“Menopause and its associated hormonal changes can make life extremely difficult”

Iveta Ramonaite, Dental Tribune International

Wed. 29 October 2025

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Dr John Viviano, a dentist and credentialled diplomate of the American Board of Dental Sleep Medicine, has dedicated his career to managing sleep disordered breathing and bruxism. As clinical director of the Sleep Disorders Dentistry Research and Learning Center, near Toronto in Canada, he combines clinical expertise with education and research to advance understanding of sleep medicine in dentistry. In this interview with Dental Tribune International, he discusses how menopause affects women’s oral and sleep health and why greater awareness and collaboration across disciplines are essential.

According to Dr John Viviano, many dentists feel unprepared to discuss menopause with patients, highlighting the need for better education for dental teams. (Image: Dr John Viviano)

Dr Viviano, from your perspective as both a dentist and an expert in sleep apnoea medicine, how does menopause affect women’s overall oral and sleep health?
During menopause, there is a reduction in oestrogen and progesterone, and this leads to a host of changes that go far beyond oral health and include sleep disturbances, mood disorders and gut imbalances. There may be an increase in periodontal disease, even though hygiene habits and plaque load remain unchanged, as well as dry mouth, altered taste, burning mouth syndrome, caries, temporomandibular disorder, and altered bone metabolism and density.

Sleep disturbances include snoring, upper airway resistance syndrome, sleep apnoea and insomnia, along with mood, anxiety and depression issues. Clearly, menopause and its associated hormonal changes can make life extremely difficult. These patients need awareness, compassion, understanding and guidance. Dentists and their teams are ideally positioned to participate in this initiative and refer these patients appropriately.

In your experience, what has been the most surprising insight about the intersection of menopause, oral health and sleep medicine?
I suppose that the most surprising discovery for me has been realising that the tools we use daily to screen for sleep disorders are biased towards men. In the past, research projects were often geared towards men, and therefore, the results for women do not accurately represent the female population.

An example of this is sleep apnoea. Screening questionnaires have been found to be biased in identifying men but miss many women with sleep apnoea. The reason for this is that females present differently and answer questions differently, and thus are often underdiagnosed. Thankfully, current research is addressing this by providing guidance on how to modify the scales of commonly used tools and by introducing new screening instruments, such as the General Practice Sleep Scale developed in Australia, which better represents the female population.

Do you think that the oral changes and sleep disturbances associated with menopause are often overlooked in clinical practice?
Despite their high prevalence, menopause-related oral and sleep issues are often under-recognised in dentistry. Barriers include patient stigma and uncertainty about relevance to the mouth, limited formal training on menopause in dental curricula and the absence of standardised screening prompts in dental and medical histories.

Regarding sleep disordered breathing, women with sleep apnoea or upper airway resistance syndrome may present with insomnia, fatigue, headaches or mood changes rather than the classic loud snoring and sleepiness typically found in men suffering from sleep disordered breathing. These differences in presentation contribute to delayed referral and misdiagnosis or underdiagnosis.

Similarly, oral dryness, changes in taste and burning mouth syndrome may be attributed to stress alone, without consideration of menopause-related hormonal causes. Closing this gap requires both normalising the topic through open conversation and simple chairside prompts as well as building clear referral pathways to healthcare providers who can establish a medical diagnosis and prescribe appropriate care.

Sleep disturbances are frequently reported during menopause. How do these changes relate to oral conditions such as bruxism, temporomandibular disorder or sleep apnoea?
Of course, the menopause journey is different for everyone, but as a rough guide, beginning in the mid-40s, watch for early xerostomia and mild periodontal changes. From the ages of 50 to 54, xerostomia peaks and increased gingival inflammation is common. From 55 to 59, burning mouth syndrome, attachment loss, bone loss, sleep and mood disturbances, bruxism and temporomandibular disorder become common. After this, tooth mobility and bone density changes are often seen.

“Once a dentist or dental auxiliary is aware of the impact of menopause on oral health and sleep, it should be malpractice to ignore it.”

Is menopause currently addressed in dental or sleep medicine training programmes?
Unfortunately, there is very little—if any—coverage of this topic in the dental curriculum, and all too often, even medical physicians specialising in this topic, such as obstetricians and gynaecologists, still have outdated ideas about the menopause transition and do not provide the support these patients need to help them navigate the changes their bodies are experiencing. These patients would benefit from both dentists and physicians being more knowledgeable about the menopause transition and how it affects female patients.

As a male dentist with 42 years in practice and many thousands of continuing education hours, aside from the recent research that I have done in this area, I had never heard anything about the impact of hormonal changes during menopause on oral health, sleep disturbances or mood changes. How could I possibly feel comfortable speaking to a female patient about these issues? Education must first begin with dentists and their teams—then thoughtful, empathetic, educated conversations can take place.

How can interprofessional collaboration—between dentists, gynaecologists and sleep medicine specialists—enhance patient care for women experiencing menopause?
Ever since I completed this deep dive into the subject of menopause, I have looked at my female patients approaching the age of 50 very differently. I now have a better understanding of their sleep issues and concerns and know that their reported symptoms may not always align with the severity of their sleep condition.

Once a dentist or dental auxiliary is aware of the impact of menopause on oral health and sleep, it should be malpractice to ignore it. Incorporating awareness and screening programmes into the general dental practice will benefit half of the patient base in most practices. It simply does not make sense to ignore menopause. Patients whose symptoms suggest that menopause may be influencing their oral or sleep health should be referred to the appropriate healthcare provider to best manage their needs.

How do you envision the role of dental professionals evolving as awareness of menopause-related health issues continues to grow?
Dentists and their teams should develop the necessary knowledge to feel truly comfortable having these discussions chairside. These discussions should be as natural and routine as conversations about regular periodontal maintenance. This starts with coverage of menopause across all dental curricula, including hygiene and assisting, which would produce better-educated dentists and auxiliaries. This enhanced level of knowledge, along with the regular implementation of awareness and screening protocols in general dental practice, would go a long way in helping these patients. This, I believe, is the future.

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