Group+9

Group 9 Stress Members: //**Denise, Beth and Duncan**// e-Facilitator: **Sophie**

> //scientific literature//
 * //Learning Outcomes://**
 * //Describe possible factors that can initiate a stress reponse in the human body.//
 * //Discuss the effects that stress has on the body//
 * //Analyse the possible effects that stress can have on the periodontium through a review of current//
 * //Prepare and present a scientific poster of your findings.//

C O N T E N T S

1 What is stress? - Acute vs chronic stress - Short term effects - Long term effects

2 Effects of stress on the body - Glucocorticoids - Effects on heart, lungs, circulation - Effects on immune system - Chronic stress on the body - Salivary glands - Effects of stress on salivary glands and saliva - Caries susceptibility

3 Effects on the periodontium - Periodontal disease - Acute necrotizing ulcerative gingivitis (ANUG) - Recurrent apthous ulcerations (RAU) - Recurrent herpes labialis (RHL)

4 Stress in the dental setting

**S T R E S S **

1 **What is stress?** Stress is described as the human body’s response to stimuli which creates a homeostatic imbalance (Marieb & Hoehn, 2007). The body is designed to respond to stress either physiologically or psychologically, and occurs in reaction to either acute or chronic episodes of stress. The body’s response to stress occurs when the hypothalamus part of the brain fist detects the stressor, which activates the sympathetic division of the nervous system, triggering a chain of events to occur within the body. Physiological changes occur in response to an acute stressor so to assist the brain to assess whether or not to fight or run away from the stressful stimuli, known as the fight or flight response (Marieb & Hoehn, 2007). Ultimately, these alarm physiological responses to a stressor help to protect the body from harm, however chronic stressors have the ability to deplete the body’s energy levels and result in exhaustion.



**Acute vs chronic stress** Acute stress refers to the sudden and temporary incidence of a stressor whereby a definite onset and offset is present. This short term stressor causes the body to activate a fight or flight response via the sympathetic nervous system and can be viewed as an alarm safety mechanism to keep individuals alert and prepared to avoid danger and harm. Chronic stress refers to an ongoing, intermittent or a series of stress sequences over a continuous period of time whereby individuals face continual stress without relief between such episodes. Such long term stressors cause more prolonged physiological responses as a result of steroid hormone secretion and result in exhaustion.

**Short term physiological effects of stress - fight or flight** The body’s response to stress begins when stressful stimuli cause the hypothalamus portion of the brain to activate the adrenal medulla via the autonomic nervous system (ANS), stimulating the sympathetic division which regulates involuntary activities of smooth muscles, cardiac muscles and glands (Marieb & Hoehn, 2007). The sympathetic division initiates a sequence of physiological changes within the body as it generates the secretion of adrenalin and noradrenalin. This process mobilises the body during stressful events so to provide optimal conditions and focus the body’s blood supply, oxygen and energy towards areas most needed so to appropriately respond to the stressful stimuli. Such physiological fight or flight responses during acute stress include increased blood pressure and a rise in blood glucose levels which induces responses such as sweat and an increased heart rate among other activities (Marieb & Hoehn, 2007). This acute alarm reaction to stress also has an opposite effect to bodily activities that are considered nonessential during times of stress and thus temporarily inhibiting involuntary actions involved in the parasympathetic division such as gastrointestinal activity (Marieb & Hoehn, 2007).

**Long term physiological effects of stress - exhaustion** Continued exposure to stressful stimuli generates a more moderate physiological response, causing the hypothalamus to activate the adrenal cortex via hormonal signals (secretion of steroid hormones) (McEwen & Lasley, 2002). This secretion of steroid hormones instigates the retention of water and sodium by the kidneys (increasing blood volume and blood pressure) and the conversion of proteins and fats into glucose (increasing blood glucose and suppressing the immune system). Extensive continued exposure to stress can cause adaptation resources to be depleted and thus potentially leas to exhaustion (Marieb & Hoehn, 2007). The flow chart below illustrates short term and long term physiological response to stressors.



<span style="font-family: 'Arial','sans-serif'; font-size: 16pt;">2 Effects of stress on the body

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Glucocorticoids <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"> Glucocorticoids are essential to life as they influence the energy metabolism of most body cells and help people to resist stressors. The onset of severe stress dramatically increases the output of glucocorticoids, which helps the body respond to the issue. Only the glucocorticoids hormone cortisol is secreted in significant amounts in humans. Specific hormones regulate body processes mainly by their influence on morphogenesis (building of the structure of the body), the integration of body functions together with the nervous system and the maintenance of the internal environment (homeostasis). The secretion of cortisone is illustrated below.



Through stress, there is a dramatic rise in blood levels of glucose, fatty acids, and amino acids, all provoked by the stress hormone cortisol. In the body, cortisol has a prime metabolic effect to form glucose from fats and protein. Idea amounts of glucocorticoid are required to function normally. However, when there is an excess amount of cortisol, anti-inflammatory and anti-immune effects are subsequently affected. Marieb (2005) argues that excessive levels of cortisol may influence the following: - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Depress cartilage and bone formation - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Inhibit inflammation by decreasing the release of inflammatory chemicals - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Depress the immune system - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Promote changes in cardiovascular, neural and gastrointestinal function

The body is altered in this state to acknowledge the stressor and conserve energy for use in specific areas during stress. Various types of stress can be seen to be more influenced during the day time than night time. This is because at night individuals are more likely to be relaxed rather than during the day when they are faced with numerous challenges. As a result, it is expected that more stress hormones would be released during the day, illustrated below.



**Effects on the heart, lungs and cirulation** Acute stress has the ability to activate the sympathetic division of the automatic nervous system. The effector cells that sensory neurons synapse with include smooth muscles, cardiac muscle and glands. Marieb (2007) argues that the following occurs during activation of the sympathetic division: - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Heart rate and blood pressure increase instantaneously - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Breathing becomes rapid and the lungs take in more oxygen - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">The spleen discharges red and white blood cells allowing the blood to transport more oxygen through out the body - <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Blood flow may increase up to 400%, priming the muscles, lungs and brain for added demands

As a result, a person under acute stress would find it increasingly difficult to breathe and possibly bring about panic.

**Effects on the immune system** <span style="color: black; display: block; font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 150%;">There is both a positive and negative relation between stress and the immune system. “Acute stress galvanizes an organism’s protective systems” (Lenz, 2007). This positive aspect revolves around acute stress, which mobilises a defense mechanism to potentially critical areas. Steroid hormones reduce activity in parts of the immune system, so that specific white blood cells or other immune molecules can be repositioned. These immune cells and molecules are sent to where injury or infections most likely to occur, such as the skin and the lymph nodes. On the other hand, in chronic stress, the body is not given the opportunity to return to its normal state. So this impairs the immune response and makes the body vulnerable to infections, including those within the oral cavity, and reduces healing time. This is also known as immune suppression. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 150%;">Through prolonged stress, the immune system shifts from their adaptive changes seen in the "fight or flight" response to more negative changes. In the early stages there are negative changes at the cellular level which soon continue onto affect broader immune functions. On a cellular level, toll-like receptor 4’s mediate chronic restraint stress-induced immune suppression.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Effects of chronic stress on the body <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Chronic stress can lead to serious health problems as it can disrupt nearly every system in the body (Pfaff, 2002). It can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed the aging process (Pfaff, 2002). Additionally, long term stress can leave individuals to be more vulnerable to anxiety and depression, chronic fatigue, headaches, and back pain (Hugo et al. 2008).

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Salivary glands <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Salivary glands are located in the oral cavity and secrete a mucous like substance called saliva. Four primary salivary glands exist, illustrated in figure 5 below. Saliva can clear the mouth of food particles, has a buffering capacity to maintain optimal ph balance within the oral cavity, provide a moist environment to aid speech, and contain chemicals to aid in swallowing food and digestion.



<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Composition of saliva <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">The majority of saliva consists of water with the remaining consisting of both organic and inorganic components. The inorganic components include calcium, phosphate, fluoride, sodium and potassium. Organic components include mucins (glycoprotein), defensins, proteins, enzymes and IgA (antibody). As a result, saliva has the ability to protect the oral cavity from micro organism, inhibit bacterial growth, lubricate the oral cavity and initiate an immune response by alerting white blood cells.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"> <span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Effects of stress on salivary glands and saliva <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">According to Hugo et al. (2008), chronic stress in older individuals can impair the salivary glands’ function and thus reduce salivary flow. Studies of saliva and the salivary glands indicate that there are qualitative and quantitative alterations of the saliva during stress (Barber et al. 1985). The saliva therefore becomes more viscous with less volume and more acid and thus has a lower pH. Decreased salivary flow may result in xerostomia, also known as dry mouth. Symptoms of xerostomia include difficulty in speaking, eating, swallowing, difficulty in wearing dentures, loss of taste sensation and an increased urge to drink water.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Caries susceptibility <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Dental caries is a disease where cariogenic bacterial processes damage the tooth structure (Bath-Balogh & Fehrenbach, 2006). Past reviews suggest that some individuals may have a personal style of coping with stressful situations that results in increased caries (Richards et al. 1999). Data from the review stated that acute caries was observed in 24% of adults within a month after the onset of stress. Richard et al. (1999) proved that changes in oral hygiene or diet alone could not have accounted for carious lesions. This was later linked with the effects of stress and salivary glands and saliva. Furthermore, Hugo et al. (2008) states that individuals with xerostomia are more prone to develop dental caries and gingival infections due to decreased oral pH. The cortisol level of the body increases when the body is stressed and therefore produces a more acidic oral environment. This increased acidity creates an optimal environment for bacteria and other foreign bodies to colonise. This forms a weak barrier to bacteria, allowing lesions and cavities to develop. Furthermore, stress may cause the body to flush out minerals such as calcium, which is essential in maintaining good oral health, and thus increases one’s susceptibility to dental caries.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 16pt;">3<span style="font-family: 'Arial','sans-serif'; font-size: 16pt;"> **Effects on the periodontium** <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"> As stress can cause adverse effects on the human body; bodily systems such as the oral cavity can potentially become compromised, including the periodontium. The periodontium consists of the gingival, alveolar bone, cementum and periodontal ligaments. Some of the diseases within the oral cavity resulting from stress include acute necrotizing ulcerative gingivitis (ANUG), recurrent herpes labialis (RHL), recurrent apthous ulcerations (RAU) as well as periodontal disease.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Periodontal disease <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">Many studies have concluded that changes occur within the oral cavity tissues when exposed to chronic psychophysical stress. In particular, Ng and Leung (2006) came to the understanding that there were three stress levels: stressors, moderating/mediating factors and stress reaction. It is found that people with greater stressors in their life were at a greater risk for periodontal attachment loss, however not one factor alone can be singled out to explain tissue destruction (Ng & Leung, 2006). It had been suggested that stress has associated changes with the level of corticosteroid hormones within the saliva and circulatory system, affecting changes within the periodontium (Eli, 1992).

<span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">As mentioned previously, under the subheading 'effects on the immune system' it is thought that immunosuppression can lead to destruction of the oral cavity, in particular the destruction of both gums and jaw bone (Gutall k, 2007). Whilst immunosupression has the potential to exaggerate the inflammatory response, there is little evidence to support the link between long term immunosupression drugs and chronic/aggressive periodontitis (Stanford T, Rees T, 2003). When the body is immunosuppressed it allows invading bacteria to invade beneath the gum line due to a lack of defence from the body. This causes both the body’s immune system and bacteria to begin to breakdown the gum tissue and as a protective mechanism causes the bone to resorb further from the site of infection.

Periodontal disease has different stages of severity, from minimal to advance and once a person has periodontal disease, they will have it for the continuation of their life as a person is unable to reform lost bone. Therefore, the only way to prevent the disease from becoming worse is to manage and help a patient to maintain good oral hygiene, and to recommend patients to seek professional help if the periodontal disease is due to the suffering of chronic stress.







<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"> Acute necrotizing ulcerative gingivitis (ANUG) <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">ANUG is found to be the most associated form of disease in correlation with stress. There are many studies suggesting that from an increased amount of stress, there is an increased probability of ANUG (Eli, 1992). The symptoms of ANUG are bulbous interdental papilla, swelling and redness of the gums, lack of stippling, colour variation and ulcerations of the gingiva, as illustrated in the images below.

**Recurrent apthous ulcerations (RAU)** When the body is stressed, it places a great pressure onto various bodily systems, and as a result, systems will often not function as well as they should. It has been suggested that through clinical observations and epidermiological research the occurrence of the oral conditions of both RHL and RAU have an association with stress (Eli, 1992). After completing a study on 1738 patients, Sirous et al. (1957) determined that over 21% of patients in the study had RAU, indicated by lesions within the oral cavity proceeding periods of mental stress. Severe and emotional stress immediately preceded onset of ulcerations in approximately 60% of these patients. RAU can be broken down into 3 different forms of ulcers: minor, major and herpiform. The severity of ulcers was found to increase during times of stress and decrease during times of relaxation. Other studies also concluded similar findings with the severity of the disease seeming to be related emotional factors (Eli, 1992).



<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Recurrent herpes labialis (RHL) <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">The diagnosis of RHL is based on the characteristic, clinical appearance and the location of the lesions (Siegel, 2002). There are two types of herpes simplex virus, with HSV-1 associated with oral and labial lesions and HSV-2 associated in the genital area. Depending on the genetic makeup of a person, some may be more susceptible to the virus than others. RHL can be either contracted by an infected individual or may be hereditary. When dealing with patients, dental practitioners must treat active RHL on an individual level depending on the stage of the lesions. However, all stages of RHL are contagious and infectious is therefore a potentially transmissible disease. If a patient appears to have signs of RHL, infection control practices are important to prevent potential spread of the disease.



<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 16pt;">4<span style="font-family: 'Arial','sans-serif'; font-size: 16pt;"> **Stress in the dental setting** <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;"> There are numerous reasons as to why a patient may fear a dental visit which may result in stress. Dental dear and anxiety can be a major challenge for oral health practitioners to manage. When dealing with an anxious patient, it is important to try and understand the reason behind the anxiety or fear, whether it is from a previous experience or through a vicarious experience, in which a patient hears about another individual’s experiences at a dentist (Mostofsky et al. 2006).

Dental stimuli for anxiety may include fear of overtreatment, cost, pain, aesthetics and end result. In such cases, transparency and explanation of dental treatment to be performed and aids such as brochures, diagrams, laughing gas (nitrous oxide) or fixed pricing may help to reduce dental anxiety. Dental fear is likely to result in dental avoidance which may lead to deterioration of the condition of teeth and oral cavity. Patients may therefore experience shame and guilt for not obtaining oral care earlier or embarrassment for the severity that they have allowed their oral condition to progress to (Rowe, 2005). Consequently, it is vital not to amplify their feeling of guilt or embarrassment through criticism, but to focus more on collaborating with the patient to achieve improved oral health.

There are different management strategies used by oral health practitioner’s in attempting to help manage a patient’s stress. Dental practitioners can manage the stress of a patient by attempting to alter the stressor through problem solving, confrontation, seeking support or referral to a professional. Alternatively, dental practitioners can help a patient adapt to stress by positive reappraisal, escape/avoidance or relaxation techniques such as hypnosis.

<span style="color: black; display: block; font-family: 'Arial','sans-serif'; font-size: 10pt;">**REFERENCES**

Bath-Balogh & Fehrenbach 2006, 'Dental Embryology, Histology and Anatomy', Second Edition, Elsevier Saunders, USA

Eli I (1992) //Oral Psychocphysiology Stress, Pain and Behaviour in Dental care,// CRC Press, Florida <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 10pt; line-height: 115%;"> Gutall K 2007, //Stress and Periodontal Diseases Linked,// viewed 13 October 2009, []

Hugo F et al. (2008) <span style="display: block; font-family: 'Arial','sans-serif';">Association of chronic stress, depression symptoms and cortisol with low saliva flow , 25(1):18-25.

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McEwen & Lasley (2002) <span style="display: block; font-family: 'Arial','sans-serif';">The End Of Stress As We Know It, The Dana Press, United States, p61-61

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