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STRESS AND PERIODONTITIS
L E T T E R S
LETTERS ADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
J
STRESS AND PERIODONTITIS
Dr. Anwar Merchant and colleagues’ December JADA article, “A Prospective Study of Social Support, Anger Expression and Risk of Periodontitis in Men,” states that anger expression and social isolation, associated with stress, had not previously been evaluated as related to the risk of developing periodontitis. This is not true. Their alleged new finding is actually old hat. Over half a century ago, I and Samuel Charles Miller (then professor of periodontia and chair of that department at New York University College of Dentistry) together researched and published such results in a study entitled, “Psychosomatic Factors in the Etiology of Periodontal Disease,”1 which also was incorporated as a chapter in Dr. Miller’s 1950 Textbook of Periodontia.2 We detailed and demonstrated (replete with photographs of patients’ dentitions, X-rays, case histories and laboratory data) how “emotional tension may create oral disease through a disturbance of the physiology,” such as, for example, brux40 6
ism due to unrealized aggression, or a change in salivary composition and blood calcium levels caused by an emotional disturbance. Indeed, we had found so much evidence that our study was subtitled, “A Critical Review of the Literature.” The majority of cases presented a reciprocal relationship with greater or lesser percentages of psychic and somatic phases in innumerable variations. For example, as we did our study soon after [World War II], we observed many returning veterans in whom psychosomatic tension factors produced extreme alveoloclasia, where a few years previously only a mild situation had been present. We found that many people who could not cope with stress in an active and practical way had the greatest risk of developing severe periodontosis. The destructive psychosomatic mechanisms were many and varied, such as dreduction of local nutrition through vasospasm; ddevelopment of objective habits, such as pencil and fingernail biting, which are antagonistic to the health of periodontal tissues; dinduced excessive clenching or grinding of teeth; dcreating taste perversions for harmful foods, such as candy, cake, coffee and alcoholic beverages, as well as smoking to excess and insufficient intake of proper nutrition; dbodily conditions inimical to the health of periodontal tissues (as a decrease in blood calcium and phosphorus in tense, agitated, depressed stations); dneglect of oral hygiene and avoidance of professional care by those who are mentally pre-
occupied or depressed. In 1947, we also provided an in-depth explanation of how and why unrelieved anger and stress are particularly destructive to the periodontal mechanism. For example, we stated that psychosomatic factors such as excessive chewing, clenching or grinding create excessive wear and excessive pressures. L. Rittenberg, a psychiatrist whom we consulted, explained therein: “Within the personality there exists an aggressive group of instincts. They strive to find expression in the outside world. They would destroy, they would engulf, they would annihilate the outside world if they could get there. We can occasionally see this happening in the insane. But under ordinary circumstances, the world of personal and social reality sets up barriers to the unchecked gratification of these instincts, in the form of conscience, morality, education and training. When the dynamic relationship of aggressive drives and repressing forces begin to show strain, the muscles of the mouth may begin to show irrational phenomena. They may contract unconsciously in response to aggressive instincts, and bruxism results … .”1 We also quoted Frohman3 in our article. He related how one of his psychiatric patients responded favorably to surgical periodontal treatment, only to have a return to the old condition. The dentist then discovered that clamping of the jaws was the main etiologic factor. Frohman relieved the condition by psychotherapy, producing a recovery surprising to the analyst, patient and dentist. While I applaud the publication of this recent article, which once again explains and proves
JADA, Vol. 135, April 2004 Copyright ©2004 American Dental Association. All rights reserved.
L E T T E R S
that stress, anger expression and poor coping behaviors are risk factors for periodontosis, perhaps the authors might have first done further library research, and thus not declared their research tenets and methodology, conclusion and clinical implications to be recent and original. Julian M. Firestone, D.D.S. New York 1. Miller SC, Firestone JM. Psychosomatic factors in the etiology of periodontal disease. Am J Ortho Oral Surg 1947;33:675-86. 2. Miller SC. Psychosomatic relations in the etiology of periodontal disease. In: Miller SC. Textbook of periodontia. 3rd ed. Philadelphia: Blakiston; 1950;99-113. 3. Frohman BS. Occlusal neuroses: application of psychotherapy to dental problems. Psychanal Rev 1932;19:297.
Authors’ response: Dr. Firestone is correct in stating that he and Dr. Miller have published findings relating stress and oral disease. Unfortunately, like most researchers, our literature search was limited to PubMed, which does not include articles before 1966. We thank him for pointing out his study to us and appreciate his astute clinical acumen. We did not claim to be the first to forward the hypothesis that stress may be related to periodontitis. We had, in fact, quoted a number of studies that previously reported the possibility of such an association in our article. These included case series,1 cross-sectional studies,2-4 and case-control studies.5,6 Dr. Firestone’s study, which includes analysis of a case series and hypothesizing plausible mechanisms, is an important first step in the identification of risk factors. The strength of our study was its prospective cohort design. We started the study with people free of periodontitis, measured stress and anger ex-
pression, and waited to see which of them developed more disease after taking into account pre-existing risk factors. To the best of our knowledge, ours is the first study to prospectively test the stressperiodontitis hypothesis using this powerful, analytic epidemiologic technique. Anwar T. Merchant, D.M.D., Sc.D. Assistant Professor McMaster University Clinical Epidemiology and Biostatistics Hamilton, Ontario Canada Waranuch Pitiphat, D.D.S., Sc.D. Assistant Professor Khon Kaen University Khon Kaen, Thailand Kaumudi Joshipura, B.D.S., Sc.D. Associate Professor Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, and Department of Epidemiology, Harvard School of Public Health Boston 1. De Marco TJ. Periodontal emotional stress syndrome. J Periodontol 1976;47(2): 67-8. 2. Monteiro da Silva AM, Oakley DA, Newman HN, Nohl FS, Lloyd HM. Psychosocial factors and adult onset rapidly progressive periodontitis. J Clin Periodontol 1996;23(8):789-94. 3. Genco RJ, Ho AW, Grossi SG, Dunford RG, Tedesco LA. Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Periodontol 1999;70(7): 711-23. 4. Hugoson A, Ljungquist B, Breivik T. The relationship of some negative events and psychological factors to periodontal disease in an adult Swedish population 50 to 80 years of age. J Clin Periodontol 2002;29(3):247-53. 5. Moss ME, Beck JD, Kaplan BH, et al. Exploratory case-control analysis of psychosocial factors and adult periodontitis. J Periodontol 1996;67(10 supplement):1060-9. 6. Croucher R, Marcenes WS, Torres MC, Hughes F, Sheiham A. The relationship be-
tween life-events and periodontitis: a casecontrol study. J Clin Periodontol 1997;24(1):39-43.
NITROUS OXIDE
When I first began my journey in Occupational Safety and Health Administration [OSHA] compliance/infection control, I had a sense of some of what I thought I might run into, and a curiosity about those unexpected experiences that I might encounter. Given OSHA’s compressedgas standard and what they call their 5A1 General Duty clause in all of their standards, along with the presence of these very large cylinders of compressednitrous tanks on most of our premises, it is certainly reasonable for a compliance officer to require an air quality test for low levels of nitrous oxide. Compliance officers can ask you to have such a test done, or may conduct it themselves, if they have reason to believe that a problem exists. They may, for example, be alerted to a possible problem by complaints of an unusual number of infertility problems of a sort in a particular facility. I have had the opportunity to be involved in approximately 100 nitrous air quality tests in dental offices. More offices than I would have believed or expected were mildly to excessively over the permissible limit. Although some controversy exists, the most accepted reasonable limits on long-term exposure to low doses of nitrous oxide are 50 parts per million, or ppm, in the operatory during administration, and 25 ppm outside the operatory. In some cases, I found levels as high as 800 to 900 ppm. Now, no need to panic. We aren’t all potentially dealing
JADA, Vol. 135, April 2004 Copyright ©2004 American Dental Association. All rights reserved.
40 7
LETTERS ADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be signed. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
J
STRESS AND PERIODONTITIS
Dr. Anwar Merchant and colleagues’ December JADA article, “A Prospective Study of Social Support, Anger Expression and Risk of Periodontitis in Men,” states that anger expression and social isolation, associated with stress, had not previously been evaluated as related to the risk of developing periodontitis. This is not true. Their alleged new finding is actually old hat. Over half a century ago, I and Samuel Charles Miller (then professor of periodontia and chair of that department at New York University College of Dentistry) together researched and published such results in a study entitled, “Psychosomatic Factors in the Etiology of Periodontal Disease,”1 which also was incorporated as a chapter in Dr. Miller’s 1950 Textbook of Periodontia.2 We detailed and demonstrated (replete with photographs of patients’ dentitions, X-rays, case histories and laboratory data) how “emotional tension may create oral disease through a disturbance of the physiology,” such as, for example, brux40 6
ism due to unrealized aggression, or a change in salivary composition and blood calcium levels caused by an emotional disturbance. Indeed, we had found so much evidence that our study was subtitled, “A Critical Review of the Literature.” The majority of cases presented a reciprocal relationship with greater or lesser percentages of psychic and somatic phases in innumerable variations. For example, as we did our study soon after [World War II], we observed many returning veterans in whom psychosomatic tension factors produced extreme alveoloclasia, where a few years previously only a mild situation had been present. We found that many people who could not cope with stress in an active and practical way had the greatest risk of developing severe periodontosis. The destructive psychosomatic mechanisms were many and varied, such as dreduction of local nutrition through vasospasm; ddevelopment of objective habits, such as pencil and fingernail biting, which are antagonistic to the health of periodontal tissues; dinduced excessive clenching or grinding of teeth; dcreating taste perversions for harmful foods, such as candy, cake, coffee and alcoholic beverages, as well as smoking to excess and insufficient intake of proper nutrition; dbodily conditions inimical to the health of periodontal tissues (as a decrease in blood calcium and phosphorus in tense, agitated, depressed stations); dneglect of oral hygiene and avoidance of professional care by those who are mentally pre-
occupied or depressed. In 1947, we also provided an in-depth explanation of how and why unrelieved anger and stress are particularly destructive to the periodontal mechanism. For example, we stated that psychosomatic factors such as excessive chewing, clenching or grinding create excessive wear and excessive pressures. L. Rittenberg, a psychiatrist whom we consulted, explained therein: “Within the personality there exists an aggressive group of instincts. They strive to find expression in the outside world. They would destroy, they would engulf, they would annihilate the outside world if they could get there. We can occasionally see this happening in the insane. But under ordinary circumstances, the world of personal and social reality sets up barriers to the unchecked gratification of these instincts, in the form of conscience, morality, education and training. When the dynamic relationship of aggressive drives and repressing forces begin to show strain, the muscles of the mouth may begin to show irrational phenomena. They may contract unconsciously in response to aggressive instincts, and bruxism results … .”1 We also quoted Frohman3 in our article. He related how one of his psychiatric patients responded favorably to surgical periodontal treatment, only to have a return to the old condition. The dentist then discovered that clamping of the jaws was the main etiologic factor. Frohman relieved the condition by psychotherapy, producing a recovery surprising to the analyst, patient and dentist. While I applaud the publication of this recent article, which once again explains and proves
JADA, Vol. 135, April 2004 Copyright ©2004 American Dental Association. All rights reserved.
L E T T E R S
that stress, anger expression and poor coping behaviors are risk factors for periodontosis, perhaps the authors might have first done further library research, and thus not declared their research tenets and methodology, conclusion and clinical implications to be recent and original. Julian M. Firestone, D.D.S. New York 1. Miller SC, Firestone JM. Psychosomatic factors in the etiology of periodontal disease. Am J Ortho Oral Surg 1947;33:675-86. 2. Miller SC. Psychosomatic relations in the etiology of periodontal disease. In: Miller SC. Textbook of periodontia. 3rd ed. Philadelphia: Blakiston; 1950;99-113. 3. Frohman BS. Occlusal neuroses: application of psychotherapy to dental problems. Psychanal Rev 1932;19:297.
Authors’ response: Dr. Firestone is correct in stating that he and Dr. Miller have published findings relating stress and oral disease. Unfortunately, like most researchers, our literature search was limited to PubMed, which does not include articles before 1966. We thank him for pointing out his study to us and appreciate his astute clinical acumen. We did not claim to be the first to forward the hypothesis that stress may be related to periodontitis. We had, in fact, quoted a number of studies that previously reported the possibility of such an association in our article. These included case series,1 cross-sectional studies,2-4 and case-control studies.5,6 Dr. Firestone’s study, which includes analysis of a case series and hypothesizing plausible mechanisms, is an important first step in the identification of risk factors. The strength of our study was its prospective cohort design. We started the study with people free of periodontitis, measured stress and anger ex-
pression, and waited to see which of them developed more disease after taking into account pre-existing risk factors. To the best of our knowledge, ours is the first study to prospectively test the stressperiodontitis hypothesis using this powerful, analytic epidemiologic technique. Anwar T. Merchant, D.M.D., Sc.D. Assistant Professor McMaster University Clinical Epidemiology and Biostatistics Hamilton, Ontario Canada Waranuch Pitiphat, D.D.S., Sc.D. Assistant Professor Khon Kaen University Khon Kaen, Thailand Kaumudi Joshipura, B.D.S., Sc.D. Associate Professor Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, and Department of Epidemiology, Harvard School of Public Health Boston 1. De Marco TJ. Periodontal emotional stress syndrome. J Periodontol 1976;47(2): 67-8. 2. Monteiro da Silva AM, Oakley DA, Newman HN, Nohl FS, Lloyd HM. Psychosocial factors and adult onset rapidly progressive periodontitis. J Clin Periodontol 1996;23(8):789-94. 3. Genco RJ, Ho AW, Grossi SG, Dunford RG, Tedesco LA. Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Periodontol 1999;70(7): 711-23. 4. Hugoson A, Ljungquist B, Breivik T. The relationship of some negative events and psychological factors to periodontal disease in an adult Swedish population 50 to 80 years of age. J Clin Periodontol 2002;29(3):247-53. 5. Moss ME, Beck JD, Kaplan BH, et al. Exploratory case-control analysis of psychosocial factors and adult periodontitis. J Periodontol 1996;67(10 supplement):1060-9. 6. Croucher R, Marcenes WS, Torres MC, Hughes F, Sheiham A. The relationship be-
tween life-events and periodontitis: a casecontrol study. J Clin Periodontol 1997;24(1):39-43.
NITROUS OXIDE
When I first began my journey in Occupational Safety and Health Administration [OSHA] compliance/infection control, I had a sense of some of what I thought I might run into, and a curiosity about those unexpected experiences that I might encounter. Given OSHA’s compressedgas standard and what they call their 5A1 General Duty clause in all of their standards, along with the presence of these very large cylinders of compressednitrous tanks on most of our premises, it is certainly reasonable for a compliance officer to require an air quality test for low levels of nitrous oxide. Compliance officers can ask you to have such a test done, or may conduct it themselves, if they have reason to believe that a problem exists. They may, for example, be alerted to a possible problem by complaints of an unusual number of infertility problems of a sort in a particular facility. I have had the opportunity to be involved in approximately 100 nitrous air quality tests in dental offices. More offices than I would have believed or expected were mildly to excessively over the permissible limit. Although some controversy exists, the most accepted reasonable limits on long-term exposure to low doses of nitrous oxide are 50 parts per million, or ppm, in the operatory during administration, and 25 ppm outside the operatory. In some cases, I found levels as high as 800 to 900 ppm. Now, no need to panic. We aren’t all potentially dealing
JADA, Vol. 135, April 2004 Copyright ©2004 American Dental Association. All rights reserved.
40 7