensis was done by means
of their colony color and morphology in medium,
34
analysis by multiplex polymerase chain reaction,
35
and reactivity with a latex agglutination test specific
for C. dubliniensis
36,††
and an anti–C. dubliniensis
antiserum.
37
Statistical Analyses
Descriptive analyses of data were expressed as mean
–SD. Significance of group comparisons was deter-
mined by the Student ttest or the chi-square test with
the Yates’ correction when appropriate. Statistical
significance was set at P<0.05.
RESULTS
Ninety-two females entered this study. They were di-
vided into those taking OCs (n =41) and a control
group of those not taking OCs (n =51). The mean
age for the two groups did not significantly differ, be-
ing 30.34 –6.24 (range, 19 to 40) years for the OC
group and 30.31 –4.7 (range, 20 to 38) years for
the control group.
Females on hormonal OCs used three types of
brands that contained different concentrations of
ethinyl estradiol, gestoden, and drospirenone. Brand
one was used by 24 patients and contained 0.015
mg of ethinyl estradiol and 0.06 mg of gestoden.
‡‡
Brand two was used by 13 patients and contained
0.03 mg of ethinyl estradiol and 3 mg of drospirenone.
§§
Brand three was used by four patients and contained
0.02 mg of ethinyl estradiol and 3 mg of drospirenone.
ii
No statistically significant differences in periodontal
health were found among patients using any of the three
brands (data not shown).
The prevalence of periodontal diseases in OC users
is shown in Table 1. Individuals had an average of 27
permanent teeth (range, 26 to 32). Most of the pa-
tients (89.13%) did not wear a removable partial den-
ture or prosthesis (data not shown). Patients on OCs
iCHROMagar, BioMerieux, Marcy l’Etoile, France.
¶ Anaerocult system, Merck KGaA, Darmstadt, Germany.
# API 20 A and API NH, BioMerieux.
** API 20 C AUX, BioMerieux.
†† Bichro-Dubli Fumouze, Fumouze Diagnostics, Levallois-Perret, France.
‡‡ Mirelle, Bayer HealthCare, Buenos Aires, Argentina.
§§ Yasmin, Bayer HealthCare.
ii Yasminelle, Bayer HealthCare.
Oral Contraceptives and the Risk for Severe Periodontitis Volume 81 • Number 7
1012
showed a statistically significant increase in the prev-
alence of severe periodontitis. A similar situation was
recorded for smokers versus non-smokers (P<0.01;
Table 1). The OC group (n =41) was comprised
of 21 smokers (51.2%): nine (42.8%) smoked
<10 cigarettes a day and 12 (57.2%) ‡10. From these
last 12 subjects, seven (33.3%) had severe peri-
odontitis and five (23.8%) had moderate periodontitis.
The OC non-users (n =51) had 20 smokers (39.3%),
13 of them (65%) smoked <10 cigarettes a day and
seven (35%) ‡10. From these last seven subjects
one (5%) had severe periodontitis; two (10%) had
moderate periodontitis; three had mild periodontitis
(15%); and one (5%) had gingivitis (data not shown).
The increase in prevalence of severe periodontitis
correlated with the age of patients and plaque index
but not with BOP (Tables 2 and 3). OC users pre-
sented a higher proportion of GI scores ‡1 (95%) com-
pared to non-users (82%) (Table 2). Furthermore, OC
users had higher proportions of GI scores ‡2 (63%)
compared to non-users (43%) and this difference
was statistically significant (P<0.01; Table 2). OC
users (83%) had significantly deeper probing depths
‡5 mm than non-users (66.7%). OC users (46.3%)
had more areas with CAL ‡3 mm than non-users
(23.5%). Moreover, OC users (24.4%) presented
more areas with CAL ‡5 mm than non-users (9.8%;
Table 2). Control patients >26 years showed a statisti-
cally significant (P<0.01) increase in periodontal dis-
ease (Table 3). OC users <25 years had a higher rate
of periodontitis compared to controls (Table 3).
The duration of OC use also had an influence on
periodontal health. The mean –SD of duration of
OC was 33.7 –25.7 months (data not shown). In gen-
eral, patients on OCs for >3 years showed a higher
prevalence of moderate and severe periodontitis. Sub-
jects taking OCs >3 years presented 25% and 41.7% of
moderate and severe periodontitis, respectively, ver-
sus 20.7% and 17.2% in the OC group of <3 years of
duration (data not shown). The prevalence of gingival
health/gingivitis and mild periodontitis decreased
in the group taking OCs >3 years (0% and 33.3%,
respectively) compared to OC users of <3 years
(24.1% and 37.9%, respectively) (data not shown).
Fungal cultures yielded 80 isolates of seven Can-
dida species including 25 C. albicans,15C. tropicalis,
14 C. parapsilosis, nine C. krusei, nine C. dubliniensis,
seven C. glabrata, and one C. guilliermondii. In most
Ta b l e 1 .
Prevalence of Periodontal Disease in OC Use or Smoking Habit
Contraceptive Smoker OC user Non-OC user
Users Non-Users Yes No Smoker Non-Smoker Smoker Non-Smoker
Clinical Status n % n % n % n % n % n % n % n %
Health/gingivitis 7 17.1* 17 33.3 7 17.1
†
17 33.3 2 9.6
‡
525525
§
12 38.7
Mild periodontitis 15 36.6 22 43.1 16 39 21 41.2 7 33.3 8 40 9 45 13 41.9
Moderate periodontitis 9 21.9 7 13.8 8 19.5 8 15.7 5 23.8 4 20 3 15 4 12.9
Severe periodontitis 10 24.4* 5 9.8 10 24.4
†
5 9.8 7 33.3
‡
3 15 3 15 2 6.5
Total 41 100 51 100 41 100 51 100 21 100 20 100 20 100 31 100
* Chi-square test (P<0.01 versus contraceptive non-user group).
† Chi-square test (P<0.01 versus non-smoking group).
‡ Chi-square test (P<0.01 versus non-smoking OC-user group).
§ Chi-square test (P<0.05 versus non-smoking non–OC-user group).
Ta b l e 2 .
Clinical Parameters in OC Users Versus
Non-Users
Contraceptive
Users Non-Users
Clinical Parameter n % n %
Gingival index ‡1 39 95* 42 82
Gingival index ‡2 26 63* 22 43
Plaque index ‡13995
†
43 84
Plaque index ‡2 25 61* 15 29
Probing depth ‡5 34 83* 34 66.7
Probing depth ‡6 19 46.3* 12 23.5
Clinical attachment level ‡3 19 46.3* 12 23.5
Clinical attachment level ‡5 10 24.4* 5 9.8
* Chi-square test (P<0.01 versus the contraceptive non-user group).
† Chi-square test (P<0.05 versus the contraceptive non-user group).
J Periodontol • July 2010 Brusca, Rosa, Albaina, Moragues, Verdugo, Ponto
´n
1013
cases, one Candida species was isolated from the sul-
cus. Two Candida species (C. albicans and C. dublin-
iensis) were recovered only from one patient with
severe periodontitis and not taking OCs. The preva-
lence of Candida colonization was 95.1% in the
OC group and 78.4% in the control group (Table 4).
Patients on OCs had a statistically significant
(P<0.05) higher number of cultures positive for Can-
dida. The number of Candida species was the same in
both groups of patients. However, some species were
isolated more frequently in one of the groups (Table
4). C. dubliniensis was only isolated in control pa-
tients (P<0.01), and C. guilliermondii was only iso-
lated in patients on OCs. C. parapsilosis and C.
tropicalis were isolated more frequently in the OC
group (13 versus 1 and 10 versus 5, respectively),
but only in the case of C. parapsilosis were differences
statistically significant (P<0.001). C. parapsilosis was
isolated more frequently in patients with periodontitis
(12 versus 1) (P<0.05). C. albicans was isolated more
frequently in control patients (19 versus 6) (P<0.01).
C. krusei and C. glabrata were isolated in similar num-
bers in both groups (Table 4).
Time of OC usage did not show a significant influ-
ence on the distribution of Candida species. Patients
on OCs for >3 years showed a less varied species pro-
file than patients on oral hormonal contraceptives for
£3 years (five versus six, respectively). Only five Can-
dida species (C. albicans,C. parapsilosis,C. krusei,C.
tropicalis, and C. glabrata) were isolated in patients on
OCs for >3 years (data not shown). The patient’s age
did not show statistically significant differences in the
number of Candida species isolated from patients
taking OCs (data not shown). However, control pa-
tients with ages £25 years showed only two Candida
species (C. albicans and C. tropicalis) compared to
the more varied species profile of patient groups with
ages between 26 and 35 years and >36 years (five
Candida species each).
Candida isolation was accompanied by subgin-
gival presence of P. gingivalis and P. intermedia in
82.9% and 85.4%, respectively, of patients taking
OCs (Table 5). In most cases, P. gingivalis and P. in-
termedia were isolated in patients with periodontitis.
Patients on OCs and isolation of P. gingivalis or P. in-
termedia showed a statistically significant (P<0.01)
increase in the prevalence of severe periodontitis
compared to controls. A. actinomycetemcomitans
was isolated in patients with moderate and severe
periodontitis (P<0.01) and in association with P. gin-
givalis,P. intermedia, and Candida. Control patients
showed a lower prevalence of the three periodonto-
pathogens, especially in the case of P. intermedia
and A. actinomycetemcomitans, compared to the
OC group (Table 5). In six patients taking OCs, isola-
tion of A. actinomycetemcomitans was accompanied
by a Candida species, three of them C. parapsilosis.
In 16 patients there was no isolation of periodontal
bacteria from the periodontal pockets; 11 of them
were OC non-users. The clinical presentations in pa-
tients with no isolation of periodontal bacteria in
the periodontal pockets ranged between gingival
health/gingivitis and moderate periodontitis (data
not shown). OC usage lowered the percentage of pa-
tients with gingival health and gingivitis but increased
the percentage of patients with mild and moderate
periodontitis. Candida species were isolated in 10 pa-
tients negative for periodontal bacteria in the peri-
odontal pockets (data not shown). Six of them were
OC non-users. Candida krusei was isolated in pa-
tients negative for periodontal bacteria irrespective
of OC usage. However, C. albicans and C. dublinien-
sis were isolated in the periodontal pockets of OC non-
users negative for periodontal bacteria, whereas C.
tropicalis and C. glabrata were grown from the peri-
odontal pockets of OC users without isolation of peri-
odontal bacteria.
DISCUSSION
The present study aims to assess the influence of OC
usage on the distribution of specific periodontopatho-
gens (Candida spp., P. gingivalis,A. actinomycetem-
comitans, and P. intermedia) in women with an
average age of approximately 30 years (range, 19 to
40). A further objective was to find associations
Table 3.
Prevalence of Periodontal Disease
According to Age and OC Use
Age
19 to
25 years
26 to
35 years
>36
years
Clinical Status n % n % n %
Contraceptive Users
Health/gingivitis 4 33.3 2 11.7 1 8.3
Periodontitis 8* 15 11
Mild periodontitis 8 66.7 4 23.6 3 25
Moderate periodontitis 0 0 6 35.3 3 25
Severe periodontitis 0 0 5 29.4 5 41.7
Subtotal 12 100 17 100 12 100
Contraceptive Non-Users
Health/gingivitis 7 100 8 24.2 2 18.2
Periodontitis 0 25
†
9
†
Mild periodontitis 0 0 15 45.5 7 63.6
Moderate periodontitis 0 0 6 18.2 1 9.1
Severe periodontitis 0 0 4 12.1 1 9.1
Subtotal 7 100 33 100 11 100
* Chi-square test (P<0.01 versus the contraceptive non-user group).
† Chi-square test (P<0.01 versus the 19- to 25-year group).
Oral Contraceptives and the Risk for Severe Periodontitis Volume 81 • Number 7
1014
between duration of drug use, age, and severity of the
disease.
OC use increased the risk for severe periodontitis
and seemed to cause a selection of certain Candida
species subgingivally. C. albicans,C. parapsilosis,
C. krusei,C. tropicalis, and C. glabrata were the spe-
cies presenting the ability to survive subgingivally after
3 years. Moreover, OC users showed a higher preva-
lence of P. gingivalis,P. intermedia, and A. actinomy-
cetemcomitans compared to non-users.
The influence of OC use on oral health has been ad-
dressed in several studies.
1-7
Although it is widely ac-
cepted that female sex hormones have an impact on
oral structures and there is evidence suggesting that
sex hormones may produce gingival inflammation
by altering the microvascular component of the gin-
giva,
38,39
the influence of OC usage
by females of child-bearing age on
the progression of periodontitis is
controversial.
1,7
OC users had 20% higher propor-
tion of GI scores ‡2 (63%) compared
to non-users (43%) in the present
study (P<0.01). Regardless of smok-
ing status, BOP (GI ‡2) was signifi-
cantly higher in OC users. Smoking
‡10 cigarettes a day in the OC group
accounted for the most severe forms
of periodontitis compared to OC
non-users. Smoking is a well-known
risk factor for periodontitis and could
have acted synergistically with OC
use in its progression. In fact, this
study reports that non-OC users
who smoke had less severe periodon-
tal disease than OC users who smoke.
However, these data should be inter-
preted with caution because of the
small sample size of smokers (‡10
cigarettes a day) in this group. Fur-
ther studies are needed to elucidate
the potential synergistic effect of
smoking and OC use in the progres-
sion of periodontitis.
The results presented in this study
suggest that OC use has a role in peri-
odontal health because patients on
OCs tend to have poorer periodontal
health than non-users and show a sta-
tistically significant increase in the
prevalence of severe periodontitis
and major periodontopathogens.
The effect was more marked in pa-
tients with >3 years of OC use, who
showed a higher prevalence of mod-
erate and severe periodontitis. These
results are in agreement with the work of Mullally
et al.
1
who reported that current users of OCs had
poorer periodontal health than non-user controls.
However, other factors, such as patients’ age, may
also play a role because control patients >26 years
not taking OCs showed an increase in periodontal
disease compared to younger controls. Older age
was found to be a risk factor for severe periodontal
disease in a Swedish adult population.
40
Candida species, notably C. albicans, are frequent
colonizers of the oral cavity. A number of studies have
reported on the isolation of yeasts, mainly Candida,
from periodontal pockets in a large number of patients
with periodontitis (7.1% to 44.4%).
18-20,41-43
Higher
percentages of Candida colonization have been found
in HIV-infected patients with periodontal lesions
Ta b l e 4 .
Prevalence of Candida spp. Isolation on
Periodontal Diseases
Contraceptive
Users (n =41) Non-Users (n =51)
Clinical Status n Species % n Species %
Health/gingivitis 3 C. tropicalis 7.69 8 C. albicans 19.51
§
1C. parapsilosis 2.56
†
2C. dubliniensis 4.88*
1C. glabrata 2.56 2 C. krusei 4.88
1C. albicans 2.56 1 C. tropicalis 2.44
1 No growth — 4 No growth —
Subtotal 6 15.37 13 31.71
Mild periodontitis 5 C. parapsilosis 12.82
†i
6C. albicans 14.63
4C. krusei 10.27 5 C. dubliniensis 12.20*
2C. tropicalis 5.13 3 C. krusei 7.32
2C. albicans 5.13 3 C. tropicalis 7.32
1C. guilliermondii 2.56
†
1C. glabrata 2.44
1C. glabrata 2.56 4 No growth —
Subtotal 15 38.47 18 43.91
Moderate periodontitis 3 C. parapsilosis 7.69
†i
1C. tropicalis 2.44
3C. tropicalis 7.69 1 C. parapsilosis 2.44
2C. albicans 5.13 1 C. albicans 2.44
§
1C. glabrata 2.56 1 C. glabrata 2.44
3 No growth —
Subtotal 9 23.07 4 9.76
Severe periodontitis 4 C. parapsilosis 10.27
†i
4C. albicans 9.75
§
2C. glabrata 5.13 2 C. dubliniensis 4.88*
2C. tropicalis 5.13
1C. albicans 2.56
1 No growth —
Subtotal 9 23.09 6 14.63
Total 39
‡
100 41 100
* Chi-square test, Yates correction (P<0.01 versus the contraceptive user group).
† Chi-square test, Yates correction (P<0.001 versus the contraceptive non-user group).
‡ Chi-square test, Yates correction (P<0.05 versus the contraceptive non-user group).
§ Chi-square test (P<0.01 versus the contraceptive user group).
iChi-square test (P<0.01 versus the health/gingivitis group).
J Periodontol • July 2010 Brusca, Rosa, Albaina, Moragues, Verdugo, Ponto
´n
1015
(42.3% to 53.7%).
18,43,44
In the present study, the
prevalence of Candida colonization was 95.1% in
the OC group and 78.4% in the control group. The rea-
son for the high percentage of Candida colonization
observed in this study is presently unknown but it
may be linked to gender and dietary factors. It has
been reported that oral Candida colonization in pa-
tients with periodontitis is significantly higher in fe-
males compared to males.
45
Several yeast species have been isolated from peri-
odontal pockets in patients with periodontitis. C. albi-
cans was the species most frequently isolated but
other species including C. dubliniensis,C. glabrata,
C. parapsilosis,C. tropicalis,C. lipolytica,C.guillier-
mondii,C. sake,Saccharomyces cerevisiae,Tricho-
sporon mucoides, and Rhodotorula spp. have also
been identified.
18-20,43,44
In the present study, seven
Candida species were isolated. Six of them have been
described in other studies (C. albicans,C. tropicalis,
C. parapsilosis,C. dubliniensis,C. glabrata, and C.
guilliermondii),
18-20,43,44
but to our knowledge this
is the first study reporting on the isolation of C. krusei
from periodontal pockets.
Although in this study the number of Candida spe-
cies in the group of patients taking OCs versus the
control group was very similar, some species were
more frequently isolated in one of the two groups.
The present findings suggest that OC use may cause
a subgingival selection for certain Candida species,
such as C. guilliermondii,C. parapsilosis, and C. tropi-
calis. This selection was more evident for individuals
on OCs >3 years because only five Candida species
(C. albicans,C. parapsilosis,C. krusei,C. tropicalis,
and C. glabrata) were iso-
lated. Conversely, C. dub-
liniensis was not isolated
from periodontal pockets
of patients on OCs. The ab-
sence of C. dubliniensis in
the periodontal pockets of
patients taking OCs was
surprising and suggests
that changes caused by
sex hormones in the peri-
odontium may reduce or
limit C. dubliniensis growth.
A reduction in the number
of Candida species at sub-
gingival sites compared to
oral mucosa has been re-
ported by Urzu
´aetal.
18
The association between
Candida and periodontitis
is controversial. Although
different Candida species
have been isolated from
periodontal pockets of patients with periodonti-
tis
18,19,43,44
and hyphae have been found to invade
the periodontal connective tissue,
46
the absolute
proof implicating Candida in the pathogenesis of peri-
odontitis is still lacking. In our study, a significant as-
sociation between Candida and periodontitis was only
found for C. parapsilosis. For the rest of the Candida
species there were no significant differences between
the range of species found in patients with gingivitis or
periodontal health and patients with periodontitis.
However, in most cases Candida isolates were ac-
companied by well-known periodontopathogens,
such as P. intermedia,P. gingivalis, and A. actinomy-
cetemcomitans. In those cases, it seems likely that the
bacteria co-isolated with Candida were the putative
agents responsible for the development of peri-
odontitis. In a limited number of patients, Candida
species were not co-isolated with periodontal bacte-
ria. However, because most of those subjects pre-
sented gingivitis or mild to moderate periodontitis, it
is plausible to speculate that Candida species might
have played a secondary role in the pathogenesis
and progression of periodontitis.
One of the main limitations of this study is the rel-
atively small sample size. Further studies are needed
to elucidate the impact of OC use on women’s peri-
odontal health and the subgingival occurrence of
not well-known periodontopathogens, such as Can-
dida species.
CONCLUSIONS
OC use may increase the risk of severe periodontitis
and seems to cause a selection of certain Candida
Table 5.
Prevalence of P. gingivalis,P. intermedia,A.
actinomycetemcomitans, and Candida in Periodontal Diseases
Microorganism
P. gingivalis P. intermedia A. actinomycetemcomitans Candida spp.
Clinical Status n % n % n % n %
Contraceptive Users 41 100 41 100 41 100 41 100
Health/gingivitis 2 4.9 5 12.2 0 0 6 14.6
Mild periodontitis 15 36.5 12 29.3 0 0 15 36.5
Moderate periodontitis 7 17.1 8 19.5 1 2.4 9 22
Severe periodontitis 10 24.4* 10 24.4* 5 12.2* 9 22
Subtotal 34 82.9 35 85.4 6 14.6 39 95.1
Contraceptive Non-Users 51 100 51 100 51 100 51 100
Health/gingivitis 6 11.8 6 11.8 0 0 13 25.5
Mild periodontitis 18 35.3 12 23.5 0 0 18 35.3
Moderate periodontitis 7 13.7 6 11.8 0 0 4 7.8
Severe periodontitis 5 9.8 5 9.8 1 2 6 11.8
Subtotal 36 70.6 29 56.9 1 2 41 80.4
* Chi-square test (P<0.01 versus the contraceptive non-user group).
Oral Contraceptives and the Risk for Severe Periodontitis Volume 81 • Number 7
1016
species in periodontal pockets. OC users showed
a higher prevalence of P. gingivalis,P. intermedia,
and A. actinomycetemcomitans compared to non-
users. C. albicans,C. parapsilosis,C. krusei,C. tropica-
lis, and C. glabrata were the species with the ability to
survive in the conditions created by the sex hormones
after 3 years. C. dubliniensis seemed to be negatively
affected because it was not isolated in the periodontal
pockets of OCs users.
ACKNOWLEDGMENTS
The authors thank Dr. Pedro Hecht, professor of bio-
physics at the School of Odontology, Buenos Aires
University, Buenos Aires, Argentina, for his help with
the statistical analysis. This work was supported in
part by grants IT-264-07 from the Department of Ed-
ucation, Universities and Research, and S-P08BUN10
from the Department of Industry, Trade and Tourism,
Basque Government, Spain. The authors report no
conflicts of interest related to this study.
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Correspondence: Professor Jose
´Ponto
´n, Department of
Immunology, Microbiology and Parasitology, School of
Medicine and Odontology, University of Basque Country,
Apartado 699, 48080 Bilbao, Vizcaya, Spain. Fax: 34-94-
6013495; e-mail: jose.ponton@ehu.es.
Submitted October 14, 2009; accepted for publication
February 28, 2010.
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