|Year : 2020 | Volume
| Issue : 2 | Page : 106-110
To correlate the anxiety, depression, and symptoms of stress levels among patients affected by oral lichen planus and lichenoid reaction
Tulika Sharma1, Ishita Vaghela2, Neha Raghuwanshi3, Amit Kumar Dabas4, Rudra Prasad Chatterjee5, Heena Mehta1
1 Department of Oral Medicine and Radiology, Darshan Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of Prosthodontics and Crown and Bridge, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India
3 Department of Oral Medicine and Radiology, Daswani Dental College and Research Centre, Kota, Rajasthan, India
4 Department of Orthodontics and Dentofacial Orthopedics, Daswani Dental College and Research Centre, Kota, Rajasthan, India
5 Department of Oral and Maxillofacial Pathology, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India
|Date of Submission||29-Oct-2020|
|Date of Acceptance||22-Dec-2020|
|Date of Web Publication||28-Jan-2021|
Dr. Tulika Sharma
Department of Oral Medicine and Radiology, Darshan Dental College and Hospital, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Psychosomatic factor-like depression and depressive symptoms play an important role in the causation of different forms of mucosal changes among which one of them is oral lichen planus (OLP). Oral diseases may be a direct expression of emotions or conflicts. The research aimed to provide a precise estimate by assessing anxiety, depression, and stress in OLP patients and lichenoid reaction (LR) as compared to healthy controls using a self-report scale questionnaire.
Materials and Methods: This methodological cross-sectional study comprised of 150 subjects, 50 normal healthy controls (control), 50 patients with OLP, and 50 patients with LR were recruited. The outcome measures of this study were done with pretested, prestructured 21 multiple-choice questions designed to evaluate depression, stress, anxiety levels were assessed using respectively Beck Anxiety Questionnaire, Beck Depression Questionnaire, and Holmes and Rahe Stress Inventory Scales depending on how the questions were answered at the time of presentation (enrolment).
Results: The mean anxiety, depression, and stress scores were significantly (P <0.001) different and higher in both OLP and LR groups as compared to the control group. However, mean anxiety, depression, and stress scores were found similar (P >0.05) between the OLP and LR groups.
Conclusion: The present study's findings may help direct future management strategies for the patient with OLP and LR. It also helps to understand the patient's behavior in respect of anxiety, depression, and stress. Ministry of health and family welfare – Dental Education should enhance dentistry and give training on how to screen anxiety and depression among Oral disease patients and should develop guidelines to screen and treat depression and anxiety among such patients.
Keywords: Anxiety, depression, lichenoid reaction, oral lichen planus, stress
|How to cite this article:|
Sharma T, Vaghela I, Raghuwanshi N, Dabas AK, Chatterjee RP, Mehta H. To correlate the anxiety, depression, and symptoms of stress levels among patients affected by oral lichen planus and lichenoid reaction. Saint Int Dent J 2020;4:106-10
|How to cite this URL:|
Sharma T, Vaghela I, Raghuwanshi N, Dabas AK, Chatterjee RP, Mehta H. To correlate the anxiety, depression, and symptoms of stress levels among patients affected by oral lichen planus and lichenoid reaction. Saint Int Dent J [serial online] 2020 [cited 2022 Jan 25];4:106-10. Available from: https://www.sidj.org/text.asp?2020/4/2/106/308180
| Introduction|| |
The psychosomatic factor plays an important role in the causation of different forms of mucosal changes among which one of them is oral lichen planus (OLP). Oral diseases may be a direct expression of emotions or conflicts. The mouth is directly or symbolically related to major human instincts and is charged with high psychological potential, most prevalent being lichen planus. OLP is a mucocutaneous disorder with psychosomatic disease and is considered to be a common chronic inflammatory autoimmune disease affecting the skin, hair, nails, oral cavity, and mucous membranes. Higher frequency of psychiatric symptoms, poor quality of life, a higher level of anxiety, depression, and stress, all these factors, will enhance the exacerbation of this disease., The published research has proven a high estimated prevalence of LP with relation to Depression, anxiety, stress is in the range of 0.22%–5% worldwide with the female usually shown with recurrences and periods of clinical exacerbations and remissions; however, it may be a transient disorder. OLP may occur clinically in various forms including reticular plaques, hyperkeratotic plaques, mucosal erythema, erosions, or ulcerations.,
A similar clinical and histological lesion is called a Lichenoid reaction (LR) is induced by external factors that could be either topical or systemic. This mucosal reaction is seen commonly in areca nut/tobacco Product users also. Several triggering factors such as restorative materials, graft versus host reaction, and a broad group of drugs are known to cause LR.,,
| Materials and Methods|| |
A cross-sectional self-report questionnaire-based study was conducted on subjects selected from the outpatient Department of Oral Medicine, Diagnosis, and Radiology. The study protocol was approved by the Ethical Committee of the college and Ethical clearance for the study was taken was-Ref. No. PDCH/16/EC-37.
The present research comprises 150 subjects/patients divided into three groups (100 study groups and 50 control group) selected from outpatient department, Department of Oral Medicine, and Radiology. Group 1: Control group, comprising of 50 subjects who were healthy without the presence of any acute or chronic illness at the time of evaluation (without any H/P evaluation).Group 2: This group comprises 50 patients affected by OLP Group 3: This group consists of 50 patients affected by LR based on etiology. Informed written consent was taken from each subject which was written both in English and Hindi languages. Inclusion criteria involve patients with complete history including etiology to differentiate clinically diagnosed and histopathologically confirmed with OLP, LR irrespective of age and gender. Exclusion criteria include patients with immune-compromised state and pregnant patients, patients with systemic-associated disorders, endocrinal disorders such as diabetes, hypo/hyper-thyroid, OLP, and LR with any other mucosal or skin disorder/diseases, patients on already undergoing treatment for OLP, LR, anxiety, depression and stress, patients with a history of pain due to odontogenic infection, patients who are not willing to participate in the study.
Anxiety-, Depression-, and stress-related questionnaire was provided to each patient after taking their consent to compare the anxiety, Depression, and stress level in OLP, LR, and healthy individuals - Beck Anxiety questionnaire for Anxiety, Beck Depression questionnaire for Depression and Holmes and Rahe Stress Inventory Scale for Stress. All the patients were informed regarding the purpose and design of the research and were asked to sign the consent form.
Data were summarized in Mean ± standard deviation (SD) Groups were compared by one-way analysis of variance (ANOVA) and the significance of the mean difference between the groups was done by Tukey's honestly significant difference post hoc test. Discrete data (categorical) were summarized in number (n) and percentage (%) and compared by the Chi-square test. A two-tailed (α= 2) P < 0.05 was considered statistically significant. Analyses were performed on SPSS software (windows Version 21.0 Chicago, IL, USA).
| Results|| |
The demographic characteristics (age and sex) of three groups (control, OLP, and LR) are summarized in [Table 1]. The mean (± SD) age (years) of control, OLP, and LR were 34.94 ± 12.40, 35.77 ± 13.90, and 32.42 ± 10.75, respectively. Further, in control groups, there were 24 (48.0%) females and 26 (52.0%) males, in OLP, it were 22 (44.0%) and 28 (56.0%), respectively, whereas in LR, it were 20 (40.0%) and 30 (60.0%), respectively.
The anxiety score of the three groups is summarized in [Table 2] and also shown in [Figure 1]. The mean (± SD) anxiety (score) of control, OLP, and LR were 12.88 ± 5.50, 20.40 ± 5.10, and 19.64 ± 5.40, respectively. The OLP group's mean anxiety score was the highest, followed by the LR group and control group the least (control < LR < OLP). Comparing the mean anxiety score of three groups, ANOVA showed significantly different scores among the groups (F = 30.09, P < 0.001) [Table 2]. Further, comparing the difference in mean anxiety score between the groups, the Tukey's test showed significantly different and higher anxiety scores in both OLP (36.9%) and LR (34.4%) groups as compared to the control group [Table 3] and [Figure 1]. However, it did not differ (P > 0.05) between the OLP and LR groups, i.e., found to be statistically the same.
|Table 3: Comparison of the difference in mean anxiety score between groups by Tukey's test|
Click here to view
The depression score of the three groups is summarized in [Table 4] and also shown in [Figure 2]. The mean (±SD) depression (score) of control, OLP, and LR were 8.12 ± 6.24, 14.98 ± 6.70, and 17.60 ± 6.80, respectively. The mean depression score of the LR group was the highest followed by the OLP group and control group the least (control < OLP < LR). Comparing the mean depression score of three groups, ANOVA showed significantly different scores among the groups (F = 27.64, P <0.001) [Table 4]. Further, comparing the difference in mean depression score between the groups, the Tukey's test showed significantly different and higher depression scores in both OLP (45.8%) and LR (53.9%) groups as compared to the control group [Table 5] and [Figure 2]. However, it did not differ (P > 0.05) between the OLP group and LR group, i.e., found to be statistically the same.
|Table 5: Comparison of difference in mean depression score between groups by Tukey's test|
Click here to view
The stress score of the three groups is summarized in [Table 6] and also depicted in [Figure 3]. The mean (± SD) stress (score) of control, OLP, and LR were 77.44 ± 36.00, 141.54 ± 39.30, and 149.60 ± 33.00, respectively. The mean stress score of the LR group was the highest followed by the OLP group and control group the least (control < OLP < LR). Comparing the mean stress score of three groups, ANOVA showed significantly different scores among the groups (F = 59.68, P < 0.001) [Table 6]. Further, comparing the difference in mean stress score between the groups, the Tukey's test showed significantly different and higher stress scores in both OLP (45.3%) and LR (48.2%) groups as compared to the control group [Table 7] and [Figure 3]. However, it did not differ (P >0.05) between the OLP and LR groups, i.e., found to be statistically the same.
|Table 7: Comparison of difference in mean stress score between groups by Tukey's test|
Click here to view
| Discussion|| |
The present research work aimed to assess the level of the anxiety, stress, and depression in the patient diagnosed with OLP, LR and compared the stress, depression and anxiety levels between the patients affected by OLP and LR with the healthy control group. The incidence of OLP had increased in the Indian Population for the last few decades. Approximately affected OLP patients are 0.5%–2.5% of the general population with more males affected than females [Table 1]. The study population was male predominance. On comparing, the subjects of the three groups were found age and sex-matched (P > 0.05), thus may not influence the study outcome measures (anxiety, depression, and stress).
More than 30% of patients suffering from OLP had shown mild-to-severe depression, stress, and anxiety and approximately 16% had shown all three symptoms. This research was performed to ascertain the association between depression, stress, and anxiety in OLP and LR affected patients. This statistical analysis shows a high level of depression, stress, and anxiety in patients suffering from OLP and Even with LR. The results correlated are in accordance with Sandhu et al., Liao and et al., Vallejo et al., Kalkur et al. and not in accordance with Allen et al., and Rödström et al. However, a complete cure for OLP is very hard to obtain due to the chronic existence of this disease. Even In today's era, we do not have any standardized treatment method to cure OLP and the ongoing treatment methods to cure OLP always vary from one person to another. Nevertheless, Calcineurin inhibitors such as pimecrolimus and tacrolimus were in use as a second line of therapy in a few OLP cases. Still, experts and research published suggest these drugs should be used with caution and preferable for short.
However, our research has certain pitfalls and limitations. OLP in its chronic form can itself make patients suffer from depression, anxiety, and stress. Differentiation between OLP and LR was very difficult job for completion of this research and to get accurate results as studies published has concluded that LR s can only be diagnosed by clinical examination., The scales and questionnaires used in this study were based on subjective analysis to measure the level of depression, stress, and anxiety.
What is new?
In this study, three different Beck Anxiety, Beck Depression, and Holmes and Rahe Stress Questionnaire were used to evaluate with the help of a self-report questionnaire consists of all symptoms which were divided into three subscales: depression scale, anxiety scale, and stress scale. The use of all the three scales are reliable and a valid measure to constructs so it was intended to assess.
| Conclusion|| |
On the statistical evaluation, the difference in the stress level, depression, and anxiety level of Group-1 patient, Group-2 patients with Group-3 healthy control were quite significant. It is noticeable that there was a little similarity in the value of Group-1 (OLP) and Group-2 (LR) as a comparison of the Group-3 (CG). The findings of the present study help to direct future management strategies for the patient with OLP and LR. It also helps to understand the patient's behavior in the respect of stress, depression, and anxiety. The present study confirmed that OLP and LR are associated with elevated stress levels, depression, and anxiety.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shavit E, Hagen K, Shear N. Oral lichen planus: A novel staging and algorithmic approach and all that is essential to know. F1000Res 2020;9:F1000.
Amadori F, Bardellini E, Conti G, Majorana A. Oral mucosal lesions in teenagers: A cross-sectional study. Ital J Pediatr 2017;43:50.
Lauritano D, Arrica M, Lucchese A, Valente M, Pannone G, Lajolo C, et al
. Oral lichen planus clinical characteristics in Italian patients: A retrospective analysis. Head Face Med 2016;12:18.
Lu SL, Qi XM, Dong G, Chen SL, Guo DW, Wang YL, et al
. Clinical characteristics and analysis of familial oral lichen planus in eight Chinese families. Exp Ther Med 2016;12:2281-4.
Gravina G, Wasén C, Garcia-Bonete MJ, Turkkila M, Erlandsson MC, Silfverswärd TS, et al.
: Survivin in autoimmune diseases. Autoimmun Rev 2017;16:845-55.
Lundqvist EN, Wahlin YB, Bergdahl M, Bergdahl J. Psychological health in patients with genital and oral erosive lichen planus. J Eur Acad Dermatol Venereol 2006;20:661-6.
Cerqueira JD, Moura JR, Arsati F, Lima-Arsati YB, Bittencourt RA, Freitas VS, et al
.: Psychological disorders and oral lichen planus: A systematic review. J Invest Clin Dent 2018;9:e12363.
Manczyk B, Gołda J, Biniak A, Reszelewska K, Mazur B, Zając K, et al
.: Evaluation of depression, anxiety and stress levels in patients with oral lichen planus. J Oral Sci 2019;61:391-7.
Sandhu SV, Sandhu JS, Bansal H, Dua V. Oral lichen planus and stress: An appraisal. Contemp Clin Dent 2014;5:352-6.
] [Full text]
Liao H, Luo Y, Long L, Peng J, Qiu X, Yuan P, Xu H, Jiang L. Anxiety and oral lichen planus. Oral Dis. 2020 Jul 22. doi: 10.1111/odi.13569. Epub ahead of print. PMID: 32697012.
Vallejo MJ, Huerta G, Cerero R, Seoane JM. Anxiety and depression as risk factors for oral lichen planus. Dermatology 2001;203:303-7.
Kalkur C, Sattur AP, Guttal KS. Role of depression, anxiety and stress in patients with oral lichen planus: A pilot study. Indian J Dermatol 2015;60:445-9.
] [Full text]
Allen CM, Beck FM, Rossie KM, Kaul TJ. Relation of stress and anxiety to oral lichen planus. Oral Surg Oral Med Oral Pathol 1986;61:44-6.
Rödström PO, Jontell M, Hakeberg M, Berggren U, Lindstedt G. Erosive oral lichen planus and salivary cortisol. J Oral Pathol Med 2001;30:257-63.
Di Stasio D, Lauritano D, Gritti P, Migliozzi R, Maio C, Minervini G, et al
. Psychiatric disorders in oral lichen planus: A preliminary case control study. J Biol Regul Homeost Agents 2018;32:97-100.
Wiriyakijja P, Porter S, Fedele S, Hodgson T, McMillan R, Shephard M, Ni Riordain R. Health-related quality of life and its associated predictors in patients with oral lichen planus: a cross-sectional study. Int Dent J. 2020 Sep 1. doi: 10.1111/idj.12607. Epub ahead of print. PMID: 32875594.
Do Prado RF, Marocchio LS, Felipini RC. Oral lichen planus versus oral lichenoid reaction: Difficulties in the diagnosis. Indian J Dent Res 2009;20:361-4.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]