Impact of Stress on Periodontium

INTRODUCTION

Periodontitis is a chronic inflammatory disease, characterized by gingival bleeding, periodontal pocket formation, connective tissue destruction and alveolar bone loss.¹ Oral bacterial pathogens are responsible for the initiation and progression of periodontitis.² Abnormal host response to bacterial pathogens also play a crucial role in the progression of periodontitis.³

The relationship of sound mind in maintaining healthy body has been recognized from most of history recorded i.e. from the time of ancient Romans, Greeks and Chinese.⁴

Stressors are those forces that have the potential to challenge the adaptive capacity of the organism. The group of stressors could be either mental/psychosocial/physical. Theses stressors either lead to eustress/distress, which are body’s adaptive to restore homeostasis.⁵

Direct association between periodontal disease and stress remains to be proven, which is partly due to lack of an adequate animal models and difficulty to quantifying the amount and duration of stress and also there are many factors influencing the incidence and severity of periodontal disease.⁶

THE DEFINITION OF STRESS

Stress is defined as a state of physiological or psychological strain which is caused by adverse stimuli such as physiological, mental, emotional, internal or external that disturbs the functioning of an organism. Stress typically describes a negative condition or a positive condition that can have an impact on a person's mental and physical well-being.⁷

RISK FACTORS AND RISK INDICATORS

As with many other chronic infections, the onset and progression of periodontal disease is largely programmed by the influence of certain local and systemic risk factors that have a dramatic effect on the resistance of the host to pathologic bacteria. In periodontal disease, we call these pathogenic bacteria “periodontal pathogens” and the factors that increase the risk for periodontal disease (risk factors) include diabetes, smoking, and a genetic variable called the interleukin-1 polymorphism (IL-1 genotype). Smokers are 4 times more likely to have periodontitis than nonsmokers.⁸

Diabetic patients with poor metabolic control of their glycated hemoglobin have a much greater risk for progressive bone loss compared to well-controlled patients, with odds ratio of 11.4 to 2.2, respectively. The IL-1 genotype is a specific genetic marker that identifies patients who have increased risk of developing severe periodontal disease.⁹

Nonsmokers or former light smokers (< 5pack/year) genotype-positive individuals are more than 3 times more likely to have moderate-to-severe periodontal disease than individuals who are genotype negative.5Patients who are both genotype positive and also smoke may be 7.7 times more likely to have tooth loss than nonsmokers who are genotype negative.^10,11

MODELS OF STRESS

These include the biologic model and the behavioral model.¹²

The biological mechanism emphasizes how stress and depression can reduce immune system function and facilitate chronic inflammation. These effects are mediated through the hypothalamic-pituitary-adrenal axis and the production of cortisol, a glucocorticoid capable of reducing immunocompetence by inhibiting immunoglobulin A and G and neutrophil function, which leads to increased biofilm colonization and reduced ability to prevent connective tissue invasion.

The behavioral mechanism emphasizes that people suffering from stress and depression may increase poor health behaviors, such as smoking or drinking more frequently, consuming an unhealthy diet and neglecting their oral hygiene. This leads to increased oral biofilm burden and decreased resistance of the periodontium to inflammatory breakdown.

AFFECT OF STRESS ON IMMUNE SYSTEM

Stress can result in the down regulation of the immune system which is mediated primary through the hypothalamus pituitary adrenal and sympathetic adrenal medullary axis. The function of cortisol is to depress the immune system by diminishing the IgA and IgG secretions. HPA response is a component of the organism’s adaptive system for maintaining function under changing environmental circumstances.¹³

STRESS AND PERIODONTAL DISEASE

GINGIVAL CIRCULATION

Smoking and stress have been implicated in reducing gingival blood flow which in turn could increase the possibility of necrosis of tissues, with subsequent reduced resistance to plaque.

ALTERATION IN SALIVARY FLOW AND COMPONENTS

It is assumed that both increase and decrease in salivary flow, induced by emotional disturbance, may affect the periodontium adversely. Emotional distress may also produce changes in saliva pH and chemical composition like IgA secretion.

STRESS AND ACUTE NECROTIZING ULCERATIVE GINGIVITIS

ANUG patients were also more stressed than controls and data suggest that depression of some host defense mechanisms, under stress conditions, may be necessary in the pathogenesis of ANUG. It is not uncommon to have outbreaks of ANUG among college students during examinations and people during military service.¹⁴

STRESS AND SYSTEMIC INFLAMMATORY DISEASE

A number of chronic recurrent conditions, in addition to periodontal disease, are characterized by a fluctuating course, with ongoing disease punctuated by bouts of greater severity. It is well-established that cardiovascular disease, diabetes mellitus, preterm delivery, osteoporosis, rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematous etc., are related to stress either as a physiological response to stress or as a behavioral response.¹⁵

STRESS AND WOUND HEALING

Stress suppresses certain aspects of the cellular immune response such as mitogen stimulation, antibody and cytokine production, and NK cell activity. Furthermore, since stress deregulates inflammatory and immune response, stress can alter the course of oral wound healing and affect the management of other oral diseases, e.g., periodontitis.^16,17

PREVENTIVE MEASURES 18

1. Anticipation of disaster in high risk areas
2. Disaster management
3. Positive coping strategies

TREATMENT 19

• Careful history needs to be taken for checking any underlying stress/psychological disorder
• Patient should be referred to a psychiatrist before commencing of the dental treatment

Basics approaches of dealing with stress²⁰

• Removal/alteration of the source of stress
• Learning to change way of perceiving stressful events
• Reducing the effect of stress on the body
• Learning alternative ways of coping proactive coping: dealing with stress in advance.
• Breathing exercises
• Drug therapy- antidepressants and benzodiazepines
• Supportive psychotherapy

CONCLUSION

Direct association between periodontal disease and stress remains to be proven, which is partly due to lack of an adequate animal models and difficulty to quantifying the amount and duration of stress. Furthermore, multiple variables affect the severity of periodontal disease and there is uncertainty about the individual’s onset of periodontal disease. Moreover, it is not possible to separate the effects of physical stress from emotional stress in these animal studies.

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