Stress and periodontitis

Exploring the concepts of acute and chronic stress and their association to periodontal disease

We’ve all been there. We all know the feeling, the alarming discomfort.

Buzzing noise in the ears. Heart beating violently. Dry mouth. Cheeks briefly flushing, then turning ghost pale. Tense body.

Two weeks ago, I was standing in the middle of a stage, in front of a big group of dentists, dental hygienists and academicians and experiencing my own personal, very public acute stress response.

Play reverse – few months back I got an invitation to speak at the Periocampus Alumni conference. I didn’t think twice about it, and it was out of sheer self-dignity that I didn’t reply back within seconds with an overly enthusiastic “yes” written in capital letters. As a former Periocampus participant, I couldn’t wait to get back. The theme of the conference was right up my alley and I was given an opportunity to give a talk on a topic I am very passionate about. Not even the fact that I was to give the lecture in Italian language could discourage me. Surely, I was self-taught in Italian, but… if I can hold a decent everyday conversation, talking about periodontitis that is my daily bread shouldn’t pose much of a problem with some preparation, right? (Spoiler alert: it did.)

I have never had issues with stage fright, and working at the university really made me at ease with speaking in front of large groups of people. Preparing for this lecture though, it turned out that with Italian I couldn’t allow myself the spontaneity of thoughts and words as with my Croatian or English. Beating myself up about every spoken grammar mistake didn’t help much either. I was frustrated, slightly worried, but I did not yield, I never do.

And so, when The Day finally arrived, I went up on that stage, with my carefully prepared slides behind my back, opened the lecture in a TED-talk style and, as planned, spoke in Italian. Sentences rolled by. People were listening. They actually seemed to understand what I was saying. At some point, though, my brain started making mental notes: “You’ve made a mistake in combining the preposition with the word’s article”, “You sure the correct accent was l’ànsia and not l’ansìa?”, “Larisa, how can you still battle with numbers in Italian, it’s child’s play!”. At some point my brain was finally going into over drive. The rest of the body could feel it coming.

Buzzing noise in the ears. Heart beating violently. Dry mouth. Cheeks briefly flushing, then turning ghost pale. Tense body.

What an absolute irony, I was thinking to myself. Larisa Music, you are stressed out to the point where you can’t seem to find appropriate words to continue your lecture that happened to be… “Stress and periodontitis”.

Who says stress is bad?

Nowadays, wherever you turn it seems that the word stress pops up eventually. Being “stressed out” is the curse of the modern age. In everyday language we (ab)use it to describe the feeling of overload and struggle to cope with demands.

In terms of biological and behavioural processes, stress implies how mental (e.g. death of a close person) or physical (gunshot), external (mobbing at work) or internal (illness) factors affect the body. A term, even more appropriate to describe the active process by which the body responds to stressors and works towards maintaining its equilibrium (homeostasis) is allostasis.

The problem I have with the perception of stress and its physiological mechanisms is that they get a very bad reputation. Everybody seems to forget that acute stress is in its essence a good thing! It is the Evolution’s deed that got our ancestors into the next generation. Finding yourself in front of a predator (… or on a stage, for that matter!) triggers the body’s autonomous sympathetic nervous system. Stimulated adrenal glands release what we best know as „stress hormones“, cathecolamines, which include adrenaline and noradrenaline. This response to acute stress, so called „fight-or-flight“, represents the choices our ancestors made when facing danger – you could either fight or flee.  Either way, the body was ready to take action. Rapid heartbeat and respiration rate aim to provide the much-needed energy and oxygen. The blood flow is redirected from the surface areas towards the muscles and the brain. Blood clotting ability increases in order to prevent excess blood loss in case of an injury. Dialated pupils allow more light into the eyes. Muscles are tense and primed for action.

Yet, as The Persuaders might’ve sung if they knew more about stress, there’s a thin line between protection and damage. Unlike our ancestors, we’re not facing giant hyenas, cave bears and lions anymore. These predators have now morphed into bills, loans, angry bosses, that one extra assignment due on Tuesday. It is the urban modern life and everyday ordinary activities that make our hearts beating faster. And, boy, do they make it beat faster. All. The. Time.  If the body is chronically challenged, its attempts to achieve balance (allostasis) can become increased or dysregulated, leading to what we now as the “tear and wear”, or allostatic load and overload.

Mouth falling apart

I’m pretty sure the first periodontal clinical entity associated to stress that comes to everyone’s minds are periodontal necrotizing diseases. These patients are memorable. Extreme oral malodour, layers of plaque and necrotic papillae with pseudomembranes make up for a clinical presentation one does not easily forget. These patients also report oral pain, a symptom we don’t hear about very often in our everyday periodontal practice. The first written trace of mouth pain among soldiers goes back to the time of the Alexander the Great. Necrotizing gingivitis also got called “the trench mouth” as it was observed to occur to soldiers during World War I. Many of the main risk factors for necrotizing diseases are very often related to stress: lack of sleep, poor nutrition, bad oral hygiene, excessive smoking, alcohol consumption and recent illnesses.

One of my patients, 22 y/o male student, that showed up during stressful university exam session in February. He reported almost complete abstention of sleep (“I have 5 exam is 3 days!!!”), more than 2 packs of cigarettes per day and crisps as his primary food choice. He didn’t remember the last time he washed his teeth, he “didn’t have time”. Notice the negative papillae and pseudomembranes!

So, how does stress affect periodontal health?

As mentioned earlier, it is the chronic stress and the chronic production of stress hormones that eventually lead to the tear and wear of the body.

Before blaming it all on the hormones, though, we should be reminded that stress works in far more intricate ways, and the mechanisms through which stress is associated with periodontitis are quite complex, to say the least.

Psychological stress can have indirect effects on periodontal health through changes in behaviour and lifestyle. People that report to be under stress are also more likely to neglect their oral hygiene, smoke and drink more, sleep less and also adopt an unhealthy diet, consuming far more fat and sugar. So, while poor oral hygiene leads to plaque accumulation, and thus directly affecting periodontal health, smoking, nutrition and sleep disturbances do it through altered host response.

A way to quantify and assess environmental and self-perceived stress is through questionnaires and interviews. These tools helped us understand that there is no one single type of stress associated with periodontitis. We can categorize stress(ors) into 3 groups, i. micro-stressors, ii. major life events and iii. disasters/crises. Research tells us that all of them, in all their forms (i.e. daily hassles and strains at workgetting a divorce and a tsunami!), are associated with impaired periodontal status and progressing disease.

Association between stress and periodontitis is a subject of behavioural and psychoneuroendocrinoimmunological interaction!


While we most commonly think of (nor)adrenaline in connection to stress, it is another major stress hormone, cortisol, on which we put the blame for the negative effects of stress on periodontal health. Cortisol is a glucocorticoid produced by the adrenal gland cortex in a reaction chain known as the hypothalamo-pituitary-adrenal axis (HPA). Speaking short-term, again, cortisol has beneficiary effects on our bodies – in situations of acute stress it will reduce the inflammation and mobilize the immune system. Conversely, chronic production of cortisol hinders our immunological competence and increases susceptibility to periodontal disease. Cortisol levels can even be used as a neuroendocrine biomarker quantifying stress. What we know from research is that periodontally-affected persons reporting stress and strain have elevated cortisol levels measured in the serum and the saliva. Measuring cortisol is certainly still not a common procedure in the dental setting, but in the future it might be used as a stress assessment tool.

Coping with stress and how can we, as dental professionals, help?

Interestingly enough, it is not just the stress, but the ways our patients cope with stress that can influence the periodontal disease, and also the outcome of our treatmentOne of the best known studies on periodontal disease and stress showed that while financial strain and distress are significant risk indicators for more progressed periodontal disease, this stress risk may be reduced with adequate stress-coping behavior. Coping presumes the effort to try to control, reduce and tolerate the negative and unpleasant effects of stress. Coping mechanisms can generally be divided into emotion-focused and problem-focused ones. Emotion-focused coping behaviours include avoidance strategies (i.e. alcohol consumption), while problem-focused coping behaviours presume “plan-of action” and situation control. Which leads us to our next question…

Besides doing periodontal treatment, can we, and in what ways, help our patients?

Understanding the (pato)physiological mechanisms of stress can give us more self-confidence when expanding our role of a dental professional. I personally very often employ breathing exercises with patients who perceive me and my treatment as the stressor that leads them to acute stress response. Something as simple as a short guided breathing exercise can influence the (hyper)activity of the autonomous sympathetic nervous system (and lower cortisol!) and while it takes 5 extra minutes of time, it creates a comfortable and safe environment for the patient in front of us.

But passion for yoga and mind-body connection is not indispensable to address stress in the dental setting. Asking questions and taking time for a conversation with the patient are good to begin with. I cannot stress enough (pun intended!) the blessing us, dental professionals, have for being able to see and spend time with our patients on rather frequent occasions. If we’re already working towards controlling risk factors such as diabetes or smoking, how much more would it cost us to inspect a bit further whether that one patient turning up at the practice looking unexpectedly raggedy and underslept is going through a rough patch at the moment? After all, if we manage to identify certain psychosocial factors that are associated with poor periodontal outcomes, we can then recommend intervention measures such as counseling that will not only help the patient, but also act as an adjunctive approach to our treatment of periodontal disease and maintenance of periodontal health.

A picture from this year's Periocampus Alumni taken at the end of my lecture on Stress and periodontitis. We did a short, 5-minute meditation for stress-relief. Even though it was me that was leading the meditation, I was surely the one in need of it. 😉