War stress and oral health: beyond psychological trauma

Chronic stress related to armed conflicts constitutes a major systemic factor altering the neuroendocrine, metabolic, and immunoinflammatory regulations of the patient. For the practitioner, the challenge is to understand how this extreme environmental pressure translates into concrete clinical pathologies. This systematic review of the literature, covering the period 2021-2026, was conducted by querying the PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and Epistemonikos databases, in order to structure knowledge on these complex interactions.

The objective of this work was to synthesize data regarding the role of war stress in the development of allostatic load and metabolic dysregulations, while specifying their consequences on the stomatognathic system. The authors explored the hypothesis of a multidirectional impact where prolonged activation of the hypothalamic-pituitary-adrenal axis and altered glycemic control degrade periodontal health. The study also evaluates how neuromuscular and behavioral pathways induced by conflict lead to specific prosthetic complications, such as pathological dental wear, restoration chipping, and mechanical overload of prosthetic constructions.

Methodological approach to the analysis

The analysis synthesises the most recent clinical data extracted from major databases (PubMed/MEDLINE, Scopus, Web of Science, Google Scholar) and specialised publisher repositories (Elsevier, Springer Nature, Wiley) over the period 2021–2026. The selected corpus integrates systematic reviews, meta-analyses, as well as clinical and retrospective studies.

The selection protocol focused on evaluating allostatic load and its systemic dysregulations. The synthesis of the results was structured around four major clinical impact axes:

• Neuroendocrine and metabolic pathways: Analysis of hypothalamic-pituitary-adrenal axis dysregulation, cortisol levels, and altered glycemic control (type 2 diabetes).
• Immuno-inflammatory pathways: Evaluation of the role of systemic inflammation and oxidative stress on the integrity of periodontal tissues.
• Neuromuscular and pain pathways: Study of the prevalence of bruxism (clenching), temporomandibular disorders (TMD), myofascial pain and central sensitization mechanisms.
• Occluso-mechanical pathways: Observation of the direct consequences on pathological dental wear, chipping of restorations, and prosthetic overload phenomena.

Systemic impact and metabolic deregulation

The data synthesis highlights a direct correlation between prolonged exposure to war stressors and major systemic disruptions. The neuroendocrine pathway manifests through a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, leading to an alteration in cortisol response. On a metabolic level, data report a degradation of glycemic control, an increased incidence of type 2 diabetes and metabolic syndrome, as well as an elevation of oxidative stress and systemic inflammation.

Periodontal and neuromuscular manifestations

Periodontal tissues undergo the combined impact of cortisol, sleep disorders, and stress-induced behavioral changes. At the same time, the neuromuscular sphere shows a high prevalence of pathologies related to pain and muscular hyperactivity.

Clinical Field	Reported Observations
Neuromuscular	Bruxism (clenching/grinding), myofascial pain.
Orofacial Pain	Temporomandibular disorders (TMD), central sensitization.
Periodontium	Tissue alteration related to stress and behavioral factors.

Occluso-prosthetic consequences

The analysis highlights concrete mechanical repercussions on the masticatory system and the existing rehabilitations:

• Dental wear: Development of pathological wear facets related to war bruxism.
• Prosthetic failures: Increased cases of chipping (ceramic fractures) on restorations.
• Mechanical overload: Increased risk of overload on prosthetic constructions and implants, compromising their long-term durability.

These results indicate that chronic stress acts as an interdisciplinary risk factor, modifying the immune response and the mechanical tolerance of the stomatognathic system.

Analysis of systemic and local repercussions

This review highlights that war stress extends far beyond the psychological sphere to become a major interdisciplinary risk factor in dentistry. The synthesized data reveal three critical axes of degradation: metabolic, periodontal, and biomechanical. The dysregulation of the hypothalamic-pituitary-adrenal axis and the alteration of the cortisol response directly impact glycemic control, promoting type 2 diabetes and systemic inflammation, which weakens the supporting tissues.

Clinically, this vulnerability results in increased susceptibility to periodontology diseases, exacerbated by sleep disorders and behavioral changes. Mechanically, prolonged stress activates neuromuscular pathways leading to bruxism (awake and sleep), temporomandibular disorders (TMD), and central pain sensitization. For the implantology specialist or prosthodontist, the consequences are direct: pathological dental wear, chipping of ceramics, and risk of overloading prosthetic or dental implant constructions.

Limits and perspective

Although this synthesis is based on robust meta-analyses — notably on the prevalence of post-traumatic stress disorder (PTSD) and TMD in veterans — it compiles data from heterogeneous populations (refugees, military, civilians). This diversity makes it difficult to establish a universal treatment protocol. However, the strength of the study lies in demonstrating that restoration failure or the worsening of periodontology issues in these patients is often only the tip of the iceberg of a profound metabolic disorder.

Study summary

Compiled data demonstrate that conflict-related chronic stress triggers dysregulation of the hypothalamic-pituitary-adrenal axis, increasing systemic cortisol. This state impairs glycemic control (type 2 diabetes) and exacerbates periodontal inflammation. Mechanically, studies report an increased prevalence of bruxism, temporomandibular disorders (TMD), and prosthetic failures due to mechanical overload (ceramic chipping, implant overloading).

In concrete terms, for the practitioner:

• Anticipating mechanical failures: In patients exposed to intense stress, prioritize more resilient prosthetic materials and systematize the prescription of protective splints to prevent restoration fractures and peri-implant overloads related to bruxism.
• Adapting periodontal management: Integrate the metabolic factor into your treatment plan; a stressed patient presents a risk of faster periodontal progression due to hypercortisolemia and a degraded immune response.
• TMD screening: Systematically evaluate central sensitization and myofascial pain before any complex occlusal rehabilitation, as the pain tolerance threshold is often lowered by the patient's neuroendocrine context.

Chronic stress related to conflict is not limited to psychological distress; it constitutes a major systemic risk factor altering neuroendocrine, metabolic, and immunoinflammatory balance. For the practitioner, the challenge is to identify how these disturbances translate clinically within the masticatory system, beyond obvious psychological symptoms.

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