Individuals with PCOS have a 1.3x increased risk of gum disease or periodontal disease (PDD) than individuals without the condition.[1]  In this article we explore the link between PCOS and Gum Disease.

Gum disease is a common but serious infection that affects the soft tissue around the teeth.[2]  In its early stages, it is referred to as gingivitis, reversible inflammation of the gums with redness, swelling and bleeding during brushing.  As it advances it becomes PDD, involving irreversible damage such as gum recession, periodontal pockets and potential tooth loss.

Gum disease occurs when plaque or tartar builds up on the surfaces of the teeth and results in a loss of periodontal tissue (gum) attachment and alveolar bone matter, the bone that forms the socket supporting your teeth.[3],[4]  Symptoms can include:[5],[6]

• Discoloration that is bright red, dark red or dark purple (healthy gums are light pink, dark pink or brown depending on the individual);

• Bleeding from the gums when brushing teeth;

• Pain and/or discomfort when touched or chewing;

• Receding gums that pull away from the teeth (healthy gums fit snugly around teeth);

• Loose teeth or loss of teeth;

• Pus between the teeth and gums; and

• Changes in the way teeth fit together (the “bite”) or spaces between the teeth that look like black triangles (“periodontal pockets”).

Once diagnosed, periodontal disease is classified based on stage of progression between I and IV (with IV being the most severe) based on severity of Clinical Attachment Loss (CAL), radiographic bone loss, tooth loss and degree of localization.[7]  Further to this classification it is assigned a grade of A, B or C (with C being the most rapid) for the potential for disease progression and disease outcome based on historical pace of progression and certain modifiers including use of tobacco and diabetes.[8] 

In addition to tooth loss, the bacteria that cause periodontal disease can enter the blood stream and cause a range of potential health complications, including:[9],[10]

• Respiratory disease including asthma, chronic obstructive pulmonary disease (COPD) and pneumonia;

• Rheumatoid arthritis;

• Cardiovascular diseases (CVD), including carotid atherosclerosis/coronary artery disease (CAD), the reduction of blood flow to the brain and heart, myocardial infarction/heart attack and hypertension/high blood pressure;

• Chronic kidney disease (CKD), progressive damage or loss of function of the kidneys;

• Cancer;

• Dementia including Alzheimer’s Disease (AD);

• Pregnancy complications including pre-term birth, low birth weight and preeclampsia; and

• Diabetes, with a two-way relationship between control of blood sugar and oral health.

  
  

PCOS is linked with increased risk of PDD through a number of different mechanisms, many of which are linked to the immune response, including:[11],[12],[13],[14]

• Elevated androgens and elevated estrogen resulting in a disruption to the local subgingival microbiota, the microorganisms that live beneath the gums and in the saliva;

• Elevated estrogen can also decrease the structural effectiveness of the gum by depleting stores of folate (one of the B Vitamins) and interfering with the cell lining (epithelium);

• Insulin resistance (or its progression to Type II diabetes) leads to an increase in reactive oxygen species (ROS) and pro-inflammatory cytokines leading to chronic low-grade inflammation.  ROS are unstable molecules or “free radicals” that react easily with other molecules in a cell and can cause damage to DNA, RNA and proteins and cause cell death.[15]  Pro-inflammatory cytokines are small proteins that activate immune cells as part of the immune response with the aim of fighting pathogens, organisms that cause disease;[16]

• Insulin resistance (or its progression to Type II diabetes) leads to an increase in advanced glycation end (AGE) products and therefore oxidative stress in gum tissue.  AGE products are proteins or fats that become glycated, gaining an extra sugar molecule, after exposure to sugars.[17]  Oxidative stress occurs where there is an imbalance of free radicals in your body that can cause cell damage throughout the body;[18]

• Insulin resistance decreases osteroprotegerin (OPG) expression and increases receptor activator of nuclear factor-κB ligand (RANKL) expression, resulting in accelerated bone resorption and therefore reduced bone density, including the alveolar bone that supports the teeth.  OPG’s role is to regulate bone remodeling and therefore is a key determinant of bone mass;[19] and

• Obesity leads to an increase in macrophage infiltration and an increase in pro-inflammatory cytokines leading to chronic low-grade inflammation.  Macrophage infiltration is the migration of a type of white blood cell to an area of the body as part of the immune response.[20]

   

Other risk factors for gum disease include:[21]

• Genetics;

• Poor oral hygiene;

• Poor nutrition, including low vitamin C;

• Use of tobacco or recreational drugs;

• Use of alcohol, especially heavy use or alcohol use disorder;

• Certain medications that cause dry mouth or gum changes;

• Hormonal changes, including around pregnancy, menopause and use of hormonal contraceptives;

• Health conditions that lower immunity, such as leukemia, HIV/AIDS and treatment for cancer; and

• Other diseases such as diabetes, rheumatoid arthritis and Crohn’s disease.

Gum disease is initially diagnosed through a combination of visual inspection and clinical tests at a regular dental or hygienist appointment.  Tests to clinically evaluate the disease and its progression include periodontal charting and dental X-rays.

Gum disease at the earliest stages (gingivitis) is reversible with the proper treatment:[22]

• Improved dental hygiene at home;

• Dental prophylaxis, routine cleaning at regular intervals to remove the plaque and tartar from the surface of your teeth; and

• Scaling and root planing, a dental “deep clean” that extends below the gum line to remove plaque and tartar on the surface of the roots of your teeth.

As the disease progresses to PDD, further treatments may be used:[23]

• Antibiotics placed in the space between the gums and teeth; and/or

• Laser periodontal therapy, the use of a tiny laser to remove infected tissue and kill bacteria.

More advanced PDD, where there is damage to the gums and bone, may require more invasive treatments, including:[24]

• Pocket reduction surgery or flap surgery, a procedure to remove the plaque and tartar from the roots of your teeth and reshape the damaged bone to reduce the opportunity for bacteria to thrive;

• Bond grafting, a procedure to rebuild areas of bone that have been damaged using your bone, synthetic bone or donated bone as a scaffold;

• Gum grafting, a procedure to rebuild areas of gum that have been damaged using your own tissue, synthetic tissue or donated tissue; and

• Guided tissue regeneration, a procedure to enable bone growth/repair by using a membrane to prevent gum tissue from growing where bone should be.

Lifestyle modifications, including smoking cessation and more effective control of diabetes/insulin resistance, are part of a comprehensive disease management plan.

Reviewed by Christine Horton CHD RHD FAAOSH CH-OSE, expert on oral health and PCOS Health Coach

Source/(s)

[1] https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2023.1008675/full

[2] https://www.mayoclinic.org/diseases-conditions/periodontitis/symptoms-causes/syc-20354473

[3] https://my.clevelandclinic.org/health/treatments/10907-gum-disease-treatment

[4] https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis

[5] https://www.mayoclinic.org/diseases-conditions/periodontitis/symptoms-causes/syc-20354473

[6] https://my.clevelandclinic.org/health/treatments/10907-gum-disease-treatment

[7] https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis

[8] https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis

[9] https://www.mayoclinic.org/diseases-conditions/periodontitis/symptoms-causes/syc-20354473#

[10] https://www.ada.org/resources/ada-library/oral-health-topics/periodontitis

[11] https://pmc.ncbi.nlm.nih.gov/articles/PMC5972486/

[12] https://karger.com/mpp/article/33/2/148/894195/Impact-of-Polycystic-Ovary-Syndrome-on-Periodontal

[13] https://pmc.ncbi.nlm.nih.gov/articles/PMC10652058/

[14] https://pmc.ncbi.nlm.nih.gov/articles/PMC2758498/

[15] https://www.cancer.gov/publications/dictionaries/cancer-terms/def/reactive-oxygen-species

[16] https://www.thermofisher.com/ie/en/home/life-science/cell-analysis/cell-analysis-learning-center/immunology-at-work/proinflammatory-cytokines-overview.html

[17] https://www.ahajournals.org/doi/10.1161/circulationaha.106.621854#

[18] https://my.clevelandclinic.org/health/articles/oxidative-stress

[19] https://arthritis-research.biomedcentral.com/articles/10.1186/ar2165

[20] https://pubmed.ncbi.nlm.nih.gov/8044947/

[21] https://www.mayoclinic.org/diseases-conditions/periodontitis/symptoms-causes/syc-20354473#

[22] https://my.clevelandclinic.org/health/treatments/10907-gum-disease-treatment

[23] https://my.clevelandclinic.org/health/treatments/10907-gum-disease-treatment

[24] https://my.clevelandclinic.org/health/treatments/10907-gum-disease-treatment