Summer 2014

Gums Under Attack

Stress may cause periodontal disease

By Michael Blanding

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Cortisol, released by the body during times of stress, can play a role in gum disease. Photo: CNRI/Science Source

We all know what contributes to gum disease—poor brushing, forgetting to floss, avoiding checkups, smoking. But what about a tough day at the office or dire financial straits? Surprisingly, the stress brought on by emotional struggles might have just as much to do with the disease, according to a review of the literature by three researchers at Tufts University.

“It’s been shown there is a significant association between emotional stress and periodontal disease,” says Evangelos Papathanasiou, an assistant professor of periodontology at Tufts School of Dental Medicine.

“The more modern concept [of gum disease] is that the inflammatory response from the immune cells plays a significant role.” —Evangelos Papathanasiou

Before he came to Tufts, Papathanasiou was a dentist in the Greek air force and saw a number of soldiers under high stress who developed mouth ulcers and bleeding gums. Closer to home, he recently experienced bleeding while brushing his own teeth. “I realize that when I am under stress, my gums tend to bleed more when I am brushing,” he says. Papathanasiou was aware of previous studies that showed that financial strain and academic stress can lead to more plaque and gum inflammation.

That led him and two pathobiologists from the Sackler School of Graduate Biomedical Sciences, Theoharis Theoharides and Iro Palaska, to investigate further. In the review they published in the Journal of Biological Regulators & Homeostatic Agents, they propose a novel theory for how stress can regulate gum inflammation—a phenomenon whereby the body, in an effort to protect itself from mouth bacteria, essentially attacks its own gums.

The accepted cause of gum disease is this: When people fail to brush adequately, bacteria build up on teeth and gums, eventually leading to decay and disease. And that’s exactly what happens—up to a point, says Papathanasiou. “When bacteria build up, they begin to release toxins. Those are like their weapons,” he says. “Their goal is to create more space so more bacteria can form.” The pockets that toxins create in the gums help anaerobic mouth bacteria thrive and cause gingivitis, the early stages of gum disease.

An Inflammatory Response

But that’s only half the story. At the same time these bacteria are attacking the teeth and gums, the body is producing immune cells to fight them off. In a perfect world, immune cells and bacteria are in balance and thus protect the teeth and gums. At a certain point, however, immune cells become so numerous that they begin to inflame tissue and hasten disease rather than prevent it—the same way an allergic reaction can cause the body more harm than good. At this point, gingivitis, which is reversible, gives way to bone loss around teeth and full-blown periodontitis, which is not.

“For many years, the theory was that bacteria were mainly responsible, which is why most therapies have targeted bacteria,” says Papathanasiou. “But the more modern concept is that the inflammatory response from the immune cells plays a significant role.” The intensity of this immune response seems to be modified by a number of factors, including genetics, diabetes and smoking.

The researchers’ literature review found that emotional stress was also associated with accelerated periodontal disease, Papathanasiou says. There are two theories about that. The first is behavioral. When people are under emotional stress, they tend to abandon healthy behaviors and eat sugary foods, smoke, drink more alcohol and brush and floss less—all of which promote bacteria growth.

The second, and more surprising, theory is biological. When the body is under stress, it produces more of the hormone cortisol, which usually acts as an anti-inflammatory agent. But when cortisol is produced in the gums, it seems to stimulate mast cells to produce more proteins, increasing inflammation and therefore increasing the progression of gum disease.

Papathanasiou emphasizes that this biological cause-and-effect has not yet been fully explored in relation to gum disease, and that he and Theoharides are planning to test the hypothesis in the lab.

“The future of periodontal therapy is not only to target the bacteria, but to try to control the inflammation, too,” he says.

Michael Blanding is a freelance writer in Brookline, Mass.

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