The Effects of Stress on Oral and Systemic Health

“You think you’re stressed? I’ll tell you about stress…” It almost seems like a competition these days, as if the amount of stress we can endure is a badge of honor. Every one of us experiences stress. Stress can come from all sorts of circumstances we perceive to be frightening, dangerous, or threatening in some way.

Our genes play a role in our emotional response to stress. Our life experiences also affect the way we react to stress. Those who have experienced more trauma in their lives may be more vulnerable to stress than those who have had fewer experiences with hunger, homelessness, abuse, accidents, crime, or violence.

Our perceptions affect our experiences. When I speak at dental conferences, I perceive that my audiences are friendly and eager to learn, so it is a safe and enjoyable experience for me. One of my friends, for example, feels that public speaking is wrought with danger and swears if she had to speak in front of thousands of people she would surely die on the spot. Yet she loves roller coasters, while I am terrified of those death traps. These reactions are examples of an amygdala hijack, which is the condition of one’s emotions overreacting and sending one into fight-or-flight mode when there is no actual threat to safety.

The human body is built to handle small amounts of stress and once the perceived danger has passed, homeostasis returns. But when you constantly feel in danger or under attack, as in the case of someone in a toxic work environment, for example, the fight-or-flight reaction does not abate, and chronic stress is the result. Chronic stress can be very damaging, can affect multiple body systems, and can increase the risk for chronic diseases.⁴

ENDOCRINE SYSTEM

The amygdala is an almond-shaped mass of tissue in the brain that processes emotions, interprets circumstances as dangerous, and sends an emergency signal to activate the hypothalamus-pituitary-adrenal (HPA)-axis.

When the HPA-axis is activated, it, in turn, sets off a series of physiological changes in the body which evolved as a survival mechanism, enabling people to react quickly to life-threatening situations. The HPA axis is the primary driver of the endocrine system stress response.

The hypothalamus prompts the pituitary gland to trigger a cascade of stress hormones that stimulate the adrenal glands to release cortisol, our primary stress hormone. Cortisol enables the brain to think clearly and limits nonessential functions in an urgent situation, redirecting our energy resources toward fighting off a threat or escaping from an enemy. This is the mechanism of the fight-or-flight response.

The HPA axis is also responsible for the production of glucocorticoids, including cortisol, the primary stress hormone.

Cortisol increases the energy fuel available to the heart and muscles by mobilizing glucose and fatty acids from the liver. This energy enables the fight-or-flight response during times of extreme stress.

Another stress hormone, adrenaline, increases blood pressure, causes the heart to pump more blood, makes muscles contract, and joins with cortisol to sharpen senses and keep the brain hyper-focused on the stressful situation at hand.

Prolonged stress may result in impaired communication between the HPA axis and the immune system, raising the risk of diabetes, obesity, chronic fatigue, depression, and immune disorders.¹⁰

IMMUNE SYSTEM

For brief periods, stress can boost immune function by sparking an inflammatory response to fight invading germs. Long-term stress produces sustained high levels of cortisol and corticosteroid levels, which results in resistance to cortisol, leading to deficient anti-inflammatory effects on the immune system. Pervasive inflammation decreases lymphocyte activity, increasing the risk for viruses and other infections.

MUSCULOSKELETAL SYSTEM

Muscles tense up when the body experiences stress to guard against injury and pain.⁷ In sudden onset stress, the muscles tense all at once, and the tension is released when the stressful situation eases. In chronic stress, the muscles remain in a state of tension, which can result in stress-related disorders.⁷ Both tension headaches and migraine headaches are associated with chronic muscle tension in the head, neck, and shoulders. Stress, especially job stress, has been linked to pain in the lower back and upper extremities.

RESPIRATORY SYSTEM

Stress can affect the respiratory system causing the airway between the nose and lungs to constrict. This results in shortness of breath and rapid breathing. For those who have pre-existing respiratory problems such as asthma and chronic obstructive pulmonary disease (COPD), psychological stress can exacerbate breathing problems.¹⁷ Acute stress, such as the death of a loved one, can precipitate an asthma attack or a panic attack, as difficulty breathing can heighten anxiety.¹⁷

CARDIOVASCULAR SYSTEM

The stress hormones, cortisol, adrenaline, and noradrenaline, cause increased heart rate and stronger contractions of the heart muscle during times of acute stress.⁸ As part of the fight-or-flight response, the blood vessels dilate, increasing the amount of blood volume pumped to the large muscles and to the heart, causing a short-term increase in blood pressure. Long-term elevation in heart rate, blood pressure, and circulating stress hormones can increase the risk of hypertension, heart attack, and stroke.¹⁸

The fight-or-flight response triggers the release of triglycerides, boosting “bad” cholesterol. The way a person reacts to stress can affect cholesterol levels, as well.

Women’s risk for heart disease associated with stress is different from men’s risk. Premenopausal women who have normal levels of estrogen, which keeps blood vessels dilated, have more protection against heart disease than postmenopausal women and men who have lower levels of estrogen.

BRAIN

Stress appears to influence progression from mild cognitive development to dementia. Dysregulation of the HPA axis and elevated cortisol, as seen in stress responses, are common in people with neurodegenerative diseases. Researchers are currently studying the relationship between stress and Alzheimer’s disease and other dementias.

GASTROINTESTINAL SYSTEM

The gut is home to hundreds of millions of neurons that communicate constantly with the brain through what is called the gut-brain axis (GBA). Stress can affect this GBA, by prompting pain, bloating, and other gut discomforts.²³ Gut bacterial flora can be reshaped by stress and inflammation and in turn, this alteration can change eating behavior and mood. Dysregulated eating can be the result of the introduction of certain bacterial species. Studies have pointed to a bidirectional relationship between diet, stress, and gut bacteria and their combined effect on health and immune function. Changes in gut microflora can ultimately increase the risk for gastrointestinal disease and dysfunction.

Esophagus: Some individuals feel tightness in the throat when stressed and may have trouble swallowing. Corticotropin-releasing hormone triggered by the stress reaction and the HPA axis can influence esophageal motility.

Stress may also increase the amount of air that is swallowed while eating, resulting in gassiness, bloating, burping, and discomfort. Stress can also cause people to eat much more or much less than usual. This change in diet can result in acid reflux and/or heartburn.

Frequent or long-term acid reflux can irritate the lining of the esophagus, leading to ulcers, esophagitis, strictures, aspiration pneumonia, Barrett’s esophagus (a pre-cancerous condition) and even esophageal cancer.

Stomach: Stress can affect digestion, either slowing it down, causing constipation, bloating and pain, or speeding it up, causing diarrhea.

Stress was found to be an independent risk factor for peptic ulcers regardless of Helicobacter pylori infection and non-steroidal anti-inflammatory drug use.

Intestin: Stress can trigger muscle spasms in the intestines, which can be painful and affect the intestines’ ability to absorb nutrients. Gas production may increase with stress, exacerbating the discomfort.

The major effects of stress on the GI system are:

• Alterations in gastrointestinal motility
• Increase in visceral perception of gastrointestinal sensations
• Changes in gastrointestinal secretions
• Increase in intestinal permeability
• Negative effects on the regenerative capacity of GI mucosa and mucosal blood flow
• Negative effects on intestinal microbiota

People with chronic gastrointestinal disorders, such as irritable bowel syndrome or inflammatory bowel disease, may be especially affected by stress.³⁶ Stress can induce frequent urination and bladder dysfunction. The fight-or-flight response disrupts normal hormonal functioning, causing the bladder to contract. Some people even experience involuntary urination when under duress.

REPRODUCTIVE SYSTEM

Excess cortisol, which is produced during the stress response, can affect the male reproductive system in several negative ways. Chronic stress can reduce testosterone production, resulting in a drop in libido, and can even cause erectile dysfunction or impotence. Sperm production and maturation are also negatively impacted by chronic stress. A study analyzing the effects of stress on semen quality found that men who experienced two or more stressful life events in the past year had a lower percentage of sperm motility (ability to swim) and a lower percentage of sperm of normal morphology (size and shape), compared with men who did not experience any stressful life events.

Absent or irregular menstrual cycles, changes in the length of cycles, and more painful periods may be associated with high levels of stress. Premenstrual syndrome (PMS) symptoms, such as cramping, fluid retention, bloating, mood swings, irritability, and feeling “blue,” may all be worsened by stress. Stress has also been implicated in the reduction of sexual desire in women. The stresses of personal, family, professional, financial, health, and other demands can overwhelm someone and result in a lowered libido.⁴⁰

The ability to conceive, the health of a pregnancy, and postpartum adjustment can all be negatively impacted by stress. Stress increases the risk of developing depression and anxiety, and depression is the leading complication of pregnancy and postpartum adjustment. According to research, maternal stress can negatively affect fetal development, ongoing childhood development, and maternal bonding.

Menopause can be a stressor in itself, as the changes it brings can include anxiety, mood swings, and feelings of distress. Many of the physical changes, such as hot flashes and vaginal dryness, can cause stress as well.⁴² And research shows that emotional stress may exacerbate physical symptoms.⁴² Stress can worsen the symptoms of polycystic ovarian syndrome and herpes simplex virus, as well as those of reproductive cancers. Being diagnosed with cancer and treatment for cancer would cause significant stress, creating a vicious cycle.⁴²

HAIR

Stress can lead to premature graying or telogen effluvium, which is the scientific name for stress-induced hair loss.

SLEEP

Insomnia can be the result of an overactive mind due to stress. Anxiety can cause sufferers to be unable to relax, unwind, and fall asleep.

SKIN

Stress can aggravate hormonal acne breakouts. It can also lead to hives, and skin rashes, and trigger a flare-up of oral herpes fever blisters.⁴⁵ Emotional stress has also been linked to urticaria, pruritis, rosacea, psoriasis, atopic dermatitis, seborrheic eczema, alopecia areata, and lichen planus. Since stress can suppress the immune system, it is believed that stress may also play a role in shingles outbreaks.

ABDOMINAL FAT

Non-overweight women who are vulnerable to the effects of stress are more likely to have excess abdominal fat according to a 2020 Yale study. Abdominal fat is related to an increased risk of cardiovascular disease and diabetes.

ORAL HEALTH

A 2016 study published in BioMedCentral concluded that people with greater perceived levels of stress report poorer oral health.⁶⁴ Depression, low energy, and other mental health disorders can all affect motivation for self-care, including oral hygiene. Stress can weaken the immune system, decreasing one’s ability to control oral pathogens, resulting in gingivitis and periodontitis. The immune system is also thought to be responsible for the occurrence of aphthous ulcers during stressful periods.

Stress may also manifest in bruxism, resulting in tooth and joint trauma. Stressed individuals have a 97% increased chance of bruxism than people who report low stress.⁶⁵ Bruxism may also be a sign of airway restriction, so a thorough evaluation is necessary before beginning treatment. A nightguard to protect teeth from the damage caused by grinding and clenching may exacerbate problems with the airway.

Salivary flow insufficiency, a leading driver of dental caries, may be caused by stress, anxiety, and depression as well as by medications used to treat those conditions.⁶⁶ When stressed, people may breathe through their mouth, increasing risk of xerostomia.

STRESS MANAGEMENT

Few among us can avoid stress completely. Some say stress is inescapable in our modern lives. Many studies reveal that an individual’s reaction to stress determines the extent of the burden on the body and the risk for chronic conditions or diseases.

There are a variety of stress management practices that can minimize the impact of stress. The following may be beneficial for the dental professional to use personally and to share with patients who exhibit stress:

• Make self-care a priority
• Eat a healthful diet⁵⁰
• Exercise regularly⁵⁰
• Get plenty of sleep
• Maintain a healthy social support network and ask for support when needed⁵¹
• Practice relaxation techniques such as yoga and deep breathing
• Practice meditation
• Enjoy a massage
• Practice mindfulness
• Keep a gratitude journal
• Spend time participating in hobbies you enjoy, such as reading, listening to or playing music, or watching a favorite movie or TV show
• Have a sense of humor, find ways to include humor and laughter in your life
• Volunteer in your community
• Seek professional counseling to develop coping strategies
• Avoid unhealthy ways of managing stress, such as overuse of alcohol, tobacco, drugs, and overeating ,

The benefits of a lower-stress lifestyle include improved creativity and increased productivity. Appropriately managing stress leads to improved mental and physical health, and increased peace of mind, and it might lead to a longer, healthier life.⁶³ As healthcare practitioners in particular, we must effectively manage our stress so we can not only take care of ourselves and our families, but also our patients. 

Oral Health welcomes this original article.

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About the Author:

Kathryn Gilliam is a consultant, coach, international speaker, and oral wellness practitioner. She founded her company, PerioLinks, in 2001 to educate and empower dental professionals to elevate their identities as oral wellness specialists before joining her dream team, Inspired Hygiene, in 2021. Kathryn coaches dental professionals to elevate their standard of care with protocols based on sound scientific principles and proven strategies for optimal patient care and outstanding practice growth.