6 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status Depression status in relation to dental caries and salivary C- Reactive Protein among 17 years old secondary school female in Baghdad City/Iraq. Noor A. Al-Bazaz(1) , Nada Jafer MH Radhi (2) https://doi.org/10.26477/jbcd.v33i1.2921 ABSTRACT Background: Depression is a state of low mood and aversion to activity, it can affect a person's thoughts, behavior and sense of well-being. It can affect oral health and lead to an increased risk of dental caries. Dental caries is the most common oral infectious diseases that stresses the immune system and causes changes in cellular and molecular components of peripheral blood and C-Reactive Protein is one of these components, considered a key biomarker of inflammation. This study was conducted to assess the effect of depression status on dental caries among 17 years old secondary school female students in relation to salivary C-Reactive Protein. Materials and Methods: A cross sectional study was carried and the whole sample composed of 500 female students selected from First Alrasafa Directorate schools in Baghdad/ Iraq. Consent form was achieved from the ethical approval committee in College of Dentistry/University of Baghdad. All students were subjected to Children Depression Inventory questionnaire by Kovacs in 2011. Dental caries was registered according to Manji et al. 1989, Decay (1-4) Missing-Filled surface index. Subsamples were selected from high and low grade of depression to analyze C-Reactive Protein. Results: The percentage of occurrence of depression was 100%. The mean value of caries experience and severity were found to be higher among female students with high depression grade in comparison with low depression grade. The mean value for C- Reactive Protein was higher in high depression grade. There is a diversity in the results of caries experience with C-Reactive Protein. The percentage of depression occurrence was 100% which means a high degree of depression, and this could be due to the life difficulties, tension and economic issues that all lead to mental problems. The severity of dental caries increased as a result of stress and anxiety that may cause poor dental health. Psychological factors interact through complex pathophysiological and behavioral mechanisms that may cause elevated C-Reactive Protein. Conclusion: Depression has a negative impact on a person’s oral health including dental caries. Elevated C-Reactive Protein levels have been associated with psychological depression. Key words: Depression, Children Depression Inventory, Dental caries, C-Reactive Protein. (Received: 12/12/2020, Accepted: 19/1/2021) INTRODUCTION Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest or pleasure in most or all normal activities (1). It can be considered as one of the significant causes of mortality and morbidity and a contributor to the global burden of disease (2). It can affect oral health as a result of neglecting oral hygiene procedures, cariogenic nutrition, and avoidance of necessary dental care which leads to an increased risk of dental caries (3). Children Depression Inventory (CDI) is one of various approaches that are available to measure depression for children and adolescent (4). It is self-report as the person being evaluated records his/ her answers on the test sheet, other than giving verbal answers to questions, then analyzed by the examiner (5). (1) Master Student, Department of preventive dentistry, College of Dentistry, University of Baghdad. (2) Assistant Professor, Department of preventive dentistry, College of Dentistry, University of Baghdad. Corresponding author, salwanby@gmail.net Reliability and validity of the depression inventory scale CDI2 -were guaranteed as this scale was used and tested for its reliability and validity earlier by Salman, 2014 and Muwafaq, in 2019 (5,6,7). Depression like dental caries, both are chronic diseases. Dental caries is a preventable - disease, bacterially established and progressed when acid producing by bacteria utilizes dietary sugars, diffuses into the tooth and dissolves its minerals, causing demineralization (8,9). Dental caries is the biggest threat to oral health and by far the most common oral infection disease. It has been well proven that the oral cavity contains some of the most varied and vast flora in the entire human body that cause infection which can also seriously stress the immune system and diminish its ability to deal with other infections and diseases. Infection causes changes in cellular and molecular components of peripheral blood - and C-Reactive Protein is one of these components, considered a key biomarker of - inflammation (10). It - is" an acute phase protein produced by liver and widely used as a marker of inflammation (11). Elevated https://doi.org/10.26477/jbcd.v33i1.2921 mailto:salwanby@gmail.net 7 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status levels of this protein hasbeen associated with psychological depression (12). Since there is no previous Iraqi study regarding the effect of depression on dental caries among 17 years old secondary school female students in Baghdad / Iraq in relation to salivary C-Reactive Protein, this study was conducted. The study hypothesis was that depression has no effects upon salivary C- Reactive Protein in relation to oral health status. MATERIALS AND METHODS The current study was carried out in Baghdad/Iraq starting from November, 2019; till July, 2020. Total sample involved 500 randomly selected females students aged 17 years from secondary schools in First Alrasafa Directorate in Baghdad/ Iraq in which their total number was 9567 students using specific statistical program called Epi Info 7 (is a public software package designed for the global public health community of practitioners and researchers) (13). Official consent was received fromthe Iraqi Ministry of Education and - from schools authority to observe the students without obligation and to ensure help. The age was calculated according to last birthday according to World Health Organization, 1997 (14). A scale called Children’s Depression Inventory (CDI2) was used to divide the sample into three groups according to the severity of depression (low, medium, high grade). Arabic version and translation validity of CDI2 was obtained by Salman in 2014 and Muwafaq in 2019, by two translators who translated the items of the test from its original language to the target language (Arabic) in Ministry of higher education and scientific research (6,7). All sample was requested to fill all items of the scale questionnaire by themselves. Subgroups of 45 students were taken arbitrarily from high grade and 45 students from low grade of depression to make comparisons regarding salivary C-Reactive Protein. Oral health assessments were carried out according to the basic procedures of the oral health which surveys of the World Health Organization 1997 (14). Dental caries was recorded according to Manji et al. (1989) (15) index criteria; this criteria permit for recording caries lesion for permanent teeth by its severity. Clinical examinations were carried out using plane mouth dental mirrors and probe. Unstimulated salivary samples were collected in sterile screw capped tubes (16), then taken to the laboratory for centrifugation and analysis. In the saliva of 90 students, C-Reactive protein concentration in mg/dl was measured by ELISA Kit using Enzyme Linked Immuno-Sorbent Assay (ELISA) machine. The principle of reagent preparation, technique assay and calculation of results were all completed according to manufactures procedure instructions. Statistical package for social sciences (SPSS version 21) was used for data description, presentation and analysis. For quantitative variables, mean and standard error were used. One Way Analysis Of Variance (ANOVA) was used to identify differences. Pearson correlation test was used for correlation between quantitative variables (17). For the level of significance, it was Not significant P>0.05, Significant P≤0.05. RESULTS Table 1 shows the distribution of sample according to depression grades . It was found that the higher occurrence (49%) was for low depression grade followed by medium grade (23.8%) then high grade (18.2%) was the lowest. Table 1: Distribution of the sample according to depression grade. Groups Number % Low 245 49.00 Medium 164 32.80 High 91 18.20 Caries experience - in each grade of depression is shown in Table 2. For decay surface (Ds), Missing surfaces (Ms) and DMFs, the higher value was among high grade of depression. the fillings component(Fs) of DMFs index, higher value was among medium grade. Table 3 demonstrates the mean values of caries severity represented by grades of lesion (D1-4). The mean of all grades of lesion severity was higher among high grade of depression. Concerning Table 4, it showed the result of salivary C-Reactive Protein according to depression grades, the mean value was higher in high grade with significant difference among groups. 8 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status Table 2: Dental caries experience according to depression grade Variables Low Medium High F Probability Value Mean SE Mean SE Mean SE DS 7.992 0.345 8.366 0.401 10.626 0.494 8.773 0.000* MS 0.469 0.127 0.415 0.168 0.769 0.258 0.875 0.418 FS 21.637 0.156 2.829 0.201 2.527 0.273 12.080 0.000* DMFS 10.098 0.352 11.610 0.416 13.923 0.589 16.638 0.000* Degree of freedom=2, SE: standard error, Ds: Decay surface, Ms: Missing surfaces, Fs: Fillings surface, *=significant at p≤0.05. Table 3: Caries severity represented by grades of lesion according to depression grade Variables Low Medium High F Probability Value Mean SE Mean SE Mean SE D1 6.082 0.241 6.720 0.297 7.407 0.336 4.594 0.011* D2 1.869 0.101 1.732 0.121 3.044 0.179 22.537 0.000* D3 0.078 0.021 0.067 0.023 0.110 0.043 0.501 0.606 D4 0.010 0.011 0.000 0.000 0.011 0.011 1.293 0.275 SE: standard error, Decay (1-4) Missing-Filled surface index, *=significant at p≤0.05 Table 4: Salivary C-Reactive protein in ml/min according to depression grade Variables Groups df Probability Value High Low Mean SE Mean SE CRP 2.625 0.143 1.399 0.068 88 0.000* SE: standard error , df: Degree of freedom, CRP: C- Reactive Protein. In Table 5, the correlation coefficient of caries experience with C-Reactive Protein according to grades of depression can be seen. For low depression grade, the relations goes in weak positive direction except for Decay surface which goes in weak negative direction. Regarding high depression grade, all relations go in weak negative direction. There was a significance in low depression grade for the relation between Missing surfaces and C-Reactive Protein, while other relations shows no significance. 9 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status Table 5: Correlation coefficient of caries experience with C-Reactive Protein according to grades of depression. Groups C-Reactive Protein R P Low Depression DS -0.186 0.220 MS 0.406 0.006* FS 0.108 0.481 DMFs 0.027 0.860 High Depression DS -0.116 0.447 MS -0.080 0.599 FS -0.266 0.077 DMFS -0.227 0.134 Ds: Decay surface, Ms: Missing surfaces, Fs: Fillings Surface, *= significant at p≤0.05. Correlation coefficient of caries severity was represented by D1-4 with C-Reactive Protein according to different grades of depression demonstrated in table 6. For all depression grades, the correlations were in weak negative non- significant direction except for D3 (grade 3) of high depression grade, it was weak positive, however the correlation of D4 (grade 4) of low grade depression shows a significant relation. Table 6: Correlation coefficient of caries severity with C-Reactive Protein according to different grade of depression Groups C-Reactive Protein R P Low depression D1 -0.174 0.253 D2 -0.225 0.137 D3 -0.083 0.586 D4 . 0.000* High depression D1 -0.152 0.318 D2 -0.038 0.806 D3 0.002 0.991 D4 -0.291 0.053 Decay (1-4), *= significant at p≤0.05. DISCUSSION All female students included in the study have symptom of depression (percentage of depression occurrence is 100%), and this could be due to the difficult life conditions represented by stress and financial difficulties that all lead to severe psychological problems (18,19). The mean values of caries experience concerning Decayed, Missing surfaces and DMFs values were higher among high grade of depression. Also caries severity represented by grades of lesion washigher in high depression grade, this result is in agree with other studies (6,20). The reasons for these results could be due to: ➢ Behavioral effects of stress and anxiety in depressed patients may cause poor dental health. It can be difficult to have the discipline to follow a strict tooth care routine when battling a mental health condition. Depressed people are also more likely to skip visits to the dentist due to dental fear especially in females (21). ➢ Depression causes diminishing in immune system function causing activation and colonization of pathogenic and cariogenic bacteria (20). ➢ Increased tendency to have sweet food to give happiness and pleasure to the brain, and this type of food is cariogenic and ends with the development of dental caries (22,23). ➢ Increased carbohydrate intake as a result of decrease serotonin metabolism which occurs during depression, and this will provide a noble environment for the development of acidic uric bacteria (23). Filled component of DMFs index (filled surface) was higher in medium and high grade than low grade of depression and this could be due to mysophobia (germophobia) which is “ a term used to describe a pathological fear of germs, bacteria, uncleanliness, contamination, and infection”. 10 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status Depressed people are at higher risk of developing phobias and may start focusing on germs, increased use of hygiene measures and triesto visit dentist whenever they have decay as a result of depressed mentality (24). The mean value for C- Reactive Protein was higher in high depression grade with significant difference. This result goes in line with some other studies (25,26). The underlying mechanism between inflammation and depression is not fully understood. Systemic inflammation and psychological factors interact through complex pathophysiological and behavioral mechanisms. First, inflammation may lead to depression as proinflammatory cytokines might contribute to decreased production of serotonin and increased production of kynurenic and quinolinic acids (27) that leads to decreased production of trophic factors, including brain- derived neurotrophic factor, a factor associated with depression. Second, depression may also lead to inflammation. Psychological stress activates the hypothalamic-pituitary-adrenocortical axis and sympathetic nervous system, which releases stress and depressive hormones. These hormones, together with cytokine release, initiate the acute- phase response triggering inflammation. (28,29). The diversity in the results of caries experience with C-Reactive Protein has many explanations. For positive correlations, this may be attributed first to the immune response during caries progression, development and thus indicative of inflammation. Similar results were concluded by the previous studies (30). Negative correlations of caries experience with C-Reactive Protein can be explained by the fact that dental caries is a multi- factorial disease, caused by complex interactions among acid-producing bacteria, fermentable carbohydrates and many host factors including saliva rather than to be related to single factor (31). Also presence of abundant proteins in human saliva such as amylases, proline rich proteins, statherin, histatin, mucin and cystatins that have a “double edged swords” role, so any modification indicate various physiological and pathological fluctuations (32,33). They may play a protective role or may increase colonization of microorganism depending on their location and action (34). CONCLUSION The percentage of depression occurrence was 100%. Caries experience was found to be higher among high depression grade. The same result for caries severity grade 1 (D1) and grade 2 (D2) produced significant differences. The correlations of Salivary C-Reactive Protein with caries experience and caries severity showed diversity in the results. REFERANCES 1. Kotov R, Gamez W, Schmidt F, Watson D. Linking "big" personality traits to anxiety, depressive, and substance use disorders: a meta-analysis. Psychological Bulletin. 2010; 136 (5): 768–821. 2. Kessler R.C., Nelson C.B., McGongale K.A., Liu J., Swartz M. and Blazer DG., Comorbidity of DSMIIIR major depressive disorder in the general population, Results from the US National Comorbidity Survey, Br J Psychiatry. 2006; 168: 17-30. 3. Taskinen, H., Kankalla, T., RajavaarA, P., Pesonen, P. Self-reported causes for referral to dental treatment under general anaesthesia (DGA): a cross-sectional survey. Eur Arch Paediatr Dent. 2014; 15(2):105-12. 4. Kovacs, M. Children Depression Inventory (CDI) manual Toronto, Canada: Multi Health Systems, 1992. 5. Kovacs, M. Children Depression Inventory (CDI2) manual Toronto, Canada: Multi-Health Systems, 2011. 6. AL-SALMAN H. Depression status in relation to oral health condition and salivary physiochemical characteristics among 15 years old school students in AL-Swera City-Wassit Governorate-Iraq. A master Thesis Submitted to the College of Dentistry, University of Baghdad. 2014. 7. Muwafaq S. The Impact of Depression Status on Oral Health Condition and Salivary Growth Hormone Related to Anthropometry Among Internally Displaced Adolescence in Baghdad/Iraq. A master thesis / College of Dentistry / University of Baghdad. 2019. 8. Selwitz, R.H., Ismail, A., Pitts, NB. Dental caries. Lancet. 2007; 369(9555): 51-9. 9. Iaas, J. A., Griffen, AL., Dardis, SR., Lee, AM., Olsen, I., Dewhirst, FE., Paster, BJ. Bacteria of Dental Caries in Primary and Permanent Teeth in Children and Young Adults. Journal of Clinical Microbiology.2008; 46(4): 1407-17. 10. Lopez R, Baelum V, Hedegaard CJ, Bendtzen K. Serum levels of C-reactive protein in adolescents with periodontitis. J Periodontol. 2011;82: 543–49. 11. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Hong Y, Myers GL, Rifai N, Smith SC, Taubert K, Tracy RP, Vinicor F. Markers of inflammation and cardiovascular disease. Application to clinical and public health practice. Circulation. 2003;107:499–511. 12. Yunsheng MA, David E., Sherry L, Milagros C. Rosal S. Ockene. Association between Depression and C- Reactive Protein. Cardiology Research and Practice. 2010; Volume 2011 |Article ID 286509. 13. CDC (Centers For Disease Control And Prevention). 2009. "Epi-Info-Community-Edition/license. 14. WHO. World Health Organization. Oral health surveys. Basic methods, Geneva.1997. 15. Manji, F., Fejerskov, O., Baelum, V. Pattern of Dental caries in an adult rural population. Caries Research 1989; 23(1): 55-62. 11 J Bagh College Dentistry Vol. 33(1), March 2021 Depression status 16. Navazesh M., Kumar SKS. Measuring salivary flow: challenges and opportunities. J Amer Dent Assoc 2008; 139 (2): 35-40. 17. Jennifer DC. Pearson's Product-Moment Correlation: Sample Analysis. University of Hawaii at Mānoa. Department of Nursing. United Kingdom. 2015. 18. Lando, B. 4 Years Later: Dump Those Ungrateful, Vicious Iraqis. The Huffington Post. J The blog 2007; 2(13) :22-28. 19. UNICEF. Geneva. The Unicef Children's Fund, 15th of March US Preventive Services Task Force. Guide to Clinical Preventive Services, 2013; 2nd ed, Alexandria, Va., International Medical Publishing. 20. Rashid T and Heider I. "Life Events and Depression" (PDF). Annals of Punjab Medical College.2008; 2(1):44-56. 21. Taskinen, H., Kankalla, T., Rajavaara, P., Pesonen, P. Self-reported causes for referral to dental treatment under general anaesthesia (DGA): a cross-sectional survey. Eur Arch Paediatr Dent. 2014; 15(2):105-12. 22. THONGKUMPALA, Yupin. Cariogenic Food Consumption Behaviors and Associated Factors in Primary School Students Wat Donwai School Tambon Bangkrateuk Amphur Sampran Nakhonpathom Province. Region 4-5 medical journal-วารสาร แพทย ์เขต 4-5, 2010: 219- 229. 23. Mennella, JA, Pepino, MY., Lehmann-Castor, SM., Yourshaw, LM. Sweet preferences and analgesia during childhood: effects of family history of alcoholism and depression. Addiction, 2010; 105: 666–75. 24. Grant JE. "Clinical practice: Obsessive-compulsive disorder". The New England Journal of Medicine. 2014; 371 (7): 646–53. 25. Liukkonen T, Silvennoinen-Kassinen S, Jokelainen J, Räsänen P, Leinonen M, Meyer-Rochow VB, Timonen M. The association between C-reactive protein levels and depression: results from the Northern Finland 1966 Birth Cohort Study. Biol Psychiatry. 2006;60(8):825-830. 26. Hamer M, Batty GD, Marmot MG, Singh-Manoux A, Kivimäki M. Anti-depressant medication use and C- reactive protein: results from two population-based studies. Brain Behav Immun. 2011;25(1):168-173. 27. Raison CL, Miller AH. Is depression an inflammatory disorder? Curr Psychiatry Rep. 2011;13(6):467-475. 28. Capuron L, Miller AH. Immune system to brain signaling: neuropsychopharmacological implications. Pharmacol Ther. 2011;130(2):226-238. 29. Kyrou I, Tsigos C. Stress hormones: physiological stress and regulation of metabolism. Curr Opin Pharmacol. 2009;9(6):787-79319758844 30. Gawri S, Shukla P, Chandrakar A survey of micro flora present in dental caries and it’s relation to environmental factors. Science and Technology , 2012, 4: 09-12. 31. Martins C, Buczynski AK, Maia LC, Siqueira WL, Castro GF. Salivary proteins as a biomarker for dental caries--a systematic review. J Dent 2013; 41:2-8. 32. Loo JA, Yan W, Ramachandran P, Wong DT. Comparative human salivary and plasma proteomes. J Dent Res 2010; 89: 1016-1023. 33. Kościelniak D, Jurczak A, Zygmunt A, Krzyściak W. Salivary proteins in health and disease. Acta Biochim Pol 2012; 59: 451-457. 34. Vibhakar PA, Patankar SR, Yadav MR, Vibhakar PA. Salivary total protein levels and their correlation to dental caries. Inter J Oral & Maxillofac Path 2013; 4: 13- 16. : المستخلص . يةالرفاهب : االكتئاب هو حالة من المزاج المنخفض والنفور من النشاط، ويمكن أن تؤثر على أفكار الشخص، والسلوك والشعور خلفيةال األسنان هوو تسوس تسوس األسنان. خطر ويؤدي إلى زيادة صحة الفم يؤثر على شيوعا رأكث يمكن أن التي في الفم األمراض المعدية هو سي –المتفاعل العالي البروتينان على الجهاز المناعي ويسبب تغييرات في المكونات الخلوية والجزيئية من الدم المحيطي و ضغطت وكان الهدف من هذه الدراسة لتقييم تأثير حالة االكتئاب على تسوس األسنان .عتبر عالمة حيوية رئيسية لاللتهابي واحد من هذه المكونات و .سي– المتفاعل العالي البروتينالمدارس الثانوية في ما يتعلق الباتة من طسن 17 في عمر األولى في رصافةطالبة تم اختيارهن من مدارس مديرية ال 500من تتكون العينة اإلجمالية تم اجراء دراسة مقطعية : العمل طرقالمواد و الطالب جميع وخضع بغداد. جامعة األسنان/ طب كلية في األخالقية الموافقة لجنة من الموافقة نموذج على الحصول تم بغداد/العراق. لمانجي Decay 1-4 شدة التسوس لمؤشر . تم تسجيل تسوس األسنان وفقا2011الستبيان جرد اكتئاب األطفال من قبل كوفاكس في عام .سي– المتفاعل العالي البروتينمنخفضة من االكتئاب لتحليل العالية والدرجة المن مجموعات فرعية. تم اختيار 1989وآخرون الطالبات الالتي اتصفن باكتئاب مرتفع. وكان القيم الوسطية لشدة تسوس أعلى بين %. ووجد أن 100كانت نسبة حدوث االكتئاب النتائج: . سي– المتفاعل العالي البروتين أعلى في درجة االكتئاب العالية. هناك تنوع في نتائج تجربة تسوس مع التفاعلي Cمتوسط قيمة بروتين االكتئاب حدوث نسبة وه100تبلغ والقضايا ذا%، والتوتر الحياتية الصعوبات بسبب ذلك يكون وقد االكتئاب من عالية درجة يعني تؤدي جميعها إلى مشاكل عقلية. األسنان. االقتصادية التي صحة سوء يسبب قد والقلق الذي نتيجة لإلجهاد تسوس األسنان شدة ازدادت .سي – المتفاعل العالي البروتين السلوكية المعقدة التي قد تسبب ارتفاعو ا المرضيةتتفاعل العوامل النفسية من خالل اليات الفسيولوجي – المتفاعل العالي البروتينان ارتفاع مستويات للشخص بما في ذلك تسوس األسنان.: االكتئاب له تأثير سلبي على صحة الفم اتستنتاجاال .االكتئاب قد ارتبط معسي Articles Published by Journal of Baghdad College of Dentistry is licensed under a Creative Commons Attribution 4.0 International License. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/