Relations of Psychosocial Factors and Cortisol with Periodontal and Bacterial Parameters: A Prospective Clinical Study in 30 Patients with Periodontitis Before and After Non-Surgical Treatment

Stress and mental health symptoms in early pregnancy are associated with the oral microbiome

BACKGROUND

Research has revealed associations between microbes of the gastrointestinal tract and stress, anxiety and depression in pregnant or postpartum women. While these studies suggest a gut-brain-behaviour axis, no studies have examined microbes of the oral cavity in relation to maternal mental health.

OBJECTIVE

To explore a potential oral-brain-behaviour axis related to maternal mental health.

METHODS

Microbes were measured in saliva obtained from 224 second-trimester (mean±SD = 17±2 weeks) women oversampled for stress. Oralome data were associated with women's recent or cumulative pregnancy stress, trait and state anxiety, depression symptoms and post-traumatic stress disorder (PTSD) symptoms. Covariates explored included age, income, alcohol and tobacco use, dental issues and physical health problems.

RESULTS

Pregnant women in the high trait anxiety or depression symptom groups had higher oral alpha diversity, indicating higher richness of species within samples. Groups with high and low PTSD symptoms differed in beta diversity, reflecting differences in community composition. Linear discriminant analysis showed differently abundant microbes in women with high stress versus low life stress, anxiety, depression, and PTSD, with the affected microbes mostly differing by symptom. Notably, members of phylum Proteobacteria were more abundant in women with high recent life stress and Spirochaetes was more abundant in women with high depression symptoms. Members of phylum Firmicutes were more abundant in the high trait anxiety and high depression groups. Genus Dialister (previously found to be lower in the gut of depressed non-pregnant people) was higher in women experiencing either high trait or state anxiety, or experiencing high depression symptoms, while genus Eikenella was elevated with high trait anxiety, depression or PTSD.

CONCLUSIONS

The oral microbiome is associated with stress and mental health in pregnant women, in ways different from the gut microbiome or what has been found in non-pregnant people.

CLINICAL IMPLICATIONS

Understanding oral microbiome-mental health relations may reveal future microbial targets to improve maternal psychological well-being.

A Study of Oral Health Parameters and the Properties and Composition of Saliva in Oncological Patients with and without Medication-Related Osteonecrosis of the Jaw Who Take Bisphosphonates

Background and Objectives: The aim of this study was to examine how the status of the oral cavity, composition and properties of saliva change in oncological patients with and without Medication-Related Osteonecrosis of the Jaw (MRONJ) undergoing bisphosphonate therapy. Materials and Methods: A retrospective case-control study of 49 oncological patients using bisphosphonates (BPs) was conducted. The study population was divided into two groups-Group I consisted of 29 patients with MRONJ and Group II of 20 patients without MRONJ. The control group consisted of 32 persons without oncological history and without antiresorptive therapy. Standard dental examination included the assessment of the number of teeth remaining, teeth with caries and fillings, Approximal Plaque Index (API) and Bleeding on Probing (BOP). In terms of MRONJ, localization and stage were assessed. Laboratory tests of saliva included determination of pH and concentrations of Ca and PO₄ ions, total protein, lactoferrin, lysozyme, sIgA, IgA, cortisol, neopterin, activity of amylase at rest, and stimulated saliva. The buffering capacity and microbiological tests (Streptococcus mutans, Lactobacillus spp. load) of stimulated saliva were also determined. Results: There were no statistically significant differences between the selected oral parameters and saliva of Group I and Group II. Significant differences were found between Group I and the control group. BOP, lysozyme and cortisol concentration were higher, while the number of teeth with fillings, Ca and neopterin concentrations were lower in comparison to the control group. In Group I, a significantly higher percentage of patients with a high colony count (>10⁵) of Streptococcus mutans and Lactobacillus spp. was also found. The significant differences between Group II and the control group concerned the concentrations of lysozyme, Ca ions, sIgA, neopterin and the colony count of Lactobacillus spp. In the Group I patients who received a significantly higher cumulative dose of BP compared to the Group II, a significant positive correlation was found between the received BP dose and the BOP. Most MRONJ foci were stage 2 and were mainly located in the mandible. Conclusions: Among oncological patients with and without MRONJ undergoing BP therapy compared to the control group, there are statistically significant differences in the dental, periodontal and microbiological status and in the composition of the saliva. Particularly noteworthy are the statistically significant differences in the decreased level of Ca ions, the increased level of cortisol and the elements of saliva related to the immune response (lysozyme, sIgA, neopterin). Additionally, a higher cumulative dose of BPs may affect the susceptibility to the development of osteonecrosis of the jaws. Patients undergoing antiresorptive therapy should receive multidisciplinary medical care, including dental care.

Impact of Stress on Periodontal Health: Literature Revision

Stress is a physiological response of the body to stressful life events but may not be when the individual is persistently exposed to the stress trigger, and it negatively affects certain physiological functions, thus triggering psychosomatic diseases. In literature, chronic stress and inadequate coping strategies are found to mediate the risk and development of periodontitis; mechanisms have therefore been proposed to explain the effects of stress on the periodontium. Since stress is a prevalent problem in modern life and given the importance of maintaining oral health, the present literature review aimed to estimate the association between stress and periodontal disease. The research question adopted is the following: "Are psychological stress and periodontal disease related?" The search was conducted in August 2022 and limited to articles in electronic databases from 2017 to 2022 in English, excluding reviews and literature reviews. From the electronic databases, a total of 532 articles were identified and became 306 after reviews and duplicates were removed. An additional bibliographic search was conducted through the same electronic databases, controlled terms and keywords including only systematic reviews, which were previously excluded. Through the bibliography cited in the systematic reviews, an additional 18 articles were identified, with a new total of 324. As a result of reading the title and abstract of these 324 articles, an additional 295 were excluded. Reading the full text of the remaining 29 studies, 2 articles were excluded due to non-adherence to the eligibility criteria. The remaining 27 results were included in our literature review. It has been suggested in the literature that adverse socioeconomic conditions elicit a stress response, which can trigger periodontal inflammation. Most of the 27 articles included in the study confirm and demonstrate a positive association between psychological stress and periodontal disease. Numerous studies have shown the mechanisms through which chronic stress negatively affects periodontal tissues. Therefore, in the light of the results obtained from this review, it is important that oral health professionals, also for general health purposes, consider stress factors among the risk factors of periodontal disease, its severity and decreased efficacy of treatments. It is therefore advisable to act preventively through the interception of chronic stress.

Effect of psychosocial stress and coping strategies on non-surgical periodontal therapy in patients with generalized stage III/IV periodontitis: a longitudinal intervention study

OBJECTIVES

The aim of this longitudinal intervention study was to assess the impact of psychosocial stress and coping response strategies on the clinical outcomes in periodontitis patients treated with non-surgical periodontal therapy (NSPT).

MATERIALS AND METHODS

After the administration of psychological questionnaires, patients diagnosed with generalized stage III-IV periodontitis were categorized into different groups depending on their stress levels (10-item perceived stress level (PSS-10)) and coping response strategies (coping responses inventory (CRI)). Clinical data were collected 1 week before and 3 months after the completion of NSPT.

RESULTS

Of the 90 patients included at baseline, 27 presented major and 63 minor stress levels, while 40 had avoidance and 50 approach coping behavior. All clinical parameters were similar at the baseline across different categories. At re-evaluation, full-mouth bleeding score (FMBS), mean probing pocket depth (PPD), and number of residual pathological pockets were significantly superior in groups with higher stress levels (p <0.001, p =0.001, and p =0.020, respectively), while higher full-mouth plaque scores (FMPS) and FMBS were found in patients with avoidance coping strategies (p =0.009 and p <0.001, respectively). When jointly evaluated, an added detrimental effect of coping styles on allostatic load was observed. Multivariate analysis confirmed a significant effect of stress levels and coping strategies on final FMBS, but not of coping on mean PPD.

CONCLUSION

Psychosocial stress and avoidance coping strategy seem to negatively influence the clinical outcomes of NSPT at short term (NCT04739475; 9/1/2017).

PRACTICAL IMPLICATIONS

Based on these findings, patients reflecting these psychological profiles should be considered at greater risk for poor NSPT response and may benefit from complementary stress management strategies.

Role of hormones in bone remodeling in the craniofacial complex: A review

Background

Diseases such as periodontitis and osteoporosis are expected to rise tremendously by 2050. Bone formation and remodeling are complex processes that are disturbed in a variety of diseases influenced by various hormones.

Objective

This study aimed to review and present the roles of various hormones that regulate bone remodeling of the craniofacial complex.

Methods

A literature search was conducted on PubMed and Google Scholar for studies related to hormones and jawbone. Search strategies included the combinations ("name of hormone" + "dental term") of the following terms: "hormones", "oxytocin", "estrogen", "adiponectin", "parathyroid hormone", "testosterone", "insulin", "angiotensin", "cortisol", and "erythropoietin", combined with a dental term "jaw bone", "alveolar bone", "dental implant", "jaw + bone regeneration, healing or repair", "dentistry", "periodontitis", "dry socket", "osteoporosis" or "alveolitis". The papers were screened according to the inclusion criteria from January 1, 2000 to March 31, 2021 in English. Publications included reviews, book chapters, and original research papers; in vitro studies, in vivo animal, or human studies, including clinical studies, and meta-analyses.

Results

Bone formation and remodeling is a complex continuous process involving many hormones. Bone volume reduction following tooth extractions and bone diseases, such as periodontitis and osteoporosis, cause serious problems and require a great understanding of the process.

Conclusion

Hormones are with us all the time, shape our development and regulate homeostasis. Newly discovered effects of hormones influencing bone healing open the possibilities of using hormones as therapeutics to combat bone-related diseases.

Mental health and periodontal and peri-implant diseases

Mental health disorders, particularly depression and anxiety, affect a significant number of the global population. Several pathophysiological pathways for these disorders have been identified, including the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and the immune system. In addition, life events, environmental factors, and lifestyle affect the onset, progression, and recurrence of mental health disorders. These may all overlap with periodontal and/or peri-implant disease. Mental health disorders are associated with more severe periodontal disease and, in some cases, poorer healing outcomes to nonsurgical periodontal therapy. They can result in behavior modification, such as poor oral hygiene practices, tobacco smoking, and alcohol abuse, which are also risk factors for periodontal disease and, therefore, may have a contributory effect. Stress has immunomodulatory effects regulating immune cell numbers and function, as well as proinflammatory cytokine production. Stress markers such as cortisol and catecholamines may modulate periodontal bacterial growth and the expression of virulence factors. Stress and some mental health disorders are accompanied by a low-grade chronic inflammation that may be involved in their relationship with periodontal disease and vice versa. Although the gut microbiome interacting with the central nervous system (gut-brain axis) is thought to play a significant role in mental illness, less is understood about the role of the oral microbiome. The evidence for mental health disorders on implant outcomes is lacking, but may mainly be through behaviourial changes. Through lack of compliance withoral hygiene and maintenance visits, peri-implant health can be affected. Increased smoking and risk of periodontal disease may also affect implant outcomes. Selective serotonin reuptake inhibitors have been linked with higher implant failure. They have an anabolic effect on bone, reducing turnover, which could account for the increased loss.

Comparison of Whole Salivary Cortisol and Interleukin 1-Beta Levels in Light Cigarette-Smokers and Users of Electronic Nicotine Delivery Systems before and after Non-Surgical Periodontal Therapy

There are no studies that have compared whole salivary cortisol (CL) and interleukin 1-beta (IL-1β) levels in cigarette-smokers (CS) and electronic nicotine delivery systems (ENDS)-users before and after non-surgical periodontal therapy (NSPT). The aim was to compare whole salivary CL and IL-1β levels in light CS and ENDS users before and after non-surgical periodontal therapy (NSPT). Self-reported current CS, ENDS users, and non-smokers were included. A questionnaire was used to collect demographic data. All patients underwent NSPT. Periodontal parameters (probing depth (PD], gingival index (GI], clinical attachment loss (AL], plaque index (PI], and marginal bone loss (MBL]) and whole salivary CL and IL-1β were measured at baseline. At 3-months of follow-up, clinical parameters and whole salivary CL and IL-1β were re-assessed. p-values < 1% were arbitrated as statistically significant. Fifty-four individuals (18 CS, 18 ENDS users, and 18 non-smokers) were included. Clinical AL, MT, PD, PI, and MBL were similar in all groups at baseline. At 12-weeks of follow-up, PI (p < 0.01) and PD (p < 0.01) were high in CS and ENDS-users than non-smokers. Among non-smokers, there was a statistically significant correlation between whole salivary cortisol and IL-1β levels at 12-weeks' follow-up (p < 0.001). There was no difference in whole salivary cortisol and IL-1β levels in CS and ENDS users at baseline and at 12-weeks follow-up. At 12-weeks of follow-up, there was a significant reduction in IL-1β (p < 0.01) and CL (p < 0.01) than baseline. In light CS and ENDS users without periodontal disease, clinical periodontal parameters and whole-salivary CL and Il-1β levels remain unchanged after NSPT.

Relationship between Psychological Stress Determined by Voice Analysis and Periodontal Status: A Cohort Study

In modern society, evaluation and management of psychological stress may be important for the prevention of periodontal disease. The purpose of this study was to examine the relationship between psychological stress (vitality and mental activity) evaluated by Mind Monitoring System (MIMOSYS) and periodontal status. Forty students of Okayama University underwent the oral examination and self-reported questionnaire on the first day (baseline) and the 14th day (follow-up). Voice recording was performed every day with the MIMOSYS app during the whole study period. The participants completed the Patient Health Questionnaire (PHQ)-9 and Beck Depression Inventory (BDI) at baseline and at follow-up. Spearman’s rank correlation coefficient was used to determine the significance of correlations among variables. The PHQ-9 and BDI scores were negatively correlated with vitality in the morning. Change in vitality in the morning was significantly correlated with changes in periodontal inflammation. Mental activity was significantly correlated with change in mean probing pocket depth. This result shows that measurement of psychological stress using a voice-based tool to assess mental health may contribute to the early detection of periodontal disease.

Paraprobiotics in Non-Surgical Periodontal Therapy: Clinical and Microbiological Aspects in a 6-Month Follow-Up Domiciliary Protocol for Oral Hygiene

Periodontal disease represents a progressive destruction of tooth-supporting tissues. Recently, paraprobiotics are regarded as an adjunctive therapy to the non-surgical Scaling-and-Root-Planing (SRP). The aim of this study is to evaluate the efficacy of two new formulations of paraprobiotics, a toothpaste and a mouthwash, respectively, for the domiciliary hygiene. A total of 40 patients were randomly assigned to the following domiciliary treatments: Group 1 (SRP + Curasept Intensive Treatment 0.2% chlorhexidine) (control) and Group 2 (SRP + Biorepair Peribioma toothpaste + Biorepair Peribioma Mousse mouthwash) (trial). At baseline (T0) and after 3 and 6 months (T1-T2), periodontal clinical (Bleeding on Probing, Probing Pocket Depth, Clinical Attachment Loss, Bleeding Score, Sulcus Bleeding Index, Plaque Index, Approximal Plaque Index, Adherent Gingiva, Gingival Recession, and Pathological Sites) and microbiological parameters (Pathological Bacteria, Saprophytic Bacteria, Enlarged Red Complex, Red Complex, Orange Complex, and counts of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythensys, Treponema denticola, Prevotella intermedia, and Fusobacterium nucleatum). The use of the experimental products resulted in a significant reduction of most of the clinical indices assessed, which occurred at a major degree with respect to the conventional chlorhexidine considered as control. Additionally, after 6 months of use, the abovementioned products significantly decreased the percentage of pathological bacteria and the counts of those bacteria constituting the "Red Complex", more related to the periodontal disease. Accordingly, the paraprobiotics-based products tested in this study seem to represent a valid support to SRP with a benefit on both clinical indices and on specific periodontopathogens.

Exosomes derived from 3D-cultured MSCs improve therapeutic effects in periodontitis and experimental colitis and restore the Th17 cell/Treg balance in inflamed periodontium

Although mesenchymal stem cell-derived exosomes (MSC-exos) have been shown to have therapeutic effects in experimental periodontitis, their drawbacks, such as low yield and limited efficacy, have hampered their clinical application. These drawbacks can be largely reduced by replacing the traditional 2D culture system with a 3D system. However, the potential function of MSC-exos produced by 3D culture (3D-exos) in periodontitis remains elusive. This study showed that compared with MSC-exos generated via 2D culture (2D-exos), 3D-exos showed enhanced anti-inflammatory effects in a ligature-induced model of periodontitis by restoring the reactive T helper 17 (Th17) cell/Treg balance in inflamed periodontal tissues. Mechanistically, 3D-exos exhibited greater enrichment of miR-1246, which can suppress the expression of Nfat5, a key factor that mediates Th17 cell polarization in a sequence-dependent manner. Furthermore, we found that recovery of the Th17 cell/Treg balance in the inflamed periodontium by the local injection of 3D-exos attenuated experimental colitis. Our study not only showed that by restoring the Th17 cell/Treg balance through the miR-1246/Nfat5 axis, the 3D culture system improved the function of MSC-exos in the treatment of periodontitis, but also it provided a basis for treating inflammatory bowel disease (IBD) by restoring immune responses in the inflamed periodontium.

The Effects of Prednisone/Ketoprofen Administration in Association with Amoxicillin Clavulanate Following Periodontal Surgical Therapy in Patients with Severe Chronic Periodontitis

Background and Objectives: The aim of this study was to evaluate and compare the effects of two different anti-inflammatory drugs (ketoprofen and prednisone) combined with an antibiotic (amoxicillin + clavulanic acid) and periodontal surgery on dental and periodontal parameters in patients with severe chronic periodontitis. In addition, salivary stress expressed by cortisol levels was assessed. Materials and Methods: An interventional study was performed on 22 periodontal subjects and 19 clinical healthy controls. The patients were divided in four groups, depending on treatment planning, as follows: eight patients received prednisone and antibiotherapy, associated with surgical periodontal therapy; seven patients received ketoprofen and antibiotherapy, associated with surgical periodontal therapy (group II); seven patients received only prednisone. Periodontal healthy patients underwent routine scaling and polishing. Bleeding on probing (BOP), dental mobility and salivary cortisol (ng/mL) were assessed before and after treatment. The means and standard deviations for the salivary cortisol levels (SCLs), dental and periodontal parameters were calculated for all groups using each patient as a unit of analysis. Results: Data analyses showed that the two different anti-inflammatory drugs associated with or without surgical therapy were efficient on inflammation periodontal parameters (BOP, dental mobility). Prednisone treatment alone was associated with a significant decrease of SCLs between pretreatment and post-treatment. Conclusions: In the present study, the effects of either of the anti-inflammatory drugs on inflammation evolution and salivary stress were comparable in patients undergoing antibiotherapy and surgical periodontal therapy.

The Role of the Oral Microbiota Related to Periodontal Diseases in Anxiety, Mood and Trauma- and Stress-Related Disorders

The prevalence of anxiety, mood and trauma- and stress-related disorders are on the rise; however, efforts to develop new and effective treatment strategies have had limited success. To identify novel therapeutic targets, a comprehensive understanding of the disease etiology is needed, especially in the context of the holobiont, i.e., the superorganism consisting of a human and its microbiotas. Much emphasis has been placed on the role of the gut microbiota in the development, exacerbation, and persistence of psychiatric disorders; however, data for the oral microbiota are limited. The oral cavity houses the second most diverse microbial community in the body, with over 700 bacterial species that colonize the soft and hard tissues. Periodontal diseases encompass a group of infectious and inflammatory diseases that affect the periodontium. Among them, periodontitis is defined as a chronic, multi-bacterial infection that elicits low-grade systemic inflammation via the release of pro-inflammatory cytokines, as well as local invasion and long-distance translocation of periodontal pathogens. Periodontitis can also induce or exacerbate other chronic systemic inflammatory diseases such as atherosclerosis and diabetes and can lead to adverse pregnancy outcomes. Recently, periodontal pathogens have been implicated in the etiology and pathophysiology of neuropsychiatric disorders (such as depression and schizophrenia), especially as dysregulation of the immune system also plays an integral role in the etiology and pathophysiology of these disorders. This review will discuss the role of the oral microbiota associated with periodontal diseases in anxiety, mood and trauma- and stress-related disorders. Epidemiological data of periodontal diseases in individuals with these disorders will be presented, followed by a discussion of the microbiological and immunological links between the oral microbiota and the central nervous system. Pre-clinical and clinical findings on the oral microbiota related to periodontal diseases in anxiety, mood and trauma- and stress-related phenotypes will be reviewed, followed by a discussion on the bi-directionality of the oral-brain axis. Lastly, we will focus on the oral microbiota associated with periodontal diseases as a target for future therapeutic interventions to alleviate symptoms of these debilitating psychiatric disorders.