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Introduction Oral health
According to the World Health Organization (WHO), oral health is the condition of the mouth, teeth, and orofacial structures that allows individuals to carry out essential activities including eating, breathing, and speaking. It also includes psychosocial aspects like self-confidence, wellbeing, and the capacity to socialize and work without experiencing pain, discomfort, or embarrassment. Oral health changes throughout life, from childhood to old age, is crucial for overall health, and helps people participate in society and reach their potential.1
Orofacial pain, oral infections, periodontal diseases, tooth decay, tooth loss, and other orofacial disorders that can influence a person's general physical and mental health as well as their social well-being are considered indicators of poor oral health. Good dental health is an essential part of overall wellbeing, both physically and mentally. It reflects the physiological, social, and psychological characteristics that are essential to quality of life. Further, dental health exists along a continuum that is influenced by the values and attitudes of individuals and communities including the individual's shifting experiences, perceptions, expectations, and capacity for adaptation.2
Mental Health
Mental health is defined as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" by the WHO.3 Mental health promotion is defined as the improvement of a person's ability to strengthen or support positive emotional, cognitive, and related experiences. Rather than focusing on reducing symptoms and impairments, it is crucial to emphasize the importance of mental health and enhance coping behaviors across a spectrum of external influences.4
Oral and Mental Health: An Interrelationship
Oral and mental wellness are strongly correlated.5,6 It is well-established that individuals with mental health disorders have demonstrated suboptimal oral hygiene and nutrition, frequent consumption of sugary beverages, concomitant substance misuse including tobacco, alcohol, or psychostimulants, as well as financial or other barriers to dental care, medication-related xerostomia, and gingivitis. Individuals with mental disorders are more likely to experience oral health issues, and the severity of the mental health concerns has been correlated to an increased prevalence of oral disease.7
Conversely, about half of all dental patients report feeling some level of worry prior to their appointments and, in extreme circumstances, this may present as dental phobia. Regardless of the severity of oral disease, depression and/or anxiety can result in decreased oral health status and increased dental anxiety.7
Mental Health Disorders
A mental health disorder is a medical condition whose symptoms are predominantly psychological (behavioral) in character, or if physical, can only be comprehended through the lens of psychology. Impairments due to poor mental health may be interpersonal, sexual, physical, or perceptual. Treatment of mental health is imperative due to the high potential for serious morbidity and mortality associated with untreated mental health conditions.8
Types of Mental Health Disorders
The types of mental health disorders, including mood disorders, depressive disorders, bipolar disorder, schizophrenia, eating disorders, disruptive behavior and dissocial behavior, neurodevelopmental disorders, and post-traumatic stress disorder (PTSD), are defined in a chart accompanying this article (Figure 1).
Understanding Stress
The term "stress" refers to the negative consequences that environmental and psychosocial factors have on a person's bodily and/or mental health. These behavioral and environmental influences, also referred to as stressors, put the organism's typical homeostatic mechanisms under stress and cause a number of physiological responses. When stress levels are high, the host's immune system is activated in preparation for upcoming challenges. Contrarily, persistent stress can lead to long-lasting inflammatory processes that might exacerbate disease locally or systemically, including diabetes mellitus, cardiovascular disease and periodontitis.17
The chronicity of stress experienced has a differential impact on innate and cellular immunological responses and has been the subject of extensive research. Acute stress seems to produce quick-acting, transient effects that upregulate the innate immune response, including changes to the number and composition of circulating leukocytes and an increase in pro-inflammatory cytokines. Conversely, chronic stress appears to have long-term effects linked to dysregulation of innate and cellular immune responses, enhancing proinflammatory cytokine responses, decreasing levels of leukocytes, and increasing levels of regulatory/suppressor T cells.18
During times of chronic stress, the hypothalamic-pituitary-adrenal (HPA) axis is engaged, and corticotropin-releasing hormone and arginine vasopressin are secreted from the hypothalamus stimulating the pituitary gland to release adrenocorticotropic hormone. Adrenocorticotropic hormone stimulates adrenal glands which increases cortisol production and release. As a result, the neurological system and peripheral nerve fibers may be stimulated to release chemicals needed to combat the stressor, such as neuropeptides (substance P), salivary alpha-amylase, and chromogranin A (CgA). According to Mesa et al., cortisol has the potential to weaken the immune system over time by blocking immunoglobulins A (IgA) and G (IgG), changing the ratio of T-helper to T-suppressor cells, and modifying Natural Killer cells.19,20
Biological Mechanisms to Explain Stress
The HPA axis, the autonomic nervous system, and the immunological system are just a few of the pathophysiological pathways that have been associated with mental health disorders. Increased cortisol levels are a risk factor for further impairment, and HPA changes are associated with reduced cognitive function. Changes that lead to neurologic changes seen in some mental health disorders can be sparked by chronic low-grade inflammation. Peripheral infection can lead to immune-related brain alterations known as neuroinflammation. The peripheral release of inflammatory cytokines can activate the HPA axis. Reduced protein synthesis and neural repair may contribute to the brain alterations associated with depression.17
Three main pathways of psychoneuroimmunity modulated by psychological stress include:21 The HPA, the Locus Ceruleus-Sympathetic-Adrenal medulla system (SAM), and the Peptidergic Nerve System (PNS) (Figure 2).
Explanation of the Oral-Systemic Connection
It is now widely accepted that low-grade chronic inflammation is a significant risk factor for mental health disorders, and studies have clearly demonstrated that periodontitis and/or the bacterial agents responsible for it can trigger this reaction.22 This induces hypo-regulation of the HPA axis and behavioral alterations. Bacteremias and/or endotoxemias can trigger a neuroinflammatory response and the release of proinflammatory cytokines, which may lead to a persistent systemic inflammatory response. Such widespread inflammation may result in neurovascular dysfunction, an increase in blood-brain barrier permeability, a decrease in nutrient intake, and an increase in neurotoxic substances.17 Lipopolysaccharides (LPS) have the potential to impair blood-brain barrier (BBB) function and increase permeability.23 Such increased permeability of the BBB can result in access to the neural tissues by periodontal bacteria. The upregulation of toll-like receptor 4 (TLR4) expression by LPS can potentiate neuroinflammation, creating a vicious cycle of continued systemic and neurologic inflammation.17
Stress Markers and Receptors in the Oral Cavity
In response to stress, activation of the HPA axis results in the production of glucocorticoids (GC) like cortisol-a potent marker of stress. GC receptors in the periodontal tissues are responsive to glucocorticoids released by the HPA axis. Many cells in the oral cavity express GC receptors and in response to stimulation by elevated GC levels demonstrate immune dysfunction, including suppression of macrophage and natural killer cell function and the inhibition of T lymphocyte cell formation.24 Further, GC receptor binding can upregulate the production of proinflammatory cytokines, e.g. IL1 and TNF-α, as well as the suppression of lymphocyte proliferation.17 In addition, other proinflammatory mediators may be stimulated by catecholamines released in response to stress, including chromogranin A (CgA) and the neurotransmitter substance P. Such mediators result in the downstream production of proinflammatory cytokines and bioactive peptides.17,25
Oral Microbiota and the Development of Mental Disorders
It is likely that stress brought on by psychological factors may have an impact on the periodontal biofilm given the interaction between pathogens and the host's immune system. The most significant bacteria that are commonly isolated from periodontal pockets are gram-negative bacteria. Examples of these bacteria include Aggregatibacter actinomycetemcomitans, Eikenella corrodens, Fusobacterium nucleatum, Prevotella intermedia, Porphyromonas gingivalis, and Tannerella forsythia.26 The stress hormones, catecholamines, dopamine, and cortisol have been shown to promote T. forsythia and F. nucleatum proliferation.27 One of the earliest gram-negative species to establish itself in plaque biofilms, F. nucleatum, is a dominating bacterium within the periodontium and is thought to act as a link between the first and later colonizers of the biofilm, essentially facilitating the transition from a eubiotic biofilm associated with health to a dysbiotic biofilm associated with periodontitis. Additionally, depending on the bacterial species, catecholamines seem to have an impact on periodontal bacterial development. A. actinomycetemcomitans and P. gingivalis show decreased proliferation when noradrenaline is present, whereas E. corrodens, A. naeslundii, and C. gracilis demonstrate increased proliferation. It's interesting to note that noradrenaline has been demonstrated to boost P. gingivalis gingipain expression.28 These results suggest that stress-related hormones may alter the development and virulence factor expression of some bacterial species, leading to oral dysbiosis.
Stress and Necrotizing Periodontal Diseases (NPD)
Individuals are more susceptible to developing NPD if they have certain personality traits and/or behaviors, have difficulty coping with stress, or experience severe acute psychological stress. The immune system responds differently under stress and patients demonstrate behavior changes. Patients who present with NPD also demonstrate elevated levels of GC in serum and urine, demonstrating evidence of the influence of stress on the development of NPD.29 According to Georgieva et al., stress lowers tissue resistance and raises corticosteroid and catecholamine levels. As a result, there is a reduction in the microcirculation in the gingiva and saliva as well as the neutrophil and lymphocyte activities, which makes it easier for bacteria to invade periodontal tissues, elicit immune responses, and cause a necrotizing lesion. Studies suggest that a lack of support mechanisms and stress are associated with increased incidence of NPD. NPD is more common in people who are emotionally and mentally stressed, such as members of the military, people who suffer from depression and other emotional illnesses, and students who are taking exams.30
When periodontitis is active or untreated, pro-inflammatory mediators in the gingival crevicular fluid are found high. The increased risk of periodontal disease in stress may be explained in part by inflammation-mediated damage, as chronic stress induces immune system dysregulation and raises levels of cytokines and other pro-inflammatory mediators.31
Stress-Related Behaviors and Oral Health Conditions
Diabetes mellitus and cardiovascular disease have been linked to mental health issues. This may be related to lifestyle and comorbidities, such as smoking, inactivity, a poor diet, obesity, hypertension, or a failure to follow health recommendations or programs that are frequently observed in people with mental health disorders.32 Sex, age, race/ethnicity, education, marital status, geography, work status, chronic illness, substance misuse, and family history of psychiatric illness are all characteristics that can increase one's risk of developing depression as an adult.33 It should also be noted that major depressive illness is understood to be predisposed by exposure to stressful childhood events. While older individuals show an overall lower prevalence of depression, depression in this group is associated with a distinct risk profile, including physical impairment, difficult grief, persistent sleep disturbance, loneliness, and a history of depression. Furthermore, serious depressive disorder is linked to poor health and earlier mortality. Heart disease, diabetes, obesity, cognitive impairment, disabilities, and cancer.17
According to Vasiliou et al., individuals with higher levels of perceived stress also tend to have worse oral health, and dental insurance and socioeconomic status may have an impact on this relationship. These results highlight the importance of socioeconomic disparities in oral health broadly.34
Stress Management in Dentistry
Dental anxiety is a frequent condition that can appear before, during, or after dental treatment. An increase in heart rate, blood pressure, respiratory rate, and cardiac output are all parts of the physiological reaction. As a result, prolonged distress affects oral and overall health by causing avoidance of dental care and repeated missed appointments. Behavioral techniques in psychotherapy can alter the patient's experience in a minimally invasive manner with no or very little side effects, contingent upon the patient's traits, degree of anxiety, and clinical conditions. These treatments include hypnosis, acupuncture, muscle relaxation, biofeedback, guided imagery, physiological monitoring, distraction, and desensitization. Pharmacological intervention involves the use of oral sedation, conscious intravenous sedation, or relative analgesia (nitrous oxide).35 Progressive muscle relaxation, which focuses on tightening and relaxing particular muscle groups and effectively results in the relaxation of the mind and reduction of physical tension, is a frequently used treatment for controlling stress and anxiety in dentistry that has been proposed by Labus et al.36
The "Four Habits Model" discussed by Willumsen et al, promotes mastery of communication skills and can function as a structural framework for dental appointments (Figure 3).37
Conclusion and Future Perspectives
Evidence suggests that stress and mental health disorders can alter behavior, including poor oral hygiene habits, tobacco use, and alcohol misuse. These behaviors are also risk factors for periodontal disease.
Stress also has immunomodulatory effects that control immune cell counts and functionality as well as the generation of pro-inflammatory cytokines. A significant focus has been given to the biological connection between psychosocial stress and systemic disease; nonetheless, the functions of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system remain poorly understood. A low-grade chronic inflammation seems to be linked to psychosocial stress and a range of mental health conditions, including anxiety disorders, depression, bipolar disorder, schizophrenia, and Alzheimer's disease.
Effective stress management and treatment of mental health issues may be helpful to the periodontal care of patients. Analysis of potential connections between periodontal and mental diseases is made more difficult by the variability of these disorders in relation to their origin, psychopathology, symptoms, and level of disability. So far, only associations have been made, and future investigations of underlying mechanisms are needed.
About the Authors
Layal Bou Semaan DDS
Periodontology resident
University of Alabama at Birmingham
Department of Periodontology
Birmingham, Alabama
Maria L. Geisinger, DDS, MS
Professor
University of Alabama at Birmingham
Department of Periodontology
Birmingham, Alabama
References
1. Draft global strategy on oral health. In: Seventy-fifth World Health Assembly, Geneva, 22-28 May 2022. Provisional agenda item 14.1. Geneva: World Health Organization. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_10Add1-en.pdf. April 27, 2022. Accessed December 9, 2024.
2. Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. British Dental Journal. 2016 Dec 16;221(12):792-793.
3. World Health Organization. Prevention and promotion in mental health. Mental health: evidence and research. In: Dependence. D.o.M.H.a.S. (Ed.), Prevention and promotion in mental health. Mental health: evidence and research. 2002.
4. Fusar-Poli P, de Pablo GS, De Micheli A, Nieman DH, Correll CU, Kessing LV, Pfennig A, Bechdolf A, Borgwardt S, Arango C, van Amelsvoort T. What is good mental health? A scoping review. European Neuropsychopharmacology. 2020 Feb 1;31:33-46.
5. Tang WK, Sun FC, Ungvari GS, O'donnell D. Oral health of psychiatric in-patients in Hong Kong. International Journal of Social Psychiatry. 2004 Jun;50(2):186-191.
6. Burchell A, Fernbacher S, Lewis R, Neil A. Dental as Anything. Inner South Community Health Service Dental Outreach to People with a Mental Illness. Australian Journal of Primary Health. 2006;12(2):75-82.
7. Kisely S. No mental health without oral health. The Canadian Journal of Psychiatry. 2016 May;61(5):277-282.
8. Spitzer RL, Endicott J. Medical and mental disorder: Proposed definition and criteria. InAnnales Médico-psychologiques, revue psychiatrique. Elsevier Masson. 2018;(176)7: 656-665.
9. Sekhon S, Gupta V. Mood Disorder. In: StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK558911/. Updated May 8, 2023. Accessed December 9, 2024.
10. Depression (major depressive disorder). Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007. Updated October 14, 2022. Accessed December 9, 2024.
11. Carvalho AF, Firth J, Vieta E. Bipolar disorder. New England Journal of Medicine. 2020 Jul 2;383(1):58-66.
12. Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. Pharmacy and Therapeutics. 2014 Sep;39(9):638.
13. Vieta E, Berk M, Schulze TG, Carvalho AF, Suppes T, Calabrese JR, Gao K, Miskowiak KW, Grande I. Bipolar disorders. Nature reviews Disease primers. 2018 Mar 8;4(1):1-6.
14. Junewicz A, Billick SB. Conduct disorder: Biology and developmental trajectories. Psychiatric Quarterly. 2020 Mar;91:77-90.
15. Parenti I, Rabaneda LG, Schoen H, Novarino G. Neurodevelopmental disorders: from genetics to functional pathways. Trends in Neurosciences. 2020 Aug 1;43(8):608-621.
16. Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: Systematic review and meta-analysis. European journal of psychotraumatology. 2020 Dec 31;11(1):1709709.
17. Ball J, Darby I. Mental health and periodontal and peri‐implant diseases. Periodontology 2000. 2022 October;90(1):106-124.
18. Rohleder N. Stress and inflammation-The need to address the gap in the transition between acute and chronic stress effects. Psychoneuroendocrinology. 2019 Jul 1;105:164-171.
19. Mesa F, Magán-Fernández A, Muñoz R, et al. Catecholamine metabolites in urine, as chronic stress biomarkers, are associated with higher risk of chronic periodontitis in adults. J Periodontol 2014;85(12):1755-1762.
20. Castro MM, Ferreira RD, Fagundes NC, Almeida AP, Maia LC, Lima RR. Association between psychological stress and periodontitis: a systematic review. European journal of dentistry. 2020 Feb 18;14(01):171-179.
21. Zhang J, Lin S, Luo L, Zhang Q, Jiao Y, Liu W. Psychological stress: neuroimmune roles in periodontal disease. Odontology. 2023 Jul;111(3):554-564.
22. Cecoro G, Annunziata M, Iuorio MT, Nastri L, Guida L. Periodontitis, low-grade inflammation and systemic health: a scoping review. Medicina. 2020 May 30;56(6):272.
23. Frister A, Schmidt C, Schneble N, Brodhun M, Gonnert FA, Bauer M, Hirsch E, Müller JP, Wetzker R, Bauer R. Phosphoinositide 3-kinase γ affects LPS-induced disturbance of blood-brain barrier via lipid kinase-independent control of cAMP in microglial cells. Neuromolecular medicine. 2014 Dec;16:704-713.
24. Cirillo N, Prime SS. Keratinocytes synthesize and activate cortisol. Journal of cellular biochemistry. 2011 Jun;112(6):1499-1505.
25. Bartold PM, Kylstra A, Lawson R. Substance P: an immunohistochemical and biochemical study in human gingival tissues. A role for neurogenic inflammation? Journal of Periodontology. 1994 Dec;65(12):1113-1121.
26. Patini R, Staderini E, Lajolo C, Cordaro M, Gallenzi P, Lopetuso L, Mohammed H, Rocchetti V, Rimondini L, Franceschi F. Relationship between oral microbiota and periodontal disease: a systematic review. European Review for Medical & Pharmacological Sciences. 2018 Sep 15;22(18).
27. Jentsch HF, März D, Krüger M. The effects of stress hormones on growth of selected periodontitis related bacteria. Anaerobe. 2013 Dec 1;24:49-54.
28. Saito T, Inagaki S, Sakurai K, Okuda K, Ishihara K. Exposure of P. gingivalis to noradrenaline reduces bacterial growth and elevates ArgX protease activity. Archives of oral biology. 2011 Mar 1;56(3):244-250.
29. Georgieva I. Necrotizing periodontal disease-predisposing factors. A review. Scripta Scientifica Medicinae Dentalis. 2020 Dec 17;6(2):7-11.
30. Spector AM, Postolache TT, Akram F, Scott AJ, Wadhawan A, Reynolds MA. Psychological stress: a predisposing and exacerbating factor in periodontitis. Current Oral Health Reports. 2020 Sep;7:208-15.
31. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370(9590):859-877.
32. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for de- pression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
33. Vasiliou A, Shankardass K, Nisenbaum R, Quiñonez C. Current stress and poor oral health. BMC Oral Health. 2016 Dec;16:1.
34. Hoffmann B, Erwood K, Ncomanzi S, Fischer V, O'Brien D, Lee A. Management strategies for adult patients with dental anxiety in the dental clinic: A systematic review. Australian Dental Journal. 2022 Mar;67:S3-13.
35. Labus A, Radenković B, Rodić B, Barać D, Malešević A. Enhancing smart healthcare in dentistry: An approach to managing patients' stress. Informatics for Health and Social Care. 2021 Sep 2;46(3):306-319.
36. Willumsen T, Agdal ML, Hauge MS, Storå B. Psychological Prevention and Management of Dental Anxiety. In: Oral Health Psychology: Psychological Aspects Related to Dentistry. Springer International Publishing. 2022;179-194.
