Introduction

Periodontitis is a biofilm-associated chronic inflammatory disease of the supporting tissues of the teeth primarily caused and initiated by specific periopathogenic microorganisms and their metabolic products (Socransky & Haffajee, 1992; Page & Kornman, 1997). Epidemiological studies indicate several so-called risk factors that may be closely related to the emergence, severity, and progression of periodontitis (Genco, 1996). On the one hand, susceptibility to the disease may be increased by inherent biological conditions and, on the other hand, factors influencing the disease may be acquired in the course of one’s life and render a primarily resistant individual susceptible to the disease (Genco & Löe, 1993). Of the immanent factors, mainly genetic factors like polymorphisms and gene mutations, are those that influence the immune system and are associated with a harmful progression of the disease (Kornman et al., 1997; Laine, Crielaard, & Loos, 2012). In addition to systemic diseases like diabetes mellitus (Lalla & Papapanou, 2011), unfavorable forms of behavior such as smoking (Walter, Kaye, & Dietrich, 2012), diet (Kaye, 2012), or individual oral hygiene may be related to the pathogenesis and development of periodontal disease. Following some earlier research by Giddon (Goldhaber & Giddon, 1964; Giddon, 1966) and the summary of prior studies (Giddon, 1999), it has been assumed that psychological stresses and psychosocial factors play a role in the development of periodontal disease. It is also suspected that stress enhances the individual’s susceptibility to periodontitis (overview studies by Ballieux, 1991; Monteiro da Silva, Newman, & Oakley, 1995; Breivik et al., 1996; Monteiro da Silva et al., 1998; Solis et al., 2004). The mechanisms by which psychological strains, psychosocial factors, or individual internalized physiological changes and/or behavior in response to stress influence the initiation or progression of periodontitis are nearly unknown and remain hypothetical. Two models are discussed on how stress mediates increased susceptibility to periodontal diseases (Genco et al., 1998): First, sress-mediated activation of the hypothalamic–pituitary–adrenal axis promotes secretion of the hypothalamic hormone called corticotrophin-releasing hormone (CRH), which in turn stimulates the pituitary to release the hormone adrenocorticotrophic hormone (ACTH). ACTH stimulates the adrenal cortex to secretion of glucocorticoids, like cortisol, which has suppressive effects on immune system (Salvi et al., 1997). Additionally, stress-mediated stimulation of the autonomic nervous system promotes the adrenal medulla to secretion of catecholamines, such as adrenalin and noradrenalin. Catecholamines promote formation of tissue destroying prostaglandins and proteases. Second, behaviorally, promotion of health-damaging behaviors, such as smoking, neglect of oral hygiene, and unhealthy, fatty food intake, leads to an aggravation of periodontitis (LeResche & Dworkin, 2002). Psychosocial factors, such as occupational stress, quality of relationships, strains because of being jobless, and amount of stressful event in a certain period, can be manifested in a depression. Such factors promote the development and progression of a periodontitis. Causality of this association is the promotion of unhealthy behaviors, such as smoking, neglect of oral hygiene, consumption of alcohol, unhealthy food intake, and physical inactivity (Sheiham & Nicolau, 2005). In regard to these two mechanisms, the influence of stress on periodontal wound healing is discussed (Boyapati & Wang, 2007).

In this chapter in particular, the influence of individual stress coping strategies upon the emergence, progression, and treatment of periodontal disease will be investigated, and clinical implications thereof will be discussed.

Studies on Stress Coping

The majority of stress-relevant studies dealing with the impact of stress on oral conditions try to establish an association between the influence of various psychological and psychosocial stresses and their potential disease-producing outcomes (Stanford & Rees, 2003). However, they do not consider individual reactions or responses to such stresses. The mode of confronting stressors and dealing with them or the efforts made to overcome difficulties, stress, and stressful situations is termed coping. The manner in which individuals cope with stressful events is, according to Lazarus (1966), more important for their psychological and physical well-being than the frequency and severity of the stressors as such. Either consciously or unconsciously, individuals use coping measures as a response to stress in order to reduce its intensity or to overcome stress altogether. In a large cross-sectional study, Genco et al. (1999) found that psychosocial stress factors in conjunction with financial worries are significant risk indicators for adult periodontal disease. Furthermore, the authors point out that adequate coping behaviors, as evidenced by high levels of problem-based coping, may reduce the stress-associated risk. The results of this study justify the assumption that the individual concept of stress coping is especially significant and that inadequate stress coping strategies might modulate the impact of stress on periodontal disease. Psychosocial variables, such as amount of strains and stress coping strategies, are potential risk factors for development and progression of a periodontitis (Heitz-Mayfield, 2005).