The Impact of Stress on Periodontal Disease: Risk Indicator or Risk Factor?

But today, the oral health community is increasingly grappling with a less visible and less understood – but undoubtedly impactful – patient condition: chronic stress.

Because mental health is so personal, and because “stress” can feel somewhat ambiguous (nearly all of us feel some level of stress at times), this has often been a challenging subject for dentists to broach with their patients. But as mounting evidence draws a clear connection between chronic stress conditions and risk for periodontal disease, it is one you should strongly consider addressing.

Chronic stress and periodontal disease: risk indicator or risk factor?

Throughout modern history, stress has generally been categorised as a “risk indicator” for periodontal disease as opposed to a “risk factor,” meaning that correlations are observed but without strong evidence of a causal relationship.

“However,” Decker et al. notes in a review article for Periodontology 2000, “as the evidence in this field matures with additional clinically controlled trials, more homogeneous data collection methods, and a better grasp of the biologic underpinnings of stress-mediated dysbiosis, emerging evidence suggests that chronic stress and related diseases (depression, anxiety) may be significant contributing factors in periodontal/peri-implant disease progression and inconsistent wound healing following periodontal-related therapeutics.”

Another recent study by Coelho et al. concludes that “an association exists between stress and periodontitis, signalling the necessity of a multidisciplinary attention when considering the psychological status in the management of oral and general health conditions of the individual.”

Understanding the underlying mechanisms of this association can help dental professionals offer the best guidance to their patients.

Why and how does stress impact periodontal disease risk?

Research has identified a number of factors that may be in play regarding chronic stress conditions and their influence on periodontal risk. The bottom line is that stress has real physical effects on the body, with implications to the oral microbiome, to the inflammatory burden, and oral health more generally.

A systematic review from Decker et al. assessing stress, depression, and inflammation as a collective risk factor for periodontal diseases advises that, “Stress-related disorders should be included in the list of globally screened diseases because it can change the biochemistry of both the local periodontal microenvironment as well as the global systemic inflammatory burden.”

One distinct phenomenon that’s been recognized is the presence of higher cortisol levels in those experiencing stress.

“Combination of changes in inflammatory responses and depression of the immune system caused by elevated levels of cortisol in the body lead to the recognition of psychological stress as a potential factor for the pathogenesis of chronic diseases such as periodontitis,” according to Castro et al. “Besides blood and saliva, the increased cortisol levels in the gingival crevicular fluid were also associated with the severity of periodontitis.”

“It is important to emphasize the importance of new research that relates high levels of cortisol in the body to the level of alveolar bone loss,” the authors conclude.

In their own examination of stress and periodontitis, Pitzurra et al. cite another phenomenon based on “indications that neurons are able to secrete pro-inflammatory cytokines and chemokines that worsen chronic inflammatory reactions in the periodontium and compromise immune fitness.”

While acknowledging that the specific impact of stress on periodontal risk and its influence on the results of treatment are difficult to estimate clinically, the authors advise that “attention to and awareness of stress as an aspect of the comprehensive set of risk factors for periodontitis can diminish its negative impact on immune fitness.”

Understanding patient stress

Of course, most dental professionals are not trained as mental health professionals. With that said, there are evaluative instruments that can be used to gain a baseline understanding of patient stress as a possible risk indicator for periodontal disease.

Perhaps the best known among these is the Perceived Stress Scale, developed by Dr. Sheldon Cohen. It is a simple 10-item questionnaire “designed to tap how unpredictable, uncontrollable, and overloaded respondents find their lives.”

Whereas acute stress is relatively normal and often reactive to surrounding circumstances (e.g. a busy day at work or sitting in traffic), chronic stress is a persistent long-term condition that is more likely to elicit the biochemical effects and oral health implications being discussed. The Perceived Stress Scale can be used to assess whether patient stress falls more into the acute or chronic category.

For those with chronic stress conditions, how can the dentist play a helpful role in supporting oral health without overstepping their bounds?

Helping dental patients cope and reduce stress

It is critical, first and foremost, that helping patients understand stress and how it impacts their oral health is part of a dental practitioner’s job. Just as it is in your interest to dissuade smoking due to its clearly adverse relationship with periodontal outcomes, you also should seek to address the topic of chronic stress head-on. Serve as an advocate for your patient, projecting confidence and expertise while acknowledging that you don’t specialise in the area of mental health.

“The role of the dental specialists is to discuss lifestyle in a broader concept than just oral hygiene, they should be more psychologically oriented,” wrote Reners et al. in a 2007 article on stress and periodontal disease that still holds up today. With evidence continuing to reinforce a meaningful relationship between the two conditions, the article’s concluding guidance only further resonates: “it should be mandatory for us to help patients to have less stress and, when needed, to refer them to a psychologist or other specialists in the field of stress medicine.”

This all contributes to a growing narrative around the expanded role of a dental professional in patient success. Our focus must go beyond the teeth and gums, in accordance with the reality that oral health is irrevocably tied to systemic health and patient behaviours.

At a basic level, the most useful thing you can do as a dentist to help patients reduce and cope with stress is to adamantly promote a healthy lifestyle. Many of the most helpful and proven techniques for stress reduction relate back to this core objective: getting physically active, eating a nutritious diet, and avoiding harmful habits like drinking alcohol, smoking, or eating unhealthy foods.

You might also use this line of reasoning to reinforce coinciding strong oral care rituals at home. After all, treatments for cavities and other oral health issues tend to become major sources of stress for many patients. Avoiding such outcomes is a win/win scenario from this perspective!