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ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 61-64

Correlation of periodontal status with perceived stress scale score and cortisol levels among transgenders in Puducherry and Cuddalore


Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Affiliated to Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India

Date of Web Publication9-Jul-2019

Correspondence Address:
Dr. K S Sivaranjani
Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Affiliated to Sri Balaji Vidyapeeth (Deemed to be University), Puducherry - 607 402
India
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DOI: 10.4103/srmjrds.srmjrds_27_19

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  Abstract 

Background: The stigmatization of transgender community can lead to various physical/psychological problems compared to the general population. The social discrimination in the transgender community causes undue stress which disrupts homeostasis and alters the immune system, which is one of the contributing factors to the severity of periodontal problems. To the best of our knowledge, there are no studies reported in the transgender community correlating periodontal status with stress in terms of perceived stress scale (PSS) and salivary cortisol levels. Materials and Methods: Periodontal status was assessed in 75 transgender participants in terms of probing pocket depth (PPD) and clinical attachment level (CAL). Stress scores were assessed by means of a PSS questionnaire and salivary cortisol levels were estimated by ELISA in 40 participants. Results: The mean PPD and CAL of participants were 4.06 ± 0.70 and 3.97 ± 0.68, respectively. The mean cortisol level of the transgender population was 6.02 ng/mL. The mean PSS score was estimated as 28. Positive correlation of PPD and CAL values with PSS scores (r = 0.592 and r = 0.618, respectively) was observed. Conclusion: There is high perceived stress as per the PSS scale scores and a positive correlation of PSS scale scores with salivary cortisol levels (r = 0.774, P = 0.000) in our study population.

Keywords: Cortisol, perceived stress scale, stress, transgender


How to cite this article:
Sivaranjani K S, Balu P, Kumar R S, Muthu J, Devi S S, Priyadharshini V. Correlation of periodontal status with perceived stress scale score and cortisol levels among transgenders in Puducherry and Cuddalore. SRM J Res Dent Sci 2019;10:61-4

How to cite this URL:
Sivaranjani K S, Balu P, Kumar R S, Muthu J, Devi S S, Priyadharshini V. Correlation of periodontal status with perceived stress scale score and cortisol levels among transgenders in Puducherry and Cuddalore. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Nov 12];10:61-4. Available from: http://www.srmjrds.in/text.asp?2019/10/2/61/262380


  Introduction Top


Transgender population occupies only a small fraction of the total population, as the census data on them do not exist. They are considered as the most vulnerable, frustrated, and insecure community in the country. They are also denied general, oral health, and psychological assistance.[1] In Indian context, they were commonly rejected by family, undergo early discontinuation of education and start begging for livelihood.[2] They, therefore, experience unique sources of stress and stigma as a result of having a gender identity or gender presentation which falls outside rigid male–female binaries.

Compared to the general population, lesbian, gay, bisexual, and transgender people are more prone to experience stressful life events including stigma, discrimination, financial hardship, and abuse.[3],[4] Hence, they are at high risk for developing high psychological stress and as a result are prone to depression, drug abuse, and deleterious habits.[5] Long-term psychosocial stress leads to emotional disturbances and neglect of oral hygiene. This initiates and perpetuates periodontal disease.[6],[7],[8]

Assessment of stress can be done either by questionnaire-based methods or more objectively by estimating cortisol levels in serum or saliva. There are many scales to estimate stress such as “effort-reward imbalance scale,” “Skala sozialer Stressoren am Arbeitsplatz,” “The Social Readjustment Rating Scale,” and “Perceived Stress Questionnaire.” Among them, the Perceived Stress Scale (PSS) (1983) is the most commonly used measure of general perceived stress.[9],[10]

We have used PSS Questionnaire in our study to estimate stress scores in the transgender population.[11],[12] Cortisol, the end product of the hypothalamic–pituitary–adrenocortical axis, is an important objective measure of estimating stressful life experiences.[13]

To the best of our knowledge, there are no studies reported in the transgender community correlating periodontal status with stress in terms of PSS and salivary cortisol levels. Therefore, we intend to estimate stress among transgenders in terms of PSS and cortisol levels in saliva and periodontal status by means of probing pocket depth (PPD) and clinical attachment level (CAL).


  materials and Methods Top


The participants (n = 75) were recruited from the Sahodaran Community Oriented Health Development (SCOHD) society for evaluating the periodontal status. A section of 40 participants were randomly selected for estimation of stress in terms of salivary cortisol and PSS, from the previous study done by Refulio et al.[14] Informed consent was obtained from the participants. Periodontal status was assessed by recording PPD and CAL using William's periodontal probe. Stress assessed in terms of salivary cortisol levels and PSS[15] was evaluated among the participants and was correlated with the periodontal disease severity.

The participants were selected based on the following inclusion and exclusion criteria. Self-identified transgender individuals, who were willing to participate in the study, of about 18–65 years of age were included in the study. Mentally challenged participants, participants under hormonal therapy, and participants who underwent periodontal therapy within 6 months were excluded from the study. Participants with HIV/hepatitis were also excluded because of immunocompromised systemic conditions.

The PSS scores were obtained by administering the 10-item PSS Questionnaire to the participants. PSS scores were obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8), and then, all the scale items were added. Individual scores on the PSS can range from 0 to 40, with higher scores indicating higher perceived stress.

Sample collection

Unstimulated salivary samples were collected and stored at −20 until analysis. The samples were centrifuged at 3000 rpm for 15 min, and the clear supernatant was used for analysis. Salivary cortisol levels were assessed with Salivary Cortisol ELISA Kit (DiaMetra) which allows the determination of cortisol from 0.5 ng/ml to 100 ng/ml (normal range of cortisol as per the kit used – 3.0–3.9 ng/mL). The assay procedures were carried out carefully as mentioned in the manual. It was done in the biochemistry department of JIPMER.


  Results Top


The mean PPD and CAL of participants were 4.06 ± 0.70 and 3.97 ± 0.68, respectively. The mean cortisol level was 6.02 ng/mL. A strong, positive correlation was observed between mean cortisol levels and periodontal parameters assessed (probing depth and cortisol –r = 0.592, P = 0.000; clinical attachment loss and cortisol levels –r = 0.618, P = 0.000). There was a positive correlation between cortisol level and PSS scores, which was statistically significant with an r = 0.774 and P = 0.000 [Figure 1]. The mean perceived scale score obtained was 28 which indicated high stress among the participants [Table 1].
Figure 1: Calibration curve of cortisol levels obtained

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Table 1: Correlation of probing pocket depth and clinical attachment level with perceived stress scale and cortisol levels

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  Discussion Top


The mean age of the participants was 31.63 ± 8.5 years.[16],[17] Patients with HIV and hepatitis were excluded from the study as they are immunocompromised and prone to infections which might alter periodontal status. The same exclusion criteria were reported in a previous study.[17] In a study done in Bhopal, eunuchs had poor oral health-related knowledge, attitude, and practices along with higher prevalence of tobacco-related habits.[18] They are abused regularly and form the lower socioeconomic strata of the general population.[19] The mean PPD and CAL of participants in our study were 4.06 ± 0.70 and 3.97 ± 0.68, respectively. A study done in Bhopal reported that the prevalence of deep pockets was high among transgender participants (>12 mm PPD in 6.3% of the study population) as compared to male and female gender. In another study, the prevalence of 4–6 mm PPD was reported in 12.4% of the transgender population in Chennai. In comparison with these studies, the PPD and CAL were observed to be lesser in our study population. The reason might be that the transgender population in our study is a fixed population associated with a welfare society (SCOHD), which provides employment and facilitates access to medical and dental ailments by way of organizing camps.

Transgender population face numerous potential sources of stress and have a higher likelihood of experiencing negative mental health outcomes due to lack of support, lack of perceived safety, and limited access to resources and like peers.[20] A study reported that, after controlling for characteristics of individuals who identify as transgender, such as age and sex, the fear of discrimination and maltreatment in the dental clinic, and experiences of discrimination and maltreatment, were significantly associated with the level of dental fear.[21] In general, transgender people are expected to have more stress. Stress is one of the contributing factors for progression of periodontal disease. In an attempt to evaluate stress and related biochemical changes, we analyzed PSS and salivary cortisol levels among them. The mean salivary cortisol level was 6.02 ng/mL. The mean perceived scale score obtained was 28. PSS scores are classified as high-, moderate-, and low-stress categories based on the scores obtained. The score 28 is considered as high-stress category, implying the prevalence of high-stress levels among participants. This probably is due to the stigma and discrimination they undergo in their day-to-day lives.[22] A strong, positive correlation between cortisol level and PSS scores was also observed (r = 0.774, P = 0.000). A similar positive correlation between PSS scores and cortisol levels was reported in another study conducted among transitioning transgender men in California.[23] Correlation of cortisol levels and periodontal parameters showed a positive correlation between cortisol level and probing depth, which was statistically significant (r = 0.592, P = 0.000). There was a positive correlation between cortisol level and clinical attachment loss which was statistically significant (r = 0.618, P = 0.000). To the best of our knowledge, our study is the first of its kind to correlate stress levels with salivary cortisol and periodontal parameters in the transgender population.

Lack of comparison of cortisol levels and PSS scores with male and female gender is the limitation in this study. Furthermore, we cannot provide evidence-based dental care to a subset of the population, if that population has yet to be studied.


  Conclusion Top


In our study, there is high perceived stress and high cortisol levels among transgender participants. A strong positive correlation between stress parameters and periodontal parameters was observed. This indicates the need to take measures to integrate the community into the mainstream to reduce overt stress perceived among them. Accessibility to dental services as well as oral health education and counselling is necessary to ensure the optimum dental health.

Financial support and sponsorship

Nil.

Conflicts of support

There are no conflicts of support.

 
  References Top

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Eunuchs of India – Deprived of Human Rights. Available from: http://www.humanrightsdefence.org/eunuchs-of-india-deprived-of-humanrights.html. [Last accessed on 2013 Sep 22].  Back to cited text no. 2
    
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Deinzer R, Granrath N, Spahl M, Linz S, Waschul B, Herforth A. Stress, oral health behaviour and clinical outcome. Br J Health Psychol 2005;10:269-83.  Back to cited text no. 3
    
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Levenstein S, Prantera C, Varvo V, Scribano ML, Berto E, Luzi C, et al. Development of the perceived stress questionnaire: A new tool for psychosomatic research. J Psychosom Res 1993;37:19-32.  Back to cited text no. 10
    
11.
Andreou E, Alexopoulos EC, Lionis C, Varvogli L, Gnardellis C, Chrousos GP, et al. Perceived stress scale: Reliability and validity study in Greece. Int J Environ Res Public Health 2011;8:3287-98.  Back to cited text no. 11
    
12.
Mozumder MK. Validation of Bengali perceived stress scale among LGBT population. BMC Psychiatry 2017;17:314.  Back to cited text no. 12
    
13.
Rosania AE, Low KG, McCormick CM, Rosania DA. Stress, depression, cortisol, and periodontal disease. J Periodontol 2009;80:260-6.  Back to cited text no. 13
    
14.
Refulio Z, Rocafuerte M, de la Rosa M, Mendoza G, Chambrone L. Association among stress, salivary cortisol levels, and chronic periodontitis. J Periodontal Implant Sci 2013;43:96-100.  Back to cited text no. 14
    
15.
Available from: http://www.mindgarden.com/documents/PerceivedStressScale.pdf. [Last assessed on 2018 Apr 10]  Back to cited text no. 15
    
16.
Torwane NA, Hongal S, Saxena E, Rana PT, Jain S, Gouraha A, et al. Assessment of periodontal status among eunuchs residing in Bhopal city, Madhya Pradesh, India: A cross-sectional study. Oral Health Dent Manag 2014;13:628-33.  Back to cited text no. 16
    
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Saravanan N. A study to assess the periodontal status of transgender in Chennai city. Biosci Biotech Res 2014;11:1673-7.  Back to cited text no. 17
    
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Hongal S, Torwane NA, Goel P, Byarakele C, Mishra P, Jain S. Oral health-related knowledge, attitude and practices among eunuchs (hijras) residing in Bhopal city, Madhya Pradesh, India: A cross-sectional questionnaire survey. J Indian Soc Periodontol 2014;18:624-31.  Back to cited text no. 18
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Peeran SW, Ramalingam K. Study on eunuchs/transgenders: An opinion. J Forensic Dent Sci 2016;8:108-9.  Back to cited text no. 19
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20.
Ignatavicius S. Stress in female-identified transgender youth: A review of the literature on effects and interventions. J LGBT Youth 2013;10:267-86.  Back to cited text no. 20
    
21.
Heima M, Heaton LJ, Ng HH, Roccoforte EC. Dental fear among transgender individuals-a cross-sectional survey. Spec Care Dentist 2017;37:212-22.  Back to cited text no. 21
    
22.
Ludwig DC, Morrison SD. Should dental care make a transition? J Am Dent Assoc 2018;149:79-80.  Back to cited text no. 22
    
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DuBois LZ, Powers S, Everett BG, Juster RP. Stigma and diurnal cortisol among transitioning transgender men. Psychoneuroendocrinology 2017;82:59-66.  Back to cited text no. 23
    


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