Influence of Psychosocial Factors on Periodontal Diseases and Tooth Loss

Many studies suggest that psychosocial stress and ineffective coping mechanisms can influence the onset and progression of chronic inflammatory conditions, such as periodontitis.4,5,43,53-61 The role of stress in some acute periodontal conditions, such as necrotizing periodontal diseases, is well-established through both temporal associations of disease onset and a stressor and biological measurements, e.g., urinary cortisol levels.62-64 High rate of progression (Grade C) periodontitis (formerly called “aggressive periodontitis”) and chronic periodontitis have both been associated with stress and depression.53-61,65,66 Increasing salivary cortisol levels have been linked to worsening periodontal disease parameters and tooth loss, adjusted for other behavioral and stress variables and increasing stress/distress and depression were linked to periodontal disease severity in a dose-dependent fashion.57 Increased coping mechanisms seemed to mitigate this interaction.4 The mechanisms of these interactions is less clear, but several hypotheses have been proposed.5 Chronic stress and depression reduce immune responsiveness, and this may result in more periopathogenic bacteria leading to increased periodontal tissue destruction.5 Psychosocial disorders, including anxiety disorders and depression, have also been associated with increased levels of systemic pro-inflammatory cytokines, which may potentiate the action of the initiating bacterial insult and worsen the host-mediated periodontal destruction.5 Finally, chronic stress and depression may result in alterations in health-related behaviors, including oral hygiene, smoking, and dietary intake.5 Individuals with high stress levels who did not brush their teeth during stressful periods were at increased risk of tooth loss when compared to individuals who maintained oral hygiene despite increasing stress and anxiety.57 This may indicate that a combination of factors stemming from underlying psychosocial disorders interact resulting, ultimately, in worsening periodontal conditions in individuals with chronic stress and depression (Figure 3).5

Figure 3. Model of the Effects of Anxiety/Depression on the Immune System and Oral Health.5,79
Model of the Effects of Anxiety/Depression on the Immune System / Oral Health

Changes in health related behaviors (oral hygiene, diet, smoking)

  • Dysregulated hypothalamic pituitary-adrenal axis
  • Cortisol and adrenal disturbances
  • Immune dysfunction
  • Excessive secretion of proinflammatory cytokines
  • Periodontal tissue breakdown
  • Periodontal pathogens endotoxin
  • Poor oral hygiene
  • Excessive secretion of proinflammatory cytokines
  • Psychosocial effects (low self-esteem)
  • Anxiety/Depression
  • Anti-depressive medications
  • Xerostomia
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