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Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 213-218
Effect of non-surgical periodontal therapy on stress and salivary Chromogranin-A levels: A clinico-biochemical study

Department of Periodontics and Implantology, The Oxford Dental College and Hospital, Bengaluru, Karnataka, India

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Date of Web Publication29-May-2019


Aim: The aim of the study was to compare chromogranin A (CgA) and stress levels before and after non-surgical periodontal therapy (NSPT). Materials and Methods: A sample of 40 patients in the age range 25–60 years were included in the study and were divided into gingivitis (10 subjects), chronic periodontitis (CP) (15 patients) and aggressive periodontitis (AgP) (15 patients). The patients were asked to complete two sets of stress questionnaires, plaque index, gingival index, probing depth and clinical attachment levels (CAL) were recorded. Salivary samples were taken at baseline and were repeated three months post NSPT. Results: CgA was detected in saliva samples of all the groups. A statistically significant correlation was established between levels of CgA and stress parameters, which was shown to be the highest in AgP (P < 0.001), followed by CP group (P < 0.005) at baseline. Following NSPT, an overall reduction was observed in the levels of CgA, which was correlated with the overall reduction in stress levels for AgP group (P < 0.005) followed by CP group (P < 0.037). Amongst the clinical parameters, CAL showed the strongest correlation with CgA both at baseline and after NSPT (P < 0.001). Conclusion: Stress was directly correlated to the levels of salivary CgA levels, which was the highest for aggressive periodontitis at baseline. NSPT showed a marked improvement in all the parameters. Levels of CgA and CAL showed a significant correlation in both the CP and AgP groups.

Keywords: Aggressive periodontitis, anxiety, chromogranin A, nonsurgical periodontal therapy, stress

How to cite this article:
Lihala R, Jayaram P, Chatterjee A, Joshi A. Effect of non-surgical periodontal therapy on stress and salivary Chromogranin-A levels: A clinico-biochemical study. Indian J Dent Res 2019;30:213-8

How to cite this URL:
Lihala R, Jayaram P, Chatterjee A, Joshi A. Effect of non-surgical periodontal therapy on stress and salivary Chromogranin-A levels: A clinico-biochemical study. Indian J Dent Res [serial online] 2019 [cited 2023 Mar 20];30:213-8. Available from:

   Introduction Top

Periodontitis is a destructive inflammatory disease of the supporting tissues of the teeth and is caused either by specific microorganisms or by a group of specific microorganisms, resulting in progressive destruction of periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession, or both. It is a known fact that bacteria are the etiological agents of periodontal diseases, although the mere presence of bacteria is not capable of producing advanced tissue destruction in all individuals. There is also an individual response and adaptive ability to a certain amount of bacterial plaque without progression of the disease.[1]

The link between periodontal disease and systemic diseases has been scientifically proven over the last two decades. The principle reason for this oral-systemic connection is dissemination of locally produced pro-inflammatory mediators such as C-reactive protein, interleukins-1 beta (IL-1β) and IL-6 and tumor necrosis factor alpha.[2] However, a significant proportion of the variation in the occurrence of periodontal disease cannot be explained by taking only these factors into account.[3] The role of factors such as stress, depression and anxiety has been identified in observational studies. The biological plausibility for such an association is supported by studies that have demonstrated that psychological states such as depression and exposure to stress agents could modify the immune response making the individual more susceptible to develop an unhealthy condition and may also have an impact on periodontal health.[4]

One of the possible mechanisms of the influence of stress and psychosocial factors on periodontal conditions is the modification of the patients' behaviour. Individuals with high stress levels tend to adopt habits which are harmful to periodontal health. These include negligent oral hygiene, intensification of smoking or changes in eating habits which negatively influence the immunological system functions.[5]

Studies have shown that psychological stress can down-regulate the cellular immune response by at least three mechanisms. One proposed mechanism is that stress-induced response is transmitted to the hypothalamo-pituitary-adrenal (HPA) axis and promotes the release of corticotropin-releasing hormone from the pituitary gland and glucocorticoid hormones from the adrenal cortex. Glucocorticoids released into the cortex of the supra-renals decrease the production of pro-inflammatory cytokines (interleukins, prostaglandins, and tumor necrosis factor). Secondly, exposure to stressor agents can induce the sympathetic nervous system to release adrenaline and noradrenaline from the adrenal medulla and, therefore, can exert an immunosuppressive effect,[6] which can indirectly provoke periodontal tissue breakdown.[7] Another mechanism is that stress can induce the release of neuropeptides from sensory nerve fibres (neurogenic inflammation), and the presence of neuropeptides has been implicated as a neurogenic promoter in various inflammatory processes, modulating the activity of the immune system and the release of cytokines.[1]

While cortisol has long been assayed as a stress marker that reflects both mental and physical stress, levels of salivary CgA correlate only with mental health and thus give a better picture of mental stress symptoms.[8] CgA is a member of a family of highly acidic proteins, chromogranins, which are co-stored and co-released with adrenaline and noradrenaline in the adrenal medulla in response to splanchnic stimulation. CgA is now known to be stored in the secretory granules in a wide variety of neurons and paraneurons secreting peptide hormones. It has recently been proposed that the chromogranins may be precursors of multifunctional hormones. Since CgA is much more stable than catecholamines in the circulatory system, the circulating level of CgA co-released with catecholamines may be an accurate index of the activity of sympathetic—adrenomedullary system during the initial phase of the stress response.[9] Salivary CgA has gained attention as a novel stress marker.

The aim of this study was to compare CgA levels before and after non-surgical periodontal therapy (NSPT).

   Materials and Methods Top

Study population and source of data

The study protocol was approved by the ethical committee of The Oxford Dental College and hospital, Bangalore. Forty patients who visited the Department of Periodontics, The Oxford Dental College and Hospital, Bangalore were recruited in the study.

All patients were given a detailed verbal and written description of the study and signed a written informed consent form prior to commencement of the study.

The patients were divided into three groups.

Group I consisted of 10 systemically healthy patients with gingivitis.

Group II consisted of 15 systemically healthy patients with mild to moderate generalized CP (more than 30% site showing attachment loss of 3–4mm).

Group III consisted of 15 systemically healthy patients with generalized AgP (interproximal bone loss present in more than three teeth other than incisors and molars).

Saliva sample was collected from all the patients at baseline and 3 months after NSPT.

Inclusion criteria

Systemically healthy patients under the age group of 25–60 years, presenting with at least 20 natural teeth suffering from either mild gingivitis or probing pocket depth between 4–6mm and/or clinical attachment loss of 3–4mm were included in the study.

Exclusion criteria

  • Patients with known systemic diseases such as diabetes mellitus, rheumatoid arthritis and renal disease.
  • Pregnant and lactating women.
  • Patients presenting with salivary gland dysfunction.
  • Patients undertaking antibiotic, steroids or non-steroidal anti-inflammatory medication within the past three months.
  • Smokers.
  • Drugs which interfere with salivary secretions.

Clinical examination

During the first visit, the following clinical parameters were recorded: 1. gingival index:[10] 2. plaque index:[11] 3. probing pocket depth, 4. clinical attachment level, and 5. radiographic assessment using digital orthopantomogram (OPG).

Method of evaluation of stress

The General Health Questionnaire (GHQ)[12] -12 items version and Hospital Anxiety and Depression Scale (HADS)[13] were translated into three languages (English, Hindi, Kannada) and administered to the patients included in the study to evaluate the stress levels. The Hospital Anxiety and Depression Scale was split into two components—HADS for Anxiety (HAD-A) and HADS for depression (HAD-D) and analysed separately.

Method of collection of sample

Unstimulated whole saliva was collected as given by Navazesh method[14] on the second day. Prior to collection, the patient was advised to avoid food and beverages at least one hour before the test session following which the patient was asked to rinse the mouth with water to remove food residues. The patient was then asked to relax for five minutes to avoid sample dilution before collection. During sample collection patient was instructed to minimize movements of the mouth, they were then asked to lean their head forward and saliva was allowed to drain passively into an Eppendorf tube. Following sample collection, the samples were refrigerated immediately and transported in an ice box for storage at or below –400 C, for further analysis of CgA levels using an Enzyme Linked Immunosorbent Assay (ELISA) kit.

Phase I periodontal therapy

After collection of the saliva samples at baseline, patients in group I and group II underwent non-surgical periodontal therapy (NSPT) which included patient education and motivation, scaling and root planing (SRP) and oral hygiene instructions. Patients were put on oral hygiene maintenance which included oral hygiene instructions and recall every month for three months.

Following NSPT, at the end of three months, saliva samples were collected from group I and group II patients and all the clinical parameters were recorded in the same manner as mentioned above.

Statistical analysis

Statistical analysis was done using SPSS version 18. A P value of <0.05 was considered statistically significant. Comparison between the three groups was done using ANOVA with post-hoc Games Howell test and independent sample t test. Correlation of CgA with other parameters such as Pearson correlation and two-tailed test were used.

   Results Top

The demographic data [Table 1] revealed that the mean age for gingivitis, CP and AgP group was 28.20, 39.07 and 29.87, respectively. No statistically significant difference existed between the patients selected in all the 3 groups in relation to gender (P < 0.12). Based on the post-hoc test results, the GHQ score was the highest in CP and AgP group compared to gingivitis group at baseline and three months, post treatment. Post-NSPT improvement in the GHQ scores was statistically highly significant for both CP (P < 0.006) and AgP (P < 0.001) group [Table 2] and [Figure 1], [Figure 2]. The HAD-A score was the highest in AgP and CP compared to gingivitis group at baseline and three months post treatment. Patients with aggressive periodontitis showed improvement in HAD-A score, post intervention (P < 0.006). Based on the post-hoc test results, the HAD-D score was the highest in AgP and CP group compared to gingivitis group at baseline and was the highest in the CP group, followed by AgP group and was the least in gingivitis group three months post treatment [Table 2] and [Figure 1], [Figure 2]. In contrast to the control group, both AgP and CP group showed change in the HAD-D score post treatment (P < 0.001). The salivary CgA score was the highest in AgP group, followed by CP group and was the least for the gingivitis group at baseline [Table 3] and showed no statistically significant inter-group difference three months post treatment [Table 4]. The change in the levels of CgA post intervention was statistically highly significant (P < 0.001) for all the 3 groups. Post intervention, a statistically significant and positive correlation was established for salivary CgA and CAL (P < 0.034) and HAD-D scale (P < 0.037) for CP group. Also, a statistically significant and positive correlation was established between salivary CgA level and PI (P < 0.005), GI (P < 0.001) PD (P < 0.003), CAL (P < 0.001) GHQ (P < 0.030) and HAD-D scale (P < 0.005) in AgP group. The correlation was highly significant for CAL and CgA levels in CP and AgP group both at baseline and post-NSPT [Table 3] and [Table 4].
Table 1: Age distribution

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Table 2: Before and after intra-group comparison

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Figure 1: Comparison of baseline characteristics

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Figure 2: Comparison of posttreatment characteristics

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Table 3: Correlations at baseline

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Table 4: Correlations at follow-up

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   Discussion Top

A correlation has been proposed between stressful life events and altered behavioural modifications with an increased incidence and severity of chronic periodontitis. Studies have also found increased plaque accumulation and inflammatory biomarkers in GCF and saliva in stressed individuals.[15],[16] Several authors have stated that depression and loneliness were more prevalent in patients with aggressive periodontitis than in those with either chronic periodontitis or good periodontal health.[17]

In addition to cortisol as a well-known marker of stress loading, other stress-related hormones and neuropeptides such as CgA, α-amylase (AA) and β-endorphin are supposed to link the activity of the neuroendocrine system to periodontitis. Recently, CgA has gained attention as a sensitive and substantial index for psychological stress because the level of CgA gets elevated immediately before any oral presentation of stress.[8]

The General Health Questionnaire (GHQ), introduced by Golderberg and Williams, is among the more popular questionnaires used for assessing stress.[12] Its reliability coefficients have ranged from 0.78–0.95 in various studies. The GHQ is simple to administer, easy to complete and is widely used in many studies.[18] Another added advantage of the GHQ is that it is widely used in research, which allows simple comparisons with results obtained in other studies and it rarely fails to provide reliable and effective measures of well-being.[19]

The Hospital Anxiety and Depression Scale (HADS) is a brief (14-item), self-report measure of anxiety and depression developed by Zigmond and Snaith.[13] It contains two subscales measuring symptoms of depression (HAD-D) and anxiety (HAD-A). The HADS has sensitivity and specificity of about 80%, and a predictive validity for identification of about 70%.[20]

Owing to its high sensitivity and predictability, the GHQ and HADS scales were used in the present study. GHQ scale was used as a preliminary diagnosing tool to identify stressed individuals from the non-stressed and the HADS scale was used to recognize them as anxious (HAD-A) or depressed (HAD-D) or both. Both the scales were validated for reproducibility on Indian population in regional languages by previous studies.[21],[22]

Comparisons within the group showed that patients with CP and AgP had positive GHQ scores compared to gingivitis cases. The findings of the present study could be attributed to the reason that any external stimulus such as stress modulates the immune response and aggravates the intensity of bacterial induced periodontal destruction. Behavioral changes may also occur as adaptations or coping responses to stressors, which may further influence disease risk.[23] After three months, there was a statistically significant reduction in the scores seen in all the groups (P < 0.001) which could be due to the influence of NSPT on behavioral factors such as plaque control and modulation of host response.[24]

The anxiety trait was positive in CP and AgP patients compared to gingivitis group at baseline. There was no significant improvement in the HAD-A scores in the CP group after NSPT, which could be due to passive coping behaviors shown by CP patients.[25] The anxiety trait showed significant improvement only in the AgP group, post NSPT (P < 0.006). The improvement in the anxiety trait could be attributed to the improved periodontal healing after scaling. It may have also been due to active coping strategies which occur as a result of stress. To the best of our knowledge, no interventional studies have been conducted to evaluate effect of NSPT on anxiety trait in AgP patients. The HAD-D values at baseline for gingivitis, CP and AgP groups were 8.60, 15.27 and 16.93, respectively. Depression reduces immune responsiveness, resulting in a higher rate of infection with pathogenic organisms and a greater degree of periodontal tissue destruction. The depression trait showed significant improvement in the CP and AgP group, post intervention (P < 0.006). Improvement in the depression trait after NSPT could be due to improvement in the oral hygiene behavior and improvement in the host modulated immune response which could have led to positive coping in depressed individuals.[24]

In the present study, salivary CgA levels were the highest in the AgP group, followed by CP group and the gingivitis group. Higher CgA levels were observed with periodontal disease, which could be due to increased release of CgA by the nerve endings and locally released by PMNs and Merkel cells. These results can be supported by the results from a previous study conducted by Rai et al.[26] Overall, there was a statistically significant reduction in the levels of CgA for all the groups. CgA is not only a stress-related hormone; it is also released by the resident PMN and Merkel cells during stress. It has also been shown to play a role in increasing the levels of pro-inflammatory cytokines, thus linking stress to the local inflammatory reaction.[27] The overall reduction in the inflammatory burden after NSPT could lead to decrease in the levels of CgA. To the best of our knowledge, no interventional studies have been conducted to evaluate effect of NSPT on salivary CgA levels.

In the current study, a statistically significant correlation between the stress scales and CgA levels was established. A possible explanation could be attributable to the alteration of neuroendocrine immune functions and the reaction of the nervous system interpreting immune activation as a stressor or linked to a higher systemic stress loading. Also, active phase of AgP often associates with depression which is also stated by previous studies done by Page et al., could also be a plausible reason for associated of levels of CgA with HAD-D scores.[28]

   Conclusion Top

Within the limitations of the study, a conclusion could be inferred that stress could plausibly be either the cause or effect of periodontitis. Salivary CgA was correlated to levels of stress, highest being for the AgP group. Apart from causing an overall reduction in clinical parameters, NSPT also improved the levels of CgA and stress. CAL was most significantly correlated with levels of CgA for the periodontitis group.

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Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. Praveen Jayaram
Department of Periodontics and Implantology, The Oxford Dental College and Hospital, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_273_17

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