What clinicians need to know about how PTSD can affect dental health

One psychiatric condition that presents specific challenges in relation to periodontal health is post-traumatic stress disorder (PTSD), which manifests as a complex psychological reaction to one or more traumatic events experienced through direct involvement, witnessing, or exposure to extreme events. PTSD is generally understood as the body’s attempt to cope with a traumatic, often life-threatening, situation through counter-regulatory mechanisms.

Unlike the acute stress reaction, which is aimed solely at survival, PTSD leads to long-term psychological and physical impairment. There may also be a delayed onset, where the full range of symptoms only becomes apparent six months or more after the trauma.

The clinical picture is characterized by clusters of symptoms that persist for more than one month and lead to significant functional impairment: intrusive thoughts, avoidance behaviour, negative changes in cognition and mood, and hypervigilance. Those affected suffer from recurrent, uncontrollable, and distressing memories of the trauma, which manifest as flashbacks, nightmares, or intense physical and psychological reactions when confronted with trauma-associated stimuli. Complex PTSD is characterized by multiple traumatic events and the resulting combined clinical presentations.

Estimates of the prevalence of PTSD vary between two and ten percent on veterans. The latest estimate from the World Health Organization is that an estimated 3.9% of the world population has had PTSD at some stage in their lives.

In relation to dentistry, PTSD patients may have a fear of blood and injury, memory impairment, an increased prevalence of clinically significant dental anxiety (CDSA) that may include avoidance behaviour lasting more than two years, dentine hypersensitivity, and heavy tobacco use as a coping mechanism, which increases the risk of periodontitis. Bruxism, restricted mouth opening, and painful temporomandibular dysfunction (pTMD) are also significant problems in PTSD patients.

A group of Norwegian researchers from Oslo and Kristiansand has been examining and treating refugees from the Middle East and Africa since 2019. The objectively assessed dental-treatment requirements among those examined differed little from those of the Norwegian population. However, the CSDA was 6.1 times higher among refugees who had personally experienced violence compared with other refugees, and 9.3 times higher among patients who had subsequently developed PTSD (Høyvik et al., 2019).

As the treatment of orofacial functional disorders is minimally invasive and can significantly alleviate suffering, it is recommended that people with PTSD and temporomandibular joint pain or masticatory muscle pain be referred for dental assessment—even if they have an additional CSDA—in order to arrange adjuvant dental therapy for pTMD, where appropriate.

Therapy with dental reflex splints has been shown to lead to a reduction in temporomandibular joint/masticatory muscle pain, a reduction in nightmares, and an increase in the duration of uninterrupted sleep. The therapeutic reduction in TMD pain achieved through splint therapy in PTSD patients is maintained over long periods, even if the PTSD persists (Woerner et al., 2024.

The relationship between periodontitis and PTSD

Periodontitis is regarded as a multifactorial chronic inflammatory disease, the development of which is influenced by both microbial factors and systemic and immunological factors. Through elevated levels of IL-6 and CRP that cross the blood-brain barrier, inflammatory periodontal diseases can influence neurotransmitter metabolism, neuroplasticity, and the stress-response system in mental-health conditions.

Against this background, the investigation of PTSD as a potential risk factor for periodontal disease, and vice versa, is of increasing clinical relevance. A study of Croatian war veterans showed that patients with PTSD had significantly higher plaque and bleeding indices compared with a healthy control group and patients with severe periodontitis. The prevalence of the periodontal pathogens Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis and Eikenella corrodens was similarly high in PTSD patients without periodontitis and in patients without PTSD but with severe periodontitis. This led to the conclusion that people with PTSD should be classified as a risk group for the development and progression of periodontal disease (Haban et al., 2003).

One study has found both increased tobacco use and a higher prevalence of severe periodontitis (stages III/IV) in the group of military veterans with PTSD (Tagger-Green et al., 2022). Another study found no significant differences in the prevalence of periodontitis of any severity level between veterans with PTSD and a control group without PTSD who had comparable lengths of overseas deployment and were of similar ages (Wörner et al., 2021). It is possible that regular dental check-ups and supportive periodontal therapy, as protective factors within the military system, offset smoking as a modifiable risk factor.

Akinkugbe et al. (2025) investigated the long-term oral health consequences of traumatic events following the terrorist attacks of 11 September 2001 over a follow-up period of up to 17 years. The results showed an incidence rate of periodontitis of 7.6 per 1,000 participants among those with PTSD, compared with 4.3 per 1,000 in participants without PTSD. After adjusting for relevant covariates, there was a 52% increased risk of periodontitis in patients with PTSD. Furthermore, PTSD was also associated with an increased risk of tooth loss.

People with PTSD should be classified as a risk group for developing periodontal disease

A recent systematic review comprising 13 studies involving 1,610 patients used a meta-analysis to establish that, following periodontal therapy and three months of supportive periodontal care, patients with stress-related disorders or depression achieved 1mm less gain in periodontal tissue compared with mentally healthy patients (Mauland and Neupane, 2025). Another recent review identified significantly greater residual periodontal inflammation following periodontal therapy in these patients across eight studies (Villafuerte et al., 2025).

Hamid and Dashash (2019, 2021) investigated the link between PTSD and periodontal health in refugee children. In their case-control study, 60 children aged between nine and 14 were examined during the Syrian civil war (2011-2014): 30 with a diagnosis of PTSD and 30 healthy control subjects. The results showed significantly higher values for both the plaque index and the gingival index in the traumatised children (P < 0.0001). Furthermore, the severity of PTSD symptoms correlated positively with plaque accumulation and signs of gingival inflammation.

As part of a six-week oral-hygiene training programme held twice a week in a refugee camp, researchers found significant differences between children in the intervention group and those in the control group who received no oral-hygiene training. Among other things, the authors discuss behavioural factors such as impaired oral hygiene in the context of psychological distress, changes in stress regulation, and reduced access to dental care in crisis areas as possible mechanisms. The study thus demonstrates that traumatic stress experienced as early as childhood may be associated with a deterioration in periodontal health.