Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

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Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Original Article

Investigation of the levels of different salivary stress markers in chronic T

periodontitis patients
Hakan Develioglua, Saygin Korkmaza, Serkan Dundarb,∗, Ulrich Schlagenhaufc
a
Sivas Cumhuriyet University, Faculty of Dentisty, Department of Periodontology, Sivas, Turkey
b
Firat University, Faculty of Dentistry, Department of Periodontology, Elazig, Turkey
c
Würzburg University, Faculty of Dentistry, Department of Periodontology, Würzburg, Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Background and aim: In this study, we aimed to determine the salivary levels of cortisol, α-amylase, β-endorphin,
Periodontitis and chromogranin (CgA) in saliva and to investigate their relationship with periodontitis.
Clinical attachment loss Methods: Thirty-seven female and 43 male periodontitis patients who presented to the Periodontology
Salivary stress markers Department of the XXX University Faculty of Dentistry participated in the study. The individuals were divided
Salivary cortisol
into three groups: mild, moderate, or severe chronic periodontitis. Plaque index (PI), gingival index (GI), clinical
attachment loss (CAL), and probing depth (PD) measurements were recorded for all the participants. All par-
ticipants underwent the State–Trait Anxiety Inventory test (STAI 1 and 2). Between 09:00 and 11:00 a.m., saliva
samples from the participants were collected into tubes within an average of five minutes.
Results: Higher cortisol measurements were detected in the saliva samples of participants with severe chronic
periodontitis than in those who had mild chronic periodontitis (P < 0.05). There were statistically significant
age differences among patients with mild–moderate, moderate–severe, and mild chronic periodontitis, the se-
verity of the disease increasing with age (P < 0.05). There was also a positive correlation between STAI 1 stress
scores and cortisol levels. Similarly, there was a positive correlation between CAL and cortisol levels (P < 0.05).
However, a significant difference was found among groups only in terms of salivary cortisol levels (P < 0.05).
Conclusion: Within the limitations of this study, there was found to be a relationship between saliva cortisol
levels and periodontitis and between salivary cortisol levels and stress.

1. Introduction be positively correlated with the occurrence and severity of period-

Periodontitis is one of the most common causes of tooth loss. In
addition, systemic risks such as diabetes mellitus, smoking, age, and
genetic factors affect the onset and progression of periodontal disease.
Emotional stress is considered to be an important risk factor for peri-
odontitis, but the biological mechanisms of the disease's progression
remain unclear.1–3 Stress is a physical, emotional, cognitive, and be-
havioral response to events that are viewed as threats or difficulties.
The psycho neuro immunological model attempts to link stress with
periodontitis through mentally triggered immunological response
changes. It is assumed that periodontal health is affected negatively if
the individual is not coping adequately with stress.4 Psychosocial stress
conditions lead to centrally induced immune suppression and an in-
crease in inflammation, which has an adverse influence on chronic
inflammatory disease.4,5 Cortisol, one of the stress-related biomarkers
of the hypothalamic–pituitary–adrenal axis, has already been shown to
ontitis and periodontitis.5 Saliva sampling is a non-invasive, painless,
rapid, and promising method for evaluating biomarkers.6 Studies have
shown that many biomarkers are found in saliva, some of which have
been associated with periodontal disease, including biomarkers due to a
major immune response, such as matrix metalloproteinase (MMP), os-
teoprotegerin, and interleukin-1β.7 New saliva biomarkers are still
needed to aid detection of the early stages of periodontitis, which may
facilitate earlier medical interventions.8,9
Chromogranin A (CgA) is an acidic glycoprotein with a molecular
weight of 48 kDa and consisting of 439 amino acids, and it is expressed
by the normal or neoplastic cells of various endocrine and neu-
roendocrine systems. CgA is secreted from the storage granules in the
adrenal medulla in combination with catecholamines, and it is secreted
in combination with parathormone from the parathyroid gland in re-
sponse to hypocalcemia. High CgA levels in saliva have been associated
with various conditions, such as dry mouth.9,10 In a pediatric study,

∗
Corresponding author. Firat University, Faculty of Dentistry, Department of Periodontology, Campus, Postal Code: 23119, Elazig, Turkey.
E-mail addresses: sdundar@firat.edu.tr, dtserkandundar@gmail.com (S. Dundar).

https://doi.org/10.1016/j.jobcr.2020.07.020
Received 5 February 2020; Received in revised form 25 July 2020; Accepted 28 July 2020
Available online 12 August 2020
2212-4268/ © 2020 Published by Elsevier B.V. on behalf of Craniofacial Research Foundation.
H. Develioglu, et al.
salivary CgA was shown to be a more sensitive marker for psychological
stress than salivary cortisol.11 CgA is released during stress and plays a
role in the natural immune response to bacteria, viruses, and fungi,
exhibiting a highly cationic structure.12 Neuroimmunity may play a role
in the protective response to stress associated with infectious diseases.13
Saliva α-amylase concentrations have been suggested as a reliable re-
flection of sympathetic nervous system (SNS) activity, especially under
stress situations.14 In one study, stress and saliva stress markers were
found to be associated with periodontal disease.1 Some studies suggest
that stress caused by periodontal inflammation may lead to the release
of certain saliva proteins, such as α-amylase.15
β-Endorphins are peptides found in high concentrations in the pi-
tuitary, anterior hypothalamus, septal area, and periaqueductal gray
areas. They are thought to affect pain perception, behavior, and various
psychological responses. Endorphins are released in response to stress.
β-endorphin levels have been found to be high in depressive patients.
This response may be depression-specific or it may be due to high levels
of stress unrelated to depression.
The State–Trait Anxiety Inventory (STAI) developed by Spielberger
et al. is a self-assessment questionnaire consisting of short statements,
which respondents rate on a four-point scale. This inventory, which was
originally developed to investigate anxiety in normal adults, was found
in subsequent trials to be suitable for high school students, individuals
with psychiatric disorders, and patients with physical diseases. Long-
term research has led psychologists to conclude that the inventory can
be applied to all young people and adults.16
Studies examining the relationship between saliva stress markers
and the severity of periodontitis are limited. Stress markers have been
studied separately and in paired studies, but no studies to date have
examined the impact of salivary levels of cortisol, α-amylase, β-en-
dorphin, and chromogranin A on the severity of chronic periodontitis
using the STAI. In this study, we aimed to investigate the levels of these
four salivary stress markers in the salivary samples of patients with
chronic periodontitis and the relationship between the severity of the
periodontitis and clinical parameters.
2. Materials & methods
2.1. Patient selection
The population of our study consisted of individuals diagnosed with
chronic periodontitis who presented to the Periodontology Department
of the Sivas Cumhuriyet University Faculty of Dentistry, Sivas, Turkey,
for treatment. Eighty patients were included in the study. The study was
approved by the Cumhuriyet University Clinical Research Ethics
Committee on January 17, 2017, with the decision number 2017-01/
03. The participants were informed in writing and orally about the
purpose, content, and procedures of the study in accordance with the
information and the consent form, which was signed by every partici-
pant. Excluded were: patients with diabetes, myocardial infarction,
heart disease, and allergies, individuals who smoked and consumed
alcohol, those who had had periodontal treatment in the previous six
months, those who took chronic anti-inflammatory drugs or anti-oxi-
dant vitamins, and individuals who had not used antibiotics in the
previous three months. Patients who were not lactating, who did not
have any prosthetic tooth restorations, and who did not have any lost
data in the saliva samples and stress questionnaires were included in
the study.1–5 After clinical and radiographic evaluations, the patients
were diagnosed according to the criteria for the diagnosis of general-
ized chronic periodontitis within the classification of the American
Periodontology Academy (1999).17
2.2. Patient groups
The individuals included in the study were divided into three groups
according to the severity of their periodontitis.17,18 For mild chronic
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Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518
periodontitis, the CAL, which is a sign of destructive and physiologi-
cally irreversible periodontal disease, was 1–2 mm. For moderate
chronic periodontitis, the CAL was 3–4 mm. For severe chronic peri-
odontitis, the CAL was ≥5 mm.17,18
2.3. Stress inventory
The STAI was used only in the initial session to measure the pa-
tients’ stress levels. Any questions that the patients did not understand
while filling out the questionnaire (Annexes 1 and 2) were clearly ex-
plained, and the questionnaires were completed accurately. The ques-
tionnaire consisted of two parts with 20 questions each, and each
question had four possible answers. The patients selected a score be-
tween one and four for each question; the minimum score for the
questionnaire was 20, and the maximum score was 80. In general,
higher STAI scores indicated a higher level of anxiety.19
When the literature is analyzed, it is seen that STAI 1 and STAI 2
stress scoring systems are a frequently used system. In this study, we
used the STAI 1 and STAI 2 scoring systems in accordance with the
literature.19
2.4. Clinical periodontal assessment
The PI, GI, PD, and CAL of each participant were measured by a
single clinician to determine the degree of periodontal disease. All
clinical measurements were recorded after taking saliva samples and
were made by an extensively trained, calibrated researcher according to
the study protocol.
2.5. Collection of saliva specimens and measurement of saliva stress
markers
Saliva samples were taken before clinical measurements to prevent
the contamination of saliva due to possible bleeding during probing. To
avoid affecting the stress markers in the saliva, patients were asked to
refrain from consuming any nutrients or liquids 1 h prior to the sample
collection. The samples were collected between 09:00 and 11:00 a.m.,
so that the patients were not affected by circadian rhythm changes. The
patients were asked to transfer the saliva samples to capped poly-
propylene tubes within an average of five minutes. The samples were
stored at −80 °C, before being taken to the Sivas Cumhuriyet
University Faculty of Medicine Biochemistry Laboratory, where they
were centrifuged, and biochemical analyses were performed.
2.6. Biochemical analysis of saliva samples
The saliva samples were centrifuged at 1000 g for 20 min, and the
supernatant was collected into Eppendorf tubes. Chromogranin A/
pancrea statin, amylase alpha 1, β-endorphin, and cortisol measure-
ments were taken using an Elabscience ELISA kit, in accordance with
the manufacturer's instructions.
2.7. Statistical analysis
The data obtained from our study were loaded into the SPSS (ver-
sion 22.00) program and evaluated using parametric test assumptions
(Kolmogorov–Smirnov). The Kruskal–Wallis test and the
Mann–Whitney U test were used when the parametric test assumptions
could not be fulfilled. A Spearman correlation analysis was used to
determine the relationships among the variables. A chi-squared test was
employed to evaluate the data obtained by counting, and the error level
was taken as p < 0.05.
H. Develioglu, et al.
Table 1
Comparison of age and sex measurements of groups.a Statistically significant different compared with the mild periodontitis group patients,b Statistically significant
different compared with the moderate periodontitis group patients (P < 0,05).
Mild Periodontitis (n = 26)Mean ± Sd (min- max) Moderate Periodontitis (n = 39)Mean ± Sd (min- max)
Age 38.23 ± 3.55 (35–49) 42.66 ± 7.65a (35–62)
Sex Female 17 (65.4) Female 20 (51.3)
Male 9 (34.6) Male 12 (48.7)
a
P < 0,05, The severity of periodontitis increases with age.
3. Results
3.1. Demographic characteristics of groups, stress survey values and
distribution of saliva stress marker levels
The age and sex distributions of the patients according to the se-
verity of their chronic periodontitis are presented in Table 1. The se-
verity of chronic periodontitis increased with age (P < 0.05). How-
ever, there were no statistically significant gender differences among
the chronic periodontitis groups (P > 0.05). A comparison of the se-
verity of chronic periodontitis according to STAI 1 and STAI 2 stress
scores is given in Table 2. The stress questionnaires revealed no sig-
nificant differences among the groups in terms of the severity of chronic
periodontitis (P > 0.05).
The relationship between chronic periodontitis severity and cortisol
levels was, however, statistically significant, the severity of the disease
increasing with rising cortisol levels (P < 0.05). There were no sta-
tistically significant associations between α-amylase, chromogranin A,
or β-endorphin levels and the severity of chronic periodontitis
(P > 0.05) (Tables 3 and 4).
3.2. Comparing the severity of the periodontitis and clinical parameters of
the groups
There was also no statistically significant association between
clinical measurements and the severity of chronic periodontitis
(P > 0.05) (Table 5).
4. Discussion
The immune response to host microorganisms in the pathogenesis of
periodontitis is influenced by genetic factors, changeable environ-
mental factors, and systemic factors.20,21 Many studies have shown that
stress is one of the interchangeable environmental factors that are im-
portant risk determinants for the development of periodontal dis-
eases.22,23 However, recent studies have shown that stress is not a risk
determinant but a risk factor. In this study, the effects of salivary stress
markers on periodontitis—which are risk determinants and which are
thought to be risk factors—were investigated. A positive correlation
was found in human studies between the periodontal disease index and
adverse life conditions.24 When the inflammatory activation is long and
deep enough, the systemic symptoms of the disease may become pro-
minent and may occur with periodontitis.25
There have been some studies on the relationships among stress,
depression, and periodontitis.2 Many have reported a positive
Table 2
Comparison of severity of periodontitis according to stress score. STAI: State-Trait Anxiety Inventory test, (P > 0.05).
Stress Score Periodontal Parameter
Mild Periodontitis (n = 26) Mean ± Sd (min- Moderate Periodontitis (n = 39) Mean ± Sd (min-
max) max)
STAI1 42.92 ± 10.20 (26–74) 42.43 ± 1.48 (22–74)
STAI2 45.03 ± 6.86 (27–60) 49.15 ± 8.55 (34–73)
P > 0.05.
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Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518
Severe Periodontitis (n = 15)Mean ± Sd (min- max)
55.26 ± 6.94a,b (41–68)
Female 8 (53.3)
Male 7 (46.7)
association between psychosocial stress conditions (e.g., academic
stress and occupational stress) and clinical periodontal parameters (e.g.,
plaque accumulation–PI and gingival inflammation–GI).26 High con-
centrations of cortisol and β-endorphin can regulate MMP-1, MMP-2,
MMP7, MMP-11, and tissue inhibitor metalloproteinase-1 in the gin-
gival fibroblasts of humans. This mechanism explains the increase in
periodontal destruction associated with physiological stress.1 Stress
markers found in the blood and saliva of individuals with periodontal
disease change the microbial dental biofilm composition and trigger the
development of periodontal disease via different mechanisms involving
modifications of the inflammatory response.27 Studies have examined
the relationships between saliva stress markers and periodontitis in
patients alone and in comparisons between periodontitis groups and
controls. However, no previous study has examined four different saliva
stress markers together with the STAI. Saliva is considered a good
sampling material with which to assess stress conditions, especially
depression, and the use of saliva markers to assess human stress has
become more common in the last 30 years.7,28 In their study in 2011,
Rai et al.1 investigated the association between saliva stress markers
and periodontal status and significant relationships were found among
salivary cortisol and β-endorphin levels, tooth loss, and periodontal
clinical parameters.1 The STAI was administered to individuals who
participated in the study. Many studies have used this questionnaire in
the field of dentistry to measure stress and anxiety.29 For example,
Vettore et al.29 investigated the relationship between periodontal dis-
ease and stress, using the STAI on 79 patients. They found that CAL and
an increase in PD were positively correlated with high anxiety in-
ventory scores. Kesim et al.30 used the STAI to investigate the re-
lationship between stress and the severity of periodontal disease in 141
patients. The stress questionnaire scores were significantly higher in the
chronic periodontitis group than in the gingivitis group. Because stress
is a state that can change moment to moment, patients should be ob-
served for a long time to evaluate their stress levels accurately. The role
of biological markers in investigating the effects of emotional stress on
periodontal tissues has accordingly become pertinent.
In the present study, in which the effects of stress on periodontal
disease were evaluated, saliva was preferred as the sample material,
owing to the simplicity and ease of its collection. Saliva samples were
collected in the morning between 09:00 and 11:00 a.m.,31 when, be-
cause of the circadian rhythm of cortisol, the levels of cortisol are
higher than in the afternoon.32 In evoked saliva, the volume of saliva
increases and the concentration deteriorates.33 Saliva analysis provides
more objective and measurable results than the subjective and non-
parametric data obtained from surveys. However, there are some lim-
itations to saliva sampling, such as the need for a large quantity of
Severe Periodontitis (n = 15) Mean ± Sd (min-
max)
37.06 ± 9.83 (23–51)
44.66 ± 7.07 (35–58)
H. Develioglu, et al. Journal of Oral Biology and Craniofacial Research 10 (2020) 514–518

Table 3
Comparison of severity of periodontitis according to salivary stress markers. Cortisol levels increased with the severity of periodontitis (P < 0,05). Statistically
significant differences was not detected between the severity of periodontitis and α-amylase, chromogranin A, or β-endorphin levels (P > 0.05).
Mild Periodontitis (n = 26) Mean ± Sd (min- Moderate Periodontitis (n = 39)Mean ± Sd (min- Severe Periodontitis (n = 15)Mean ± Sd (min-
max) max) max)

Cortisol 401.88 ± 254.24 (12.5–749.81) 458.21 ± 236.50a (12.50–777.94) 612.10 ± 128.66a,b (325.44–769.19)
α- Amilase 68.21 ± 37.11 (10.61–122.48) 160.90 ± 35.74 (17.70–121.83) 51.99 ± 28.36 (17.39–108.35)
β- Endorphine 336.67 ± 239.31 (15.63–823.85) 455.28 ± 268.11 (15.63–880.77) 462.46 ± 337.99 (15.63–863.08)
Chromogranin- A 369.87 ± 261.17 (30.17–1156.83) 321.68 ± 304.53 (61.83–1821.83) 273.99 ± 167.41 (62.50–565.17)

a
Statistically significant difference compared with the mild periodontitis (P < 0,05).
b
Statistically significant difference compared with the moderate periodontitis (P < 0,05).

saliva samples, the influence of saliva content on local and systemic
factors, and the use of different saliva sampling techniques that can
directly affect the findings.34
Many studies have shown the relationship between stress and per-
iodontal disease. The present study is the first to examine the re-
lationships among four different salivary stress markers, STAI scores,
and the severity of periodontitis. Although many hormonal changes are
observed in the body during stress, cortisol is the leading one.
Therefore, cortisol is frequently used in studies related to stress.35,36
Hilgert et al. investigated the relationships among the prevalence and
severity of periodontitis, cortisol levels, and stress scores in people over
50 years of age and reported a positive correlation between cortisol
levels and periodontitis.37 Rosania et al.5 observed a significant asso-
ciation between the levels of saliva cortisol and the amount of tooth loss
in 45 patients in 2009. These results are consistent with those of our
study.
In a study conducted in 2007 by Ishisaka et al.,38 the cortisol and
dehydroepiandrosterone (DHEA) levels of 171 patients (85 male, 86
female) were compared. High cortisol and DHEA levels were shown to
be statistically significantly correlated with the severity of period-
ontitis. The results of this study are exactly parallel to those of the
present study.
In a study by Johannsen et al.26 on patients who underwent regular
follow-up examinations in 2006, because they suffered from stress and
mental health problems, salivary cortisol levels did not differ sig-
nificantly between the patient and the control groups. However, the
gingival crevicular fluid cortisol levels were significantly higher in the
patient group. The results of this study are not consistent with those of
our study, because we used groups classed according to the severity of
disease, instead of a healthy patient group and a control group.
In a study on 100 patients in 2011, Rai et al.1 concluded that the
concentrations of salivary cortisol and β-endorphin were statistically
significantly correlated with the severity of periodontitis and tooth loss,
but there was no statistically significant association between the se-
verity of periodontitis and the concentrations of α-amylase and chro-
mogranin A. These results are in agreement with those of our study of
cortisol, α-amylase, and chromogranin A.
In 2012, Haririan et al.3 studied 24 patients with aggressive peri-
odontitis (AgP), 30 patients with chronic periodontitis (CP), and 30
healthy individuals, and compared their α-amylase and chromogranin
A levels. Whereas the salivary α-amylase and chromogranin A levels of
the AgP patients were higher than those of the CP patients, no sig-
nificant difference was observed between the groups in terms of the
serum α-amylase and chromogranin A levels. This study demonstrated
that saliva markers may be more important stress indicators than serum
markers. In our study, the loss of clinical attachment was higher in
patients with higher levels of saliva cortisol. There was a statistically
significant difference between mild and severe periodontitis in terms of
the amount of cortisol. This result is in agreement with the results of
other studies in the literature. Moreover, in the present study, a similar
relationship was found between the concentrations of chromogranin A
in saliva and the results of the STAI.
In a pediatric study, saliva CgA levels were shown to be a more
sensitive marker of psychological stress than salivary cortisol.13 High
saliva CgA levels occur in cases such as dry mouth. In our study, pa-
tients with chronic or acute dry mouth and those who could not obtain
saliva samples within six minutes were excluded. This limitation may
be the cause of the differences in results between previous studies and
the present study.
It has been suggested that salivary α-amylase is a reliable index for
sympathetic nervous system activity in stress situations. β-endorphins
are found in high concentrations in the pituitary, anterior hypotha-
lamus, septal area, and periaqueductal gray areas. These peptides are
thought to affect the perception of pain, behavior, and various psy-
chological responses. Endorphins are released in response to stress. β-
endorphin levels were found to be high in depressive patients. This
response may be depression-specific or it may be due to high levels of
stress unrelated to depression. In our study, no relationships were found
between the salivary concentrations of β-endorphin and α-amylase and
the severity of periodontitis.
The present study has several limitations. Saliva stress markers were
not measured periodically, as they should be. Demographic details of

Table 4
Comparison of severity of periodontitis according to salivary stress markers. Cortisol levels increased with the severity of periodontitis (P < 0,05). Statistically
significant differences was not detected between the severity of periodontitis and α-amylase, chromogranin A, or β-endorphin levels (P > 0.05). *Statistically
significant differences was not detected between the periodontitis groups for STAI levels (P > 0.05).
Biochemical Parameters Periodontal and Stress Parameters

Mild Periodontitis (n = 26) Mean ± Sd (min- Moderate Periodontitis (n = 39) Mean ± Sd Severe Periodontitis (n = 15) Mean ± Sd
max) (min- max) (min- max)

STAI LEVELS *STAI1 42.92 ± 10.20 (26–74) *STAI1 42.43 ± 1.48 (22–74) *STAI1 37.06 ± 9.83 (23–51)
*STAI2 45.03 ± 6.86 (27–60) *STAI2 49.15 ± 8.55 (34–73) *STAI2 44.66 ± 7.07 (35–58)

Cortisol (μg/dl) 401.88 ± 254.24 (12.5–749.81) 458.21 ± 236.50a (12.50–777.94) 612.10 ± 128.66a,b (325.44–769.19)
α- Amilase (IU) 68.21 ± 37.11 (10.61–122.48) 160.90 ± 35.74 (17.70–121.83) 51.99 ± 28.36 (17.39–108.35)
β- Endorphine (pg/ML) 336.67 ± 239.31 (15.63–823.85) 455.28 ± 268.11 (15.63–880.77) 462.46 ± 337.99 (15.63–863.08)
Chromogranin- A (IU/dl) 369.87 ± 261.17 (30.17–1156.83) 321.68 ± 304.53 (61.83–1821.83) 273.99 ± 167.41 (62.50–565.17)

a
P < 0,05.

517
H. Develioglu, et al.
Table 5
Comparison of the severity of periodontitis according to clinical measurements. Statistically significant differences was not detected between the groups (P > 0.05).
Periodontal Periodontitis
Parameters
Mild Periodontitis (n = 26) Mean ± Sd (min- Moderate Periodontitis (n = 39) Mean ± Sd (min-
max) max)
PI 2.23 ± 0.71 (1.00–3.00) 2.28 ± 0.64 (1.00–3.00)
GI 2 ± 0.74 (1.00–3.00) 1.82 ± 0.68 (1.00–3.00)
PPD 1.7 ± 0.9 (1–3) 3.9 ± 1.1 (2–4)
CAL 2.10+-0.55 (1.20–2.90) 3.91+-0.47 (3–4.9)
GI: Gingival index, PI:Plak index, CAL: Clinical Attachmant Loss, PPD: Pocket probing depth.
the patients were not recorded, although data regarding socioeconomic
and educational status and employment/unemployment could sig-
nificantly affect an individual's stress level. Additionally, data regarding
personal hygiene in terms of frequency of tooth brushing were not re-
corded.
5. Conclusion
Within the limitations of this study, the severity of chronic period-
ontitis was found to increase with increasing salivary cortisol levels, but
there was no correlation between the levels of other stress markers in
saliva and the severity of chronic periodontitis. Additionally, there was
no relationship between STAI 1 and STAI 2 scores and the severity of
chronic periodontitis.
Further studies involving multiple tests and repeated tests should be
conducted to determine the stress status of patients and to clarify the
association between stress and periodontitis. Such studies should also
include a larger patient population and long-term controls.
Declaration of competing interest
The authors declare that there is no conflict of interest. The authors
do not have any financial interests, either directly or indirectly, in the
products or information listed in the paper.
Acknowledgements
This study supported by Sivas Cumhuriyet University Scientific
Project Foundation Department with DİS-197 project number.
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