PSYCHOLOGICAL STRESS AND PERIODONTAL DISEASE

JALALEDDIN HAMISSI, DDS, DipPerio, MDS (Periodontics) 2 SHAHRIYAR KAKAEI, DDS 3 HESAMMEDDIN HAMISSI

ABSTRACT The aim of the study was to investigate the relationship between psychological stress and periodontal disease. The study was carried out on 496 patients aged 17-64 years from January 2007 to December 2008 at the Department of Pcriodontics, College of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran. All the patients included in the study were suffering from psychological stress and were referred to us by medical specialists, and they also showed clinical features of periodontal disease. Patients suffering from acute severe pain or system diseases were excluded. Periodontal examinations were carried out using standard protocol. It was followed by Clinical Attachment Loss (CAL) determination as a basis for evaluation of periodontal status. Later psychoso-cial factors were evaluated using internationally recommended questionnaires. The data were analysed using chi square test with p < 0.05 defined as level of significance. Among the psychosocial factors identified in this study were anxiety, depression and chronic stress and methods to adapt stress were shown to have a significant relationship with CAL. The patients having severe Clinical Attachment Loss (CAL) were found suffering from severe anxiety and they used more emotional focused coping methods frequently, Those with lower CAL used problem focussed coping methods frequently. The results of this study showed that the continuous financial strains, depression, inadequate coping ability and maladaptive trait dispositions were significant risk factors for periodontal attachment loss. Key words: Psychosocial factors, stress, anxiety, periodontal disease, clinical attach-ment loss

INTRODUCTION

behavioral and emotional life events.2 Studies have demonstrated that Periodontal disease is defined as an inflammatory process of the gingival individuals under psychological tissues, resulting in deep gingi-val sulci, and possibly producing periodontalstress are more4-18 likely to develop pockets and supporting alveolar bone loss.1 Several risk factors broadly knownclinical attachment include, but not limited to, oral hy-giene, smoking, advancing age and loss and loss of alveolar bone. systemic diseases involved.2 The relationship between psychosocial stress and During recent years, various periodontal disease has also been emphasized.3 Psychosocial stress is epidemiological stud-ies carried out in described as particularly tense various countries revealed that periodontal diseases in different societies have a differ-ent prevalence.5,6,7 For many years dental research scholars were searching the factors responsible for severe periodontal attachment loss which occurs even
1

Correspondence: Dr Jalaleddin Hamissi, Associate Professor, Department of Periodontics, College of Dentistry,

Qazvin University of Medical Sciences, Qazvin, Iran. Email: jhamissi@qums.ac.ir, jalal_hammissi@yahoo.com 2 3 Dentist Dental student, College of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran

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Psychological stress and periodontal disease

Psyciatric University in some very cleanHospital Zurish was used. mouths, whereIt is called Symptom check infection possiblylist SCL 90). These could not have beenwere used to assess chronic the initiating factors.stress. Questionnaires were This study was andistributed among patients effort to investigatewho were asked to fill whether stress andthese and they were anxiety of moderncollected 3 days later. The life could be theresponses were scored and analyzed together with the causative factor. data received from METHODOLOGY periodontal charts. Standard protocol was This was an inter used for periodontal disciplinary, crossexamination and for sectional pro-spective calculating clinical study, which was attachment loss (CAL) carried out in the Depart-ment of Periodontics at Qazvin CAL was classified in the College/Hospital offollowing groups; Dentistry, Qazvin 14 patients (8.9%) male 32 (10.6%) fema (Located at a distance 1.5m Slight 42 (23.9%) M of 140 km from 3.4m Moderate 72 (40.9%) M Teheran Iran).
5 mm Severe 48 (27.3%) M 176 patients

There were 496RESULTS patients in age range Out of 496 patients of 15-65 years. 176 were males and 320referred to department of females. Most ofperiodontics, 320 were them were referredfemales and 176 males. illustrate the from medicalTable-1 frequency specialists. All therelative distribution of demopatients had periodontal as well asgraphic characteristics of under study. psychological stresssubjects the patients prob-lems. ThoseWhen psychological data were patients who were suffering from severecollected and classified pain or other medicalbased on degree of clinical loss, the ailments wereattachment correlation of excluded from the study. For recordingpsychological factors with of clinical psychological stress aseverity attachment loss was question-naire evaluated (Fig 1). Amongst comprising 90 psychological questions used byevaluated

factors, anxiety, depression, emotional focused coping behavior and chronic stress

TABLE 1: THE RELATIVE FREQUENCY DISTRIBU-TION OF DEMOGRAPHIC CHARACTERISTICS OF PEOPLE UNDER STUDY Sample characteristics Sex Male Female Age in decades Lower than 20 21-30 31-40 41-50 51-60 Higher than 61 Marital status Single Married Education Illiterate Elementary Junior high school Secondary studies Academic studies Occupation Retiree unemployed Worker Housewife Self-employed Student (at school or university) Employees Number 176 320 36 118 134 130 66 12 104 390 28 118 108 62 44 32 266 80 18 56

were revealed to have a significant relationship with attachment loss (p<0.05). The patients who suffered from severe attachment loss used emotional focused coping behavior more frequently when facing stressful situation. On the other hand, the group with

attachment loss close lower level of anxiety to healthy level used showed less severe problem focused attachment loss in a copping behaviors significant manner and more frequently patients with lower score while facing stressful on chronic stress were events. found in better periodontal health. The chronic stress Patients with score
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Psychological stress and periodontal disease

necrotizing periodontal diseases during periods in which patients were exposed to stress (Pindborg 1951, Giddon et al 1963, Goldhaber & Giddon 1964). Other authors showed that individuals under high working load, bad marital status (Marcences & Sheiham 1992), occupational Fig 1: The dissatisfaction (Linden et relationship al 1996),and high between psychological strain clinical caused by critical life attachment event (Green et al 1986, loos andCroucher et al l997) anxiety inexhibited periodontal patients destruction more frequently. Critical life of 11-25 indicated events such as loss of that patients were in spouse may cause a normal condi-tion. transitory immune The score also suppression (Stein et al revealed a suitable 1985). balance be-tween the patients Nevertheless, (his personalities. association was dependent DISCUSSION of the patients favored For the last manycoping strategy. In people highly problem years dentalwith professionals haveorientated coping manner, been suggesting thethe study failed to show an presence of aassociation between stress relationship betweenand peri-odontal status al 1999). psychosocial stress(Genco Epidemiological studies and periodontitis. It shown that has been dem-have periodontitis does not onstrated that the emotional factors andaffect all sub-jects in the stress play a role inpopulation in a similar the etiology ofway. Some individu-als necrotizing ulcerativepresent risk conditions that them more gingivitis (Moultonmake 1952). Severalsusceptible to develop periodontal disease (Page epidemiological surveys re-vealed an1998). increase in During recent years

various epidemiological stud-periodontal diseases in ies carried out indifferent societies have a prevalence. various countriessdiffer-ent (Aieksejunience et al 2002. revealed that Alexander Saletu et al. 2005). Inflammation is considered as the causative factor of in flammatory process is the hosts response to bacterial plaque which itself is under the influence of environmental and genetical factors (Newman 2002), initiation and progress of periodontal infections are obviously potentiated by local and sys-temic situations called risk factors (Genco 1996). Dif-ferent epidemiological studies have reported various risk factors related to periodontal diseases (Mengel R,2002). Currently, risk factors including colonization with particular pathogenic bacteria in gingival regions, systemic conditions related to low number of neutro-phils, diabetes mellitus, smoking, and local factors are believed to be of importance in pathogenesis of periodontal disease. In addition to age (considering that the disease is most prevalent in elderly) and sex (also it is more prevalent in the males) recent studies refer to two risk-increasing factors of periodontal diseases including stress and coping behavior (Genco, 1996).

performed.9,13,14,15,18 Regarding the Moreover, each of these importance of stress psychological tests were and the possi-bility of reliable and valid. These the influential role of results show that anxiety other psychological and other psycho-logical factors and the way factors effect CAL of and people face with there was signi-ficant stress, this study was relationship between aimed to investigate factors and the level of the association of CAL. periodontal disease (CAL) with psychological variables. Also it was The patients with planned to reveal thehigher mean CAL showed relation betweenhigher anxiety and stressful situa-tionsdepression scores. of life and the clinicalRegarding the nine loss of periodontalpsychological factors attach-ment. In thestudied following SCL-90present study theR ques-tionnaire scoring, scale foronly two factors namely categorization ofproblem focused coping periodontal diseasesand emotional focused was based on clinicalcoping behaviors were attach-ment loss.10,11assessed. The result The questionnairesrevealed likelihood of a used in this studyhigher usage of emotional were internationallyfocused coping in patients recognized and usedwith higher CAL in other studies(p=0.0002).
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