J Bagh College Dentistry Vol.

23(4), 2011 Association between psychosocial

Association between psychosocial factors and periodontitis

Saif S. Saliem Juma, B.D.S, M.Sc. (1)

ABSTRACT
Background: Research has suggested that psychological factors that play a role in the development and
progression of periodontal disease. It is not clear, however, whether these factors lead to periodontal disease
through physiological or behavioral changes, or by some combination of the two. This study investigated the
association of anxiety and depression with periodontal disease.
Material and Methods: A total of 150 subjects took part in this study. Probing depth and clinical attachment level
were recorded at four sites per tooth and the gingival and plaque indices were also recorded. The instruments used
to assess the psychological variables were: the Beck Anxiety Inventory, State– Trait Anxiety Inventory and the Beck
Depression Inventory.
Results: Mean probing depth and clinical attachment level were 6.32 ± 0.80 and 5.81 ± 1.61in the case group and
1.98±0.71and 1.12±0.87 in the control group, respectively. Positive association of periodontitis with age (odds ratio
(OR) 1.16 95% confidence interval (CI): 1.01–1.21) and plaque index (OR 2.15,CI: 1.07–4.69) was confirmed. Analysis
did not demonstrate significant mean differences in anxiety symptoms, trait or state of anxiety, or depression
symptoms between cases and controls. Multivariate logistic regression demonstrated no significant association
between psychosocial factors and periodontal disease.
Conclusion: Within the limits of this study it is possible to conclude that there was no significant association between
periodontitis and the psychosocial factors analyzed. The association of periodontal disease to depression and
anxiety should be investigated in psychiatric populations, especially in those with depression and anxiety disorders.
Key words: Anxiety and depression; periodontal disease; Psychosocial factor. (J Bagh Coll Dentistry 2011;23(4):116-
120).

INTRODUCTION Several psychological disorders have been

Epidemiological studies have shown that
periodontitis does not affect all subjects in the
population in a similar way. Some individuals
present risk conditions that make them more
susceptible to develop periodontal disease (1).
Consistent data in the literature show that
smoking, non-controlled diabetes and infection
with specific periodontal pathogens increase the
risk for periodontitis (2). Other factors, such as
stress, depression and anxiety are not yet
confirmed as risk conditions, but have also been
identified in observational studies (3). The
biological plausibility for such an association is
supported by studies that have demonstrated that
psychological states, such as depression and
exposition to stress agents, could modify the
immune response, making the individual more
susceptible to develop an unhealthy condition and
may also have an impact on periodontal health (4).
Research has suggested that anxiety and
depression are two factors that play a role in the
development and progression of periodontal
disease. It is not clear, however, whether these
factors lead to periodontal disease through
physiological or behavioral changes, or by some
combination of the two (5).
Recently, researchers have tested the
hypothesis that psychosocial factors can
contribute to periodontitis.
(1) Lecturer. Department of Periodontics. College of Dentistry.
University of Baghdad
shown to be associated with chronic and
aggressive periodontitis, as well as with
progression of periodontal disease (6). Several
authors have shown interest in the study of the
effects of psychosocial factors on the etiology of
periodontal diseases (7,8). This is due mainly to
two reasons: the fact that stress and/or depression
affect a large section of the modern population
and, on the other hand, the effect of mental and
emotional conditions on the immune response of
individuals, predisposing the emergence of
several pathologies (9). One of the possible
mechanisms of influence of stress and
psychosocial factors on periodontal conditions is
the modification of patients’ health behavior.
Individuals with high stress levels tend to adopt
habits which are harmful to periodontal health,
such as negligent oral hygiene, intensification of
smoking or changes in eating habits with negative
reflexes to immunological system functions (7,10).
Another mechanism that can modify the
extension or severity of periodontitis is based on
the neuro-immune endocrine interaction by the
action of hormones and chemical mediators
produced by the organism in situations of anxiety
in order to coordinate the fight or flight response
(11)
. Glucocorticoids released into the cortex of the
supra renals can induce the reduction of pro-
inflammatory cytokines secretion (interleukins,
prostaglandines and tumour necrosis factor). On
the other hand, catecholamines (epinephrine and
norepinephrine) have the opposite effect,
stimulating the formation and activity of

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J Bagh College Dentistry Vol. 23(4), 2011
prostaglandines and proteolytic enzymes, which
can indirectly provoke tissue destruction (12).
Based on these evidences, this study
investigated the association of anxiety and
depression with periodontal disease.
MATERIALS AND METHODS
Population and Sample
Study was conducted at college of dentistry -
University of Baghdad; the study population was
comprised of 150 volunteers of both genders, with
ages ranging from 35 to 55 years. After signing an
informed consent consisting of the study aims,
medical history and socioeconomic data were
collected. Socioeconomic data included the
following: age, gender, schooling, smoking
history and insomnia.
Psychological Evaluation
Psychometric instruments are scales that
permit the recording of the reports of patients in a
standardized and reproducible way. They can be
divided into two groups: those filled out by the
observer (rating scales) and those filled out by the
subject himself (self-report scales). While the
former present problems regarding the observer’s
experience, the latter are harder to understand, and
demand greater individual cooperation (13).
The Beck depression inventory (BDI), Beck
Anxiety Inventory (BAI) (14) and State–Trait
Anxiety Inventory (STAI) (15) one of the most
widely used instruments to screen and determine
the severity and occurrence of depression and
psychology symptoms.
Beck Depression Inventory (BDI) is a self-
report scale consisting of 21 statements including
symptoms and attitudes. Each of the 21 statements
is scored from 0 to 3. These statements are related
to sadness, pessimism, and sensation of failure,
lack of satisfaction, suicidal ideation, irritability
and social retraction, among others. The BDI is
scored by adding the greatest value of each
statement. In the present study, a cut-off score of
10 or greater identified the patient with depression
symptoms.
Beck Anxiety Inventory (BAI): self report
scale consisted of 21 items, or descriptive
statements of anxiety symptoms rated by the
subject on a four-point scale. The total score
allows a classification of anxiety intensity levels:
0–10 minimum; 11–19 mild; 20–30 moderate and
31–63 severe.
State–Trait Anxiety Inventory (STAI) is
composed of two scales with 20 statements each
and designed to measure the state and trait of
anxiety. The state of anxiety is defined as a
transitory emotional state or condition of the
human mind characterized by consciously
Oral and Maxillofacial Surgery and Periodontology117
Association between psychosocial
perceived unpleasant tension and feelings of
apprehension. The anxiety trace refers to the trend
to react to situations perceived as threatening with
the intensification of the state of anxiety. The
STAI is scored by adding the keyed responses –
the scores ranging from 1 to 4. Possible total
scores range from a minimum of 20 to a
maximum of 80 in both scales.
Clinical Examinations
Patients seeking dental treatment at the college
of dentistry - University of Baghdad were invited
to answer questions on their general health and
oral hygiene habits. On agreement, they were
asked to fill out an informed consent document in
order to be included in the study. Demographic
data were also collected. The periodontal clinical
examination was carried out using a Periodontal
probes (the University of Michigan O probe, with
William’s markings at 1,2,3,5,7,8,9 and 10mm).
The clinical attachment level (CAL) and the
probing pocket depth (PD) were measured,
excluding third molars. The presence of plaque
was recorded using the plaque index (PLI) (16) and
the gingival condition using the gingival index
(GI) (17). All clinical data was collected by a single
investigator, who had been calibrated prior to the
commencement of the study. The intra-examiner
agreement was evaluated by means of repeated
measurements with a one week interval from the
first examination.
The exclusion criteria were: periodontal
therapy in the previous 3 months, patients who
reported any type of systemic alteration that might
have hindered periodontal clinical examination,
non-controlled diabetes, HIV infection, patients
with cardiovascular disease and those who made
use of immunosuppressant drugs or calcium-
channel blocking agents.
Seventy five individuals were selected in the
case group and 75 in the control group. Case
subjects were defined as individuals between 35
and 55 years of age, presenting at least 20 teeth,
and having chronic periodontitis with sever
periodontal destruction, characterized as clinical
attachment level (CAL) (>=5mm) while Control
subjects (35–55 years of age) should present at
least 20 teeth with Chronic periodontitis patients
with mild severity (1 to 2mm CAL) (18).
Data analysis
Data analyzed using software SPSS for
Windows version 10.0. Age, PD, CAL, PLI, GI,
BAI, BDI, and STAI were expressed by means
and standard deviations, compared between
groups were performed using paired t-test.
Gender, educational level, smoking and insomnia
were presented by frequency distribution and
compared between groups using the X2 test.
J Bagh College Dentistry Vol. 23(4), 2011
Differences at the 5% level were considered
significant, logistic regression models were
applied to detect variables associated to the
clinical outcome. The association between
periodontitis and risk indicators was expressed by
odds ratios and their respective 95% confidence
intervals.
RESULTS
Tables 1 and 2 show the sample description,
the mean scores of clinical and demographic
parameters and respective standard deviations.
There was a statistically highly significant
difference between case and control groups in all
clinical parameters evaluated (p<0.0001) (Table
1).
Mean age in case and control groups, were
43.76 ± 6.22 and 38.70 ± 5.17, respectively, with
statistically significant difference between them
(p<0.05) (Table 2). Regarding to gender, there
was a higher proportion of males in the control
group and a higher proportion of females in the
case group, with statistically significant
differences between groups (p<0.05).
Smoking status and educational level were
also statistically different between groups. The
distribution of smokers and non-smokers was 26
and 49 in cases; and 20 and 55 in controls,
respectively (p<0.05). Regarding to educational
level, a higher proportion of individuals with
incomplete elementary education was observed in
the case group, while in the control group there
was a higher percentage of individuals with an
high school (p<0.05). Insomnia were not
statistically different between groups (Table 2).
Regarding to BAI, BDI and STAI scales, the
groups were compared in relation to mean scores
of each scale, psychometric instrument scores
were compared between cases and controls, show
no significant differences between the groups
(Table 3). The periodontal clinical parameters
(PD, CAL, PLI and GI) were compared between
Beck-positive and negative patients and showed
not to be different (table 4).
The Logistic regression analysis was
performed controlling for age, plaque, and
smoking. For each of the scales (BAI, BDI, state
and trait anxiety) a multivariate model was fitted
to verify the risk for periodontitis. It was possible
to observe that age, plaque were associated with
periodontitis in the analysis. Table (5) shows the
final results of the multivariate analysis with all
the variables included.
DISCUSSION
In this study, the relationships between
psychological and periodontal variables were
Oral and Maxillofacial Surgery and Periodontology118
Association between psychosocial
investigated in sample of 150 subjects aged 35–55
years. Studies with similar design were conducted
by other authors, using different target
populations, threshold scores and indices to
positively identify the disease (19, 20, 21) also
applied different self-report scales as instruments
to measure psychological variables as well as
different psychological variables. These
differences may limit the comparisons between
the investigations. Discrepancies in the results
found in the literature may also be explained by
differences in sample sizes of the studies (6,22, 23,
24)
.
The present study reported results from a final
sample size of 150 individuals, calculated to find
a difference in the occurrence of depression
between cases and controls. As it is from other
studies (6, 24), the lack of an association between
psychosocial factors and periodontitis, in the
present study, must be interpreted with caution
taking into account the sample size achieve.
Another important aspect of the methodology was
the definition of the instruments of psychological
analysis (25). Up to this moment there are no
biological markers available or other measurable
ways to define safely most psychiatric
disturbances (26).
Regarding the STAI scale, there were
similarities between the findings of this study and
those by Monteiro da Silva et al. (1996), Solis
(2002), Vettore et al. (2003) and Vettore et al.
(2005) (6,19,24,27). The trait anxiety mean was
higher than the state anxiety in all studies, with no
significant difference between case and control
groups. Regarding to depression examined by
BDI, the results are in accordance with those by
Solis (2002), Solis et al. (2004) and Castro et al.
(2006) (24,28,29) as neither studies showed
significant differences in depression means
between case and control groups. Based on the
methodology used and on the results found in the
present study, it seems that periodontal disease is
more directly associated with demographic and
social-cultural characteristics of the population
than with psychosocial factors. These results
agree with the epidemiological studies that have
shown higher prevalence and severity of
periodontal disease among older individuals,
smokers and individuals of a low socioeconomic
level (2, 30, 31, 32). Based on the results obtained here
it is possible to assume that the association of
psychosocial factors with periodontitis may not be
as evident as previously supposed .The findings in
this study did not confirm the hypothesis that
depression and anxiety are associated to
periodontitis.
J Bagh College Dentistry Vol. 23(4), 2011
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Table 1: Clinical periodontal parameters in case and control groups
Clinical measurements Cases
Probing pocket depth 6.32 ± 0.80 1.98±0.71 <0.0001
Clinical attachment level 5.81 ± 1.61 1.12±0.87 <0.0001
Plaque index 1.354±0.61 0.401± 0.57 <0.0001
Gingival index 1.619±0.72 0.398±0.58 <0.0001
Oral and Maxillofacial Surgery and Periodontology119
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Control p
J Bagh College Dentistry Vol. 23(4), 2011 Association between psychosocial

Table 2: Demographic and socio variables in case and control groups

Characteristics Cases Control p
Age 43.76 ± 6.22 38.70 ± 5.17 <0.001
Gender (%)
Male 26 (31.78) 34 (35.43)
0.006
Female 49 (50.92) 41 (45.56)
Educational level (%)
Incomplete elementary school 30 (30.15) 22 (20.69)
Elementary school 18 (20.18) 15 (22.74)
High school 16 (17.30) 24 (25.62) 0.003
College 11 (10.17) 14 (15.94)
Smoking (%)
yes 26 (19.91) 20 (33.91)
0.001
no 49 (77.19) 55 (58.09)
Insomnia
Present 18 (21.88) 15 (21.74)
1.000
Absent 57 (78.12) 60 (78.26)

Table 3: Mean scores of psychometric instruments of the groups

Scale Cases Control p
BAI 7.66 ± 5.88 7.01 ± 7.87 0.27
BDI 8.12 ± 5.95 9.22 ± 6.16 0.69
Anxiety trace 38.42 ± 9.45 37.77 ± 8.90 0.58
Anxiety state 36.41 ± 8.12 37.53 ± 9.31 0.32

Table 4: Periodontal variables in patients with and without depression symptoms

Variable Beck-negative Beck-positive p
Probing pocket depth 2.13 ± 0.71 2.73 ± 0.59 0.39
Clinical attachment level 3.1 ± 1.10 2.91 ± 1.18 0.74
Plaque index 1.24 ± 0.76 1.03 ± 0.57 0.35
Gingival index 1.71 ± 0.67 1.51 ± 0.73 0.37

Table 5: logistic regression analysis expressing the Odds ratio, 95% confidence intervals and p
values
Variable Odds ratio 95% confidence interval p
age 1.16 1.01–1.21 0.000
PLI 2.15 1.07–4.69 0.000
smoking 2.46 1.81–6.84 0.14
BAI 0.84 0.76–1.14 0.35
BDI 0.67 0.25–2.13 0.49
Anxiety trace 1.01 0.85–1.09 0.81
Anxiety state 1.06 1.00–1.13 0.28

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