This document outlines the relationship between stress and periodontal disease. It begins with definitions of stress and discusses the pathophysiology, including effects on the hypothalamic-pituitary-adrenal axis and immune system. Animal and human studies show that stress can increase cortisol levels and promote a Th2 response, impairing wound healing. Stress management protocols should be incorporated into periodontal treatment to reduce distress.

2. Outlin
e
1. Introduction
2. Definition
3. Classification
4. Etiology
5. Pathophysiology
 Hypothalamic-Pitutory- adrenal axis.
 Autonomous nervous system activation.
 Sympathetic
 Parasympathetic
 Release of neuropeptides
 Alteration of Th1/Th2 ratio

3. 6. ANUG
7. Effect of stress on wound healing
8. Self-inflicting injuries
9. Cohen’s perceived stress scale
10. Studies
 Animal studies
 Human studies
11. Drawbacks of current models
12. Clinical implication, Treatment plan
Stress reduction protocol
 Dental treatment
 Psychological treatment
13. Conclusion

4. INTRODUCTI
ON
Hippocrates (1945) Health as a harmonious balance of the
elements comprising the quality of life
Selye (1967)
Terms “Stress”.
“Stressor”
“Coping “
Stress is compatible with good health being very
necessary to cope with the challenges of everyday
life . If it is sustained causes damage

5. Definitio
ns
Definitions Different authors have proposed different definitions
for stress
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
Stress is defined as 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. (GPT 4th ed)
Selye (1967)

6. “Stressor” is defined as forces that had the potential to
challenge the adaptive capacity of the organism
“Coping” is the response of the individual to stress
(emotionally and physically
Eustress -------- positive
stress
Distress -------- negative
stress

7. Classificatio
n
Classified based on reasons for the stress
Occupational Stress: E.g. Athletes, Boxers,
Diamond cutters.
Involuntary Stress: E.g. Soldiers,
Recovery from General anesthesia.
Voluntary Stress : E.g. Dancers, Musicians.
stress
Psychological
Physiologic
al
Courtesy : LAKSHMIBOYAPATI&HOM-LAYWANG, Periodontology 2000, Vol. 44, 2007, 195–
210

8. Etiology
Neglect of oral hygiene
Changes in dietary intake
Smoking and other harmful oral hiabits
Bruxism
Gingival circulation

9. Alteration in saliva flow and components
Endocrine changes
Lowered host resistance

10. Pathophysiology
Four main pathways
1. Hypothalamic-pitutory- adrenal axis.
2. Autonomous nervous system activation.
Sympathetic
Parasympathetic
3. Through release of neuropeptides
4. Alteration of Th1/Th2 ratio

11. Courtesy : LAKSHMIBOYAPATI&HOM-LAYWANG, Periodontology 2000, Vol. 44, 2007, 195–
210

12. Courtesy: EurJOralSci,1996:104:327-334

13. Neuropeptides
release
Neuropeptides released from peptidergic nerve Fibers also
modulate the activity of the immune system and the release of
cytokines.
This includes
 Substance P,
 Somatostatin,
 Endogenous opioid peptides (beta endorphin and
enkephalins),
 Nerve growth factor.
Among these the Neuropeptide SP, calcitonin gene related
peptide (CGRP) secreted from sensory C-type nerve fibers
have different immuno-modulatory functions.

14. Alteration of Th1/Th2
ratio
Breivik and co-workers 1997
Hypothalamic–pituitary–adrenal axis and its effects on T-
lymphocyte numbers
Th
cells
Th1
Th2
Protective (INF
gamma,IL2)
Destructive (IL4,5,6,10)
↑ Plasma glucocorticoid – provoke inappropriate Th2 response
A cytokine profile, consistent with a T helper 2 cell response seen
in medical students during stressful examination periods (Marshal
and coworkers 1998)

15. Effect of stress on wound healing
Health-impairing behaviors Pathophysiological effects
Poor oral hygiene Higher glucocorticoid levels (cortisol) and
higher catecholamine levels (epinephrine and
norepinephrine), which may lead to any or all
of the following
Increased consumption of cigarettes Hyperglycemia, which may impair neutrophil
function and impair the initial phase of wound
healing
Increased alcohol consumption Reduced levels of growth hormone, which may
down-regulate the tissue repair response
Forgetfulness and difficulty concentrating Altered cytokine profiles,(IL1B) which may
affect recruitment of cells important to wound
remodeling, such as macrophages and
fibroblasts
Disturbed sleeping patterns Reduced tissue matrix metalloproteinase
levels, leading to impaired tissue turnover and
reduced wound remodeling
Poor nutritional intake Decreased natural killer cell levels, reducing
the host ability to mount an appropriate
immune response to periodontal pathogensCourtesy : LAKSHMIBOYAPATI&HOM-LAYWANG, Periodontology 2000, Vol. 44, 2007, 195–

16. Animal
studies
Courtesy : LAKSHMIBOYAPATI&HOM-LAYWANG, Periodontology 2000, Vol. 44, 2007, 195–

17. Concluded that stress causes
↓ Vascular permeability in gingivomucosal
tissue
↓IL1 mRNA expression
↓Response to vaccines
↓Clot stabilization, wound strength

18. Courtesy : LAKSHMIBOYAPATI&HOM-LAYWANG, Periodontology 2000, Vol. 44, 2007, 195–
Human
studies

19. Concluded that stress causes
• ↑ plasma cortisol levels
• Stressor is directly related to periodontal
disease
• No difference in plaque scores between test and
control groups

20. ANU
G
According to (Cohen- Cole et al )
Compared to controls the ANUG patients presented the following
significant differences
• More state anxiety before disease resolution
• Th2 dominant immune response
• Depressed lymphocyte proliferation
• Elevated serum cortisol levels before ANUG resolution
• Decreased neutrophill cheamotaxis and phagocytosis

21. Psychiatric influence of self-inflicted injuries
• Grinding and clenching of the teeth, nibbling of the foreign
objects,nail biting all are potentially injurious to the periodontium.
• Self inflicted injuries like gingival recession have been described in
both children and adults.
• Some authors reported that these injuries are not common in
psychiatric patients (sandhu et al)

22. Cohen’s perceived stress
scale

24. 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

25. There are several major problems with this relatively simplistic
classification
• 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.
• Stress studies differ regarding whether acute or chronic stress
but these are somewhat arbitrary terms

26. • Lack of a uniform method of quantifying stress
• Lack of proper Questionnaires
• The effects of stress may be altered by gender,
personality type, age, lifestyle, psychological disorders,
and varying coping styles

27. Clinical implications and treatment plan
Periodontal
management
• Careful history
• Debridement of root surfaces,
• Optimizing oral hygiene,
• Utilization of antimicrobial
substances,
• Adjunct use of growth factors
in various delivery vehicles.

28. Stress management
There are four basic approaches to dealing with
stress:
• Removal or alteration of the source of stress
• Learning to change how you see the stressful
event
• Reducing the effect on your body that stress
has
• Learning alternative ways of coping

29. Stress reduction
protocol
Stress reduction for the oral health
patient
Pre treatment
protocol
Physical
classification
(ASA) and
acute anxiety
recognition
Proper rest
and diet
Initial
consulting
appointment
and
prescription
for the pre
operative
medication
Short
morning
appointment
s,
Early in the
week, early
in the
morning
Pain control Vocal
sedation and
relaxation
techniques
Music, aroma
therapy,
massage
Hypnosis
and
acupuncture
NO
inhalation,
local
anesthetic
use
Post
treatment
protocol
Referral if
needed
Written
recommenda
tions
Medication:O
TC,
prescription
Fallow up:
telephone
call
Courtesy : Clinical feature july 2004

30. References
1. Clinical periodontology, Carranza, 10th ed
2. The role of stress in periodontal disease and wound healing, Periodontology
2000, Vol. 44, 2007, 195–210
3. Emotional stress effects on immunity, gingivitis and periodontitis,
EurJOralSci1996:104:327-334
4. Stress, Depression, Cortisol, and Periodontal Disease, J Periodontol
2009;80:260-266
5. Effects of academic stress on oral hygiene – a potential link between stress
and plaque associated disease? J Clin Periodontol 2001; 28: 459–464
6. Psychosocial stress, lifestyle and periodontal health, J Clin Periodontol 2002;
29: 326–335
7. Psychosocialfactors in inflammatory periodontal diseases,
/ClinPeriodontol1995:22:516-526
8. Chromogranin A: Novel biomarker between periodontal disease and
psychosocial stress, Journal of Indian Society of Periodontology- Vol 17, Issue
2, Mar-Apr 2013
9 Models to Evaluate the Role of Stress in Periodontal Disease, Ann Periodontol
1998;3:
288-302.
10.coping with stress, its influence on periodontal diseases,J
Periodontal,2002,73,1343-1351