stress.ppt stress and its influence on periodontitis

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1. Good afternoon ..

2. Stress & Periodontal
Disease

3. 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……
Including perception of the patients' psyche is vital both to….
understand the pathogenesis of the disease
ability of the patient to cope with the proposed management
regimen.

4. 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.

5. 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 diseaserelated conditions.
The periodontal tissues of susceptible individuals are
in balance with their oral flora,
Disease results
Disrupted
A deleterious effect on stress and psychosocial factors on health was
extensively elucidated by Selye (1946).
He established the term “General adaptation syndrome”,describing the
sum of all nonspecific, systemic reactions of the body that ensue upon
long, continued exposure to stress.

6. Depression of immune responsiveness is seen 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)

7. 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”.

8. “ Psychophysiological response of the
organism to a perceived challenge or
threat.” (Breivik et al 1996)
“ Stress is not what happens to someone,
but how someone reacts to what happens”

9. In general stress acts to prepare the individual for
action but reduces the immune systems’ ability to
cope with infection.
Actsasariskfactorindisease,increasingthe
susceptibleindividual'sprobabilityoffallingillwiththe
disorder.
Gaddini (1982),themind is not simply located and
restricted to the brain but is distributed throughout
the body

10. Life events and stress
Life eventsin 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

12. Degree to which stress is associated with ill
health is related to coping ties
Short-term coping strategies (use of alcohol and
tobacco) acts to exacerbate stress and anxiety
Emotional link exists between life events & personality
Changes in social circumstances are felt as a stressful
life event with accompanying feelings of helplessness
and hopelessness, leading to a state of stress

13. Wimmer et al 2005

14. •Minimization-To represent as having the least degree of
importance, value, or size.
•Self-aggrandizement-The act or practice of enhancing
or exaggerating one's own importance, power, or
reputation.
•Distraction -Extreme mental or emotional disturbance.
•Substitute gratification–state of being pleased or
satisfied.
•Self affirmation–Solemn declaration
•Rumination–think deeply.

15. Wimmer et al 2005
Inordertominimizethenumberofvariableswithequalfactorcharge,five
factorswereextractedfromthe19subtestsoftheSVF,usingafactor
analysisaccordingtotheprincipalcomponentmethod

16. Molecular & Endocrine
Mechanisms Of The Stress
Response

17. Hypothalamic/Pituitary/Adrenal (HPA) axis

18. Glucocorticoids Major suppressive effects
(Schleimer 1990,Williams et al 1990)
↓Functionssuchaschemotaxis,secretion,anddegranulation,
Lymphocytes, monocytes, eosinophils & mast cells
lymphocyte proliferation, and lymphocyte differentiation to
mitogens
InhibitsproductionofcytokinesincludingIL-1,IL-2,IL-3,
andIL-6,TNF-α,INF-γ,M-CSF
Inhibitsarachidonicacid-derivedproinflammatory
mediatorssuchasprostaglandinsandleukotrienes.

19. BEHAVIOURAL &
PSYCHOLOGICAL
EFFECTS OF
STRESS
This psycho-neuro-
immunologic network may
explain the role of stress in
infections and inflammatory
diseases of man.

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 NUG
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
Blood and urine was collected for tests of immune and
endocrine function
ANUG patients presented the following significant differences
More state of anxiety before disease resolution
Higher scores on the depression and psychopathic
deviation scales
A greater magnitude of recent stressful events

26. More life eventsduring the previous year, more overall
distress and readjustment related to these events, and
also more negative life events
Higher scores in the emotionally disordered rangeon
the general health questionnaire
Elevated serum/urine cortisollevels before ANUG
resolution,
Depressed lymphocyte proliferationafter mitogen
stimulation
Depressed PMNchemotaxis and phagocytosis

27. THE ROLE OF PSYCHOSOCIAL STRESS IN CHRONIC PERIODONTITIS
Belting and Gupta (1961)using the Russell Periodontal
Index, found that periodontal disease was more severe in
the psychiatric patientsas compared to controls when oral
hygiene frequency, level of calculus, age, bruxism and
clenching were held constant.
Early studies did not account for coping behaviorsand
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 Scalewere
assessed in 5 subscales:
Job strain
Financial strain
Spouse strain
Strain of being single
Strain related to parenting children
Pearlin and Schooler(1978)
Subjectswereaskedtorespondonlytoitemswhichappliedtothem.
Asked to indicate the extent to which they agree with a statement
Responses were coded as 1 to 4, average score calculated

30. Tomeasurepsychologicaldistress(Derogatis&Cleary1977)
9areas:
Anxietyfeelings of fear, nervousness, and restlessness
Somatizationdistress arising from bodily complaints
such as dizziness, hot spells, and weakness
Interpersonal sensitivityproblems associated with
self-image such as feeling inferior and being easily hurt
Psychoticismsevere psychotic thought patterns
Depression-feelings of loneliness and worthlessness

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)
oProblem-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.
oEmotion-focused coping is aimed at reducing or
managing the emotional stressassociated with a
disturbing situation. Emotion-focused coping tends to
predominate when a situation must be endured.
oBad coping

33. 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 ,F. nucleatum, P. gingivalis, &
P. intermedia.

34. Thefollowingobservationsweremade:
Strong association between levels of B. forsythusand
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 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 circulationManhold 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-inducedhormonesinthegingivalcrevicularfluid
couldprovideanutrientthatfavoursthesubgingival
growthofpathogenicmicrobialpopulations(McGlynnet
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-βm-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
Rozlog et al (1999)

42. Rozlog et al (1999)

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

44. Clinical implications of stress in
periodontal disease
•Evaluate stress status in patients with
periodontal disease
•Provide information on possible association to
patients
•Address indirect effects/habits induced by stress
(smoking, oral hygiene)
•Avoid surgical treatment during acute phases of
stress
•Referral to physician/ psychiatrist/ counseling

45. Conclusion….
Sufficient evidence exists to prove that stress reduces
the body’s normal immune response
Psychosocial measures of stress associated with
financial strain and distress (manifested as depression) are
significant risk indicators for periodontal disease in adults
Coping mechanisms/ behaviour play a major role…
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…
To study the phenomenon of disease without
books is to sail an uncharted sea, while to
study books without patients is not to go to
sea at all.
Sir William Osler

50. Genco et
al 1998