{"paper_id":"681d2fe9-0229-4fc0-bd87-f4694b6f27a5","body_text":"©zubada/iStock/Getty Images Plus\nIntroduction\nOne in ten women of reproductive age in the \nUK suffer from endometriosis1 and it is the \nsecond most common gynaecological condition \nin the UK.2 Endometriosis affects 1.5 million \nwomen; a similar number of women are affected \nby diabetes.3 Y et, endometriosis is rarely spoken \nabout, with many individuals not having heard \nof the disease and not aware of the impact it \ncan have on someone’s quality of life. Being \ndiagnosed with endometriosis myself and \nrecently becoming a qualified dental hygienist, I \nam fascinated by research that has been carried \nout about a possible link between periodontal \ndisease and endometriosis.  \nWhat is endometriosis? \nEndometriosis is a chronic condition which \nresults from an anomalous accumulation of \nendometrial cells outside the uterus, when these \ncells are usually found inside the uterus. This \ncauses a chronic inflammation detrimental \nto the female reproductive system, which is \ncharacterised by intense intestinal pain.\nSigns and symptoms \nEndometriosis can also have a significant impact \non an individual’s personal life, such as causing:\n   Chronic pain\n   Fatigue/lack of energy\n   Depression/isolation\n   Problems with a couple’s sex life/relationships\n   An inability to conceive\n   Difficulty in fulfilling work and social \ncommitments.4\nDental hygienist Laura Snewin1 explores the links between \nperiodontal disease and a chronic gynaecological condition.\nEndometriosis and \nperiodontal disease\nAuthor information\n1Laura Snewin began dental nursing \nin 2013 and graduated as a dental \nhygienist from Eastman Dental \nHospital in 2020. She is now working in \nLewes and Uckfield in East Sussex. \nDue to these signs and symptoms being \ncommon with other conditions, it is easy for \nendometriosis to be misdiagnosed as other \nconditions such as interstitial cystitis, irritable \nbowel syndrome (IBS) and painful menstrual \ncramps. \nAssociated conditions which are linked to \nwomen with endometriosis include:\n   Allergies\n   Asthma\n   Chemical sensitivities\n   Autoimmune diseases\n   Chronic fatigue syndrome\n   Fibromyalgia\n   Breast cancer\n   Ovarian cancer.5 \nTreatment\nThere is no cure for endometriosis, but there \nare options to have it removed and to reduce \nthe regrowth of endometriosis. A common \nprocedure to remove endometriosis is \nthrough having a laparoscopy – this is \nalso the general way to diagnose \nendometriosis if it doesn’t \nshow up on a CT scan. The \nendometriosis can be \nremoved using a laser \nor surgically removed \nduring the laparoscopy. \nOther treatments that \nare used to suppress \nthe endometriosis \ninclude the Mirena \nCoil (a hormonal \nintrauterine \ndevice) and \ncertain \ncontraceptive \npills. Ultimately, \na lot of women \ndecide to go \nthrough with a \nhysterectomy. A \nlot of women are also \nadvised to become pregnant to help relieve \ntheir symptoms, although endometriosis can \ncause infertility, and this may not be appropriate \non an individual basis to help get relief from \nendometriosis. \nEndometriosis and periodontal \ndisease \nEndometriosis and periodontal disease are \nchronic, inflammatory diseases that are \nmore common in individuals with systemic \nautoimmune disorders, with both being found \nto alter immune modulators. Thomas et al.6 \nstudied the association between endometriosis \nand periodontal disease which may share a \ncommon pathogenesis. The proportion of \n12  BDJ Team www.nature.com/BDJTeam\nFEATURE\n© 2021 British Dental Association. All rights reserved.\n\nhttps://doi.org/10.1038/s41407-021-0527-x  \nwomen with severe periodontitis was higher \namong women with endometriosis. There was \na commonality of altered levels of immune \nmodulators in patients with endometriosis \nand periodontal disease. Oxidative stress of \nthe periodontal disease may enhance the stress \nfor endometriosis. The immune dysregulation \nseen in periodontal disease can be the reason \nfor the local immune deficiency propagating \nendometriosis.7 However, this case-control \nstudy screened 25 women with endometriosis \nand 25 women without endometriosis for \nperiodontal diseases; further studies with larger \ncohorts of endometriosis are required to provide \nevidence regarding the association between \nendometriosis and periodontal disease. \nIn addition, increased levels of cytokines \nand factors such as IL (interleukin)-1beta, \nIL-6, IL-8, tumor necrosis factor-alpha, \nvascular endothelial growth factor, RANTES \n(regulated upon activation, normal T cell \nexpressed and secreted), and monocyte \nchemoattractant protein-1, have been \ndemonstrated in the peritoneal fluid of women \nwith endometriosis.8,9,10,11,12,13,14,15 Chronic \nperiodontitis is linked to a chronic systemic \ninflammatory burden secondary to the systemic \ndissemination of periodontal pathogenic \nbacteria, their products (eg lipopolysaccharides), \nand locally-produced inflammatory mediators \n(ie, IL-1β, IL-6, TNF-α, prostaglandin E2, and \nthromboxane B2).16,17,18\nImportance\nAlthough there are only a handful of \nstudies, and there is still a lot to learn about \nendometriosis, it is important to educate \npatients with endometriosis about the link with \nperiodontal disease. Having good oral hygiene is \nimportant as it has many links with the human \nbody, and improved oral hygiene could lead to \nan improvement in endometriosis signs and \nsymptoms.\nCaring for patients holistically, it is always \nbeneficial to be mindful of what each patient \nmay be going through on an individual \nbasis. Various medical conditions such as \nendometriosis can have a huge impact on a \nare chronic, inflammatory diseases that \n‘Endometriosis and periodontal disease \nsystemic autoimmune diseases...'\nare more common in individuals with \npatient not only physically, but also mentally. \nWhen bearing this in mind treating each \npatient, try to have brief discussions with your \npatients and ask them how their day-to-day life \nis. Y ou could suggest that they use oral aids such \nas interdental brushes and floss while watching \ntelevision, for example, if they are experiencing \nan endometriosis episode, which may make it \neasier and more comfortable for the patient to \ncarry out efficiently. \nAlthough it may seem limited as to what \ndental care professionals can do to support \npatients with endometriosis, it can be beneficial \nto have a discussion with patients in regard to \nthe link between endometriosis and periodontal \ndisease. Education and motivating patients \nwith the importance of plaque removal is \nour ‘bread and butter’ , promoting health and \npreventing disease for all our patients. This may \nindirectly help patients with managing their \nendometriosis, and we can hope that more \nresearch is carried out investigating the possible \nlink between both conditions. \nReferences\n1. Rogers P A, D’Hooghe T M, Fazleabas \nA et al. Priorities for endometriosis \nresearch: recommendations from an \ninternational consensus workshop. Reprod Sci \n2009; 16: 335-346\n2. University College London Hospitals. General \ninformation about endometriosis. Available \nat: https://www.uclh.nhs.uk/our-services/\nfind-service/womens-health-1/gynaecology/\nendometriosis/general-information-about-\nendometriosis (accessed January 2021).\n3. Diabetes UK. Diabetes in the UK 2012 (April \n2012). Available at: https://www.diabetes.org.\nuk/professionals/position-statements-reports/\nstatistics/diabetes-in-the-uk-2012 (accessed \n30 January 2021).\n4. Endometriosis UK. Understanding \nendometriosis. Available at: https://\nendometriosis-uk.org/understanding-\nendometriosis (accessed January 2021).\n5. Smith L. What to know about endometriosis. \nMedical News Today, 4 January 2018. \nAvailable at: https://www.medicalnewstoday.\ncom/articles/149109 (accessed 30 January \n2021).\n6. Thomas V , Uppoor A S, Pralhad S, Naik D \nG. Towards a common etiopathogenesis: \nperiodontal disease and endometriosis. J \nHum Reprod Sci 2018; 11: 269-273.\n7. Onur I. The relationship between periodontal \ndisease and endometriosis. EndoNews, 12 \nFebruary 2019. Available at: https://www.\nendonews.com/the-relationship-between-\nperiodontal-disease-and-endometriosis \n(accessed January 2021).\n8. Hammond M G, Oh S T, Anners J, Surrey E \nS, Halme J. The effect of growth factors on the \nproliferation of human endometrial stromal \ncells in culture. Am J Obstet Gynecol 1993; \n168: 1131-1136.\n9. Ryan I P , Tseng J F , Schriock E D, Khorram \nO, Landers D V , Taylor R N. Interleukin-8 \nconcentrations are elevated in peritoneal fluid \nof women with endometriosis. Fertil Steril \n1995; 63: 929-932.\n10. Lebovic D I, Bentzien F , Chao V A, Garrett \nE N, Meng Y G, Taylor R N. Induction of \nan angiogenic phenotype in endometriotic \nstromal cell cultures by interleukin-1b. Mol \nHum Reprod 2000; 6: 269-275.\n11. Iwabe T, Harada T, Sakamoto Y et al. \nGonadotropin-releasing hormone agonist \ntreatment reduced serum interleukin-6 \nconcentrations in patients with ovarian \nendometriomas. Fertil Steril 2003; 80: \n300-304.\n12. Wieser F , Fabjani G, Tempfer C et al. \nAnalysis of an interleukin-6 gene promoter \npolymorphism in women with endometriosis \nby pyrosequencing. J Soc Gynecol Investig \n2003; 10: 32-36.\n13. Wu M Y , Ho H N. The role of cytokines in \nendometriosis. Am J Reprod Immunol 2003; \n49: 285-296.\n14. Dmowski W P , Gebel H M, Rawlins R G. \nImmunologic aspects of endometriosis. \nObstet Gynecol Clin North Am 1989; 16: \n93-103.\n15. Y ang W-C, Chen H-W , Au H-K et al. Serum \nand endometrial markers. Best Pract Res Clin \nObstet Gynaecol 2004; 18: 305-318. \n16. Offenbacher S, Beck J D. A perspective on \nthe potential cardioprotective benefits of \nperiodontal therapy. Am Heart J 2005; 149: \n950-954.\n17. Loos B G. Systemic markers of inflammation \nin periodontitis. J Periodontol 2005; 76: \n2106-2115.\n18. D’ Aiuto F , Graziani F , Tete S, Gabriele \nM, Tonetti M S. Periodontitis: from \nlocal infection to systemic diseases. Int J \nImmunopathol Pharmacol 2005; 18(3 Suppl): \n1-11.\nFEATURE\nwww.nature.com/BDJTeam BDJ Team  13\n© 2021 British Dental Association. All rights reserved.","source_license":"CC0","license_restricted":false}