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Original Article

Schizophrenia and periodontal

disease: An oro-neural connection? A
cross-sectional epidemiological study
Shreya Shetty, Aditi Bose

Department of Abstract:
Periodontics, Background: Schizophrenia is a psychosis characterized by delusions and hallucinations occurring in clear
Bangalore Institute of consciousness. Studies have shown that the cytokines may modulate dopaminergic metabolism and schizophrenic
Dental Sciences and symptomatology in schizophrenia. Cytokine involvement in periodontal disease is also well documented. To date,
Postgraduate Research, however, there has been relatively little research assessing periodontal status of patients with schizophrenia. The
Bangalore, Karnataka, present study was therefore mainly intended to understand the exact link, if any, between periodontal disease
and schizophrenia. Materials and Methods: A total of 250 schizophrenic patients (140 males and 110 females),
between 25 and 55 years of age, were selected from the out patient department of National Institute of Mental
Health and Neural Sciences, Bangalore and their periodontal status was assessed as part of this cross-sectional
epidemiological survey. Results: ANOVA showed that there was increased evidence of poor periodontal condition,
as evidenced by gingival index and plaque index in patients who had been schizophrenic for a longer duration
of time (P < 0.001). So also, higher probing pocket depths were found in schizophrenics suffering from a longer
period of time than others (P < 0.001). Conclusions: Although oral neglect might be a cause of poor periodontal
health in schizophrenics, the possible link between periodontal diseases giving rise to schizophrenia cannot be
overlooked due to the presence of cytokine activity which is present both in schizophrenia and periodontal disease.
Key words:
Access this article online Chronic periodontal disease, cytokines, oral health, periodontal disease-systemic interactions, schizophrenia
DOI: Australia, over 280,000 people in Canada, and
over 250,000 diagnosed cases in Britain.[4]
Quick Response Code: c h i z op h r en i a is a mental di s or der
S c h a r a c t e r i z e d by a d i s i n t e g r a t i o n
of thought processes and of emotional
The exact cause of schizophrenia is not yet
known; however, there are strong indications
responsiveness.[1] It most commonly manifests that it results from abnormalities in brain
as auditory hallucinations, paranoid or bizarre development and maturation that adversely
delusions, or disorganized speech and thinking, affect neural circuits and neurotransmitter
and it is accompanied by significant social systems. The delusions and hallucinations
or occupational dysfunction. The onset of may result from excess dopamine activity in
symptoms typically occurs in young adulthood; limbic areas of the brain. Decreased emotional
with a global lifetime prevalence of about responsiveness, paucity of speech content, and
0.3-0.7%. [2] Diagnoses is based on observed a lack of goal-initiated behaviors may result
behavior and the patient’s reported experiences. from dopamine deficiency in pre-frontal areas.
Aberrant levels of the neurotransmitter serotonin
Schizophrenia is a severe form of mental also have been implicated as a possible cause of
illness affecting about 7 per thousand of both negative and positive symptoms. Structural
Address for
the adult population, mostly in the age imaging studies have shown that patients
Dr. Shreya Shetty, group 15-35 years. Though the incidence with schizophrenia have reduced whole-brain
Department of is low (3-10,000), the prevalence is high volume and specific reductions in cortical gray
Periodontics, Bangalore due to chronicity. [3] The prevalence rate for and white matter, frontal lobes, thalamus,
Institute of Dental Sciences schizophrenia is approximately 1.1% of the and limbic system structures (amygdala,
and Postgraduate population over the age of 18 (source: NIMH) hippocampus, parahippocampal gyrus). [5]
Research, Hosur Road, or, in other words, at any one time as many Functional imaging studies such as regional
Bangalore - 560 029, cerebral blood flow and positron emission
as 51 million people worldwide suffer from
Karnataka, India.
E-mail: drshreyak@
schizophrenia, including 6 to 12 million people tomography have demonstrated that the in China (a rough estimate based on the prefrontal cortex suffers impaired blood flow,
population), 4.3 to 8.7 million people in India as well as inadequate oxygen use and glucose
Submission: 08-08-2012 (a rough estimate based on the population), metabolism, when a patient with the disorder
Accepted: 06-10-2013 2.2 million people in USA,285,000 people in performs problem-solving tasks.[6,7]

Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014 69

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Shetty and Bose: Schizophrenia and periodontal disease

Advanced dental disease is seen frequently in patients with Higher mean GI [Table 2], PI [Table 3], and PPD [Table 4]
schizophrenia for several reasons:[8] were recorded in 11 years and above group followed by
• The disease impairs ability to plan and perform oral hygiene 1-3 years group, 4-6 years group and 7-10 years group,
procedures respectively. The difference in mean GI, PI, and PPD
• Some of the antipsychotic medications have adverse effects between the groups was found to be statistically significant
such as xerostomia or dry mouth (P < 0.001). Further, using the Bonferroni method for
• Limited access to treatment because of lack of financial multiple comparisons, it was found that significant
resources and adequate number of dentists comfortable in difference existed between 11 years and above group and
providing care. all the other groups (P < 0.001).

Reports have confirmed the association of periodontal disease In the overall sample, and when males and females were taken
with various neurologic conditions such as Alzheimer’s individually, correlation between duration of disease and GI
disease[9] and Schizophrenia.[8] Although a bidirectional link was found to be moderate and significant (P < 0.001). So also,
between Alzheimer’s disease and periodontal disease has been correlation between duration of disease and PI and between
proposed, reports of the association between schizophrenia and duration of disease and PPD was found to be moderate and
periodontal disease have so far concluded only a unidirectional significant (P < 0.001) [Table 5].
link with poor periodontal health in schizophrenics being
attributed to a partial or complete neglect of oral health. DISCUSSION

The present study was aimed at exploring for the first time Schizophrenia ranks among the top 10 causes of disability
the possible bidirectional link between periodontal disease in developed countries worldwide.[10] Social problems, such
and schizophrenia. The objective was primarily directed at as long-term unemployment, poverty, and homelessness,
assessing the periodontal status of schizophrenic patients and are common. The average life expectancy of people with
assess if there was a correlation, if any between the duration the disorder is 12 to 15 years less than those without, this
of illness in both the conditions. being the result of increased physical health problems and
a higher suicide rate (about 5%).[2] Schizophrenia has great
MATERIALS AND METHODS human and economic costs.[2] It results in a decreased life
expectancy of 12-15 years, primarily because of its association
Following approval of the Ethical Committee, Bangalore with obesity, sedentary lifestyles, and smoking.[2] It is also
Institute of Dental Sciences and National Institute of Mental a major cause of disability, with active psychosis ranked
Health And Neural Sciences, Bangalore, 250 patients (140 males as the third-most-disabling condition after quadriplegia
and 110 females) with a positive history of schizophrenia were and dementia and ahead of paraplegia and blindness.[11]
selected from the out-patient department of National Institute Approximately three-fourths of people with schizophrenia
of Mental Health And Neural Sciences, Bangalore, during the have ongoing disability with relapses.[12] Schizophrenia affects
period from June 2011 to September 2011. A detailed case history around 0.3-0.7% of people at some point in their life,[2] or
was recorded for each patient with special emphasis on the 24 million people worldwide as of 2011.[3] It occurs 1.4 times
medications being used and duration of schizophrenia. Patients more frequently in males than females and typically appears
with any other co-existing systemic disease or condition as well earlier in men,[13] the peak ages of onset being 20-28 years for
any other neurological disorder were ruled out of the study. In males and 26-32 years for females.[14]
addition, patients with any kind of periodontal therapy done
in the past were also excluded from the study. An accurate understanding of the etiology and pathogenesis
of the condition is not yet clear. A combination of genetic and
The following periodontal parameters were examined: environmental factors may play a role in the development of
• Gingival index (GI) schizophrenia.[2,13] People with a family history of schizophrenia
• Plaque index (PI) who suffer a transient or self-limiting psychosis have a
• Probing pocket depth (PPD). 20-40% chance of being diagnosed 1 year later.[15] To this
effect, a number of attempts have been made to explain the
All the 250 patients were on antipsychotic medication as link between altered brain function and schizophrenia.[16]
prescribed by the neurophysician and reported no history of One of the most common is the dopamine hypothesis, which
any other systemic illness and also no history of any kind of attributes psychosis to the mind’s faulty interpretation of the
periodontal treatment in the past. misfiring of dopaminergic neurons.[16] Dopamine dysregulation
can be caused due to a number of factors including systemic
The parameters assessed were statistically analyzed by the mini infections, inflammations, etc., Studies have suggested the
tab version 14 and ftss version 13 statistical program using
analysis of variance (ANOVA). In case of significant difference Table 1: Sample distribution according to duration of
between groups, multiple comparisons (post hoc test) using the disease
Bonferroni test was carried out. Duration (years) N %
1-3 51 20.4
RESULTS 4-6 57 22.8
7-10 34 13.6
The 250 selected patients were divided on the basis of duration 11 and above 108 43.2
of schizophrenia in years [Table 1]. Total 250 100

70 Journal of Indian Society of Periodontology - Vol 18, Issue 1, Jan-Feb 2014