Huda.doc J Bagh College Dentistry Vol. 27(2), June 2015 Depression status Pedodontics, Orthodontics and Preventive Dentistry158 Depression status in relation to caries experience and salivary physiochemical characteristics among 15 years old students in Al-Swera city – Wassit Governorate-Iraq Huda S. Khiala, B.D.S. (1) Ban S. Diab, B.D.S., M.Sc., Ph.D. (2) ABSTRACT Background: Depression is a common mental disorder that presents with depressed mood;it can become chronic or recurrent and affect dental health .Thus this research aimed to assess the prevalence and severity of dental caries among students with different grade of depression in relation to physicochemical characteristics of stimulated whole saliva. Materials and methods: The total sample involved for depression status assessment is composed of 800 students for both gender aged 15 years old that were selected randomly , This was performed using children depression inventory (CDI) index that divided the students into four groups of depression(low or average grade, high average grade, elevated grade and very elevated grade). The diagnosis and recording of dental caries was by using decay, Missing, Filled surface index (DMFs); and according to the criteria ofManji et al (1989), Salivary samples was collected from 30 student with very elevated grade of depression and 30 from low or average grade under standardized conditions, then analyzed for measuring salivary flow rate and viscosity, in addition to estimation salivary elements that includes total protein, zinc, copper, chromium and Lithium. Results: the data of the present study showed that the percentage of Caries free students was higher among very elevated grade (8.60%) followed by low or average grade (8.52%), the less was among elevated grade of depression (5.04%).Concerning caries experience, the highest result was among elevated grade of depression followed by low or average grade, the lower result was among high average grade. While the sever grade of dental caries (D4) was found to be highly significant differ among different grade of depression, The data analysis of salivary elements found that the protein was higher in very elevated grade than low or average grade while other elements show the opposite result with significant concerning copper and zinc among very elevated grade that show significant difference. DMFs correlated negatively with salivary flow rate among low or average grade and very elevated grade; while concerning salivary viscosity, the correlation was direct with DMFs. With highly significant in very elevated grade, Salivary elements show positive relation with not significant except copper that show negative relation with significant. Conclusion: The results of the current research revealed that depression status had an adverse effect on salivary physicochemical characteristics and dental status including caries experience Key words: Depression, dental caries, salivary elements. (J Bagh Coll Dentistry 2015; 27(2):158-162). INTRODUCTION Depression is a common mental disorder that presents with depressed mood, loss of interest pleasure, decreased energy lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities(1). Depression is an important cause of morbidity, and the World Health Organization (WHO) has predicted that depression will be the second leading contributor to the global burden of disease (2). Varity of studies indicated there is a relation between depression and concentration of different nutritional and toxic elements in human body (total protein, zinc, copper, chromium and lithium) (3-7). Dental caries is one of the most common, communicable and intractable infectious disease in human (8). Dental caries is strongly age–related, as there is an often an increase in severity and prevalence with increase age (9). (1)M.Sc. Student Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad (2)Professor, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad Adolescence can be defined as a major life stage in which a child matures physically into an adult (10). Psychological changes begin during puberty and continue through adolescence directly affected nutritional status and nutritional needs (11). Depression is always connected with a declined metabolism of serotonin, which is later linked to the high carbohydrate intake. This lays the foundation for favorable conditions for the development of acid uric bacteria. The existence of a high prevalence of these bacteria indicates the growth and progression of dental caries (12). Many of protein molecules secreted by the salivary glands are of extreme importance in protecting the integrity of the teeth (13), they found a significant effect of zinc salts rinsing in decreasing Streptococcus Mutans counts (14). Thus, several researches found inverse correlation of salivary zinc with dental caries (15,16), whereas the elements copper and lithium present in food or water protect the teeth and act as cariostatic (17), whereas Cr ions may play a role in improving mineralization and crystallity of teeth (18). J Bagh College Dentistry Vol. 27(2), June 2015 Depression status Pedodontics, Orthodontics and Preventive Dentistry159 Saliva is a biologic fluid in the oral cavity, composed of a mixture of secretary products from the major and minor salivary glands (19), reduced salivary flow rate and hyposalivation leading to oral dryness might be the effect of psychological processes (anxiety, stress, depression etc.) (20). There is a negative relation between the salivary flow rate and dental caries (21).Viscosity means the resistance to flow or alteration of shape by any substance as a result of molecular cohesion (22), increased salivary viscosity plays a role in increasing caries incidence (23). MATERIALS AND METHODS The sample size composed of 800 students male and female, that they were distributed in secondary schools of Swera center which randomly selected from different areas and represented 90% of the number of intermediate schools of Al-Swera center. The whole male and females age 15 year old attending the selected secondary schools were examined depression status assessment by children Inventory index (CDI2 (24) and oral examination; Then subgroups of 30 students from both very elevated grade and low or average grade were randomly selected for salivary analysis. The caries experience was recorded by decay, missing, filling index (DMFs) and by using the criteria of Manjie et al (25), which allow recording decayed lesion by severity. The collection ofstimulated salivary samples were performed under standard condition following instruction cited by Tenovuo and Lagerl (26). The salivary flow rate was measured as milliliter per minute (ml / min); while viscosity was assessed by using Ostwald's viscometer. Target salivary elements were analyzed at The Poisoning Consultation Center / Specialized Surgeries Hospital. Salivary total protein, zinc, copper, chromium and lithium, analyzed, using absorption spectrophotometer (Buck scientific, 210VGPUSA) following standardized procedure, while the method used to determine the level of salivary total protein is colometric method by using of special kits according to the manufactured instructions. Data analysis was conducted by application of SPSS program version 21. RESULTS The result of the present study showed that the percentage of Caries free students was higher among very elevated grade (8.60%) followed by low or average grade (8.52%), the less was in elevated grade of depression (5.04%) and that showed in table (1). Concerning cariesexperience, the highest result was among elevated grade of depression followed by low or average grade with not significant. Concerning the severity of dental caries (D1-D4), the result was higher among very elevated grade with highly significant (P=0.01), followed by low oraverage grade and then high average grade and the lower one was elevated grade The data analysis of salivary elements found that the protein was higher in very elevated grade than low or average grade while other elements show the opposite result with significant concerning copper and zinc in very elevated grade that show significant difference, while others the differences were not significant. DMFs and its grades correlated negatively with salivary flow rate among low or average grade and very elevated grade; while concerning salivary viscosity, the correlation was direct with highly significant in very elevated grade. Salivary elements show positive not significant relation except copper that show negative relation with significant. Table 1: Distribution of caries free students according to depression Depression grades Very elevated Elevated High average Low or average % No % No % No % No 27.63 221 14.88 119 17.88 143 39.63 317 Total Table 2: Dental caries experience DMFs and its components (Ds, Ms, Fs)(Median, Mean rank) according to depression grade by gender . Chi Depression grades Vey elevated Elevated High average Low or average Mean Rank Median Mean Rank Median Mean Rank Median Mean rank Median 4.19 407.75 6.00 426.14 7.00 368.57 5.00 400.5 6.00 DS 2.87 393.53 0.00 414.42 0.00 393.54 0.00 404.11 0.00 MS 0.20 402.03 0.00 402.53 0.00 398.79 0.00 400.52 0.00 FS 5.68 402.26 6.00 431.85 7.00 365.16 6.00 403.97 7.00 DMFS J Bagh College Dentistry Vol. 27(2), June 2015 Depression status Pedodontics, Orthodontics and Preventive Dentistry160 Table 3: Severity of dental caries represented by grades of (D1-D4) (Median, Mean Rank) according to depression grades by gender Chi Depression grades Very elevated Elevated High average Low or average Mean Rank Median Mean Rank Median Mean Rank Median Mean Rank Median 1.25 201.14 2.00 189.95 2.00 201.82 1,00 198.86 2.00 D1 1.01 405.67 0.00 396.12 0.00 384.97 1,00 405.49 1.00 D2 1.31 404.73 0.00 410.56 0.00 393.56 0,00 397.05 0.00 D3 11.28** 421.95 0.00 361.95 0.00 390.19 0.00 405.05 0.00 D4 ** Highly significant P≤ 0.01 Table 4: The salivary physicochemical characteristics among students with very elevated grade and low or average grade of depression U-test Z Depression grades Very elevated Low or average Mean Rank median Mean Rank Median 436.500 -0.20 31.58 80.68 30.44 60.69 Protein (mg ∕l) 392.000 -0.85 28.76 3.69 33.33 4.15 Zinc (µg ∕l) 396.000 -0.80 34.06 2.60 27.94 2.70 Copper (µg ∕l) 432.500 -0.25 29.2 0.11 32.8 0.11 Chromium (µg∕l) 413.000 -0.54 29.77 1.07 32.23 1.12 Flow rate (ml ∕min) Table 5: Salivary viscosity (poise) among students with very elevated grade and low or average grade of depression Depression grades Statistical difference Low or average Very elevated df t-value P Mean ±SD Mean ±SD Total 0.0143 0.0075 0.0154 0.0087 58 -1.03 0.428 Table 5: Correlation coefficient between the salivary physicochemical characteristics and caries experience (Ds and DMFs) DMFs Ds Very elevated Low or average Very elevated Low or average p r p r p r p r 0.48 0.13 0.08 0.32 0.55 0.11 0.05* 0.35 Protein 0.07* 0.32 0.86 0.03 0.09 0.31 0.27 0.20 zinc 0.07* 0.33 0.49 0.13 0.17 0.25 0.20 0.23 copper 0.83 0.04 0.12 0.28 0.31 0.18 0.20 0.23 chromium 0.41 0.22 0.41 -0.15 0.30 -0.22 0.44 -0.41 Flow rate 0.005** 0.499 0.63 -0.09 0.004** 0.507 0.995 -0.001 Saliva viscosity *significant P≤ 0.05 ** Highly significant p≤0.01 DISCUSSION In this study, the prevalence and the experience of dental caries among elevated grade were non- significantly higher than other grades of depression, the increased dental caries in depressed individuals agrees with other study (27), could be attributed to that depression is always connected with a declined metabolism of serotonin, which is later linked to the high carbohydrate intake. Other explanation could be the Limitations in sunlight exposure that was reported among depressed person that leads to Vitamin D deficiency (28), as individual patients may have symptoms of depression related to potentially deficient vitamin D levels (29) that reported to be associated with increased dental caries (30). Moreover, other condition could be the decreased in salivary flow rate among students with very elevated grade of depression, thehigher the flow rate, faster the clearance, higher the buffer capacity(31),(32). this result also found in the present study by the inverse relation between the salivary flow rate and dental caries among both groups Other factor could be increase in salivary viscosity among students with very elevated grade than low or average grade with not significant and that agree with other study (33).The higher viscosity the less capable of flowing freely to oral sites where its protective functions such as J Bagh College Dentistry Vol. 27(2), June 2015 Depression status Pedodontics, Orthodontics and Preventive Dentistry161 clearance would be affected (34,35). This also found in the present study as Saliva viscosity show positive relation with dental caries in very elevated grade. All elements in this study related positively with dental caries with not significant in the two grade of depression, for total protein, the host salivary protein CSP-1 binds to S. Mutans cells and may influence the initial colonization of this pathogenic bacterium onto the tooth surface (36). Additionally, Salivary copper as other trace elements are essential for growth and metabolism of bacteria, but become injurious if presents in a high concentration (37). Concerning salivary zinc enhanced remineralization especially in deeper part and exhibited detrimental effects on remineralization in a dose response manner (38). This study did not show any results for the concentration of lithium in saliva using spectrophotometer device, the likelihood that small concentration of lithium in the two grade that was not detected in the device and that need further studies, also the distribution of depression was 100% and lithium has been shown to reduce the oxidative stress that occurs with multiple episodes of mania and depression, lithium is the first drug used for depression (39). REFERENCES 1- Rosner RM. Text book of Adolescent psychiatry. 1st ed. New York University; 2003. 2- Kessler R. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R) JAMA 2003; 289: 3095– 3105. 3- Hani M, Esashi T. The effects of calcium, phosphorus, magnesium, sodium and zinc in improving the depression of gonadal development in growing male rats kept under disturbed daily rhythm –investigations based on the L(16)(2(15)-type orthogonal arry. 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CNS Drugs, 2013; 27(2):135-53. الخالصة وھذا یھدف ھذا البحث إلى تقییم مدى انتشار وشدة تسوس . االكتئاب ھو اضطراب عقلي لمشترك مع مزاج مكتئب، ویمكن أن تصبح مزمنة أو متكررة وتؤثر على صحة األسنان األسنان بین الطالب مع درجة مختلفة من االكتئاب بالنسبة للخصائص الفیزیائیة للعاب المحفز .المحفز یھدف ھذا البحث إلى تقییم مدى انتشار وشدة تسوس األسنان بین الطالب مع درجة مختلفة من االكتئاب بالنسبة للخصائص الفیزیائیة لللعاب:ھالدراس اھداف سنة التي تم اختیارھا عشوائیا، تم تنفیذ ذلك باستخدام 15طالب لكال الجنسین الذین تتراوح أعمارھم بین 800تكون العینة الكلیة المعنیة لتقییم الوضع االكتئاب من :المواد واالسالیب وكان ). ارتفاع ، و مرتفع ودرجة مرتفعة جداالدرجة المنخفضة أو المتوسط ، متوسط (وتم تقسیم الطالب إلى أربع مجموعات من االكتئاب ) CDI(مؤشر األطفال االكتئاب لالطفال من الدرجة المنخفضة أو 30طالب بتقدیر مرتفع جدا من االكتئاب و 30، تم جمع العینات اللعابیة من ,Manji) 1989(وفقا لمعیار ).DMFs(التشخیص باستخدام مؤشر التسوس .ك والنحاس والكروم واللیثیومزنفي ظل ظروف موحدة، ثم تحلیلھا لقیاس معدل تدفق اللعاب واللزوجة، باإلضافة إلى تقدیر عناصر اللعابیة التي تتضمن البروتین الكلي والالمتوسط ، وكانت أقل بین )٪8.52(، یلیھ الدرجة المنخفضة أو المتوسطھ )٪8.60(أظھرت بیانات ھذه الدراسة أن نسبة تسوس الطالب كان أعلى بین درجة مرتفعة جدا من االكتئاب :النتائج ، كانت النتیجة أقل بین متوسط ة أعلى بین الدرجة المرتفعة من االكتئاب تلیھا الدرجة المنخفضة أو المتوسطفیما یتعلقبالتسوس ، كانت النتیج). ٪5.04(درجة مرتفعة من االكتئاب ن كان أعلى في ووجد تحلیل البیانات للعناصر اللعابیة أن البروتی. كانت كبیرة بین الدرجھ العالیھ من االكتئاب وبصوره واضحھ ) D4(في حین ان شده تسوس األسنان . الدرجة العالیة على DMFsوكان المؤشر .في حین تظھر عناصر أخرى العكس وكانت الصوره واضحھ في الزنك والنحاس, الصف مرتفعة جدا من االكتئاب من الدرجة المنخفضة أو المتوسطھ واضحھ في ,مع أھمیة . DMFsھ اللعاب كانت عالقتھا مباشره مع المؤشر، بینما لزوج. ودرجة مرتفعة جداعالقھ سلبیھ مع معدل تدفق اللعاب بین الدرجة المنخفضة أو المتوسط .. الصفوف المرتفعة جداز تظھر العناصر اللعابیة عالقة إیجابیة و غیر الھامة باستثناء النحاس التي تظھر عالقة سلبیة مع أھمیة .على الخصائص الفیزیائیة اللعابیة وحالة تسوس األسنان كشفت نتائج األبحاث الحالیة أن الوضع االكتئاب لھ تأثیر سلبي :االستنتاجات