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 expression, 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 stress-periodontitis hypothesis using this powerful, analytic epidemiologic technique.
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