1. Griffith Health Institute
Depression and periodontal health
Dr Jane Manakil MDS, PHD,MRACDS.
Introduction: Depression is a psychiatric disorder in which negative affect, depressed mood, disturbed thoughts, and altered behaviors persist for a minimum of two weeks, and potentially for more protracted periods (APA 2004,Hasler.G 2010). Clinical observations and epidemiologic studies suggest that some negative life events and psychological factors may contribute to an increased susceptibility to oral disease and periodontal disease. The physiological effects of depression such as altered serotonin metabolism lead to a change in the dietary pattern and favoring the aciduric pathogens leading to an increase in dental caries and progressive demineralization eventually decay and periodontal disease progression.
Review of literature: Depression is a phenotype for a range of stress-related disorders which lead to an activation of the hypothalamic-pituitary-adrenal axis, a dysregulation of the autonomic nervous system and a release of pro-inflammatory cytokines, in insulin resistance, increased cortisol and other glucocorticoids (GCs) that affect immune function. The depression and antidepressants contribute to an alteration of the endocrine and monoamine regulatory systems leading to dysfunction of neurotransmitter metabolism, which in turn affects the amount and nature of salivary production ultimately leading to xerostomia with an increased incidence of oral infections e.g. candidiasis and periodontal disease. Decreased energy and motivation, as well as negative self-views associated with depression can have a detrimental effect on oral hygiene habits (Elter. et al 2002). Stress can be physiological and pathological, so can be it be considered as short term ( acute )or prolonged period (chronic), whci can lead to pathological changes.
Gingivitis if Untreated may evolve into periodontitis, a chronic inflammatory state resulting in periodontal attachment loss and eventually tooth loss. Research has shown that stress, depression, and ineffective coping may contribute to the development of periodontitis. Genco et al(1998); in the evaluation of stress in periodontitis has reported that chronic activation of the hypothalamic-pituitary adrenal axis may influence the initiation and progression of periodontitis through dysregulation of circulating cortisol (CORT) and other glucocorticoids (GCs) that affect immune function. The depressed immunity and chronically elevated CORT may result in inflammation and more destructive periodontitis(Rosania et al 2009). Monteiro da Silva.et al(1996). examined psychosocial variables in those with generalized aggressive periodontitis, routine chronic periodontitis (RCP), and has reported that generalized aggressive periodontitis is significantly higher in self reported depression and loneliness than subjects with RCP and controls. Boyapati and Wang 2007 has suggested that stress may inhibit the tissue healing leading to progressive periodontal disease and poor response to treatment outcome. Assessment of patient stress level and stress reduction protocols can be utilized as part of the treatment strategy. Various studies have shown stress, depression, inadequate coping, and maladaptive trait dispositions are significant risk indicators for periodontal disease and difficulty in disease management (Ng et.al 2006). Although clinical depression has been associated with progressive periodontal destruction and impaired tissue healing, further studies are required to understand the precise correlation of psychological factors in periodontal disease.
Problem
Impact
Depression & stress
Modifying factor of periodontal disease,
influence periodontal disease progression
Periodontal disease treatment outcome & maintenance; Influenced by
Behavioral factors
Patient may be reluctant to make appointments, show up for appointments,
Neglect in oral hygiene measures, Low self esteem, Lack of self-management, smoking, alcohol abuse, increased carbohydrate consumption, reduced nutrition
Pathophysiological factors
Higher Glucocorticoids(CORT)& catecholamine‘s, Diabetes(Hypergylycemia) , Reduced GH, psychoneuroimmunologic changes, Altered Th1 & Th2 & cytokine profiles, immunosuppression, reduced tissue matrix metalloproteinase.
Pathophysiology of Stress/depression
Conclusion / Clinical Implications: Although the dentists cannot treat depression/stress, a familiarity with the patient’s medical history, current prescriptions, and general indicators of depression could alert the dentist to possible problems, advise the treatment intervention, and possibly facilitate an appropriate referral for evaluation of the depressive symptoms. The significance is understanding there is an increased number of patients in dental and periodontics clinic practices that are under stress/depression, evaluation of the potential mechanism of depression and planning the modification of the treatment is crucial for an healthier outcome.
School of Dentistry
Griffith Health Institute