Journal of Indian Association of Public Health Dentistry

: 2019  |  Volume : 17  |  Issue : 1  |  Page : 36--40

Effect of stress, depression, and anxiety over periodontal health indicators among health professional students

Gautami S Penmetsa, Pasagadugula Seethalakshmi 
 Department of Periodontics and Implantology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Correspondence Address:
Dr. Gautami S Penmetsa
Department of Periodontics and Implantology, Vishnu Dental College, Bhimavaram, Andhra Pradesh


Background: Stress has become a part of one's life, which results in the development of depression and anxiety. This is commonly thought to have a net-negative effect on the efficacy of the immune response, subsequently resulting in periodontal breakdown. Aim: The aim of this study was to assess the effect of depression, anxiety, and stress [DAS] over periodontal health indicators among the health-care professional students. Materials and Methods: The study was conducted in 375 undergraduate health professional students, of which 125 were medical students, 125 were dental students, and 125 were pharmacy students, who were taken from three colleges in Andhra Pradesh. Questionnaires (self-reported oral hygiene questionnaire and DAS Scale questionnaire) were given to the participants, and clinical examination was conducted in all the participants to assess the plaque index (PI), gingival index (GI), probing depth, and clinical attachment level. Statistical analysis was performed using the ANOVA test and post hoc test to compare the psychological parameters with periodontal parameters among three groups of health professional students. P < 0.05 was considered statistically significant. Results: Medical students depicted higher mean stress levels (8.00 ± 2.75) (P < 0.001) and mean DAS score (20.23 ± 6.21) (P < 0.001) than dental and pharmacy students; the mean PI (1.05 ± 0.38) (P < 0.001) and the mean GI (0.72 ± 0.38) (P < 0.001) scores are also increased with stress levels among medical students. Conclusion: Psychological factors have an adverse effect over the plaque levels and gingival status among the students.

How to cite this article:
Penmetsa GS, Seethalakshmi P. Effect of stress, depression, and anxiety over periodontal health indicators among health professional students.J Indian Assoc Public Health Dent 2019;17:36-40

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Penmetsa GS, Seethalakshmi P. Effect of stress, depression, and anxiety over periodontal health indicators among health professional students. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Apr 24 ];17:36-40
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Periodontal diseases are multifactorial infections[1],[2] characterized by destructive inflammatory process affecting tooth-supporting tissues that induce elevation of pro-inflammatory cytokines,[3],[4] resulting in tissue destruction. Evolution and progression of the periodontal disease are influenced by many local or systemic risk factors,[5] with the dental plaque being a primary etiologic factor harboring specific periodontal pathogens. In addition to the associated risk factors of periodontal disease such as systemic diseases, genetic polymorphisms, socioeconomic status, and tobacco smoking, depression, anxiety, and stress (DAS) also have shown a strong association with periodontitis.[6] Stress is the reaction of the body to forces of deleterious nature, infections, and various abnormal states that are found to destruct its normal physiological equilibrium.[7] This psychological stress is commonly thought to have a net-negative effect on the efficacy of the immune response, subsequently resulting in periodontal breakdown. On the other hand, depression and anxiety are also the most common psychiatric conditions associated with periodontitis and have shown a biological plausibility in the literature.[8]

Literature evidences that an association between a sound mind and a healthy body does exist; it was not classic until the work done by Selyes et al. in 1930 and 1940s wherein they stated that anxiety as well as other emotional or psychological stresses produce well-characterized neuroendocrine and biochemical changes in animal models.[9] It was shown that psychological responses to emotional stresses modulate the immune system, resulting in significant adverse effects on the proper functioning of the immune system.

Furthermore, the emphasis on stress and depression in reducing the immune system function facilitating inflammation has also been reported in several studies.[10]

On the other hand, stress has become a part of one's life, with the features of feeling down and anxiousness in the present era.

Even though student's life has many benefits, it also imposes stresses that are inevitable. Due to the various factors such as tight academic schedule, competition among the medical, dental, and pharmacy students who are designated as health professional students and also they being the future health-care professionals suffer from the burden of achieving various targets amongst them contributing to the development of psychological stress. This excessive stress inturn increases the prevalence of psychological factors such as depression, anxiety, and substance abuse and suicidal thoughts. Literature suggests that psychological stress has a detrimental effect oral health;[10] hence, this study was undertaken in an attempt to assess the effect of DAS over periodontal health indicators among the health-care professional students.

 Materials and Methods

This study was conducted in 375 undergraduate health professional students. The sample size was estimated to be 375 to detect a correlation value of 0.86 between DAS and periodontal health indicators, with 95% confidence level and 80% power of the study. Out of 375 students, 125 were medical students, 125 were dental students, and 125 were pharmacy students, who were taken from three colleges in Andhra Pradesh. Only systemically healthy students were included in the study. Students having diabetes, respiratory tract infection, and/or under antibiotic treatment within the previous 3 months and students with habits such as smoking and alcohol consumption were excluded from the study group.


Self-reported oral hygiene questionnaire

Questionnaire was prepared, and the pilot study was done. The validity of the questionnaire was conducted using Cronbach's alpha and obtained a score of 0.78. This pro forma consists of questions about oral health behavior, i.e., daily tooth brushing, frequency of brushing, flossing, and usage of mouthwashes.

Depression Anxiety Stress Scale

The DAS Scale (DASS) is a 21-item self-report questionnaire designed to measure the severity of a range of symptoms common to DAS.[11] Each question has four specified alternative answers giving scores ranging from 0 to 3: score 0 indicating that the question is “never applied to me,” score 1 indicating that “applied sometimes to me,” score 2 indicating that “applied often to me,” and score 3 indicating that “applied almost always to me.” Scale to which each item belongs is indicated by the letters D (depression), A (anxiety), and S (stress). Higher scores indicate greater DAS levels in individuals. The questionnaire has adequate internal consistency ranging from 0.70 for the stress subscale and 0.88 for the overall scale, with a sensitivity of 79.1% and a specificity of 77.0%.

Periodontal parameters

Along with the questionnaires, which pertained to DAS, periodontal parameters such as plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment level (CAL) were also assessed.[12]


The study was approved by the Institutional Review Board (VDC/IEC/2017/39) after which written informed consent was obtained from all the participants and questionnaires were given to them followed by clinical examination, wherein PI, GI, PD, and CALs were assessed. The questionnaires that were duly filled by the participants were given to the investigator in return once the clinical examination was completed.

Statistical analysis

Data were collected, entered into MS Excel spreadsheet, and analyzed through the Statistical Package for the Social Sciences package version 20 software (SPSS Inc. Chicago, IL, USA).

Statistical analysis was performed using the ANOVA test and post hoc test (Tukey's honestly significant difference test). P < 0.05 was considered statistically significant.


Medical students had maximum mean stress value (8.0 ± 2.75) and mean periodontal health indicator values (PI - 1.05 ± 0.38, GI - 0.72 ± 0.38, PD - 1.74 ± 0.35, CAL - 1.74 ± 0.35), whereas pharmacy students had higher mean values of depression (6.53 ± 3.70). The mean values of anxiety scores of medical and pharmacy students were similar (6.4 ± 3.09), whereas dental students had the least mean values of psychological and periodontal parameters. Periodontal parameters increased with psychological parameters and a statistically significant (P < 0.001) difference existed with regard to these parameters among all the groups [Table 1].{Table 1}

In medical students group, depression showed a strong correlation (P < 0.001) with PI and GI and showed moderate correlation with the PD and CAL (P < 0.001). Anxiety and stress showed a moderate correlation with the periodontal parameters, and DAS score showed a strong correlation with all periodontal parameters (P < 0.001) [Table 2].{Table 2}

A strong correlation (P < 0.001) was evident among the dental students with respect to psychological parameters (DAS) and periodontal parameters (PI, GI, PD, and CAL) [Table 2].

Among pharmacy students, these psychological factors were strongly correlated (P < 0.001) with the PI and GI, but they are moderately correlated with the PD and CAL [Table 2].


Oral health reflects the general health and overall health status of an individual. Periodontal disease and tooth decay are among the most common ailments of the oral cavity. Periodontitis, which is a multifactorial disease, is modified by various systemic conditions and risk factors such as age, diabetes, genetics, and psychological stress. On the other hand, stress has shown a direct association to periodontal disease which stands proven in the literature.[10]

The role of stress on the host immune system has been well documented in the literature.[10] Stress experienced in day-to-day life varies among the individuals depending on the various factors they are subjected to. Similarly, there is a variation in stress between professionals and nonprofessionals, wherein professionals have shown higher levels of stress when compared to nonprofessionals.[13] Among the various professionals, health professionals are the one who play a vital role in the society. Being the forerunners for health-care system, they are subjected to greater stress-related responsibilities.[14] Hence, this study was taken up in an attempt to evaluate the effect of DAS over periodontal health indicators among health professional students.

Medical students are considered as the first-line health-care professionals and are confronted with significant stressors. Education in the medical field intends an intensive preparation of graduates in an attempt to achieve a personally rewarding and socially meaningful career, and hence, strenuous medical programs may have physical and psychological effects on the well-being of medical students. Literature search has also showed that medical students experience high levels of stress during the tenure of their undergraduate training.[15] In the present study, medical students have depicted higher stress levels than pharmacy and dental students, and these results are in accordance with a study where stress levels among medical, dental, pharmacy, and nursing students were compared.[16]

On the other hand, the academic and professional outcomes, which can be attributed to lower grades and career dissatisfaction, are the reasons behind stress attributed to the pharmacy student population. Even though the previously identified stressors in pharmacy students included were examinations, lack of English proficiency, overstressed workload, etc., the scarcity of research on stress and mental health of pharmacy students makes it difficult to identify the predisposing factors behind. Previous studies suggested that pharmacy students have elevated levels of stress, but not necessarily harmful.[17] In our study, higher depression levels and comparable anxiety levels were evident among pharmacy students, and these results are in coincidence with the results of a study conducted among health professional students.[18]

On the other hand, dentistry being an art and science in to and due to the demanding nature of the training itself evidenced from the research, it was shown that dental students experience considerable amount of stress during training. However, the research confirms that the main effects of stress are attributed to low academic performance and psychoemotional well-being. The fear of failing in examinations has been the main stressor across the 5-year study period to be the underlying cause that can be attributed to the stress among dental students, regardless of the year of BDS course, and the reason attributed to the stress experienced by student was the significant workload, and these findings of our study are in coincidence with the study conducted to compare stress levels among medical and paramedical students.[19] However, in contrary to our findings, other studies suggested higher stress levels in dental students than that of medical and pharmacy students.[20],[21] However, conflicting results were obtained from various studies, regarding the comparison of these psychological factors among health professional students.

Chronic stress has been thought to have net-negative effect on immune response, leading to imbalance between host and parasites, thereby resulting in periodontal breakdown. Previous studies have shown that academic stress among students can cause gingival inflammation and diminution of the quality of oral hygiene.[22]

It has become more apparent that stress can negatively influence the oral health status.[23],[24] The present study revealed that PI and GI values were higher among medical students followed by pharmacy students and dental students, and this increase in periodontal parameters is in positive correlation with increasing stress values among these three groups. As a result of an increase in stress values, increase in PI and GI values was also evident. This correlation may be due to the negligence of oral hygiene practice under stressful conditions. A few studies suggested that under conditions of stress, students generally neglect their oral health care, thereby affecting the plaque and gingival scores.[25],[26] These findings are in coincidence with the findings of our study. Similarly, other studies conducted to observe the effect of examination stress on periodontal health status suggested that there is a strong evidence of association between examination stress and periodontal parameters.[27]

Since 1950s, the role of emotional factors with regard to periodontal disease has been elicited in the literature. The association of stress with periodontal disease is difficult to prove since some of the factors that are assumed in the causation of periodontal disease have not been identified.

In the present study, higher levels of GI were seen among the students with higher mean values of DAS. One of the probable factors that can lead the patient to neglect oral hygiene could be attributed to the psychological disturbances having an unfavorable effect on the periodontal tissues.

On the other hand, participants who are highly susceptible to depression had shown higher values of PI and GI, the reason behind this being attributed to the direct influence of stress on the immune system, thereby resulting in increased susceptibility to periodontal disease.[28]

Similarly, a direct correlation between the severity of periodontal disease and the severity of depression has been evidenced in the literature.[29]

The periodontal parameters, which have been evidenced to be low among the dental students in our study, have shown a positive correlation with psychological parameters; this could be attributed to the increased levels of awareness in the dental students regarding oral hygiene practices.

Although most of the studies in the literature do exist eliciting evidence with regard to the effect of these psychological parameters over periodontal health indicators, there are few studies which do not suggest significant relationship between the duo.[29] Interestingly, the findings of our study are in coincidence with most of the studies in the literature that have shown a significant relationship between the effects of DAS over periodontal health indicators.


Among the three groups, medical students depicted higher values of both psychological and periodontal parameters compared to dental and pharmacy students. Therefore, it was concluded that the psychological factors have an adverse effect over the plaque levels and gingival status among the students. The worsening of plaque values and GI values could be attributed to the negligence nature of oral hygiene maintenance during stressful conditions. Hence, it can be recommended that students should be educated about their oral hygiene maintenance and stress – oral hygiene relationship, thereby avoiding the stress-induced factor behind the negligence of oral hygiene.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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