When the body is under stress, it produces more of the hormone cortisol, which acts as an anti-inflammatory agent. When cortisol is produced peripherally in the gums, it stimulates mast cells to produce more proteins, simultaneously increasing inflammation and the progression of periodontal disease.

1. Good Morning

2. The Association Between
Stress & Periodontal
Disease

3. “The trouble with our times is that the future
is not what it used to be”
- ‘Paul Valery’
Introduction……

4. Human behavior is complex, involving innate skills, learned
behavior, social interactions and relationships with others.
Health care professionals are often wrongly criticized for
not being "holistic enough": ( not treating the patient as a
whole)
Introduction……
Unfair Criticism: physicians, dentists and other health
care professionals routinely take a wider view.
Including perception of the patients' psyche is vital both to….
understanding the pathogenesis of the disease
ability of the patient to cope with the proposed management
regimen.

5. Some patients may not be as mentally healthy as
appearances suggest.
WHY KNOW THIS ?
Not only are bacteria required to cause periodontitis, but
there must also be a susceptible host.

6. . Investigations are currently focusing on assessment of risk
“RISK FACTOR” an aspect of personal behaviour 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.
The periodontal tissues of susceptible individuals are
in balance with their oral flora,
Disease results
Disrupted

7. Depression of immune responsiveness as a result of
factors such as physical and mental stress
Little has been done to assess the mechanism by which
psychosocial stress, distress, and coping influence
periodontal disease initiation and progression.
Poor oral hygiene in subjects with mental disorders
is associated with higher levels of gingival
inflammation, particularly in institutionalized groups
(Hede 1995)

8. Stress
It is clear that the body makes no differentiation between
psychological , physical and social stress
In general.. “The reactions of the animal body to forces of
a deleterious nature ,infections and various abnormal states
that tend to disturb its normal physiological equilibrium.”
(Stedman’s Medical
Dictionary)
In psychology… “ A physical or psychological stimulus
which when impinging upon an individual, produces strain
or disequilibrium”.

9. In general acts to prepare the individual for action
but reduces the immune systems’ ability to cope
with infection.
Acts as a risk factor in disease, increasing the
susceptible individual's probability of falling ill with the
disorder.
Gaddini (1982), the mind is not simply located and
restricted to the brain but is distributed throughout the
body

10. Life events and stress
 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.
Relationship between life
events, stress and illness
Fritz 1950s

11.  Life event itself,
 Personality traits
 Social interactions
Modify the disturbing
nature of the life event
Life events
External factors (for
example, social networks)
Internal factors
(personality traits)
Elliot & Eisdorser (1982)
Stress response

12. Emotional link exists between life events & personality
Changes in social circumstances are felt as a stressful
life event with accompanying feelings of helpless ness
and hopelessness, leading to a state of stress
Type A behavior
Individuals who are highly competitive, high
achievers, aggressive, hasty, impatient
and restless
Describes people who believe
they have little control over their
lives
External locus of control
Type A personalities and have an external locus of control

13. Degree to which stress is associated with ill
health is related to coping ties
With release of stress resolution of physical
and mental symptoms
Short-term coping strategies (use of alcohol and
tobacco) acts to exacerbate stress and anxiety
Type A behavior.

14. Wimmer et al 2005

15. Wimmer et al 2005

16. Molecular & Endocrine
Mechanisms Of The Stress
Response

17. Hypothalamic/Pituitary
/Adrenal (HPA) axis
GLUCOCORTICOIDS

18. Feed back mechanism
Feedback arm consisting of stimulation of the
HPA axis by cytokines.( IL-2, IL-6, ,INF- γ, macrophage-
derived IL-1, and TNF-α )
This psycho-neuro-immunologic network may
explain the role of stress in infections and
inflammatory diseases of man.

19. BEHAVIOURAL &
PSYCHOLOGICAL
EFFECTS OF
STRESS

20. Mental Stress
Response
Leading To At-
Risk health
behaviors
Poor oral hygiene, poor compliance with
dental care
Overeating
( a high-fat
diet)
Inadequate coping and distress, such
as depression,
Smoking

21. Stress as a common
pathway for several
related chronic
diseases of man

22. ASSOCIATION BETWEEN
PSYCHOSOCIAL STRESS &
PERIODONTAL DISEASES

23. Psychosocial stress &
its effect on behavior
as manifested by
periodontal disease

24. Psychosocial factors and ANUG
Most studied periodontal disorder in relation to
psychosocial predisposing factors.
Cohen-Cole et al. (1983)
Cogen et al. (1983)
Investigated the role of psychosocial factors and
immunosuppression in ANUG.
35 patients showing ANUG and 35 controls,

25. Cohen-Cole et al. (1983) Cogen et al. (1983)
Matched for age, sex, and dental hygiene,
Completed rating questionnaires,
Gave blood and urine for tests of immune and endocrine
function
ANUG patients presented the following significant differences
More state anxiety before disease resolution
Higher scores on the depression and psychopathic
deviation scales
A greater magnitude of recent stressful events

26. More life events during the previous year, more overall
distress and readjustment related to these events,, and
also more negative life events
Higher scores in the emotionally disordered range on
the general health questionnaire
Cohen-Cole et al. (1983) Cogen et al. (1983)
Elevated serum/urine cortisol levels before ANUG resolution,
Depressed lymphocyte proliferation after mitogen stimulation
Depressed PMN leukotaxis and phagocytosis

27. THE ROLE OF PSYCHOSOCIAL STRESS IN ADULT PERIODONTITIS
Belting and Gupta (1961)
Using the Russell Periodontal Index, they found that
periodontal disease was more severe in the psychiatric
patients as compared to controls when oral hygiene
frequency, level of calculus, age, and bruxism and
clenching were held constant.
Early studies did not account for coping behaviors and
other potential modifiers of the stress response.

28. The Erie County Epidemiological
Assessment (Grossi et al 1994)
Association between psychosocial stress,
measures of distress, and coping
behaviors
Self-administered questionnaires to assess
these parameters

29. The strains measured in the Daily Strain Scale were
assessed in 5 subscales:
 Job strain,
 Financial strain,
 Spouse strain,
 Strain of being single
 Strain related to parenting children
Pearlin and Schooler(1978)
Subjects were asked to respond only to items which applied to them .
Asked to indicate the extent to which they agree with a statement
Responses were coded as 1 to 4, average score calculated

30. To measure psychological distress (Derogatis & Cleary 1977)
9 areas:
 Anxiety feelings of fear, nervousness, and restlessness;
Somatization distress arising from bodily complaints
such as dizziness, hot spells, and weakness;
 Interpersonal sensitivity problems associated with
self-image such as feeling inferior and being easily hurt;
 Psychoticism severe psychotic thought patterns,
although the authors feel this is more a measure of
alienation
 Depression - feelings of loneliness and worthlessness;
Brief Symptom Inventory

31. Paranoid ideation - a high degree of suspiciousness;
Hostility - a tendency towards confrontation.
Phobic anxiety - fears and uneasiness associated with
unfamiliar surroundings
 Obsessive-compulsive - cognitive functioning
difficulties, such as trouble remembering things and difficulty
making decisions
measure psychological distress…..

32. Coping style was assessed by using the COPE
Inventory. (Carver et al1989)
o Problem-focused coping scale- generally respond
to stressful situations by taking action, which can be
described as a coping style aimed at solving problems
as they arise.
o Emotion-focused coping is aimed at reducing or
managing the emotional stress associated with a
disturbing situation. Emotion-focused coping tends to
predominate when a situation must be endured.
o Bad coping

33. A clinical examination
Assessments of supragingival plaque,
Gingival bleeding,
Subgingival calculus,
Probing depth, and
Clinical attachment level.
Following microorganisms were assessed
A. actinomycetemcomitans, B forsythus, C rectus,
Capnocytophaga sp , E saburreum, F nucleatum,
P. gingivalis, & P intermedia.

34. The following observations were made:
 Strong association between levels of B. forsythus and
periodontal disease among individuals with a high
depression score
 Individuals with high levels of clinical attachment loss
had higher scores on the financial strain scales
 It was found that those who were high emotion-focused
copers, a form of inadequate coping, had a higher risk of
more severe attachment loss and alveolar bone loss
 Subjects with high levels of financial strain and poor
coping strategies and had significantly higher levels of
salivary cortisol

35. POSSIBLE MECHANISMS OF ACTION OF
PSYCHOSOCIAL FACTORS ON PERIODONTAL
TISSUES
1) Neglect of oral hygiene
2) Changes in dietary intake
The consumption of excessive quantities of refined
carbohydrates and softer diets, requiring less vigorous
mastication
3) Smoking and other harmful oral habits
 Smoking is possibly the most important in relation to
worsened periodontal conditions.
 Effects of circulating nicotine
Monterio Da Silva
et al (1988)

36. 4) Bruxism …. thought to be induced by stress
5) Gingival circulation Manhold et al. (1971)
Tested the hypothesis that in long or continued emotions a
constant constriction of the blood vessels
Oxygen and nutrient materials for the periodontal tissues.
They found a lower ability of the tissues of rats under
stress to utilize oxygen.

37. Stress can alter pituitary function and subsequently
influence carbohydrate and calcium metabolism,
affecting the mouth
6) Endocrine changes
Alterations in the concentration of adrenal corticoids
and other hormones involved in the general adaptation
syndrome
Stress-induced hormones in the gingival crevicular fluid
could provide a nutrient that favours the subgingival
growth of pathogenic microbial populations (McGlynn et
al. 1990).

38. 8) Lowered host resistance (Elenkov et al 1996)
Under stress, the release of adrenaline & non-adrenaline
7) Alteration in saliva flow and components
It is assumed that both increase and decrease in salivary
flow, induced by emotional disturbance, may affect the
periodontium adversely (Gupta 1966)
Emotional distress may also produce changes in saliva
pH and chemical composition
↓ IL-12, ↑ IL-10 Shift from Th-I to Th-2 profile
DECREASED CMI

39. STRESS AND NEUROPEPTIDES (CGRP,VIP,NPY&SP)
Stressors
Autonomic nervous system &
release of neuropeptides
(Substance –P)
(Brelvilc et al
1996),
Excessive cytokine production
in response to stress
Periodontal disease

40. STRESS AND WOUND HEALING
Undoubtedly… stress depresses the cell mediated
immune response
Rozlog et al (1999)
Study in caregivers of dementia
victims
 More time for wound healing (48.7 vs 39.3 days)
 Lymphocytes produced less IL1-β m-RNA, in
response to LPS

41. STRESS AND VIRAL STIMULATION (HERPES & EBV)
Unlike common cold viruses, which are effectively eliminated
by the immune system, herpes viruses become ‘latent’ in the
target cells and are reactivated during immunosupressive
conditions.
The body tries to fight back Increasing the Antibody
production (IgG) [ Reduced in stressful conditions]
Direct reactivation of the latent herpes viruses from viral
genome +ve cells by Glucocorticoids
DECREASED IgG LEVELS REACTIVATION by GCC
VIRAL
INFECTIONS
Rozlog et al (1999)

42. Rozlog et al (1999)

43. Occupational
details
Patient’s
lifestyle
Stress levels of
the patient
Altered hormonal
levels
Disturbed
immune system
Harmful habits
(smoking)
Decreased
frequency of care
Risk of periodontal disease
+
Response to periodontal
therapy
(Axtelius et al 1998)
Personal history

44. Genco et
al 1998

45. Conclusion….
 Sufficient evidence exists to prove that stress reduces
the body’s normal immune response
 Coping mechanisms/ behaviour play a major role…
 Psychosocial measures of stress associated with
financial strain and distress (manifested as depression) are
significant risk indicators for periodontal disease in adults
Long term Studies of mechanism(s) by which
psychosocial stress or distress exert effects on periodontal
disease are needed ….

46.  Studies using stress management to reduce stress
or distress with randomized controlled trial
methodology are necessary
Conclusion….
 Stress-associated risk for periodontal disease is related
to psychoneuroimmunologic changes and/or behavioral
changes is yet to be determined.

47. Thank You…