Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 2  |  Page : 573-577

Stress levels in patients visiting for dental treatment: a cross-sectional hospital-based study


1 Department of Preventive Dental Sciences, Division of Periodontology, College of Dentistry, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
2 Department of Oral Medicine and Radiology, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Oral Medicine and Radiology, Sri Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh, India
4 Department of Pedodontics and Preventive Dentistry, Sri Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh, India
5 Department of Oral and Maxillofacial Surgery, Sri Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh, India
6 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India

Date of Submission21-Oct-2021
Date of Decision25-Jan-2022
Date of Acceptance30-Jan-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Abhishek S Nayyar
Oral Medicine and Radiology, Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani- 431 401, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_212_21

Rights and Permissions
  Abstract 


Background
Potentially stressful life events are thought to increase risk for a given disease. In turn, perception of stress might influence the pathogenesis of physical disease by causing negative affective states which, then, exert direct effects on the physiological processes of the individual that influence the predisposing and/or, risk factors for a given disease process.
Objective
To assess stress levels in patients coming for dental treatment using perceived stress scale.
Patients and methods
The present cross-sectional study consisted of 598 individuals randomly selected from the Outpatient Department aged 18 years and above over a period of 6 months, while perceived stress scale was used to measure perception of stress.
Results
In the present study, data collected revealed that unskilled individuals (29.4%) sought dental treatment more than other categories of occupational groups, while a correlation between occupation and the levels of stress revealed that stress levels were considerably lower in professionals with the results being highly significant, P value being 0.002.
Conclusion
From the present study, it could be concluded that in most of the cases, stress and dental problems were closely linked with one other with one aggravating the other.

Keywords: autoimmune diseases, behavioral patterns, disease process, immune system, physiological processes, psychological stress, risk factors, well-being


How to cite this article:
Suresh BJ, Chandolu S, Muthusamy D, Ramana RM, Navaneet SS, Ramesh NB, Nayyar AS. Stress levels in patients visiting for dental treatment: a cross-sectional hospital-based study. Menoufia Med J 2022;35:573-7

How to cite this URL:
Suresh BJ, Chandolu S, Muthusamy D, Ramana RM, Navaneet SS, Ramesh NB, Nayyar AS. Stress levels in patients visiting for dental treatment: a cross-sectional hospital-based study. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:573-7. Available from: http://www.mmj.eg.net/text.asp?2022/35/2/573/352150




  Introduction Top


The word stress is generally used to imply to the things that pose a challenge or, a threat to the normal well-being of an individual. Potentially stressful life events are thought to increase risk for a given disease when one perceives that the demands, these events impose, exceed an individual's adaptive capacity. In turn, the perception of stress might influence the pathogenesis of physical disease by causing negative affective states which, then, exert direct effects on the physiological processes or, behavioral patterns of the individual that influence the predisposing and/or, risk factors for a given disease process. It is a common assumption among the health researchers that the impact of subjectively stressful events is, to a certain extent, determined by an individual's perception of their stressfulness[1]. The psychological states and traits of an individual might influence the immune system in a manner that might alter body's ability to fight-off a given disease process. Psychological stress is thought to influence a wide range of physiological processes and disease states with existing evidence supporting stress as a risk factor in depression, cardiovascular disease, HIV/AIDS, delayed wound healing, upper respiratory infections, autoimmune diseases, and overall mortality in the individuals[2],[3]. Sometimes, it is difficult to distinguish conceptually between an individual's perceived stress and psychological distress. For example, feelings of stress and overload are viewed as symptoms of psychological disorder. As a result, a correlation between a scale assessing perceived stress and one assessing psychological distress may be partly or totally attributable to the fact that some of the items in the two scales measure similar or identical concept. In short, cross-sectional correlation between perceived stress and psychological distress may be totally artificial and correlation between perceived stress and physical disorder may actually reflect an association between psychological distress and physical disorder[1]. Perceived stress scale (PSS) is one such objective questionnaire that has been designed to tap the degree to which individuals find their lives unpredictable, uncontrollable, and overloading. These three issues have been repeatedly found to be the central components of the experience of stress. Surprisingly, this theoretical perspective has not been accompanied by development of psychometrically valid measures of perceived stress in the field of odontogenic problems. The present study was thus planned as an attempt to assess stress levels in patients coming for dental treatment using PSS questionnaire used to measure an individual's perception of stress over the past months and to determine the likelihood of whether this perceived stress might be making them more susceptible to stress-induced compromises of health. The aim of the present study was to assess stress levels in patients coming for dental treatment using PSS.


  Patients and methods Top


The present cross-sectional study consisted of 598 individuals randomly selected from the Outpatient Department aged 18 years and above over a period of 6 months, while PSS was used to measure perception of stress [Table 1]. The said scale was tested for internal validity before the actual conduct of the study and was found to have good internal consistency/reliability with a Cronbach's alpha coefficient of 0.78. A written, informed consent was obtained from all the participants before their inclusion in the study, while ethical clearance was obtained from the Institutional Ethics Committee before the start of the study via Institutional Ethics Committee Letter approval no SDDC/IEC/02-39-2019. Higher PSS scores have been found to be associated with higher levels of stress and indicate a greater likelihood for stress interfering with the lifestyle patterns and the ability of the affected individuals to improvise. Higher scores have also been found to be associated with an increase in an individual's vulnerability to compromised health and with an increased susceptibility to stress-induced illnesses.
Table 1: Perceived stress scale scores and associated levels of health concern

Click here to view


Statistical analysis used

The data were analyzed using SPSS, version 15.0 (SPSS Inc., Chicago, Illinois, USA). The statistical software used for the analysis of the data included SAS 9.2, SPSS, version 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0, and R-environment, version 2.11.1, while Microsoft word and Excel were used to generate tables, graphs, etc., The results on continuous data were presented as mean ± SD (minimum–maximum), while the results on categorical measurements were presented in numbers and percentage. Also, χ2/Fisher's exact test were used to find significance of the study parameters on the categorical scale between two or more groups, while P value of less than 0.05 was considered statistically significant.


  Results Top


The distribution of the patients according to their occupation revealed most of them to be from the unskilled group with 176 (29.4%) patients, while the least commonly seen were from the group of miscellaneous category with only eight (1.3%) patients in the said group [Table 2]. Housewives and students constituted the second and third largest groups with 152 (25.4%) patients and 102 (17.1%) patients observed in those groups [Table 2]. The study groups divided on the basis of clinical/radiological diagnosis revealed 245 (40.9%) patients diagnosed with chronic generalized gingivitis, while the least-common condition diagnosed was leukoplakia with only nine (1.5%) cases reported [Table 3]. Surprisingly, perceived stress levels among the patients revealed maximum patients falling under the category of high-level stress with scores between 16 and 20 constituting 42.0% patients followed by the category of very-high-level stress with 130 (21.7%) patients' involvement [Table 4]. Only 38 (6.4%) patients were observed with very-low-level stress with scores of less than 6 [Table 4]. The present study also investigated the correlation between the clinical/radiological diagnosis and perceived stress levels in which patients diagnosed with oral submucous fibrosis (OSF) and lichen planus showed highly significant results with relatively higher-level stress with corresponding P values of 0.027 and 0.03, respectively [Table 5]. Similarly, the findings of the present study revealed the correlation between the occupation of the patients and perceived stress levels depicting strongly significant results for the professionals with significantly low-level stress with the corresponding P value of 0.002 [Table 6].
Table 2: Distribution of patients according to occupation

Click here to view
Table 3: Study group split on the basis of clinical/radiological diagnosis

Click here to view
Table 4: Perceived stress levels among patients

Click here to view
Table 5: Distribution of patients based on clinical/radiological diagnosis and perceived stress levels

Click here to view
Table 6: Distribution of patients based on occupation and perceived stress levels

Click here to view



  Discussion Top


Psychological stress has been found to contribute to increased disease risk, accelerated disease progression, greater symptom reporting, more frequent health-service utilization, and increased mortality apart from the mentioned morbidity-related features. The term 'psychological stress' has been defined as the extent to which an individual perceives (appraises) that demands exceed the ability to cope in life. PSS was developed by Cohen et al.[3] to measure the degree to which situations in an individual's life are appraised as stressful and was first published in 1983. Since then, it has become one of the most widely used instruments for measuring nonspecific perceived stress. The associated questionnaire is used to measure an individual's perception of stress and to determine the likelihood of whether perceived stress might be making them more susceptible to stress-induced compromises of health.

PSS has been used in a plethora of studies assessing the stressfulness of the situations, the effectiveness of stress-reducing interventions, and the extent to which there are associations between psychological stress and psychiatric and physical disorders [4–12]. The PSS predicts both, the objective biological markers of stress and the increased risk for disease among individuals with higher perceived levels of stress [13–24]. The scale also includes a number of direct queries about current levels of experienced stress wherein the questions asked are easy to understand and the response alternatives are simple to grasp. Moreover, the questions are of a general nature and hence, are relatively free of content specific to any group.

The questions in PSS ask about the feelings and thoughts during the last months of an individual's life. In each case, respondents are asked how often they felt a certain way. PSS is easy to use and is an economical scale that can be administered only in a few minutes and is easy to score[1]. Furthermore, it provides better predicition than obtained with life-event scales of psychological and physical symptoms and utilization of health services. It has also been used as an outcome variable with life events, coping processes, and personality factors prospectively prediciting changes in the PSS scores[1].

Prior to the development of PSS, assessment of stress tended to focus on objective indicators of specific stressors. This tendency subsequently overlooked the influence an individual's subjective interpretation of a stressor, including long-term impact, it might have upon the life of an individual[3]. Cohen et al.[3] viewed this void of subjective component in assessing stress and developed PSS in response. Specifically, PSS is based on Lazarus's original transactional model of stress that argues that the experience of a stressor is influenced by evaluations on the part of the individual as to how well an individual can manage the stressor given the coping resources[25].

The original PSS consisted of 14 items that were purported to form a unidimensional scale of global perceived stress[3]. Although scores on the 14-item PSS tended to exhibit good reliability estimates across the literature, four of the items tended to perform poorly when evaluated using exploratory-factor analysis[1]. As a result, PSS is commonly implemented using the 10-item form[26]. Up till now, comparing stress levels in our society has been impeded by a lack of study of stress. So, an attempt was made to assess stress levels in patients coming for dental treatment using PSS questionnaire.

In the present study, data collected revealed that unskilled individuals (29.4%) sought dental treatment more than other categories of occupational groups, including the skilled, business, executive, service, and professional groups followed by housewives (25.4%) and students (17.1%). Out of the 598 patients screened who came for dental treatment, 40.9% cases were diagnosed to have chronic generalized gingivitis as the patients experienced symptoms of bleeding, halitosis, and other gingival problems, which were the main reasons of concern followed by tooth decay (22.4%) and pain and swelling in relation to the teeth (acute periapical abscess, 9%). On the other hand, oral potentially malignant epithelial lesions like leukoplakia cases reported were rare (1.5%), most of which were diagnosed during routine clinical examinations and were not the basis of patients' chief complaints. When patients were questioned regarding the same, it was found that they were not worried about them much since such lesions did not pose any problem in the normal functioning of their lives. This posed as a challenge in educating the patients regarding the risky nature of such lesions as being more prone for frank malignant degenerations.

Furthermore, in the present study, it was found that patients coming for dental treatment had high levels of stress with 251 (42%) of the patients falling under the same category followed by very high level of stress observed in 130 (21.7%) patients, suggesting that patients coming for dental treatment were stressed out in their lives regarding their personal and family problems. The correlation between levels of stress and disease prevalence in oral cavity showed a moderately significant relation with the corresponding P value being 0.01 with the respective P values for the same in case of OSF and oral lichen planus being 0.027 and 0.03, respectively. When the patients were counseled, it was observed that the conditions that made the patients to visit the hospital were difficulty in opening the mouth and burning sensation with difficulty in chewing food being the prime concerns in the said situations that brought the patients under high and very high levels of stress eventually resulting in their visit to dental hospitals for the treatment.

The said two conditions were followed by chronic generalized gingivitis with a P value being 0.11 for which the patients had significant amount of stress, leading to their visit to dental hospitals for treatment. On the other hand, most of the edentulous patients reported to dental hospitals to get dentures. In patients with acute periapical abscess, stress level was found to be 0.163, which was not found to be statistically significant. Similarly, in case of patients diagnosed with chronic irreversible pulpitis, the stress levels were not found to be statistically significant as the patients did not experience any symptoms of pain and/or discomfort, except while having food.

Correlation between the occupation and stress showed that stress levels were considerably lower in the professionals with the results being highly significant, P value being 0.002 while higher in unskilled groups (farmers, labors, and shopkeepers), P value being 0.804 and others, and P value being 0.925 showing the impact of education and social well-being affecting the same in a considerable manner with the conclusion that the patients who were well-educated were well-versed with the conditions and related problems of the oral cavity.


  Conclusion Top


From the present study, it could be concluded that in most of the cases, stress and dental problems were closely linked with one another. This can be further substantiated from the fact that restricted mouth opening and burning sensation perceived in OSF patients aggravated stress in such patients, while in case of lichen planus, stress itself was the major predisposing factor and got aggravated in the affected patients due to perception of burning sensation, thus further worsening the situation. It, therefore, becomes all the more important to combat stress in addition to management of the primary concern per se, be it OSF or lichen planus in such situations.

Acknowledgements

Acknowledgment: to all the patients who contributed in the study without whom this study would not have been feasible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are o conflicts of interest.



 
  References Top

1.
Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S, (editors). The social psychology of health: claremont symposium on applied social psychology. Newbury Park, CA: Sage; 1988. pp. 31–67.  Back to cited text no. 1
    
2.
Kelly G, Percival M. Perceived stress scale [Internet]. Health Science Investigation; 2006–2010. [Place of publication unknown].  Back to cited text no. 2
    
3.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24:385–396.  Back to cited text no. 3
    
4.
Leon KA, Hyre AD, Ompad D, DeSalvo KB, Muntner P. Perceived stress among a workforce 6 months following hurricane Katrina. Soc Psychiatry Psychiatr Epidemiol 2007; 42:1005–1011.  Back to cited text no. 4
    
5.
McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KWT, Sham PC, et al. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry 2007; 52:241–247.  Back to cited text no. 5
    
6.
Cruess DG, Antoni MH, Kumar M, Ironson G, McCabe P, Fernandez JB, et al. Cognitive-behavioral stress management buffers decreases in dehydroepiandrosterone sulfate (DHEA-S) and increases in the cortisol/DHEA-S ratio and reduces mood disturbance and perceived stress among HIV-seropositive men. Psychoneuroendocrinology 1999; 24:537–549.  Back to cited text no. 6
    
7.
Holzel BK, Carmody J, Evans KC, Hoge EA, Dusek JA, Morgan L, et al. Stress reduction correlates with structural changes in the amygdala. Soc Cogn Affect Neurosci 2010; 5:11–17.  Back to cited text no. 7
    
8.
Lane JD, Seskevich JE, Pieper CF. Brief meditation training can improve perceived stress and negative mood. Altern Ther Health Med 2007; 13:38–44.  Back to cited text no. 8
    
9.
Marcus MT, Fine PM, Moeller FG, Khan MM, Pitts K, Swank PR, et al. Change in stress levels following mindfulness-based stress reduction in a therapeutic community. Addict Disord Their Treat 2003; 2:63–68.  Back to cited text no. 9
    
10.
Culhane JF, Rauh V, McCollum KF, Hogan VK, Agnew K, Wadhwa PD. Maternal stress is associated with bacterial vaginosis in human pregnancy. Matern Child Health J 2001; 5:127–134.  Back to cited text no. 10
    
11.
Garg A, Chren MM, Sands LP, Matsui MS, Marenus KD, Feingold KR, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol 2001; 137:53–59.  Back to cited text no. 11
    
12.
Kramer JR, Ledolter J, Manos GN, Bayless ML. Stress and metabolic control in diabetes mellitus: methodological issues and an illustrative analysis. Ann Behav Med 2000; 22:17–28.  Back to cited text no. 12
    
13.
Epel ES, Blackburn EH, Lin J, Dhabhar FS, Adler NE, Morrow JD, et al. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci U S A 2004; 101:17312–17315.  Back to cited text no. 13
    
14.
Malarkey WB, Pearl DK, Demers LM, Kiecolt-Glaser JK, Glaser R. Influence of academic stress and season on 24-hour mean concentrations of ACTH, cortisol, and beta-endorphin. Psychoneuroendocrinology 1995; 20:499–508.  Back to cited text no. 14
    
15.
Pruessner JC, Hellhammer DH, Kirschbaum C. Burnout, perceived stress and cortisol responses to awakening. Psychosom Med 1999; 61:197–204.  Back to cited text no. 15
    
16.
van Eck MM, Nicolson NA. Perceived stress and salivary cortisol in daily life. Ann Behav Med 1994; 16:221–227.  Back to cited text no. 16
    
17.
Maes M, Van Bockstaele DR. The effects of psychological stress on leukocyte subset distribution in humans: evidence of immune activation. Neuropsychobiology 1999; 39:1–9.  Back to cited text no. 17
    
18.
Burns VE, Drayson M, Ring C, Carroll D. Perceived stress and psychological well-being are associated with antibody status after meningitis C conjugate vaccination. Psychosom Med 2002; 64:963–970.  Back to cited text no. 18
    
19.
Cohen S, Doyle WJ, Skoner DP. Psychological stress, cytokine production and severity of upper respiratory illness. Psychosom Med 1999; 61:175–180.  Back to cited text no. 19
    
20.
Glaser R, Kiecolt-Glaser JK, Marucha PT, MacCullum RC, Laskowski BF, Malarkey WB. Stress-related changes in pro-inflammatory cytokine production in wounds. Arch Gen Psychiatry 1999; 56:450–456.  Back to cited text no. 20
    
21.
Carpenter LL, Tyrka AR, McDougle CJ, Malison RT, Owens MJ, Nemeroff CB, et al. Cerebrospinal fluid corticotropin-releasing factor and perceived early-life stress in depressed patients and healthy control subjects. Neuropsychopharmacology 2004; 29:777–784.  Back to cited text no. 21
    
22.
Cohen S, Tyrrell DA, Smith AP. Negative life events, perceived stress, negative effect and susceptibility to the common cold. J Pers Soc Psychol 1993; 64:131–140.  Back to cited text no. 22
    
23.
Dyck DG, Short R, Vitaliano PP. Predictors of burden and infectious illness in schizophrenia caregivers. Psychosom Med 1999; 61:411–419.  Back to cited text no. 23
    
24.
Ebrecht M, Hextall J, Kirtley LG, Taylor A, Dyson M, Weinman J. Perceived stress and cortisol levels predict speed of wound healing in healthy male adults. Psychoneuroendocrinology 2004;29:798–809.  Back to cited text no. 24
    
25.
Shewchuk RM, Elliott TR, MacNair-Semands RR, Harkins SW. Trait influences on stress appraisal and coping: an evaluation of alternative frameworks. J Appl Soc Psychol 1999; 29:685–704.  Back to cited text no. 25
    
26.
Taylor JM. Psychometric analysis of the ten-item perceived stress scale. Psychol Assess 2015; 27:90–101.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed638    
    Printed20    
    Emailed0    
    PDF Downloaded74    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]