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Everyday stress may be an integral part of life, but more extreme stress affects your oral health in more ways than you'd have guessed — even leading to gum disease.

What is stress?

Stress is the term used to describe your body's response to challenge, danger or threat. When your body senses threat, it produces hormones which in turn stimulate a range of physical and emotional reactions to support your response. Acute stress may come from many sources, is very common and for the most part is positive; it can aid productivity or focus (through increased adrenaline, for example). However, it becomes problematic when there is a disparity between the response and reaction or the response becomes chronic and prolonged. So for example, rather than having occasional bouts of stress that arise from the demand of completing an assignment at work (acute stress), a person becomes increasingly stressed even when out of work and any association with work generates that stress reaction (chronic stress reaction).

How does it affect health?

Again, in small doses, stress is good for the body as it stimulates the immune system to respond to threat which might mean helping the body fight infection, for example. However, it can become problematic to health because it can interfere with the body's communication systems that enable the immune, endocrine and nervous systems to work in harmony to achieve function.

How can stress increase the risk of gum disease (periodontitis)?

Periodontal disease refers to disease affecting the structures holding the teeth in-situ, including gums, ligaments and bone. Early on in the disease, in gingivitis, the gums become inflamed; when it progresses to periodontitis, both soft and hard tissues are affected.

A large-scale, longitudinal meta-analysis conducted over 26 years found more than half of the studies included showed a link between stress, anxiety and other mental health issues and social isolation and periodontal disease. They concluded that cortisol, found in higher amounts in the body when stressed, may be a key factor in lowered immunity. However, it was also acknowledged that people experiencing chronic stress were more likely to engage in a lifestyle not conducive to good oral health (such as a poor diet, smoking, inadequate dental hygiene or care, for example).

Further studies conducted more recently support the idea that stress and other psychosocial issues might be linked to periodontal disease and argue for a more proactive, preventative approach to address these issues as risk factors in the disease.

Connections between psychosocial factors and periodontitis

Endocrine changes in stress

The research into this area continues and no definitive conclusions have been reached. However, it is thought that hormonal changes found in saliva at times in cases of chronic stress disrupt the balance of the oral microbiome. We have heard recently about the gut microbiome and how it can be damaged; it appears the oral microbiome is just as vulnerable. Disruption or dysbiosis of the microbiome leads to a growth in the mouth of particular bacteria; and at the same time, high levels of adrenaline and cortisol are thought to directly depress immune function, making it harder for the body to fight infection.

Poor oral hygiene

Mental well-being is likely to have a significant impact upon an individual's level of self-care and of course, it is well-established that poor oral hygiene creates an environment conducive to gum disease.

Nutrition

Stress is likely to have a negative impact on an individual's diet; perhaps leading to consumption of more processed foods and those with higher carbohydrate (sugar) content; or even just inadequate intake of vitamins and minerals necessary for good oral health. Both of these increase the risk of the development of calculus (tartar), increasing the risk of periodontitis.

Smoking

Smoking tends to be more common in high-stress individuals and is thought to be a key risk factor in the development of periodontitis.

Gum circulation

Chronic stress impacts upon muscle tone of the blood vessels and over time this can lead to constriction which prevents adequate oxygen and nutrient supply to the oral tissues.

Salivary production and flow

The amount and flow of saliva is assumed to have a negative impact on oral health and states of stress are known to change your salivary flow: for example, a dry mouth in anxiety. In addition, the ph of the saliva is thought to change at times of stress as is salivary immunoglobulin, the most commonly found antibody (and key infection-fighting agent) in mucous membranes.

Bruxism

The grinding or gritting/clenching of teeth known as bruxism has long been asserted to be a risk factor for periodontal disease however this appears to be anecdotal only as there appears to be limited research to support this claim.

Reduced resistance to disease

As stated earlier, stress has a negative impact on the immune system and its functioning, especially with regards to fighting bacteria, which is fundamental in fighting inflammatory gum disease.

Acute necrotizing ulcerative gingivitis

This condition occurs most frequently (apart from in smokers) in those who are under chronic stress while debilitated as well as in those with chronic sleep deprivation, which is also common in those under chronic stress. Again this is thought to be due to excessive growth of bacteria as well as generally impaired immunity.

Aggressive periodontitis

Associations have also been made between this rare condition and psychosocial stress. While research is still underway, this is thought to be again due to high levels of specific bacteria and generally impaired immunity.

Stress and systemic inflammatory disease

There appears to be a complicated interrelationship between chronic generalized inflammation and in the body (as seen in disorders such as diabetes, lupus or rheumatoid arthritis, for example), mental ill-health and/or reactive stress and periodontitis. Systemic inflammation is linked to a range of mental health disorders including anxiety and depression, which in turn can influence an individual's dental hygiene, diet and other factors linked to periodontitis. This appears to be a cyclical relationship where neuroinflammation affects mood and behavior leading to periodontitis which further causes systemic inflammation, worsening existing inflammatory conditions and worsening mood.

Stress and tissue repair

Stress is thought to impact negatively upon the body's ability to effectively fight infection, repair damaged tissues and heal wounds. In addition, individual coping styles is thought to be linked to recovery from dental procedures/treatments for periodontal disease; it is not clear if this is mechanical or behavioral in action.

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