Periodontal Emotional Stress Syndrome: Review of Basic Concepts, Mechanism and Management


Stress is an unavoidable consequence of life. It is described as adverse emotions or reactions to unpleasant experiences. Thus, stress can be viewed as a process with both psychological and physiological components. The possible mechanisms by which psychosocial factors act on periodontal tissues are oral hygiene negligence, changes in dietary intake, smoking, bruxism, gingival circulation, alteration in salivary component and flow, hormonal changes and lowered host resistance. During stress hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system interact and release glucocorticoid which has myriad of effects that disrupt homeostasis and lead to increased susceptibility to periodontal diseases. The dental practioner, thus, may always decide to refer patients to appropriate professional for assistance and counselling. Therefore, reducing stress and improving coping strategies may improve the periodontal prognosis and treatment outcomes. The aim of this review is to provide an insight into the relationship between psychological stress and periodontal diseases.

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Bansal, J. , Bansal, A. , Shahi, M. , Kedige, S. and Narula, R. (2014) Periodontal Emotional Stress Syndrome: Review of Basic Concepts, Mechanism and Management. Open Journal of Medical Psychology, 3, 250-261. doi: 10.4236/ojmp.2014.33026.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Koolhaas, J.M., Bartolomucci, A., Buwalda, B. et al. (2011) Stress Revisited: A Critical Evaluation of the Stress Concept. Neuroscience & Biobehavioral Review, 35, 1291-1301.
[2] Selye, H. (1976) Stress in Health and Disease. Butterworths, Boston.
[3] Breivik, T., Thrane, P.S., Murison, R. and Gjermo, P. (1996) Emotional Stress Effects on Immunity, Gingivitis and Periodontitis. European Journal of Oral Sciences, 104, 327-334.
[4] De Marco, T. (1996) Periodontal Emotional Stress Syndrome. Journal of Periodontology, 47, 67-68.
[5] Leresche, L. and Dworkin, S.F. (2002) The Role of Stress in Inflammatory Disease, Including Periodontal Disease: Review of Concepts and Current Findings. Periodontology 2000, 30, 91-103.
[6] Rosania, A.E., Low, K.G., McCormick, C.M. and Rosania, D.A. (2009) Stress, Depression, Cortisol, and Periodontal Disease. Journal of Periodontology, 80, 260-62.
[7] Bartold, P., Kylstra, A. and Lawson, R. (1994) Substance P: An Immunohistochemical and Biochemical Study in Human Gingival Tissues. A Role for Neurogenic Inflammation? Journal of Periodontology, 65, 1113-1121.
[8] Kamma, J.J. and Baehni, P.C. (2003) Five-Year Maintenance Follow-Up of Early-Onset Periodontitis Patients. Journal of Clinical Periodontology, 30, 562-572.
[9] Wimmer, G., Janda, M., Wieselmann-Penkner, K., Jakse, N., Polansky, R. and Pertl, C. (2002) Coping with Stress: Its Influence on Periodontal Disease. Journal of Periodontology, 73, 1343-351.
[10] Hilgert, J.B., Hugo, F.N., Bandeira, D.R. and Bozzetti, M.C. (2006) Stress, Cortisol, and Periodontitis in a Population Aged 50 Years and over. Journal of Dental Research, 85, 324-328.
[11] Rai, B., Kaur, J., Anand, S.C. and Jacobs, R. (2011) Salivary Stress Markers, Stress, and Periodontitis: A Pilot Study. Journal of Periodontology, 82, 287-292.
[12] Goyal, S., Jajoo, S., Nagappa, G. and Rao, G. (2011) Estimation of Relationship between Psychosocial Stress and Periodontal Status Using Serum Cortisol Level: A Clinico-Biochemical Study. Indian Journal of Dental Research, 22, 6-9.
[13] Dhabbar, F.S. (2002) Stress-Induced Augmentation of Immune Function—The Role of Stress Hormones, Leukocyte Trafficking, and Cytokines. Brain, Behavior, and Immunity, 16, 785-798.
[14] Culshaw, S., Mcinnes, I.B. and Liew, F.Y. (2011) What Can the Periodontal Community Learn from the Pathophysio- logy of Rheumatoid Arthritis? Journal of Clinical Periodontology, 38, 106-113.
[15] Chida, Y. and Hamer, M. (2008) An Association of Adverse Psychosocial Factors with Diabetes Mellitus: A Meta-Analytic Review of Longitudinal Cohort Studies. Diabetologia, 51, 2168-2178.
[16] Backe, E.M., Seidler, A., Latza, U., Rossnagel, K. and Schumann, B. (2012) The Role of Psychosocial Stress at Work for the Development of Cardiovascular Diseases: A Systematic Review. International Archives of Occupational and Environmental Health, 85, 67-79.
[17] Stabholz, A., Soskolne, W.A. and Shapira, L. (2010) Genetic and Environmental Risk Factors for Chronic Periodontitis and Aggressive Periodontitis. Periodontology 2000, 53, 138-153.
[18] Freeman, R. and Goss, S. (1993) Stress Measures as Predictors of Periodontal Disease—A Preliminary Communication. Community Dentistry and Oral Epidemiology, 21, 176-177.
[19] Ng, S.K. and Keung Leung, W. (2006) A Community Study on the Relationship between Stress, Coping, Affective Dispositions and Periodontal Attachment Loss. Community Dentistry and Oral Epidemiology, 34, 252-266.
[20] Peruzzo, D.C., Benatti, B.B., Ambrosano, G.M., Nogueira-Filho, G.R., Sallum, E.A., Casati, M.Z. and Nociti, F.H. (2007) A Systematic Review of Stress and Psychological Factors as Possible Risk Factors for Periodontal Disease. Journal of Periodontology, 78, 1491-1504.
[21] Rosania, A.E., Low, K.G., McCormick, C.M. and Rosania, D.A. (2009) Stress, Depression, Cortisol, and Periodontal Disease. Journal of Periodontology, 80, 260-266.
[22] Ballieux, R. (1991) Impact of Mental Stress on the Immune Response. Journal of Clinical Periodontology, 18, 427-430.
[23] Linden, G.J., McKinnell, J., Shaw, C. and Lundy, F.T. (1998) Substance P and Neurokinin A in Gingival Crevicular Fluid in Periodontal Health and Disease. Journal of Clinical Periodontology, 24, 799-803.
[24] Monteiro da Silva, A., Newman, H. and Oakley, D. (1995) Psychosocial Factors in Inflammatory Periodontal Diseases. Journal of Clinical Periodontology, 22, 516-526.
[25] Buduneli, N., Ozcaka, O. and Nalbantsoy, A. (2011) Salivary and Plasma Levels of Toll-Like Receptor 2 and Toll-Like Receptor 4 in Chronic Periodontitis. Journal of Periodontology, 82, 878-884.
[26] Pani, S.C., Al Askar, A.M., Al Mohrij, S.I. and Al Ohali, T.A. (2011) Evaluation of Stress in Final-Year Saudi Dental Students Using Salivary Cortisol as a Biomarker. Journal of Dental Education, 75, 377-384.
[27] Johannsen, A., Bjurshammar, N. and Gustafsson, A. (2010) The Influence of Academic Stress on Gingival Inflammation. International Journal of Dental Hygiene, 8, 22-27.
[28] Poll, E.M., Kreitschmann-Andermahr, I., Langejuergen, Y., Stanzel, S., Gilsbach, J.M., Gressner, A. and Yagmur, E. (2007) Saliva Collection Method Affects Predictability of Serum Cortisol. Clinica Chimica Acta, 382, 15-19.
[29] Dickerson, S.S. and Kemeny, M.E. (2004) Acute Stressors and Cortisol Responses: A Theoretical Integration and Synthesis of Laboratory Research. Psychological Bulletin, 130, 355-391.
[30] Groer, M., Murphy, R., Bunnell, W., Salomon, K., Van Eepoel, J., Rankin, B., White, K. and Bykowski, C. (2010) Salivary Measures of Stress and Immunity in Police Officers Engaged in Simulated Critical Incident Scenarios. Journal of Occupational & Environmental Medicine, 52, 595-602.
[31] Kunz-Ebrecht, S.R., Mohamed-Ali, V., Feldman, P.J., Kirschbaum, C. and Steptoe, A. (2003) Cortisol Responses to Mild Psychological Stress Are Inversely Associated with Proinflammatory Cytokines. Brain, Behavior, and Immunity, 17, 373-383.
[32] Papacosta, E. and Nassis, G.P. (2011) Saliva as a Tool for Monitoring Steroid, Peptide and Immune Markers in Sport and Exercise Science. Journal of Science and Medicine in Sport, 14, 424-434.
[33] Gatti, R., Antonelli, G., Prearo, M., Spinella, P., Cappellin, E. and De Palo, E.F. (2009) Cortisol Assays and Diagnostic Laboratory Procedures in Human Biological Fluids. Clinical Biochemistry, 42, 1205-1217.
[34] Webster Marketon, J.I. and Glaser, R. (2008) Stress Hormones and Immune Function. Cellular Immunology, 252, 16-26.
[35] Hansel, A., Hong, S., Camara, R.J. and Von Kanel, R. (2010) Inflammation as a Psychophysiological Biomarker in Chronic Psychosocial Stress. Neuroscience & Biobehavioral Reviews, 35, 115-121.
[36] Ben-Eliyahu, S., Shakhar, G., Page, G.G., Stefanski, V. and Shakhar, K. (2000) Suppression of NK Cell Activity and of Resistance to Metastasis by Stress: A Role for Adrenal Catecholamines and Beta Adrenoceptors. NeuroImmuno-Modulation, 8, 154-164.
[37] Padgett, D.A. and Glaser, R. (2003) How Stress Influences the Immune Response. Trends in Immunology, 24, 444-448.
[38] Takai, N., Yamaguchi, M., Aragaki, T., Eto, K., Uchihashi, K. and Nishikawa, Y. (2004) Effect of Psychological Stress on the Salivary Cortisol and Amylase Levels in Healthy Young Adults. Archives of Oral Biology, 49, 963-968.
[39] Hamaguchi, T., Fukudo, S., Kanazawa, M., Tomiie, T., Shimizu, K., Oyama, M. and Sakurai, K. (2008) Changes in Salivary Physiological Stress Markers Induced by Muscle Stretching in Patients with Irritable Bowel Syndrome. Bio-PsychoSocial Medicine, 2, 20.
[40] Nakane, H., Asami, O., Yamada, Y. and Ohira, H. (2002) Effect of Negative Air Ions on Computer Operation, Anxiety and Salivary Chromogranin A-Like Immunoreactivity. International Journal of Psychophysiology, 46, 85-89.
[41] Saruta, J., Tsukinoki, K., Sasaguri, K., Ishii, H., Yasuda, M., Osamura, Y.R., Watanabe, Y. and Sato, S. (2005) Expression and Localization of Chromogranin A Gene and Protein in Human Submandibular Gland. Cells Tissues Organs, 180, 237-244.
[42] Pradeep, A.R., Raj, S., Aruna, G. and Chowdhry, S. (2009) Gingival Crevicular Fluid and Plasma Levels of Neuropeptide Substance-P in Periodontal Health, Disease and after Nonsurgical Therapy. Journal of Periodontal Research, 44, 232-237.
[43] Miller, D.B. and O’Callaghan, J.P. (2002) Neuroendocrine Aspects of the Response to Stress. Metabolism-Clinical and Experimental, 51, 5-10.
[44] Soell, M., Elkaim, R. and Tenenbaum, H. (2002) Cathepsin C, Matrix Metalloproteinases, and Their Tissue Inhibitors in Gingiva and Gingival Crevicular Fluid from Periodontitis-Affected Patients. Journal of Dental Research, 81, 174-178.
[45] Buduneli, N., Biyikoglu, B., Sherrabeh, S. and Lappin, D.F. (2008) Saliva Concentrations of RANKL and Osteoprotegerin in Smoker versus Non-Smoker Chronic Periodontitis Patients. Journal of Clinical Periodontology, 35, 846-852.
[46] Sheiham, A. and Nicolau, B. (2005) Evaluation of Social and Psychological Factors in Periodontal Disease. Periodontology 2000, 39, 118-131.
[47] Genco, R.J., Ho, A.W., Kopman, J., Grossi, S.G., Dunford, R.G. and Tedesco, L.A. (1998) Models to Evaluate the Role of Stress in Periodontal Disease. Annals of Periodontology, 3, 288-302.
[48] Ishisaka, A., Ansai, T., Soh, I., Inenaga, K., Yoshida, A., Shigeyama, C., et al. (2007) Association of Salivary Levels of Cortisol and Dehydroepiandrosterone with Periodontitis in Older Japanese Adults. Journal of Periodontology, 78, 1767-1773.
[49] Johannsen, A., Rydmark, I., Soder, B. and Asberg, M. (2007) Gingival Inflammation, Increased Periodontal Pocket Depth and Elevated Interleukin-6 in Gingival Crevicular Fluid of Depressed Women on Long-Term Sick Leave. Journal of Periodontal Research, 42, 546-552.
[50] Giannopoulou, C., Kamma, J.J. and Mombelli, A. (2003) Effect of Inflammation, Smoking and Stress on Gingival Crevicular Fluid Cytokine Level. Journal of Clinical Periodontology, 30, 145-153.
[51] Mengel, R., Bacher, M. and Flores-De-Jacoby, L. (2002) Interactions between Stress, Interleukin-1Beta, Interleukin-6 and Cortisol in Periodontally Diseased Patients. Journal of Clinical Periodontology, 29, 1012-1022.
[52] Soeda, R., Tasaka, A. and Sakurai, K. (2012) Influence of Chewing Force on Salivary Stress Markers as Indicator of Mental Stress. Journal of Oral Rehabilitation, 39, 261-269.
[53] Olkinuora, M. (1972) Psychosocial Aspects in a Series of Bruxists Compared with a Group of Non-Bruxists. Suomen Hammaslaakariseuran Toimituksia, 68, 200-208.
[54] Mercado, F.B., Marshall, R.I. and Bartold, P.M. (2003) Inter-Relationships between Rheumatoid Arthritis and Periodontal Disease. Journal of Clinical Periodontology, 30, 761-772.
[55] Deinzer, R., Granrath, N., Stuhl, H., Twork, L., Idel, H., Waschul, B. and Herforth, A. (2004) Acute Stress Effects on Local IL-1β Responses to Pathogens in a Human in Vivo Model. Brain, Behavior, and Immunity, 18, 458-467.
[56] Deinzer, R., Foster, P., Fuck, L., Herforth, A., Stiller-Winkler, R. and Idel, H. (1999) Increase of Crevicular Interleukin 1b under Stress at Experimental Gingivitis Sites and at Sites of Perfect Oral Hygiene. Journal of Clinical Periodontology, 26, 1-8.
[57] Deinzer, R., Kottman, W., Foster, P., Herforth, A., Stiller-Winkler, R. and Idel, H. (2000) After Effects of Stress on Crevicular Interleukin-1β. Journal of Clinical Periodontology, 27, 74-77.
[58] Deinzer, R., Hilpert, D., Bach, K., Schawacht, M. and Herforth, K. (2001) Effects of Academic Stress on Oral Hygiene— A Potential Link between Stress and Plaque Associated Disease? Journal of Clinical Periodontology, 28, 459-464.
[59] Deinzer, R., Rüttermen, S., Mobes, O. and Herforth, A. (1998) Increase in Gingival Inflammation under Academic Stress. Journal of Clinical Periodontology, 25, 431-433.
[60] Axtellius, B., Edwardsson, S., Theodorsson, E., Svensater, G. and Attstrom, R. (1998) Presence of Cortisol in Gingival Crevicular Fluid. A Pilot Study. Journal of Clinical Periodontology, 25, 929-932.
[61] Pindborg, J.J. (1951) Gingivitis in Military Personnel with Special Reference to Ulceromembranous Gingivitis. Odontologisk Tidskrift, 59, 407-493.
[62] Cogen, R.B., Stevens Jr., A.W., Cohen-Cole, S., Kirk, K. and Freeman, A. (1983) Leukocyte Function in the Etiology of Acute Necrotizing Ulcerative Gingivitis. Journal of Periodontology, 54, 402-407.
[63] Walsh, L.J., Trinchieri, G., Waldorf, H.A., Whitaker, D. and Murphy, G.F. (1991) Human Dermal Mast Cells Contain and Release Tumor Necrosis Factor α, Which Induces Endothelial Leukocyte Adhesion Molecule 1. Proceedings of the National Academy of Sciences of the United States of America, 88, 4220-4224.
[64] Frangogiannis, N.G., Lindsey, M.L., Michael, L.H., Youker, K.A., Bressler, R.B., Mendoza, L.H., Spengler, R.N., Wayne Smith, C. and Entman, M.L. (1998) Resident Cardiac Mast Cells Degranulate and Release Preformed TNF-α, Initiating the Cytokine Cascade in Experimental Canine Myocardial Ischemia/Reperfusion. Circulation, 98, 699-710.
[65] Spencer, L.A., Melo, R.C.N., Perez, S.A.C., Bafford, S.P., Dvorak, A.M. and Weller, P.F. (2006) Cytokine Receptor Mediated Trafficking of Preformed IL-4 in Eosinophils Identifies an Innate Immune Mechanism of Cytokine Secretion. Proceedings of the National Academy of Sciences of the United States of America, 103, 3333-3338.
[66] Oynebraten, I., Bakke, L., Brandtzaeg, P., Johansen, F.E. and Haraldsen, G. (2004) Rapid Chemokine Secretion from Endothelial Cells Originates from 2 Distinct Compartments. Blood, 104, 314-320.
[67] Bandeira-Melo, C., Sugiyama, K., Woods, L.J. and Weller, P.F. (2001) Cutting Edge, Eotaxin Elicits Rapid Vesicular Transport-Mediated Release of Preformed IL-4 from Human Eosinophils. Journal of Immunology, 166, 4813-4817.
[68] Gibbs, B.F., Wierecky, J., Welker, P., Henz, B.M., Wolff, H.H. and Grabbe, J. (2001) Human Skin Mast Cells Rapidly Release Preformed and Newly Generated TNF-Alpha and IL-8 Following Stimulation with Anti-IgE and Other Secretagogues. Experimental Dermatology, 10, 312-320.
[69] Gibbs, B.F., Haas, H., Falcone, F.H., Albrecht, C., Vollrath, I.B., Noll, T., Wolff, H.H. and Amon, U. (1996) Purified Human Peripheral Blood Basophils Release Interleukin-13 and Preformed Interleukin-4 Following Immunological Activation. European Journal of Immunology, 26, 2493-2498.
[70] Schroder, A.K., Uciechowski, P., Fleischer, D. and Rink, L. (2006) Crosslinking of CD66b on Peripheral Blood Neu- trophils Mediates the Release of Interleukin-8 from Intracellular Storage. Human Immunology, 67, 676-682.
[71] Utgaard, J.O., Jahnsen, F.L., Bakka, A., Brandtzaeg, P. and Haraldsen, G. (1998) Rapid Secretion of Prestored Inter-leukin-8 from Weibel-Palade Bodies of Microvascular Endothelial Cells. Journal of Experimental Medicine, 188, 1751-1756.
[72] Page, R.C., Altman, L.C., Ebersole, J.L., Vandesteen, G.E., Dahlberg, W.H., Williams, B.L. and Osterberg, S.K. (1983) Rapidly Progressive Periodontitis: A Distinct Clinical Condition. Journal of Periodontology, 54, 197-209.
[73] Monteira da silva, A., Oakley, D., Newmann, H., Nohl, F. and Lloyd, H.M. (1996) Psychosocial Factors and Adult Onset Rapidly Progressive Periodontitis. Journal of Clinical Periodontology, 23, 789-794.
[74] Genco, R.J., Ho, A.W., Grossi, S.G., Dunford, R.G. and Tedesco, L.A. (1999) Relationship of Stress, Distress and In-adequate Coping Behaviors to Periodontal Disease. Journal of Periodontology, 70, 711-723.
[75] Wimmer, G., Kohldorfer, G., Mischak, I., Lorenzoni, M. and Kallus, K.W. (2005) Coping with Stress: Its Influence on Periodontal Therapy. Journal of Periodontology, 76, 90-98.
[76] Reners, M. and Brecx, M. (2007) Stress and Periodontal Disease. International Journal of Dental Hygiene, 5, 199-204.

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