Influence of stress on oral health: Combining a dental and psychological view

INTRODUCTION

Stress has become an unavoidable issue for everyone in this modern world, ranging from children to adults in various lifestyles. Chronic stress negatively affects health due to physiological changes such as elevating cortisol levels, which impact the immune system’s response to stimuli; having a less-responsive immune system can lead to an increased risk of gum infection, slower healing, and make individuals more vulnerable to tooth decay.^[1] An overactive immune system could cause the body to react to substances that are usually harmless, such as dust or pollen, potentially resulting in oral inflammation and tissue damage. This idea is supported by a scientific quote stating, “having an allergic reaction is the most common example of an overactive immune system.”^[2] Often overlooked is how stress influences oral health habits, including brushing, flossing, and regular dental check-ups, all of which are vital in maintaining overall health.^[3]High stress levels frequently lead to behaviors detrimental to oral health, such as teeth grinding (bruxism), neglecting oral hygiene, and consumption of sugary foods as comfort mechanisms, which provides a high risk of periodontal disease.^[4] In Manfredie’s paper, four of the papers with uncertain findings described a higher failure rate in bruxers, identifying a trend toward a positive bruxism–implant failure relationship.^[5] A bruxer is an individual who exhibits repetitive jaw-muscle activity characterized by clenching or grinding of the teeth, commonly during sleep or periods of heightened psychological stress, a condition clinically referred to as bruxism.^[6] Understanding the relationship between the different behaviors detrimental to oral health reveals why maintaining oral hygiene routines becomes particularly challenging under stress.

THE PHYSIOLOGICAL BASIS OF STRESS AND HOW IT AFFECTS BEHAVIOR

Stress triggers the body’s “fight or flight” response, leading to an increase in stress hormones such as cortisol and adrenaline.^[1] While these hormones do indeed prepare individuals to handle threats right away, exposure over a long period of time disrupts daily health routines, including basic self-care such as oral hygiene. Elevated cortisol specifically suppresses the immune system,^[1] making the oral cavity more susceptible to infections and periodontal diseases. Chronic stress also influences cognitive functions, emphasizing immediate survival while neglecting long-term health goals, which can directly result in behaviors such as teeth grinding or ignoring oral hygiene practices.^[7]

STRESS-DRIVEN HABITS THAT IMPACT ORAL HEALTH

Persistent psychological stress manifests in behaviors that significantly harm oral health, including bruxism, neglect of routine oral hygiene practices, and increased consumption of cariogenic foods.^[4] Furthermore, stress-driven cravings for comfort foods high in refined sugars increase the risk of dental caries by promoting acidogenic bacterial growth and oral microbiome dysbiosis.^[8] Bruxism, triggered by elevated stress hormones and physical tension, leads to enamel erosion, jaw pain, and potential jaw disorders.^[3] Another major problem is the neglect of regular oral care routines due to feeling overwhelmed and reduced motivation. Anxiety associated with dental visits, influenced by stress, further contributes to avoidance behaviors, causing delays in necessary treatment and escalating dental problems over time.^[9] Furthermore, stress-driven cravings for comfort foods that are typically full of sugar heightens risks of cavities and oral bacterial growth, further complicating dental health.

PSYCHOLOGICAL THEORIES ON HOW STRESS AFFECTS ORAL HEALTH HABITS

Psychological theories like the health belief model (HBM) and social cognitive theory (SCT) offer valuable insights into understanding stress-related behaviors in oral health contexts. The HBM is a widely accepted psychological framework that emphasizes internal decision-making and evaluations when deciding how to act upon perceived health threats.^[10] The framework was developed in the 1950s, as a response to the need for tuberculosis screening and immunizations. In the former environment, a person may perceive a health threat when undergoing a chest X-ray to determine whether they have tuberculosis. An individual may determine that changing their behavior (i.e., getting an immunization shot) may mitigate the health threat, and be more likely to act accordingly. In the current context of literature, stress may act as a perceived barrier, becoming an obstacle to perform the recommended health action (i.e., going to the dentist, flossing, etc.,), when going through the evaluation process of determining one’s health. The HBM emphasizes individuals’ perceived vulnerability and severity of health issues, suggesting that under stress, individuals might perceive oral hygiene as less critical due to shifting priorities.^[10]

Furthermore, the HBM recognizes the significance of the interaction between the stimuli and cognitive factors. Specifically, HBM highlights the importance of self-efficacy.^[10] Self-efficacy, or the belief one has in themself to perform a task effectively, is directly related to how likely someone is to perform the desired behavior. For example, stress induced negative thoughts may create a perception that someone cannot take care of their oral hygiene, leading to actively neglecting regular oral care practices. Furthermore, physical manifestations of stress, such as exhaustion, fatigue, or brain fog, may further contribute to lower self-efficacy and motivation when it comes to maintaining oral hygiene.

SCT expands on the HBM by demonstrating how environmental and cognitive factors interact, influencing oral health habits.^[11] For example, stress-induced negative thoughts and reduced self-efficacy can lead individuals to neglect regular oral care practices. A positive example of SCT would be to encourage the usage of virtual reality (VR) headsets in surgical procedures, especially for pediatrics. Likert test data showed that 21 of 22 subjects reported less discomfort after navigating through the virtual environment; physiological data generally supported the Likert data, with 64% of patients lowering their respiratory rate, moderated blood carbon dioxide levels, and decreased diastolic blood pressures in another 64% of patients.^[12] In addition, cognitive behavioral theory (CBT) highlights how stress-related negative thought patterns reinforce harmful habits. For example, a lack of confidence in one’s oral health can exemplify cognitive shortcuts that further exacerbate the neglect of oral hygiene, particularly under stressful conditions.^[3]

METHODOLOGY

This review looks at how psychological stress can affect people’s oral health habits. To find the research, we searched databases such as American Psychological Association PsycINFO and Google Scholar for peer-reviewed articles, mainly from 2000 to 2024, though we also included a few older key papers when they were important to the topic. We used search terms such as psychological stress, oral health, bruxism, dental anxiety, behavioral dentistry, HBM, SCT, and stress-related health behaviors.

We included studies that discussed how stress affects the body, how it shapes behavior, or how it relates to dental health outcomes. We left out non-peer-reviewed sources and articles that did not directly connect stress to oral health behaviors. After selecting the studies, we looked for common themes, patterns, and ideas about how stress affects oral health and how dental professionals might address it. The goal was not to run statistics on treatment outcomes, but rather to bring together insights from different fields to better understand and teach such a vague and complicated topic.

RESEARCH ON THE LINK BETWEEN STRESS AND ORAL HEALTH

Recent research emphasizes the relationship between psychological stress and oral health outcomes. Wide Boman et al., (2013) provided substantial evidence through population studies that stress and anxiety significantly increase dental care avoidance, with a large percentage of such people showing an increase in absence from work and avoiding social situations.^[3] Another study by Wide Boman et al., (2013) provides insight into new learning techniques for dental students, finding that reducing stress through role-play scenarios between the therapist and patient helped students not only manage their own oral health better but also deal with patients’ dental anxiety.^[3] The study by Syed et al., (2024) also featured role-play as a useful tool for student learning, but included virtual clinical scenarios to better aid dental students in knowledge retention and potential experiential learning.^[13] By giving students realistic experiences, these methods build their understanding of how stress impacts both their own health habits and those of their future patients.

Andrick (2013) takes a historical look at behavioral dentistry, focusing on the importance of “chairside manner” to help patients manage anxiety and stress.^[7] His work suggests that understanding and reducing patient stress during dental visits can improve outcomes, as it encourages people to come back regularly instead of avoiding care due to fear. Andrick (2013) research into the history of behavioral dentistry shows how techniques such as hypnosis and suggestion therapy were foundational for managing patients in dental care.^[7] In the late 19^th and early 20^th centuries, some dentists started using hypnosis to calm patient anxiety and make treatments, especially pain management, more effective. This was a time when there were not many options for anesthesia, so hypnotic suggestion was a helpful way to get patients to relax and feel less discomfort. Andrick (2013) notes that, “for those dentists employing hypnotic therapeutics, suggestion psychology was credited with playing an important role in the administration and effectiveness of general anesthesia, the most popular of which was nitrous oxide-oxygen.”^[7]

Early focus on the psychological side of patient care set the stage for what we now call behavioral dentistry. Today’s approaches still recognize how important a patient’s emotional and mental state is to their overall experience and outcomes in the dentist’s chair. Andrick’s work shows how these techniques, such as “suggestion therapy,” helped dentists understand and address dental anxiety before and after surgical operations, an issue that’s still very relevant to us nowadays in the dental field. These studies underscore that stress management is crucial for both patients and dental practitioners. Reducing stress, whether through therapy, educational techniques, or patient-centered care, can lead to better dental health for everyone involved.

CONCLUSION

The relationship between stress and oral health habits is complicated, requiring consideration of physiological responses and processes, psychological theories, and behavioral patterns. Stress influences oral health by triggering habits which compromise dental well-being. Through the lens of psychological theories such as the HBM, SCT, and CBT, this study has shown how stress can weaken self-efficacy, alter an individual’s perception of healthcare practices and professionals, and foster avoidance behaviors. These insights are necessary for both dental and mental health professionals who strive to understand and reduce the impact of stress on oral health.

Empirical research conducted by credible, peer-reviewed researchers has brought to light the importance of addressing dental anxiety and stress in clinical settings. Studies suggest that psychological suggestion, stress-reducing techniques, supportive patient interactions, and positive feedback can improve oral health altogether by encouraging healthier habits, reducing avoidance behaviors, and promoting the positive, professional relationships between patients and dentists that are necessary for building a strong foundation of trust. Including mental health strategies into dental practices, therefore, holds much potential for promoting better oral health. By recognizing and addressing the psychological factors that contribute to poor dental health habits, professionals can help patients adopt more useful oral care routines, ultimately benefiting the patient’s overall health.

From a practical standpoint, stress-reduction interventions in dental care must account for feasibility, accessibility, and cultural sensitivity. While tools such as VR and hypnosis show promise, their implementation may be limited by cost, practitioner training, and patient acceptance. Ethical considerations also arise when psychological techniques are used adjunctively in clinical care, particularly regarding informed consent and patient autonomy. Addressing these factors is essential to ensure equitable and responsible integration of psychological strategies into routine dental practice.

In conclusion, understanding the influence of stress on oral health is vital for holistic healthcare. Maintaining positive oral habits is a lifestyle, one that individuals maintain every day throughout their lives. As stress remains a prevalent aspect of modern life, further research and intervention in this area can empower individuals to maintain their oral health even during challenging times, especially with how skeptical consumers are of modern pharmacology. Psychological suggestion techniques may prove to be extremely effective in reducing dental anxiety amid news of and during oral surgical procedures; perhaps, a consideration of the usage of a calming VR environment could be very helpful, as it would potentially distract patients from a possibly painful experience.