Sex differences in dental caries experience: clinical evidence, complex etiology

A sex difference in oral health has been widely documented through time and across cultures. Women's oral health declines more rapidly than men's with the onset of agriculture and the associated rise in fertility. The magnitude of this disparity in oral health by sex increases during ontogeny: from childhood, to adolescence, and through the reproductive years. Representative studies of sex differences in caries, tooth loss, and periodontal disease are critically reviewed. Surveys conducted in Hungary, India, and in an isolated traditional Brazilian sample provide additional support for a significant sex bias in dental caries, especially in mature adults. Compounding hormonal and reproductive factors, the sex difference in oral health in India appears to involve social and religious causes such as son preference, ritual fasting, and dietary restrictions during pregnancy. Like the sex difference in caries, tooth loss in women is greater than in men and has been linked to caries and parity. Results of genome wide association studies have found caries susceptible and caries protective loci that influence variation in taste, saliva, and enamel proteins, affecting the oral environment and the micro-structure of enamel. Genetic variation, some of which is X-linked, may partly explain how sex differences in oral health originate. A primary, but neglected, factor in explaining the sex differential in oral health is the complex and synergistic changes associated with female sex hormones, pregnancy, and women's reproductive life history. Caries etiology is complex and impacts understanding of the sex difference in oral health. Both biological (genetics, hormones, and reproductive history) and anthropological (behavioral) factors such culture-based division of labor and gender-based dietary preferences play a role.