15: Stress, Coping, and Periodontal Disease


Stress, Coping, and Periodontal Disease

Gernot Wimmer and Walther Wegscheider

Key points
  • Stress may have a negative impact on general health.
  • It has been assumed that psychological stresses and psychosocial factors may play a role in the development of chronic diseases like periodontitis.
  • Individual stress coping strategies may exert influence on the onset, development, and severity of periodontal disease.
  • Inadequate stress coping strategies might modulate the impact of stress and may be considered as potential risk factor for periodontal disease.


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).

Coping with Stress: Its Influence on Periodontal Disease

Using a stress coping questionnaire, the coping patterns used by patients with existing periodontal disease to react to specific stressful situations were determined; that is, do patients with periodontitis have specific stress coping strategies that differ from the coping strategies of periodontally intact controls (Wimmer et al., 2002)? For a psychodiagnostic registration of data concerning stress coping, all persons answered a stress-coping questionnaire (SVF) consisting of 114 questions which included a total of 19 actional and intrapsychic stress coping modes (Janke, Erdmann, & Kallus, 1985). Each of these 19 subtests was optionalized with 6 questions. Activity-related coping included behaviors which signify attack, escape, social contact, withdrawal, and so on, that is, all strategies that aim to actively alter the stressful situation or one’s own reaction to it. Intrapsychic strategies are processes such as perception, thinking, imagination, and all motivational-emotional processes, for example, distraction, devaluation, denial, and overestimation of one’s own resources.

The test instrument (stress questionnaire) had the following three features: (1) The 19 subtests provided a very detailed documentation of stress coping measures, which made the test different from other instruments that attempt to study stress coping on the basis of a single dimension or a few dimensions. (2) The questionnaire also contained questions about “stress-enhancing” strategies such as “social isolation,” as it is assumed that the measures used by the individual do not only “reduce” stress but may also aggravate it. (3) The questionnaire did not address cognitive strategies alone, but also recorded behavior-oriented strategies such as “escape,” “avoidance,” and “pharmaceutical drugs.” The respondent was repeatedly confronted with one and the same statement: “When I am thwarted, inwardly upset, or made to lose my balance by something or someone. …” This statement was followed by various items such as “I visit pleasant friends or acquaintances” or “What I’d like to do most is run away.” The five-point Likert-scale answers ranged from “0 = not at all” to “4 = very likely.” t-Transformed scale values were then calculated from raw data to permit comparisons with the random sample used for standardization. Using a factor analysis, 5 factors that strongly correlated with each other were extracted from the 19 subtests (Table 15.1).

Table 15.1 Extracted Factors after Factor Analysis

Factors Subtests
Factor 1 = resigned coping Avoidance, escape, social withdrawal, resignation, self-pity, rumination
Factor 2 = active coping Response control, situation control, minimization, positive self-instruction
Factor 3 = distractive coping Distraction, search for self-affirmation, substitute gratification, need for social support
Factor 4 = defensive coping Averting blame, accusation of self, playing down in comparison with others
Factor 5 = coping with aggression and drug use Aggression, drug use

Factor 1 was termed resigned coping and included the following subtests: avoidance, escape, social withdrawal, resignation, self-pity, and rumination. Factor 2 comprised the subtests response control, situation control, positive self-instruction, and minimization, and was termed active coping. A similar degree of charge was found for the subtests in the extracted factor 3, which was termed distractive coping. The subtests for this factor were distraction, search for self-affirmation, substitute gratification, and need for social support. Factor 4 was termed defensive coping and included the following subtests: averting blame, accusation of self, and playing down in comparison with others. For the subtests aggression and drug use, no association with other factors was found. Therefore, these two variables were summarized as factor 5 and designated accordingly. Factors 1 and 2 describe active problem-oriented coping strategies while the factor groups 3 and 4 (5) describe passive emotion-oriented coping.

Statistical evaluation revealed that, in the present study, the stress coping behavior of patients with periodontitis differed from that of controls in regard to stress coping strategies. Patients had significantly less loading for factor 2 (active coping) than did controls. In other words, patients used active stress coping strategies to a lesser extent than did controls. On the other hand, patients had a />

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 15: Stress, Coping, and Periodontal Disease
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