Endometriosis Associated with Periodontal Disease: Two Case Reports

This case report details a 40-year-old woman who reported to the Periodontics Department of King Saud Medical City in Riyadh, Saudi Arabia, with primary symptoms of gingival bleeding and tooth mobility. The patient’s medical history included endometriosis, a gynecological disorder managed with oral progestin. The patient was a 40-year-old woman with a medical history of endometriosis, diagnosed in 2019 and managed with Visanne 2 mg daily. The patient indicated significant alterations in the oral cavity after the diagnosis of endometriosis. Upon examination, the patient had edematous gingiva, a spongy texture, and bulbous papillae. The documented periodontal metrics were plaque score, gingival score, probing pocket depth, and clinical attachment loss. The patient had widespread deep periodontal pockets measuring 4 to 8 mm and clinical attachment loss ranging from 2 to 7 mm, with Grade 1 mobility seen in the majority of the teeth. A plaque score of 45% and a bleeding score of 98% were recorded. The radiographic assessment indicated a widespread horizontal bone loss of up to 40%, with the extraction of the upper first teeth and many restorations. The patient was diagnosed with endometriosis in 2019 and received treatment with Visanne at a dosage of 2 mg per day. The patient indicated significant alterations in her mouth cavity after a diagnosis of endometriosis. The patient arrived to the Periodontics Department in 2020 with primary concerns of gingival hemorrhage and tooth mobility. The patient received a diagnosis of Stage III Grade C widespread periodontitis after clinical and radiological assessments. The patient’s treatment included scaling and root planning, along with oral hygiene instructions and reinforcement. She was advised to continue endometriosis treatment and schedule regular dental examinations to monitor her oral health. A 40-year-old woman visited the Periodontics Department at King Saud Medical City, Riyadh, KSA, in 2020, complaining of bleeding gums and shifting teeth. She noticed changes in her oral cavity following her diagnosis of Stage III endometriosis, confirmed by laparoscopy in 2019, and managed with a daily 2 mg dose of Visanne, an oral progestin used to alleviate symptoms of endometrial lesions. The extraoral examination revealed no abnormalities. The intraoral examination showed edematous gingiva with a spongy texture and bulbous papillae. Periodontal metrics included plaque index, gingival index, probing depth, and clinical attachment loss. Generalized periodontal pockets measured 4 to 8 mm, with clinical attachment loss between 2 and 7 mm, and Grade 1 mobility in most teeth. A plaque score of 45%, a bleeding score of 98% [ Figure 1 ], and up to 40% generalized horizontal bone loss were observed, along with excised upper first teeth and several restorations. The 2014 radiograph, taken before the endometriosis diagnosis, indicated a 40% reduction in horizontal bone support over six years. Periodontal diagnosis was generalized. Periodontitis Stage III Grade C. Clinical and Radiographic images of Case 1 A 27-year-old woman reported to the Periodontics Department at King Saud Medical City, Riyadh, KSA, in 2021, with the primary complaint of “My gums are bleeding and I have pain in my lower teeth.” The patient said that her gums had consistently shown bleeding. The patient’s medical history includes confirmed Stage IV endometriosis, diagnosed in 2018 via laparoscopy. The treatment consists of Visanne 2 mg daily and a monthly injection of Leuprolide Acetate 7.5 mg/2 ml, a synthetic gonadotropin-releasing hormone utilized for men with prostate cancer and women with endometriosis. The extraoral examination showed no abnormalities or diseases present. The clinical intraoral examination indicated edematous gingiva, spongy texture, bulbous papillae, and widespread blood clots. The documented periodontal metrics were plaque index, gingival index, probing depth, and clinical attachment loss [ Figure 2 ]. Clinical and Radiographic images of Case 2 Generalized deep pockets of 4–6 mm and clinical attachment loss of 2–4 mm were seen. The plaque and bleeding scores were 45% and 100%, respectively. The radiographic examination revealed up to 20% widespread horizontal bone loss associated with removed lower first molars and several carious teeth. Diagnosis of Periodontal Disease Generalized Periodontitis Stage II Grade B. The surgical phase includes pocket reduction procedures, osseous recontouring, and, if necessary, guided tissue regeneration. Restoration of edentulous areas with fixed partial dentures or dental implants. The patients were monitored for six months after the first therapy. Throughout this time, the patient’s oral hygiene and periodontal metrics showed substantial improvement. The patients indicated decreased hemorrhaging and improved dental health.

Periodontitis is a chronic inflammatory condition caused by host-mediated inflammation due to microbes, leading to the loss of periodontal attachment. The illness involves the interaction of subgingival bacteria, host immune and inflammatory responses, and environmental factors. Recent data show that chronic periodontitis affects about 60–65% of North Americans aged 65 and older. Endometriosis is a nonmalignant inflammatory condition with estrogen-dependent endometrial tissue outside the uterus, common among women. It primarily manifests as infertility, dyspareunia, and persistent pelvic pain, often found in the pelvic peritoneum, rectovaginal septum, or ovaries. Confirming the diagnosis pathologically requires surgical intervention. The prevalence of endometriosis is underestimated due to the necessity of laparoscopy, the preferred diagnostic method. This condition affects at least 10% of women of reproductive age, typically diagnosed between 25 and 29 years. Rouzi et al. (2013)[ 1 ] studied the incidence of endometriosis in women undergoing gynecological laparoscopy at a university hospital in Jeddah, Saudi Arabia, finding it in 11.1% of 190 laparoscopies performed.

Periodontal disease differs fundamentally from endometriosis, making any comparison seem speculative. However, given their shared pathophysiology, the increased prevalence of severe periodontal disease in individuals with endometriosis is significant. Observations of moderate-to-severe periodontitis and elevated bleeding ratings in patients align with previous research outcomes. More extensive cohort studies at various stages are needed to provide epidemiological support for this correlation. Nil.

The link between systemic diseases and oral health is well established. The patient’s endometriosis may have triggered or worsened her periodontitis. Hormonal fluctuations associated with endometriosis can affect the oral cavity, causing inflammation and increased susceptibility to periodontal disease. Oral progestin used for treating endometriosis may have further aggravated her periodontal condition. Endometriosis is a complex gynecological disorder that presents substantial treatment challenges. It is classified into four stages based on lesion quantity and infiltration extent: Minimal (Stage I), Mild (Stage II), Moderate (Stage III), and Severe (Stage IV).[ 2 ] Chronic periodontitis is linked to a persistent systemic inflammatory burden due to the spread of periodontal bacteria, their byproducts, and locally produced inflammatory mediators. In women with endometriosis, peritoneal fluid shows increased expression of reactive oxygen species (ROS), elevated cytokines, and factors like IL-1b, IL-6, IL-8, TNF-a, PGE2, vascular endothelial growth factor, RANTES, and monocyte chemoattractant protein-1, which are also observed in chronic periodontitis.[ 3 4 5 ] No research has been conducted to determine if periodontitis causes or promotes endometriosis onset. However, a link between endometriosis and periodontal disease has been indicated through inflammatory and oxidative stress pathways, supported by only two cross-sectional studies. Women with endometriosis had a 57% higher prevalence of periodontitis.[ 6 7 8 ]