Polycystic Ovarian Syndrome and Periodontal Disease: Is There a Link?

What is Polycystic Ovarian Syndrome (PCOS)?
When young women experience infrequent or irregular menstrual cycles, it is quite common for them to receive a diagnosis of PCOS from their physician. PCOS affects 4-21% of reproductive age women and is the leading cause of anovulatory infertility.^1,2 The most commonly used diagnostic criteria states that women with PCOS must present with two of the following: oligo- or amenorrhea, hyperandrogenism, and/or polycystic ovaries as seen by ultrasound.³ Since PCOS is a syndrome, or group of symptoms, several phenotypes exist depending on which combination of symptoms are present. PCOS is largely a result of increased production and circulation of androgens. Normally, androgens are converted to estrogen in the ovaries. This process is regulated by luteinizing hormone and follicle stimulating hormone, hormones that stimulate the ovaries and regulate menstrual cycles – however, disruption of female sex hormones, as seen with PCOS, can cause infertility and symptoms including ovarian cysts, menstrual irregularities, hirsutism, acne, and male-pattern baldness.^3-5 While PCOS has previously been considered a reproductive disorder, it may also be considered an endocrine disorder due to some of its key metabolic components. Insulin resistance is a common feature of PCOS and can result in compensatory hyperinsulinemia. As a result, women with PCOS appear to be at an increased risk of obesity and metabolic syndrome as well as other chronic diseases. PCOS has also been associated with an increased number of risk factors for cardiovascular disease and an increased risk of diabetes, obesity and cancer.^1,6 Additionally, an increased risk of periodontal disease has also been associated with PCOS. Of note, women with PCOS may have several common risk factors for periodontal disease (Table 1).

Table 1

What is the Relationship Between PCOS and Periodontal Disease?
Findings from a systematic review and meta-analysis by Kellesarian et al.⁶ suggests that women with PCOS are at increased risk of periodontal disease. Numerous studies in this review reported greater probing depths among patients with PCOS when compared to controls, and all studies reported positive associations between PCOS and periodontal disease.⁶ Of particular interest is the young age of most participants (15-45 years) as well as the fact that patients with known risk factors for periodontal disease – obesity and/or type II diabetes – were excluded from this analysis. In fact, most studies that have investigated the relationship between PCOS and periodontal disease have excluded women who present with common risk factors of periodontal disease. Thus, this suggests that the higher risk of periodontal disease stems from features intrinsic to PCOS.

Metabolic disruption in PCOS refers to the hormonal imbalances and altered metabolic pathways contributing to insulin resistance and hyperinsulinemia which also contribute to hyperandrogenism in PCOS.⁷ Low-grade chronic inflammation is closely tied to metabolic disruption, and both may contribute to increased periodontal disease risk.^6,8 Several studies reported positive correlations between inflammatory markers (tumor necrosis factor alpha, interleukin (IL)-17A, C-reactive protein, and IL-6) and periodontal parameters (bleeding on probing, plaque index, and probing depth) in women with PCOS.⁶ While these relationships are not fully understood, it has been suggested that insulin resistance, which contributes to low-grade chronic inflammation in PCOS and periodontal disease, may be the linking factor. There is some evidence to demonstrate that PCOS and periodontal disease share a bi-directional relationship based on studies analyzing levels of serum and salivary inflammatory markers in both conditions. (Fig. 1) Thus, maintaining periodontal health may benefit the management of PCOS symptoms.

Fig. 1

Proposed Factors Linking Polycystic Ovarian Syndrome and Periodontal Disease: Evidence suggests
polycystic ovarian syndrome (PCOS), which can contribute to insulin resistance; type II diabetes; and hyperandrogenism, can also cause low-grade chronic inflammation through increased production of
inflammatory cytokines. This could have direct effects on periodontal tissue and lead to periodontal disease.
(Young HE & Ward WE, 2020, unpublished).

Furthermore, elevated levels of female sex hormones have previously been linked to periodontal disease, particularly during pregnancy, puberty, and with use of first-generation oral contraceptives that contained high doses of estrogen.^9-11

Evidence of estrogen and progesterone receptors in gingival tissue have further affirmed the link between these hormones and periodontal health.^12-14 While the exact mechanisms and extent to which these hormones act to influence periodontal health is currently unknown, it seems that high levels of estrogen and progesterone play a role in gingival inflammation and periodontal disease development. Women with PCOS experiencing menstrual irregularities may have elevations in their levels of estrogen and progesterone that could impact oral health, and several studies suggest the links between PCOS and periodontal disease may be hormonal.¹⁵ One study of periodontal health in women with PCOS demonstrated that women newly diagnosed with PCOS had worse periodontal parameters than women being medically treated (with oral contraceptives, metformin, and/or lifestyle modifications) for at least six months.⁸ While this evidence is limited, it suggests that women with PCOS who are receiving a medical treatment such as an oral contraceptive may be at lower risk for periodontal disease than women who are not receiving any medical treatment for their PCOS. This could be caused by promoting regular menstrual cycles and improvements in insulin regulation, contributing to improved oral health and reduced low-grade chronic inflammation. Combined with knowledge suggesting that current low-dose oral contraceptive pills do not increase risk of periodontal disease as reviewed by Preshaw¹⁶, women with PCOS and periodontal disease may see some oral health benefits from being on an oral contraceptive, which will help to regulate their estrogen and progesterone levels, thus regulating androgen levels and potentially insulin. (Fig. 1). It is also worth noting that PCOS may exacerbate risk of periodontal disease during pregnancy. Women with PCOS are at increased risk of gestational diabetes, which could have negative implications for periodontal health such as increased gingival inflammation and bleeding of gums.^17,18 Gestational diabetes is associated with serious maternal and fetal complications, suggesting that in women with PCOS, maintaining periodontal health may also support better pregnancy outcomes.

Guidance for Patients
An important message for women with PCOS and periodontal disease is that managing their PCOS may help prevent periodontal disease development and progression. Given that women with PCOS are at increased risk of obesity, insulin resistance and type II diabetes – all risk factors for periodontal disease – preventing and managing these conditions can improve their oral health as well as their overall health. Reinforcing the idea that oral health and overall health are interconnected may be a good place to start, and the following points can guide your patients:

• Encourage patients to regularly follow-up with their doctors regarding their PCOS and insulin resistance/diabetes status. Good glycemic control is important for preventing
  complications resulting from diabetes and periodontal disease.
• Promote a healthy lifestyle. Maintaining a healthy diet and participating in regular exercise is frontline treatment for PCOS. Also, there is strong evidence that a healthy diet can play a key role in periodontal health.¹ Recommendations for exercise and nutrition for PCOS are aligned with the general Canadian guidelines for exercise and nutrition; links to these resources can be found below.
• Encourage good oral hygiene practices and regular dental visits to limit chronic inflammation associated with periodontal disease, as increased chronic inflammation could lead to increased risk of chronic diseases to which women with PCOS are already vulnerable.
• Oral contraceptive use does not appear to increase risk of periodontal disease. Women with PCOS can be assured that their oral contraceptive use should not negatively affect their periodontal health and could potentially provide some benefit by stabilizing their estrogen and progesterone levels which has the potential to reduce periodontal swelling and inflammation.
• Encourage women to continue regular dental appointments during and after pregnancy. Women with PCOS are at increased risk of gestational diabetes that may also compromise periodontal health.

There are several resources that may be helpful when learning about PCOS or referring your patients to materials. Firstly, we recommend referring to the International evidence-based guideline for the assessment and management of polycystic ovary syndrome.¹ Additionally, the following webpages are recommended:

Oral Health welcomes this original article.

References

1. Teede, H. et al. International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018. National Health and Medical Research Council 1–198 (2018).
2. Lizneva, D. et al. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertil. Steril. 106, 6–15 (2016).
3. Fauser, B. C. J. M. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil. Steril. 81, 19–25 (2004).
4. Carey, A. H. et al. Evidence for a single gene effect causing polycystic ovaries and male pattern baldness. Clin. Endocrinol. (Oxf). 38, 653–658 (1993).
5. Fauser, B. C. J. M. et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil. Steril. 97, (2012).
6. Kellesarian, S. V. et al. Association between periodontal disease and polycystic ovary syndrome: A systematic review. Int. J. Impot. Res. 29, 89–95 (2017).
7. Baptiste, C. G., Battista, M. C., Trottier, A. & Baillargeon, J. P. Insulin and hyperandrogenism in women with polycystic ovary syndrome. Journal of Steroid Biochemistry and Molecular Biology vol. 122 42–52 (2010).
8. Porwal, S., Tewari, S., Sharma, R. K., Singhal, S. R. & Narula, S. C. Periodontal status and high-sensitivity C-reactive protein levels in polycystic ovary syndrome with and without medical treatment. J. Periodontol. 85, 1380–1389 (2014).
9. Güncü, G. N., Tözüm, T. F. & Ça ˇglayan, F. Effects of endogenous sex hormones on the periodontium–Review of literature. Aust. Dent. J. 50, 138–145 (2005).
10. Tilakaratne, A. et al. Periodontal disease status during pregnancy and 3 months post-partum, in a rural population of Sri-Lankan women. J. Clin. Periodontol. 27, 787–792 (2000).
11. Tilakaratne, A. et al. Effects of hormonal contraceptives on the periodontium, in a population of rural Sri-Lankan women. J. Clin. Periodontol. 27, 753–757 (2000).
12. Domingues, R. S. et al. Influence of combined oral contraceptives on the periodontal condition. J. Appl. Oral Sci. 20, 253–259 (2012).
13. Vittek, J., Gordon, G. G., Munnangi, P. R., Rappaport, S. C. & Southren, A. L. Biosynthesis of 17ß-estradiol and its binding to specific receptors in human gingiva. J. Dent. Res. 62, 341–343 (1983).
14. Asnani, K. P., Hingorani, D., Kheur, S., Deshmukh, V. L. & Romanos, G. E. Expression of nuclear receptors of gingiva in polycystic ovarian syndrome: A preliminary case study. Aust. Dent. J. 59, 252–257 (2014).
15. Kim, J. & Amar, S. Periodontal disease and systemic conditions: A bidirectional relationship. Odontology vol. 94 10–21 (2006).
16. Preshaw, P. M. Oral contraceptives and the periodontium. Periodontol. 2000 61, 125–159 (2013).
17. Abariga, S. A. & Whitcomb, B. W. Periodontitis and gestational diabetes mellitus: A systematic review and meta-analysis of observational studies. BMC Pregnancy Childbirth 16, (2016).
18. Lo, J. C. et al. Increased prevalence of gestational diabetes mellitus among women with diagnosed polycystic ovary syndrome: A population-based study. Diabetes Care 29, 1915–1917 (2006).

About the Authors

Hannah Young holds a BKin from the University of the Fraser Valley and is currently a MSc candidate in the Faculty of Applied Health Sciences at Brock University. Hannah’s research focuses on women’s health and periodontal disease for which she was awarded an Ontario Graduate Scholarship.

Wendy Ward is a Professor and Canada Research Chair in the Department of Kinesiology in the Faculty of Applied Health Sciences at Brock University. Her team’s overall research goal within the Nutrition, Bone and Oral Health Research Group is to develop dietary strategies that help protect against osteoporosis and related fractures while also understanding the complex relationships with other health conditions such as periodontal disease.