Dental Tribune USA

Stress—Friend or enemy?

By Michèle Reners
April 17, 2019

“Stress” is a term that is often misused and applied inappropriately. In today’s world, being stressed is often associated with a busy, active work life. In reality, what we call “stress” is actually a complex phenomenon that weakens our organism and whose main purpose is to maintain internal balance. Stress is blamed for many illnesses and, more than just a risk factor, it is a real affliction.

But it was not always like this. Primitive humans lived under much more stressful conditions than we do today, since their survival was constantly at stake. They had to hunt to survive and were required to either fight or flee. The reactions generated by stress were a source of energy that allowed them to survive in the aggressive world they lived in. They immediately channelled their energy into action. In today’s world, aggression is evidently more often verbal and it is impossible to fight or flee from a board of examiners, the boss or a traffic jam. Stress often lasts longer and is more intense (bullying in the workplace, for example) and it is here that the pathology becomes ingrained.

But what is stress?

It is an adaptive response. In 1920, Cannon proposed a scientific description of stress: “the body of any complex animal manifests a stereotyped response pattern to any environmental threat disturbing its balance”, the well-known fight or flight response. It was Selye who in 1936 named it the “general adaptation syndrome”. He described three stages of physiological responses. The first is the alarm stage, when faced with a difficult situation. This stage aims to mobilise resources: breathing accelerates, fat is burned and glucose released. The heart rate increases and the five senses become sharper. Digestion is interrupted and saliva production decreases. Priority is given to the muscles and the brain. All of these reactions, or adaption efforts, are normal and useful and they allow our body to adapt to a continually moving environment. If no action is possible and no solution conceivable for adapting to the threat, the resistance stage begins. This stage corresponds to a state of heterostasis, and it is at this stage that psychological and/or psychosomatic problems may begin. The stage of exhaustion marks the end of the stage of resistance with the exhaustion of resources and the abandoning of effort. This is burn-out.

Of course, everyone reacts differently to stressors, because everyone sees things differently and has his or her own capacity for adaptation (or ability to cope). We talk about successful coping behaviour when the individual has a feeling of confronting and staying in control. It would be a failure if he or she were overwhelmed by events (stressors). Selye also made a distinction between negative stress (distress) and positive stress (eustress). The latter is beneficial to everyone, as it allows one to push one’s boundaries without losing one’s internal balance and reach a fixed objective (for example, the stress of a sportsperson before a competition).

What is the link between stress and periodontal disease?

Periodontal disease is an inflammatory multifactorial bacterial disease. In necrotic periodontitis, stress has long been recognised as a major risk factor. Alexander the Great’s soldiers were already suffering from this pathology, and later, it affected soldiers in World War I, when it was known as “trench disease”. Stages of activity have been described in the development of periodontal disease. Stress is considered to be an aggravating factor owing to two phenomena: stress generates a change in behaviour on the one hand and a reduction in immune defences on the other. Many studies, some very old, have shown that patients with depression have a tendency to eat poorly, take less care of themselves and increase their consumption of tobacco, alcohol and medication. We know that periodontal disease is stabilised if patients carry out daily meticulous cleaning of their teeth and interdental spaces. Internal motivation is reduced in depressed patients and so negligence of dental hygiene increases the amount of biofilm and changes its composition. Nutritional deficiencies are also responsible for decreased immunity. Tobacco use is a recognised risk factor for periodontal disease. The accumulation of all these changes in behaviour increases the risk of developing periodontitis or of relapsing.

The way in which stress acts on the immune system is summarised according to the hypothalamic-pituitary-adrenal axis. Psychosocial stress is capable of activating the hypothalamus, which will secrete adrenocorticotropic hormone, which will in turn stimulate the adrenocortical gland to produce glucocorticoids, of which cortisol has an immunosuppressive action. The adrenal cortex will produce catecholamines because it is stimulated by the autonomic nervous system.

It is interesting to note that coping behaviour is a determining factor in the outcome of periodontal treatment: results are better in patients who are good at coping. The latest research highlights emotional intelligence; the higher it is, the better patients respond to periodontal treatment.

How should we deal with stress?

We must diagnose stress in our patients and direct them to specialised therapists. However, patients are not the only ones who suffer from stress; dentistry is a highly stressful profession. It is, therefore, important to detect stress early and manage it effectively. We know more now than ever about the causes of stress, how it works, its consequences and antidotes. To start with, we can adopt a healthy lifestyle and follow some recommendations. Sport is the ideal way of reducing stress, since physical activity frees the energy accumulated by stressful situations. Whatever sport one chooses, one should enjoy it and set reachable goals at the beginning. Some prefer relaxation with yoga or meditation, including Meditation-Based Stress Reduction. It has also been shown that these techniques directly stimulate the regions of the brain associated with well-being, relax muscles and have an analgesic effect. Having pleasant social interactions and avoiding isolation reduces the secretion of cortisol. Similarly, relaxation techniques reduce the concentration of catecholamines.

Stress is our body’s alarm signal, and it is important to detect it. It can remain our friend if we listen to it. However, if we ignore the warning signs and fail to recover the internal balance, it can quickly become our worst enemy.

Editorial note: A list of references can be obtained from the publisher.

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