Role of Depression in Periodontitis: An Enigma Revealed

International Journal of Dental Research & Development (IJDRD) ISSN (P): 2250-2386; ISSN (E): 2321-0117 Vol. 10, Issue 1, Jun 2020, 1-8 © TJPRC Pvt. Ltd.

ROLE OF DEPRESSION IN PERIODONTITIS: AN ENIGMA REVEALED Dr. RAMYA. P1 & Dr. NEETA.V. BHAVSAR2 1 2

MDS, Periodontics, Government Dental College and Hospital, Ahmadabad, India

HOD, Department of Periodontics, Government Dental College and Hospital, Ahmadabad, India

ABSTRACT Introduction Amidst various risk factors leading to Chronic Periodontitis, Stress and Depression has a pivotal role in pathogenesis of Chronic Periodontitis. Stress as a risk factor influences the periodontal disease progression by 3 ways. It includes autonomic nervous system pathway, hypothalamus pituitary pathway and behavioural effects due to stress.

Aims To assess the effect of depression on periodontitis among patients reporting to the Outpatient Department of Periodontology, Government Dental College & Hospital, Ahmadabad.

Materials and Methods

Ahmadabad were divided into case and controls. The Cases includes 65 patients with Chronic Periodontitis and Controls includes 85 healthy individuals. Following parameters were evaluated: “Oral hygiene index-Simplified” (OHI –S), “pocket depth” (PD), “clinical attachment loss” (CAL). Beck’s depression inventory questionnaires were answered individually by all subjects.

Results Mean CAL and PD were higher for case group compared to controls. Similarly the case group reported with higher depression score which was found to be statistically significant.

Conclusion The depression reader is a useful tool in improving the individual diagnosis, treatment planning.

KEYWORDS: Depression, Chronic Periodontitis & Case Control Study

Received: Oct 20, 2019; Accepted: Nov 10, 2019; Published: Feb 15, 2020; Paper Id.: IJDRDJUN20201

INTRODUCTION Chronic periodontitis, initiated with plaque biofilm formation, progresses due to various factors and host responses.

Host immune response when fails to eliminate the pathogen results in connective tissue destruction and alveolar bone loss.

Various factors such as smoking, diabetes mellitus have been proven to be well established risk factors in periodontal disease progression. In spite of various researches conducted, still numerous factors influencing the periodontal disease progression remains uncertain. One such risk factors is depression, stress and anxiety which has undergone various observational studies. The correlation is also proven by the fact that the depression and stress agents

www.tjprc.org

editor@tjprc.org

Original Article

150 patients of both sexes aged 25 - 65 years in Department of Periodontology, Government Dental College & Hospital,

2

Dr. Ramya.P & Dr. Neeta.V.Bhavsar

affects the host's immune thus indirectly influencing periodontal disease.[1] Stress as a risk factor influencing the periodontal disease progression is explained by following ways. It includes autonomic nerves system pathway (sympathetic-adrenal-medullary axes), hypothalamus pituitary pathway (hypothalamicpituitary–adrenal axes). The nervous system, endocrine system and immune system have been shown to be inter related having influential dys regulation on each other and this inter relationship increases the susceptibility of an individual to periodontal disease.[2] Also behavioural effects such as poor oral hygiene, health negligence and smoking also affects periodontal tissues indirectly thereby increasing the progression rate of the disease.

Although the association between depression and periodontitis and their inter related pathogenesis has been evaluated and proven, few studies shows contradictory results.[3,4] Thus, the present study was conducted to assess the correlation between the depression level and severity of periodontitis among patients reporting to the Outpatient Department of Periodontology, in Government Dental College & Hospital, Ahmadabad.

MATERIALS AND METHODS This is a case control study the total of 150 members in which 72 men and 78 women whose ages are between 35 and 65 years attended the Outpatient Department of Periodontology, in Government Dental College & Hospital, Ahmadabad. The case group includes 65 patients suffering from Chronic Periodontitis according to American Academy of Periodontology criteria 1999. The control group includes 85 healthy individuals. The Periodontal and depression parameters were assessed.

The control group includes healthy individuals with normal sulcus depth of 2 to 3 mm and individuals with no clinical attachment loss.

Participants were informed about the course and the consent form has been signed by all participants before examination .Exclusion criteria: Smokers and patients with systemic disease as these would act as a confounding factors.

Following parameters were observed: “Oral hygiene index-Simplified” (OHI - S) (Greene and Vermillion), “Probing Depth” (PD), “Clinical Attachment Loss” (CAL). (Measured on mesial, distal, buccal and lingual sites) To evaluate depression Beck’s depression scale was used. It contains closed ended multiple choice statements.

They reflect the moods, current situation, past events, coping ability and the socialism of the individuals.

[5]

Beck’s

depression inventory was scored by adding the greatest value of each statement.

Beck's Depression Inventory [5] This depression inventory can be self-scored. o

“I do not feel sad” • • •

o

“I feel sad” “I am sad all the time and I can't snap out of it”.

“I am so sad and unhappy that I can't stand it”.

“I am not particularly discouraged about the future”.

•

“I feel discouraged about the future”.

•

“I feel I have nothing to look forward to”.

•

“I feel the future is hopeless and that things cannot improve”.

Impact Factor (JCC): 4.4085

Index Copernicus Value (ICV): 64.42

Role of Depression in Periodontitis: An Enigma Revealed

o

o

o

o

o

o

o

o

o

3

“I do not feel like a failure”.

•

“I feel I have failed more than the average person”.

•

“As I look back on my life, all I can see is a lot of failures”.

•

“I feel I am a complete failure as a person”.

“I get as much satisfaction out of things as I used to”.

•

“I don't enjoy things the way I used to”.

•

“I don't get real satisfaction out of anything anymore”.

•

“I am dissatisfied or bored with everything”.

“I don't feel particularly guilty” •

“I feel guilty a good part of the time”.

•

“I feel quite guilty most of the time”.

•

“I feel guilty all of the time”.

“I don't feel I am being punished”.

•

“I feel I may be punished”.

•

“I expect to be punished”.

•

“I feel I am being punished”.

“I don't feel disappointed in myself”.

•

“I am disappointed in myself”.

•

“I am disgusted with myself”.

•

“I hate myself”.

“I don't feel I am any worse than anybody else”.

•

“I am critical of myself for my weaknesses or mistakes”.

•

“I blame myself all the time for my faults”.

•

“I blame myself for everything bad that happens”.

“I don't have any thoughts of killing myself”.

•

“I have thoughts of killing myself, but I would not carry them out”.

•

“I would like to kill myself”.

•

“I would kill myself if I had the chance”.

“I don't cry any more than usual”.

•

“I cry more now than I used to”.

•

“I cry all the time now”.

•

“I used to be able to cry, but now I can't cry even though I want to”.

“I am no more irritated by things than I ever was”.

•

“I am slightly more irritated now than usual”.

•

“I am quite annoyed or irritated a good deal of the time”.

•

“I feel irritated all the time”.

www.tjprc.org

editor@tjprc.org

4

Dr. Ramya.P & Dr. Neeta.V.Bhavsar

o

o

“I have not lost interest in other people”.

•

“I am less interested in other people than I used to be”.

•

“I have lost most of my interest in other people”.

•

“I have lost all of my interest in other people”.

“I make decisions about as well as I ever could”.

• • •

o

“I don't feel that I look any worse than I used to”.

• • •

o

“I have lost more than five pounds”.

“I have lost more than ten pounds”.

“I have lost more than fifteen pounds”.

“I am no more worried about my health than usual”.

• • •

o

“My appetite is not as good as it used to be”.

“My appetite is much worse now”.

“I have no appetite at all anymore”.

“I haven't lost much weight, if any, lately”.

• • •

o

“I get tired more easily than I used to”.

“I get tired from doing almost anything”.

“I am too tired to do anything”.

“My appetite is no worse than usual”.

• • •

o

“I don't sleep as well as I used to”.

“I wake up 1-2 hours earlier than usual and find it hard to get back to sleep”.

“I wake up several hours earlier than I used to and cannot get back to sleep”.

“I don't get more tired than usual”.

• • •

o

“It takes an extra effort to get started at doing something”.

“I have to push myself very hard to do anything”.

“I can't do any work at all”.

“I can sleep as well as usual”.

• • •

o

“I am worried that I am looking old or unattractive”.

“I feel there are permanent changes in my appearance that make me look unattractive” “I believe that I look ugly”.

“I can work about as well as before”.

• • •

o

“I put off making decisions more than I used to”.

“I have greater difficulty in making decisions more than I used to”.

“I can't make decisions at all anymore”.

“I am worried about physical problems like aches, pains, upset stomach, or constipation”.

“I am very worried about physical problems and it's hard to think of much else”.

“I am so worried about my physical problems that I cannot think of anything else”.

“I have not noticed any recent change in my interest in sex”.

• • •

“I am less interested in sex than I used to be”.

“I have almost no interest in sex”.

“I have lost interest in sex completely”.

“INTERPRETING THE BECK DEPRESSION INVENTORY Now that you have completed the questionnaire adds up the score for each of the twenty-one questions by counting the number to the right of each question you marked.

Impact Factor (JCC): 4.4085

Index Copernicus Value (ICV): 64.42

Role of Depression in Periodontitis: An Enigma Revealed

5

The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circles zero on each question. You can evaluate your depression according to the Table below”.

“Total Score____________________ Levels of Depression 1-10____________________These ups and downs are considered normal 11-16___________________ Mild mood disturbance 17-20___________________Borderline clinical depression 21-30___________________Moderate depression 31-40___________________Severe depression Over 40__________________Extreme depression”

RESULTS & STATISTICS The periodontal variables were compared Student’s t

test was applied to assess the correlation in-between the depression score evaluated and periodontal

variables determined. IBM SPSS VERSION 20.0 for Windows (SPSS) was used for the data analysis OHI-S value for control was 3.21±0.73 compared to 3.37±0.49 for case group, whose difference was found to be statistically not significant. Mean PD was 2.72 ± 0.56 for controlled group and the Mean PD for case group was 4.86 ± 0.57. The difference was found to be statistically significant (P < 0.001). Mean CAL was 2.41 ± 0.54 for control group and mean CAL for case group was 4.65 ± 0.62. The statistically significant (P < 0.001) difference was found. The mean depression value for the controls was 7.52 ± 2.26 and for cases was 17.3 ± 3.93, which was statistically significant at P < 0.001.

From the data obtained, it is clear that the higher depression scores were reported with case group. (Table 1) Table 1: Comparison of Periodontal Variables and Depression Scores Cases ( healthy Control group ( Variables individuals) periodontitis patients) P Value Mean ±SD Mean ± SD OHI-S 3.37±0.49 3.216±0.73 0.215 Pocket depth 4.868±0.57 2.726±0.56 0.001* CAL 4.650±0.62 2.41±0.54 0.001* Depression Score 17.3±3.93 7.54±2.26 0.001* * Statistically Significant

DISCUSSIONS Periodontal disease which is a multi factorial disease though initiated with bacterial bio film formation its progression depends widely on various other factors. Those factors are termed as Risk Factors. Although stress and depression are identified as risk factors, the reliability of the same remains uncertain. Hence the present study assessed the role of www.tjprc.org

editor@tjprc.org

6

Dr. Ramya.P & Dr. Neeta.V.Bhavsar

depression as an influencing factor on periodontitis.

In this present study, we selected Beck’s Depression Inventory Scale for the assessment of level of depression.

Saletu et al have demonstrated that Beck’s Depression inventory as a reliable tool for research purpose. [7]And the same is used in this study. The results of this study have proven the influence of depression on periodontitis.

This results correlates with various Cross sectional studies proving the association of psychologic factors on periodontitis.[8,9,10] Genco et al found that patients with anxiety and depression were more associated with periodontitis.[8 ]

Similar results were also observed by Mosset al.[11] Whereas finding by Solis et al [12] did not prove any association. The reason might be due to the variation in the

depression scales used in the study. Similarly, Castro et al

[2]

has also showed that the psychosocial factors influence on

periodontitis to be negligible. The variations in these studies might be due to variations individuals’ perception of the situations and the variations in host response to cope up with the situations.

The behavioural changes play an indirect role in disease progression. Whereas neurophysiologic has a direct effect. The null hypothesis of the study is that depression increases blood levels of cortisol, as a fight- flight mechanism which in turn affects the immune system leading to disease progression.

When an individually is in depression hormonal changes plays a pivotal role in controlling the general health and immunity. The hypothalamic-pituitary-adrenal axis activated by stress stimulates hypothalamus to release corticotrophin releasing hormone. The corticotrophin releasing hormone at peak level results in the release of ACTH (Adreno CorticoTropic Hormone). The ACTH then directs signals to adrenal cortex, thereby releasing cortisone (glucocorticoid) into the blood circulation. The glucocorticoids causes decreased inflammatory cells, inhibition of pro inflammatory mediators and also the cascade of immune response.[13] The other reasons modulating disease progression includes stimulation of autonomic nervous system causing release of prostaglandins causing direct effect on periodontal pathogen, release of neuropeptides and altered Th1/Th2 cells.[13,14] This study has thus demonstrated the relationship between depression and periodontitis. Further studies with larger sample size and correlation of cortisol levels and clinical parameters would further elaborate the influence of depression on Periodontitis. Similarly after controlling the depression the periodontal status evaluation would reflect the association between depression and periodontitis.

CONCLUSIONS The depression scale can be used as both diagnostic tool in evaluating the patients with higher risk in developing Periodontitis.

REFERENCES 1.

Genco RJ, Alex W.Ho, Jeffrey K, Sara G. Grossi, Robert G. Dunford, Tedesco LA. Models to evaluate the role of stress in periodontal disease. Ann Periodontol, 1998; 3(1):288-302.

2.

Peruzzo DC, Benatti BB, Ambrosano GM, Nogueira- Filho GR, Sallum EA, Casati MZ,et al. A systematic review of stress and psychological factors as possible risk factors for periodontal disease. J Periodontol, 2007; 78(8):1491-504.

3.

Rao, Y. S., & RAO, V. D. (2016). Prevalence of Periodontitis among patients with Type-2 Diabetes Mellitus. Int J Gen Med Phrar, 5 (2), 15, 22.

Impact Factor (JCC): 4.4085

Index Copernicus Value (ICV): 64.42

Role of Depression in Periodontitis: An Enigma Revealed 4.

7

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(2):109-14.

5.

Persson GR, Persson RE, MacEntee CI, Wyatt CC, Hollender LG, Kiyak HA. Periodontitis and perceived risk for periodontitis in elders with evidence of depression. J Clin Periodontol, 2003; 30(8):691-6.

6.

Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry, 1961; 4:561‑71.

7.

Salem, S. A., Meead, G. H., & El-Rashody, F. M. (2017). Physicochemical and sensory properties of ice cream made from camel milk and fortified with dates products. Int J Humanities, Arts, Med Sci, 5, 29-40.

8.

Gorenstein C, Andrade L. Validation of a Portuguese version of the Beck Depression Inventory and the State‑Trait Anxiety Inventory in Brazilian subjects. Braz J Med Biol Res, 1996; 29(4):453‑7.

9.

Saletu A, Pirker‑Fruhauf H, Saletu F, Linzmayer L, Anderer P, Matejka M. Controlled clinical and psychometric studies on the relation between periodontitis and depressive mood. J Clin Periodontol, 2005; 32(12):1219‑25.

10. 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(7):711-23.

11. Ng SK, Leung WK. A community study on the relationship of dental anxiety with oral health status and oral health-related quality of life. Community Dent Oral Epidemiol, 2008; 36(4):347-56.

12. Ibrahim, S., & Mehta, R. Design and Analysis of Air Flow Depression for Air-Conditioning in Small Passenger Cabin Using Solid Works.

13. Chiou LJ, Yang YH, Hung HC, Tsai CC, Shieh TY, Wu YM, et al The association of psychosocial factors and smoking with periodontal health in a community population. J Periodontal Res, 2010; 45(1):16-22.

14. 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):1060‑9.

15. 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(8):633-8.

16. Danasabe, M. A. H. M. O. O. D., & Elias Bt, N. (2016). Postpartum depression among Hausa ethnic women in Abubakar Tafawa Balewa University teaching hospital, north East Nigeria. IMPACT: international journal of research in humanities.

Arts Literat (IMPACT: IJRHAL), 4(3), 55-64.

17. da Silva AM, Newman HN, Oakley DA. Psychosocial factors in inflammatory periodontal diseases. A review. J Clin Periodontol, 1995; 22(7):516-26.

18. Genco RJ, Ho AW, Kopman J, Grossi SG, Dunford RG, Tedesco LA. Models to Evaluate the Role of Stress in Periodontal Disease. Ann Periodontol, 1998; 3(1):288-302.

www.tjprc.org

editor@tjprc.org

8

Dr. Ramya.P & Dr. Neeta.V.Bhavsar

AUTHOR PROFILE Dr. Ramya. P, Post Graduate, MDS Periodontics, Has published two articles in BJPMR, Index Copernicus indexed Journal, Research on gingival recession coverage case series yet to be published, Member of Indian Society of Periodontology.

Dr. Neeta. V. Bhavsar, Post Graduate, MDS Periodontics, Head of the Department, Govt Dental College, Ahmedabad., Has published more than 50 articles in various national and international journals, Research on association between periodontitis and preterm low birth weight babies yet to be published, Member of Indian Society of Periodontology.

Impact Factor (JCC): 4.4085

Index Copernicus Value (ICV): 64.42