Indian Journal of Dental Research

: 2022  |  Volume : 33  |  Issue : 2  |  Page : 120--125

Assessment of clinical depression in abdominally obese subjects with periodontal disease

Sheetal Acharya1, Anurag Satpathy1, Rajdeep Beura2, Pratiti Datta1, Utkalika Das1, Pranab Mahapatra3,  
1 Department of Periodontics and Oral Implantology, Institute of Dental Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Periodontics, Hi Tech Dental College and Hospital, Bhubaneswar, Odisha, India
3 Department of Psychiatry, Kalinga Institute of Medical Sciences, KIIT (Deemed to be University), Bhubaneswar, Odisha, India

Correspondence Address:
Dr. Anurag Satpathy
Department of Periodontics and Oral Implantology, Institute of Dental Sciences, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar, Odisha - 751003


Background: Depression is a commonly prevailing condition that goes undetected in clinical settings. Both abdominal obesity and periodontal disease have a bearing on mental health and have an impact on the quality of life. Objective: To assess the level of clinical depression in abdominally obese subjects with periodontal disease. Methods: Two hundred and ten subjects with a mean age of 37.45 ± 9.59 years (males = 117; females = 93) were grouped as per their abdominal obesity and periodontal status and assessed for their clinical depression levels (mental health) using the Centre for Epidemiologic Studies-Depression Scale (CES-D). Collected data were analysed. Results: The clinical depression score significantly varied in subjects with different periodontal status in both non-obese (F (2,102) = 113.66, P < 0.0001) and abdominally obese subjects (F (2,102) = 132.04, P < 0.001). Significantly higher depression score was demonstrated in healthy (P < 0.001), gingivitis (P < 0.001), and periodontitis (P < 0.001) groups in abdominally obese subjects. Conclusion: Clinical depression is significantly associated with abdominal obesity and periodontal disease in subjects with abdominal obesity and severe periodontal disease demonstrating higher depression scores.

How to cite this article:
Acharya S, Satpathy A, Beura R, Datta P, Das U, Mahapatra P. Assessment of clinical depression in abdominally obese subjects with periodontal disease.Indian J Dent Res 2022;33:120-125

How to cite this URL:
Acharya S, Satpathy A, Beura R, Datta P, Das U, Mahapatra P. Assessment of clinical depression in abdominally obese subjects with periodontal disease. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 1 ];33:120-125
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Depression is a mental disorder that is associated with low self-esteem, loss of interest in daily life activities, and pain without a clear cause.[1] The current reported prevalence of depression in India is estimated to be 7.9–8.9 per thousand.[2] However, it is a treatable disorder that often goes undetected in clinical settings. It not only leads to a decrement in overall health but also worsens the quality of life significantly more when present with co-morbid conditions than when present alone.[3]

The prevalence of obesity in India is on the rise,[4],[5],[6] and it is now accepted as a systemic disease[7] with greater mortality and morbidity associated with it. Furthermore, obesity and depression are reported to be associated because it is accompanied by social stigma, poor self-esteem, and chronic ailments.[8] Obesity affects quality of life and is associated with cognitive dysfunction, premature mortality, and decreased life expectancy.[9] Hypothalamic-pituitary- adrenal (HPA) dysregulation, inflammation oxidative stress, and endocrine abnormalities have been the suggested mechanism for a possible link.[10] Similarly, periodontal disease, a prevalent polymicrobial inflammatory disease of the supporting structures of the tooth, is associated with loss of function and aesthetics[11] and depression.[12],[13] Depression and periodontitis are also suggested to be linked through dysregulated HPA axis and upregulation of inflammatory pathways.[14]

While several Indian studies have evaluated the association of general obesity in objective terms with periodontal disease,[15],[16],[17],[18] none have focused on the ensuing depression from co-morbid conditions such as abdominal obesity. Therefore, the present study was carried out to assess clinical depression in subjects with abdominal obesity and periodontal disease.

 Materials and Methods

Study setting and population

This study followed a cross-sectional observational study design conducted over 12 months from September 2015 to August 2016. Subjects were recruited from those that reported to the outpatient services of our department. Subjects of either gender aged between 18 and 50 years were eligible for the study. Those having a history of consumption of tobacco or alcohol, suffering from diabetes mellitus, cardiovascular diseases, immunologic disorders, hepatitis, immuno-compromised conditions, having a history of antidepressant or antimicrobial use or periodontal treatment in the past 6 months, pregnant, lactating, and unwilling to participate were excluded from the study. The study design and the protocol were approved by the institutional review board (Letter No: 210-12/16/01/2015), and it was conducted in accordance with the ethical principles and guidelines of the Helsinki Declaration. Before commencement, details of the study were verbally explained to the subjects in the language of their understanding, and written consent was obtained.


Waist circumference and hip circumference were measured to compute the waist to hip ratio (WHR). Abdominal obesity was defined as WHR of >0.81 for females and >0.89 for males.[19] Based on this, the subjects were categorised as abdominally obese and non-obese.

Plaque accumulation was recorded using Turesky–Gilmore–Glickmann modification of the Quigley–Hein plaque index.[20] Gingival inflammation was recorded using a gingival index.[21] Percentage of bleeding sites (bleeding on probing – BOP%) was calculated by dividing the number of sites by the total number of sites examined. Periodontal support was recorded with UNC 15 (UNC-15 probes Hu-friedy, Chicago, IL, USA) periodontal probe to determine probing depth (PD) and clinical attachment level (CAL). Recording of periodontal parameters was done at four different sites (mesiobuccal, mid-buccal, distobuccal, and lingual) per tooth. Third molars were not included. Based on their periodontal findings, subjects were sub-grouped as periodontal healthy, gingivitis, and chronic periodontitis as per the criteria described in the American Academy of Periodontology 1999 Consensus Classification of Periodontal Diseases.[22]

Assessment of depression levels (mental health) in subjects was done by using the Centre for Epidemiologic Studies-Depression Scale (CES-D).[23] The 20 items in CES-D have been used for screening for depression in research and clinical settings, including those conducted in Indian population.[24],[25] This scale contains 20 questions on a scale of 0–3 and measures the symptoms of depression under four categories: Depression affect, somatic complaints/activity inhibition, positive affect, and interpersonal difficulties. A total score of >16 is set as cut off, which is possible for mild to major depression. Questionnaire administration was carried out by the authors in the patient waiting area of the department.

Assessment of reproducibility of clinical recording

All clinical examinations and recordings were done by a single examiner and intra-examiner measurement reliability was determined before commencement of the study. Clinical recordings from five patients with severe periodontitis were analysed for repetition, 97% were found to be within 1 mm for PD and 96% were within 1 mm for CAL.

Statistical analysis

A prior sample size estimation for fixed effects, special, main effects, and interactions to detect a change in the clinical depression scores at 95% confidence interval, 5% allowable error, an effect size of 0.3, and power of 85% was estimated for 210 subjects in this study.[26] A total of 35 subjects in each subgroup were planned to be enrolled. A two-way ANOVA test was done to examine the main effects and interactive effects of obesity and periodontal disease on the depression scores. Student's t-test was done for comparisons of abdominally obese and the non-obese groups. One-way ANOVA was done to compare between subjects with healthy periodontium, gingivitis, and periodontitis. Multiple comparisons were done with post-hoc Tukey's-HSD test. Comparison between categorical variables was made using Chi-square test. The Statistical Package for Social Sciences software (SPSS Inc., version 20, Chicago, IL, USA) was used for data processing and data analysis.

A validity assessment of the CES-D scale for the studied population was conducted using the Pearson's product moment correlations, where score obtained by a subject on each item on the questionnaire was correlated with the total score. All the questions were significantly correlated with the total score indicating validity (P < 0.001). Reliability was assessed by determining the Cronbach's alpha that was found to be 0.78 (high reliability), and it did not increase on deletion of any of the questions [See [Supplementary Table S1].[INLINE:1]


A total of 323 subjects were screened, out of which the study included a total of 210 subjects with a mean age of 37.45 ± 9.59 years (males = 117; females = 93). [Table 1] shows the descriptive data of the study population. Main effects and interactive effects of obesity and periodontal status on depression score are displayed in [Table 2]. The interaction effect between the two independent variables was not statistically significant (F = 2.57, P = 0.079) as also seen in the profile plot in [Figure 1]. The main effect of obesity (F = 238.11, P < 0.001) and periodontal status (F = 63.11, P < 0.001) on depression score was statistically significant indicating that both obesity and periodontal status had an independent and significant influence on depression.{Figure 1}{Table 1}{Table 2}

[Table 3] shows a comparison of depression scores between abdominally obese and non-obese subjects, which reveals that abdominally obese subjects had significantly higher depression scores (P < 0.001) in all the three sub-groups, i.e., healthy, gingivitis and periodontitis as also depicted in [Figure 2]. Furthermore, comparisons among these three groups revealed that there was a significant difference in depression scores among subjects with different periodontal status in both non-obese (F(2,102) = 113.66, P < 0.001) and abdominally obese groups (F(2,102) = 132.04, P < 0.001). [Table 4] shows intra-group comparisons indicating that subjects with periodontitis had a significantly higher depression score compared to subjects with healthy periodontium and gingivitis in both non-obese and abdominally obese groups.{Figure 2}{Table 3}{Table 4}

There was a significant association between the depression status and periodontal status among abdominally obese (P < 0.001) and non-obese (P < 0.001) subjects [Table 5]. It was observed that abdominally obese subjects with gingivitis and periodontitis suffered more from clinical depression. Overall, 68.57% of abdominally obese subjects suffered from clinical depression compared to 52.38% of non-obese subjects.{Table 5}


This is the first of its kind study investigating the relationship between a systemic condition (abdominal obesity) and mental health (depression) in subjects with varying degree of a local inflammatory condition such as periodontitis.

Our study results revealed a non-significant interaction effect, which suggests that abdominal obesity and periodontal status not only have a significant effect on depression scores but also this effect was independent of each other. Presence of an interaction effect indicates that the effect of one variable depends on the value of another variable and needs further analysis to interpret results.

We observed that the abdominally obese subjects had a significantly higher depression score irrespective of their periodontal status. In addition, subjects with higher severity of periodontal disease had significantly higher depression scores. These observations point to a possible dual contribution to depression scores from both periodontal disease and abdominal adiposity.

Periodontal disease has been shown to be associated with obesity by several researchers.[15],[27],[28] Furthermore, a psychological condition such as depression has been found to be associated with periodontitis[28],[29] and obesity[8],[10],[30] in isolated studies. However, our study focuses on mental health in subjects with abdominal obesity and periodontal disease.

We found that while 94.29% of subjects with abdominal obesity and periodontitis suffered from clinical depression, 91.43% of subjects were non-depressed when they were non-obese and periodontally healthy. Obese subjects were defined as per their WHR, a parameter more accepted in comparison to body mass index. A skewed WHR and body type is more reflective of the self-image of an individual and may have a more significant bearing in their mental health. It is particularly true for Asian Indians, who suffer from childhood malnutrition, have less skeletal mass, and smaller pelvic dimensions but are seen to have excess fat accumulation in the abdominal region. Periodontal disease, however, is an inflammatory disease[31] with oral symptoms that has a bearing on the confidence and self-esteem of an individual.[32]

Self-reported depression scales have been regularly used in identification and determining the severity of depression associated with obesity.[33],[34] Depressive symptoms in the study subjects were assessed using CES-D,[23] which is a frequently used self-reported scale that has been shown to be a reliable and valid instrument in several studies related to obesity.[33],[35],[36] This scale was also used by Elter et al.[37] in a longitudinal study who reported that subjects with higher scores had more rapid periodontal disease progression. Similarly, Sundararajan et al.[38] and Fatima et al.[39] used the Beck's depression scale and the Hamilton depression rating scale, respectively, and reported an association between the severity of periodontal disease and depression.

Both the periodontal disease and depression have been reported to have a bi-directional connection. Depression acts as a mediator of periodontal disease through a chronic dysregulated HPA axis, with cortisol and adrenal disturbances, immune dysfunction, and increased levels of pro-inflammatory cytokines.[40],[41],[42],[43] However, periodontal disease may increase the susceptibility for depression by means of several psychosocial effects, such as embarrassment and isolation because of poor oral hygiene, dirty teeth, bleeding gums, gum recession, loose teeth, and halitosis.[44],[45] Because the untreated periodontal disease is associated with a loss of chewing efficiency, edentulousness, and marred facial aesthetics, it weakens the self-esteem and eventually adversely affects the quality of life.[46]

Depression if undiagnosed remains untreated, leading to a poor quality of life and workplace productivity.[3] It is imperative that clinicians do not ignore or miss the presence of depression.[47] In the present context, presence of co-morbid conditions may have a worse prognosis and diminished treatment response in comparison to major depression alone.[48]

This study has a few limitations. First, the depression was assessed using a self-reported scale and not formally diagnosed with a structured clinical interview. However, the CES-D scale is popularly used to assess the major depression and has good psychometric properties. Second, the cross-sectional design of the study comes with its limitation of single-point collection of data; thus, it is difficult to establish a temporal relationship. In future, longitudinal studies can be used for a causal relationship. In addition, only the scale allows assessment of recent depressive symptoms and not the chronic course of depression.

Within the limitations of the study, it may be concluded that clinical depression is significantly associated with abdominal obesity and periodontitis. Abdominal obesity and periodontal disease independently contribute to the severity of depression. We may speculate that the correct body type and the oral health may be helpful in the maintenance of mental health. However, long-term studies must be conducted to establish this.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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