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Stress and periodontium
- 1. PRESENTED BY: DR. THASLIM FATHIMA SECOND YEAR POSTGRADUATE DEPARTMENT OF PERIODONTOLOGY
- 2. • INTRODUCTION • DEFINITIONS • CLASSIFICATION • ETIOLOGY • COMPONENTS OF STRESS • PSYCHOLOGICAL STRESSORS • PHYSIOLOGY OF THE STRESS RESPONSE • STAGES OF STREES • CENTRAL CONTROL STATIONS OF THE STRESS SYSTEM • REGULATION OF THE STRESS RESPONSE • STRESS BIOMARKERS • PATHOPHYSIOLOGY • POSSIBLE MECHANISMS OF ACTION OF PSYCHOSOCIAL FACTORS ON PERIODONTAL TISSUES. • ORAL PSYCHOSOMATIC DISORDERS • STRESS AND SYSTEMIC INFLAMMATORY DISEASE • EFFECT OF STRESS ON WOUND HEALING • COHEN’S PERCEIVED STRESS SCALE • MANAGEMENT OF PSYCHOSOMATIC ORAL DISEASES • STUDIES • DRAWBACKS OF CURRENT MODELS • TREATMENT PLAN - STRESS REDUCTION PROTOCOL • - DENTAL TREATMENT • - PSYCHOLOGICAL TREATMENT • CONCLUSION • REFERENCES
- 3. INTRODUCTION STRINGERE It is a response state of the organisms to forces acting simultaneously on the body which, if excessive that is, straining the capacity of adaptive processes beyond their limits led to diseases of adaptation and eventually to disease of exhaustion and death
- 4. “Human behavior is complex involving innate skills, learned behavior, social interactions and relationships with others. RISK FACTOR is an aspect of personal behavior or lifestyle, an environmental exposure, or an inborn/inherited characteristic which on the basis of epidemiologic evidence is known to be associated with disease-related conditions.
- 5. “Perception of the patient‘s psyche is vital to understand the pathogenesis of the disease and the ability of the patient to cope with the proposed management regimen. Not only are bacteria required to cause any disease such as periodontitis, but there must also be a susceptible host. Depression of immune responsiveness is seen as a result of factors such as physical and mental stress. Little is understood to assess the mechanism by which psychosocial stress, distress, and coping influence the periodontal disease initiation and progression. WHY DO WE NEED TO KNOW THIS?
- 7. • Stressor is any stimuli, situation or circumstance that has a potential to induce stress. • Subsequently, it compels the mind and body to be in an almost constant alarm-state in preparation to fight or flee. STRESSOR
- 8. Selye defined forces that had the potential to challenge the adaptive capacity of the organism as ‘stressors’ and stated that stressors could be physical or mental (e.g. emotional)
- 9. It is a state of physiological or psychological strain caused by adverse stimuli, physical, mental or emotional, internal or external, that tend to disturb the functioning of an organism and which the organism naturally desires to avoid. (Dorland’s Illustrated Medical Dictionary) DEFINITIONS • Stress is defined as a total transaction from demand to resolution in response to an environmental encounter that requires appraisal, coping and adaptation by the individual.(J Oral Health Comm Dent 2010) D
- 11. BASED ON DURATION Acute stress Episode acute stress Chronic stress BASED ON REASONS Occupational Stress Involuntary Stress Voluntary Stress (Lakshmi Boyapati &Hom-Laywang, Periodontology 2000, vol. 44, 2007, 195– 210)
- 14. Daily hassles Environmental influences Major life events Psychological factors Systemic illness The strains measured in the Daily Strain Scale were assessed in 5 subscales.. (Pearlin and Schooler(1978) ETIOLOGY
- 15. “Holmes 1967 developed a scale to measure stress in terms of life changes
- 16. “ • Life event itself • Personality traits • Social interactions Modify the disturbing nature of the life event
- 18. PHYSIOLOGY OF THE STRESS RESPONSE General adaptation syndrome…..
- 19. 1. ALARM STAGES OF STRESS 2. RESISTANCE 3. EXHAUSTION
- 20. STAGE 1
- 21. STAGE 2 • If the stressor persists, it becomes necessary to attempt some means of coping with the stress. • Although the body begins to try to adapt to the strains or demands of the environment, the body cannot keep this up indefinitely, so its resources are gradually depleted.
- 22. STAGE 3
- 24. CENTRAL CONTROL STATIONS OF THE STRESS SYSTEM
- 29. PATHOPHYSIOLOGY 4 main pathways 1 2 3 4
- 30. HPA AXIS
- 32. PATHOPHYSIOLOGY OF THE STRESS RESPONSES.
- 33. NEUROPEPTIDES Neuropeptides released from peptidergic nerve fibers also modulate the activity of the immune system and the release of cytokines.
- 34. Breivik and co-workers (1997 ) Hypothalamic–pituitary–adrenal axis and its effects on T- lymphocyte numbers Th cells --Th1 (INF gamma,IL2) --Th2 (IL4,5,6,10) Neuropeptides selectively regulate Th1/Th2 cytokine secretion and may regulate immune response. ↑ Plasma glucocorticoid – provoke inappropriate Th2 response. ALTERATION OF TH1/TH2 RATIO
- 36. Oral hygiene negligence Changes in dietary intake Smoking and other harmful habits Bruxism Gingival circulation Endocrine Changes Lowered host resistance and Stress Alteration in salivary flow & components POSSIBLE MECHANISMS OF ACTION OF PSYCHOSOCIAL FACTORS ON PERIODONTAL TISSUES.
- 37. Belling and Gupta (1961)1.ORAL HYGIENE NEGLIGENCE It has been reported that psychological disturbances can lead patients to neglect oral hygiene and that the resultant accumulation of plaque is detrimental to the periodontal tissues. Academic stress is also a risk factor of periodontal disease. Comparing psychiatric patients with controls found that the severity of inflammatory periodontal disease increased significantly in both groups as levels of calculus increased. They also found more moderate and heavy calculus in the psychiatric group than in the control group.
- 38. 2.CHANGES IN DIETARY INTAKE: • Emotional conditions are thought to modify dietary intake, thus indirectly affecting periodontal status. • This can involve, for instance, the consumption of excessive quantities of refined carbohydrates and so other diets, requiring less vigorous mastication and therefore predisposing to plaque accumulation at the approximal risk site.
- 40. 3.SMOKING AND OTHER HARMFUL HABITS It has not been established whether this correlation occur because, (1)Tobacco smoking has a direct toxic effect on the gingiva (2)Vascular or other changes are induced by nicotine or other substance (3)Smoking and ANUG are both reflections of stress. Kenney et al mentioned that the circulating nicotine have following effect,
- 44. 7. LOWERED HOST RESISTANCE
- 47. LICHEN PLANUS(LP) Erythema multiforme (EM) and mucous membrane pemphigoid (MMP) • Remissions and exacerbations of long standing MMP are often related to specific periods of psychologic tension.
- 48. Periodontal diseases are infections associated with specific pathogenic bacteria that colonize the sub gingival area. Onset and progression of periodontal infections are clearly modified by local and systemic host conditions or risk factors that markedly affect the resistance of the host to infecting periodontal organisms. Emotional factors play a significant role in the complex etiology of CPD, in which the gingival and underlying periodontal tissue cannot respond adequately to the local irritation of bacterial plaque and calculus. The loss of tissue resistance has been attributed to variety of systemic factors, including emotional stress.
- 50. RHL occurs due to either physical trauma or emotional stress leading to lesions of skin and labial mucosa.
- 51. Biting of oral mucosa (self mutilation) Biting of oral mucosa or tongue can induce severe trauma. Neurotic patients may also traumatize their mouth with foreign objects such as sharp pencils, toothpicks, or fingernails. Gingival recession on a maxillary canine caused by self-inflicted trauma from the pressure from patient's fingernail.
- 52. GLOSSOPYROSIS
- 53. DYSGEUSIA
- 54. “• Patients with MPDS report psychological symptoms such as Frustrations, Anxiety, Depression, Hypochondriasis and Anger. • Maladaptive behaviours such as pain verbalization, poor sleep, dietary habits, lack of exercise, clenching, bruxism can be seen when pain becomes prolonged. MYOFACIAL PAIN DYSFUNCTION SYNDROME
- 55. Xerostomia: • …..common clinical finding in psychiatric patients. • Dryness of mouth affects the quality of life.
- 61. COHEN’S PERCEIVED STRESS SCALE
- 66. “Following observations were made: T. forsythia and periodontal disease…… Individuals with high levels of clinical attachment loss…. Severe attachment loss and alveolar bone loss. Higher levels of salivary cortisol….
- 67. MANAGEMENT OF PSYCHOSOMATIC ORAL DISEASES Stress relaxation training Behavioral/relaxation techniques a. Relaxation through yoga or meditation b. Hypnosis c. Biofeedback d. Cognitive-behavioral therapy
- 71. DRAWBACKS OF CURRENT MODELS Two major models to study the effect of stress on systemic health are: • Role of major life events • Day-to-day stresses. It is obvious that not all factors inducing stress fall neatly into one or another of these categories It is difficult to determine whether it is the stressful events that caused the altered disease pattern, or whether the stress response is a consequence of having a disease. This area of investigation, within the dental field, is the lack of a uniform definition of stress. Lack of proper Questionnaires The effects of stress may be altered by gender, personality type, age, lifestyle, psychological disorders, and varying coping styles
- 72. The stress reduction protocol includes two series of procedures that when used either individually or collectively, act to minimize stress to the patient during treatment and thereby decrease the degree of risk presented to the patient adjustment adaptation confrontation
- 73. 1)Recognition of medical risk and anxiety. 2) Medical consultation. 3) Premedication (Antianxiety or sedative- hypnotic drugs given one night before the appointment or one hour before appointment). 4) Appointment scheduling and minimized waiting time to reduce anxiety. 5) Vital signs monitoring: BP, heart rate, rhythm and respiratory rate. Stress Reduction Protocol in Dental Office Includes
- 74. Regular exercise helps to burn off and use up the stress hormones and neuroche micals. The benefits of meditation and other relaxation techniques . Eliminatio n of alcohol use. Strengthen your relationshi ps by building a strong support network Learn better ways to manage time Take good care of yourself Speak up and ask for help Stress Reduction by the Patient Includes
- 75. Careful history. Evaluat e stress status. Debride ment of root surfaces . • Optimiz ing oral hygiene . • Utilizati on of antimic robial substan ces. Provide informa tion on possible associat ion to patients . Address indirect effects/ habits induced by stress (smokin g, oral hygiene ) Avoid surgical treatme nt during acute phases of stress. Referral to physicia n/ psychia trist/ counsell ing Clinical implications and periodontal treatment plan
- 76. The most awaited slide
- 77. References:
- 78. THANK YOU
Editor's Notes
- The term stress is Derived from a latin word called String er.. Meaning to “draw tight” Stress is found to be a predictable factor of periodontal disease.
- the brain prepares the body for defensive action—the fight or flight response by releasing stress hormones, namely, cortisol and adrenaline (epinephrine). These hormones raise the blood pressure and the body prepares to react to the situation.
- This state of accumulated stress that we all encounter in everyday life can increase the risk of both acute and chronic psychosomatic illnesses and weaken the immune system of the human body.
- Hans Selye He conducted many important scientific work on the hypothetical non-specific response of an organism to stressors.
- Occ.athletes ,boxers Invol.. Recovery from GA Vol…musicians?
- Eustress is the good stress/positive stress that motivates the individual to continue working. Distress is the negative stress which is difficult to bear or cope with. Negative, threatening homeostasis with pain, discomfort and physical pathology When someone is not experiencing positive stress and it can lead to more problems and produce boredom and hopelessness. Outcome of stress and occurs when someone is being pushed too hard to meet deadlines…
- These are the factors that.. Life events in this context refers to any break in continuity in a person's life. Death of a spouse, retirement or redundancy etc., which results in a disturbing or unexpected incident, may be called a life event. Emotional link exists between life events & personality ……Short-term coping strategies (use of alcohol and tobacco) exacerbates stress and anxiety Changes in social circumstances are felt as a stressful life event with accompanying feelings of helplessness and hopelessness, leading to a state of stress
- Involve the way in which we mentally process what is going on around us. when stressed,it often becomes difficult to concentrate and gets distracted. our atitudde towards life situations determine how we respond…. people start thinking negatively and self defeating…
- The systemic reaction that affect the body to produce an interrelated nonspecific tissue change resulting from continued exposure to stress.
- Dr. Hans Selye, an endocrinologist, developed a three-stage model of the body’s response to stress as general adaptation syndrome (GAS). The first phase is an alarm reaction, the second stage is one of resistance or adaptation, and the final stage is one of exhaustion.
- alarm
- resistance
- exhaustion
- ..long-term damage may result, as the body’s immune system becomes exhausted, and bodily functions become impaired, resulting in………
- Any lesions in dese areas causes diff effects in immune system Brain locus for fear related behaviors and enhances its stoges as ltm or stm in hippo
- 1st-----Interplay of several neurotransmitter systems in the brain underlies the characteristic phenomenology of behavioral, endocrine, autonomic and immune responses to stress….
- locus ceruleus and other noradrenergic cell groups of the medulla and pons are collectively known as the LC/NE system
- Four main pathways: 2
- The pituitary gland is connected to the hypothalamus by the infundibulum, a stalk of tissue that contains nerve fibers and small blood vessels. Secretory IgA may decrease initial colonization by pathogens, and IgG opsonizes bacteria so they can be phagocytized and killed by neutrophils. Suppression of the immune response by increased stress-induced cortisol levels increases the potential for pathogen-related periodontal destruction.
- This results in decreased immune cell response to antigens and a decrease in T-cell activity and antibody production….mediates cvs and metabolic effects…. is less pronounced and cholinergic receptors are found In epithelial cells of thymus,bone marrow and t cells.
- The second major pathway to be activated is the sympathetic nervous system. That is the flight or fight response. The adrenal medulla is actually a modified sympathetic ganglion..it secretes products directly into the bloodstream. The release of catecholamines results in the hormonal secretion of norepinephrine and epinephrine from the adrenal medulla, which results in changes in immune responses. Catecholamines, released during stress, contribute to the development of hyperglycemia by directly stimulating glucose production and interfering with the tissue disposal of glucose, In addition, the sympathetic nervous system has a role in regulating immune cell activities
- any of a group of compounds which act as neurotransmitters and are short-chain polypeptides They are also present in gingival and periodontal tissues and penetrate into the epithelium. long lasting emotional stress may increase SP release, resulting in enhanced and imbalanced inflammatory reactions, which may promote tissue damage.
- Described the hpa axis amd .. T1 stimulate cellular imunity through production of….hypothesized thatt2 response increases susceptibility to infectious diseases…t1 may actually be protective against perio whereas t2 response may increase perio breakdown
- Via sympathetic ns,sensoric peptidergic ns,neuroendocrine s, cells of immune system…..neurotransmitters neuropeptides and hormones of stress..unfavourable shift Antigen presenting cells
- ….Among the many harmful oral habits which are believed to be induced by emotional disturbances, smoking is possibly the most important in relation to worsened periodontal conditions. reported that 98% of the ANUG patients were smokers and that the frequency of ANUG increased with an increasing exposure to tobacco smoke Vasoconstriction, produced by the release of Adrenaline and non-Adrenaline, which is supposed to result in lack of nutrients for the periodontal tissue (2) Suppression of secondary antibody responses (3) Inhibition of oral neutrophil functions
- may result in wear of teeth, trauma to periodontal tissues, and occasionally facial musculature and temporomandibular joint structures.
- tested the hypothesis that in long or continued emotions a constant constriction of blood vessels could produce a lack of oxygen and nutrient materials for the periodontal tissues..
- It has been known that stress can affect the endocrine system….stress can alter pituitary function and subsequently influence carbohydrate and calcium metabolism, affecting the mouth……..studies…glucocorticoids causes anug by altering the response of oral tissues to bacterial toxins…pmn and reduced proliferation of lymphocytes
- Psychologic factors are known to influence the rate of secretion and composition of saliva. Mental activity, stress, muscular effects or emotional disturbances produce a transient reduction of salivary flow, changes in the salivary enzyme count,sliva ph and chemical composition like igA secretion
- LP & Glossitis areata, the lesions often appear after an episode of intense emotional stress… In EM and MMP, emotional stress plays a significant role in determining the severity of the disease as well as recurrent episodes.
- ANUG is a fusospirochetal infection caused by local and systemic predisposing factors
- Self-inflicted injuries are a common pathological behavior pattern in many stressful conditions and in psychiatric disorders.
- cohen
- MPDS is a muscle-contraction headache-like pain of the face.
- Saliva plays a significant role in the maintenance of oral and general health. Xerostomia is the abnormal reduction of saliva and can be a
- people with aggressive periodontitis were more depressed and socially isolated than people with chronic periodontitis or control group.
- Chronic recurrent conditions….either as a….stress is a common risk factor….and periodontal disease.of course diff stressors and diff responses may be operative in each disease,,immune response and inflammation
- Altered cortisol and catecholamine level……affect recruitment of macrophage and fibroblast…whivh impairs tissue turnover and dec. wound healing
- : The Perceived Stress Scale (PSS) is the most widely used psychological instrument for measuring the perception of stress.
- Strong association between levels of …among individuals with a high depression score… 2. had higher scores on the financial strain scales…Genco et al. (1999) studied relationship between psychosocial stress, coping, and periodontal disease in a study of 1426 adults. The results indicated a significant role of financial strain in relation to alveolar bone loss and periodontal attachment loss. 3. It was found that those who were high emotion-focused copers, a form of inadequate coping, .. 4. Subjects with high levels of financial strain and poor coping strategies had significantly
- Various approaches are:
- Alprazolam. (0.25 to 0.5 mg/day) Phenelzine (15 to 90mg/day), Nortriptyline (25 mg/day)
- There are several major problems with this relatively simplistic classification
- Coping against stress is the effort to try to reduce, control or tolerate the state of stress. Successful coping is when the subject has the feeling to face the stress and able to control the given situation.
- 1)
- In our daily practice we frequently come across patients with psychosomatic disorders, patients who are emotionally disturbed frequently presents with oral symptoms. Recognition of such emotional disturbance and psychological management of such case should be taken into consideration when treating patients with these psychosomatic disorders. The dental practioner may always decide to refer patients to appropriate professional for assistance and counselling Determining patients under chronic stress could develop specific multidisciplinary treatment strategies for ultimate effects of coping with stress factors and improvement of prognosis and outcome of periodontal treatment.