National Journal of Maxillofacial Surgery

: 2022  |  Volume : 13  |  Issue : 1  |  Page : 90--94

Evaluation of association between potential stress markers and periodontal health in medical and dental students: A questionnaire-based study

Prerna Agarwal1, Hirak S Bhattacharya1, Pavitra Rastogi1, Manvi Chandra Agarwal1, Ashutosh Agarwal2,  
1 Department of Periodontics, Institute of Dental Sciences, BIU, Bareilly; Department of Periodontics, Faculty of Dental Sciences, KGMU, Lucknow, Uttar Pradesh, India
2 Department of Periodontics, Institute of Dental Sciences, BIU, Bareilly, Uttar Pradesh, India

Correspondence Address:
Dr. Manvi Chandra Agarwal
Room No 228, Institute of Dental Sciences, BIU, Bareilly, Uttar Pradesh


Aims and Objectives: Psychological conditions, particularly psychosocial stress, have been implicated as risk indicators for periodontal disease. The aim of the present study was to explore the role of psychosocial stress on periodontium through questionnaire and serum cortisol level. Subjects and Methods: Two hundred medical and dental undergraduates were recruited for the study. Case group included 82 examination going and control group had 79 nonexam going students. Their stress level was evaluated using a standard questionnaire (perceived stress scale). Gingival index, periodontal disease index, bleeding on probing index, serum cortisol level, and serum alpha-amylase level were also measured. Statistical Analysis Used: Bivariate correlations and multiple regression tests were done. Results: A positive correlation was found among stress scores, salivary cortisol, alpha-amylase, and periodontal disease measures. Conclusion: Periodontitis can be related to immunologic changes related to psychological states

How to cite this article:
Agarwal P, Bhattacharya HS, Rastogi P, Agarwal MC, Agarwal A. Evaluation of association between potential stress markers and periodontal health in medical and dental students: A questionnaire-based study.Natl J Maxillofac Surg 2022;13:90-94

How to cite this URL:
Agarwal P, Bhattacharya HS, Rastogi P, Agarwal MC, Agarwal A. Evaluation of association between potential stress markers and periodontal health in medical and dental students: A questionnaire-based study. Natl J Maxillofac Surg [serial online] 2022 [cited 2022 Jun 28 ];13:90-94
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Full Text


Periodontitis is an inflammatory disease involving the destruction of the investing tissues around the teeth, resulting in loss of tooth support, ultimately tooth loss.

The etiology of periodontal disease involves numerous risk factors such as age, smoking, specific infections, uncontrolled diabetes, psychosomatic conditions such as anxiety and psychosocial stress.[1],[2],[3]

Stress is a state of physiological or psychological strain caused by adverse stimuli, physical, mental, emotional, internal or external that tend to disturb the functioning of an organism.[4] Researchers have reported an association between psychological stress and gingival inflammation and periodontitis.[5],[6],[7],[8],[9]

Gingivitis is mild, reversible form of periodontal disease characterized by gingival inflammation without attachment loss and detected clinically by bleeding on probing (BOP). Untreated gingivitis may evolve into periodontitis, a chronic inflammatory state resulting in periodontal attachment loss.[10] Clinical indicators of periodontitis include probing pocket depth, gingival recession, clinical attachment level, and radiographic loss of alveolar bone.[11]

Chronic activation of the hypothalamic–pituitary–adrenal axis may influence the initiation and progression of periodontitis showing dysregulation of circulating cortisols and other glucocorticoids that affect immune function.[12] Green et al. reported higher incidence of periodontal diseases in those experiencing stressed life events and a particularly strong correlation between stressors and periodontal disease.[13]

In addition to this, occupational and academic stress may be associated with progression of periodontal disease. In a small study over the Nigerian students, those undergoing academic examinations had more periodontal inflammation than controls.[14]

A systematic review[15] of case control, cross-sectional and prospective studies examining psychological stress and periodontal disease indicated that 57.1% of the studies reported a positive correlation between psychological stress and periodontal disease and 14.2% did not.

The present study extends the research on chronic stress, depression and periodontal disease by measuring behaviors, psychological variables, and salivary stress markers such as alpha-amylase and cortisol levels to explore the behavioral and immunologic correlates of periodontal parameters.

 Subjects and Methods

Study population

The study was conducted in Rohilkhand Medical College and Hospital and Institute of Dental Sciences (IDS), Bareilly.

A total of 200 dental and medical undergraduates were included. Out of these, 100 undergraduates were undergoing professional examination and 100 were in nonexam giving group.

The subjects were in the age range of 18–21 years with minimum 20 teeth excluding third molars. Participants on antibiotics, steroids, chemotherapeutic agents, or antipsychotic drug therapy and with immunosuppressive diseases were excluded [Table 1].{Table 1}

The study protocol was approved by the ethical committee of IDS (Reference Number: IEC/IDS/102/2019) dated 6th January 2022 and informed written consent was taken from all the participants.

Clinical parameters and health survey

The clinical parameters

Gingival index (GI), Loe and Silness 1963,[16] records qualitative changes in gingivaPeriodontal disease index (PDI), Ramfjord 1967,[17] assess the prevalence and severity of gingivitis and periodontitis within the individual dentitions and in population groupsBOP index.

These were measured by a single examiner and the stress scale ratings by the other.

The health and oral hygiene survey included questions about age, family history of periodontal disease, smoking, and frequency of brushing and flossing. Participants also indicated whether they neglected oral hygiene during periods of stress or depression.

Psychological evaluation

Participants from both, examination giving and nonexam-giving group answered a questionnaire pertaining to the level of stress that they perceive[18] perceived stress scale, [Table 2]. According to the interpretation of the scores [Table 3], participants from the exam giving group who scored above 20 were included in case group. Similarly, participants from nonexam-giving group who scored <11 were included in the control group. This made a case group of 82 participants and control group of 79 participants.{Table 2}{Table 3}

Saliva sample

Saliva was collected by passive drool through a 1-inch straw into a vial. Samples were drawn between 9 am and 10 am to avoid circadian rhythm changes.[19] Refrigerate samples within 30 min, and freeze at or below −20°C within 4 h after collection. On day of assay, thaw completely, vortex, and centrifuge at 1500 × g (@3000 rpm) for 15 min. Samples should be at room temperature before adding to assay plate. Salivary cortisol and alpha-amylase were assayed using skits (Salimetrics salivary cortisol assay kit).

Statistical analyses

Mean stress scores, salivary stress markers, and clinical parameters were calculated for both case and control groups [Table 4]. Bivariate correlations were done among psychosocial variables, salivary stress markers, and periodontal disease measures [Table 5] and [Table 6]. Correlation was significant at 0.01 level and it was one tailed. Multiple regressions were used to relate periodontal disease measures with psychosocial variables, stress scores, and salivary stress markers [Table 7], [Table 8], [Table 9].{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}


Of the total 161 participants, 36% were smokers and 46% had a history of alcoholism. Most of the participants brushed their teeth twice daily (about 66.5%) and 34.2% gave a history of no brushing during stress [Table 1]. The GI and PDI means (standard deviation) were 1.75 (0.42) and 0.92 (0.43) respectively for control group and 2.69 (0.21) and 1.79 (0.13) respectively for case group. A positive correlation existed among stress scores, salivary cortisol and alpha-amylase and the periodontal disease measures. Stress score was significantly correlated with all three periodontal disease measures, i.e., GI, PDI, and BOP index [Table 6]. However, there was negative correlation between stress score and brushing frequency [Table 5].


The present study showed direct correlation between periodontal disease measures, stress scores, and salivary stress markers. The results were consistent with previous studies suggesting the association of periodontal disease with stress.[3],[12]

In terms of behavior, the study did not show any significant correlation between brushing frequency and stress scores and markers. This was in contradiction to the previous studies.[20],[21] Thus, the relationships among stress, oral hygiene, and markers of periodontal disease were unclear. The effect of oral hygiene may not be apparent because of socioeconomic class of sample selected and maintenance and awareness of hygiene maintenance.

A positive relationship exists among depression scores, salivary cortisol, and alpha-amylase and the indices of periodontal disease. This is likely because of altered immune responses that facilitate increased colonization by pathogenic bacteria and the symptoms of periodontal disease.[20],[22],[23]

The immune response does not operate autonomously but in close cooperation with the neuroendocrine systems. When the body is in stress, the glucocorticoids released through the activation of the hypothalamus–pituitary–adrenal axis seem to be important, due to their ability to regulate the recruitment of immune cells into inflamed tissues and to skew the Th1/Th2 balance toward a Th2-dominant response, thereby leading to the progression of periodontal disease.[24] In the presence of stress hormone, collagen production is shown to be decreased due to increase in amounts of glucocorticoids.[25] Deinzer et al. reported that academic stress can lead to gingival inflammation with increased crevicular interleukin-1b and diminished quality of oral hygiene. Furthermore, stress modifies the salivary pH and its chemical composition like IgA secretion, thus contributing to gingival and periodontal inflammation.[7]

Multiple regression analysis showed that stress scores and salivary amylase were highly significant predictors of PDI and cortisol was marginally significant predictor after controlling for sex, smoking, and alcohol history and brushing frequency [Table 7].

Analysis also depicted cortisol and amylase as highly significant predictors of GI [Table 8], While for BOP, stress scores, cortisol, and amylase emerged to be highly significant predictors after controlling for sex, smoking, alcohol, and brushing frequency [Table 9].

Salivary cortisol showed positive correlation with periodontal disease measures, but in regression models, it was seen that cortisol was a marginally significant predictor of PDI. Although this finding may seem counterintuitive, it is consistent with recent research on stress that distinguishes between acute stress and the chronic, debilitating negative effect that is more likely to be associated with depression and flattened cortisol patterns.[26] Subjective distress, feeling out of control, and traumatic or physically threatening stress are associated with lower morning levels and suppressed diurnal variability of cortisol.[26]

Patients experiencing such changes in cortisol may eventually have immune effects that result in periodontitis.


The results showed positive correlations among stress, salivary stress markers and PDI, independent of dental hygiene. Therefore, it can be concluded that periodontitis can be related to immunologic changes related to psychological states. Further, cortisol seems to have different associations with periodontal outcomes in regression models involving stress.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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