Research Article

Effects of stress on oral health among information technology professionals in chennai M. Gayathri1, Revathi Duraisamy1, M. P. Santhosh Kumar2*

ABSTRACT

Background: Jobs of information technology (IT) professionals require high skilfulness and increased concentration. They usually have to work for extended hours and under such conditions “stress” is an inevitable consequence. Stress stimulates the hypothalamic pituitary adrenal axis of our body thus leading to an increased overall hormonal secretion especially the adrenal gland. This can lead to effects such as muscle contraction, decreased salivary and synovial fluid secretion, bone resorption, and restlessness. Concerning the oral cavity, the changes can lead to a deteriorative process such as attrition due to bruxism, dental caries due to xerostomia, and temporomandibular disorders (TMD). Objective: The aim of the study was to determine the effects of stress on oral health among IT professionals in Chennai and to analyze if IT professionals require increased awareness and dental help to maintain their oral health. Materials and Methods: A total of 153 IT professionals consisting of 77 males and 76 females with a work experience between 1 and 5 years were included in the survey. A questionnaire to analyze the subjects on stress symptoms and oral health were prepared and distributed. The data thus received were statistically analyzed using SPSS package 20.0. The correlation between stress and oral health manifestations such as TMD, bruxism, dry mouth, and mouth ulcers was statistically evaluated, and results were obtained. Results: Bivariate analysis and correlation coefficient tests showed a significant relationship between age, work experience, working hours, daily exercises, systemic illness, and stress levels with oral health manifestations such as bruxism, TMD, mouth ulcer, and dry mouth. Conclusion: It is concluded from our study that stress can significantly affect the oral health of IT professionals. Hence, it is necessary to create awareness through dental camps and screening for early intervention and maintenance of the oral health.

KEY WORDS: Bruxism, Information technology professionals, Mouth ulcer, Oral health, Stress, Temporomandibular disorder

INTRODUCTION (SAM) of our body thus leading to an increased overall hormonal secretion especially the adrenal gland.[3,4] Jobs of information technology (IT) professionals Prolonged stress can alter the HPA and SAM axis. require high skillfulness and increased concentration. Concerning the oral cavity, increase in serum cortisol They usually have to work for extended hours and levels can reduce the immune and inflammatory under such conditions “stress” is an inevitable response leading to increased cariogenic activity in consequence.[1] Stress is a biological and psychological the oral cavity; can prolong the healing process; can response of the brain to any demand; it can be triggered decrease salivary and synovial fluid secretion; can by many things, including change. Changes may be cause increased bone resorption; and can lead to positive or negative, real or perceived. Changes may parafunctional habits such as bruxism and clenching due to masticatory muscle hyperfunction.[5] Bruxism be recurring, short or long-term and may include trivial is defined as a diurnal or nocturnal parafunctional things like commuting to school or work every day.[2] activity that includes clenching, bracing, gnashing, Stress stimulates the hypothalamus pituitary adrenal and grinding of teeth. Awake or diurnal bruxism occurs (HPA) axis and sympathetic-adrenal-medullary axis during daytime mainly as clenching, whereas nocturnal bruxism is a stereotyped movement of clenching and Access this article online grinding type activity and is mainly sleep related.[6] Bruxism can lead to jaw muscle pain, dental wear, Website: jprsolutions.info ISSN: 0975-7619 temporal headaches, and fatigue, and in some severe

1Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 2Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr. M. P. Santhosh Kumar, Saveetha Dental College and Hospital, Saveetha University, 162, Poonamallee High Road, Velappanchavadi, Chennai – 600 077, Tamil Nadu, India. Phone: +91-9994892022. E-mail: [email protected]

Received on: 24-03-2018; Revised on: 26-04-2018; Accepted on: 29-05-2018

1468 Drug Invention Today | Vol 10 • Issue 8 • 2018 M. Gayathri, et al. forms, it can lead to a problem in oral functions such Inclusion Criteria [7,8] as speaking, chewing, and swallowing. The following criteria were included in the study: 1. IT workers with 1–5 years of experience Temporomandibular disorders (TMD) are 2. IT workers without habits such a smoking, characterized by alterations in jaw kinesiology, alcoholism, and drug abuse joint sounds, and pain in stomatognathic system 3. IT workers without medications for sleep disorders [9] structures. The major cause of TMD is muscular 4. IT workers without bone pathologies, psychiatric, hyperactivity induced by psychological stress, as and neurological disorders the muscular fatigue causes spasm resulting in 5. IT workers without on-going orthodontic treatment. temporomandibular displacement. Laskin further noted that this displacement causes occlusal Exclusion Criteria abnormality, articular deformation, and muscular The following criteria were excluded from the study: [10] alteration, leading to organic disorder. TMD is a 1. IT workers with more than 5 years of work fluctuating and a progressive disease due to the fact experience especially those who have well learned that it may change the HPA axis due to the presence of to organize their work schedule. pain. Depression and anxiety symptoms may reflect 2. IT workers who are psychologically affected or have a clinical manifestation of painful TMD. Conversely, been affected and not under any medications for the depression and anxiety symptoms may trigger muscle same hyperactivity followed by muscle abnormality 3. IT workers who have recently had a traumatizing and pain. They may also start a joint inflammation family events such as divorce or death of a close process followed by biomechanical changes which relative. may induce joint pain. Second, TMD may be related 4. IT workers with congenital hypoplastic teeth such as to an abnormal trigeminal system process caused amelogenesis imperfecta, osteogenesis imperfecta, by imbalances in common neurotransmitters, such and dentinogenesis imperfecta. as serotonin and catecholamines.[9] According to 5. IT workers with severe dental fluorosis. Muthukrishnan et al. in 15–20% of the population, the signs change into symptoms for which the patient An online questionnaire containing 3 sections was will seek treatment. The frequency to seek treatment prepared. The online mode was chosen as it was easy increases only if the symptoms interfere with day- to store and verify the data. The summary of each and to-day activities.[11] Hence, an early diagnosis and every participant was recorded with ease. prevention are necessary especially in people with • Section one contained questions on demographic a lot of stress. Thus, the aim of our study was to details, presence of systemic disease, details on determine the effects of stress on oral health among daily physical exercise, and diet. IT professionals in Chennai and to analyze if IT • Section two contained questions on stress and professionals require increased awareness and dental general stress symptoms. Stress level of the person help to maintain their oral health. was graded as follows: • 0-never MATERIALS AND METHODS • 1-few times The study was conducted in Chennai, Tamil Nadu, • 2-frequently between October 2017 and December 2017. Chennai • 3-regularly comprises the most number of software companies and • 4-always. IT professionals in Tamil Nadu; hence, it is the most • Section three was on oral health, parafunctional suitable place to conduct this research. Chennai was habits, and the presence of TMD. The questionnaire divided into north, south, east, and west regions. Four was distributed, and data were collected [Table 1]. companies were selected from each region of Chennai, and 213 participants were invited to take up the study. Statistical Analysis The study was proposed to and was approved by the The data received were statistically analyzed using Institutional Ethical Committee, Saveetha Dental Pearson’s Chi-square test and Pearson’s correlation College, Saveetha Institute of Medical and Technical coefficient test using SPSS package 20.0 and results Sciences, Chennai. Informed consent was obtained were obtained. from the respective companies. Professionals with a work experience of 1–5 years were selected, as the RESULTS newly joined are usually demanded more and would need to work on managing stress. The data were A total of 153 IT professionals consisting of 77 males obtained from 153 participants who were willing for and 76 females with a work experience between 1 the study. and 5 years were included in this survey. This study

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Table 1: Questionnaire regarding general and oral health manifestations Parameters Responses Palpitations Yes No Dry mouth Yes No Irritation or mood swings Yes No Depression Yes No Headache Yes No Sleeplessness Yes No Bad dreams or nightmare Yes No Jaw pain Yes No Stuck or tight jaw Yes No Presence of mouth ulcers Yes No Clicking or popping noise on speaking, chewing, or opening or closing jaw Yes No Pain radiating to the head, ear or jaws on speaking, chewing or opening, or Yes No closing jaw Feeling uncomfortable to close and open your mouth Yes No Jaw pain after waking up in the morning Yes No Sensitivity Yes No If you have sensitivity, is it in One particular One whole side of the jaw tooth or all the tooth Is your jaw deviating while opening or closing mouth Yes No Presence of fractured tooth in the absence of physical trauma Yes No Presence of multiple fillings Yes No Presence of artificial teeth Yes No Food getting stuck between teeth frequently Yes No Feeling that the teeth have worn down Yes No Presence of loose or missing teeth Yes No included 32% of people with systemic diseases such as hypertension, diabetes, asthma, thyroidism, and hypercholesterolemia. In our study, the average age of the participants was 35 years with an average work experience of about 4.5 years. The mean daily working hours were about 8.67 h though it may range from 4 to 14 h. The average minutes of exercise per day were about 14 min [Figure 1].

On the contrary to the belief that IT professionals have high stress during working days, most participants Figure 1: Basic information about the participants (70%) have graded their stress levels as only 1 (few times). Only 11% of the respondents have graded 2 (frequently), a few people have graded their stress as 3 (regularly), only one person as 4 (always), and 9% have even graded 0(never) [Figure 2].

The question on stress symptoms irritation, palpitation, and headache was answered positively by a majority of the people while only 41% of people felt that they have depression due to stress, 45% sleeplessness due to stress. TMD symptoms like jaw pain on awakening in the morning were seen in 34 % of people, 26% of people complained of stuck or locked jaws, 23% of people had clicking or popping noise on jaw movements, and pain radiating to head or ear was seen in 18% of people, while 8% of participants complained Figure 2: Stress levels among the participants of deviation of jaw on opening or closing jaw. Bruxism related signs such as grinding were seen in proximal caries. 25% of participants had short span 28% of participants; teeth wear in 39% of participants, prosthesis, and 16% of participants had periodontally teeth sensitivity in 67% of respondents, and fracture compromised teeth [Figure 3]. of teeth due to clenching in 42% of participants. A number of participants (49%) also complained of In our study, age was found to be related to the oral food getting stuck between the teeth in the absence of health symptoms such as bruxism, TMD, dry mouth,

1470 Drug Invention Today | Vol 10 • Issue 8 • 2018 M. Gayathri, et al. and mouth ulcers. Among the symptoms, TMD was 103 exam going students were examined by Mottaghi strongly correlated to age. Gender seems to have et al. and a possible relationship between anxiety and no association with TMD, bruxism, mouth ulcer, TMD was found.[12] Similarly, according to Yoon et al. or dry mouth. Work experience is correlated but stress levels affect the severity and treatment outcome weakly with the presence of TMD, bruxism, and of TMD after analyzing 169 patients.[13] Patil et al. mouth ulcer. However, the daily working hours are reported that there was a positive correlation between strongly correlated with mouth ulcer and bruxism. jaw pain, depression, and stress with TMD after Daily exercise may also play a role in causing TMD. statistically analyzing the responses of 120 patients.[14] The Pearson correlation value is only 0.006; hence, Several studies have been conducted on the association only a negligible role is played by exercise. Systemic of stress and bruxism. Abekura et al. evaluated the illness also influences oral health manifestations such salivary CgA (cortisol) levels of bruxers and non as mouth ulcer, bruxism, and dry mouth. As for the bruxers before and after experimental stress task association of stress levels with the oral symptoms, and found that CgA level had markedly increased in it is a major factor causing bruxism, TMD, and dry mouth [Tables 2 and 3). bruxers after stress task thus confirming that stress is a cause of bruxism.[15]

DISCUSSION Carvalho et al. surveyed 700 police officers and [16] Several studies have similarly been conducted concluded the same. Ahlberg et al. and Sutin et al. by researchers in various places and different had also concluded that stress is the most significant populations. Kanehira et al., in 2008, concluded that factor in predicting the frequency and severity of stress was significantly correlated with TMD and bruxism.[17,18] Similarly, in our study, there was a parafunctional habits after reviewing the response of significant relationship between stress levels and 3225 people from the general population of Japan.[5] oral health manifestations such as TMD and bruxism

Figure 3: Questionnaire responses of the participants

Table 2: Pearsons Chi‑square test Pearsons Chi‑square Age Gender Experience Work hours Daily Systemic Stress level value exercise illness TMD 0* 0.145 0.001* 0.067 0* 0.289 0.005* Mouth ulcer 0* 0.153 0.003* 0.022* 0.071 0.007* 0.408 Bruxism 0* 0.88 0* 0.004* 0.464 0.003* 0.015* Dry mouth 0.009* 0.106 0.086 0.111 0.342 0.015* 0.044* *Statistically significant at P<0.05. TMD: Temporomandibular disorders

Table 3: Pearson’s correlation test Pearsons R Age Gender Experience Work hours Daily Systemic Stress level exercise illness TMD 0.309 0.95 0.263 0.775 0.006 0.016 0.546 Mouth ulcer 0.001 0.224 0.016 0.736 0.002 0.008 0.662 Bruxism 0 0.342 0 0.304 0.034 0 0.044 Dry mouth 0.193 0.15 0.377 0.763 0.192 0.017 0.026 Strength of Association of Pearson’s R value; 0.1<|r|<0.3‑ small correlation; 0.3<|r|<0.5‑medium/moderate correlation; |r|>0.5‑ large/strong correlation. TMD: Temporomandibular disorders

Drug Invention Today | Vol 10 • Issue 8 • 2018 1471 M. Gayathri, et al. among the IT professionals. The results of our study hours, daily exercises, systemic illness, and stress were contradicted by the study of Roopa et al. in levels with oral health manifestations such as which no relationship was found between bruxism bruxism, TMD, mouth ulcer, and dry mouth. It is and age, sex, job experience, and working hours after clearly demonstrated that stress is an important factor examination of 232 software workers. However, she affecting the oral health in our study population. had reported that stress was responsible for bruxism Further studies are needed to obtain a more accurate after Chi-square test at P < 0.001.[19] Yoshino et al. data as this study contained a lesser sample size and proved that stress played a major role in causing were a short-term research. In this study, stress was clicking noise on jaw movements, jaw pain difficulty in not graded using standardized methods to make the mouth opening, and tooth loss on surveying 950 male questionnaire easy to perceive and complete by the financial workers in Japan.[20] Manfredini et al. said participants. Hence, studies with standardized stress that bruxism was more common in females while in scales could be done for better results in the future. our study there was no relationship between gender and any of the oral health manifestations analyzed.[21] CONCLUSION Molina and dos Santos reported that bruxers differs from non bruxers in the presence of depression, It is concluded from our study that stress can increased levels of hostility and stress sensitivity thus significantly affect the oral health of IT professionals. suggesting that stress may be a factor for initiating Since IT professionals are said to have more stress bruxism.[22] Monaco et al. studied bruxism in children every day, it is important that they should be educated and found that bruxing children are more anxious than on the effects of stress on their oral health. Regular non bruxers.[23] dental check-ups at least once in 6 months and camps from academic institutions can be organized A multifactorial large-scale population study by in software companies to prevent stress-related oral Ohayon et al. on sleep bruxism revealed that highly problems and maintain oral health of these individuals. stressful life is a significant risk factor of bruxism.[24] A study by Selms et al. demonstrated that daytime ACKNOWLEDGMENT time clenching could significantly be explained by experienced stress, although experienced stress and We sincerely thank the software companies where anticipated stress were unrelated to sleep bruxism the study was conducted and the participants of this as recorded with ambulatory devices.[25] 59 women study. We would also like to thank Miss Samyuktha, between 18 and 40 years of age with a diagnosis of Assistant Statistical Investigator, Department of myogenous TMD were evaluated using the Fonseca Economics and Statistics, Government of Tamil Nadu, Index to determine the degree of the disorder by de who had helped with the statistics for the research. Paiva Tosato et al. Salivary cortisol levels were then determined and surface electromyography was used to REFERENCES evaluate electrical activity in the masticatory muscles. 1. Rao SK, Bhat M, David J. Work, stress, and diurnal bruxism: The increase in cortisol, which is a hormone released A pilot study among information technology professionals in in situations of stress, was concomitant with greater Bangalore City, India. Int J Dent 2011;2011:1-5. muscle activity and TMD severity.[26] There were 2. Kothapalli J. Stress-a precipitating factor in juvenile myoclonic epilepsy (Jme). 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