Associations of decayed teeth and localized periodontitis with mental stress in young adults: the cardiorespiratory fitness and health in eastern armed forces (CHIEF) oral study

doi:10.21203/rs.3.rs-1540627/v1

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Associations of decayed teeth and localized periodontitis with mental stress in young adults: the cardiorespiratory fitness and health in eastern armed forces (CHIEF) oral study

https://doi.org/10.21203/rs.3.rs-1540627/v1

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Background: The associations of psychological stress with decayed teeth in children and that with generalized peritonitis in middle- and old-aged adults have been well established. However, there were rare studies for young adults. This study aimed to investigate the associations of decayed teeth and localized periodontitis with psychological stress in young adults.

Methods: This study included 334 participants, aged 19-45 years in Taiwan. Psychological stress was assessed by the brief symptom rating scale-5 (BSRS-5) which included five items of anxiety, depression, hostility, interpersonal sensitivity and insomnia, yielding a maximal score of 20. Participants with symptomatic mental stress were defined as BSRS-5 >5 (n = 34). Multiple linear and logistic regression analyses were utilized to determinate the correlations of decayed teeth and localized severer periodontitis with BSRS-5, adjusting for sex, exercise frequency, cigarette smoking, serum high-density lipoprotein cholesterol and fasting glucose.

Results: The BSRS-5 was positively correlated with decayed teeth numbers [β: 0.26 (95% confidence intervals (CI): 0.02-0.50)]. In addition, those who had more than two decayed teeth (Odds ratio: 3.55, 95% CI: 1.50-8.43) had a higher risk of symptomatic mental stress. On the contrary, the correlation between BSRS-5 and localized severer periodontitis was null.

Conclusions: Our study recommended that decayed teeth rather than localized severer periodontitis in oral cavity, was a possible risk factor of psychological stress in military young adults in Taiwan.

Decayed teeth

Localized periodontitis

Psychological stress

Young adults

Psychological stress was often presented in military personnel, who have to take multiple deployments, heavy training, and responsibility [1]. The prevalence of symptomatic mental stress varies from 2.0–37.4% in military personnel worldwide [1–4]. Under stress, organisms might present corresponding physical responses in order to adapt the situation; however, psychological stress would have detrimental effects when it remains constant [5, 6]. In oral cavity, recurrent aphthous stomatitis [7], temporomandibular disorder [8], myofascial pain [9], poor oral hygiene [10], periodontal disease [11] and dental caries [12] have been reported to be related to psychological stress.

Dental caries, otherwise known as tooth decay, is the most common, chronic, non-communicable, preventable oral disease worldwide [13]. The World Health Organization (WHO) report pointed out that 95% of the world population had suffered from dental caries [14]. Dental caries form through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors such as teeth and saliva [15]. Many studies indicated a positive association between the presence of decayed teeth and salivary cortisol levels, a potential psychological stress biomarker [16], in primary and mixed dentition [12] but not in permanent dentition. In addition, it was inconvenient for detecting salivary cortisol in dental clinical environment.

Periodontal disease was also a common disease in the oral cavity [17]. Past studies have demonstrated that there was a positive correlation between psychological stress and generalized periodontitis in middle-aged elderly [11, 18]. However, the association for localized periodontitis in young adults is rarely explored. Thus, we used the Brief Symptom Rating Scale-5 (BSRS-5), a short questionnaire with five questions, to inspect the association of psychological stress with decayed teeth numbers and localized periodontitis in young military personnel.

Study population

The present study used a historical cohort of 334 military personnel, averaged 32.6 years of age from the cardiorespiratory fitness and health in eastern armed forces (CHIEF) oral health study [19] performed in Taiwan during 2018. Subjects were divided into two groups (the normal and those with psychological stress) according to the BSRS-5 score [20]. All participants self-reported a questionnaire for education level, exercise activity, smoking status and psychological status assessments. Participants also received the annual military health examination, including oral health, physical and laboratory examinations.

Clinical and demographic measures

For each participant, body height and body weight were assessed in a standing position. Body mass index was defined as the ratio of body weight (kilogram) to the square of height (meter²). Measurement of waist circumference was taken at the midpoint between the highest point of the iliac crests and the lowest point of palpable ribs. Hemodynamic parameters of each participant, such as systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured after resting for at least 25 minutes and taken once from the right arm in a sitting position with an automated FT-201 BP monitor (Parama-Tech Co Ltd, Fukuoka, Japan). Routine blood tests, including leukocyte count, fasting plasma glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and serum triglycerides were measured using an automated hematology analyzer (Olympus AU640 auto-analyzer, Olympus, Kobe, Japan). All blood samples of the participants were collected after an overnight 12-hour fast at the same blood drawing station [21–25].

Oral health measures

Dental caries were assessed by recording the caries index, DMFT (number of decayed, missing and filled teeth), according to the criteria recommended by the WHO [26]. Impacted tooth and third molar were excluded in this study. The selected subjects in the present study with dental caries had a history of pain or infection. Comprehensive oral treatment was given to all the participants after recording the baseline DMFT scores.

The severity of localized periodontitis was classified based on the 2017 world workshop of both the American Academy of Periodontology and the European Federation of Periodontology [27]. For all participants, the extent of periodontitis was defined as localized (< 30% of teeth involved) [27]. Localized stage II and III periodontitis were defined as localized severer periodontitis in this study [28–30].

Psychological stress measurements

The BSRS-5 has been used to evaluate the severity of psychological stress of the military personnel in the past weeks in Taiwan for several years. The BSRS-5 is composed of five domains, including feeling blue (depression), feeling tense (anxiety), feeling easily annoyed or irritated (hostility), feeling inferior to others (interpersonal sensitivity), and trouble falling asleep (insomnia). The scoring of each domain ranges from 0 (none) to 4 (extremely) in severity [20]. Those with a BSRS-5 score > 5 was defined to have symptomatic metal stress, and those with a BSRS-5 score ≤ 5 was defined as the normal group [31, 32]. Internal consistency (Cronbach alpha) coefficients of the BSRS-5 has been documented ranging from 0.77 to 0.90. The test-retest reliability coefficient was 0.82 [20, 33, 34].

Statistical analysis

The variables were expressed as mean ± standard deviation (SD) for continuous data, and numbers (percentages) for categorical data. The continuous variables were compared by one-way ANOVA, and the categorical variables were compared by chi-square test. Multivariable liner regression analysis was used to determine the β value and their 95% confidence intervals (CI) of BSRS-5 score and the five domains of anxiety, depression, hostility, interpersonal sensitivity and insomnia with the decayed teeth number. Multivariable logistic regression analysis was utilized to determine the odds ratio (OR) and their 95% CI of more than two decayed teeth and localized severer periodontitis with symptomatic mental stress. The covariates were selected if a difference was present between the normal and those with symptomatic mental stress, and stepwise adjusted in three models for decayed teeth numbers and localized severer periodontitis. In model 1, sex and exercise frequency were adjusted. In model 2, cigarette smoking status was further adjusted. In model 3, serum HDL-C and fasting plasma glucose were further adjusted. A value of p < 0.05 was considered significant. SPSS statistical software was used for all the statistical analyses (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. International Business Machines Corporation, Armonk, NY, USA).

Table 1 shows the clinical characteristics of participants with normal (N = 300) and symptomatic mental stress (N = 34). Those with symptomatic mental stress had a lower serum HDL-C level, less weekly exercise frequency and a greater BSRS-5 score. The flow diagram for the selection of participants is shown in Fig. 1.

Table 1

Clinical characteristics of the normal and the symptomatic mental stress groups (N = 334)
Clinical characteristics	Normal (N = 300)	Psychological stress (N = 34)	p-value
BSRS-5 scores	1.36 ± 1.76	7.53 ± 1.56	< 0.001
Sex
Male	270 [90.0]	32 [94.1]	0.43
Female	30 [10.0]	2 [5.9]
Age (years)	32.74 ± 4.86	31.47 ± 4.00	0.14
Education level
Senior high school	17 [5.7]	2 [5.9]	0.62
College/University degree	275 [91.7]	32 [94.1]
Postgraduate degree	8 [2.7]	0 [0.0]
Exercise frequency
Never or occasionally	54 [18.0]	8 [23.5]	< 0.001
1–2 times per week	120 [40.0]	24 [70.6]
≥ 3–5 times per week	126 [42.0]	2 [5.9]
Current cigarette smoker	102 [34.0]	10 [29.4]	0.59
Systolic blood pressure (mmHg)	121.14 ± 12.23	122.50 ± 11.79	0.53
Diastolic blood pressure (mmHg)	73.47 ± 9.77	74.47 ± 10.01	0.57
Body mass index (kg/m²)	25.80 ± 3.21	25.30 ± 2.60	0.38
Waist circumference (cm)	85.90 ± 8.63	85.04 ± 5.96	0.57
Blood test
Total cholesterol (mg/dL)	181.20 ± 34.19	176.88 ± 36.82	0.48
HDL-C (mg/dL)	48.93 ± 10.56	44.35 ± 9.41	0.01
LDL-C (mg/dL)	109.17 ± 32.37	105.71 ± 31.68	0.55
Serum triglycerides (mg/dL)	132.61 ± 94.54	154.79 ± 99.63	0.19
Fasting plasma glucose (mg/dL)	93.02 ± 15.06	98.26 ± 23.41	0.07
Leucocyte count (10⁹/L)	6.92 ± 1.60	7.04 ± 1.45	0.67
DMFT index
Decayed teeth (numbers)	0.54 ± 1.33	0.93 ± 1.08	0.12
Missing teeth (numbers)	1.27 ± 1.58	1.13 ± 0.97	0.65
Filled teeth (numbers)	5.32 ± 3.84	4.67 ± 3.92	0.38
Localized stage II/III periodontitis	84 [28.0]	10 [24.9]	0.86
Continuous variables are expressed as mean ± SD (standard deviation), and categorical variables as N [%].
Abbreviations: BSRS-5; brief symptom rating scale-5, DMFT; decayed, missing and filled teeth numbers, HDL-C; high-density lipoprotein cholesterol, LDL-C; low-density lipoprotein cholesterol.

Table 2 reveals the results of multivariable linear regressions for decayed teeth number with BSRS-5 score in models 1–3. Greater decayed teeth numbers were correlated with greater BSRS-5 [β: 0.26 (95% CI: 0.02–0.50)] and its components of anxiety [β: 0.07 (95% CI: 0.02–0.12)] and depression [β: 0.07 (95% CI: 0.02–0.12)] in all models. Although there was a positive association between decayed teeth numbers and insomnia degree in model 1 and 2, the association became insignificant in model 3.

Table 2

Multivariable liner regression analysis for decayed teeth numbers with BSRS-5 score
		Model 1			Model 2			Model 3
	β	95% CI	p-value	β	95% CI	p-value	β	95% CI	p-value
BSRS-5 scores	0.28	0.04–0.51	0.02	0.26	0.02–0.50	0.03	0.26	0.02–0.50	0.03
Anxiety	0.07	0.02–0.12	0.006	0.07	0.02–0.12	0.009	0.07	0.02–0.12	0.01
Depression	0.08	0.02–0.13	0.005	0.07	0.02–0.12	0.01	0.07	0.02–0.12	0.01
Hostility	0.01	-0.05–0.08	0.72	0.01	-0.06–0.08	0.73	0.01	-0.06–0.08	0.75
Interpersonal sensitivity	0.05	-0.003–0.11	0.06	0.05	-0.01–0.11	0.08	0.06	-0.002–0.12	0.056
Insomnia	0.06	0.008–0.11	0.02	0.05	0.00–0.11	0.04	0.05	-0.004–0.10	0.07
Data are presented as β-value and 95% confidence intervals (CI) using multiple liner regression analysis for
Model 1: sex and exercise frequency adjustments.
Model 2: sex, exercise frequency and cigarette smoking adjustments.
Model 3: sex, exercise frequency, cigarette smoking, serum high-density lipoprotein cholesterol and fasting plasma glucose adjustments.
Abbreviations: BSRS-5, brief symptom rating scale-5

Table 3 demonstrates the estimates of the risk of symptomatic mental stress for decayed teeth ≥ 2 and localized severer periodontitis. Those with more than two decayed teeth in oral cavity had a higher risk of symptomatic mental distress in model 1 [OR: 3.63 (95% CI: 1.59–8.24)], model 2 [OR: 3.87 (95% CI: 1.67–8.94)] and model 3 [OR: 3.55 (95% CI: 1.50–8.43)]. However, the association between localized severer periodontitis and psychological stress was not significant.

Table 3

Multivariable logistic regression analysis for decayed teeth ≥ 2 and localized moderate to severe periodontitis with symptomatic mental stress
		Model 1			Model 2			Model 3
	OR	95% CI	p-value	OR	95% CI	p-value	OR	95% CI	p-value
Decayed teeth number ≥ 2	3.63	1.59–8.24	0.002	3.87	1.67–8.94	0.002	3.55	1.50–8.43	0.004
Localized periodontitis	1.11	0.50–2.48	0.80	1.12	0.50–2.50	0.78	1.06	0.46–2.42	0.89
Data are presented as odds ratios (OR) and 95% confidence intervals (CI) using multiple logistic regression analysis for
Model 1: sex and exercise frequency adjustments.
Model 2: sex, exercise frequency and cigarette smoking adjustments.
Model 3: sex, exercise frequency, cigarette smoking, serum high-density lipoprotein cholesterol and fasting plasma glucose adjustments.

The main findings of the present study were that decayed teeth numbers was positively correlated with BSRS-5 scores, particularly in anxiety and depression after adjusting for potential covariates. More than two decayed teeth, but not localized severer periodontitis in oral cavity was associated with psychological stress in the military personnel in Taiwan.

Periodontal disease relevant to psychological stress can induce glucocorticoid hormone and catecholamines (epinephrine and norepinephrine) secretion and resulted in increased serum glucose and suppressed immune response [35, 36]. In addition, psychological distress might also stimulate the sympathetic nervous system and reduced salivary flow and resulted bacteria plaque accumulation [37]. Furthermore, psychological stress would cause healthy-impairing behaviors, like dietary habits and nutrient intake changing, smoking, and lesser frequency of dental visit and assist adverse effects on the oral health [18, 38, 39]. The majority of studies have demonstrated a positive relationship between mental stress or psychological factors and generalized periodontitis in middle-aged individuals and the elderly [11, 18]. However, the association was absent for localized severer periodontitis among young adults in the present study. This was the first report to demonstrate a null association for the early phase of periodontal disease and when the periodontal disease progressing to a generalized condition and a high inflammatory status with aging could increase the mental stress.

Prior studies have clearly revealed that psychological stress might influence the development of carious lesions in children [40]. By contrast, in adults, there lacked sufficient evidence on the association between mental stress and dental caries [41]. Both the Brazil [42] and Swedish [43] studies demonstrated no correlations between mental stress and decayed teeth among middle aged individuals. Nevertheless, occupation and race/ethnicity might have different effects on this relationship. For instance, mental stress was associated with greater levels of dental caries in adults with intellectual disabilities [44], in soldiers participating the War [45], and in the Japanese adults [46]. The present study further filled the gap for the different findings between Children and middle- or old-aged adults in prior studies that in young adults, there was an association of decayed teeth with mental stress.

There were some limitations in this study. Firstly, young women accounted for about one tenth of the military population, making it difficult to perform sex-specific analysis. Second, since the present study was a cross-sectional design, the temporality and causality could not be assessed. Third, although a number of covariates were adjusted, it was impossible to adjust all confounders which might result in a bias. By contrast, the present study also had some advantages. Firstly, the psychological stress was measured by a self-reported questionnaire, which could be objectively and quantitatively analyzed. Second, since the daily life of military such as diet, training, and stress source was unified in the county, many unmeasured confounders had been controlled at baseline. Third, all the dental examinations were carried out by the same dentist and the blood tests were performed in the central lab that the examining bias could be reduced.

Our study findings suggested that decayed teeth rather than localized severer periodontitis in oral cavity, was a possible risk factor of psychological stress in military young adults in Taiwan. These findings contradicted to the association of mental stress for generalized periodontitis in middle- or old-aged adults, and were consistent with the results for decayed teeth in children in prior studies.

CHIEF

Cardiorespiratory fitness and Health In Eastern armed Forces

WHO

World Health Organization

BSRS-5

Brief Symptom Rating Scale-5

SBP

Systolic blood pressure

DBP

Diastolic blood pressure

DMFT

Decayed, Missing and Filled Teeth

Confidence Intervals

Odds Ratio

HDL-C

High-Density Lipoprotein Cholesterol

LDL-C

Low-Density Lipoprotein Cholesterol.

Ethics approval and consent to participate

This cross-sectional CHIEF study was reviewed and approved by the Institutional Review Board of the Mennonite Christian Hospital (No. 16-05-008) in the Hualien City of Taiwan. All methods were performed in accordance with the relevant guidelines and regulations and written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Availability of data and materials

The data that supports the findings of this study is available from the CHIEF oral study cohort, restriction apply to the availability of these data, it was obtained under license and therefore not publicly available. Questions or requests concerning this data is directed to author, Gen-Min, Lin.

Competing interests

The authors declare no competing interests.

Funding

This study was supported by the Medical Affairs Bureau Ministry of National Defense and Hualien Armed Forces General Hospital, Taiwan, under the grants MND-MAB-D-11115 and HAFGH-D-111003.

Author contributions

Kun-Zhe Tsai, contributed to conception, design, data acquisition and interpretation, drafted and critically revised the manuscript; Ko-Huan Lin, contributed to conception, data analysis and interpretation, performed all statistical analyses, drafted and critically revised the manuscript; Pang-Yen Liu, contributed to conception, and critically revised the manuscript; Yen-Po Lin, contributed to conception, and critically revised the manuscript; Gen-Min Lin, contributed to conception, design, data acquisition, and interpretation, drafted and critically revised the manuscript. All authors gave their final approval and agree to be accountable for all aspects of the work.

None.

Author details

¹Department of Stomatology of Periodontology, Mackay Memorial Hospital, Taipei, Taiwan. ²Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan. ³Departments of Dentistry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. ⁴Graduate Institute of Dental Science, National Defense Medical Center, Taipei, Taiwan. ⁵Department of Psychiatry, Taipei Veterans General Hospital Yuli Branch, Hualien, Taiwan. ⁶Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. ⁷Department of Critical Care Medicine, Taipei Tzu-Chi Hospital, New Taipei City, Taiwan

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No competing interests reported.

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Associations of decayed teeth and localized periodontitis with mental stress in young adults: the cardiorespiratory fitness and health in eastern armed forces (CHIEF) oral study

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Background

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Study population

Clinical and demographic measures

Oral health measures

Psychological stress measurements

Statistical analysis

Results

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