|Year : 2015 | Volume
| Issue : 4 | Page : 241-245
Psychological stress: Its effect on periodontal status of individuals
Gagan R Jaiswal1, Shradha G Jaiswal2
1 Department of Periodontics, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
2 Department of Oral and Maxillofacial Pathology and Microbiology, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
|Date of Web Publication||14-Dec-2015|
Gagan R Jaiswal
Ramayan, FH-325, Scheme Nu-54, Vijay Nagar, Indore - 452 010, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Periodontitis is the inflammation and infection of the tissues that support the teeth. Growing evidence suggests that the psychosocial factors such as stress, depression, and level of social support provoke changes in host defense mechanisms that modify the disease process.
Aims: This study aimed to determine if any correlation existed between social support, stress, and periodontal status of individuals.
Materials and Methods: A cross-sectional study was carried out on 630 subjects (aged 25-70 years) suffering from chronic periodontitis. Questionnaire was the primary tool for data collection. Oral hygiene status and periodontal status were assessed using plaque index and clinical attachment level.
Results: The data were analyzed by using statistical software Statistical Package for the Social Sciences (SPSS) version 17.0. Periodontitis showed a significant correlation with work tension, economic problems, plaque index, and unsecured job.
Conclusion: Stress is an important risk factor for periodontal disease and has a confounding effect in presence of plaque on the periodontal status. We suggest that patients who are under stress should be provided meticulous periodontal care to avoid worsening of periodontal disease.
Keywords: Periodontitis, plaque, psychological stress
|How to cite this article:|
Jaiswal GR, Jaiswal SG. Psychological stress: Its effect on periodontal status of individuals. J NTR Univ Health Sci 2015;4:241-5
| Introduction|| |
Stress is body's mechanism to respond to a stressor. Negative life events manifested as psychological stress and depression are common in day-to-day life, emphasizing the relationship between the person and environment. 
Studies have demonstrated the importance of subjective factors in oral infections such as stress ,, and also the importance of psychological disturbances on the progression of periodontitis , and its response to treatment.  How these factors are associated with an increase in periodontal disease susceptibility is poorly understood at this stage.
Thus, we aimed to evaluate the effects of psychological stress on the periodontal status of individuals from various stages of life.
| Materials and Methods|| |
This was a prospective cross-sectional study. Ethical clearance was obtained prior to the commencement of the study from the Ethical Committee of Sri Aurobindo College of Dentistry, Indore. The tools for study were two pretested questionnaires for data collection to observe the opinion and attitude toward the day-to-day stress encountered by individuals. Subjects who came to the outpatient department (OPD) of the Department of Periodontics in Sri Aurobindo College of Dentistry, Indore, for oral prophylaxes were included in this study. A pilot study was performed with a sample of 30 subjects. The reexaminations to evaluate reproducibility "during the study" were performed 2 h after the end of the initial examination of the participants. The questionnaire was modified based on the experience of the pilot study and was used for the final study.
The study spanned over a period of 2 years. The nature of the study was explained to all the participants and consent was obtained prior to the commencement of the study. Patients were given the questionnaire to be filled by them before they could be clinically evaluated. Two questionnaires were used, Center for Epidemiologic Studies Depression (CESD) scale and Multidimensional Scale of Perceived Social Support (MSPSS) scale, for measuring stressors including changes, significant life event, and stress reactions including physiological and affective responses. After the evaluation and scoring based on the questionnaire, the patients were subdivided into the two groups (happy/satisfied and unhappy/unsatisfied).
Two independent examiners performed the clinical examinations. The clinicians evaluating the patients were blinded to the findings of the questionnaire to avoid bias in results. Clinical attachment levels (CALs) were measured and recorded to the nearest millimeter, at six sites per tooth, using the William's graduated periodontal probe. Individuals with a probing depth ≥4 mm and CAL ≥3 mm at the same site, in at least four teeth, were considered to have chronic localized periodontitis.  The plaque was assessed by using the Silness-Löe plaque index (1964). 
Patients who fulfilled the following criteria were included in the study:
- Patients within the age range of 21-70 years and
- Patients having at least 20 teeth in the mouth.
- Diabetic patients.
- Patients who were chronic smokers.
- Patients who were under immunosuppressive drug therapy.
- Persons with depressed immunity.
- Patients who had undergone periodontal treatment 6 months before the examination.
Seven hundred and five patients agreed to join the study, out of which 684 patients filled the questionnaire completely. However, only 664 patients completed both the subsets of the study (i.e., questionnaire and clinical evaluation). While analyzing the data, subjects were divided in the age groups of 25-40 years, 41-55 years, and 56-70 years (created for valuation of psychological stress), the number of subjects per group was uneven. For the ease of statistical analysis, equal number of subjects needed to be taken in each group, hence only 630 patients were finally included in the statistical analysis.
These 630 patients were divided into 2 groups - group A (employed/happy/satisfied) and group B (unemployed/unhappy/unsatisfied)-based on the results of the questionnaire. Group A comprised of 315 patients, who were further subdivided into 3 subgroups: A-1 (105 patients, 25-40 years, employed/happy/satisfied), A-2 (105 patients, 41-55 years, employed/happy/satisfied), A-3 (105 patients, 56-70 years, happy/satisfied and living with children). Group B comprised of 315 patients, who were subdivided into 3 subgroups-B-1 (105 patients, 25-40 years, unemployed/unhappy/unsatisfied), B-2 (105 patients, 41-55 years, unemployed/unhappy/unsatisfied), B-3 (105 patients, 56-70 years, unhappy/unsatisfied and not living with children.)
Statistical analyses included both descriptive and inferential methods. The data were analyzed by using statistical software Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS-Inc., Chicago, US). Descriptive statistical analysis was used to depict the main features and characteristic of the collected samples. Results on categorical measurements were presented in numbers (%).
One-way analysis of variance (ANOVA) was used to identify the significance of mean differences in plaque index, and psychological stress was measured using the CESD scale and MSPSS scale scores among subgroups (A1, B1, A2, B2, A3, and B3). The probability value P < 0.05 was considered as significant while P < 0.001 was considered as highly significant.
| Results|| |
The age of all the subjects varied between 25 years and 70 years. The mean age of the subjects (N = 630) was found to be 47.84 ± 13.38 years. The mean plaque index of all the subjects was 1.31 ± 0.85. The spread of mean stress as shown by CESD scale among all the subjects was 62.87 ± 17.52 while that shown by MSPSS scale was 48.82 ± 24.35.
| Discussion|| |
This study was primarily carried out with the motive of determining the relation between periodontal health and psychological stress. Hence, the study groups were created keeping in mind the factor, such as age, that could create psychological stress in the mind of an individual as different age groups have different kinds of psychological stressors. In the young, environment and friends are the major contributors of happiness; in the middle aged, job security and monetary aspects are the major predictors of satisfaction; and in the elderly, the association with younger generation that is children and grandchildren brings about happiness. Thus, the grouping was primarily based on the psychology of a person, and the subgrouping was based on the different stressors commonly encountered by different age groups. The periodontal status was evaluated by clinicians blinded to this categorization so as to eliminate bias.
The plaque index was good in group A1 [25-40 years, employed/happy (96.2%)] followed by group A2 [41-55 years, employed/satisfied/ happy (86.7%)], and the index was fair in groups B1 [25-40 years, unemployed/ unhappy (85.7%)] and A3 [56-70 years, living with children/grandchildren (81.9%)], while the index was poor in groups B2 [41-55 years, unemployed/unsatisfied/unhappy (91.4%)] and B3 [56-70 years, not living with children/grandchildren (93.3%)] [Table 1].
These findings show that subjects who did not live with their children or are unsatisfied/unhappy were found to develop more plaque. This finding is in accordance with that of Deinzer et al.  who found that when stress and plaque are present together, stress affects periodontal health by increasing interleukin (IL)-1β, which is an osteoclast-activating factor and bone-formation inhibitor. This was especially so when oral hygiene was neglected. They later also found that if a patient was first exposed to stress and then oral hygiene was neglected, stress may persistently alter the immunological effects of the microbial challenge to the periodontium.  Researchers also found that adrenaline and nonadrenaline that are released during stress influence the composition of subgingival biofilm in response to stress-induced changes in catecholamine levels and plays a significant role in the etiology and pathogenesis of periodontal diseases. They also found that psychological stress also has a marked impact on the localized immune response to Porphyromonas gingivalis, which is the most often cited periodontal pathogen implicated in the link between periodontal disease and stress. On evaluating the periodontal status [Table 2], it was found that subjects in A1 group who were employed/happy/satisfied had mild periodontitis. Moderate periodontitis was found in patients in groups B1 (25-40 years, unemployed/unhappy) and A3 (56-70 years, living with children/grandchildren), while severe periodontitis was found in groups B3 (56-70 years, not living with children/grandchildren) and B2 (40-55 years, unemployed/unhappy). This was found in accordance with DeMarco et al. who suggested that emotional stability and stress should be assessed in patients suffering from periodontal emotional stress syndrome (PESS), which is manifested clinically as severe horizontal and vertical bone loss.  Genco et al. also proposed that financial strain is significantly associated with greater attachment and alveolar bone loss. They found that salivary cortisol levels depress the immune response and is manifested as severe periodontitis. They also found that chronic stressors accelerate the risk of age-related diseases by prematurely aging the immune response. 
On evaluating the association between plaque index and stress scores, it was found that plaque index was dependent on the psychological status of the subjects [Table 3].
|Table 3: Comparison of Mean Plaque Index, CESD, and MSPSS Scale Scores Among Subgroups|
Click here to view
One-way ANOVA showed that mean difference among all groups (A1, B1, A2, B2, A3, and B3) was strongly significant (P < 0.001) as confirmed statistically. The mean plaque index and stress scores (P < 0.001) for the subjects who were employed/happy/satisfied were significantly different from those who were unemployed/unhappy/unsatisfied and not living with children.
These findings lay stress on the social support required for a person to be less stressed. Thus, as it is said that man is a social animal, so people who have better social support will be less likely to be stressed over life, whereas those who do not have good support will be more likely to be stressed even on smaller problems.
| Summary and Conclusion|| |
To summarize, we can say that stress acts as an important factor that leads to negligence of oral health thereby promoting increased plaque deposition, thus creating a favorable environment for growth of P. gingivalis, which is the primary periodontal pathogen responsible for the development of periodontitis. Hence, we propose that psychoanalysis should be an integral part of case history taking. Also stress may make periodontal patients resistant to the therapy; hence, in such patients instruction and motivation for oral hygiene maintenance must be given prime importance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lazarus RS. Toward better research on stress and coping. Am Psychol 2000;55:665-73.
Marcenes WS, Sheiham A. The relationship between marital quality and oral health status. Psychol Health 1996;11:357-69.
da Silva AM, Newman HN, Oakley DA. Psychosocial factors in inflammatory periodontal diseases. A review. J Clin Periodontol 1995;22:516-26.
Croucher R, Marcenes WS, Torres MC, Hughes F, Sheiham A. The relationship between life-events and periodontitis. A case-control study. J Clin Periodontol 1997;24:39-43.
Freeman R, Goss S. Stress measures as predictors of periodontal disease--a preliminary communication. Community Dent Oral Epidemiol 1993;21:176-7.
Moss ME, Beck JD, Kaplan BH, Offenbacher S, Weintraub JA, Koch GG, et al
. Exploratory case-control analysis of psychosocial factors and adult periodontitis. J Periodontol 1999;67(Suppl):1060-9.
Gomes-Filho IS, Cruz SS, Rezende EJ, Dos Santos CA, Soledade KR, Magalhães MA, et al
. Exposure measurement in the association between periodontal disease and prematurity/low birth weight. J Clin periodontol 2007;34:957-63.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35.
Deinzer R, Rüttermann S, Möbes O, Herforth A. Increase in gingival inflammation under academic stress. J Clin Periodontol 1998;25:431-3.
Deinzer R, Förster P, Fuck L, Herforth A, Stiller-Winkler R, Idel H. Increase of crevicular interleukin 1beta under academic stress at experimental gingivitis sites and at sites of perfect oral hygiene. J Clin Periodontol 1999;26:1-8.
De Marco TJ. Periodontal emotional stress syndrome. J Periodontol 1976;47:67-8.
Genco RJ, Glurich I, Haraszthy V, Zambon J, DeNardin E. Overview of risk factors for periodontal disease and implications for diabetes and cardiovascular disease. Compend Contin Educ Dent 2001;22:21-3.
[Table 1], [Table 2], [Table 3]