|Year : 2020 | Volume
| Issue : 8 | Page : 106-112
Relationship among perceived stress, oral health status, stomatitis, and xerostomia in the community during the COVID-19 pandemic: A cross-sectional survey
Agus Susanto1, Indah Suasani Wahyuni2, Felisha Febriane Balafif3
1 Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
2 Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
3 Department of Oral Biology, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia
|Date of Submission||27-Aug-2020|
|Date of Decision||03-Oct-2020|
|Date of Acceptance||02-Nov-2020|
|Date of Web Publication||30-Nov-2020|
Department of Periodontics, Faculty of Dentistry Universitas, Padjadjaran, Sekeloa Selatan I, Bandung 40132.
Source of Support: None, Conflict of Interest: None
Aim: The aim of the study was to analyze the relationship between self-reported stress, oral health status, xerostomia, and stomatitis in the community during the COVID-19 pandemic.Materials and Methods: This is a cross-sectional study of 380 community respondents from the city of Bandung, Indonesia, consisting of 82 men and 298 women. Data obtained from online questionnaires using consecutive sampling method showed that the respondents agreed to participate in the study by filling in the informed consent. Furthermore, demographic data including age, education level, occupation, and total income were recorded. The variables measured by a questionnaire are self-reported stress, oral health status, xerostomia inventory, and stomatitis. Data distribution was performed by a descriptive statistic, χ2 test, Phi, and Spearman rank test for correlation analysis.Results: There was a significant correlation between perceived stress scale with oral health status (r’s = 0.135; P = 0.003), with stomatitis (r’s = 0.176; P = 0.015), and with xerostomia (r’s = 0.296; P = 0.022). In addition, age, education level, and total income also showed a significant correlation with stress level.Conclusion: From the findings of this study, it can be concluded that oral health status, xerostomia, and stomatitis were associated with levels of stress. Higher stress indicates poor oral health status, as well as severe xerostomia and stomatitis.
Keywords: Oral Health Status, Stomatitis, Stress, Xerostomia
|How to cite this article:|
Susanto A, Wahyuni IS, Balafif FF. Relationship among perceived stress, oral health status, stomatitis, and xerostomia in the community during the COVID-19 pandemic: A cross-sectional survey. J Int Oral Health 2020;12, Suppl S2:106-12
|How to cite this URL:|
Susanto A, Wahyuni IS, Balafif FF. Relationship among perceived stress, oral health status, stomatitis, and xerostomia in the community during the COVID-19 pandemic: A cross-sectional survey. J Int Oral Health [serial online] 2020 [cited 2021 Apr 16];12, Suppl S2:106-12. Available from: https://www.jioh.org/text.asp?2020/12/8/106/301870
| Introduction|| |
Currently, there is a global pandemic in several countries due to a contagious infection from COVID-19. It was first identified in December 2019 at a food market in Wuhan, China, and has the largest single-stranded positive RNA genome. Transmission is believed to occur after symptoms of lower respiratory tract infections appear due to its ability to infect lung epithelial cells. Meanwhile, patients infected showed symptoms resembling pneumonia such as fever, cough, fatigue, and difficulty in breathing.
Subsequently, WHO declared the COVID-19 virus outbreak as a public health emergency of international concern because it is highly contagious and can be fatal to many people around the world. The transmission is easy due to human movement or mobility, as well as the ability of the virus to survive in infected host cells. An infected individual may not exhibit any symptoms, and can still involve in activities and interact as usual. However, such infected persons can spread the virus through salivary droplets when coughing, sneezing, or talking.
The COVID-19 pandemic has spread fear, panic, and anxiety not only among individuals but also at the community level, including uncertain situations, panic due to fear of contracting the virus, self-limiting policies, and lack of proper treatment, as well as the lack of proper care or vaccinations. With the COVID-19 pandemic and the existence of a large-scale social restriction program (PSBB) in several cities in Indonesia, some people are reportedly under stress.
Stress is the result of several influences of environmental change which causes life balance disruption when expectations do not match reality. It can emanate from the environment or the individual’s perceptions, which can cause anxiety, emotions, negative feelings, stress, pain, and sadness. People with stress tend to have issues in the body which can lead to dental and oral health problems. Some previous oral diseases that have been treated may reappear, such as thrush, gingivitis or swelling of gums, dental infections, opportunistic infections, and oral diseases due to certain systemic complications and their treatment, as well as recurrence of autoimmune diseases.
On the basis of the description above, during the COVID-19 pandemic and lock-down, a person may experience stress that can affect the behavior of maintaining healthy teeth and mouth, as well as cause dental and mouth disease. The most positive cases of COVID-19 in West Java Province are in Bandung City. The hypothesis in this study is that stress levels are associated with oral health status, xerostomia, and stomatitis. This study is the first to describe the relationship between stress levels and oral health status, stomatitis severity, and xerostomia, in the COVID-19 pandemic situation.
| Materials and Methods|| |
This research used a cross-sectional method and data collection was by filling out a questionnaire on Google form, which was distributed online, in accordance with the consecutive sampling method. The subject’s selection in this study was based on filling out a questionnaire through Google form from the community of Bandung City in June–July 2020, with a total of 531 respondents. However, only 446 people passed the inclusion criteria, namely Bandung residents aged 19-60 years who can fill out a questionnaire on Google form. Respondents with systemic diseases (such as diabetes, heart disease, hypertension, leukemia) and pregnant women were excluded from the study. Therefore, the final result of the study sample was 380 people.
The sample size determination was calculated using a single population proportion formula:
With 95% confidence level (Z = 1.96), d is degree of accuracy (0.05), and p is proportion of the target population’s health status as well as dental and oral disease (0.50). On the basis of this formula, a minimum of 288 respondents was required.
The questionnaire used consisted of a dental and oral health status (modified from the study of Levin et al.), severity of oral ulceration (self-prepared/home-made modification from Gallo et al.), oral dryness/short-form version of Xerostomia Inventory (SXI-D short version, re-adaptation from Thomson), as well as a stress level (trans-adapted from Yokokuro et al. s Perceived Stress Scale-10). Furthermore, the questionnaire was tested on 55 respondents, and the validity and reliability were tested with Spearman rank correlation and Cronbach’s alpha, respectively.
Determination of dental and oral health degree by adding up the scores for each question consists of frequency of brushing teeth (score = 0 or 2), visits to the dentist (0 or 2), visits to clean tartar (0 or 2), smoking (0 or 1 or 2), bleeding when brushing (0 or 2), having loose teeth (0 or 2), cavities/not (0 or 1 or 2), tooth pain (0 or 2), bad breath (0 or 2). When the total score is 0–6, it is included in the category of good oral health status and, when total score is 7–12, it belongs to the moderate status. However, when the total score is within the range of 13 to 18, then it is included in the poor category
Determination of the severity of oral lesions was also conducted by aggregating the scores for each question, including frequency, number, and size of ulcers, as well as oral dysfunction due to the ulceration experienced by respondents. The score of 0 for the answer is never; a score of 1 for occasional responses or 1–2 ulcers count; Score 2 for frequent responses or more than 2 times per year or number of ulcers more than 2; A score of 3 for the response is very common, or the number of ulcers is very large, or the size is large and small. When the total score is 0–4, it is included in the mild stomatitis category. Furthermore, the totals score 5–8 belongs to the category of mild stomatitis, while the total score 9–12 belongs to the category of severe stomatitis.
Determination of oral dryness degree (xerostomia) by summing the scores of each question: answers never (score = 1), rarely/sometimes (score = 2), often (score = 3). When the total score is 0–5, 6–10, and 11–15, it is categorized as mild, moderate, and severe xerostomia, respectively. The stress level is also determined by summing the scores of each question: never (score = 0), almost never (score = 1), sometimes (score = 2), often (score = 3), very often (score = 4). When the total score is 0–7, 8–11, and 12–25, it belongs to normal, low, and moderate stress categories, respectively. Also, when the total score is 16–20 and ≥ 21, it belongs to high and very high-stress categories, respectively.
An analysis was conducted using Statistical Package for the Social Sciences software version 20.0 (New York, USA). The study data were presented descriptively by indicating the number and percentage, while statistical examinations were used for the analytical calculation namely the Phi correlation analysis, χ2 test, and Spearman rank correlation. The significance of the results was determined following the P < 0.05.
| Result|| |
The study subjects were 380 respondents, consisting of 82 (21.6%) men and 294 women (78.4%). Their characteristics were based on the type of sex, age, education level, occupation, income, and systemic diseases suffered are presented in [Table 1]. The respondent’s age is in the range of 20 to 29 years for as many as 124 people (32.6%), the most education level is S1 for as many as 220 (57.9%). Also, 122 respondents do not have a permanent job (32.1%) and do not have income as many as 71 (18.7%).
[Table 2] showed that the dental health status is generally in the good category of 255 (67.1%), the degree of stomatitis is in the mild category of 235 (61.8%), the status of oral dryness is in the mild category of 374 (98.4%), and the results of stress level measurement (PSS-10) showed that as many as 195 (51.3%) experienced severe stress and 53 (13.9%) experienced very severe stress.
The relationship of stress with gender, age, education level, occupation, income, and systemic diseases suffered is shown in [Table 3]. There was a significant relationship between stress and age, occupation, and income. In addition, the analysis results showed a negative correlation, the older the age, the lower and greater level, and the greater the income.
Furthermore, there was also a significant relationship between stress and dental health status, the severity of stomatitis, and oral dryness/xerostomia (P < 0.05). The analysis results showed a positive correlation, and it means that the heavier the stress experienced by a person, the worse the oral health status, the more severe the degree of stomatitis, the more severe the dryness of the mouth. This showed that stress is one of the factors that can affect oral health status, the severity of stomatitis, and xerostomia [Table 4].
|Table 4: Relationship between stress and oral health status, stomatitis severity, and dry mouth status|
Click here to view
| Discussion|| |
The results (PSS-10) showed that 97.6% of respondents experienced stress at different levels, consisting of 35 (9.2%), 88 (23.5%), 195 (51.3%), and 53 (13.9%) in the mild, moderate, severe and very severe stress categories respectively. The stress experienced is due to the influence of the pandemic situation in the world. The Covid-19 pandemic happened suddenly and beyond human expectations. In addition to causing illness and death due to viral infection, this pandemic situation also creates mental and psychological stress for people. However, stress during this pandemic is very normal since it is a form of response to the pressure experienced. The freedom to travel and socialize with different kinds of people during this pandemic is limited.,, Previous study by Salari et al., stated that the prevalence of stress, anxiety, and depression was 29.6%, 31.9%, and 33.7% respectively. The results showed that the percentage of people experiencing stress is due to different measuring instruments, demographics, and socio-culture of society as well as differences in data collection.
Furthermore, there is a correlation between stress and age, occupation, and income. The stress experienced by a person is the psychological response of the body in dealing with the pressure or problems experienced. However, people develop methods to deal with this stress, which is influenced by experiences and the environment. As healthy people age, the likelihood of life problems increases, likewise the experience of dealing with them will increase. The higher a person’s income, the less financial worries there are of being quarantined during the pandemic. The results of a previous study conducted in Iran, which is one of the countries with the largest number of sufferers of Covid-19 infection in the world, reported that stress tends to be more common in women, individuals with chronic diseases, middle or productive age, and low education levels.
Individuals that experience stress is prone to having health problems, which can lead to dental and oral health problems. Stress can trigger the progressive development of dental and oral diseases in two ways: first, it contributes to diseases in the oral cavity, such as drug use, alcohol, smoking, poor diet, and sedentary behavior. These behaviors include being lazy to maintain cleanliness and oral health as well as not paying attention to nutritious food intake and adequate drinks. Second, stress contributes to the adaptation process which can lead to dysfunction of the physiological system and also affects the mechanisms of disease progression. Some oral diseases that have been previously possessed but do not cause symptoms may reappear, such as recurrent ulceration, gingivitis or swelling of gums, dental, opportunistic, and oral infections due to certain systemic complications and their treatment, as well as recurrence of autoimmune diseases., Stress decreases the flow rate, quantity, and quality of saliva as well as result in xerostomia.
The results indicate that the dental health status of the people at Bandung city is generally in the good category by 255 respondents (67.1%). Previously, a study was conducted on people in Bandung related to periodontal health, and the oral hygiene of most people was in the moderate category (68%), the incidence of gingivitis and periodontal disease was 55.25%. and 44.75%. Furthermore, the analysis showed a positive correlation between stress level and oral health status. This means that the more stress is experienced by a person, the more serious is the oral health status. This is in line with the study of Vasiliou et al., 2016, which indicates that more stress is experienced by a person, and the poorer is the health. However, when they have dental health insurance or are at high socioeconomic status, it shows a different correlation. A study regarding the prevalence of stress in high school students also reported that its increased level can be a risk indicator and have a negative impact on oral health.
Measurement of stomatitis severity showed that 235 (61.8%) respondents were in the mild category and it showed a significant relationship with stress (P < 0.05). Stomatitis is painful recurring ulceration of the lining of the mouth, which can be single or multiple, usually without keratin on the oral mucosa. The ulcer lesions appear yellow or white and are surrounded by halo erythema. The prevalence in the general population is about 20% with predilection in women, and its factors trigger relapse. Some studies suggest that psychological disorders such as stress and anxiety act as triggers or modifying factors in the onset and recurrent aphthous stomatitis (RAS) lesions, but not as a causative factor (etiology).,[24-27]
Stress, anxiety, and depression can affect unstimulated salivary flow rates and lead to xerostomia. Increased stress can also increase the dry mouth incidence which impairs quality of life. This study used the Short-form version SXI-D questionnaire to measure people’s oral dryness status at Bandung city. The results showed that most people were in the mild xerostomia category, a number of 374 respondents (98.4%). Furthermore, the result showed a significant relationship between stress and dryness of the mouth/xerostomia (P < 0.05).
Public concern about this uncertain pandemic situation increases stress and lowers the body’s immunity, which may lead to various oral and dental diseases. Therefore, a medium that can meet this need by minimizing human contact should be provided, and one of which is telemedicine/teledentistry. The questionnaire can be used as early detection for dental professionals or a self-assessment for the community regarding oral health status, the degree of stomatitis severity, and xerostomia. The people may answer the questionnaire on the ground that the dentists are able to check dental and oral health status, the severity of stomatitis, and xerostomia, prior to consultation and examination services. This is conducted through telemedicine/teledentistry and online services, as well as through interviews.
This is the first study to connect stress levels with oral health status, stomatitis, and xerostomia in the community during the Covid-19 pandemic using a questionnaire and conducted online. Furthermore, the results of this study may be used by the government as a reference in determining stress prevention and management programs, as well as dental and oral diseases for the community during the Covid-19 pandemic. However, some limitations encountered are measurements based on self-report by subjects, conducted at a certain time (cross-sectional design), and only in one area.
| Conclusion|| |
From the findings of this study, it can be concluded that oral health status, xerostomia, and stomatitis were associated with levels of stress. Higher stress indicates poor oral health status, as well as severe xerostomia and stomatitis. Stress contributes to the adaptation process which can lead to dysfunction of the physiological system and also affects the mechanisms of disease progression including dental and oral diseases.
Further research is needed to analyze the relationship between stress, oral health status, xerostomia, and stomatitis in people confirmed with positive by Covid-19, so that interventions can be made to improve the quality of life of patients.
We would like to acknowledge all respondents who participated in this study.
Financial support and sponsorship
This research was supported by an Internal Research Grant (RDPD Schema) from Universitas Padjadjaran (Contract Number: 1735/UN6.3.1/LT/2020)
Conflict of interest
There are no conflicts of interest.
AS: Concepts, design, experimental study, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, guarantor. ISW: Concepts, design, literature search, experimental study, data acquisition, statistical analysis, manuscript preparation, manuscript review, FFB: Concepts, design, literature search, experimental study, data analysis, manuscript preparation, manuscript review.
Ethical policy and institutional review board statement
This study has received ethical approval from the Research Ethics Commission of Padjadjaran University No. 570/UN6.KEP/EC/2020.
Patient declaration of consent
Written consent was obtained electronically upon initiation of the survey questionnaire; all anonymity measures were undertaken to ensure participant identity privacy.
Data availability statement
Data can be obtained upon written correspondence to the corresponding author on a valid request.
| References|| |
Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al
. Genomic characterisation and epidemiology of 2019 novel coronavirus: Implications for virus origins and receptor binding. Lancet 2020;395:565-74.
Munster VJ, Koopmans M, van Doremalen N, van Riel D, de Wit E A novel coronavirus emerging in china - key questions for impact assessment. N Engl J Med 2020;382:692-4.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Topcuoglu N Public Health Emergency of International Concern: Coronavirus Disease 2019 (COVID-19). Open Dent J 2020;14:71-2.
Shuja KH, Aqeel M, Jaffar A, Ahmed A COVID-19 pandemic and impending global mental health implications. Psychiatr Danub 2020;32:32-5.
Shahsavarani AM, Ashayeri H, Lotfian M, Sattari K The effects of stress on visual selective attention: The moderating role of personality factors. J Am Sci 2013;9(6s):1-16.
Vasiliou A, Shankardass K, Nisenbaum R, Quiñonez C Current stress and poor oral health. BMC Oral Health 2016; 16:88.
Shankardess K Place-based stress and chronic disease: A systems view of environmental determinants. In: O’Campo P, Dunn JR, editors. Rethinking Social Epidemiology: Towards a Science of Change. New York: Springer Publishing Company; 2012. p. 117-8.
Pourhoseingholi MA, Vahedi M, Rahimzadeh M Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench 2013;6:14-7.
Levin L, Shpigel I, Peretz B The use of a self-report questionnaire for dental health status assessment: A preliminary study. Br Dent J 2013;214:E15.
Gallo CdB, Mimura MAM, Sugaya NN Psychological stress and recurrent aphthous stomatitis. CLINICS 2009;64:645-8.
Thomson WM Dry mouth and older people. Aust Dent J 2015;60(Suppl 1):54-63.
Yokokura AVCP, Silva AAMD, Fernandes JKB, Del-Ben CM, Figueiredo FP, Barbieri MA, et al
. Perceived stress scale: Confirmatory factor analysis of the PSS14 and PSS10 versions in two samples of pregnant women from the BRISA cohort. Cad Saude Publica 2017;33:e00184615.
Tavakol M, Dennick R Making sense of Cronbach's alpha. Int J Med Educ 2011;2:53-5.
Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al
Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. Global Health 2020;16:1-11.
Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A The impact of stress on body function: A review. Excli J 2017;16:1057-72.
Dagli RJ Fear and anxiety-coping strategies during COVID-19 pandemic in lockdown. J Int Oral Health 2020;12:187-8.
Vinkers CH, van Amelsvoort T, Bisson JI, Branchi I, Cryan JF, Domschke K, et al
. Stress resilience during the coronavirus pandemic. Eur Neuropsychopharmacol 2020;35:12-6.
Maarefvand M, Hosseinzadeh S, Farmani O, Farahani AS, Khubchandani J Coronavirus outbreak and stress in Iranians. Int J Environ Res Public Health 2020;17:4441.
Dziedzic A, Wojtyczka R The impact of coronavirus infectious disease 19 (COVID-19) on oral health. Oral Dis2020:1-4. https://dx.doi.org/10.1111/odi.13359
Bulthuis MS, Jan Jager DH, Brand HS Relationship among perceived stress, xerostomia, and salivary flow rate in patients visiting a saliva clinic. Clin Oral Investig 2018;22:3121-7.
Susanto A, Carolina DN, Amaliya A, Setia Pribadi IM, Miranda A Periodontal health status and treatment needs of the community in Indonesia: A cross sectional study. J Int Oral Health 2020;12:114-9.
Arman K, Petruninaitė A, Grigalauskienė R, Slabšinskienė E Stress experience and effect on self-perceived oral health status among high school students. Stomatologija 2016;18:75-9.
Dhopte A, Naidu G, Singh-Makkad R, Nagi R, Bagde H, Jain S Psychometric analysis of stress, anxiety and depression in patients with recurrent aphthous stomatitis-A cross-sectional survey based study. J Clin Exp Dent 2018;10:e1109-14.
Keenan AV, Spivakovksy S Stress associated with onset of recurrent aphthous stomatitis. Evid Based Dent 2013;14:25.
Rao AK, Vundavalli S, Sirisha NR, Jayasree CH, Sindhura G, Radhika D The association between psychological stress and recurrent aphthous stomatitis among medical and dental student cohorts in an educational setup in India. J Indian Assoc Public Health Dent 2015;13:133-7.
Ajmal M, Ibrahim L, Mohammed N, Al-Qarni H Prevalence and psychological stress in recurrent aphthous stomatitis among female dental students in Saudi Arabia. Clujul Med 2018;91:216-21.
Gholami N, Hosseini Sabzvari B, Razzaghi A, Salah S Effect of stress, anxiety and depression on unstimulated salivary flow rate and xerostomia. J Dent Res Dent Clin Dent Prospects 2017;11:247-52.
[Table 1], [Table 2], [Table 3], [Table 4]