Pathological

Communication

Biosci. Biotech. Res. Comm. 10(2): 88-92 (2017)

Relationship between stress, anxiety, depression and

salivary IgA with periodontal disease

Mohammadreza Karimi

, Shahryay Elyahoo

*, Leyla Golchin

and Tahereh Kermani

Assistant Professor, Periodontics Department, Dental Branch, Islamic Azad University, Tehran, Iran

Post graduate student, Periodontics Department, Dental Branch, Islamic Azad University, Tehran, Iran

General Dentist

Psychiatrist

ABSTRACT

Psychological stress, if sustained over an extended period of time can have deleterious effects on the body. Psycho-

logical stress has been implicated as risk indicators for periodontal disease. So, the aim of the current study was to

determine the relationship of stress, anxiety and depression level and salivary IgA with periodontal disease. A total

30 patients who referred to periodontology included to the study and divided into 2 experimental groups. Group

control patients do not suffer from any periodontal disease and patients CAL up 3 millimeters or more and BOP in

upper teeth (case group). All cases were evaluated for stress, anxiety and depression level by DASS42 test. Salivary

samples were obtained using spitting method and IgA level is determined with ELISA. Data was analyzed by 2 and

Mendle-hazel tests. The patients suffering from periodontal disease were not encountering higher level of stress and

anxiety (P=0.3). People suffering periodontal disease (86.7%) were depressed while 60% of people neither periodontal

disease nor depressed (P=0.1). A signi cant difference detected in salivary IgA level in control group (312.66+107.3)

compared to case group (207.95+57.21) (P=0.001). Conclusion: these results suggested a correlation exists between

incidence of the periodontal disease and immunity.

KEY WORDS: PERIODONTAL DISEASE, STRESS, ANXIETY, DEPRESSION, IGA

ARTICLE INFORMATION:

*Corresponding Author:

Received 10

Jan, 2017

Accepted after revision 10

May, 2017

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Mohammadreza Karimi et al.

INTRODUCTION

Periodontal disease is a multifactorial disease. Dental

plaque which harbours speci c periodontal pathogens is

its main aetiologic factor. Numerous factors have been

associated with periodontitis, such as systemic diseases,

genetic polymorphisms, socio-economic and/or educa-

tional status, smoking and psychological stress. Stress is

considered as one of the essential factors with etiology

of the periodontal disease (Boyapati and Wang, 2007).

Psychological stress down regulates the cellular immune

response (Castro et al. 2006). There is interconnection

among the central nervous system and the immune sys-

tem which happens via a complex network of bidirec-

tional signals linking the nervous, endocrine, and immune

systems (Gundala et al. 2012 Shende et al. (2016).

Chronic stress has a net negative effect on the

immune response which leads to an imbalance between

host and parasites and consequently resulting in perio-

dontal break down (Radafshar et al. 2012). The potential

relationship between stress and oral in ammatory infec-

tious diseases is known for many years. A wide range of

biomarkers is measurable in saliva, including hormones

and their metabolites, enzymes, immunoglobulins (IgA),

other proteins (eosinophil cationic protein) and DNA

(Koh et al. 2007). Anxiety, depression, burnout and staff

turnover are correlated with several salivary biomarkers.

Chronic stress is associated with the activation of the

hypothalamic–pituitary–adrenal (HPA) axis, as well as

with the depression of immune function, mainly salivary

IgA and lysozyme (Heinrichs et al. 2005).

Periodontal disease and its progression associated with

psychosocial,  nancial stress and depression (Rosania et al.

2009). However, there are reports no association between

stress and periodontal disease. Therefore, more research is

needed to get a clearer understanding of this relationship

(Rai et al. 2011). So, the aim of the current study was to

determine the relationship of stress, anxiety and depres-

sion level and salivary IgA with periodontal disease.

MATERIAL AND METHODS

PATIENTS

For this case-control study, 30 patients (15 male and 15

female) referred to periodontology department, Islamic

Azad University, Dental Branch, Tehran, Iran during

2015 were included. The average age for the patients

was 42-44 years old. All patients were informed about

the study and signed the agreement form.

STUDY PROTOCOL

Two types of the patients were included into the study.

The criteria for control group were the patients who not

being periodontal disease and the case group were the

patients who suffer periodontal disease. Then patients

were divided into 2 experimental groups (n=15 in each).

Group control patients do not suffer from any periodon-

tal disease and patients CAL up 3 millimeters or more

and BOP in upper teeth (case group). The probing pocket

depth (PPD), clinical attachment level (CAL), plaque

index (PI), Gingival Index (GI) and bleeding on probing

(BOP) examinations were done. All cases were evaluated

for stress, anxiety and depression level by DASS42 test.

Salivary samples were obtained using spitting method.

Brie y, patients collected the oral cavity saliva for 5

minutes; collected into a sterile container ant -20˚C and

then IgA level is determined with enzyme-linked immu-

nosorbent assays (ELISA) detecting kits. To minimize

experimental error, all experimental procedure was done

at 11:00 AM until 13:00 PM.

STATISTICAL ANALYSIS

Data analyzed by repeated measure two-way analysis of

variance (ANOVA) using SPSS 16.0 for Windows (SPSS,

Inc., Chicago, IL, USA). For treatment showing a main

effect by ANOVA, means were compared by 2 and

Mendle-hazel tests. Data is presented as mean ± stand-

ard deviation. P<0.05 was considered as signi cant dif-

ferences between treatments.

RESULTS

The demographic information of the patients included

into the study is presented in the table 1. According to

the results, there was no signi cant difference for gen-

der, age and educational level among the control (with-

out periodontal disease) and case (with periodontal dis-

ease) groups.

As seen in table 2, no signi cant difference detected

for PDD and PI indexes in control compared to the

Table 1. the demographic information of the patients included into the study

Gender Age (years) Education level

Periodontal disease Male Female Diploma < Diploma University

Control (n=15) 9 6 42.4±5.4 8 6 1

Case (n=15) 9 6 44.53±8.4 3 10 2

P value 0.09 0.4 0.8

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS RELATIONSHIP BETWEEN STRESS, ANXIETY, DEPRESSION AND SALIVARY IGA WITH PERIODONTAL DISEASE 89

Mohammadreza Karimi et al.

Table 2. The frequency of the Periodontal disease index

among patients

Experimental groups

Control (n=15) Case (n=15) P value

PPD (mm) 1.8 ± 0.7 2.7 ± 0.4 P=0.05

CAL (mm) 0 3.002 ± 0.6 P=0.001

PI (%) 61.8 ± 27.2 75.6 ± 22.9 P=0.4

GI 1.02 ± 0.5 2.1 ± 0.7 P=0.001

BOP (%) 10.3 ± 10.5 20.5 ± 10.4 P=0.001

PPD: probing pocket depth; CAL: clinical attachment level; PI: plaque

index; GI: Gingival Index; BOP: bleeding on probing.

Table 3. The correlation between stress, depression and salivary IgA levels with periodontal disease

Experimental groups

Factors Control (n=15) Case (n=15) P value

Stress

No 5 (33.3) 4 (26.6)

P=0.9

Yes 10 (66.7) 11 (73.4)

Anxiety

No 6 (40) 3 (20)

P=0.3

Yes 9 (60) 12 (80)

Depression

No 6 (40) 2 (13.3)

P=0.1

Yes 9 (60) 13 (86.6)

Salivary IgA - 312.66+107.3 207.95+57.21 P=0.001

case groups, P=0.05 and P=0.4, respectively. However,

a signi cant difference detected for CAL (P=0.001),

GI (P=0.001) and BOP (P=0.001) indexes between two

groups.

The correlation between stress, anxiety, depression

and salivary IgA levels with periodontal disease is pre-

sented in table 3. According to the results, there was no

signi cant difference on stress (P=0.9), anxiety (P=0.3)

and depression (P=0.1) in control compared to the case

groups. However, a signi cant difference detected in

salivary IgA levels in control compared to the case

groups (P=0.001).

DISCUSSION

Periodontitis is an in ammatory disease caused by peri-

odontopathic bacteria in the dental bio lm, leading to

destruction of the tooth supporting tissues. Systemic dis-

eases, habits, social factors, and psychological stress are

considered risk factors in uencing disease incidence and

progression. Although psychological stress was found to

be an important risk factor for periodontitis, the biologic

mechanisms of its implication for disease progression is

not fully elicited (Haririan et al. 2012).

In this study patients suffering from periodontal dis-

ease were not encountering higher level of stress and

anxiety. People suffering periodontal disease (86.7%)

were depressed while 60% of people neither periodontal

disease nor depressed. There are several factors included

age, smoking, systemic diseases and psychological stress

which are important risk factors for periodontitis (Ishi-

saka et al. 2007). In this regard, De Marco (1976) coined

the term “Periodontal Emotional Stress Syndrome” for

individuals with severe periodontitis who had emotional

stress associated with active service in Vietnam suggest-

ing a role of occupational stress in the progression of

periodontitis.

Periodontitis patients with inadequate stress behav-

iors strategies were suggested to be at higher risk for

severe periodontal diseases (Wimmer et al. 2002). Lit-

erature reported the relationship between stress, depres-

sion and periodontal disease are signi cant because they

address critical areas of interest surrounding an impor-

tant perio–systemic connection (Peruzzo et al. 2007).

During stress, the HPA axis and sympathetic nervous

system interact which leads to up-surge of the glucocor-

ticoid and increases the susceptibility of the periodon-

tal diseases (Bansal et al. 2014). The mediating effect

of chronic stress on periodontium can be explained by

diminished immune response which causes release of

local neuropeptides such as substance P and neurokinin

A, may provide a mechanism for neural modi cation

of in ammatory changes in the periodontium (Linden

et al. 1998).

In the current study, no signi cant difference detected

for the PDD and PI indexes in control compared to the

case group while a signi cant difference detected for

CAL, GI and BOP indexes between two groups. Shende et

al. (2016) no signi cant differences showed on PI, prob-

ing depth, CAL among the subjects with varying levels

of stress. There was no statistical signi cance for stress

to be contributing toward the periodontal disease. Saliva

testing is a novel, quick, painless, non-invasive diag-

nostic method for various diseases, in particular for oral

diseases (Giannobile et al. 2009). There are numerous

speci c and nonspeci c biomarkers affecting the bio lm

which is a plaque formed by aggregates of proteins and

90 RELATIONSHIP BETWEEN STRESS, ANXIETY, DEPRESSION AND SALIVARY IGA WITH PERIODONTAL DISEASE BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Mohammadreza Karimi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS RELATIONSHIP BETWEEN STRESS, ANXIETY, DEPRESSION AND SALIVARY IGA WITH PERIODONTAL DISEASE 91

micro bacterium. The major speci c defense factors of

saliva are the IgA, IgG, and IgM (Sindhu and Jagan-

nathan, 2014).

The adherence of bacteria and bacterial metabolism

interfered in presence of the immunoglobulins, particu-

larly with the IgA type. Many biomarkers have been

found in saliva and some of these were shown to be

involved in periodontal disease (Giannobile et al. 2009).

The salivary concentrations of these immunoglobulins

increase in periodontitis which decreases following peri-

odontal therapies (Sindhu and Jagannathan, 2014). As

seen in this study, salivary IgA decreased in periodontal

patients compared to the normal people (without peri-

odontal disease). These results suggested a correlation

exists between incidence of the periodontal disease and

immunity. In condition pain, anxiety and stress, many

metabolic and endocrine changes occur in the body,

the most common effect of which is increased cortisol

level in the blood. It plays a role in the regulation of the

immune system and vascular reactions. Also known as

the stress hormone, cortisol is a decisive index in stress-

ful situations (Ismail et al. 2007). One of the likely mech-

anisms of such relationship is activation of the HPA axis

following stressful life events, which leads to elevation

of cortisol concentrations in gingival crevicular  uid,

serum, and other body  uids. Leukocytic, chemotactic,

polymorphonuclear leukocytes, IgG production and sali-

vary IgA secretion are considerably declined by contin-

ued elevation in cortisol concentrations, placing the host

in an immunosuppressive status, hence more vulnerable

to periodontal infection and breakdown (Wong, 2008).

The IgA level measurement is a reliable method to

determine the immune system function (Shah et al. 2009).

Chronic stress decreases the immune system performance

and suppresses the immunoglobulin production. So, the

IgA levels play a role in the pathogenesis of oral mucosa

and its associated clinical changes (Rabiei et al. 2012).

The IgA and IgG levels Increased in patients with lichen

planus (Sistig et al. 2002) and lichenoid reaction Lesions

(Ghalayani et al. 2009). Also, Sato et al. (1991) studies

compared the salivary IgA level in patients with differ-

ent oral diseases using the ELISA method. An increase

in the salivary IgA level was observed in patients with

oral leukoplakia, oral lichen planus and carcinoma of

the oral cavity. Higher IgA levels facilitate the antigen

supply by Langerhans cells, make changes in the basal

layer destruction and dispatch immune cells to the area

(Nosratzehi et al. 2014). Furthermore, Salivary IgA lev-

els in uenced by mental stress and several studies have

suggested a negative correlation between the levels of

salivary IgA and stress (Fukui et al. 2010). Despite the

mechanism for how Salivary IgA affects by mental stress

is not fully elicited, it is reported Chromogranin A is

an acidic glycoprotein which is released along with cat-

echolamines from the adrenal medulla and the sympa-

thetic nerve endings, and has been receiving attention

as a novel stress marker in the saliva (Fukui et al. 2010).

In conclusion these results suggested a correlation

exists between incidence of the periodontal disease and

immunity. We think obtained results can use as informa-

tion for clinical applications in human therapies. Also,

we think further researches is needed to determine the

direct molecular and cellular mechanism for observed

data.

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