JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 111-114

Determining the association between stress and periodontal disease: A pilot study

Department of Periodontics, JMF's A.C.P.M. Dental College, Dhule, Maharashtra, India

Date of Web Publication15-Jul-2016

Correspondence Address:
Dr. Alkesh S Shende
9/704, Premsagar Housing Complex, Mankhurd Link Road, Chembur, Mumbai - 400 043, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0754.186417

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Aim: To evaluate the relationship between stress and periodontal disease. Materials and Methods: This study included fifty chronic periodontitis subjects. The clinical parameters assessed for the full-mouth periodontal examination were as follows: Plaque index (PI), probing depth (PD), and clinical attachment level (CAL). The subjects were provided with a questionnaire for the assessment of stress based on the Zung's self-rating depression and anxiety scale, the scores of which were correlated with the periodontal findings. Results: The number of subjects showing depression and anxiety were significantly less and the severity of depression and anxiety was mild in them. The clinical parameters (PI, PD, CAL) showed no significant differences among the subjects with varying levels of stress. There was no statistical significance for stress to be contributing toward the periodontal disease. Conclusion: The present study showed no association between stress and periodontal disease, and future longitudinal studies directed at larger population, might yield conclusive results.

Keywords: Anxiety, depression, periodontal disease, stress

How to cite this article:
Shende AS, Bhatsange AG, Waghmare AS, Shiggaon LB, Mehetre VN, Meshram EP. Determining the association between stress and periodontal disease: A pilot study. J Int Clin Dent Res Organ 2016;8:111-4

How to cite this URL:
Shende AS, Bhatsange AG, Waghmare AS, Shiggaon LB, Mehetre VN, Meshram EP. Determining the association between stress and periodontal disease: A pilot study. J Int Clin Dent Res Organ [serial online] 2016 [cited 2022 Aug 7];8:111-4. Available from: https://www.jicdro.org/text.asp?2016/8/2/111/186417

   Introduction Top

Periodontitis is a multifactorial disease, where microbial dental biofilms are considered the main etiological agent for the initiation of inflammatory process, but still the host and environmental factors play an important role in the progression of periodontal disease. Environmental risk factors, such as smoking and diabetes mellitus, may modify the host response and hence, modify disease progression, severity, and outcome.[1] Other factors, such as stress, depression, and anxiety, are not yet confirmed as absolute risk conditions but have been identified in some observational studies as potential factors that may affect periodontal disease.[2],[3] With respect to other possible factors influencing chronic periodontitis, evidence is emerging that chronic stress, anxiety, and depression may negatively influence disease progression.[4]

Stress is compatible with good health, which is necessary to cope with the challenges of everyday life. Problems start when the stress response is inappropriate to the size of the challenge, producing neuroendocrine and biochemical changes that result in significant adverse effects on the proper functioning of the immune system.[5],[6] It is a state of physiological or psychological strain caused by adverse stimuli, physical, mental, or emotional, internal or external that tend to disturb the functioning of an organism and which the organism naturally desires to avoid.[7] It is an important factor which governs the host defenses through the hypothalamic-pituitary adrenal axis and could have an influence over the pathogenesis of periodontitis.[8]

There have been many studies over the association between periodontal disease and psychological factors, but still the correlation is unclear between them. The latest research by workspace provider Regus shows that Indian workers are getting more stressed. The survey reveals that work (51%) and personal finances (50%) are the contributing factors for the increased stress levels of the Indian workforce. In a large cross-sectional study, Genco et al. found that psychological stress factors in conjunction with financial worries are significant risk indicators for adult periodontal disease.[9] Wimmer et al. concluded that the stress coping strategies of the periodontitis patients influenced the effect of stress on periodontal disease and were at a greater risk for severe periodontal disease.[10] Recently, a study done by Refulio et al. found a significant association between emotional depression, level of anxiety, and chronic periodontitis based on the Zung's self-rating scale. However, the mechanisms leading to such interactions are still not clear.[4]

Studies done in India have suggested stress to be a risk factor for periodontal disease, as stress accompanied by altered oral hygiene habits leads to the accumulation of plaque and obstructs the immunity of the person through the endocrinal connections. Furthermore, some studies have considered it to be an important risk factor for periodontal disease.

Need for the study

Studies have shown a positive correlation between stress and periodontal disease. On the contrary, studies have also shown no correlation between the two. The objective of this study was to evaluate the role of stress in the periodontal disease by measuring the periodontal clinical parameters and recording the psychosocial stress scale values.

   Materials and Methods Top

Study design and population

The study included randomly selected fifty systemically healthy subjects (27 males; 23 females), with an age range of 25–70 years, having chronic periodontitis (probing depth [PD] >5 mm; clinical attachment level [CAL] >4 mm) that reported to the Outpatient Department of Periodontics, A.C.P.M. Dental College, Dhule. The study was carried out from August 2015 to September 2015, after the approval from the Ethical Committee of A.C.P.M. Medical College, Dhule, with the following reference number: E-2/2240/2015. The subjects received detailed information about the proposed research and gave informed consent. Exclusion criteria included individuals, who chronically used corticosteroids or immune suppressor drugs as well as those with immunosuppressive diseases, individuals who used antibiotics within the last 6 months, those who had symptoms of acute illness and smokers. Moreover, the subjects with known systemic conditions that could interfere with periodontal disease and who had undergone periodontal treatment along with systemic antibiotics in the previous 6 months were not included.

Clinical examination

A full-mouth periodontal examination was performed. The clinical parameters included were plaque index (PI), PD, and CAL.

The evaluation of stress

All the subjects were evaluated for stress (depression and anxiety) using the Zung's self-rating depression (SDS) and self-rating anxiety scale (SAS).[11] The questionnaire was originally designed in English, and it was modified to a bilingual one with questions in both English and Marathi (local language) for better understanding of the questions by the participants. The questionnaire consisted of twenty questions each for the depression and anxiety scale. Each question was rated on a four-point scale. The questions in the questionnaire were related to almost all the relative components of daily life events. The summation of the individual scores of all the questions gave the score for each participant. They were scored as following: 20–49 normal, 50–59 mild, 60–69 moderate, >70 severe.

Statistical analysis

The data were analyzed using SPSS Inc. Version 16.0. Chicago. The frequency and percentage distribution of the proportion of respondents score was tabulated, and the comparison of mean PD, PI, and CAL was done in between different scores of respondents and also score range using one-way ANOVA test and unpaired t-test. The significance level was of 0.05 (P < 0.05).

   Results Top

A total of fifty subjects were evaluated for stress (depression and anxiety) with a mean age of 42 years. Out of the total subjects examined based on the Zung's scale, majority of the subjects (n = 36) had no depression and the remaining subjects (n = 14) showed mild/moderate depression. Similarly, anxiety was not seen in greater number of subjects (n = 46) with only few of the subjects (n = 4) showing mild anxiety [Table 1]. In relation to the self-depression scale recorded, the PI showed no significant differences between the varying levels of depression among the subjects. It was seen that mean PD among the subjects with no depression (4.61 ± 0.90) though not significant but was greater than those with mild/moderate depression, whereas the mean CAL (3.16 ± 0.62) also did not show any significant difference [Table 2]. In the anxiety scale also, the PI (2.36 ± 0.30), PD (4.52 ± 1.04), and CAL (3.13 ± 0.72) showed higher values for subjects with no anxiety than those with mild anxiety, but the difference was not statistically significant [Table 3].
Table 1: Percentage distribution of the subjects for the self--depression scale and self-anxiety scale

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Table 2: Mean deviations of the self-rating depression scale with the clinical parameters (plaque index, probing depth, clinical attachment loss)

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Table 3: Mean deviations of the self-anxiety scale with the clinical parameters (plaque index, probing depth, clinical attachment loss)

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   Discussion Top

Since long, it has been considered as stress to be one of the factors promoting periodontal disease. However, it has still not been established that depression and anxiety may be primarily responsible for periodontitis. Since many studies have shown varying results, it remains to see to what extent stress can play a role in periodontal disease.

Psychosocial factors lead to changes in the oral habits and in behavioral responses of the host, such as poor hygiene, smoking, and the host's responses to the environmental determinants, such as stress.[12] Stress can be best understood as part of a complex and dynamic system of transactions between individuals and their environment. It is a part of the human condition that is present universally, but to varying degrees, and has different effects on individuals.[13]

Earlier studies done by Moss et al.[2] found out that the psychological measures taken can be one of the environmental factors in adult periodontitis. Similarly, Croucher et al.[14] and Axtelius et al.[15] found psychological stress factors to be an important determinant for periodontitis. Recently, Refulio et al.[4] showed a strong relationship between emotional depression, level of anxiety, and the risk of having chronic periodontitis. Some of the Indian studies done by Goyal et al. (2011)[7] have also concluded stress to be a contributing factor in periodontal disease showing a positive correlation between stress and periodontitis. Similarly, Mannem and Chava [16] found stress to be an important risk factor for periodontal disease.

In the present study also, the relationship between stress and periodontal disease has been evaluated using the Zungs's SDS and SAS. Though the results showed increased clinical parameters for those with increasing stress, the association was not significant. This study failed to show stress to be one of the causative factors for periodontal disease. Moreover, since a random population was taken, the number of individuals with stress was significantly less, which can be due to the bias on the side of the patient not answering with the appropriate response. This study has been in agreement with the previous studies done, where Monteiro da Silva et al. found no correlation between psychosocial stress and periodontal disease.[17] Solis et al. found no evidence of association between depression, hopelessness, psychiatric symptoms, and established periodontitis.[18] Castro et al. concluded that there was no significant association between periodontitis and the psychosocial factors analyzed.[19]

Similarly, Mengel et al.[20] and Vedhara et al.[21] did not find any association between cortisol level and psychological stress. Therefore, there are studies supporting both sides of the results thereby not providing a definite link between stress and periodontal disease. This could be due to the different instruments/scales used for the psychological assessment. No biologic marker or any other measurable mean to safely define most psychiatric disturbances is available.[22] Usually, the psychological variables are measured by self-reported scales and do not allow an assessment of the subjective and behavioral aspects of individuals. When this type of instrument is used in research, one should bear in mind that the informer may supply incorrect information and that situation bias also may take place, i.e. the condition of instability of the clinical phenomenon being evaluated.[18] Stress is not the same experienced by everyone, as it depends on how much social support, if any, is available from family and friends, which could lessen the potential stress. Furthermore, more important than the presence of stressful agents is how a person handles or copes with them.[23] Discrepancies in the results found in the various studies may be explained by differences in the psychometric instruments used and the diversity of the psychological factors variables examined.

Within the limitations of this study, it was concluded that there was no difference in the frequency distribution of periodontitis between individuals with and without depression. In addition, the clinical parameters did not suggest any predilection of periodontal disease toward stress. Moreover, still it has to be mentioned that the influence of stress on periodontal disease cannot be excluded, as there are many studies supporting the role of stress in periodontal disease. Hence, accordingly, it is required to evaluate the role of stress among varying population to determine the exact relationship between stress and periodontal disease.

Futuristic studies considering larger sample size might yield significant correlation between stress and periodontal disease. In addition, in this regard, a comprehensive outcome might be possible if biochemical parameters such as cortisol level in serum and urine analysis are carried out.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol 1996;67 10 Suppl: 1041-9.  Back to cited text no. 1
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 1996;67 10 Suppl: 1060-9.  Back to cited text no. 2
Monteiro da Silva AM, Oakley DA, Newman HN, Nohl FS, Lloyd HM. Psychosocial factors and adult onset rapidly progressive periodontitis. J Clin Periodontol 1996;23:789-94.  Back to cited text no. 3
Refulio Z, Rocafuerte M, de la Rosa M, Mendoza G, Chambrone L. Association among stress, salivary cortisol levels, and chronic periodontitis. J Periodontal Implant Sci 2013;43:96-100.  Back to cited text no. 4
Riley V. Psychoneuroendocrine influences on immunocompetence and neoplasia. Science 1981;212:1100-9.  Back to cited text no. 5
Croiset G, Heijnen CJ, de Wied D. Passive avoidance behavior, vasopressin and the immune system. A link between avoidance latency and immune response. Neuroendocrinology 1990;51:156-61.  Back to cited text no. 6
Goyal S, Jajoo S, Nagappa G, Rao G. Estimation of relationship between psychosocial stress and periodontal status using serum cortisol level: A clinico-biochemical study. Indian J Dent Res 2011;22:6-9.  Back to cited text no. 7
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Mahendra L, Mahendra J, Austin RD, Rajasekhar S, Mythili R. Stress as an aggravating factor for periodontal disease. J Clin Diagn Res 2011;5:889-93.  Back to cited text no. 8
Genco RJ, Ho AW, Grossi SG, Dunford RG, Tedesco LA. Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Periodontol 1999;70:711-23.  Back to cited text no. 9
Wimmer G, Janda M, Wieselmann-Penkner K, Jakse N, Polansky R, Pertl C. Coping with stress: Its influence on periodontal disease. J Periodontol 2002;73:1343-51.  Back to cited text no. 10
Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.  Back to cited text no. 11
Sheiham A, Nicolau B. Evaluation of social and psychological factors in periodontal disease. Periodontol 2000 2005;39:118-31.  Back to cited text no. 12
Cooper CL, Cooper EB, Eaker LH. Living with Stress. 1st ed. Middlesex, UK: Penguin; 1988. p. 11-2.  Back to cited text no. 13
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.  Back to cited text no. 14
Axtelius B, Söderfeldt B, Nilsson A, Edwardsson S, Attström R. Therapy-resistant periodontitis. Psychosocial characteristics. J Clin Periodontol 1998;25:482-91.  Back to cited text no. 15
Mannem S, Chava VK. The effect of stress on periodontitis: A clinicobiochemical study. J Indian Soc Periodontol 2012;16:365-9.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
Monteiro da Silva AM, Newman HN, Oakley DA, O'Leary R. Psychosocial factors, dental plaque levels and smoking in periodontitis patients. J Clin Periodontol 1998;25:517-23.  Back to cited text no. 17
Solis AC, Lotufo RF, Pannuti CM, Brunheiro EC, Marques AH, Lotufo-Neto F. Association of periodontal disease to anxiety and depression symptoms, and psychosocial stress factors. J Clin Periodontol 2004;31:633-8.  Back to cited text no. 18
Castro GD, Oppermann RV, Haas AN, Winter R, Alchieri JC. Association between psychosocial factors and periodontitis: A case-control study. J Clin Periodontol 2006;33:109-14.  Back to cited text no. 19
Mengel R, Bacher M, Flores-De-Jacoby L. Interactions between stress, interleukin-1beta, interleukin-6 and cortisol in periodontally diseased patients. J Clin Periodontol 2002;29:1012-22.  Back to cited text no. 20
Vedhara K, Miles J, Bennett P, Plummer S, Tallon D, Brooks E, et al. An investigation into the relationship between salivary cortisol, stress, anxiety and depression. Biol Psychol 2003;62:89-96.  Back to cited text no. 21
Menezes PR, Nascimento AF. Validation and reliability of evaluation scales in psychiatry. In: Gorenstein C, Andrade LH, Zuardi AW, editors. Clinical Evaluation Scales in Psychiatry and Psychopharmacology. 1st ed., Vol. 2. Sao Paulo: Lemos; 2000. p. 23-8.  Back to cited text no. 22
Lazarus RS, Folkman S. Stress, Appraisal and Coping. Vol. 156-157. New York: Springer Publishing; 1984. p. 328-33.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3]

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