ABSTRACT
Introduction:
The most prevalent oral mucosal conditions in humans are leukoplakia, oral lichen planus (OLP), and oral submucous fibrosis (OSMF). These conditions should be studied as psychosomatic conditions, but little research has been done on how these conditions relate to stress.
Materials and Methods:
A total of 280 patients of both genders with ages 35–60 years were divided into four groups: leukoplakia, OSMF, OLP, and control. Whole blood samples were collected from all the participants and analyzed for serum cortisol by using ELISA with a commercial kit. Detailed case history and DASS-21 questionnaire were recorded for psychological assessment. To assess the variables, the student t test and Chi-square test were used. P values of <0.05 were regarded as significant.
Results:
In this study, it was found that higher levels of serum cortisol were found in OLP patients, with advanced erosive lesions showing the highest levels of serum cortisol, followed by OSMF and leukoplakia. Patients with Oral Lichen Planus showed higher levels of stress, anxiety and depression than patients of OSMF and leukoplakia.
Conclusion:
This study emphasized stress and anxiety as a predisposing factor in the occurrence and progression of OSMF apart from re-establishing the role of stress and anxiety in OLP with consideration to depression in triggering role for OLP. Furthermore, it demonstrated that serum cortisol levels play a significant role as an indicator of psychological stress.
KEYWORDS: Anxiety, depression, oral submucous fibrosis, serum cortisol
INTRODUCTION
The leading etiological factor in many diseases is stress. Cortisol, also known as stress hormone, is the major glucocorticoid that influences metabolism and regulates immune function, vascular and inflammatory response, and cognitive behavior.[1] In India, the frequency of oral lichen planus ranges from 0.02% to 0.4%, oral leukoplakia ranges from 0.2% to 5.2%, and OSF varies from 0.03% to 3.2%.[2]
To determine the impact of psychological stress on the incidence and extent of oral submucous fibrosis, oral lichen planus, and leukoplakia, as well as their relationship to serum cortisol, the current study was carried out.
MATERIALS AND METHODS
The current study was carried out among 280 patients of both genders with ages 35–60 years, who reported in the daily outpatient department of the hospital. The selected patients (n = 280) were divided into four groups: leukoplakia, OSMF, OLP, and healthy age- and sex-matched controls without oral deleterious habits. The ethical committee of the institution gave their consent before the study’s commencement. The study participants provided written, informed consent.
Clinical evaluations were performed on patients of both genders who were between the ages of 35 and 60 years.[3] Each patient was clinically examined and diagnosed based on the criteria by WHO 2005 criteria for leukoplakia, OSMF, and oral lichen planus and graded according to predetermined criteria such as van der Waal OSMF (J. N. Khanna, N.N. Andrade, 1995), and for oral lichen planus ( Malhotra AK et al., 2008).[4] Detailed case history and DASS-21 questionnaire were recorded for psychological assessment.
Incisional biopsy of the clinically diagnosed lesions was done and sent for histopathological evaluation. Morning (8–10 am) whole blood samples were collected from all the participants and sent for serum cortisol evaluation. The ELISA commercial kit analysis of the serum samples was conducted in accordance with the manufacturer’s instructions. Cortisol levels in the morning are typically within the range of 138–635 nmol/L.[5]
Patients taking antipsychotics, having psychological illnesses, or having a persistent systemic illness or medicine that interacts with the HPA axis and patients with a history of menstruation, postmenopausal stress, hormonal abnormalities, or pregnancy were not allowed to participate in the study.[3]
RESULTS
There were 280 patients in total; 195 of them were men and 85 of whom were women. Patients with leukoplakia constituted mainly males (60), whereas patients with oral lichen planus mainly comprised females (39). Maximum study subjects were of the age group of 35–45 years. OLP patients (36) had higher blood cortisol levels than OSMF patients (34) (whose levels ranged from 200 to 400 nmol/L), while the majority of leukoplakia patients (36) had levels that were less than 200 nmol/L [Table 1].
Table 1.
Distribution of the study population according to serum cortisol levels
| Serum cortisol (nmol/L) | Study population | Total | |||
|---|---|---|---|---|---|
|
| |||||
| OSMF | OLP | Leukoplakia | Control | ||
| ≤200 | 25 | 10 | 36 | 49 | 120 |
| ≥201-≤400 | 34 | 36 | 25 | 20 | 115 |
| ≥401-≤600 | 11 | 21 | 09 | 01 | 42 |
| ≥601-≤800 | 00 | 03 | 00 | 00 | 03 |
With increasing severity of OLP, a total of 21 patients showed higher ranges of serum cortisol in the range of ≥401–≤600 nmol/L, with a total of three patients in the serum cortisol range of ≥601–≤800 nmol/L, which was the maximum among all the study groups. Thus, the increase in severity of the OLP correlated with increasing serum cortisol levels [Table 1].
Patients of OLP showed moderate to severe levels of stress, anxiety, and depression, whereas OSMF followed by leukoplakia patients had mild levels of stress, anxiety, and depression. DASS 21 scale assessment showed that psychological stress was more significantly associated with OLP patients [Table 2].
Table 2.
Distribution of the study population according to perceived psychological stress, anxiety, and depression
| Lesions | OSMF | Leukoplakia | OLP | Control |
|---|---|---|---|---|
| Stress | ||||
| Normal | 23 | 31 | 14 | 41 |
| Mild | 32 | 24 | 21 | 20 |
| Moderate | 10 | 9 | 22 | 08 |
| Severe | 3 | 5 | 8 | 01 |
| Extremely Severe | 2 | 1 | 5 | 00 |
| Anxiety | ||||
| Normal | 22 | 31 | 10 | 51 |
| Mild | 33 | 22 | 27 | 13 |
| Moderate | 8 | 11 | 18 | 05 |
| Severe | 4 | 4 | 10 | 01 |
| Extremely Severe | 3 | 2 | 05 | 00 |
| Depression | ||||
| Normal | 34 | 35 | 14 | 50 |
| Mild | 21 | 19 | 21 | 17 |
| Moderate | 13 | 14 | 12 | 02 |
| Severe | 02 | 2 | 13 | 01 |
| Extremely Severe | 00 | 00 | 10 | 00 |
DISCUSSION
In the current investigation, we discovered that OLP patients had increased serum cortisol levels, followed by OSMF and leucoplakia. According to research conducted by Shetty VS et al., Muhamood M et al. (2018), and Chaitanya KV et al., patients with OLP had mean serum cortisol levels that were greater than those of normal participants.[6] EL Tawil et al. (2009) and Nadendla LK et al. (2014) conducted studies that revealed that serum cortisol levels rise as a result of stress brought on by pruritus and persistent skin lesions. Patients with OLP had statistically significantly higher salivary cortisol levels than controls in these two studies.[7]
The current study observed that serum cortisol levels were higher in cases of erosive lichen planus. These findings are consistent with research conducted by Shah B et al. (2009), Ivanovski K et al. (2005), and Jose S et al. (2009), which concluded that psychosocial stresses through neuroendocrine and neuroimmunology mechanisms were the primary cause of the significant increase in serum cortisol levels observed in patients with erosive OLP than in controls and non-erosive OLP patients.[8,9]
In our study, higher serum cortisol levels were observed in OSMF when compared to the leukoplakia and control groups. This finding is consistent with research by Monisha K et al. (2018) and Kanodia S et al. (2017), which found that OSMF had higher serum cortisol levels than the control group.[10,11]
In addition, OLP patients in this study exhibited greater depression phases, followed by OSMF and leucoplakia. According to a study by Kanodia S et al., the majority of OSMF patients reported mild anxiety. OLP patients had moderate to severe stress, while OSMF patients exhibited mild to moderate stress and anxiety. Most of the leucoplakia participants in this study experienced minor stress. In a similar vein, research conducted by Mubeen K et al. (2010), Raja JV et al. (2013), and Arjun TN et al. (2014) concluded that more severe OSMF stages have been linked to increased psychiatric morbidity.[12]
CONCLUSION
In summary, it has been determined that higher depressive and stressful states were predominant in OLP patients followed by anxiety, whereas the majority of the patients with mild anxiety and stress were of OSMF, suggesting that anxiety and stress can be implicative of OSMF. Patients with Oral Lichen Planus showed higher serum cortisol levels along with higher levels of stress, anxiety and depression than patients of OSMF and leukoplakia. Thus, the study suggests considering stress and anxiety as a predisposing factor in the occurrence and progression of OSMF apart from reaffirming the already established role of stress in OLP with consideration to depression in the triggering role for OLP.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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