Addressing Dental Issues in Transgender Patients

Transgender individuals face unique challenges in the dental setting related both to barriers to care and oral health implications. Multiple qualitative studies have uncovered an overwhelming tendency for transgender individuals to avoid dental care due to the fear of discrimination stemming from providers being undereducated on transgender healthcare.¹ Additionally, research directly related to the comprehensive management of oral health implications for transgender individuals is significantly lacking.

As of 2022, more than 1.6 million individuals in the United States and nearly 25 million globally identify as transgender or gender nonbinary.¹ Compared to the general US population, these individuals are at increased risk of interpersonal violence, homelessness or housing insecurity, poverty, unemployment, and workplace mistreatment.² These social determinants of health become even more harmful when combined with factors like race, ethnicity, and disability, directly contributing to the barriers to care faced by transgender individuals and worsening health outcomes.³ Oral health providers must have a better understanding of the nuances related to the transgender experience to overcome these determinants of health and advance patients’ overall health.

Barriers to Accessing Dental Care

The literature finds that barriers to care often have the most detrimental effect on health outcomes experienced by transgender individuals. Common barriers include fear of discrimination based on a perceived lack of knowledgeable and culturally competent providers, exclusionary healthcare systems and practices, and financial constraints.^2,3 Although few studies uncovered instances of blatant discrimination in which a transgender patient was harassed or denied treatment by a provider, fear of discrimination is the most recurring barrier across studies reviewed.⁴ This fear rarely stemmed from specific interactions with oral health professionals, rather it resulted from the perception that the provider was unknowledgeable in the treatment and support of transgender patients.^4,5

In a separate study that surveyed dental providers, 56% of respondents could not properly define gender.¹ Furthermore, a quarter of respondents improperly defined a trans male or trans female and could not properly relate health disparities commonly experienced by transgender individuals.¹ Table 1 provides definitions of terms relating to transgender individuals.^6,7

Despite the unique healthcare needs of transgender individuals, oral health providers lack the education and cultural competence required to properly care for this population. Patients become acutely aware of inadequate education through instances of incorrect pronoun use, inappropriate questioning, and general lack of knowledge, which reinforces the fear of discrimination.⁴

Coupled with fear of receiving biased treatment, financial constraints also interfere with accessing dental care. Financial insecurity and the inability to afford necessary dental treatment are directly associated with social determinants of health, such as increased incidence of poverty and unemployment. Lack of access to stable employment and thus employer-provided private insurance carriers and inconsistent sources of income create additional barriers for transgender patients.⁵

Oral Health Implications

When gender identity and/​or expression differs from cultural expectations based on the sex assigned at birth, an individual may develop gender dysphoria.⁸ However, not all individuals seek to address this incongruence in the same ways. Multiple processes are used for transitioning, including social and medical mechanisms.

Social mechanisms for transitioning include alterations to one’s social expression such as changing attire or choosing a different name and/​or pronouns. Hormone replacement therapy, surgical intervention, and psychotherapy are mechanisms for medical transitioning, which may have more direct oral health implications.⁸

Social factors, including alcohol consumption, smoking, drug abuse, and eating and stress-related disorders, can significantly impact oral health. Transgender individuals experience significantly elevated rates of alcohol and drug abuse along with smoking, which increases susceptibility for nicotinic stomatitis, edentulism, candidiasis, fibrosis, and oral cancer.⁵

Medical mechanisms for transitioning can incite body dysmorphia, which increases the incidence of eating disorders.^1,8 Anorexia, bulimia, and binge eating are linked to broader nutritional concerns and enamel erosion, increasing caries risk.⁵ Lastly, the prevalence of sexually transmitted infections, specifically human papillomavirus, is significantly higher among transgender individuals compared to the general population.^1,5 This statistic implies an increased risk of oropharyngeal cancers in the same population.⁵

Sustained inflammation resulting from chronic, elevated stress and the effects of inflammation on periodontal health are well-documented in the general population.^5,9 Meyer’s minority stress theory states sexual minorities experience distinct, chronic stressors related to stigmatized sexual orientation and gender identities including victimization, prejudice, and discrimination.^10,11 This theory reinforces the increased susceptibility to periodontal diseases experienced by transgender individuals due to stress-related chronic inflammation.^10,11 Additionally, stress is associated with an increased risk for aphthous stomatitis, herpes labialis, bruxism, and temporomandibular pain/​disorders.⁹

Hormonal irregularities significantly impact the oral health of transgender individuals. However, there is a great need for targeted research on the oral effects of hormone replacement therapy within this population.⁹ Significant research has been conducted on the effects of sex hormones on periodontal health, primarily in menopausal women related to osteoporosis.¹² These findings can be extrapolated and applied to the management and care of transgender individuals undergoing hormone therapy.

Fluctuating hormone levels are associated with an exaggerated inflammatory response, leading to conditions such as pregnancy-induced gingivitis and increased occurrence of pyogenic granulomas.¹² Similar hormonal changes are also associated with an increased risk for diabetes and thus, periodontal diseases. Expanding on these physiological processes, estrogen receptors in osteoblasts exhibit direct action on alveolar bone. Estrogen receptors have also been identified in fibroblasts of the lamina propria and periodontal ligament showing the action of sex hormones on the periodontium.⁹

As with estrogen, testosterone receptors have been identified in periodontal tissue and are associated with maintaining bone density via osteoprotegerin, a bone remodeling marker. Osteoprotegerin inhibits osteoclast formation and activation by neutralizing ligand function, which determines whether resorption or deposition occurs. Furthermore, similar symptoms to those experienced during menopause may be observed: xerostomia, lichen planus, pemphigoid, and Sjögren and burning mouth syndrome.⁹ Many of these symptoms are also related to increased caries susceptibility due to impaired saliva production.

Alternatively, hormone replacement therapy may enhance salivary production in menopausal women, suggesting that its effects could vary significantly between individuals transitioning from male to female and those transitioning from female to male.¹² In the latter population, testosterone therapy drives conversion of testosterone to dihydrotestosterone, which is the androgen responsible for stimulating the development of certain male characteristics including hair production and patterning.¹³

There may be a connection between testosterone therapy and increased risk for diabetes and obesity due to weight redistribution for transgender individuals; however limited research on the subject is available.^14,15 The comorbid, bidirectional relationship between periodontal diseases and diabetes has been well-documented in the general population. Research supports a similar relationship between obesity and periodontal diseases.^14–16

Hormone replacement therapy is often used as an umbrella term representing both feminizing and masculinization modalities.^17,18 Further research is indicated to evaluate the effects not only estrogen and testosterone therapy have on oral health, but also the medications used to block testosterone production during feminization hormone therapy. Typically, spironolactone is prescribed to block androgen receptors thus decreasing testosterone production. Dehydration is a well-documented side effect of spironolactone use, which leads to xerostomia.¹⁹

Conclusion

Despite the need for further research on the oral manifestations of hormone replacement therapy in transgender individuals, the evidence-based principles related to the oral-systemic link in the general population can be used to better care for these patients. The effects of hormonal changes, chronic inflammation, and stress on oral health are widely evident in the general population.

Proper education on the oral health implications experienced by transgender individuals and training on the provision of inclusive, patient-centric care to transgender patients are necessary. This targeted education and training will equip providers to apply general oral health principles more effectively in caring for transgender patients, addressing their unique oral health needs and overcoming barriers to care.

Until this training is more widely accessible, oral health professionals can make a difference by collaborating with transgender individuals’ primary care and specialists. Additionally, creating an open dialogue about a patient’s identity is important to building a productive patient-provider relationship and proving a commitment to improving competence related to gender identity.

References

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17. Mayo Clinic. Feminizing Hormone Therapy. Mayo Clinic. 2024. Available at: mayoclinic.org/​tests-procedures/​feminizing-hormone-therapy/​about/​pac-20385096. Accessed October 9, 2024.
18. Mayo Clinic. Masculinizing Hormone Therapy. Available at mayoclinic.org/​tests-procedures/​masculinizing-hormone-therapy/​about/​pac-20385099. Accessed October 9, 2024.
19. Cleveland Clinic. Spironolactone Tablets. Available at my.clevelandclinic.org/​health/​drugs/ᘋ-spironolactone-tablets. Accessed October 9, 2024.

From Decisions in Dentistry. October/November 2024;10(6):8-13.