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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 262-269

Oral manifestations of stress-related disorders in the general population of Ludhiana


1 Department of Oral Medicine and Radiology, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana, Punjab, India
2 Department of Conservative Dentistry and Endodontics, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana, Punjab, India

Date of Submission09-Jan-2016
Date of Acceptance02-Dec-2016
Date of Web Publication13-Dec-2016

Correspondence Address:
Dr. Damanpreet Kaur
Department of Oral Medicine and Radiology, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana - 141 010, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.195671

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   Abstract 

Introduction: Oral diseases associated with psychological disorders have long been known in medicine. Emotional as well as psychological factors may act as significant risk factors in the initiation and progression of oromucosal diseases. Aims and Objectives: The aim of this study was to determine a correlation between stress and development of certain oral conditions such as lichen planus, myofacial pain dysfunction syndrome, xerostomia, bruxism, aphthous ulcers, and burning mouth syndrome. Materials and Methods: An observational comparative study was conducted among patients reporting to the Department of Oral Medicine and Radiology. A total of 130 patients gave a positive history of oral lesions, out of which 62 were stress related and the other 68 patients served as the control group (oral lesions with no history of stress). All these patients were subjected to routine systemic and oral examination. The results obtained were statistically compared using P value, t-test, and Chi-square test. Results: It was found that lichen planus and burning mouth syndrome were more common in females and myofacial pain dysfunction syndrome was prevalent in males. Xerostomia was found to increase with age. Conclusion: It was concluded that, though the etiology of most oral lesions is not known, the role of stress and other psychogenic factors cannot be ruled out in their occurrence.

Keywords: Aphthous ulcer, burning mouth syndrome, lichen planus, myofacial pain dysfunction syndrome


How to cite this article:
Kaur D, Behl AB, Isher PP. Oral manifestations of stress-related disorders in the general population of Ludhiana. J Indian Acad Oral Med Radiol 2016;28:262-9

How to cite this URL:
Kaur D, Behl AB, Isher PP. Oral manifestations of stress-related disorders in the general population of Ludhiana. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2019 Oct 17];28:262-9. Available from: http://www.jiaomr.in/text.asp?2016/28/3/262/195671


   Introduction Top


Psychological stress adversely affects the physiological functioning of a person to a significant point of distress.[1] The National Institute of Mental Health and Neurosciences (NIMHANS) in Bengaluru estimated that 20 million Indians need help for serious mental disorders, while a further 50 million suffer from mental illnesses that are not considered very serious.[2] These diseases have physical symptoms originating from mental or emotional causes, most common of which are stress, anxiety, and depression.[3] Stress is defined as a physical, mental, or emotional response to events that cause bodily or mental tension.[4] Human body undergoes a series of chemical events during stress, which affect various organs enabling us for bearing these unpleasant stimuli. As a side effect of prolonged exposure to these chemical changes, the body develops various homeostatic/metabolic/endocrinal/immunological disturbances. A few common examples are headache, hypertension, gastric ulcerations, diabetes mellitus, etc.[5]

A psychosomatic disorder is the one that involves both the body and mind as they are one and influence each other. Diseases interact between body and mind and mind and body.[3] Mouth is directly or symbolically related to major human instincts and passion.[6] Oral diseases with psychosomatic etiology have long been known in medicine. Mental or emotional factors may act as risk factors that could influence the initiation and progression of oromucosal diseases,[7],[8] Symptoms of stress include:[9]

  • Cognitive symptoms – memory problems, inability to concentrate, poor judgement, seeing only negative, constant worrying
  • Emotional – moodiness, irritability, short temper, inability to relax, sense of loneliness and isolation, depression
  • Physical symptoms – aches and pains, diarrhoea and constipation, nausea, rapid heartbeat, frequent cold
  • Behavioral symptoms – eating more or less, sleeping too much or too little, isolating oneself.


People with stress might develop parafunctional habits, i.e., unconscious efforts to reduce stress such as biting, chewing on pencil, or any other object leading to dental attrition of teeth; abnormal positioning and tight closure of the jaws affecting the masticatory muscles leading to bruxism and myofacial pain dysfunction syndrome (MPDS)-like symptoms. Gastric disturbances with irregular eating habits can cause vomiting leading to dental erosion.[10],[11]

There are other oral problems that also start as a result of stress and need special attention. Some of these are MPDS, aphthous ulcers, oral lichen planus, xerostomia, burning mouth syndrome, and bruxism.[12],[13],[14] Anecdotal reports suggest an increase in young adults presenting with stress-related oral conditions, particularly students appearing for exams.[15] A brief etiological background of stress related oral lesions is discussed below.

Lichen planus is an autoimmune condition with psychological stress as a major risk factor.[4] Laskin's psycho-physiological theory states that MPDS is primarily a result of emotional rather than occlusal and mechanical factors. The theory states that stress can cause clenching and grinding, which in turn can lead to muscle fatigue and finally spasm.[16] Patients with MPDS report psychological symptoms such as frustration, anxiety, depression, and maladaptive behavior such as pain, poor sleep, dietary habits, and clenching. Bruxism is seen when the problem becomes prolonged.[17] Psychological stress as a triggering factor for recurrent aphthous stomatitis (RAS) has been mentioned in literature, and the lesions are found to occur in stressful situations [18] such as school exams, dental treatment,[19] and periods of significant changes in life.[20] Sleep disturbances and behavioral/psychiatric disorders are common etiological factors of bruxism.[15] Burning mouth syndrome is a condition which is commonly found in people with sleep disturbances and behavioral or psychogenic disorders.[4] Dry mouth also known as xerostomia, which is the abnormal reduction of saliva, can be a common finding in psychiatric patients.[15]

Aims and objectives

The aims of the present study were to determine the positive correlation between stress and various oral lesions as well as to evaluate:

  • The role of stress in oral lesions such as lichen planus, MPDS, burning mouth syndrome, aphthous ulcers, bruxism, xerostomia
  • Correlation between the stress and oral lesions and their prevalence according to age and gender of the patients.



   Materials and Methods Top


An observational comparative study was conducted among patients reporting to the Department of Oral Medicine and Radiology. A total of 130 patients gave a positive history of oral lesions, out of which 62 were stress related, and the other 68 patients served as control group (oral lesions with no history of stress). During a 2-year follow up, 6 patients did not report back and were excluded from the study. In the cases (stress-related group), there were 22 male and 40 female patients, whereas in the control group, there were 19 male and 43 female patients [Table 1].
Table 1: Sex distribution of participants

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After a detailed case history, all these patients were subjected to routine systemic and oral examination. A clinical diagnosis based on the examination and findings was formulated and a symptomatic treatment plan was initiated with a regular follow up of the patients. The results obtained were compared statistically using P value, t-test, Chi-square test.

Inclusion criteria

  • Patients within the age group of 20–70 years [Table 2]
  • Patients having MPDS, oral lichen planus, burning mouth syndrome, aphthous ulcers, bruxism, and xerostomia.
Table 2: Age distribution of participants

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Exclusion criteria

  • Patients <20 years and >70 years of age
  • Patients not reporting for follow-up during the study period
  • Confounding factors associated with the abovementioned diseases were ruled out prior to the selection of the study sample.



   Results Top


Incidence of oral diseases according to age of cases is presented in [Table 3]. It was seen that MPDS was more prevalent in the age group of 31–40 years followed by 20–30 years. The severity of xerostomia increased with increasing age, and was found to be significantly more in the age group of 61–70 years. Incidence of diseases according to the age in control group is presented in [Table 4]. The presence of lesions in control group was not found to be statistically significant. Incidence of diseases according to specific age group among cases and controls are presented in [Table 5],[Table 6],[Table 7],[Table 8],[Table 9].
Table 3: Incidence of diseases according to the age in cases

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Table 4: Incidence of diseases according to the age in controls

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Table 5: Incidence of diseases in 20-30 years of age among cases and controls

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Table 6: Incidence of diseases in 31-40 years of age among cases and controls

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Table 7: Incidence of diseases in 41-50 years of age among cases and controls

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Table 8: Incidence of diseases in 51-60 years of age among cases and controls

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Table 9: Incidence of diseases in 61-70 years of age among cases and controls

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When the comparison between cases and controls was done, in ages 31–70 years, there was a significant increase in the lesions in cases than that in controls. Incidence of various diseases among cases and controls is presented in [Table 10]. When cases and controls were compared, there was a significant difference between the incidence of burning mouth syndrome in patients of the case group than those in control group, i.e., 8:1. Incidence of various diseases according to gender in cases and controls is presented in [Table 11] and [Table 12], respectively.
Table 10: Incidence of diseases among cases and controls

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Table 11: Incidence of diseases according to the sex in cases

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Table 12: Incidence of diseases according to the sex in controls

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When both the genders were compared, lichen planus more commonly affected females (24), than males (7). The difference was found to be statistically significant, which is in accordance with a study conducted by Uma Maheshwari and Gnanasundaram.[4] When both genders were compared for MPDS, it was found that males were more predominantly affected than females, i.e., 10:6, which was statistically significant. Incidence of diseases among males belonging to case and control groups is presented in [Table 13]. Incidence of diseases among females belonging to case and control groups is presented in [Table 14]. Oral diseases were found to be significantly higher in both genders in cases than in the control group.
Table 13: Incidence of diseases among males belonging to cases and controls

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Table 14: Incidence of diseases among female subjects belonging to cases and controls

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   Discussion Top


Lichen planus

Lichen planus is a relatively common dermatoses that also affects the oral mucosa. The classical description of papules, striations, and plaques was provided by Unna in 1882. The first independent oral lesions were observed by Audry in 1894.[21] The etiology of LP comprises a cell-mediated immunological response or disturbance, which leads to the degeneration of the basal epidermal cells.[22] It consists of slightly elevated thin whitish lines in the form of a ring or ring-like lesion.[23] The most frequent conditions which may lead to lichen planus are depression, anxiety, and stress.[24]

Oral symptoms may persist for many years with periods of exacerbation and quiescence. During periods of exacerbation, there is increased erythema or ulceration with severe pain and sensitivity. During periods of quiescence, there is a decrease in symptoms.[25] Exacerbation of oral lichen planus has been linked to periods of psychological stress and anxiety,[26] which has been demonstrated in our study as well. A significant P value of 0.046 was noted in cases with lichen planus when both genders were compared, with more number of females (24) being affected as compared to males (7), which is in accordance with similar other studies.[4] Lichen planus was observed more in the age group of 41–50 years followed by 51–60 years. The results were in accordance with the study conducted by Nally and Ubaidy in 1973.[21]

Myofacial pain dysfunction syndrome

Shwartz was the first to implicate the psychological makeup of the patient as a predisposing factor in the MPDS. According to him, stress was a significant cause for clenching and grinding habits resulting in spasm of muscles of mastication.[27] According to Travell and Simons, myofacial pain results from trigger points, which are discrete focal hyperirritable spots located in the taut bands of skeletal muscles.[28] A study by Alvarez and Rockwell revealed that chronic musculoskeletal pain disorders affect approximately 10% of the population of United States of America. One of these musculoskeletal disorders is myofacial pain syndrome.[29] As stated by Simon and Backstrom, stress is defined as human body's response to a demand placed, upon which it can result in negative impact on the body such as MPDS.[30] MPDS was seen in the age group of 31–40 years followed by the age group of 41–50 years. A significant P value was noted to be 0.029. When compared between both the genders, a significant P value of 0.009 was seen with more number of males being affected (10) as compared to the females (6).

Recurrent aphthous stomatitis

It affects approximately 20% of the general population.[31] The term aphthous has been derived from the Greek word aphtha meaning ulceration.[32] One or two days before the onset of ulceration, the prodromal phase of paresthesia followed by pain is present. In cases of aphthous ulcers, acute psychological problems appear to have precipitated attacks of the disease.[33] Iron, vitamin B12, and folic acid deficiency are also considered to be predisposing factors.[34] Other factors that have readily been implicated in promotion or exacerbation of RAS include positive family history, local trauma, smoking cessation, and psychological stress.[35],[36],[37] Psychological stresses induce immunoregulatory activities by increasing the number of leukocytes at the sites of inflammation.[38] Recurrent aphthous ulcers were seen equally in the age group of 31–60 years and were more frequent in females as compared to males.

Bruxism

Bruxism is excessive grinding of the teeth that usually occurs during sleep causing mild-to-severe attrition of occlusal surfaces. Grinding of teeth is considered to be a neurotic habit. It may result in wearing of teeth and trauma to the periodontal tissues, occasionally facial musculature and temporomandibular joint (TMJ) structures.[39],[40] A study by Kaur et al. among 450 patients demonstrated bruxism in higher prevalence in psychiatric patients than in normal individuals,[1] which is a similar finding in our study. It was more prevalent in males than in females and was seen more in the age group of 31–40 years.

Burning mouth syndrome

It is associated with burning sensation of the tongue, lips, and other mucosal surfaces. Sleep disturbances are a common finding among burning mouth syndrome patients.[4] The exact cause of burning mouth is still unknown, however, suggested possible causative factors include hormonal disturbances associated with menopause; psychogenic factors such as stress, anxiety, and depression; life events; personality disorders; cancer phobia; and nerve abnormalities.[41] In our study, it was found to be more in females than in males and significantly higher in stress-related patients than that in controls. It was in accordance with the study conducted by Gnanasundaram and Uma Maheshwari in 2010, which stated that more number of females were affected than males. It was observed that maximum patients with burning mouth syndrome were in the age group of 51–60 years and 61–70 years.

Xerostomia

Dry mouth syndrome, also known as xerostomia, is the abnormal reduction of saliva and can be a common finding in psychiatric patients. Dryness of mouth affects the quality of life.[3] In young adults, the causes are usually associated with stress, anxiety, depression, and nutritional deficiencies. Alcohol abuse and use of illicit drugs also are significant contributors in the etiopathogenesis of dry mouth.[15] Xerostomia was found to be more in female than in male patients, and was reported to be higher in cases than in controls in the present study. The amount of xerostomia increases with advancing age, and was seen more in the age group of 51–60 and 61–70 years.


   Conclusion Top


Within the scope of the present study, it was concluded that, although the etiology of most oral lesions is not known, the role of stress and other psychogenic factors cannot be ruled out. The results of our study have shown stress to be one of the major contributory factors in the development and progression of oral lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]



 

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