|DENTAL SCIENCE - ORIGINAL ARTICLE
|Year : 2015 | Volume
| Issue : 6 | Page : 457-460
Estimation and comparison of serum cortisol levels in periodontally diseased patients and periodontally healthy individuals: A clinical-biochemical study
G Rohini1, S Kalaivani1, Vipin Kumar2, SA Rajasekar3, Jaishree Tuckaram4, Vinisha Pandey5
1 Department of Periodontics, CSI College of Dental Sciences and Research, Madurai, India
2 Consultant Periodontist and Implantologist, Delhi, India
3 Consultant Oral and Maxillofacial surgeon, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
4 Department of Periodontics, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India
5 Department of Conservative Dentistry and Endodontics, Rama Dental College, Kanpur, Uttar Pradesh, India
|Date of Submission||28-Apr-2015|
|Date of Decision||28-Apr-2015|
|Date of Acceptance||22-May-2015|
|Date of Web Publication||1-Sep-2015|
Dr. G Rohini
Department of Periodontics, CSI College of Dental Sciences and Research, Madurai
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Psychological conditions, particularly psychosocial stress have been implicated as risk indicators of periodontal disease. Stress increases cortisol production from the adrenal cortex by stimulating an increase in the release of ACTH from the pituitary gland. Increased cortisol production suppresses the immune response and increases the potential of periodontal tissue destruction. Aim: The aim of the present study was to estimate and compare the serum cortisol levels in periodontally diseased patients and periodontally healthy individuals. Materials and Methods: Total of 45 subjects were recruited for this study and were categorized into three groups. Group I - Comprised of aggressive periodontitis patients (n = 15), Group II - Chronic periodontitis patients (n = 15), and Group III - Healthy controls (n = 15). Serum samples were collected from each of the groups and cortisol levels were determined using cortisol immunoassay kit. Clinical examination covered probing depth, gingival index (GI), gingival recession, plaque index, and clinical attachment level. The statistical analysis was done using nonparameteric t-test and Spearman's rank correlation coefficient. Results: With respect to cortisol, the levels were higher in Group-I compared to the other groups. On comparison of mean cortisol levels among the groups, the values were statistically significant between Group-I and Group-III. Group-I showed a significant negative correlation between cortisol levels and GI. Conclusion: Within the limits of the study serum cortisol levels was higher in the chronic periodontitis group compared to the other groups. Positive correlation was found between the cortisol levels and other clinical parameters except for the GI.
Keywords: Cortisol, periodontal disease, stress
|How to cite this article:|
Rohini G, Kalaivani S, Kumar V, Rajasekar S A, Tuckaram J, Pandey V. Estimation and comparison of serum cortisol levels in periodontally diseased patients and periodontally healthy individuals: A clinical-biochemical study. J Pharm Bioall Sci 2015;7, Suppl S2:457-60
|How to cite this URL:|
Rohini G, Kalaivani S, Kumar V, Rajasekar S A, Tuckaram J, Pandey V. Estimation and comparison of serum cortisol levels in periodontally diseased patients and periodontally healthy individuals: A clinical-biochemical study. J Pharm Bioall Sci [serial online] 2015 [cited 2020 May 26];7, Suppl S2:457-60. Available from: http://www.jpbsonline.org/text.asp?2015/7/6/457/163501
Stress defined as either a stimulus or response, in the scientific study of disease or illness is nevertheless a confirmed and important factor in the etiology of many inflammatory diseases including periodontal diseases.
The concept of stress involves an attempt to understand how the body regulates itself to maintain smooth, adaptive, and homeostatic functioning, when confronted with disruptive endogenous or exogenous forces. Several cross-sectional studies revealed a clear-cut correlation between the progressive course of the periodontal disease and the psychological status of the patient. ,, Stress as a response state of the organism to forces acting simultaneously on the body which if excessive that is straining the capacity of the adaptive process beyond their limits leads to chronic distress and manifest in the organ systems in the form of peptic ulcer, arthritis, asthma, and other pathological conditions mediated by inflammation.
It has been known for several decades that stress whether inflammatory, traumatic or psychological is associated with the activation of the hypothalamus - pituitary-adrenal axis. There are several studies that have demonstrated the relationship between psychological stress and inflammation. , The stress system responds to signals from the immune system and inflammatory reactions, so that any immune challenge that threatens homeostasis constitute a stressor to the system acting as a stimulus to the organism to restore the stability.
The communication between the neuroendocrine system (hypothalamic-pituitary-adrenal [HPA]) and immune inflammatory system functions as a feedback loop which regulates the immune components of the inflammatory response. Stress-induced imbalance between TH1 and TH2 cells and the increased secretion of cytokines might play a role in the pathogenesis of periodontal diseases. 
Periodontitis is a multifactorial disease and there are several studies that have demonstrated a relationship between psychological stress and inflammation and periodontitis. , Even though the investigators have studied the impact of the immune response and psychosocial components on the periodontal status only a few studies reported the association between the actual role of stress hormones and periodontitis.  The purpose of the present study is to estimate and compare the serum cortisol levels in periodontally diseased patients and periodontally healthy subjects.
To estimate and compare serum cortisol levels in periodontally diseased patients and periodontally healthy individuals.
- To compare serum cortisol levels between chronic periodontitis and healthy controls
- To compare serum cortisol levels between aggressive periodontitis and healthy controls
- To correlate the serum cortisol levels with the clinical parameters within the groups.
| Materials and Methods|| |
A total of 45 subjects in the age group of 20-50 years were recruited for this study.
Patients were grouped into chronic and aggressive periodontitis group based on the criteria of AAP 1999.
- Group I - Chronic periodontitis patients (n = 15)
- Group II - Aggressive periodontitis patients (n = 15)
- Group III - Healthy controls (n = 15).
- Any periodontal treatment within past 6 months
- Subjects taking any medication
- Systemically ill subjects
- Pregnant or lactating subjects.
Institutional Ethical Committee approval was obtained. All the patients were instructed the course of study and informed consent was obtained from all patients prior to the start of the study.
On clinical examination
Clinical examination was carried by a one examiner. The following periodontal parameters were recorded:
- Plaque index 
- Gingival index (GI) 
- Pocket probing depth in mm
- Gingival recession in mm
- Clinical attachment level in mm was recorded in six sites of all teeth.
The radiographic examination of all patients and controls was performed using intraoral radiographs.
Three milliliter of blood samples were taken from each group from the cephalic vein between 9 am and 11 am. After collection of blood, serum was decanted and stored at −80° and sent for cortisol analysis which was done using cortisol immunoassay kit.
The mean, median, and standard deviation of the clinical parameters and of blood serum values were determined for each patient group and for controls. Comparison between the serum cortisol levels and clinical parameters was done by nonparametric t-test (Kruskal-Wallis test). Correlation between serum cortisol levels and clinical parameters were done by Spearman's rank correlation coefficient. Significance levels with respect to serum cortisol levels and age, clinical parameters were determined by Chi-square test.
| Results|| |
The mean cortisol values were higher in Group I (11.750 ± 3.534) compared to other groups [Table 1]. On comparison of mean cortisol levels among the groups, the values were statistically significant between Group-I and Group-III [Table 2].
Group-I showed a statistically significant negative correlation between cortisol levels and GI and positive correlation between cortisol levels and other clinical parameters [Table 3]. In Group-II, a negative correlation was seen between serum cortisol and GI but was not statistically significant. A positive correlation was found between cortisol and other clinical parameters [Table 4].
|Table 3: Correlation between serum cortisol levels and clinical parameters (group I)|
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|Table 4: Correlation between serum cortisol levels and clinical parameters (Group II)|
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| Discussion|| |
A relationship between periodontitis and psychosocial stress was proposed by many investigators over the years, but its relation with regard to the psycho-neuro-immunologic mechanism is poorly understood because of limited information. In the present study, mean serum cortisol levels were higher in chronic periodontitis group compared to healthy controls. This result is in agreement with the study done by Genco et al. in which the mean cortisol levels were higher in group of patients with the disease. 
Serum cortisol levels showed a negative correlation with the GI which can be explained by the anti-inflammatory effect of cortisol. , Furthermore, a positive correlation was found between serum cortisol levels and other clinical parameters in the disease groups. The impact of stress on the periodontium can be demonstrated by two models: (1) Behavioral model (2) biological model. Behavioral model explains the influence of health impairing behaviors including poor oral hygiene, increased consumption of cigarettes, alcohol, disturbed sleeping patterns, poor nutritional intake. Various studies have reported the influence of lifestyle patterns on periodontal disease status.  Biological model suggests that the stress effects may be biologically mediated through the activation of HPA axis, promoting the release of corticotrophin releasing hormone from the hypothalamus and cortisol from the adrenal cortex. 
The association between periodontitis and stress related hormones largely have been overlooked. Studies have shown a positive correlation between stress and periodontal disease. , There are many studies which do not show a correlation between them. , Cortisol is an important glucocorticoid hormone released via activation of HPA axis is important due its ability to regulate the recruitment of immune cells in to inflamed tissues as well as to skew the TH1/TH2 balance toward a TH2 dominant response  responsible for progressive periodontal disease.
Factors influencing cortisol production are age, gender, socioeconomic status, life events, marital status, smoking. On adjusting for the possible confounders, there was no correlation found for the above factors with the serum cortisol levels. In our present study, mean cortisol levels were higher in the chronic periodontitis group compared to aggressive and healthy group, even though, the values were within the reference range. This variation in the levels is explained by the alteration in the cytokine levels thus activating the HPA through negative feedback loop (BRAIN-NEURO-ENDOCRINE IMMUNE INTERACTION). This finding is in line with the study done by Harbuz et al.  which showed no correlation but explained the influence of cytokines levels on the alteration of HPA axis. However, Monteiro da Silva et al. found no correlation between psychological stress and periodontal disease.  He studied the psychological status in 40 patients with chronic and aggressive periodontitis each and found no association between psychological factor and periodontal disease.
In the present study, the presence of significant difference in the serum cortisol levels between the disease group and control group explains the influence of stress factor on the periodontal status. However, the difference in the serum cortisol levels between the chronic group and aggressive group is less significant which may be attributed to the small sample size selected for the study and the larger sample size would provide better conceptual evidence.
However, many longitudinal studies are necessary in the periodontal epidemiology area to evaluate the role of social support and stress coping strategies together with the psychosocial/physiological stress, on the establishment and progression of periodontitis.
| Conclusion|| |
Within the limits of the study serum cortisol levels were higher in the chronic periodontitis group compared to the other groups. Positive correlation was found between the cortisol levels and other clinical parameters except for the GI.
Financial support and sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Breivik T, Thrane PS, Murison R, Gjermo P. Emotional stress effects on immunity, gingivitis and periodontitis. Eur J Oral Sci 1996;104:327-34.
DaSilva AM, Newman HN, Oakley DA. Psychosocial factors in inflammatory periodontal diseases. J Clin Periodontol 1995;22:516-26.
Genco R, Ho AW, Grossi SG, Dunford RG, Tedesco LA. Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Periodontol 1999;70:711-23.
Breivik T, Opstad PK, Gjermo P, Thrane PS. Effects of hypothalamic-pituitary-adrenal axis reactivity on periodontal tissue destruction in rats. Eur J Oral Sci 2000;108:115-22.
Miller DB, O'Callaghan JP. Neuroendocrine aspects of the response to stress. Metabolism 2002;51:5-10.
Monteiro da Silva AM, Oakley DA, Newman HN, Nohl FS, Lloyd HM. Psychosocial factors and adult onset rapidly progressive periodontitis. J Clin Periodontol 1996;23:789-94.
Genco RJ. Current view of risk factors for periodontal diseases. J Periodontol 1996;67:1041-9.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Vedhara K, Miles J, Bennett P, Plummer S, Tallon D, Brooks E, et al.
An investigation into the relationship between salivary cortisol, stress, anxiety and depression. Biol Psychol 2003;62:89-96.
Genco RJ, Ho AW, Kopman J, Grossi SG, Dunford RG, Tedesco LA. Models to evaluate the role of stress in periodontal disease. Ann Periodontol 1998;3:288-302.
Hilgert JB, Hugo FN, Bandeira DR, Bozzetti MC. Stress, cortisol, and periodontitis in a population aged 50 years and over. J Dent Res 2006;85:324-8.
Mengel R, Bacher M, Flores-De-Jacoby L. Interactions between stress, interleukin-1beta, interleukin-6 and cortisol in periodontally diseased patients. J Clin Periodontol 2002;29:1012-22.
Harbuz MS, Stephanou A, Sarlis N, Lightman SL. The effects of recombinant human interleukin(IL)-1α, IL-1β or IL-6 on hypothalamo-pituitary-adrenal axis activation. J Endocrinol 1992;133:349-55.
[Table 1], [Table 2], [Table 3], [Table 4]