Trisha E. O`Hehir, RDH, BS
Do you ever feel like dental hygiene is just a cover-up for your real job as psychotherapist? Even if you aren`t a Freud-want-to-be, all you have to do is ask patients if anything has changed in their lives and, before you know it, their problems and life-traumas are laid out before you. In gathering information about our patients, we`re sometimes accused of spending too much time "talking" with them. There is a good reason for carrying on these extended conversations with our patients. Research has demonstrated a link between stress and periodontal disease. You`ve seen this yourself, long before the research was published.
Dental hygienists don`t need an advanced degree in immunology to recognize and understand the link between stress and periodontal disease. You see it every day. How many times have you observed increases in periodontal disease and simply asked patients what was going on in their life right then? You may not know the names of all the stress hormones or the cytokines that increase in concentration during stress, but you`ve seen the link between stress and periodontal disease in your own patients. Research studies now confirm what you`ve learned through experience.
Research confirms that stress is a risk factor for periodontal disease, affecting both behavior and psycho-immunology. People under stress report a decrease in their usual oral hygiene habits. They no longer follow good preventive behaviors. Poor nutrition also is associated with increased stress levels. Under stress, smokers increase tobacco use. Several studies have demonstrated a link between stress and immune function, as well as susceptibility to infectious diseases.
Medical studies use lab animals to test social stress and disease susceptibility. Lab rats subjected to crowding shortly before exposure to flu viruses demonstrated greater susceptibility to infection than rats not subjected to crowding.
To measure susceptibility in humans, they have compared the elderly caregivers of individuals with Alzheimer`s disease with age- and health-matched controls. When both groups are given a flu vaccination, those under stress produced fewer antibodies.
Most studies use self-reported information and stress questionnaires to determine who may be under more stress or coping with stress less effectively. Studies involving controlled stress situations are more difficult to design.
Dental researchers in Germany found an interesting situation that provided a unique model for studying academic stress. In Germany, medial students must take an involved exam midway through their studies. If they do not pass this three-part exam, they must withdraw from medical school. The examination involves two consecutive days of written exams, four hours each day, followed by an oral exam two weeks later. Only two retakes of the exam are allowed before expulsion. This examination process definitely produces stress.
During the last week of the academic examination, researchers took daily measurements of gingival crevicular fluid levels of Interleukin-1ß (IL-1ß), which is a cytokine associated with tissue breakdown. Half of the 26 medical students took part in the medical school examination during the time of this study.
Dental hygiene care was provided a month before the study began in order to achieve near perfect oral health for all the subjects. They were instructed to floss daily, and instructions were repeated until they all achieved a bleeding score of zero. During the study period, they refrained from all oral hygiene on either the right or left side of the mouth, from the cuspid back. This half-mouth experimental gingivitis continued for 21 days, ending two weeks after completion of the academic examination. In addition to gingival crevicular fluid samples, plaque, gingivitis, and bleeding scores were recorded every day throughout the study.
The students taking the exam produced twice as much IL-1? as the controls. Increases were observed in both experimental gingivitis sites and healthy sites, but sites with plaque accumulation showed higher rates. The control group also showed an increase in IL-1? at experimental gingivitis sites. This confirms that both stress and bacterial accumulation influence production of IL-1?. In the test subjects, the combination of stress and plaque accumulation produced a synergistic effect resulting in even higher levels of IL-1?.
In those taking the academic exam, IL-1? levels rose sharply just after the exam and remained high for a week after completing the academic exam. This finding makes sense considering people seem most susceptible to infection right after a time of stress, rather than during the stress.
Talking to our patients and asking questions about stress may provide information as valuable as that gathered through clinical assessment. Understanding the link between stress and periodontal disease and communicating that to our patients is an important component of dental hygiene care.
Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics. The Web site for Perio Reports is www.perioreports.com. Her e-mail address is trisha@perioreports. com.