|Year : 2012 | Volume
| Issue : 2 | Page : 106-110
Mood and mouth
Reddy Sudhakara Reddy1, Nimma Vijayalaxmi1, Tatapudi Ramesh1, Rudraraju Ramakrishnam Raju2, Reddy Lavanya Reddy1, Thakur Rajesh Singh1
1 Department Oral Medicine & Radiology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
2 Department of Psychiatry, Bhimavaram Hospitals, Bhimavaram, Andhra Pradesh, India
|Date of Web Publication||11-Jul-2012|
Vishnu Dental College, Bhimavaram, West Godavari, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To find the association of various aspects of oral health behavior in the patients with depressive disorders.
Study Design: This investigation was conducted as a descriptive cross-sectional study incorporating a study group diagnosed as having depression and a control group in a stipulated period of 2 months.
Materials and Methods: Subjects between the age group of 18 - 60 years were examined using diagnostic instruments, and specially designed proforma was utilized for collection of data with the approval of ethical committee and patient consent.
Results: A female preponderance (80%). Decrease in appetite with increased cravings for sugars and poor oral hygiene practices were observed in study group, which contributed to their deteriorated periodontal conditions and increased caries experience. Range of subjective symptoms showing significant association with depressive symptoms (z value > 1.96) was observed, which include dry mouth, halitosis, temporomandibular disorders, difficulty in swallowing and speech, chronic pains, and altered taste sensation, whereas control group lacked such symptoms.
Conclusion: In this study, we have found a significant association between emotional state and oral health; therefore, dentists who are cognizant of signs and symptoms of depressive disorders have an opportunity to recognize patients and make a referral to psychiatrist for confirmation of diagnosis and treatment.
Keywords: Dental manifestations, depressive disorder, halitosis, temporomandibular disorders, xerostomia
|How to cite this article:|
Reddy RS, Vijayalaxmi N, Ramesh T, Raju RR, Reddy RL, Singh TR. Mood and mouth. J NTR Univ Health Sci 2012;1:106-10
| Introduction|| |
The definition of the term 'depression' is complicated because of the inherent ambiguity involved. In the psychiatric sense, depression can be seen as a state of mood, as a special symptom manifesting itself in many different mental disorders, as a syndrome measured by depression rating scales, and as a clinical diagnosis operationalized in diagnostic classifications.  Occasional depressive mood may be experienced as low spirits, dejection, and sadness and can be considered a normal reaction to disappointments, adversities, and losses of day-to-day life, and these should be differentiated from depressive disorders, which represent an actual psychological illness and are often accompanied by distinct impairment of psychological, somatic, and social functioning.  The depressive disorders consists of major depression and dysthymia  [Table 1].
Comorbidity of somatic illnesses like cardiovascular diseases.  diabetes,  infectious diseases,  and depression is a largely reported phenomenon. The question of whether there exists comorbidity of oral diseases and depression is still unclear. The basic emotional and symbolic importance of the mouth in mental development and some characteristics connected with depression and depressive symptoms support the hypothesis that there is an association between "mood and mouth."
Thus, an integrated approach covering biological, psychological, and social factors is essential in oral health research, as a whole, there are relatively few studies concerning the association of depression or depressive symptoms with oral health. This study was conducted to know the relationship between these disease entities with multifactorial etiologies and thus to improve the facility for identifying depression and depressive symptoms as underlying or contributory factors of orofacial diseases and symptoms and vice versa.
The aims and objectives of study:
- To find out whether depressive symptoms are associated with various aspects of oral health behavior.
- Recording the oral manifestations in depressive disorder patients.
- To analyze diet, habits, and oral hygiene practices among patients with depression and among healthy patients.
| Materials and Methods|| |
A sample of 66 patients of which 33 belonged to study group who are diagnosed as having depression by the psychiatrist of Bhimavaram hospitals, Bhimavaram and another 33 patients belonged to control group who are the healthy patients visiting the outpatient department of Vishnu dental college, Bhimavaram were included into the study.
- All patients diagnosed as depressive disorder by psychiatrist between age group of 18 - 60 years.
- Patients with no symptoms of depression within 6 months and had never taken any medication for the same
- Subjects suffering from chronic systemic illness and under medications for the same.
Diagnostic instruments (mouth mirror, straight, and graduated probes) were used for oral examination of patient, and data recorded in a specially-designed proforma, which consisted of demographic details of patient, diet consumed, oral hygiene practices, adverse habits, previous visit to dentist, and subjective symptoms. An approval from college ethical committee was obtained, and consent was taken from the individual patient.
- Subjects suffering from chronic systemic illness and under medications for the same.
| Results|| |
A female preponderance (80%) in study sample, majority (51%) belonging to age group of more than 35 years, was observed. A list of variables were observed [Table 2]. Not a significant difference, but an increase in the practice of adverse habits (smoking and alcohol) was seen in study group. An overall decrease in the appetite with increase in cravings for sugars observed among the patients with depression. Oral hygiene practices lacked a significant difference between the groups, but the inter-dental cleansing agents were less preferred by the patients with depression. A range of subjective symptoms were observed, which include dry mouth, halitosis, temporomandibular disorders, difficulty in swallowing and speech, chronic pains, and altered taste sensation, whereas control group lacked such association [Figure 1], [Figure 2] and [Figure 3]. A deteriorated periodontal status with 91% patients having probing depth of pockets more than 3 mm and mobility of teeth and an increased caries experience (90%) is observed, which reflects the oral hygiene practices, habits, and diet consumed by the depressive patients.
|Figure 1: Subjective symptoms in the depressive disorder (study group) patients|
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|Table 2: Comparison between depressive disorder patients and patients of control group|
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| Discussion|| |
Depressive disorders represent a major public health problem globally. In 2000, the World Health Organization (WHO) identified depressive disorders as the fourth ranking cause of disability and premature death in the world and also projected that by 2020, there would a rise in disease burden to occupy second place only to ischemic heart disease.  Thus, a definite need for addressing this global problem arises, which is having a lifetime prevalence rates of 10% to 25% for women and 5% to 12% for men, whereas point prevalence rates are 5% to 9% for women and 2% to 3% for men. 
In our study, 80% of populations were females, and majority (51%) was belonging to age group of more than 35 years of age. One of the most consistent findings in research on depression is its higher prevalence among women.  It has been suggested that it is the social factors rather than the biological differences that are of key relevance for the female preponderance in depression.  List of subjective symptoms were observed in the study group, which include dry mouth, halitosis, temporomandibular joint dysfunctions, difficulty in swallowing and speech, chronic pain in orofacial region, myofacial pain dysfunction syndrome, and dysguesia or altered taste sensation and mucosal-related disorders such as lichen planus, apthous stomatitis, and burning mouth syndrome. The subjective sensation of oral dryness was recorded to account for 70% (statistically significant with z value 22.33 > 1.96) of study group. The subjects were asked if they felt their mouth to be dry never or rarely, sometimes, or often, only those subjects who answered 'sometimes' or 'often' were placed into the sensation of dry mouth category. In our study, the subjective sensation of dry mouth was related to unstimulated but not to stimulated salivary flow rate. In addition to the quantity of saliva, there are other factor that play a role in the genesis of subjective oral dryness and, consequently, in the existing relation between depressive symptoms and sensation of dry mouth. There are several possible mechanisms that may connect these two phenomena, both of which are likely to have multifactorial etiology. One of these mechanisms is somatization, the expression of distress in the form of physical symptoms that cannot be explained biomedically, which is known to associate with depression.  Somatization has also been suggested to be the underlying factor of diverse salivary complaints with no known biological explanation.  The other one is appetite disturbances  as found in our study an overall decrease in appetite representing 58% of patients with depressive disorder, which serves as a link between depressive symptoms and the sensation of dry mouth. Our result on the association between subjectively felt dry mouth and depressive symptoms was in accordance with the results of previous studies. 
The presence of subjective symptoms of temporomandibular disorders (TMD) was present in 52% of study population. Symptoms relating to pain and clicking had the most significant relations to depression (statistically significant with z value 8.6 > 1.96). Our results support the already existing evidence concerning comorbidity of depression and TMD.  The question of whether there is some causality between these phenomena, and/or if they share some common etiological factors cannot be answered based on this cross-sectional study. However, the associations between depressive symptoms and self-perceived symptoms of TMD remained statistically significant. Another important subjective symptom halitosis or self-perceived bad breadth was found to be present in 58% of study population (statistically significant with z value 7.16 > 1.96) and was in accordance with results of study by Nao Suzuki et al. 2008. 
Chronic pain was another finding found to be present (27%) in study group when compared to control group having 12% only, manifested as headaches and musculoskeletal pains. Depression has been found to predict the onset of chronic pain and vice versa.  some researchers have hypothesized that the pain may arise from stress-induced disruption of the HPA axis, a mechanism previously implicated as the cause of both depression and inflammatory joint disease.  Other symptoms which can be attributed to presence of dry mouth include burning sensation in the oral cavity, difficulty in speech and swallowing, and altered taste sensation. An increase in caries experience  and deteriorated periodontal condition  with increased probing depth of pockets and mobility of teeth was found in the study group, which reflected the diet consumed adverse habits and oral hygiene practices in the group. 49% of the patients with depression consumed mixed diet having an increased craving for sugar as in between meal snacks, 30% of them having habit of smoking and alcoholism. In spite of having certain kind of dental complaint, the time lapse from last dental visit is more than a year in 88% of patients with depressive disorders. Many studies identified the association of depression as one of the etiological factor in mucosal lesions such as oral lichen planus, apthous ulcers and burning mouth syndrome and others.  It can be noted here that most of the studies here intended to measure the stress level in already-diagnosed cases of mucosal disorders, but in our study, we made an attempt at observing oral manifestations in depressive disorder patients at their initial visit to psychiatrist. In our study, we could not find any mucosal alterations, which can be attributed probably to the initial phase of depression that is considered, and as ours is a cross-sectional study.
Common treatment modalities for depressive disorders includes anti-depressant drugs, which also have certain side effects like xerostomia, dysguesia, stomatitis etc.,  thus worsening the existing condition of depression. Management of depressive patients using the drugs having least oral side effects is recommended. As cross-sectional studies of this kind with a limited sample size would not explain a causal relationship; an improvement in sample size, and study design with definite diagnosis of different stages of depression, and associated oral manifestations should be considered for future research in this field.
| Conclusion|| |
In this study, we have found a significant association between emotional state and oral health; therefore, dentists cognizant of signs and symptoms of depressive disorders have an opportunity to recognize patients with occult depressive disorders and make a referral to psychiatrist for confirmation of diagnosis and treatment and vice versa. Also, offer these patients the full range of dental treatment options.
Further emphasizing that dentistry in concert with medicine has much to offer the patients with depression and consequently supporting the holistic view of health, suggesting that neither oral nor mental health should be separated from entity of general or overall health.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]