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 Table of Contents  
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 44-46

A case-control study assessing depression in patients with periodontitis

1 Department of Periodontics, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India
2 Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Suresh Rangarao
Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.200091

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Background: Chronic periodontitis is an inflammatory disease of the supporting structures of the tooth. One of the important non-oral risk factors for periodontitis is psychosocial stress and depression. Depression affects oral health by affecting the immune system through its effects on hypothalamic pituitary axis system. Periodontal inflammatory surface area (PISA) is a system used to assess inflammatory burden in the periodontal tissue. Aim: The aim of this study is to assess the relationship between PISA and depression. Settings and Design: The design of the study is case-control study. Materials and Methods: The study design is a case-control study with forty patients each in case and control groups. The periodontal inflammatory level was assessed by PISA system and the levels of depression was assessed by using Beck's Depression Inventory (BDI). Statistical Analysis: Student's t-test was used to compare PISA and BDI scores. The BDI score (mean ± standard deviation [SD]) for controls was 12.75 ± 6.82 compared to 22.73 ± 4.40 for the cases. The comparison (t = 7.78) was statistically significant at P < 0.0001. The PISA score (mean ± SD) for controls was 210.47 ± 76.80 compared to the PISA score of 1069.50 ± 204.21 for cases which was statistically significant (t = 24.90; P < 0.0001). Results: Significantly higher BDI scores were observed in patients with chronic periodontitis than healthy controls. Conclusion: This study clearly reveals a significant association between the severity of depression and inflammatory burden.

Keywords: Chronic periodontitis, depression, periodontal inflammatory surface area, stress

How to cite this article:
Sundararajan S, Muthukumar S, Rangarao S. A case-control study assessing depression in patients with periodontitis. Indian J Soc Psychiatry 2017;33:44-6

How to cite this URL:
Sundararajan S, Muthukumar S, Rangarao S. A case-control study assessing depression in patients with periodontitis. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Nov 26];33:44-6. Available from: https://www.indjsp.org/text.asp?2017/33/1/44/200091

  Introduction Top

Chronic periodontitis is a chronic inflammatory disease of infectious etiology caused by putative periodontal pathogens affecting the attachment apparatus of the tooth leading to attachment loss and eventually tooth loss.[1] However, studies have shown that bacterial infection alone is not sufficient to cause damage of periodontium.[2] The development of periodontitis and rate of development of disease vary between patients due to variation in host response. Genetics, obesity, diabetes mellitus, osteoporosis, and psychosocial factors are various nonoral risk factors causal to the progression of chronic periodontitits.[2] Psychosocial factors include depression and depressive symptoms, psychosocial stress, and traumatic life events. One among the important psychosocial factors is depressive disorders commonly called as clinical depression. Depression will be the second leading illness in the world by 2020 as projected by the World Health Organization.[3] One of the proposed mechanisms that associates psychological factors to periodontitis is negligent oral hygiene habits. It is based on the idea where depressed patients neglect oral hygiene and regular dental checkup due to lack of interest.[4] However, another important mechanism by which depression contributes to periodontal disease progression is by altering host immune response. The various mechanisms proposed to cause action of depression on host immune response includes hypothalamic-pituitary-adrenal axis, pro-inflammatory cytokines (interleukin-6), corticotrophin releasing hormone, natural killer cell activity, and C-reactive protein levels.[5] Periodontal inflammatory surface area (PISA) is a classification to assess the inflammatory burden in the inflamed periodontal tissue.[6] PISA is calculated based on clinical measurements of clinical attachment loss (CAL), gingival recession, and bleeding on probing (BOP) from six sites per tooth. The recorded values are entered onto a spreadsheet.[6] The spreadsheet yields the periodontal epithelial surface area and PISA values in mm 2. The PISA score is depicted as surface area of bleeding pocket epithelium in mm 2. It should be noted PISA scores is directly proportional to the amount of inflammation. There are various screening tools to assess depressive symptoms and to evaluate levels of depression. Beck's depression inventory (BDI) is self-reported scale and widely used because of it is inexpensive, simple, and understandable.[7]


The aim of the present study was to assess the role of depression in inflammatory periodontal disease.

  Materials and Methods Top

The study is a case-control study. It was approved by the Institutional Ethics Committee of Sri Ramachandra University, and informed consent was obtained from all the participants. Forty patients (aged between 25 and 55 years) each in case and control groups were included in the study [Table 1]. The cases and controls were taken from the Department of Periodontology, Sri Ramachandra University, Porur, Chennai. The cases and controls were matched based on demographic variables such as age, socioeconomic status, and systemic health. All the participants were systemically healthy and nonsmokers. The cases had to satisfy the American Academy of Periodontology criteria for periodontitis.[8] Control participants were selected in such a way that the CAL and probing depth (PD) was not more than 3 mm.
Table 1: Socio-demographic characteristics of cases and controls

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CAL, PD, and BOP was measured at six sites per tooth for all the patients. Chronic periodontitis is characterized by inflammation of gingiva extending into the attachment apparatus of the tooth. The diagnosis and extent of destruction of attachment apparatus around the tooth is measured by means of BOP, CAL, and PD with the help of a periodontal probe. BOP signifies the bleeding in an inflamed area around the tooth when probed. CAL and PD signifies the amount, extent, and severity of destruction of supporting structures of a tooth [8] when the PISA score was calculated based on the above measured values and with a spreadsheet obtained from www.parsprototo.info.[6] BDI scores were obtained from each participant by means of BDI, which is a self-reported questionnaire consisting of 21 questions. The questionnaire (BDI-II) was self-assessed by the participant. The score for each participant was arrived at by summing up the scores based on the response for each of the questions. One of the authors (SS) was trained to assessing depressive symptoms. The participants who were positive for depression were referred to the Department of Psychiatry, Sri Ramachandra University, Porur, Chennai. The cut-off score considered for depression was from a score of 17. The scores were interpreted and tabulated.

Statistical analysis

The statistical analysis was performed by means of SPSS software (Version 17.0 under windows 2000, SPSS Inc., Chicago, IL, USA). Student's t-test was used to determine the relationship between PISA and depression and the results were tabulated in [Table 2].
Table 2: Relationship between PISA scores and depression values

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  Results Top

The mean PISA score for controls was 210.47 ± 76.80 compared to the mean PISA score of 1069.50 ± 204.21 for cases which was statistically significant at P < 0.0001. The mean BDI score for controls was 12.75 ± 6.82 compared to the mean BDI score of 22.73 ± 4.40 which was statistically significant at P < 0.0001. The t value for PISA score was 24.90 and t value for BDI score was 7.78. In our study, it was found out that more the BDI score, more pronounced was the PISA score (inflammatory burden) [Table 2].

  Discussion Top

Chronic periodontitis has many risk factors. Out of which depression and stress also play an important role. The association between depression and chronic periodontitis is inconclusive inspite of numerous studies. Most of these studies have measured oral hygiene scores, PD or CAL which have interexaminer variability. Moreover, these studies have not measured inflammatory burden. To our knowledge this is the first study which measures inflammatory burden in periodontal tissue to study the relationship between depression and chronic periodontitis. PISA quantifies the inflammatory burden which has better reliability. There are several depression level measuring scales such as self-reported and observer rating scales. Observer rating system has the disadvantage of taking observer's experience into consideration.[9] Out of this, Beck's depression scale is self-reported and it was chosen for the study because it is simple, understandable and economical. Among the 40 cases, the average BDI score was 22.73 ± 4.40 and the corresponding PISA value was 1069.50 ± 204.21, which indicated the role of depression in chronic periodontitis. Thus, in the present study the cases have demonstrated an increased inflammatory burden which correlated with the increased BDI scores in these participants. Periodontitis is a chronic inflammatory disease and the biological plausibility linking it to various systemic diseases is based on the inflammatory burden caused by periodontitis and vice versa. The term quantifies the amount of inflammation and its systemic effects. This correlation can be attributed to the various mechanistic pathways which bring about changes in the immune system. It has been studied that depression enhances production of inflammatory cytokines notably interleukin-6 and C-reactive protein levels.[10],[11] Interleukin-6 is a potent inducer of corticotrophin releasing hormone leading to increased adrenocorticotropic hormone and eventually increased cortisol levels. There is a derangement in the hypothalamic-pituitary-adrenal axis. All these mechanistic pathways culminate in the increased inflammatory response in the host.

The results of our study are in agreement with previous studies which reveal a more exaggerated course of periodontitis in depressed patients.[12] Belting and Gupta, 1961 reported compromised periodontal status in patients with psychiatric illness when compared with controls.[13] BDI has been used as a tool to show that periodontal patients had a considerably higher total BDI score than normal controls.[14]

However the limitations of the present study are the small sample size and only depression was taken into account and not other psychiatric conditions. There could be many causes of depression in the sample, which could not be ascertained in this present study.[15] Other limitation of the study is that it is a single center experience in a urban setting which may limit the generalizability.

  Conclusion Top

The observations made in the present study clearly demonstrate the role of depression in the etiology and progression of inflammatory periodontal disease.

The above study emphasizes that the relationship between chronic periodontitis and depression is more biological than psychological or social. There are immune-based mechanistic pathways involving hypothalamic-pituitary-adrenal axis and cortisol production which will interfere with neutrophil and immunoglobulin function leading to an increased microbial invasion along with increased inflammation.[16] Oral health neglect and decreased preventive measures by depressed patients also adds up as a causative factor.[16] The positive associative studies have been found to be more compared to negative associative studies in a systematic review.[16] This study demonstrates the role of depression in the etiology and progression of inflammatory periodontal disease. The mechanistic links between these two entities needs more research and understanding at various levels.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Flemmig TF. Periodontitis. Ann Periodontol 1999;4:32-8.  Back to cited text no. 1
Offenbacher S. Periodontal diseases: Pathogenesis. Ann Periodontol 1996;1:821-78.  Back to cited text no. 2
Irwin MR, Miller AH. Depressive disorders and immunity: 20 years of progress and discovery. Brain Behav Immun 2007;21:374-83.  Back to cited text no. 3
Peruzzo DC, Benatti BB, Ambrosano GM, Nogueira-Filho GR, Sallum EA, Casati MZ, et al. A systematic review of stress and psychological factors as possible risk factors for periodontal disease. J Periodontol 2007;78:1491-504.  Back to cited text no. 4
Lutgendorf SK, Garand L, Buckwalter KC, Reimer TT, Hong SY, Lubaroff DM. Life stress, mood disturbance, and elevated interleukin-6 in healthy older women. J Gerontol A Biol Sci Med Sci 1999;54:434-9.  Back to cited text no. 5
Nesse W, Abbas F, van der Ploeg I, Spijkervet FK, Dijkstra PU, Vissink A. Periodontal inflamed surface area: Quantifying inflammatory burden. J Clin Periodontol 2008;35:668-73.  Back to cited text no. 6
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.  Back to cited text no. 7
Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol 2000 2004;34:9-21.  Back to cited text no. 8
Gorenstein C, Andrade L, Zuardi AW. Clinical valuation scales in psychiatry and psychopharmocology. 1st ed. São Paulo: Lemos Editorial; 2000. p. 438.  Back to cited text no. 9
Maes M, Bosmans E, De Jongh R, Kenis G, Vandoolaeghe E, Neels H. Increased serum IL-6 and IL-1 receptor antagonist concentrations in major depression and treatment resistant depression. Cytokine 1997;9:853-8.  Back to cited text no. 10
Zautra AJ, Yocum DC, Villanueva I, Smith B, Davis MC, Attrep J, et al. Immune activation and depression in women with rheumatoid arthritis. J Rheumatol 2004;31:457-63.  Back to cited text no. 11
Moss ME, Beck JD, Kaplan BH, Offenbacher S, Weintraub JA, Koch GG, et al. Exploratory case-control analysis of psychosocial factors and adult periodontitis. J Periodontol 1996;67 10 Suppl: 1060-9.  Back to cited text no. 12
Belting CM, Gupta OP. The influence of psychiatric disturbances on the severity of periodontal disease. J Periodontol 1961;32:219-26.  Back to cited text no. 13
Sundararajan S, Muthukumar S, Rao SR. Relationship between depression and chronic periodontitis. J Indian Soc Periodontol 2015;19:294-6.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
Mikolajczyk RT, Maxwell AE, Naydenova V, Meier S, El Ansari W. Depressive symptoms and perceived burdens related to being a student: Survey in three European countries. Clin Pract Epidemiol Ment Health 2008;4:19.  Back to cited text no. 15
Rosania AE, Low KG, McCormick CM, Rosania DA. Stress, depression, cortisol, and periodontal disease. J Periodontol 2009;80:260-6.  Back to cited text no. 16


  [Table 1], [Table 2]


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