Influence of personality traits on gingival health.

BACKGROUND: The maintenance of good oral hygiene is considered a salient issue in dental health promotion. Personality is the combination of characteristics or qualities that form an individual's distinctive character. Various personality traits have been proposed to influence the oral health. The purpose of the present study was to assess the influence of personality characteristics using questionnaire on oral hygiene performance and gingival health.
MATERIALS AND METHODS: In total, 155 patients were subjected to personality questionnaire using Eysenck Personality Questionnaire. Clinical parameters such as Patient oral hygiene performance index and gingival index were recorded. Based on Eysenck Personality Questionnaire, the subjects were divided into three groups: Psychoticism, extroversion, and neuroticism.
RESULTS: Data analysis showed that subjects in psychoticism and neuroticism groups displayed moderate gingivitis, whereas subjects in extroversion group had severe gingivitis. Subjects in all the three groups demonstrated poor oral hygiene status. No statistically significant relation was found.
CONCLUSIONS: A considerable clinical correlation was observed between the different personality traits and gingival health status of the subjects. It was not statistically significant. Further trials need to be conducted so as to ascertain this association so that psychological interventions may be undertaken to improve the oral hygiene condition of the population.

INTRODUCTION

“Menssana in corporesanois,” a famous Latin quotation means “A sound mind in a sound body.” This relationship has been proposed for centuries. Studies have reported an increased susceptibility to systemic diseases and delayed wound healing in both animals and human beings who are subjected to prolonged stress, physical or emotional.[12] One of the major health concerns is the higher prevalence of gingival diseases in young and adults.[34] Also, destructive periodontal diseases should not be perceived as a usual consequence of gingivitis which eventually leads to tooth loss. The manifestations and progression of periodontitis is also predisposed by a wide variety of determinants and factors.[5]

Recently, more emphasis has been directed toward the combined influence of lifestyle, education, psychosocial factors, and socioeconomic factors instead of regular risk factors in dealing with chronic illnesses. Age, gender, smoking habits, anxiety, stress, depression in everyday life, self-liking, self-competence, body image, care and protection were positively related with oral health behaviors.[6] Cynical hostility was also identified as a risk marker for poor oral health.[7]

Prevention of dental diseases has always been a long-standing interest of the dental profession. The maintenance of good oral hygiene is considered a salient issue in dental health promotion. Also, reductions in plaque and gingival bleeding were achieved in the short term in the majority of studies reviewed.[8]

Personality is the combination of characteristics or qualities that form an individual's distinctive character. Personality characteristics appear to affect the oral health. Also, people with particular personality behavior demonstrate their oral health state differently from others.[9]

A variety of psychological tests have been designed to examine patients in terms of their personality attributes. This has led to the increase of classifications based on people's personality types and traits.[10] The individual differences in emotional and behavioral style can be examined through a personality instrument. Brief cognitive interventions can alter the attitudes and values tapped into by personality tests, which might be useful in preventive dentistry. There is evidence that psychological approaches to behavior management such as the use of reinforcement, goal setting, and the provision of feedback can improve oral hygiene and oral hygiene-related behaviors.[11]

There has been meager research on the impact of overall personality of an individual on his/her oral hygiene condition. Hence, the aim of this study was to examine the influence of personality characteristics using questionnaire on oral hygiene performance and gingival health.

MATERIALS AND METHODS

A total of 155 outpatients attending the Department of Periodontics, Yenepoya Dental College, Mangalore, India, were selected for the present study. Subjects were accepted into the study based on the selection criteria. The inclusion criteria were (1) minimum age of 18 years of both gender, (2) minimum of 20 permanent teeth (with at least index teeth for all the indices which are used), (3) patients who are not under professionally monitored plaque control program. The exclusion criteria were (1) patient having any systemic illness, (2) patient under medication, (3) pregnancy, and (4) use of antibiotics during the previous four weeks.

Informed consent for the participation from all the subjects was obtained prior to the commencement of the study.

Ethical clearance was obtained from the institutional ethical committee of Yenepoya University prior to the commencement of the study. All subjects were examined by a single clinical examiner. For each subject, the following data were collected: Name, age, sex, a detailed medical and dental history, personal habits, and oral hygiene practice. The personality characters were assessed using the Eysenck Personality Questionnaire.[12] The Eysenck Personality Questionnaire (EPQ) is designed to give ready measure of three important personality dimensions: Psychoticism (P), extroversion (E), and neuroticism (N). Psychoticism describes the personality as solitary, troublesome, cruel, lacking in feeling and empathy, hostile to others, sensations lacking, and liking odd and unusual things. Neuroticism refers to the general emotional liability of the person, his emotional over-responsiveness, and his liability to neurotic breakdown under stress. Extroversion as opposed to introversion refers to the outgoing, uninhibited, social proclivities of a person.[13] EPQ consists of 90 questions to which the examinee answers yes or no. P and N were scored using 24 questions each and E was scored using 21 questions. A fourth factor, i.e., the lie score is used to identify the subject's truthful compliance to questions, and is derived from a total of 21 questions. If the score of Lie scale exceeded 8 for females and 7 for males, they were excluded from the study. Sufficient time was given to each subject to fill the questionnaire.

As an individual can have more than one personality trait, based on the norms, the subjects who scored above average expressed greater strength of that particular factor and were divided into three groups: P, E, and N, respectively. Subjects who scored below average in all three personality traits were considered as “Control Group.”

Clinical examinations included assessment of the oral hygiene performance (by assessing the plaque levels) and assessment of gingival status. Plaque was recorded using an index developed by Podshadley and Haley 1968 called the patient hygiene performance index (PHPI). The full mouth gingival index (GI) of Loe and Silness 1963 was used to record gingival inflammation around the entire dentition (excluding 3rd molars).

Statistics: Data were entered onto Microsoft Excel and statistically analyzed using Chi-square test (SPSS vers. 17 software). A P<0.05 was considered to be statistically significant.

RESULTS

Of the 155 subjects initially selected for the study, 13 were excluded because of high lie responses, as measured by the EPQ. As one can have more than one personality trait, a total of 203 personality traits were assessed. Relation between 203 personality traits, oral hygiene performance, and the gingival status was statistically analyzed. Based on the personality questionnaire, 96 subjects were in P group, 34 subjects in E group, and 49 subjects in N group. The total mean age was 28.11 years and 70 of them were male while 72 were female (n=142). P group consisted of 44 males and 52 females (n=96) and the mean age was 27.53 years. N group consisted of 25 males and 24 females (n=49) and the mean age was 29.18 years. E group consisted of 15 males and 19 females (n=34) and the mean age was 29.26 years [Table 1].

Table 1

The mean age and gender in all groups

Table 2 demonstrates the relation between the various scores of PHP index and different personality traits (P, E, N). No statistically significant relation was seen (P=0.388). None of the groups showed excellent patient hygiene performance. Majority of the subjects in all the three groups (P: 57.3%, E: 64.7%, N: 57.1%) showed poor oral hygiene. Table 3 demonstrates the relation between the various scores of GI and different personality traits (P, N, E). No statistically significant relation was seen (P=0.175). Majority of the subjects in P, N groups (P: 53.1%, N: 53.1%) showed moderate gingival inflammation, whereas majority of subjects in E group (50.0%) exhibited severe gingival inflammation. Table 4 shows the relation between the GI scores and PHPI scores within each group. Very high statistical significant relation was observed in group P and N, whereas high statistical significant relation was seen in group E. Table 5 demonstrates the relation of different personality traits with toothbrushing frequency, past dental visits, and use of tobacco. No statistically significant relation was seen (P=0.972, P=0.728, P=0.909, respectively). It was also observed that group P, E subjects had lower brushing frequency. When comparing the number of dental visits among the different groups, majority of the subjects in all three groups had visited the dentist before. The subjects in the control group had no history of use of tobacco. Comparatively, group E subjects had higher tendency of using tobacco.

Table 2

Relation between personality traits and PHP scores

Table 3

Relation between personality traits and GI scores

Table 4

Relation between PHPI scores and GI scores

Table 5

Relation of personality traits with toothbrushing frequency, past dental visits, and use of tobacco

DISCUSSION

Gingivitis is a nondestructive form of periodontal disease which is primarily caused by accumulation of plaque. All preventive measures are undertaken to minimize the level of plaque and thus improve the oral health. Evaluation of the oral hygiene measures employed by the patient is usually done by assessing the plaque levels and gingival status. High correlation is found between increased levels of plaque and poor gingival health. In this study, oral hygiene performance index and GI were employed to assess the influence of personality traits on gingival health. Also, these clinical parameters will be of greater benefit to both patient and clinician for further follow-up phases if required.

A personality trait is a characteristic way in which an individual perceives, feels, believes, or acts. Studies have shown the effect of personality traits on oral health and health-related behaviors.[14] Research has indicated at least three processes to be involved. First, certain personality traits predispose to poor oral health. Example: Habit of bruxism (which may in turn lead to temporomandibular joint dysfunction) among individuals who score more highly on the trait of aggressiveness. Second, certain personality traits are associated with health-damaging behaviors which may affect the oral health. Example: Individuals who are low on constraint are more likely to smoke which also affects the periodontium leading to periodontitis. Third, personality characteristics may alter the way in which individuals respond to (interpret) symptoms and thus construct their illness state. Example: Individuals who score high on the trait of stress interpret oral symptoms as being more catastrophic than would their low-scoring counterparts.[15]

Since there are no previous studies in India on the relationship between personality traits and oral health, we found it relevant to focus on the association between overall personality (on the basis of questionnaire), oral hygiene performance, and gingival status.

The study was designed in such a manner that with a sample size of 155 subjects, 95% confidence level and 90% power with the reference value r=0.48[14] could be observed. Based on the EPQ, the personalities of the individuals were grouped into three, psychoticism, neuroticism, and extroversion. No statistically significant correlation was found between P, E, N and plaque and gingival status as measured by the PHPI and GI. A statistical significant relation was observed between the PHPI values and GI values in all the groups. As PHPI measures the presence of plaque in an individual, statistical significant correlation between the two indices would ascertain that high levels of plaque relates to gingival inflammation. Also, the presence of plaque gives an outline of one's oral hygiene practice. Hence, all the subjects demonstrating gingival inflammation were associated with presence of plaque due to poor oral hygiene performance. Therefore, the authors conclude that the personality traits might not have a direct relation with poor gingival health. A trend was observed to exist, i.e., group P, E, N subjects clinically correlated with poor oral hygiene status and subjects in group P and N clinically correlated with moderate gingivitis, while Group E subjects clinically correlated with severe gingivitis. This can be attributed to the presence of various confounding factors that have been shown in the past to have an influence on the oral health such as the difference in the level of education and socioeconomic status within the groups which was not assessed in the present study.[1617] It has been reported that gingival inflammation correlated significantly to E scores.[18] Stress associated with financial strain and distress usually manifested as depression was also identified as a significant risk indicator for more severe periodontal disease in adults.[19] It was found that the intensity of cynical hostility related positively to the level of oral hygiene when all confounding factors were adjusted[20] and cynical hostility to be a risk marker for poor oral health.[7] It should be noted that stress and depression and cynical hostility are some of the characters that define the high scores of neuroticism and psychoticism, respectively, among individuals. However, some investigators did not find any difference in neurosis or introversion levels between periodontal patients in their offices and norms acquired from large population studies.[21] Also, when assessing the gingival status and hygiene of the subjects in control group, majority (58.3%) exhibited moderate gingivitis and (58.3%) fair oral hygiene.

When assessing the data on personal habits that were recorded prior to the commencement of the study, it was observed that there was preponderance of using tobacco either smoking or smokeless form among Group P, E, N subjects. And, it was found that Group E subjects (14.6%) have a greater tendency for the same, whereas subjects in the control group did not report any such habit. Further studies can be carried out with different objectives to assess this association as it will aid during habit counseling and patient education. It was also observed that Group P, E subjects had lower brushing frequency. Various personality characteristics have shown in the earlier studies to affect the toothbrushing frequency and quality of brushing.[20] It can also be suggested that people who brush poorly or less frequently may have a strong motivation and eagerness to improve but lack confidence in their success. However, majority of the subjects enrolled for the study had visited the dentist before many of them demonstrated a poor gingival health. This further supports the fact that in addition to oral hygiene instructions, psychological intervention and motivation might play an important role as well in maintaining the gingival health.

CONCLUSION

A considerable clinical correlation was observed between the different personality traits and gingival health status of the subjects which was not statistically significant. Also, a trend of using tobacco and decreased brushing frequency was observed among subjects with certain personality traits. This study shows that the personality traits might not have a direct relation with poor gingival health. Further longitudinal studies need to be carried out to identify whether overall personality has a direct association with gingival health by controlling the various confounding factors that have an influence on oral hygiene and gingival health.