Evaluation of relationship between stress and periodontal disease in different professional college students.

Background: To evaluate the association between stress and periodontitis in different professional college students. Subjects and
Methods: The study was conducted in 360 professional college students which includes Medical, Dental, Pharmacy, Nursing, Engineering, and Chartered Accountancy. From each group, 60 students were included in the study. Self-reported Depression, Anxiety, and Stress Scale questionnaire was given to all the students and clinical examination was conducted in all the participants to assess the Oral hygiene index - simplified (OHI-S), clinical attachment level (CAL), and Gingival Index Simplified (GI-S). Statistical Analysis: Statistics was performed using the ANOVA test, post hoc test, and Pearson correlation test to compare the psychological parameter of stress with periodontal parameters among six groups of students. P <0.05 was considered to be statistically significant.
Results: Group I showed higher mean stress scores (10.78 ± 0.76) compared to other groups. The mean OHI-S (1.61 ± 0.15), mean CAL (3.68 ± 0.79), and mean GI-S (1.43 ± 0.15) scores also increased with elevated stress levels among medical students. Followed by Group VI and Group II showed almost similar results.
Conclusion: The present study showed strong association between stress and periodontal disease and have an adverse effect over oral hygiene factors among the students. Copyright:

Periodontitis is defined as an inflammatory disease of supporting tissues of teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession, or both.[1]

College students often experience stress due to various reasons, of which educational demands also play a role.[2] Stress is subjective and relative; something that may be stressful for one person may not be stressful for another.[3] It is a state of physiological or psychological strain caused by adverse stimuli, physical, mental, or emotional, internal or external, that tend to disturb an organism's functioning and which the organism naturally desires to avoid.[4] The stress which is experienced by students may adversely affect their academic achievement, personal well-being, and long-term professional capabilities. Furthermore, acceleration of mental distress takes place, and it can have a negative impact on their cognitive functioning and learning.[5]

In response to various stressful stimuli, a sequence of events is initiated. This stress can result in the deregulation of the immune system, leading to periodontitis by two mechanisms stated by Genco are based on physiological response mediated by the HPA axis (Hypothalamo-Pituitary Axis), sympathetic–adrenal medullary axis, and others by the person's psychological behavior. An increased concentration of corticotropin-releasing hormone from the hypothalamus occurs following the HPA axis activation due to stress that in turn, acts on the adrenal cortex releases cortisol into the circulation, which produces a multitude of effects throughout the body. The second major pathway to be activated is the sympathetic nervous system, which releases catecholamines results in the adrenal medulla's activation for the secretion of norepinephrine and epinephrine, which results in a range of effects that may act to modulate immune responses, which shows flight or fight response to potentially harmful stimuli.[4]

Stress impairs the balance between pro-inflammatory and anti-inflammatory responses. Alterations in the levels of Gingival Crevicular Fluid, interleukin-1, interleukin-6 were mediated between stress and periodontal diseases which causes reduction in polymorphonuclear leukocyte chemotaxis, phagocytosis, reduced proliferation of lymphocytes.[6] Acute necrotizing ulcerative gingivitis, aggressive periodontitis, and latent herpes virus infection are the three conditions associated with periodontium that is severely affected by stress.[7]

Due to the various factors such as tight academic schedule, competition among the students who are designated as different professional students and they also suffer from the burden of achieving various targets between them contributing to psychological stress development. This excessive stress, in turn, increases the prevalence of psychological factors such as depression, anxiety. Literature suggests that psychological stress has a detrimental effect on oral health.[8] Hence, the Depression, Anxiety, and Stress Scale was designed to fill the gap in detecting common mental disorders.[9] One practical benefit of the Depression, Anxiety, Stress Scale-21 (DASS-21) is that it was designed as a single instrument to measure symptoms of depression, anxiety, and stress given by Lovibond and Lovibond.[1011] Hence, this study was aimed to evaluate the association between stress and periodontitis in different professional college students.

SUBJECTS AND METHODS

This study was approved by the Institutional Ethical Committee. The present study was conducted on 360 professional college students and the sample size was calculated using an effect size of 0.25 (small), alpha error-5%; power-95%; the number of groups-6. These 360 students were classified into six groups, each group consisting of 60 students. These students were taken from 6 different colleges in and around Guntur. The six groups included were Group 1-Medical, Group 2-Dental, Group 3-Pharmacy, Group 4-Nursing, Group 5-Engineering, Group 6-Chartered Accountancy.

The primary objective of this study remains to be evaluation of stress and its association with periodontal disease among students in professional colleges, the choice of study subjects from different academic disciplines was made to develop a preliminary insight into potential differences in stress, which is the exposure variable in this study, between academic groups and also its differential association with periodontal disease should there be any.

Criteria for selection of students

Students who were systemically healthy and pursuing their final year in the age group of between 20 and 30 years were included in this study. Students who received periodontal treatment in the last 6 months, had a habit of smoking and alcohol consumption, who used any medication (antibiotics, anxiolytics, anti-depressants) in the previous 6 months were excluded from the study.

Questionnaire

The DASS is the only self-report scale that measures all three negative emotional states, i.e. Depression, Anxiety, and Stress altogether. It is designed to maximize discrimination between the three components it measures. In clinical and community samples, DAS scale had shown high reliability that is compatible with allocating the items to subscales, exhibiting high validity with other measures of anxiety and depression. In the present study, we have used stress questionnaire in DASS-21, a short form of the DASS-42, and had many advantages over the full-length version, which includes it takes less time to complete, more consistent, the questions retained from the original version are generally superior to those excluded.[12]

Each component of the DAS scales contains seven items. So, only seven questions that were related to stress were selected. It also estimates difficulty relaxing, nervous arousal, and being easily agitated, irritable, and impatient. When completing the DASS-21, the respondent is required to present a symptom over the previous week. Each question has four specified alternative answers giving scores ranging from 0 to 3: Score 0-“never applied to me,” score 1 - “sometimes applied to me,” score 2 - “often applied to me,” and score 3 - “applied almost always to me.” Higher scores indicate greater stress levels in individuals.

Periodontal parameters

Along with the questionnaire, periodontal parameters like Oral hygiene index - simplified (OHI-S), clinical attachment level (CAL), GI-S were also assessed.

Procedure

A questionnaire was given to all the students included in the study, followed by clinical examination, wherein OHI-S, CAL, GI-S were assessed. The questionnaire duly filled by the participants should be given to the investigator in return once the clinical examination was completed.

Referral cards were issued to all the participating students who were found to have periodontitis to avail of oral health care at the corresponding teaching dental institutions.

Statistical analysis

Data were collected and entered into an MS Excel sheet, and results were analyzed using SPSS version software. Statistical analysis was performed using One-way ANOVA and Tukey's post hoc test with a value of P < 0.05 was considered to be statistically significant. One-way ANOVA test is used to test the differences in mean scores of DAS scale, OHI-S, CAL, GI-S between the groups. Tukey's Post-hoc test is a single-step multiple comparison test. It is used to find means that are significantly different from each other. Pearson's correlation test was performed to measure the linear correlation between two variables and has a value between +1 and −1.

RESULTS

The total number of participants who were subjected to analysis was 360. Data were collected from 6 academic streams, namely, Medical, Dental, Pharmacy, Nursing, Engineering, and Chartered Accountancy. The students who responded to the questionnaire were currently in their final year undergraduate with no gender discrimination. All the clinical parameters (OHI-S, CAL, GI-S) were evaluated with each group. The obtained data were subjected to appropriate statistical analysis, and results are discussed. The differences in the study parameters between the groups are shown in Table 1

Table 1

Differences in the study parameters between groups

Parameter	Group	n	Mean±SD	F	P
Stress	1	60	10.78±0.76	291.75	0.001*
	2	60	8.4±0.49
	3	60	4.1±2.03
	4	60	3.35±1.84
	5	60	3.4±2.03
	6	60	8.6±0.49
OHI-S	1	60	1.61±0.15	421.19	0.001*
	2	60	0.58±0.06
	3	60	0.31±0.17
	4	60	0.38±0.27
	5	60	0.25±0.17
	6	60	0.77±0.23
CAL	1	60	3.68±0.79	386.18	0.001*
	2	60	3.1±0.7
	3	60	0.63±0.39
	4	60	0.82±0.57
	5	60	0.6±0.46
	6	60	3.3±0.47
GI-S	1	60	1.43±0.15	421.94	0.001*
	2	60	0.55±0.15
	3	60	0.31±0.17
	4	60	0.32±0.18
	5	60	0.27±0.18
	6	60	0.6±0.15

*Denotes statistical significance. One way analysis of variance (ANOVA); P≤0.05 considered statistically significant. ANOVA – Analysis of variance; OHI-S – Oral hygiene index - simplified; CAL – Clinical attachment level; GI-S – Gingival index - simplified

Significant differences were observed between the study groups concerning mean stress, OHI-S, CAL, and GI-S scores (P ≤ 0.05). As significant differences between groups were found for stress, OHI-S, CAL, and GI-S, Tukey's post hoc tests were done.

Stress

The mean score of stress is found to be highest in Group 1 (10.78 ± 0.76), followed by Group 6 (8.6 ± 0.49); Group 2 (8.4 ± 0.49), and the least score was found in Group 4 (3.35 ± 1.84). According to the interpretation values by Lovibond and Lovibond,[1011] it was found that the medical students fall under the category of having a moderate level of stress and that of dental and Accountancy group students fall under the category of having mild stress. Other groups of academic students show normal stress [Table 1 and Figure 1].

Figure 1

Bar chart showing differences in mean stress scores between the study groups

OHI-S: The mean score of OHI-S is found to be highest in Group 1 (1.61 ± 0.15), followed by Group 6 (0.77 ± 0.23); group 2 (0.58 ± 0.06), and the least score was found in Group 5 (0.25 ± 0.17). Using interpretation values given by Green and Vermillion for OHI-S,[13] medical students showed fair oral hygiene scores while other groups showed good oral hygiene status in terms of debris and calculus deposits on teeth [Table 1].

Clinical attachment level

The mean score of CAL is found to be highest in Group 1 (3.68 ± 0.79), followed by Group 6 (3.3 ± 0.47); Group 2 (3.1 ± 0.7) and the least score was found in group 5 (0.6 ± 0.46). Using CAL scores,[14] Medical, Accountancy, and Dental students show stage II periodontitis, whereas other groups show no signs of periodontitis [Table 1].

GI-S: The mean score of GI-S is found to be highest in Group 1 (1.43 ± 0.15), followed by Group 6 (0.6 ± 0.15); Group 2 (0.55 ± 0.15), and the least score was found in group 5 (0.27 ± 0.18). In terms of GI-S scores, using interpretation values given by Loe,[15] moderate gingivitis was observed in medical students. In contrast, other groups showed mild gingivitis status of gingival conditions [Table 1].

The correlation and association between clinical parameters were shown in Table 2 by performing Pearson's correlation test. The correlation between stress and OHI-S showed a 0.86, and that of stress and CAL was found to be 0.92, with GI-S, 0.84 was observed. The correlation between OHI-S, and CAL, GI-S was found to be 0.77, 0.95, respectively, and that of CAL and GI-S was 0.77. All the scores showed a statistically significant strong correlation with a P ≤ 0.05.

Table 2

Correlation between the study parameters

	Stress	OHI-S	CAL	GI-S
Stress
Pearson correlation		0.86*	0.92*	0.84*
Significance (two-tailed)		0.002	0.001	0.033
OHI-S
Pearson correlation	0.86*		0.77*	0.95*
Significance (two-tailed)	0.002		0.000	0.000
CAL
Pearson correlation	0.92*	0.77*		0.77*
Significance (two-tailed)	0.001	0.000		0.000
GI-S
Pearson correlation	0.84*	0.95*	0.77*
Significance (two-tailed)	0.033	0.000	0.000

*Denotes statistical significance. Pearson’s correlation test; P≤0.05 considered statistically significant. OHI-S – Oral hygiene index - simplified; CAL – Clinical attachment level; GI-S – Gingival index - simplified

The scattered plot in Figure 2 shows the correlation between stress and OHI-S with R2-0.743, indicating that 74.3% of the variance in OHI-S was predicted by stress. Figure 3 shows the scattered plot representing the correlation between stress and CAL with R2-0.847, indicating that only 84.7% of CAL variance was predicted by stress.

Figure 2

Scatter plot showing the correlation between stress and Oral hygiene index - simplified scores

Figure 3

Scatter plot showing the correlation between stress and Clinical attachment level scores

DISCUSSION

Periodontitis is a chronic inflammatory disease in the periodontal tissue mediated by the host-associated plaque biofilms, leading to progressive destruction of tooth-supporting structures and loss of periodontal attachment. The bacteria present in the subgingival microbiota results in upregulated host immune-inflammatory response in the periodontal tissues characterized by increased production of inflammatory cytokines like interleukin, tumor necrosis factor-alpha, prostanoids like PGE2 and enzymes including MMP’s. These upregulated pro-inflammatory mediators are responsible for majority of periodontal tissue breakdown that occurs including alveolar bone resorption by the activation of osteoclasts. These changes result in the development of clinical signs of periodontal disease. The pathogenesis of the periodontal disease is modified mainly by local factors such as the presence of plaque and calculus, systemic diseases, and also environmental factors such as smoking and by genetic susceptibility.[1]

In the present study, the relationship between stress and periodontal disease has been evaluated using the DAS scale's stress component. The results of our study suggest that the psychological property of stress in DAS scale is more related to group 1 (Medical students) when compared to other groups and these results are in accordance with a study conducted by Moayedi et al., where they evaluated stress levels among medical, dental, pharmacy, and nursing students.[16]

Our study is following other studies conducted by Behere et al., where nursing students were least stressed compared to medical and engineering students;[17] Mayildurai et al. evaluated the stress among only engineering students and stated that they are distressed in a significant level.[18] Hou et al. stated that stress among accounting students might be due to 5 factors such as assistance, assessment, assignment, course difficulty, and presentation and career.[19] Nor et al. stated that 92.4% of accountancy students experience stress.[20] A study conducted by Kamble and Minchekar showed a positive correlation observed between stress and depression among college students.[21]

Study conducted by Murphy et al. showed that dental students experience more stress than medical students except in professional identity.[22] Taneja et al. stated that emotional distress is common among medical students.[23] Among dental students, clinical year students were more stressful than nonclinical year students was stated by Sravani et al.[12] Singh and Singh stated that professional students are more stressful than nonprofessional students.[24] Noureen et al. showed that stress in nursing students might be due to anxiety, fear of handling patient, solicitude, fear of distinction by teachers and staff.[25]

It has been stated that stress negatively influences oral health status.[2627] The present study revealed that OHIS, CAL, and GIS values were higher among medical students than in other groups. This increase in periodontal parameters was observed with increasing stress values. An increase in OHIS, CAL, GIS values was also evident, indicating that the students have poor oral hygiene practice under stressful conditions. A few studies suggest that students generally neglect their oral health care under conditions of stress, thereby showing poor oral status leading to periodontitis.[2829] These findings are in coincidence with the findings of our study. Similarly, another study conducted by Mahmood et al. suggested that there is strong evidence of an association between examination stress and periodontal parameters.[30]

The present study evaluated the relationship between stress and periodontitis by observing the correlation of stress with periodontal parameters, which was strong. In this study, even though there is an increased level of awareness of oral hygiene practices among dental students compared to other students, there was no difference in the periodontal parameters between them.

The role of potential confounders such as oral hygiene practices and deleterious habits cannot be ignored while attempting to ascertain such direct association. However, it can be hypothesized that oral hygiene practices and acquisition of deleterious habits can be directly influenced by the stress levels of the subjects and these factors have a mediating role to play in the association between stress and periodontitis.

Certain limitations of the present study include no clear demarcation on the type of stress that the student is facing. A self-reported questionnaire that the responders may or may not reveal their true experience of stress, heterogeneous sex distribution.

CONCLUSION

Of the six groups, medical students had shown higher values of both stress and periodontal parameters than other groups. The accountancy group and dental group showed almost similar results regarding stress and the evaluated clinical parameters. Therefore, it was concluded that psychological factors have an adverse effect on the student's oral hygiene factors. The worsening of periodontal parameters could be due to the student's negligence because of stressful conditions. Hence, education of students regarding the relationship between the stress-periodontal disease (oral hygiene), thereby avoiding the stress-induced factor behind the negligence of oral hygiene.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.