Investigația nivelurilor diferiților markeri de stres salivar la pacienții cu

parodontită cronică

Acest articol investighează un subiect suficient de studiat până acum: determinarea relației dintre stres și
cortizol alfa-amilază beta-endorfine din salivă - și parodontită. rezultate valide Articolul a fost publicat pe «
elsevier.com » publicat în Jurnalul original de biologie orală și studiul craniilor faciale ambele oferind
securitatea unui certificat științific. Subiectul este, de asemenea, interesant, deoarece înțelegerea corelației
directe dintre stres și boala parodontală poate duce la o modalitate eficientă de a o evita.
Un prim argument pentru validitatea articolului este scopul cercetării, care este clar definit atât în titlu, cât
și în rezumat. Aceasta prezintă o încercare de a identifica o nouă serie de biomarkeri legați de stadiile
incipiente ale parodontitei. Acest lucru facilitează depistarea precoce a bolii și ar permite aplicarea
tratamentului cu șanse mai mari de succes.
Un al doilea argument este studiul bibliografiei care tratează acest subiect. Un exemplu este studio care
leagă severitatea parodontitei de stres (cortizol de stres și boală parodontală). Acest lucru sugerează o
înțelegere mai largă a subiectului, cu accent doar pe datele colectate prin cercetările actuale. Studiile
anterioare care au examinat efectul biomarkerilor asupra severității parodontitei cronice utilizând STAI
(The State-Trait Anxiety Inventory) au fost, de asemenea, examinate. a rezultat din rezultatele care au
sugerat legătura dintre modul în care stresul afectează apariția bolii parodontale și cercetările actuale care
vizează măsurarea altor parametri. În studiul lui Johannsen asupra pacienților cu antecedente de boli mintale
și stres, deși nu s-a găsit nicio diferență semnificativă între nivelurile de cortizol salivar, nivelurile ridicate
de cortizol au fost observate în lichidul cefalorahidian. Este menționat și un studiu realizat de Rai. am ajuns
la concluzia că nivelurile de cortizol și beta-endorfină s-au dovedit a fi modificate.
Studierea bibliografiei confirmă validitatea ipotezei și necesitatea evaluării amănunțite a acestor biomarkeri
în corelație cu efectul stresului asupra modificărilor parodonțiului.
Alt motiv este argumentarea alegerii studierii acestor indicatori. În cazul cromograninei A, alegerea a fost
motivată printr-un studiu pediatric, în care a fost prezentată legatura dintre concentrația acesteia și stres,
fiind observată o sensibilitate mai crescută a biomarkerului, comparativ cu cortizolul salivar. Studiul
explică apariția acestui indicator prin eliberarea stimulată de stres și având acțiune asupra bacteriilor,
virusurilor, fungilor. Astfel neuroimunitatea poate avea rol în răspunsul imun la stres asociat bolii
parodontale.
Concentrația alfa-amilazei salivare a fost observată ca fiind o reflexie a sistemului nervos simpatic, prin
faptul că în boala parodontală cauzată de stres au fost eliberate o serie de proteine salivare, printre care și
alfa-amilaza.
Beta-endorfinele sunt peptide găsite în concentrație mare în glanda pituitară, anterior hipotalamului.
Endorfinele sunt eliberate în stres, beta-endorfinele fiind în concentrații mari la pacienții depresivi, însă nu
este clară cauza, putând fi corelată doar cu nivel crescut de stres.
Se poate observa motivația care a stat în spatele alegerii fiecărui indicator, toți markerii fiind deja corelați
cu tema principală a articolului, unii dintre ei fiind specifici stresului, alții inflamației. Astfel se acoperă
întreaga paletă implicată în cadrul cercetării.
Întrucât selecția pacienților este o etapă importantă în alcătuirea unui studiu, faptul că această a fost
aprobată de Comitetul de etică în studii clinice al Universității Cumhuriyet certifică desfășurarea corectă a
etapei clinice. Un număr de 80 de pacienți a fost informat în scris și oral cu privire la scopul, conținutul și
procedurile studiului, aceștia dându-și consimțământul pentru participare. Au fost excluși pacienți cu diabet,
infarct miocardic, afecțiuni cardiace, alergii, indivizi care consumă țigări sau alcool, celor cărora li s-au
realizat tratamente parodontale în ultimele 6 luni, cei care au consumat medicamente cu potențial
inflamatorii sau vitamine antioxidante. Pacienții care nu aveau restaurări protetice, care nu aveau alterate
probele salivare sau chestionarele, au fost incluși. După evaluarea clinică și radiologică, pacienții au fost
diagnosticați folosind criteriile parodontitei cronice a Academiei Americane de Parodontologie.
Pacienții au fost separați în 3 grupuri, criteriul de selecție fiind gradul de afectare parodontală. Pierderea de
atașament minoră a fost considerată cea de 1-2 mm, pierderea moderată de 3-4 mm, iar severă >5 mm.
Pentru măsurarea stării de anxietate a fost folosit STAI, chestionar care este alcătuit din întrebări scurte, pe
care subiecții le clasează pe o scală cu 4 nivele. STAI a fost utilizat doar în partea inițială a sesiunii pentru
măsurarea nivelului de stres. Orice întrebare pe care pacienții nu au înțeles-o în timpul completării
chestionarului a fost explicată, pentru a obține o acuratețe în colectarea datelor de la pacienți.
Chestionarul a consistat în 2 părți a câte 20 de întrebări fiecare, fiecare întrebare cu câte 4 răspunsuri
posibile. Pacienții au selectat un scor între 1-4 pentru fiecare întrebare, rezultatele finale încadrându-se în
intervalul 20-80, scorul mai mare indicând nivel crescut de anxietate.
Până în acest moment se poate remarca posibilitatea unei analize clare a ambilor parametri principali ai
studiului, atât a nivelului de stres, cu ajutorul chestionarului STAI, dar și a afectării parodontale, prin
aprecierea pierderii de atașament parodontale. De asemenea măsurătorile au fost făcute de un singur
clinician, pentru a elimina interferarea variațiilor de valori obținute de clinicieni diferiți.
Ambele măsuri și colectarea salivei au fost efectuate de un cercetător experimentat, urmând protocolul de
studiu. Colectarea salivei a fost efectuată înainte de măsurători pentru a evita contaminarea salivei cu
posibile picături de sânge. Pentru a nu influența biomarkerii din salivă, pacienții au fost instruiți să nu
consume lichide cu 1 oră înainte de colectare. Probele au fost transferate în tuburi din polipropilenă la 5
minute după colectare și depozitate la - 80 de grade pentru a fi centrifugate și analizate
Colectarea datelor a fost efectuată în conformitate cu un protocol clar stabilit atât în etapa de colectare,
urmând pașii dintr-o ordine care urmărește să obțină o imagine mai exactă a concentrației reale de
biomarkeri în salivă fără a implica factori care distorsionează rezultatele (cum ar fi picături de sânge apărute
în cazul măsurării inițiale a pierderii de inserție urmat doar de colectarea salivei), precum și chestionarul
care analizează nivelul de stres datorat celor 4 variante de răspuns obținând o înregistrare mai ușoară a
datelor
Analiza statistică a datelor a fost efectuată utilizând programul SPSS utilizând analiza parametrului
Kolmogorov-Smirnov sau testele Kruskal-Wallis Mann-Whitney U în circumstanțe în care prima variantă a
analizei datelor nu a îndeplinit cerințele. Datele au fost prezentate pe grupe de vârstă și sex, observând o
legătură între severitatea bolii parodontale și vârstele mai în vârstă (P> 0,05). Comparația dintre severitatea
parodontitei cronice în conformitate cu STAI 1 și STAI 2 nu a relevat niveluri semnificative. de stres în
diferite grupuri de severitate a bolii parodontale. Analiza biomarkerilor a observat o creștere a nivelurilor de
cortizol la pacienții cu parodontită severă. severitate mai mare
Studiul împarte analiza datelor în trei faze distincte, ceea ce permite o interpretare ușoară a rezultatelor,
reușind de asemenea să acopere principalele aspecte ale studiului împărțite în așa fel încât să permită un
studiu separat după o analiză interconectată a acestora pentru a corela rezultatele.
Prin urmare, ipoteza a fost confirmată doar parțial de nivelul ridicat de cortizol, dar fără modificări
semnificative în ceilalți indicatori. În cazul chestionarelor STAI 1 și STAI 2, nu s-au putut observa diferențe
care ar lega direct nivelurile ridicate. stres și diferite grade de boală parodontală
În concluzie, consider că studiul actual este valid deoarece urmărește pașii cercetării științifice, deoarece o
cunoaștere profundă a bibliografiei legate de acest subiect a justificat atât alegerea de a studia legătura
dintre stres ca factor cauzal, cât și agravarea bolii parodontale și cei patru biomarkeri salivari Deși problema
a fost studiată anterior, până în prezent nu a existat niciun studiu asupra biomarkerilor selectați pentru
prezentul articol, astfel încât întrebarea pusă de autorii articolului este fără răspuns, dar cu un mare potențial
de utilitate. datele au urmat un protocol clar privind colectarea salivei măsurarea pierderii atașamentului
completarea chestionarelor care doresc să măsoare nivelurile de stres. Clinicienii responsabili pentru
colectarea datelor au fost instruiți cu privire la modul în care ar trebui efectuate testele, astfel încât datele
care nu pot fi modificate ulterior reușind să obțină rezultate de înaltă fidelitate aceste date au împărțit
problema în trei subiecte de studiu diferite pentru organizarea eficientă a datelor inițiale utilizând nu numai
un program de testare, ci și alte două, dacă eficacitatea primului nu a îndeplinit cerințele Deși rezultatele nu
au confirmat pe deplin ipoteza, s-a putut observa o legătură între creșterea cortizolului nivelurile și
severitatea bolii parodontale, sugerând că stresul poate fi un factor major în debutul sau modificarea
severității bolii parodontale. cum o afectează posibilitatea de a trata problema înainte de a ajunge la un
stadiu avansat irecuperabil chiar și cu terapie.

Bibliografie
https://www-sciencedirect-com.dbproxy.umfiasi.ro/science/article/pii/S2212426820301147
Articol in Engleza:

Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

Contents lists available at ScienceDirect

Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Original Article

Investigation of the levels of different salivary stress markers in chronic T

periodontitis patients

a a b,∗ c
Hakan Develioglu , Saygin Korkmaz , Serkan Dundar , Ulrich Schlagenhauf
a Sivas Cumhuriyet University, Faculty of Dentisty, Department of Periodontology, Sivas, Turkey

b Firat University, Faculty of Dentistry, Department of Periodontology, Elazig, Turkey

c Würzburg University, Faculty of Dentistry, Department of Periodontology, Würzburg, Germany

ARTICLE INFO ABSTRACT

Keywords: 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.

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
Clinical attachment loss
depth (PD) measurements were recorded for all the participants. All par-ticipants 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
Salivary stress markers average of five minutes.

Salivary cortisol 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 se-verity 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.
1. Introduction

Periodontitis is one of the most common causes of tooth loss. In addition,

systemic risks such as diabetes mellitus, smoking, age, and genetic factors
affect the onset and progression of periodontal disease. Emotional stress is
considered to be an important risk factor for peri-odontitis, but the biological
1–3
mechanisms of the disease's progression remain unclear. Stress is a
physical, emotional, cognitive, and be-havioral response to events that are
viewed as threats or difficulties. The psycho neuro immunological model
attempts to link stress with periodontitis through mentally triggered
immunological response changes. It is assumed that periodontal health is
4 such as matrix metalloproteinase (MMP), os-teoprotegerin, and interleukin-
affected negatively if the individual is not coping adequately with stress.
Psychosocial stress conditions lead to centrally induced immune suppression
and an in-crease in inflammation, which has an adverse influence on chronic
4,5
inflammatory disease. Cortisol, one of the stress-related biomarkers of the
hypothalamic–pituitary–adrenal axis, has already been shown to
be positively correlated with the occurrence and severity of period-ontitis and
5
periodontitis. Saliva sampling is a non-invasive, painless, rapid, and
6
promising method for evaluating biomarkers. Studies have shown that many
biomarkers are found in saliva, some of which have been associated with
periodontal disease, including biomarkers due to a major immune response,
7
1β. New saliva biomarkers are still needed to aid detection of the early
8,9
stages of periodontitis, which may facilitate earlier medical interventions.
Chromogranin A (CgA) is an acidic glycoprotein with a molecular weight
of 48 kDa and consisting of 439 amino acids, and it is expressed by the
normal or neoplastic cells of various endocrine and neu-roendocrine systems.
CgA is secreted from the storage granules in the adrenal medulla in
combination with catecholamines, and it is secreted in combination with
parathormone from the parathyroid gland in re-sponse to hypocalcemia. High
CgA levels in saliva have been associated with various conditions, such as dry
9,10
mouth. In a pediatric study,

∗
Corresponding author. Firat University, Faculty of Dentistry, Department of Periodontology, Campus, Postal Code: 23119, Elazig, Turkey. E-mail addresses:
sdundar@firat.edu.tr, dtserkandundar@gmail.com (S. Dundar).

https://doi.org/10.1016/j.jobcr.2020.07.020

Received 5 February 2020; Received in revised form 25 July 2020; Accepted 28 July 2020

Available online 12 August 2020

2212-4268/ © 2020 Published by Elsevier B.V. on behalf of Craniofacial Research Foundation.

developed to investigate anxiety in normal adults, was found in subsequent

H. Develioglu, et al. trials to be suitable for high school students, individuals with psychiatric
disorders, and patients with physical diseases. Long-term research has led
psychologists to conclude that the inventory can be applied to all young
16
people and adults.
salivary CgA was shown to be a more sensitive marker for psychological
11
stress than salivary cortisol. CgA is released during stress and plays a role in
the natural immune response to bacteria, viruses, and fungi, exhibiting a Studies examining the relationship between saliva stress markers and the
12
highly cationic structure. Neuroimmunity may play a role in the protective severity of periodontitis are limited. Stress markers have been studied
13
response to stress associated with infectious diseases. Saliva α-amylase separately and in paired studies, but no studies to date have examined the
concentrations have been suggested as a reliable re-flection of sympathetic impact of salivary levels of cortisol, α-amylase, β-en-dorphin, and
14
nervous system (SNS) activity, especially under stress situations. In one chromogranin A on the severity of chronic periodontitis using the STAI. In
study, stress and saliva stress markers were found to be associated with this study, we aimed to investigate the levels of these four salivary stress
1
periodontal disease. Some studies suggest that stress caused by periodontal markers in the salivary samples of patients with chronic periodontitis and the
inflammation may lead to the release of certain saliva proteins, such as α- relationship between the severity of the periodontitis and clinical parameters.
15
amylase.

β-Endorphins are peptides found in high concentrations in the pi-tuitary,

anterior hypothalamus, septal area, and periaqueductal gray areas. They are
thought to affect pain perception, behavior, and various psychological 2. Materials & methods
responses. Endorphins are released in response to stress. β-endorphin levels
have been found to be high in depressive patients. This response may be
depression-specific or it may be due to high levels of stress unrelated to
2.1. Patient selection
depression.

The State–Trait Anxiety Inventory (STAI) developed by Spielberger et al.

The population of our study consisted of individuals diagnosed with
is a self-assessment questionnaire consisting of short statements, which
chronic periodontitis who presented to the Periodontology Department of the
respondents rate on a four-point scale. This inventory, which was originally
Sivas Cumhuriyet University Faculty of Dentistry, Sivas, Turkey, for Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

treatment. Eighty patients were included in the study. The study was approved
by the Cumhuriyet University Clinical Research Ethics Committee on January
17, 2017, with the decision number 2017-01/
periodontitis, the CAL, which is a sign of destructive and physiologi-cally
irreversible periodontal disease, was 1–2 mm. For moderate chronic
3. The participants were informed in writing and orally about the purpose, periodontitis, the CAL was 3–4 mm. For severe chronic peri-odontitis, the
content, and procedures of the study in accordance with the information and 17,18
CAL was ≥5 mm.
the consent form, which was signed by every partici-pant. Excluded were:
patients with diabetes, myocardial infarction, heart disease, and allergies,
individuals who smoked and consumed alcohol, those who had had
periodontal treatment in the previous six months, those who took chronic anti-
inflammatory drugs or anti-oxi-dant vitamins, and individuals who had not 2.3. Stress inventory
used antibiotics in the previous three months. Patients who were not lactating,
who did not have any prosthetic tooth restorations, and who did not have any
lost data in the saliva samples and stress questionnaires were included in the
The STAI was used only in the initial session to measure the pa-tients’
1–5
study. After clinical and radiographic evaluations, the patients were stress levels. Any questions that the patients did not understand while filling
diagnosed according to the criteria for the diagnosis of general-ized chronic out the questionnaire (Annexes 1 and 2) were clearly ex-plained, and the
periodontitis within the classification of the American Periodontology questionnaires were completed accurately. The ques-tionnaire consisted of
17 two parts with 20 questions each, and each question had four possible
Academy (1999).
answers. The patients selected a score be-tween one and four for each
question; the minimum score for the questionnaire was 20, and the maximum
score was 80. In general, higher STAI scores indicated a higher level of
2.2. Patient groups anxiety.
19

When the literature is analyzed, it is seen that STAI 1 and STAI 2 stress
scoring systems are a frequently used system. In this study, we used the STAI
The individuals included in the study were divided into three groups 19
17,18 1 and STAI 2 scoring systems in accordance with the literature.
according to the severity of their periodontitis. For mild chronic

2.4. Clinical periodontal assessment

The PI, GI, PD, and CAL of each participant were measured by a single
clinician to determine the degree of periodontal disease. All clinical
measurements were recorded after taking saliva samples and were made by an
extensively trained, calibrated researcher according to the study protocol.

2.5. Collection of saliva specimens and measurement of saliva stress

markers

Saliva samples were taken before clinical measurements to prevent the

contamination of saliva due to possible bleeding during probing. To avoid
affecting the stress markers in the saliva, patients were asked to refrain from
consuming any nutrients or liquids 1 h prior to the sample collection. The
samples were collected between 09:00 and 11:00 a.m., so that the patients
were not affected by circadian rhythm changes. The patients were asked to
transfer the saliva samples to capped poly-propylene tubes within an average
of five minutes. The samples were stored at −80 °C, before being taken to the
Sivas Cumhuriyet University Faculty of Medicine Biochemistry Laboratory,
where they were centrifuged, and biochemical analyses were performed.

2.6. Biochemical analysis of saliva samples

The saliva samples were centrifuged at 1000 g for 20 min, and the
supernatant was collected into Eppendorf tubes. Chromogranin A/ pancrea
statin, amylase alpha 1, β-endorphin, and cortisol measure-ments were taken
using an Elabscience ELISA kit, in accordance with the manufacturer's
instructions. The data obtained from our study were loaded into the SPSS (ver-sion
22.00) program and evaluated using parametric test assumptions
(Kolmogorov–Smirnov). The Kruskal–Wallis test and the Mann–Whitney U
test were used when the parametric test assumptions could not be fulfilled. A
Spearman correlation analysis was used to determine the relationships among
2.7. Statistical analysis
the variables. A chi-squared test was employed to evaluate the data obtained
by counting, and the error level was taken as p < 0.05.

515
H. Develioglu, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

Table 1

a b
Comparison of age and sex measurements of groups. Statistically significant different compared with the mild periodontitis group patients, Statistically significant different compared
with the moderate periodontitis group patients (P < 0,05).

Mild Periodontitis (n = 26)Mean ± Sd (min- max) Moderate Periodontitis (n = 39)Mean ± Sd (min- max) Severe Periodontitis (n = 15)Mean ± Sd (min- max)

a a,b
Age 38.23 ± 3.55 (35–49) 42.66 ± 7.65 (35–62) 55.26 ± 6.94 (41–68)

Sex Female 17 (65.4) Female 20 (51.3) Female 8 (53.3)

Male 9 (34.6) Male 12 (48.7) Male 7 (46.7)

a
P < 0,05, The severity of periodontitis increases with age.

which are risk determinants and which are thought to be risk factors—were
investigated. A positive correlation was found in human studies between the
3. Results periodontal disease index and adverse life conditions.
24
When the
inflammatory activation is long and deep enough, the systemic symptoms of
25
the disease may become pro-minent and may occur with periodontitis.
3.1. Demographic characteristics of groups, stress survey values and
distribution of saliva stress marker levels
There have been some studies on the relationships among stress,
2
depression, and periodontitis. Many have reported a positive
The age and sex distributions of the patients according to the se-verity of
their chronic periodontitis are presented in Table 1. The se-verity of chronic
periodontitis increased with age (P < 0.05). How-ever, there were no Table 2
statistically significant gender differences among the chronic periodontitis
groups (P > 0.05). A comparison of the se-verity of chronic periodontitis
according to STAI 1 and STAI 2 stress scores is given in Table 2. The stress
questionnaires revealed no sig-nificant differences among the groups in terms
of the severity of chronic periodontitis (P > 0.05).

The relationship between chronic periodontitis severity and cortisol levels

was, however, statistically significant, the severity of the disease increasing
with rising cortisol levels (P < 0.05). There were no sta-tistically significant
associations between α-amylase, chromogranin A, or β-endorphin levels and
the severity of chronic periodontitis (P > 0.05) (Tables 3 and 4).

3.2. Comparing the severity of the periodontitis and clinical parameters of the
groups

There was also no statistically significant association between clinical

measurements and the severity of chronic periodontitis (P > 0.05) (Table 5).

4. Discussion

The immune response to host microorganisms in the pathogenesis of

periodontitis is influenced by genetic factors, changeable environ-mental
20,21
factors, and systemic factors. Many studies have shown that stress is one
of the interchangeable environmental factors that are im-portant risk
22,23
determinants for the development of periodontal dis-eases. However,
recent studies have shown that stress is not a risk determinant but a risk
factor. In this study, the effects of salivary stress markers on periodontitis—

association between psychosocial stress conditions (e.g., academic stress and
occupational stress) and clinical periodontal parameters (e.g., plaque
26
accumulation–PI and gingival inflammation–GI). High con-centrations of
cortisol and β-endorphin can regulate MMP-1, MMP-2, MMP7, MMP-11,
and tissue inhibitor metalloproteinase-1 in the gin-gival fibroblasts of humans.
This mechanism explains the increase in periodontal destruction associated
1
with physiological stress. Stress markers found in the blood and saliva of
individuals with periodontal disease change the microbial dental biofilm
composition and trigger the development of periodontal disease via different
27
mechanisms involving modifications of the inflammatory response. Studies
have examined the relationships between saliva stress markers and
periodontitis in patients alone and in comparisons between periodontitis
groups and controls. However, no previous study has examined four different
saliva stress markers together with the STAI. Saliva is considered a good
sampling material with which to assess stress conditions, especially
depression, and the use of saliva markers to assess human stress has become
7,28
more common in the last 30 years. In their study in 2011, Rai et al.
investigated the association between saliva stress markers and periodontal
status and significant relationships were found among salivary cortisol and β-
1 deteriorates. Saliva analysis provides more objective and measurable results
endorphin levels, tooth loss, and periodontal clinical parameters. The STAI
was administered to individuals who participated in the study. Many studies
have used this questionnaire in the field of dentistry to measure stress and
29 29
anxiety. For example, Vettore et al. investigated the relationship between
periodontal dis-ease and stress, using the STAI on 79 patients. They found
that CAL and an increase in PD were positively correlated with high anxiety
30
in-ventory scores. Kesim et al. used the STAI to investigate the re-
lationship between stress and the severity of periodontal disease in 141
patients. The stress questionnaire scores were significantly higher in the
chronic periodontitis group than in the gingivitis group. Because stress is a
state that can change moment to moment, patients should be ob-served for a
long time to evaluate their stress levels accurately. The role of biological
markers in investigating the effects of emotional stress on periodontal tissues
has accordingly become pertinent.
In the present study, in which the effects of stress on periodontal disease
were evaluated, saliva was preferred as the sample material, owing to the
simplicity and ease of its collection. Saliva samples were collected in the
31
morning between 09:00 and 11:00 a.m., when, be-cause of the circadian
1
rhythm of cortisol, the levels of cortisol are higher than in the afternoon. In
32
evoked saliva, the volume of saliva increases and the concentration
33
than the subjective and non-parametric data obtained from surveys. However,
there are some lim-itations to saliva sampling, such as the need for a large
quantity of

Comparison of severity of periodontitis according to stress score. STAI: State-Trait Anxiety Inventory test, (P > 0.05).

Stress Score Periodontal Parameter

Mild Periodontitis (n = 26) Mean ± Sd (min-max) Moderate Periodontitis (n = 39) Mean ± Sd (min-max) Severe Periodontitis (n = 15) Mean ± Sd (min-max)

STAI1 42.92 ± 10.20 (26–74) 42.43 ± 1.48 (22–74) 37.06 ± 9.83 (23–51)

STAI2 45.03 ± 6.86 (27–60) 49.15 ± 8.55 (34–73) 44.66 ± 7.07 (35–58)

P > 0.05.

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H. Develioglu, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

Table 3

Comparison of severity of periodontitis according to salivary stress markers. Cortisol levels increased with the severity of periodontitis (P < 0,05). Statistically significant differences was
not detected between the severity of periodontitis and α-amylase, chromogranin A, or β-endorphin levels (P > 0.05).

Mild Periodontitis (n = 26) Mean ± Sd (min-max) Moderate Periodontitis (n = 39)Mean ± Sd (min-max) Severe Periodontitis (n = 15)Mean ± Sd (min-max)

a a,b
Cortisol 401.88 ± 254.24 (12.5–749.81) 458.21 ± 236.50 (12.50–777.94) 612.10 ± 128.66 (325.44–769.19)

α- Amilase 68.21 ± 37.11 (10.61–122.48) 160.90 ± 35.74 (17.70–121.83) 51.99 ± 28.36 (17.39–108.35)

β- Endorphine 336.67 ± 239.31 (15.63–823.85) 455.28 ± 268.11 (15.63–880.77) 462.46 ± 337.99 (15.63–863.08)

Chromogranin- A 369.87 ± 261.17 (30.17–1156.83) 321.68 ± 304.53 (61.83–1821.83) 273.99 ± 167.41 (62.50–565.17)

a Statistically significant difference compared with the mild periodontitis (P < 0,05).
b Statistically significant difference compared with the moderate periodontitis (P < 0,05).

saliva samples, the influence of saliva content on local and systemic factors,
Table 4
and the use of different saliva sampling techniques that can directly affect the
34
findings.

Many studies have shown the relationship between stress and per-iodontal
disease. The present study is the first to examine the re-lationships among four
different salivary stress markers, STAI scores, and the severity of
periodontitis. Although many hormonal changes are observed in the body
during stress, cortisol is the leading one. Therefore, cortisol is frequently used
35,36
in studies related to stress. Hilgert et al. investigated the relationships
among the prevalence and severity of periodontitis, cortisol levels, and stress
scores in people over 50 years of age and reported a positive correlation
37 5
between cortisol levels and periodontitis. Rosania et al. observed a
significant asso-ciation between the levels of saliva cortisol and the amount of
tooth loss in 45 patients in 2009. These results are consistent with those of our
study.

38
In a study conducted in 2007 by Ishisaka et al., the cortisol and
dehydroepiandrosterone (DHEA) levels of 171 patients (85 male, 86 female)
were compared. High cortisol and DHEA levels were shown to be statistically
significantly correlated with the severity of period-ontitis. The results of this
study are exactly parallel to those of the present study.

26
In a study by Johannsen et al. on patients who underwent regular
follow-up examinations in 2006, because they suffered from stress and mental
health problems, salivary cortisol levels did not differ sig-nificantly between
the patient and the control groups. However, the gingival crevicular fluid
cortisol levels were significantly higher in the patient group. The results of
this study are not consistent with those of our study, because we used groups
classed according to the severity of disease, instead of a healthy patient group
and a control group.

1
In a study on 100 patients in 2011, Rai et al. concluded that the
concentrations of salivary cortisol and β-endorphin were statistically
significantly correlated with the severity of periodontitis and tooth loss, but
there was no statistically significant association between the se-verity of
periodontitis and the concentrations of α-amylase and chro-mogranin A.
These results are in agreement with those of our study of

cortisol, α-amylase, and chromogranin A.
3
In 2012, Haririan et al. studied 24 patients with aggressive peri-odontitis
(AgP), 30 patients with chronic periodontitis (CP), and 30 healthy individuals,
and compared their α-amylase and chromogranin A levels. Whereas the
salivary α-amylase and chromogranin A levels of the AgP patients were
higher than those of the CP patients, no sig-nificant difference was observed
between the groups in terms of the serum α-amylase and chromogranin A
levels. This study demonstrated that saliva markers may be more important
stress indicators than serum markers. In our study, the loss of clinical
attachment was higher in patients with higher levels of saliva cortisol. There
was a statistically significant difference between mild and severe periodontitis
in terms of the amount of cortisol. This result is in agreement with the results
of other studies in the literature. Moreover, in the present study, a similar
relationship was found between the concentrations of chromogranin A in
saliva and the results of the STAI.
levels occur in cases such as dry mouth. In our study, pa-tients with chronic
or acute dry mouth and those who could not obtain saliva samples within six
minutes were excluded. This limitation may be the cause of the differences in
results between previous studies and the present study.
It has been suggested that salivary α-amylase is a reliable index for
sympathetic nervous system activity in stress situations. β-endorphins are
found in high concentrations in the pituitary, anterior hypotha-lamus, septal
area, and periaqueductal gray areas. These peptides are thought to affect the
perception of pain, behavior, and various psy-chological responses.
Endorphins are released in response to stress. β-endorphin levels were found
to be high in depressive patients. This response may be depression-specific or
it may be due to high levels of stress unrelated to depression. In our study, no
relationships were found between the salivary concentrations of β-endorphin
and α-amylase and the severity of periodontitis.

The present study has several limitations. Saliva stress markers were not
measured periodically, as they should be. Demographic details of
In a pediatric study, saliva CgA levels were shown to be a more sensitive
13
marker of psychological stress than salivary cortisol. High saliva CgA

Comparison of severity of periodontitis according to salivary stress markers. Cortisol levels increased with the severity of periodontitis (P < 0,05). Statistically significant differences was
not detected between the severity of periodontitis and α-amylase, chromogranin A, or β-endorphin levels (P > 0.05). *Statistically significant differences was not detected between the
periodontitis groups for STAI levels (P > 0.05).

Biochemical Parameters Periodontal and Stress Parameters

Mild Periodontitis (n = 26) Mean ± Sd (min-max) Moderate Periodontitis (n = 39) Mean ± Sd (min- Severe Periodontitis (n = 15) Mean ± Sd (min-
max) max)

STAI LEVELS *STAI1 42.92 ± 10.20 (26–74) *STAI1 42.43 ± 1.48 (22–74) *STAI1 37.06 ± 9.83 (23–51)

*STAI2 45.03 ± 6.86 (27–60) *STAI2 49.15 ± 8.55 (34–73) *STAI2 44.66 ± 7.07 (35–58)

a a,b
Cortisol (μg/dl) 401.88 ± 254.24 (12.5–749.81) 458.21 ± 236.50 (12.50–777.94) 612.10 ± 128.66 (325.44–769.19)

α- Amilase (IU) 68.21 ± 37.11 (10.61–122.48) 160.90 ± 35.74 (17.70–121.83) 51.99 ± 28.36 (17.39–108.35)

β- Endorphine (pg/ML) 336.67 ± 239.31 (15.63–823.85) 455.28 ± 268.11 (15.63–880.77) 462.46 ± 337.99 (15.63–863.08)

Chromogranin- A (IU/dl) 369.87 ± 261.17 (30.17–1156.83) 321.68 ± 304.53 (61.83–1821.83) 273.99 ± 167.41 (62.50–565.17)

a P < 0,05.

517
H. Develioglu, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

Table 5

Comparison of the severity of periodontitis according to clinical measurements. Statistically significant differences was not detected between the groups (P > 0.05).

Periodontal Periodontitis

Parameters

Mild Periodontitis (n = 26) Mean ± Sd (min- Moderate Periodontitis (n = 39) Mean ± Sd (min- Severe Periodontitis (n = 15) Mean ± Sd (min- P

max) max) max)

PI 2.23 ± 0.71 (1.00–3.00) 2.28 ± 0.64 (1.00–3.00) 2.33 ± 0.61 (1.00–3.00) > 0.05

GI 2 ± 0.74 (1.00–3.00) 1.82 ± 0.68 (1.00–3.00) 1.77 ± 0.70 (1.00–3.00)

PPD 1.7 ± 0.9 (1–3) 3.9 ± 1.1 (2–4) 6.4 ± 2.2 (5–9)

CAL 2.10+-0.55 (1.20–2.90) 3.91+-0.47 (3–4.9) 5.99+-0.50 (5.30–6.90)

GI: Gingival index, PI:Plak index, CAL: Clinical Attachmant Loss, PPD: Pocket probing depth.

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