Abstract
Objective
Depression leads to behavioral and systemic changes making individuals more susceptible to inflammatory diseases. This study was conducted to assess the periodontal status of patients with clinically diagnosed mild and moderate depression.
Subjects and Methods
This cross-sectional study included 135 participants. Test group 1 (n = 45) consisted of patients clinically diagnosed with mild depression, test group 2 (n = 45) included patients with moderate depression and the control group (n = 45) included non-depressive participants. Sociodemographic characteristics and periodontal parameters were recorded.
Results
Plaque levels and gingival inflammation were significantly (p < 0.05) higher in mild and moderate depression patients than in controls. Significant greater number of sites with bleeding on probing, increasing probing pocket depth (PPD), sites with PPD 4–5 mm, ≥6 mm, attachment loss 3–4 mm, and high prevalence with grade C periodontitis were observed in moderate depression patients, compared to patients with mild depression and healthy controls. On applying partial correlation, periodontal parameters were positively correlated with depression, while a negative correlation was found with income status. On regression analysis, bleeding on probing as a dependent variable was also associated with depression.
Conclusions
Patients with moderate depression showed high periodontal destruction and inflammation as compared to those with mild depression. Further, deep pockets were associated with depressive patients. Periodontal care is required in such patients so that the progression of periodontal diseases can be prevented at the earliest.
Keywords: Chronic periodontitis, Depression, Inflammation, Oral health
Highlights of the Study
Depression leads to systemic and behavioral changes which increase susceptibility to infections.
Periodontal parameters were significantly higher in patients with depression.
Sites with bleeding were found to be significantly greater in patients with moderate depression as compared to those with mild depression.
Introduction
Depression, a psychological disorder, is classified as the third main cause of global disability, affecting 4.4 percent of the world population [1]. It is a disorder with multiple etiologic factors presenting with most typical symptoms like depressed mood, loss of enjoyment in previously pleasurable activities, and lack of energy. It leads to alteration of the hypothalamus-pituitary-adrenal axis which can suppress as well as activate the immune system [2]. Depression is also an important risk factor for many systemic conditions including chronic inflammatory diseases [3], and periodontitis may be one of them. Periodontal diseases are chronic inflammatory diseases, with microbial plaque as the primary etiological factor. Oral bacterial biofilms may trigger immune-inflammatory responses which can affect other organ systems of body [4] including the nervous system.
Studies have found an association between negative life events and poor oral health status [5, 6]and some studies have demonstrated the impact of oral health conditions on depression [7, 8]. Consideration of self-reported depression, secondary data, and use of different case definitions of periodontitis limit the validity of results of these studies. Further, a study reported that diagnosed depression, rather than self-reported depression, acts as a risk factor for periodontitis, [9]. On the contrary, some studies failed to show any relationship between psychosocial factors and periodontal status [10, 11]. Depression has been classified into mild, moderate, and severe episodes based on the severity [12]. No study to date, to the best of our knowledge, has investigated the association of periodontal status with mild and moderate types of clinically diagnosed depression.
Depression increases the susceptibility to infections due to dysregulated immune-inflammatory responses, thus it is necessary to consider the effect of even the mild form of depression on periodontal tissues. The present study was conducted to investigate the association of mild and moderate episodes of depression with periodontal status in newly diagnosed patients with depression compared with healthy controls.
Subjects and Methods
The present study was a single blind, cross-sectional observational study conducted in the Department of Periodontology, Post Graduate Institute of Dental Sciences (PGIDS), Rohtak, India in collaboration with the Department of Psychiatry, Post Graduate Institute of Medical Sciences (PGIMS), Rohtak. The study period was from April 2020 to November 2021; the Ethics Committee of PGIDS, Rohtak approved the study. Participants were recruited consecutively from the Outpatient Department of the Department of Psychiatry, PGIMS, and the Department of Oral Medicine and Radiology, PGIDS, Rohtak (Fig. 1).
Fig. 1.
Flow chart of the study.
Inclusion criteria were subjects 18–50 years of age, new clinically diagnosed participants having mild and moderate depression according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10 criteria) [12]otherwise systemically healthy, not yet started medication for depression, having ≥20 natural teeth. Systemically healthy participants without depression were enrolled in a control group. Exclusion criteria were individuals with any systemic disease or condition affecting periodontal disease, including diabetes mellitus, osteoporosis, rheumatoid arthritis, chronic renal failure, cardiovascular disease, and pregnancy, having undergone treatment with medicines in the previous 3 months, patients having any other psychiatric disorders, such as organic mental disorders, disorders as a result of psychoactive substance use, schizophrenia and schizoaffective disorder, delirium, delusion, dementia, eating disorders, type 1 or 2 bipolar disorder, neurotic disorder, psychotic depression, patients having treatment with any antidepressant drug, patients having received any nonsurgical or surgical periodontal treatment within the previous 6 months.
A sample size of 135 participants was calculated using G Power software with the effect size of 0.6, α value 0.05, power 80% with allocation ratio of 1:1 to investigate the difference among primary parameters among three groups with 45 participants in each group. 135 participants were enrolled in three groups as follows: test group 1 (n = 45), newly diagnosed participants with mild depression otherwise systemically healthy; test group 2 (n = 45), newly diagnosed participants with moderate depression otherwise systemically healthy; control group (n = 45), systemically healthy participants with no depression.
Systemic health/systemic diseases were assessed and ruled out by taking detailed personal and family history and by investigations if necessary. Participants with depression were diagnosed clinically by a psychiatrist (PJ) and assessed on the same day for periodontal examination. The investigator (AK) assessing the periodontal parameters was not aware of the groups to which the patient belonged. The study procedure was explained to the participants in their own language and written informed consent was obtained from all participants.
Sociodemographic characteristics recorded were age, gender, income per capita (as total household monthly income divided by number of family members), education status (illiterate, primary, middle, secondary, higher secondary, college), occupational status (employed, unemployed), marital status (married living with family{M/family}, married living alone{M/alone}, unmarried living with family{UM/family}, unmarried living alone{UM/alone}, divorced or widowed living with family{div-wid/family}, divorced or widowed living alone{div-wid/alone}), history of smoking, alcohol, brushing frequency {twice daily, once daily, less frequently, no brushing}. Family history of depression was also recorded.
Periodontal parameters were recorded; full mouth periodontal parameters recorded were plaque index (PI) [13], gingival index (GI) [14], percentage of bleeding sites on probing (BOP %), probing pocket depth (PPD), and clinical attachment loss (AL) at six sites per tooth using manual periodontal probe (PCP-UNC 15, Hu-Friedy Manufacturing Co., Chicago, IL, USA). Periodontal phenotype was recorded as thick and thin using probe transparency method [15]and gingival recession (distance of gingival margin from cementoenamel junction reflecting exposure of root) was also recorded. Further, the number of sites having probing depth ≤3 mm, 4–5 mm, ≥6 mm and clinical AL of 1–2 mm, 3–4 mm, ≥5 mm was recorded. Patients were categorized into periodontally healthy, gingivitis, and periodontitis case [16]. Further staging and grading were determined on the basis of clinical and radiographic findings (intraoral peri-apical radiographs were taken for worst affected tooth with paralleling technique to assess the bone levels) [16]. Other clinical parameters recorded were number of missing teeth, tooth loss due to periodontitis, carious teeth, and cervical abrasion. Intra-examiner reproducibility was assessed by repeating the PPD and AL measurements 48 h apart on 10 randomly selected individuals prior to initiation of this study. Assessment of reproducibility was with 90% accuracy with kappa value 0.84 for PPD and 0.81 for AL, respectively. Similarly, intra-examiner reproducibility was also checked for other parameters such as PI (kappa value 0.83), GI (kappa value 0.86), and BOP (kappa value 0.89).
Statistical Analysis
Normality of data was analyzed using Shapiro-Wilk test and data followed non-normal distribution. Differences among the groups for continuous variables were assessed using nonparametric tests, Kruskal-Wallis followed by Mann-Whitney U test, applied between two groups. For categorical variables, differences were assessed using χ2 test. Partial correlation analysis was applied on pool data of all patients among all the parameters by controlling smoking and PI as a confounding variable. To rule out possible confounding effects of smoking, generalized estimation equation (GEE) analysis was also done. Association of dependent variable with independent variables was also analyzed by applying multiple linear regression analysis.
Results
135 participants meeting eligibility criteria (45 in each group) completed the study protocol. Table 1 shows similar distribution for age, gender, education status, occupation, alcohol intake, and smoking in all the three groups. Income of patients with moderate depression was significantly less as compared to patients with mild depression and controls (p < 0.05) while income of mild depression and control group patients were comparable. Brushing frequency was significantly less in depressive patients when compared with control group (p < 0.05). No significant difference was found in brushing frequency between patients with mild and moderate depression. Regarding brushing method, no significant differences were found between the three groups. Significantly more patients with depression were using a hard toothbrush as compared to healthy controls.
Table 1.
Sociodemographic characteristics and oral hygiene maintenance history comparison of study population
| Parameters | Control group (n = 45) | Test group 1 (n = 45) (mild depression) | Test group 2 (n = 45) (moderate depression) | p value (Kruskal-Wallis) |
|---|---|---|---|---|
| Agea | 35.37±10.02 | 35.33±9.94 | 37.06±10.21 | 0.643 |
| Incomea | 9,961.62±7,110.14 | 7,504.44±5,557.63 | 3,972.44±3,502.44 | 0.000b |
| Genderc | ||||
| Female | 23 (51.11%) | 25 (55.56%) | 24 (53.33%) | 0.915 |
| Male | 22 (48.89%) | 20 (44.44%) | 21 (46.67%) | |
| Marital statuscde | ||||
| M/family | 36 (80%) | 31 (68.89%) | 33 (73.33%) | 0.003b |
| M/alone | 0 (0%) | 2 (4.44%) | 0 (0%) | |
| UM/family | 9 (20%) | 4 (8.89%) | 1 (2.22%) | |
| UM/alone | 0 (0%) | 8 (17.78%) | 7 (15.56%) | |
| div-wid/family | 0 (0%) | 0 (0%) | 2 (4.44%) | |
| div-wid/alone | 0 (0%) | 0 (0%) | 2 (4.44%) | |
| Educationc | ||||
| Illiterate | 2 (4.44%) | 1 (2.22%) | 2 (4.44%) | 0.063 |
| Primary (fifth) | 0 (0%) | 2 (4.44%) | 3 (6.67%) | |
| Middle (eighth) | 4 (8.89%) | 6 (13.33%) | 6 (13.33%) | |
| Secondary (tenth) | 5 (11.11%) | 13 (28.89%) | 15 (33.33%) | |
| Higher secondary (12th) | 7 (15.56%) | 6 (13.33%) | 9 (20%) | |
| College | 27 (60%) | 17 (37.78%) | 10 (22.22%) | |
| Occupationc | ||||
| Employed | 20 (44.44%) | 18 (40%) | 16 (35.56%) | 0.690 |
| Unemployed | 25 (55.56%) | 27 (60%) | 29 (64.44%) | |
| Smoking statusc | ||||
| Yes | 7 (15.56%) | 14 (31.11%) | 14 (31.11%) | 0.151 |
| No | 38 (84.44%) | 31 (68.89%) | 31 (68.89%) | |
| Alcohol intakec | ||||
| Yes | 6 (13.33%) | 13 (28.89%) | 12 (26.67%) | 0.165 |
| No | 39 (86.67%) | 32 (71.11%) | 33 (73.33%) | |
| Family history of depressionc | ||||
| Yes | 0 (0%) | 31 (68.89%) | 24 (53.33%) | 0.000b |
| No | 45 (100%) | 14 (31.11%) | 21 (46.67%) | |
| Brushing frequencycde | ||||
| Twice daily | 11 (24.44%) | 4 (8.89%) | 3 (6.67%) | 0.001b |
| Once daily | 32 (71.11%) | 27 (60%) | 24 (53.33%) | |
| Less frequently | 2 (4.44%) | 13 (28.89%) | 18 (40%) | |
| No brushing | 0 (0%) | 1 (2.22%) | 0 (0%) | |
| Brushing methodc | ||||
| Horizontal | 21 (46.67%) | 24 (53.33%) | 32 (71.11%) | 0.06 |
| Vertical | 24 (53.34%) | 10 (22.22%) | 13 (28.89%) | |
| Type of toothbrushcdef | ||||
| Soft | 21 (46.67%) | 28 (62.22%) | 13 (28.89%) | 0.000b |
| Medium | 23 (51.11%) | 12 (26.67%) | 20 (44.44%) | |
| Hard | 1 (2.22%) | 4 (8.89%) | 12 (26.67%) |
Mann-Whitney U-test.
Statistically significant (p < 0.05).
χ2 test.
(p < 0.05) for control group versus. test group 1.
Control group versus test group 2 (p < 0.05).
Test group 1 versus test group 2.
Table 2 presents periodontal parameters of all the groups of the study population. Plaque levels and gingival inflammation score were significantly (p < 0.05) higher in depression group patients than in the control group. These scores were comparable for patients with mild and moderate depression. A significantly greater percentage of sites with BOP and increased pattern of mean PPD were observed in patients with moderate depression as compared to patients with mild depression and healthy controls (p < 0.05). Similarly, patients with mild depression also presented with significantly more bleeding sites and probing depth as compared to control subjects. Mild and moderate depression groups presented with significantly greater mean AL as compared to healthy controls.
Table 2.
Periodontal parameters of study population
| Parameters | Control group (n = 45) |
Test group 1 (mild depression) (n = 45) |
Test group 2 (moderate depression) (n = 45) |
p value (using Kruskal-Wallls test) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| mean ± SD | median | 95% CI | mean ± SD | median | 95% CI | mean ± SD | median | 95% CI | ||
| PI (score) | 0.95±0.25 | 1.01 | 0.87–1.03 | 1.22±0.33a | 1.13 | 1.12–1.32 | 1.34±0.44b | 1.30 | 1.20–1.47 | 0.000c |
| GI (score) | 1.07±0.44 | 1.05 | 0.94–1.21 | 1.34±0.39a | 1.25 | 1.22–1.45 | 1.47±0.42b | 1.35 | 1.34–1.60 | 0.000c |
| BOP (% sites) | 31.04±27.63 | 19.01 | 22.02–39.00 | 54.71±32.07a | 51.00 | 45.07–64.34 | 79.31±25.52bd | 88.00 | 71.64–86.98 | 0.000c |
| PPD (mm) | 1.96±0.35 | 1.95 | 1.86–2.07 | 2.32±0.39a | 2.31 | 2.20–2.44 | 2.79±0.63bd | 2.60 | 2.60–2.98 | 0.000c |
| CAL (mm) | 0.41 ±0.48 | 0.31 | 0.027–0.56 | 0.69±0.43a | 0.64 | 0.56–0.83 | 1.06±0.97b | 0.71 | 0.77–1.35 | 0.000c |
Statistically significant on comparison between control group and test group 1 using Mann-Whitney U test.
Statistically significant on comparison between control group and test group 2 using Mann-Whitney U test.
Statistically significant (p < 0.05).
Statistically significant on comparison between test group 1 and test group 2 using Mann-Whitney test.
A significantly greater proportion of patients with moderate depression presented with thick periodontal phenotype as compared to thin phenotype while more patients with mild depression presented with thin periodontal phenotype as compared to thick phenotype (Table 3). The number of teeth with gingival recession was significantly greater in patients with mild depression when compared to patients with moderate depression (p < 0.05). The prevalence of periodontitis is significantly greater in the depression group as compared to the control group (p < 0.05) while it is similar in the mild and moderate groups (p > 0.05). Different stages of periodontitis were comparable among three groups. The prevalence of grade C periodontitis is higher in patients with moderate depression and the prevalence of grade B is higher in the mild and moderate depression groups as compared to the control group. The percentage of sites with PPD 4–5 mm and ≥6 mm was significantly higher in patients with moderate depression when compared to patients with mild depression and control groups. The proportion of sites with AL 3–4 mm and ≥5 mm was significantly higher in patients with moderate depression when compared to the control group.
Table 3.
Distribution and comparison of periodontal condition variables of study population
| Parameters | Control group (Mean ± SD) No depression | Test group 1 (Mean ± SD) Mild depression | Test group 2 (Mean ± SD) Moderate depression | Control group versus test group 1 | Control group versus test group 2 | Test group 1 versus test group 2 | ||
|---|---|---|---|---|---|---|---|---|
| Periodontal phenotypea | Thick | 42 (93.33%) | 33 (73.33%) | 45 (100%) | 0.011b | 0.078 | 0.000b | |
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| Thin | 3 (6.67%) | 12 (26.67%) | 0 (0%) | |||||
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| Teeth with Gingival recessionc (%) | 7.12±16.6 | 9.07±13.7 | 5.66±15.85 | 0.239 | 0.455 | 0.049b | ||
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| Periodontal statusa (n = 135) | Periodontally healthy | 10 (22.22%) | 0 (0%) | 0 (0%) | 0.002b | 0.003b | 0.153 | |
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| Gingivitis | 1 (2.22%) | 0 (0%) | 2 (4.44%) | |||||
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| Periodontitis | 34 (75.56%) | 45 (100%) | 43 (95.56%) | |||||
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| Periodontitis staginga (n = 122) | Stage I | 17 (50%) | 17 (37.78%) | 13 (30.2%) | 0.311 | |||
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| Stage II | 11 (32.35%) | 15 (33.33%) | 11 (25.5%) | |||||
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| Stage III | 4 (11.76%) | 7 (15.55%) | 10 (23.2%) | |||||
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| Stage IV | 2 (4.44%) | 6 (13.33%) | 9 (20.93%) | |||||
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| Periodontitis gradinga (n = 122) | Grade A | 30 (88.23%) | 30 (66.67%) | 23 (53.49%) | 0.022b | 0.005b | 0.031b | |
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| Grade B | 3 (8.82%) | 15 (33.33%) | 14 (32.56%) | |||||
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| Grade C | 1 (2.94%) | 0 (0%) | 6 (13.95%) | |||||
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| Missing teethc (%) | 4.66±7.00 | 6.09±7.81 | 5.54±8.70 | 0.328 | 0.922 | 0.355 | ||
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| Number of teeth lost due to periodontitisc | 2.5±2.34 | 3.0±2.0 | 4.09±1.97 | 0.569 | 0.200 | 0.244 | ||
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| % sites with PPD ≤3 mmc | 97.0±4.83 | 93.3±7.36 | 80.58±21.20 | 0.002b | 0.000b | 0.002b | ||
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| % sites with PPD 4–5 mmc | 2.70±5.39 | 5.96±6.64 | 15.53±15.02 | 0.001b | 0.000b | 0.002b | ||
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| % sites with PPD ≥6 mmc | 0.12±0.52 | 0.36±1.15 | 2.68±4.82 | 0.119 | 0.000b | 0.001b | ||
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| % sites with CAL 1–2 mmc | 22.84±17.38 | 40.25±16.25 | 43.47±17.06 | 0.000b | 0.000b | 0.164 | ||
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| % sites with CAL 3–4 mmc | 3.88±10.59 | 5.3±8.23 | 11.64±15.03 | 0.017b | 0.001b | 0.110 | ||
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| % sites with CAL ≥5 mmc | 0.42±1.12 | 0.23±1.8 | 3.82±13.03 | 0.088 | 0.032b | 0.560 | ||
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| Carious teethc (%) | 3.22±4.58 | 4.37±5.5 | 6.23±7.87 | 0.312 | 0.104 | 0.482 | ||
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| Cervical abrasionc (%) | 1.91±5.15 | 5.58±1.43 | 1.34±3.49 | 0.246 | 0.901 | 0.285 | ||
χ2 test.
Statistically significant (p < 0.05).
Mann-Whitney U test.
Table 4 depicts results of partial correlation analysis after controlling PI and smoking as confounders. A significant positive correlation was found among mean GI, BOP, PPD, PPD 4–5 mm, ≥6 mm, and AL 1–2 mm and patients with depression. A significant negative correlation was found for income status with depression. BOP, when considered as a dependent variable, was positively associated with GI, PPD, and depression as independent variables (Table 5). Also, the results of GEE showed no significant (p = 0.483) effect of smoking on BOP.
Table 4.
Partial correlation after controlling PI and smoking as confounding variables
| Parameters | Income per capita | GI | BOP | PPD | CAL | Missing teeth (MT) | Carious teeth (CT) | Cervical abrasion (CA) | Gingival recession (GR) | PPD ≤3 mm (% sites) | PPD 4-5 mm (% sites) | PPD ≥6 mm (% sites) | CAL 1-2 mm (% sites) | CAL 3-4 mm (% sites) | CAL ≥5 mm (% sites) | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Group | Correlation | −0.334 | 0.171 | 0.471 | 0.464 | 0.168 | −0.044 | 0.155 | −0.083 | −0.196 | −0.296 | 0.329 | 0.174 | 0.370 | 0.141 | −0.017 |
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| Significance (two tailed) | 0.000a | 0.049a | 0.000a | 0.000a | 0.053 | 0.614 | 0.075 | 0.341 | 0.023a | 0.001a | 0.000a | 0.045a | 0.000a | 0.107 | 0.846 | |
Statistically significant (p < 0.05).
Table 5.
Association of BOP (dependent variable) with depression and other periodontal parameters (GI, PPD) as independent variables using linear regression analysis
| Dependent variable | Unstandardized coefficients |
Standardized coefficients | T | Sig | R 2 | 95% confidence interval | ||
|---|---|---|---|---|---|---|---|---|
| β | std. error | |||||||
| BOP | (Constant) | −0.434 | 0.508 | −0.854 | 0.395 | 0.73 | −1.441 to 0.573 | |
| PI | 0.046 | 0.071 | 0.051 | 0.615 | 0.516 | 0.38 | −0.094 to 0.186 | |
| GI | 0.252 | 0.059 | 0.328 | 4.302 | 0.000a | 18.51 | 0.136 to 0.368 | |
| PPD | 0.255 | 0.095 | 0.430 | 2.679 | 0.008a | 7.18 | 0.066 to 0.444 | |
| CAL | −0.051 | 0.145 | −0.107 | −0.351 | 0.726 | 0.12 | −0.338 to 0.236 | |
| Group | 0.062 | 0.028 | 0.147 | 2.200 | 0.030a | 4.84 | 0.006 to 0.117 | |
Statistically significant (p < 0.05).
Discussion
The present study was conducted with the aim of assessing the periodontal status in clinically diagnosed mild and moderate depressive patients. The biological mechanisms for increased risk of periodontal diseases in depressive patients include immune suppression as well as immune activation. Immune suppression could occur due to alterations in the HPA axis leading to glucocorticoid release [2] and due to activation of the sympathetic nervous system leading to the production of adrenaline and noradrenaline from the adrenal medulla [2]. Immune activation could be mediated by cytokines [2]. Recent classification of periodontal diseases includes depression as a systemic disorder that influences the pathogenesis of periodontal diseases [17]. Lack of mental well-being and depression may lead to health-related behavioral changes, such as negligence in maintaining regular oral hygiene, attending dental check-ups; smoking, alcohol, and dietary changes may also have adverse effects on periodontal health [7].
In the present study, smokers could not be excluded as patients with depression have a higher tendency to smoke, which may be due to the temporary effect of ameliorating depressive symptoms due to nicotine [18]. Therefore, to rule out confounding effects of smoking, we included smokers in the control group to match the study population.
Gender distribution of the present study is consistent with a previous study reporting no specific association of gender with depression [19]. However, one study reported a greater proportion of females presented with depression [20]. On intergroup comparison in the present study, significantly lower income (p < 0.001) was found in patients with moderate depression when compared to those with mild depression and control subjects showing agreement with the results of a previous study [21] revealing lower household income in depressive patients. However, one study showed no association between depression and income status [22]. Due to behavioral changes, depressive patients are less likely to perform regular good oral hygiene and attend professional visits to dental office [7]. In the present study, brushing frequency was significantly (p < 0.05) lower in patients with depression when compared with healthy controls. Poorer oral hygiene was expected in depressive patients, and the present study showed significantly more plaque levels and gingival inflammation in depressive patients as compared to control group patients. These findings are consistent with previous studies [21, 23] but these studies had a small sample size [23]and recruited only female patients [21].
Bleeding on probing represents a sign of gingival inflammation and is indicative of characteristic histopathologic changes in lesions of advanced inflammatory periodontal disease [24]. We found a significantly greater proportion of sites with bleeding on probing in depressive patients with a significant positive correlation. Contrary to this, no association was found between bleeding sites and depression in a previous study [25]; however, the same study reported more periodontal disease activity in depressive patients when compared with controls [25].
In the present study, mean PPD was significantly increased in the mild depression and moderate depression groups, which is consistent with previous studies [21, 26], although these studies did not compare mild and moderate depression. Similarly, mean AL was significantly (p < 0.01) higher in depressive patients when compared with controls, in accordance with results of previous studies [21, 25, 26]. These studies differ in the use of a self-rated depression scale for assessment of depression and diagnosed periodontitis patients [26], recruitment of adolescent population, and use of a general health questionnaire for depression [25] which might not be sensitive enough to capture variations. In the present study, AL did not differ significantly in patients with mild and moderate depression. One possible reason for this is that mild depression may remain undiagnosed for a longer duration. Mild depressive symptoms may be ignored by the patients and if they do not report it early to the psychiatrist, it may lead to undiagnosed mild depression for longer duration. It is anticipated that depression will, in the long term, directly or indirectly affect periodontal health [27].
We observed that the proportion of sites with BOP and mean PPD was significantly higher in moderate depression compared to mild depression. This may suggest increasing periodontal tissue destruction as the severity of depression could be mediated by systemic effects of depression on periodontal tissues that can be described on the basis of dysregulation of HPA axis leading to modulation of the immune system [27]. The effect of smoking on BOP was further confirmed through GEE showing nonsignificant association, which rules out the influence of smoking on our results.
Significantly more patients with the thick phenotype were found in the moderate depression group, while the thin phenotype was found in the mild depression group as compared to non-depressive subjects. Previous studies [20, 21, 28] had not examined periodontal phenotype in depressive patients. The difference between stages of periodontitis was not statistically significant among different groups. In the present study, difference among the three groups was statistically significant considering grading of periodontitis which represents the risk of progression of periodontitis. The percentage of sites with PPD 4–5 mm and ≥6 mm was found to be significantly higher in patients with moderate depression when compared to patients with mild depression and the control group. The frequency of number of teeth having AL for values 1–2 mm, 3–4 mm, and ≥5 mm was significantly higher in patients with moderate depression as compared to the control group. One study reported significant correlation of deeper probing sites (PD = 5–8 mm), clinical AL of 5–8 mm, and missing teeth with Derogatis Stress Profile score; however, the study was performed on an older population with a mean age 52.69 years [29]. Contrary to this, no correlation was found between clinical attachment level, PPD, and depression in another study [28]. In the present study, a significant positive correlation was found between percentage sites with PPD 4–5 mm, ≥6 mm, AL 1–2 mm with patients with depression. Based on the results of this study, we suggest that dentists should be aware that patients having depressive illness may be more likely to need professional periodontal care compared to those without depression.
Strengths of this study include strict exclusion and inclusion criteria, clinical diagnosis of depression by experienced psychiatrist, use of ICD-10 criteria which is more sensitive [30] to a mild range of depression spectrum as compared to DSM-IV used in a previous study [28]and the use of a new classification of periodontal diseases [14]to better assess the severity and progression of periodontitis. Limitations of this study include the cross-sectional design, so causal relation cannot be established between periodontitis and depression. Sample size is relatively small so this study can be considered as a pilot study.
Conclusion
Within the limitations of the study, it can be concluded that greater inflammation and periodontal destruction in terms of BOP sites and PPD were found in moderate depression as compared to mild depression. Further, a significant positive correlation was observed among depression and periodontal parameters. Also, bleeding sites were associated with depression indicating depression may be a risk factor for periodontal disease. Interventional studies with the use of markers such as serotonin could help elucidate cause-effect relationships and also validate the results of the present study.
Statement of Ethics
The protocol of the study was approved by Institutional Review Board, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak and the ethical approval was obtained from the Ethics Committee of PGIDS, Rohtak (Clinical trials.gov ID: NCT04260880). The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2013.
Conflict of Interest Statement
The authors report no conflict of interest.
Funding Sources
None.
Author Contributions
Aparna Kaushik, Nishi Tanwar, Shikha Tewari, Rajinder Kumar Sharma, and Purushottam Jangid equally contributed to conception, design, and methodology of the study, data analysis, manuscript writing, and approved the final manuscript.
Data Availability Statement
Data supporting the findings of this study are available on request.
Acknowledgment
We thank the Post Graduate Institute of Dental Sciences, Rohtak, for providing all the facilities to conduct this research.
Funding Statement
None.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the findings of this study are available on request.