Periodontal disease as a function of life events stress

Effect of Occupational Stress on Periodontitis According to the Salivary RANKL Level Among Iraqi Employees

Background

Findings show that periodontitis does not affect all populations; similarly, some individuals present risk conditions such as occupational stress, making them more susceptible to developing periodontitis through unhealthy habits like poor oral hygiene and immune suppression. Periodontitis triggers an inflammatory host immune response; "Receptor Activator Nuclear Factor KB ligand (RANKL)" is the primary regulator of osteoclast differentiation and activity. It was found that osteoclastic bone damage caused by periodontitis depends on the RANKL produced by osteoblastic and periodontal ligament cells.

Objective

This study aimed to assess the effect of occupational stress on employees with periodontitis using salivary RANKL marker.

Material and Methods

A case-control analysis was done at my clinic with 90 male employees aged 30-50. The participants completed self-administered questionnaires and had periodontal exams. Employee occupational stress was estimated using a life events scale questionnaire. Calibrated dentists performed the parameters used in the periodontal assessment after collecting whole unstimulated salivary samples from each employee to measure salivary RANKL using ELISA technique.

Results

The present finding revealed a statistically significant difference among groups in "probing pocket depth, plaque index, bleeding on probing, clinical attachment level, and salivary RANKL level". They were higher in the stressed employees' group, which is not statistically significant.

Conclusion

The findings of this investigation observed that occupational stress increased clinical periodontal parameters and salivary RANKL of periodontitis in employees.

Prevalence of Chronic Periodontitis and Chronic Stress in the South Indian Population

Background Chronic stress is commonly thought to have a net negative effect on the efficacy of the immune response, leading to an imbalance between host and parasite and consequently resulting in a periodontal breakdown. Aim To identify the prevalence of chronic periodontitis and chronic stress as well as a comparative evaluation of clinical, demographic, and psychoanalytical parameters among the South Indian population. Materials and methods A total of 500 subjects between the ages of 30 and 60 were chosen from the Trivandrum district, Kerala, using multistage random sampling. Subjects were evaluated based on psychoanalytical parameters as well as periodontal examination. Psychoanalytical parameters were measured by the questionnaire method using the perceived stress scale. Periodontal parameters examined were the probing depth, clinical attachment loss, bleeding on probing, simplified oral hygiene index, and community periodontal index (loss of attachment). Statistical Analysis Categorical and quantitative variables were expressed as frequency (percentage) and mean ± SD respectively. Logistic regression analysis was used to analyze the association between the periodontal variables and psychoanalytical variables. All the statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows (IBM Corp., USA). Results A total of 500 subjects, of whom 308 (61.6%) were female and 192 (38.1%) were male, participated in this study. The overall prevalence of periodontitis among all the subjects was found to be 42.4%, and the proportion of periodontitis among the stressed participants was found to be 46.2%, which is 10% higher compared to the non-stressed (36.1%) participants. Conclusion Our study showed an increased frequency of periodontitis among the stressed subjects as compared to the non-stressed subjects. These findings suggest that there is a positive association between chronic stress and chronic periodontitis, but further prospective studies are required to establish the extent of the effect chronic stress has on chronic periodontitis and vice versa.

Exposure to domestic abuse and the subsequent risk of developing periodontal disease

Aims

Periodontal disease and domestic abuse (DA) are significant public health problems. Previous cross-sectional evidence indicates an association between DA exposure and development of periodontal disease. There have been no large-scale cohort studies exploring this relationship in a UK-setting. Our aim was to conduct a population-based retrospective open cohort study to explore the association between DA exposure and the subsequent development of general practitioner (GP)-coded periodontal disease.

Materials and methods

We undertook a retrospective open-cohort study using the IQVIA Medical Research Database (IMRD) UK database between the 1^st January 1995 to 31^st January 2021. Women (aged 18 years and over) exposed to DA were matched by age, deprivation, and smoking status to up to 4 unexposed women, all of whom had no pre-existing record of periodontal disease. Cox regression analysis was used to calculate crude and adjusted hazard ratios (HRs) to describe the risk of developing periodontal disease in the exposed group.

Results

23429 exposed patients were matched to 69815 unexposed patients. During the study period, 78 exposed patients had developed GP-recorded periodontal disease compared to 154 in the unexposed group, translating to an IR of 94.18 per 100,000 person years (py) and 54.67 per 100,000 py respectively. Following adjustment for key covariates, this translated to an aHR of 1.74 (95% CI 1.31-2.32), which was robust during our sensitivity analysis.

Conclusions

Our results provide further evidence that DA exposure is associated with increased risk of developing periodontal disease. There is a need for swift implementation of public health policies to improve surveillance, reporting, and prevention of DA.

Evaluation of association between potential stress markers and periodontal health in medical and dental students: A questionnaire-based study

Aims and Objectives:

Psychological conditions, particularly psychosocial stress, have been implicated as risk indicators for periodontal disease. The aim of the present study was to explore the role of psychosocial stress on periodontium through questionnaire and serum cortisol level.

Subjects and Methods:

Two hundred medical and dental undergraduates were recruited for the study. Case group included 82 examination going and control group had 79 nonexam going students. Their stress level was evaluated using a standard questionnaire (perceived stress scale). Gingival index, periodontal disease index, bleeding on probing index, serum cortisol level, and serum alpha-amylase level were also measured.

Statistical Analysis Used:

Bivariate correlations and multiple regression tests were done.

Results:

A positive correlation was found among stress scores, salivary cortisol, alpha-amylase, and periodontal disease measures.

Conclusion:

Periodontitis can be related to immunologic changes related to psychological states

Evaluation of stress, serum and salivary ghrelin and cortisol levels in smokers and non-smokers with stage iii periodontitis - A cross-sectional study

BACKGROUND

The present study aimed to investigate the serum and salivary ghrelin and cortisol levels in smokers and non-smokers with Stage III Periodontitis.

METHODS

The present study comprised of a total of 90 systemically healthy patients categorized in three groups: Group I- Periodontally healthy patients; Group II- Non-smokers with Stage III Periodontitis and Group III- Smokers with Stage III periodontitis. Clinical parameters of Probing pocket depth (PPD), Clinical attachment levels (CAL), Plaque Index (PI), Gingival Index (GI) and Papillary Bleeding Index (PBI)were recorded and biochemical parameters of serum and salivary ghrelin and cortisol levels were analyzed via Enzyme Linked Immunosorbent Assay (ELISA). Stress levels were assessed using Zung's self-rating depression scale.

RESULTS

Serum and salivary ghrelin values were found to be higher in Group II (620.25 ± 260.86 pg/ml, 892.40 ± 271.65 pg/ml respectively) as compared to Group III. Similarly, salivary as well as serum cortisol levels were higher in Group III (20.78 ± 9.23 pg/ml, 399.37 ±189.21 pg/ml respectively) as compared to Group II (16.36 ± 8.88 pg/ml, 320.68 ± 107.01 pg/ml respectively). In Group III, a direct correlation was observed between stress, serum and salivary cortisol levels while an inverse correlation was found between stress, serum and salivary ghrelin levels. Group III showed a greater number of depressed patients followed by Group II and I.

CONCLUSION

As per the results smokers with Stage III Periodontitis exhibit an elevated stress and cortisol levels, lower serum and salivary ghrelin levels as compared to the non-smokers. This article is protected by copyright. All rights reserved.

Investigation of the levels of different salivary stress markers in chronic periodontitis patients

BACKGROUND AND AIM

In this study, we aimed to determine the salivary levels of cortisol, α-amylase, β-endorphin, and chromogranin (CgA) in saliva and to investigate their relationship with periodontitis.

METHODS

Thirty-seven female and 43 male periodontitis patients who presented to the Periodontology Department of the XXX University Faculty of Dentistry participated in the study. The individuals were divided into three groups: mild, moderate, or severe chronic periodontitis. Plaque index (PI), gingival index (GI), clinical attachment loss (CAL), and probing depth (PD) measurements were recorded for all the participants. All participants underwent the State-Trait Anxiety Inventory test (STAI 1 and 2). Between 09:00 and 11:00 a.m., saliva samples from the participants were collected into tubes within an average of five minutes.

RESULTS

Higher cortisol measurements were detected in the saliva samples of participants with severe chronic periodontitis than in those who had mild chronic periodontitis (P < 0.05). There were statistically significant age differences among patients with mild-moderate, moderate-severe, and mild chronic periodontitis, the severity of the disease increasing with age (P < 0.05). There was also a positive correlation between STAI 1 stress scores and cortisol levels. Similarly, there was a positive correlation between CAL and cortisol levels (P < 0.05). However, a significant difference was found among groups only in terms of salivary cortisol levels (P < 0.05).

CONCLUSION

Within the limitations of this study, there was found to be a relationship between saliva cortisol levels and periodontitis and between salivary cortisol levels and stress.

Associations between mental and oral health in Spain: a cross-sectional study of more than 23,000 people aged 15 years and over

BACKGROUND

This study aimed to investigate associations between mental health and several parameters of oral health, controlling for a variety of important covariates, in a large representative sample of Spanish people.

METHODS

Data from the Spanish National Health Survey 2017 were analysed. Mental (i.e., depression, chronic anxiety, other psychiatric disorders) and oral health (i.e., dental caries, dental extraction, dental filling, gingival bleeding, tooth movement, dental material, missing tooth) were evaluated. Control variables included sex, age, marital status, education, smoking, alcohol consumption, and physical multimorbidity. Associations between psychiatric conditions (independent variables) and the number of poor oral health outcomes (dependent variable) were assessed using Poisson regression models. The associations were investigated in the overall population, in married participants and in those who were single/widowed/divorced/separated.

RESULTS

There were 23,089 participants [54.1% women; mean (standard deviation) age 53.4 (18.9) years]. The prevalence of at least one psychiatric condition was 15.4% in the overall sample, while the mean (standard deviation) number of poor oral health outcomes was 2.9 (1.4). There was a positive association between any psychiatric condition and the number of poor oral health outcomes [incidence rate ratio (IRR)=1.10; 95% confidence interval: 1.07-1.12], and there was a significant interaction between any psychiatric condition and marital status. The association was stronger in those participants who were single/widowed/divorced/separated.

LIMITATIONS

Cross-sectional study. Oral and mental health were assessed with Yes/No questions. Exposure, outcome and covariates were self-reported.

CONCLUSIONS

Those with poor mental health have worse oral health but being married has some protective benefits.

Association of yoga practice and serum cortisol levels in chronic periodontitis patients with stress-related anxiety and depression

AIM

Reducing the psychosocial stress by various methods can improve overall health, and yoga is now considered as an easily available alternative method. The present cross-sectional pilot study was conducted mainly to find the association of yoga practice with periodontal disease by measuring serum cortisol levels.

MATERIALS AND METHODS

A total of 70 subjects with age range of 35-60 years suffering with chronic periodontitis were divided into group I (with stress), group II (without stress), and group III (practicing yoga). Psychological evaluation was carried out using Hamilton Anxiety Rating Scale (HAM-A) and Zung Self-rating Depression Scale (ZSDS). Periodontal parameters like plaque index (PI), probing pocket depth (PPD), and clinical attachment level (CAL) at 5-8 mm and >8 mm were recorded. Blood samples were collected and serum cortisol levels were measured.

RESULTS

Mean age, plaque scores, and number of teeth with PPD and CAL at 5-8 mm and >8 mm were similar in all the groups, except between group I and group III where a multiple comparison with Tukey's post-hoc test showed significant difference in plaque index (P < 0.038) and the number of teeth with CAL 5-8 mm (P < 0.016). Serum cortisol levels and HAM-A scale and ZSDS scores showed highly significant value (P < 0.001) in group I subjects when compared with group II and group III subjects.

CONCLUSION

Cross-sectional observation done among three groups showed that individuals practicing yoga regularly had low serum cortisol levels, HAM-A scale and ZSDS scores, and better periodontal health.

Evaluation of association between psychological stress and serum cortisol levels in patients with chronic periodontitis - Estimation of relationship between psychological stress and periodontal status

Background:

Stress classically describes a destructive notion that can have a bearing on one's physical and mental health. It may also add to an increased propensity to periodontal disease.

Aim:

To investigate the association between psychological stress and serum cortisol levels in patients with chronic periodontitis.

Materials and Methods:

Forty subjects were recruited from the outpatient department at the Department of Periodontics, from a college in Mangalore, divided into two groups, i.e., twenty as healthy controls and twenty were stressed subjects with chronic periodontitis. The clinical examination included the assessment of probing pocket depth, clinical attachment level and oral hygiene index-simplified. Serum cortisol levels were estimated biochemically using the enzyme-linked immunosorbent assay method and the estimation of psychological stress was done by a questionnaire.

Results:

Descriptive statistics such as mean and standard deviation was used to review the collected data. Independent sample t-test was used for comparison and correlation was evaluation using Pearson's correlation test. As per our observation, high serum cortisol levels and psychological stress are positively linked with chronic periodontitis establishing a risk profile showing a significant correlation (P < 0.05).

Conclusion:

Routine serum cortisol assessment may be a reasonable and a valuable investigative indicator to rule out stress in periodontitis patients as it should be considered as an imperative risk factor for periodontal disease.

Role of chronic stress and depression in periodontal diseases

An extensive body of experimental and clinical evidence documents the negative impact of chronic psychological stress and depression on the immune system and health. Chronic stress and depression can result in general dysregulation of the immune system, of both cellular and humoral pathways, which may contribute to pathogenic infection and concomitant periodontal tissue destruction. In general, the evidence is consistent with the hypothesis that stress can modify the host defense and progression of periodontal infections in patients susceptible to periodontitis. However, substantial evidence also indicates that these conditions can mediate risk for disease, including periodontitis, through changes in health-related behaviors, such as oral hygiene, smoking and diet. The unequivocal interpretation of studies has also been hampered, in part, by issues related to conceptualization of stress and depression, as well as commonly associated comorbidities, such as diabetes, that can modify the onset and progression of periodontal disease. In addition, stress and depression appear to fall into a spectrum, ranging from mild to severe, involving a complex interaction of genetic background, coping strategies and environment. Differences in the conceptualization of stress and depression are probably important in assessing associations with other biologic and clinical measures. Future studies are necessary to clarify the complex interactions of chronic stress and depression in periodontal diseases.

Defining periodontal health

Assessment of the periodontium has relied exclusively on a variety of physical measurements (e.g., attachment level, probing depth, bone loss, mobility, recession, degree of inflammation, etc.) in relation to various case definitions of periodontal disease. Periodontal health was often an afterthought and was simply defined as the absence of the signs and symptoms of a periodontal disease. Accordingly, these strict and sometimes disparate definitions of periodontal disease have resulted in an idealistic requirement of a pristine periodontium for periodontal health, which makes us all diseased in one way or another. Furthermore, the consequence of not having a realistic definition of health has resulted in potentially questionable recommendations. The aim of this manuscript was to assess the biological, environmental, sociological, economic, educational and psychological relationships that are germane to constructing a paradigm that defines periodontal health using a modified wellness model. The paradigm includes four cardinal characteristics, i.e., 1) a functional dentition, 2) the painless function of a dentition, 3) the stability of the periodontal attachment apparatus, and 4) the psychological and social well-being of the individual. Finally, strategies and policies that advocate periodontal health were appraised.

I'm not sick but I'm not well,

and it's a sin to live so well.

Flagpole Sitta, Harvey Danger

Does stress predispose to periodontal disease?

The relationship of a sound mind to the maintenance of a healthy body has been recognized throughout most of recorded history. The term 'stress' is used to describe adverse emotions or reactions to unpleasant experiences. Individuals with high levels of stress and poor coping skills experience twice as much periodontal disease as compared to those with minimal stress and good coping skills. Although stress may predispose an individual to more destruction from periodontitis, the presence of periodontal pathogens remains the essential aetiologic factor. This review presents a summary of stress, discussing how it can predispose an individual to periodontal disease.

CLINICAL RELEVANCE

Stress, which is a universal phenomenon, is implicated to have various systemic effects besides being a risk factor for periodontal disease. This article elucidates the relationship between psycho-social stress and destructive periodontal disease.

The effects of stress hormones on growth of selected periodontitis related bacteria

The focus of this study was to examine in vitro the effects of stress hormones (catecholamines: epinephrine, norepinephrine, dopamine and hydrocortisone: cortisol) on the growth of four anaerobic species of periodontitis-related bacteria (Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia and Tannerella forsythia) and one facultative anaerobic species (Eikenella corrodens). Bacterial growth was determined by two different methods: fluorescence in situ hybridization (FISH), and the viable count by culture method. To simulate stress, each single strain was grown in a special growth medium with three different concentrations of each hormone, using an anaerobic chamber at 37 °C. Growth of F. nucleatum increased in the presence of all stress hormones. Growth of P. gingivalis was not significantly influenced by any hormone. Growth of P. intermedia and E. corrodens was inhibited by almost all stress hormones tested. Both methods of analysis revealed that the highest concentrations of norepinephrine and cortisol increased the growth of T. forsythia. Different hormones have a different effect on the growth of periodontitis-related bacteria in vitro. It appears that bacterial viability is more strongly influenced than is bacterial metabolic activity. The growth of F. nucleatum particularly and partially of T. forsythia is increased by several stress hormones and may have an additional negative impact on periodontal disease.

Stress increases periodontal inflammation

This study aimed to examine the effect of chronic restraint stress (RS) on the severity of experimental periodontal disease in rats. A total of 32 male Sprague Dawley (SD) rats were divided into four groups: i) Rats receiving two treatment regimens, chronic stress induced by movement restriction in acrylic cylinders for 1–1.5 h daily and induction of experimental periodontal disease, using a nylon ligature which was placed around the first left mandibular molars (n=8); ii) induction of periodontal disease, without RS (n=8); iii) RS (n=8) and iv) control (n=8). After 15 days, blood samples were obtained, and blood glucose levels and the corticosterone concentration were measured as stress markers. The severity of periodontal disease was analyzed according to the level of gingival and bone inflammation, leading to compromise of the teeth involved. Chronic stress was induced with movement restriction (P≤0.05, Mann-Whitney U-test) and increased the severity (P≤0.05, Mann-Whitney U-test) of experimental perio dontal disease in rats, according to the level of gingival and bone inflammation around the first left mandibular molars. The results of the present study showed that RS modulates periodontal inflammation and that the rat model described herein is suitable for investigating the association between stress and periodontal disease.

Social factors and periodontitis in an older population

OBJECTIVES

We assessed the prevalences of periodontitis by education and income levels among US adults with data from the third National Health and Nutrition Examination Survey.

METHODS

The study was limited to non-Hispanic Blacks, Mexican Americans, and non-Hispanic Whites 50 years of age or older with a complete periodontal assessment during the dental examination.

RESULTS

Blacks with higher education and income levels had a significantly higher prevalence of periodontitis than their White and Mexican-American counterparts. The relationship between income level and periodontitis was modified by race/ethnicity. High-income Blacks exhibited a higher prevalence of periodontitis than did low-income Blacks and high-income Whites.

CONCLUSIONS

Our findings call attention to the importance of recognizing socioeconomic status-related health differences across racial/ethnic groups within the social, political, and historical context.

Dental plaque, gingival inflammation, and elevated levels of interleukin-6 and cortisol in gingival crevicular fluid from women with stress-related depression and exhaustion

BACKGROUND

The aim of the present study was to investigate the importance of stress for the development of periodontitis by comparing oral health status, proinflammatory markers, and cortisol in gingival crevicular fluid (GCF) and saliva in patients with stress-related mental depression and controls.

METHODS

The participants consisted of 43 women with stress-related depression and exhaustion (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV], with a mean age of 42.0 (+/- 9.3 SD) years, and 29 controls, with a mean age of 54.5 (+/- 2.9 SD) years. Clinical examination included the assessment of dental plaque, gingival inflammation (GI), bleeding on probing (BOP), probing depth (PD), clinical attachment level (CAL), and number of teeth. GCF was collected with an intracrevicular washing technique from four sites in each subject. Interleukin (IL)-1beta, IL-6, and matrix metalloproteinase-9 were determined with enzyme-linked immunosorbent assay and cortisol with radioimmunoassay (125I RIA). Analysis of covariance (one-way covariance analyses) was used to remove the influence of age and smoking.

RESULTS

The amount of plaque was significantly higher in patients compared to controls (P<0.003). The patients had an average GI of 1.53 (+/-0.13 SD) compared to 0.89 (+/- 0.10 SD) for the controls (P< 0.001). The levels of cortisol in GCF was significantly higher in patients than in controls, 3.46 nmol/l (+/- 3.25 SD) and 0.30 nmol/l (+/- 0.25 SD), respectively (P<0.001), whereas cortisol in saliva did not differ between groups. The levels of IL-6 in GCF were significantly higher in the patients than in controls (P<0.05).

CONCLUSION

Women with stress-related depression and exhaustion had more plaque accumulation, GI and increased levels of IL-6 and cortisol in GCF compared to normal controls, suggesting that depression might affect immune function, which could lead to impaired periodontal health.

A community study on the relationship between stress, coping, affective dispositions and periodontal attachment loss

BACKGROUND

Psychological factors may increase the risk for periodontal diseases. Contemporary conceptualization of the stress process supports the evaluation of stress at three levels: stressors, moderating and mediating factors, and stress reactions.

OBJECTIVE

This study was undertaken to investigate the relationship of periodontal disease in terms of clinical attachment level (CAL) to psychosocial stress, making reference to the major components of stress process.

METHODS

A cross-sectional study of 1000 subjects aged 25-64 years in Hong Kong was conducted. Subjects were asked to complete a set of questionnaires measuring stressors including changes, significant life event and daily strains, stress reactions including physiological and affective responses, and coping and affective dispositions. CAL was assessed.

RESULTS

Individuals with high mean CAL values had higher scores on the job and financial strain scales than periodontally healthy individuals (P < 0.05), after adjusting for age, gender, cigarette smoking and systemic disease. Depression, anxiety trait, depression trait, problem-focused coping, and emotion-focused coping were also related to CAL. Logistic regression analysis indicated that all these factors were significant risk indicators for periodontal attachment loss, except problem-focused coping, which reduced the odds of CAL. Individuals who were high emotion-focused copers, low problem-focused copers, trait anxious, or trait depressive had a higher odds of more severe CAL.

CONCLUSION

Chronic job and financial strains, depression, inadequate coping, and maladaptive trait dispositions are significant risk indicators for periodontal attachment loss. Adequate coping and adaptive trait dispositions, evidenced as high problem-focused coping and low anxiety/depression trait, may reduce the stress-associated odds.

Association between psychosocial factors and periodontitis: a case-control study

OBJECTIVE

This case-control study investigated the association between life events, anxiety, and depression with periodontitis.

METHODOLOGY

The study counted with 165 individuals, both sexes, 35-60 years of age. Case group included 96 individuals suffering from periodontal disease; and in control group 69 subjects with no history of periodontitis. Clinical examinations were performed by a single examiner. Psychological assessment included four inventories: Life Events Scale, Beck Anxiety Inventory, State-Trait Anxiety Inventory and Beck Depression Inventory. Bivariate and multivariate logistic regression analyses were performed to compare cases and controls.

RESULTS

Mean probing depth and clinical attachment level were 3.44+/-0.80 and 4.01+/-1.61 in the case group and 1.96+/-0.19 and 0.95+/-0.50 in the control group, respectively (p<0.05). Positive association of periodontitis with age (odds ratio (OR)=1.15 95% confidence interval (CI): 1.06-1.24), male gender (OR=2.71, CI: 1.13-6.49), smoking (OR=6.05, CI: 1.67-21.94) and educational level (OR=6.49, CI: 1.14-36.95) was confirmed. Bivariate analysis did not demonstrate significant mean differences in life events, anxiety symptoms, trait or state of anxiety, or depression symptoms between cases and controls. Multivariate logistic regression, controlling for confounding factors, demonstrated no significant association between psychosocial factors and periodontal disease.

CONCLUSIONS

Within the limits of this study it is possible to conclude that there was no significant association between periodontitis and the psychosocial factors analysed.

Psychosocial factors as risk indicators of periodontitis

OBJECTIVE

Cross-sectional investigation of associations between psychosocial and periodontal parameters.

METHODS

One hundred and ten patients 18-76 years of age were examined clinically and 57 radiographically at the Department of Conservative Dentistry of the University Hospital of Heidelberg: probing depths (PDs) and attachment level (PAL-V) were obtained at six sites per tooth. Inter-proximal bone loss was assessed in 57 patients on panoramic radiographs. Further chemical and general environmental sensitivity, somatization, and smoking status were assessed by several questionnaires.

RESULTS

Significant correlations between severe bone loss and age (r=0.38, p=0.004) were observed. PAL-V and PD also correlated with age (r=0.45, p<0.001; r=0.37, p<0.001) and pack years (r=0.21, p=0.031; r=0.3, p=0.002). After adjustment for age, smoking, and sex a negative correlation between chemical odour sensitivity and bone loss, PD=4 mm as well as PAL-V=4 mm was observed. Further, a negative correlation was observed between gastrointestinal sensitivity and PAL-V=4 mm. Psychological stress correlated positively with bone loss.

CONCLUSION

The results give evidence for associations of psychosocial factors and periodontal disease. Some environmental traits seem to be related to more favourable periodontal status.

Modulation of clinical expression of plaque-induced gingivitis: effects of personality traits, social support and stress

BACKGROUND

Studies have shown an association between an acute stressful event and gingivitis. However, the possible effects of personality traits associated with stress resistance/susceptibility and current level of stress on the clinical expression of plaque-induced inflammation remain to be examined. The aim of this study was to characterize the subject-based clinical behaviour of the gingiva during experimental gingivitis in relation to personality profile, psychological stress and coping behaviour.

METHODS

Ninety-six systemically and periodontally healthy subjects (mean age: 23.6+/-1.7 years), 46 males and 50 females, non-smokers, participated in a randomized, split-mouth, localized experimental gingivitis trial. Prior to the trial, subjects were asked to complete self-administered questionnaires evaluating personality traits (Hardiness scale and Courtauld Emotional Control Scale), subjective stress (Visual Analogue Scale-Total Distress), social support (Multidimensional Scale of Perceived Social Support, MSPSS) and life events (Life Experiences Survey (LES)). The influence of psychosocial factors was investigated in the overall population as well as in two sub-populations with different inflammatory response to plaque accumulation.

RESULTS

No significant relationships were found between gingival inflammation variables and psychological measures. No significant differences were detected between subjects with different susceptibilties to plaque-associated gingivitis for any considered psychological variable. A significant association between plaque variables and LES (negative) or MSPSS (positive) was found; however, the variance explained by the model was low.

CONCLUSIONS

Differences in the current level of stress and psychosocial variables indicative of stress susceptibility do not account for variability in plaque accumulation and gingival inflammation during experimental gingivitis in young adults.

[Correlation between psychosocial factors and periodontal disease--a systematic review of the literature]

OBJECTIVES

This is a systematic review of the available empirical studies up to 2004 which deal with the question of the correlation between psychosocial factors/stress and gingival and periodontal disease.

METHOD

The three medical and psychological databases Medline, PsycInfo und Psyndex were searched systematically for relevant literature between 1946 and 2004.

RESULTS

34 empirical studies on humans (16 with and 18 without a control group) and ten empirical studies on animals are presented.

DISCUSSION

Despite serious methodological flaws in many studies, most (particularly the methodologically solid ones) indicated associations between a variety of psychosocial factors and periodontitis incidence and severity. The pathomechanisms between stress and periodontitis should therefore be the subject of further research.

Stress, oral health behaviour and clinical outcome

OBJECTIVE

Several studies indicate that stress adversely affects various health behaviours. Oral hygiene behaviour, however, has been rarely studied in this context. The present study thus aims to assess the effects of stress on oral hygiene behaviour and clinical outcome.

DESIGN

In a prospective matched controlled design 12 pairs of medical students, each consisting of 1 student participating in a major academic exam and 1 student not participating in any exams (control) were studied.

METHODS

A professional tooth cleaning was performed 4 weeks prior to exams to obtain plaque levels of 0 at all sites. Immediately prior to professional tooth cleaning and 4 weeks after exams plaque levels (as indicator of oral hygiene behaviour) and bleeding on probing (an indicator of gingivitis) were assessed.

RESULTS

No group differences were observed at the beginning of the exam period; after exams significant higher rates of plaque (p=.0005, d=1.74) and gingivitis (p=.016, d=1.01) were observed in exam students as compared with controls.

CONCLUSIONS

The study illustrates the clinical significance of stress effects on health behaviour. Stress should be included as a factor in models of patient compliance and health behaviour.

Approximal plaque and gingival sulcus bleeding in routine dental care patients: relations to life stress, somatization and depression

OBJECTIVES

Previous research on relations between life stress and periodontal conditions was often based on indicators of periodontal destruction history and stimulus-specific measures of life stress. The present study was undertaken to compare patients showing different degrees of gingival sulcus bleeding with patients without signs of bleeding, using an instrument measuring cognitive impacts of events and assessing reported symptoms of depression and somatization. Additionally the patient groups were compared with regard to dental status and dental visiting behaviour. Analog comparisons were conducted in patients with different degrees of approximal plaque.

MATERIALS AND METHODS

140 routine dental care patients attending a private dental practice were examined. Measurement devices were the sulcus bleeding index (SBI), the approximal plaque index (API), the Dental Avoidance Scale, the Life Experience Survey (LES), the Impact of Event Scale with the subtests cognitive intrusion and cognitive avoidance, and the SCL-90-R subscales somatization and depression.

RESULTS

Patients with high API scores differed from their zero-score counterparts in dental avoidance and time since last visit only. By contrast, subjects scoring high in the SBI not only had more missing teeth and reported more dental avoidance than their zero-score counterparts but also had elevated scores in intrusive and avoidant thoughts related to a stressful event as well as in symptoms of somatization and depression. No difference was found for the measure of stimulus specific recent life events (LES).

CONCLUSIONS

The results suggest that cognitive preoccupation with adverse events and the presence of somatization and depression symptoms might play a role in gingival inflammation.

Anxiety, gingival inflammation and periodontal disease in non-smokers and smokers - an epidemiological study

OBJECTIVES

The aim of the present study was to investigate the influence of anxiety, measured by one single question, on gingival inflammation and periodontal disease in non-smokers and smokers.

MATERIAL AND METHODS

The participants were 144 subjects with untreated periodontal disease 30-40 years of age, and 26 healthy controls, 30-40 years of age. All subjects were clinically examined and answered an uncomplicated question regarding anxiety in every day life, as well as smoking habits. The periodontitis subjects were divided into; an aggressive periodontitis (AP)-group and a chronic periodontitis (CP)-group. Fisher's exact probability t-test, analysis of variance (anova), Mann-Whitney U-test and analysis of covariance (ancova) were used as statistical methods.

RESULTS

Anxious subjects had a significantly higher gingival index than non-anxious subjects, when controlling for smoking (p<0.01). The healthy anxious non-smokers had an average score of GI 1.6 (+/-0.4 SD) compared with 1.2 (+/-0.4 SD), p<0.05 for the non-anxious non-smokers. Anxious smokers with periodontits (AP-/CP-group) had significantly more sites with pockets >/=5 mm, compared with non-anxious smokers, (p<0.05).

CONCLUSIONS

The results of the present study, suggest that self-reported anxiety was associated with an adverse affect on the gingiva. Anxiety seemed to be associated with increased severity of periodontal disease in smokers.

Association of periodontal disease to anxiety and depression symptoms, and psychosocial stress factors

OBJECTIVE

A cross-sectional study was conducted to investigate if anxiety, depression and hopelessness symptoms are associated with periodontal disease.

METHOD

A total of 160 subjects took part in this study. Probing depth and clinical attachment level were recorded at six sites per tooth and the gingival and plaque indices were also recorded. The instruments used to assess the psychological variables (anxiety, depression, stress, psychiatric symptoms and hopelessness) were: the State-Trait Anxiety Inventory, the Beck Depression Inventory, the Life Events Scale modified by Savoia, the Self-Report Screening Questionnaire-20 and the Beck Hopelessness Scale.

RESULTS

There was no difference in scale score means between patients with and without established periodontitis. Results of the Ordinal Logistic Regression Analysis model that included age, plaque index, smoking and psychological factors showed that patients with psychiatric symptoms (odds ratio (OR) 1.24, 95% confidence interval (CI) 0.33-4.78), depression symptoms (OR 0.57, 95% CI 0.15-2.21) and with hopelessness (OR 0.70, 95% CI 0.13-3.84) were not at a greater risk of developing established periodontitis.

CONCLUSION

In this sample, no evidence was found for an association between depression, hopelessness, psychiatric symptoms and established periodontitis. The association of periodontal disease to depression, anxiety and stress should be investigated in psychiatric populations, especially in those with depression and anxiety disorders.

Social factors and periodontitis in an older population

OBJECTIVES

We assessed the prevalences of periodontitis by education and income levels among US adults with data from the third National Health and Nutrition Examination Survey.

METHODS

The study was limited to non-Hispanic Blacks, Mexican Americans, and non-Hispanic Whites 50 years of age or older with a complete periodontal assessment during the dental examination.

RESULTS

Blacks with higher education and income levels had a significantly higher prevalence of periodontitis than their White and Mexican-American counterparts. The relationship between income level and periodontitis was modified by race/ethnicity. High-income Blacks exhibited a higher prevalence of periodontitis than did low-income Blacks and high-income Whites.

CONCLUSIONS

Our findings call attention to the importance of recognizing socioeconomic status-related health differences across racial/ethnic groups within the social, political, and historical context.

A prospective study of social support, anger expression and risk of periodontitis in men

BACKGROUND

Stress is associated with poor oral hygiene, increased glucocorticoid secretion that can depress immune function, increased insulin resistance and potentially increased risk of periodontitis.

METHODS

The authors examined the association between social support, anger expression and periodontitis in 42,523 male, U.S.-based, health professionals. Subjects were aged 40 to 75 years in 1986, and more than half were dentists. The men were free of a diagnosis of periodontitis at the start of follow-up in 1996.

RESULTS

Subjects who reported having at least one close friend had a 30 percent lower risk of developing periodontitis compared with those who did not have a close friend (relative risk, or RR = 0.70; 95 percent confidence interval, or CI, 0.51-0.96). Men who participated in religious meetings or services had a 27 percent lower risk of developing periodontitis compared with men who did not participate in religious meetings (RR = 0.73; 95 percent CI, 0.64-0.83). After the authors adjusted for potential confounding variables, men whose anger scores were in the top quintile were 72 percent more likely to report having periodontitis compared with men whose scores were in the lowest quintile (RR = 1.72; 95 percent CI, 1.39-2.12). Men who reported being angry on a daily basis had a 43 percent higher risk of developing periodontitis compared with men who reported being angry seldom.

CONCLUSION

Reduced social isolation and anger expression may play an important role in maintaining oral health, as well as general health and well-being.

CLINICAL IMPLICATIONS

When treating patients with periodontitis, clinicians should be cognizant of the social and behavioral factors that may affect oral health.

Effect of Restraint Stress on the Progression of Experimental Periodontitis in Rats

BACKGROUND

A hypothesis of an increased risk for destructive periodontal diseases due to psychological stress has long been promoted. However, the research on stress and periodontal disease is still in its infancy. One of the reasons is thought to be that there is no suitable animal model for investigating the relationship.

METHODS

One hundred male Wistar rats were included. A nylon ligature was placed around the second right maxillary molars. The animals were then divided into group S, exposed to a restraint stress for 12 hours/day for up to 10 days, and group N, controls. Ten animals were sacrificed on days 2, 4, 6, 8, and 10. Blood samples were taken, and the blood glucose level and the concentrations of adrenocorticotropic hormone, corticosterone, and adrenaline were measured as the markers of stress. The atrophies of the thymus and the spleen were measured. The furcation area of the second maxillary molars was examined histologically and histometrically.

RESULTS

In group S, all values of stress markers were increased, and the thymus and the spleen were atrophied. Whereas group N showed only slight alveolar bone resorption, a marked alveolar bone resorption occurred in group S between days 8 and 10. An increase in beaded nerve terminals occurred around the vessels in the furcation area of group S.

CONCLUSION

The results of the present study suggest that the restraint stress modulates the progression of periodontal inflammation and that this rat model is suitable for investigating the association between stress and periodontal disease.

The relationship of stress and anxiety with chronic periodontitis

AIM

This case-control study investigates the relationship of stress and anxiety with periodontal clinical characteristics.

METHOD

Seventy-nine selected patients (mean age 46.8+/-8 years) were assigned to three groups in accordance with their levels of probing pocket depth (PPD): control group (PPD< or =3 mm, n=22), test group 1 (at least four sites with PPD > or =4 mm and < or =6 mm, n=27) and test group 2 (at least four sites with PPD >6 mm, n=30). An inclusion criterion of the study required that patients presented a plaque index (PI) with a value equal to or larger than 2 in at least 50% of dental surfaces. All subjects were submitted to stress and anxiety evaluations. Stress was measured by the Stress Symptom Inventory (SSI) and the Social Readjustment Rating Scale (SRRS), while the State-Trait Anxiety Inventory (STAI) was used to assess anxiety. Clinical measures such as PI, gingival index (GI), PPD and clinical attachment level (CAL) were collected. Patient's medical history and socioeconomic data were also recorded.

RESULTS

The mean clinical measures (PI, GI, PPD and CAL) obtained for the three groups, were: control group, 1.56+/-0.32, 0.68+/-0.49, 1.72+/-0.54 and 2.04+/-0.64 mm; group 1, 1.56+/-0.39, 1.13+/-0.58, 2.67+/-0.67 and 3.10+/-0.76 mm, group 2, 1.65+/-0.37, 1.54+/-0.46, 4.14+/-1.23 and 5.01+/-1.60 mm. The three groups did not differ with respect to percentage of clinical stress, scores of the SRRS, trait and state anxiety. Frequency of moderate CAL (4-6 mm) and moderate PPD (4-6 mm) were found to be significantly associated with higher trait anxiety scores after adjusting for socioeconomic data and cigarette consumption (p<0.05).

CONCLUSIONS

Based on the obtained results, individuals with high levels of trait anxiety appeared to be more prone to periodontal disease.

The effect of chronic emotional stress on the humoral immune response to Porphyromonas gingivalis in mice

Previous studies have shown that psychological stress plays a significant role in the outcome of infectious diseases, but data related to the effect of stress on periodontal infection is limited. The present study was designed to test the impact of emotional stress on the humoral immune response to the periodontal pathogen Porphyromonas gingivalis in a mouse model of local inflammation. Chambers constructed from titanium wire were implanted in the subcutaneous dorsolumbar region of mice. All mice were immunized with P. gingivalis followed by an intrachamber challenge with the bacteria. One group of mice was used as control, while the other two experienced experimental stress conditions (isolation/restraint stress). Stress-1 group was stressed during the immunization period, while Stress-2 group was stressed during the local challenge period. Chamber exudates and serum were collected and analyzed for levels of anti-P. gingivalis antibodies (IgG, IgG1 and IgG2a). The levels of serum antibodies to P. gingivalis were not different between the three tested groups, excluding increased levels of IgG2a in Stress-1 group at baseline. The levels of antibodies in the chamber exudates were significantly lower in the stressed groups at baseline, but higher at d 7. The IgG1 to IgG2a ratio was significantly higher in the control group compared with the two stressed groups. The findings of the present study suggest that chronic psychological stress had a marked impact on the localized response to P. gingivalis challenge. The lower IgG1/IgG2a ratio observed in the stress groups suggests elevated Th1 response during stress.

Coping with stress: its influence on periodontal disease

BACKGROUND

Various forms of stress behavior were documented and in patients with periodontitis their relationship with periodontal disease was investigated.

METHODS

Eighty-nine patients with different forms of chronic periodontitis were included in this retrospective case-control study. They were all undergoing periodontal treatment at the Department of Dental Prosthetics, University of Graz, or a private dental practice. The control group consisted of 63 persons employed in health care at the Clinic of Graz. All participants completed a stress coping questionnaire of 114 items and 19 actional and intrapsychic stress coping modes. The questionnaire served as a psychodiagnostic survey aimed at collecting data on stress coping strategies. Clinical attachment loss (CAL) served as the clinical parameter.

RESULTS

With the help of a factor analysis with a factorization and Varimax rotation, 5 factors were extracted from the 19 subtests. The reliability of the questionnaire was less than 0.70 only for subtests "escape" and "pharmaceutical drugs." Otherwise the internal consistency ranged between 0.74 and 0.92, and the retest reliability between 0.72 and 0.84. Subsequent assessment with the t test for independent random samples at the 5% level showed that patients differ significantly from controls in regard of factor 2 (active coping, P = 0.40) and 3 (distractive coping, P = 0.033), and that they differ very significantly from controls in regard of factor 4 (defensive coping, P = 0.000) and 5 (coping through aggression and pharmaceutical drugs, P = 0.007). In the statistical analysis of factors with regard to the severity of periodontal disease, the patients were divided into 2 groups (mild to moderate and severe). The t test for independent random samples showed significance for factor 4 (defensive coping) in that patients with a defensive coping style had greater attachment loss (pF4 = 0.04).

CONCLUSIONS

The data corroborate the thesis that periodontitis patients with inadequate stress behavior strategies (defensive coping) are at greater risk for severe periodontal disease. However, further investigations are required to confirm the significance of inappropriate coping styles with respect to the advancement of periodontal disease.

Psychosocial stress, lifestyle and periodontal health

BACKGROUND, AIMS

The hypothesis that psychosocial stress and lifestyle are related to periodontal status was tested.

MATERIAL AND METHODS

The study was performed in 1997-98 in 10 areas in Lithuania (response rate 53%). Information comprised recordings of oral hygiene, calculated levels of remaining periodontal support and information about psychosocial and lifestyle factors. A hypothetical structure was tested in 2 age and gender subgroups by means of a structural equation model both for an overall fit and for the fit of individual parameters within the model.

RESULTS

The hypothesised structure presented high confirmatory fit index values (CFI) in all subgroup models, i.e., CFI >0.94. However the probability value of 0.01 found in the older males model presented an unlikely event. When individual parameters within the models were tested, different misspecifications were found. Therefore the hypothesised structure needed to be revised and tested repeatedly. All revised models presented high CFI and probability values (p>0.35). The testing of individual parameters did not reveal any significantly misspecified parameters.

CONCLUSIONS

The path between lifestyle and levels of remaining periodontal support was empirically supported in the present study. Although the pathway between psychosocial stress and remaining periodontal support was not empirically supported, there is reason to believe that such link is likely.

Influence of restraint stress on ligature-induced periodontitis in rats

The influence of stress on periodontal breakdown in Wistar rats was analyzed during experimental periodontitis, induced by placing silk ligatures around the maxillary right second molar teeth. The rats were divided into three groups with 10 animals in each; the first group was exposed to restraint stress for 12 h d(-1) for a period of 4 wk; the second group was exposed to restraint stress for 2.5 h d(-1) for a period of 4 wk; the third group served as a control group. Ligation for 4 wk resulted in an accelerated periodontal degradation, whereas the restraint stress by itself had no significant effect. Combined stress and ligation resulted in a significantly higher attachment loss and alveolar bone resorption than either treatment alone, while no differences were seen between the two stress regimens. After 4 wk, a reduced body weight was found in both restrained groups of rats and a reduced weight of the thymus in the rats restrained for 12 h d(-1), while no changes were observed in the weight or composition of the suprarenal glands. We conclude that stress alone does not result in periodontal disease but may modulate the pathophysiological processes of already present periodontal inflammation, resulting in accelerated degradation of periodontal tissues.