6.BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study
Stress is a catch phrase in the modern world. It is said that majority of modern diseases are psychosomatic in nature. Stress is an internal source for several external manifestations in the form of disease, disorder or disability. Hans Seyle defined stress as physiological or psychological strain caused by adverse stimuli, physical, mental or emotional, internal or external that tends to disturb the function of organism and which the organism naturally desires to avoid.1 Stress has physiological and also psychological components. It has been shown to be associated with cardiovascular diseases, gastro-intestinal disorders, various malignancies, autoimmune diseases, neuro-dermatitis, asthma and certain infectious diseases.2
Stress seems to be related to specific personality traits. Personality trait is quite often considered as better predictor of stress. Specific personality traits show high predilection towards stress and hence stress related diseases. Personality traits are discussed under psychosocial determinants of oral health. Psychosocial determinants of oral health constitute a complex domain of several psychological and social factors that have profound influence on oral health. Several salivary parameters like salivary pH, salivary secretion rate, salivary flow rate and salivary level of minerals are found to vary depending on personality traits. 3
Dental caries and periodontal diseases are the two major oral diseases which are universal in distribution and constitute the primary reason for the tooth mortality. Research has suggested that stress, depression, and ineffective coping may contribute to development of periodontal diseases and dental caries.4 Pathological levels of stress are associated with reduction in immune level, salivary flow and changes in pH in oral environment resulting in oral diseases. Certain soft tissue pathologies like ANUG and aphthous stomatitis, acute gingivitis and herpetic lesion are also found to be strongly associated with degree of stress.5 Exploration of available literature revealed that studies relating personality traits and stress to oral health status are relatively less. None of the studies have addressed these relationships comprehensively. Thus the present study is undertaken to generate the baseline data and to understand the distribution of dental caries, periodontal disease and oral hygiene status among subjects with different personality traits and with different stress levels.
6.2 Review of literature
A cross-sectional pilot study was done to explore the associations among periodontal disease, psychological factors, and salivary markers of stress, psychoneuroimmunogic variable and health behaviors. Periodontal volunteers, 100 (45 males and 55 female; age range: 40 to 56 years) were selected randomly from Jain Dental Clinic, New Delhi. Stress markers (choromogranin A, cortisol, alpha-amylase, and beta-endorphin) were measured from saliva. A dentist assessed the presence of dental plaque on lingual and buccal surfaces, the gingival index, and the number of remaining teeth with periodontal disease. Stress and Salivary stress markers were significantly correlated with clinical parameters of periodontal disease (p<0.001; R2 = 0.59).6
A study was conducted among 100 subjects aged between 18 to 50 years to assess the relationship between perceived stress and dental caries by Sandeep S. Pagare et al. in 2009. The stress was measured by using perceived stress scale and dental caries was diagnosed by using WHO criteria. The study found a consistent association between caries experience and perceived stress scale.2
A cross-sectional pilot study was conducted to find out any associations between psychologic factors, markers of periodontal disease, psychoneuroimmunologic variables and behavior. Forty five participants were recruited from 100 recall periodontal patients (31 women and 14 men) , age ranged from 45 to 82 years. A dental hygienist performed a periodontal clinical examination and Derogatis Stress Profile (DSP), a self-report measure was used to assess chronic stress. Saliva samples were collected from participants prior to maintenance visit to check cortisol level by radioimmunoassay. One tailed Pearson product-moment correlations were used to explore the relationships between stress and markers of periodontal disease. Stress was found to be positively correlated with clinical attachment loss (r = 0.25; p = 0.05).4
A study was conducted to assess the relationship of personality traits and stress with gingival inflammation and soft tissue oral pathology. The personality traits were measured by Eysenck personality questionnaire and stress level measured by Organizational and Individual Assessment Survey (OIAS). The gingival inflammation was measured by O’Leary’s gingival status and Eastman’s interdental bleeding index. Significant correlations (p<0.05) were found between personality traits and various measures to tolerance of stress.5
A study was conducted among 390 men between the ages of 29-74 years to assess the relationship between parotid flow rate and composition with personality traits. The personality traits were measured by using Cattell sixteen personality factor and stimulated flow rate, pH, osmolality and composition of saliva were measured. The introversion showed significant positive correlation with flow rate.3
6.3 RESEARCH QUESTION
What is the distribution of dental caries, periodontal disease and oral hygiene status among residents of Davangere city aged between 35-44 years belonging to different personality traits and having different stress levels?
6.4 AIM OF STUDY
To understand the distribution of dental caries, periodontal disease and oral hygiene status in 35-44 years old individuals residing in Davangere city belonging to different personality traits and having different stress levels.
6.5 Objectives of the study
1. To assess Dental caries, Periodontal status, Oral hygiene status including Dental plaque status by applying Decayed-Missing-Filled Teeth and Decayed-Missing-Filled Tooth Surfaces Indices7 (Henry T. Klein, Carrole E.Palmer and Knuston J.W, 1938 with modified criteria for caries assessment given by WHO, 1997) Community Periodontal Index8 ( WHO, 1997), OHI-S9 ( John C.Greene and Jack R.vermillion, 1964), Plaque Index10 (Silness and Loe, 1964) respectively in a sample of 35-44 years old residents of Davangere city.
2. To assess and classify above selected sample based on personality traits by applying Eysenck personality inventory as given by Eysenck in 1956.11
3. To assess and stratify above selected sample based on their stress levels using ‘Perceived stress scale’ as given by Sheldon Cohen and T.Kamarck in 1983.12
4. To find out whether any association exists between dental caries experience, periodontal status and oral hygiene status with personality traits and stress levels.
7. MATERIALS AND METHODS
7.1 Source of data:
The present study will be conducted among residents of Davangere city belonging to the age group of 35-44 years. The subjects will be visited and data collected at their houses.
Study design: Descriptive study and a Cross sectional survey.
7.2 Sample size determination
Based on the formula n = 4pq/L2
n = sample size
p=Prevalance =60% for CPI score three in adults aged 35-44 years based on the previous article by Dye BA.13
q =1-p
q=100-60
q= 40%
L=10% of the prevalence (allowable error is fixed at 10% of prevalence=6%)
Estimated size = 4 ×60×40/6×6
Minimum sample size = 267
It is rounded off to 300.
Final sample size for the study is estimated as 300.
7.3 SELECTION CRITERIA
Inclusion criteria:
· 35-44 years old residents of Davangere city with a minimum of 20 functional teeth present.
Exclusion criteria:
· Subjects who are diagnosed to have psychiatric health problems.
· Subjects who have any systemic diseases or on medications which have an influence on oral health like Diabetes mellitus, HIV, Asthma , Epilepsy , blood dyscrasia and so on.
· Subjects who fail to give the consent.
· Subjects who are physically disabled and not able to take care of their oral hygiene.
· Subjects who have xerostomia either due to local or systemic conditions.
7.4 Method of collection of data
Ethical approval will be obtained from Institutional Review Board of Bapuji Dental College and Hosiptal, Davangere.
Davangere city will be divided into four zones (North-east, South-east, North-west, and South-west). From each zone, one locality will be randomly selected followed by a street. A door to door survey will be conducted and subjects fulfilling the selection criteria will be included into study. From one street 75 subjects will be randomly selected. In a household if no subject who satisfies the criteria is found, then the next household will be considered. If in one street required quota of 75 subjects is not covered, another street of same zone will be randomly selected. Voluntary informed consent will be obtained from all the subjects after explaining the purpose of the study and providing them the required information through the patient information letter.
Oral Examination will be done by seating the subjects on an ordinary chair with a back rest under available natural light with aseptic precautions. Data related to socio-demographic profile is collected first, followed by administering Eysenck personality inventory11 (Eysenck, 1956) which consists of 57 items and Perceived stress scale12 (Sheldon Cohen et al, 1983) which consists of ten items. Later oral health status is recorded by applying the DMFT and DMFS Indices, CPI, OHI-S systematically. Mouth mirrors, tweezers, explorers, cotton rolls and CPI probes will be used to perform the oral examination followed by recording the findings.
A self- designed proforma with a provision for recording socio-demographic data of the subjects, all above said standard questionnaires and indices will be used for systematic collection of required data. A copy of it is hereby enclosed.
All examinations will be done by a single examiner, who will be calibrated against a Benchmark (Guide) to control inter-examiner variability and also calibrated to control intra-examiner variability. The data obtained will be compiled systematically in Microsoft Excel sheet and subjected to statistical analysis.
7.5 Statistical analysis
The raw data so obtained after the study will be classified, tabulated and subjected to statistical analysis.
Data will be analyzed using SPSS software. Standard descriptive statistics will be generated.
· Analysis of Co-Variance (ANCOVA) will be used to find out the significance of difference in variables measured on continuous scales such as plaque scores, mean number of sextants affected with various CPI scores and DMFT scores.
· Spearman’s correlation co-efficient will be used to find out the association between Personality traits and Oral Hygiene status, Stress and Oral Hygiene status.
7.6 Does the study require any investigation (or) intervention to be conducted on patients (or) other humans (or) animals? If so please describe briefly:
Yes. The study will be conducted among residents who will be randomly selected from Davangere city. Data will be collected by administering standard questionnaires and by oral examination. Subjects will be explained about the purpose of the study and a written informed consent will be obtained from them.
7.7 Has ethical clearance been obtained from your institution?
Yes, ethical clearance has been obtained from the Institutional Review Board and attached.
REFERENCES
1. Baum A, Tracey AR. Handbook of health psychology. Lawrance Erlbaum associates publisher, London 2001.
2. Pagare SS, Nayak CD, Kaur A. To analyze perceived stress and its relation to dental caries. J Scientific Vol-III 2001.
3. Costa PT, Chauncey HH, Rose CL, Kapur KK. Relationship of parotid saliva flow rate and composition with personality traits in healthy men. Oral Surg Oral Med Oral Pathol 1980 Nov;50(5):416-22.
4. Rosania AE, Low KG, Mc Cormick CM, Rosania DA. Stress, depression, cortisol, and periodontal disease. J Periodontol. 2009 Feb;80(2):260-6.
5. Minneman MA, Cobb C, Soriano F, Burns S, Schuchman L. Relationships of personality traits and stress to gingival status or soft-tissue oral pathology: an exploratory study. J Public Health Dent 1995 Winter;55(1):22-7.
6. Rai B, Kaur J, Anand SC, Jacobs R. Salivary stress markers, stress, and periodontitis: a pilot study. J Periodontol. 2011 Feb;82(2):287-92.
7. Klein H, Palmer CE, Knutson JW. Studies on dental caries. Public Health Rep 1938; 53:751-765.
8. World Health Organisation. Oral Health Survey: Basic Methods.3rd ed. Geneva, Switzerland: WHO; 1997.
9. Greene JC, Vermilion JR. The Simplified Oral Hygiene Index. J AM Dent Assoc 1964 Jan;68:7-13
10. Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between Oral hygiene and periodontal condition. Acta Odontol Scand 1964 Feb;22:121-35.
11. Eysenck personality inventory accessed on 25/9/2012 at 2:30 pm http:/www.psychexchange.co.uk/resource/874/
12. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Social Behaviour 1983:24;385-396.
13. Dye BA. Global periodontal disease epidemiology. J periodontol 2000 2012 Feb;58(1):10-25.
PATIENT INFORMATION FORM
I am Dr. Ambika postgraduate student in the Department of Public Health Dentistry studying in Bapuji Dental College and Hospital, Davangere. I am conducting a study to assess dental caries experience, periodontal status, oral hygiene status and their relationship with personality traits and stress in 35-44 year old residents of Davangere city. You will be given complete information about the research and invited to be a part of the same. I assure you that the details obtained during the course of study will be kept confidential and will not be revealed to anyone. You are free to decide anytime whether you want to participate in the study or not after going through the information given to you and talking to anyone, you feel comfortable with, about the study. The research procedure will involve examination of the mouth. Questionnaire eliciting related to dietary patterns, oral hygiene practices personality traits and stress will be given to you. The questionnaire form may contain few words that you might not understand. Please ask me to stop as we go through the information and whenever you have queries I will explain. You will not be compensated by any means for participating in the study.
If you are not interested to participate in the study or if you feel uncomfortable, you can withdraw or can refuse to participate in the study at any time.
NAME AND ADDRESS OF THE PRINCIPAL INVESTIGATOR:
Dr. Ambika
Postgraduate student,
Room no: 8
Department of Public Health Dentistry,
Bapuji Dental College and Hospital,
Davangere.
Mobile number: 7406062961
If you experience any grievances while participating in this study, feel free to call to this number.
Dr. K. Sadashiva Shetty: 08192 - 220575
(Member Secretary, Institutional Review Board)
Dr .L. Nagesh: 99844035470(Member, Institutional Review Board)
BAPUJI DENTAL COLLEGE AND HOSPITAL, DAVANGERE
DEPARTMENT OF PUBLIC HEALTH DENTISTRY
“ASSESSMENT OF DENTAL CARIES EXPERIENCE, PERIODONTAL STATUS, ORAL HYGIENE STATUS AND THEIR RELATIONSHIP WITH PERSONALITY TRAITS AND STRESS IN 35-44 YEAR OLD RESIDENTS OF DAVANGERE CITY - A CROSS SECTIONAL SURVEY”