Smoking, diabetes, and genetics are some of the usual suspects behind gum disease. Now a study in the February issue of the Journal of Periodontology confirms that stress and depression may be culprits as well.
Previous research has suggested that psychological stress can result in immunologic and inflammatory responses that influence periodontal disease and can reduce compliance with preventive behaviors, the authors wrote.
Biologically speaking, these responses are equally important because they are both possible mechanisms that explain how stress and depression can modify the risk for periodontal disease, said Sara Grossi, D.D.S., M.S., a faculty member at the Brody School of Medicine at East Carolina University, in an e-mail interview with DrBicuspid.com.
"The behavioral aspect is more amenable to modification or improvement as part of dental treatment," she added.
The study looked at 45 patients between the ages of 45 and 82 with a history of nonsurgical periodontal therapy, in some cases augmented by surgical intervention, followed by continued enrollment in a maintenance regimen.
Participants completed surveys on health, oral hygiene, stress, and depression. Their salivary cortisol (stress hormone) was measured, and a hygienist assessed the magnitude of periodontal disease.
The researchers found that stress, depression, and salivary cortisol do in fact serve as correlates of periodontal disease, independent of dental hygiene.
"The correlations between depression scores and number of missing teeth; stress and CAL [clinical attachment level]; and stress and PD [probing depth] confirm the hypothesized association between psychosocial variables and periodontal disease," the authors wrote (Journal of Periodontology, February 2009, Vol. 80:2, pp. 260-266).
Since the patients being studied were following established periodontal maintenance guidelines, the effects of stress and depression on periodontal disease activity might be mediated by factors more complex than merely reduced compliance, the authors noted. It is likely that periodontitis is actually related to immunologic and behavioral changes related to psychologic states.
"In our study, compliance was not an important correlate of periodontal disease, but we believe that's because we had a highly compliant sample that was getting regular dental care and there was little variability in compliance," explained Kathryn Low, a professor of psychology at Bates College and one of the study authors. Previous research has clearly demonstrated a link, she added.
"Addressing psychologic factors, such as depression, may be an important part of periodontal preventive maintenance," the study authors recommended.
So how can dental professionals help?
For starters, they should include an assessment of stress in daily life as part of their patient evaluations, Dr. Grossi said. They can also discuss the relationship between stress and periodontal disease, and talk about ways to manage stress, she added. For example:
- Explain that you cannot remove the stress or make it go away, and that you cannot modify how the body responds to it.
- Recommend that patients modify how they react and behave in stressful situations.
- Emphasize the importance of engaging in health-promoting behaviors, such as visiting the dentist more often so changes in oral health can be monitored.
"Our study suggests an association between psychological variables and periodontal outcomes," Low added. "Screening for stress and depression in patients being treated for periodontal disease can be helpful in treatment."
She recommended stress-reduction strategies such as exercise and relaxation training.
"In addition, patients should attend to dental habits when they're under stress," Low said. "Flossing and regular brushing and exams as needed may help."
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