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Jampolsky 4. Smith 3. Go Away, Shawn! What a Bath! Zanjan, Iran. Unstimulated salivary flow rate can be influenced by different factors. This study was undertaken to evaluate the effect of stress, anxiety and depression on unstimulated salivary flow rate in adults. A total of adult subjects, randomly selected from patients referring to Zanjan Dental School, were included in this investigation. The study procedures consisted of collecting salivary samples in 5 minutes , completing a form for feeling of xerostomia and completing Depression Anxiety Stress Scale DASS Questionnaire to assess the severity of stress, anxiety and depression.
The frequencies of subjects with severe and major depression in groups 1, 2 and 3 were The frequencies of subjects with severe stress in groups 1, 2 and 3 were Stress, anxiety and depression can influence unstimulated salivary flow rate and lead to xerostomia. The term stress refers to a series of events that lead to a reaction in the brain perceived stress , activating the physiological fight-or-flight response in the body.
It consists of uncertainty, helplessness and arousal physiologically. Saliva is a complex combination of major and minor salivary gland secretions, 4 which acts as a cleanser in the oral cavity, contributing to chewing foods and facilitation of swallowing. Saliva also strengthens the mucosal barrier and has antimicrobial properties. Unstimulated salivary flow rate is defined as the volume of saliva secreted by major and minor salivary glands in a minute without any stimulation. The normal range of unstimulated and stimulated salivary flow rates are 0. Sometimes an individual with normal salivary flow rate complains of dry mouth, also called xerostomia.
The prevalence of diminished salivary gland secretions varies in the general population. Reduced salivation can lead to some side effects such as speech problems, chewing disorders, inflammation of the mucosa mucositis , oral Candida infections and mucosal atrophy. It can increase accumulation of plaque and decrease the saliva buffering capacity.
Secretion of saliva might be affected by several factors such as stress, 11 anxiety and depression, 12 age, 13 previous treatment or cancer radiation therapy, 14 medications 5 and some other factors. Reduction of salivary flow may also be related to the absence of one or more of the major salivary glands, infectious or non-infectious sialoadenitis, salivary gland tumors benign or malignant or systemic diseases, which might exert direct effects on the secretion of saliva.
Among the above-mentioned different risk factors affecting saliva, stress, anxiety and depression have been taken into consideration by some researchers due to their relatively strong role and available treatments. However, sufficient evidence on the relationship between these factors and salivation is not available.
A total of patients referring to Zanjan Dental School were selected randomly and, after signing an informed consent form, were included in this study. Then a questionnaire on demographic data as well as dental and medical history was submitted to the participants. Individuals under 18 years of age, those with a positive history of systemic disease and those taking any medications at the time of the project or 6 months before or smoking were excluded.
Data were collected in this study in two parts; the first part included measurement of salivary flow rate and xerostomia. There are several ways to collect whole saliva, including draining, aspiration, spitting and use of absorbent materials; usually the last two methods are used. Salivary samples were collected from 8 to 9 in the morning. Then the participants were requested to spit saliva in special containers for 5 minutes every 60 seconds. In order to measure saliva, 2-mL syringes were provided.
Then to assess xerostomia dry mouth feeling , the symptoms were recorded in a specially prepared form by asking some questions and then based on the collected data mentioned above, the patients were classified into 4 groups:. The second part consisted of evaluating depression, anxiety and stress by using the DASS questionnaire Depression, Anxiety and Stress Scale , 20 which is the standard questionnaire in this area.
First the questionnaire was translated into Persian by two oral medicine specialists and the validity of its content was confirmed.
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Cronbach's alpha coefficient was used to assess the reliability and for each of the areas of depression, stress and anxiety the coefficients were 0. The mean Cronbach's alpha coefficient for three areas was 0. The questionnaire consists of 42 questions in 3 parts: depression, stress and anxiety.
In this study descriptive and analytical analyses were used. Descriptive analyses such as means and standard deviations were used to analyze quantitative data, and frequencies and percentages were used to analyze qualitative variables. Statistical analyses were carried out with SPSS Demographic chart regarding gender distribution in four groups frequency percentages.
Based on the results Table 2 , the frequency of subjects with severe and very severe depression score in the group exhibiting diminished salivary flow and xerostomia was The results also revealed that the frequency of subjects with severe and very severe stress scores in the group exhibiting diminished salivary flow and xerostomia was Considering the different functions of saliva in the oral cavity, any change in its volume or composition might lead to malfunction. By using this reliable, brief and comprehensive psychological scale three different major psychological disorders stress, anxiety and depression could be assessed simultaneously.
There are two techniques to evaluate the effect of mental disorders on saliva. A number of researchers have explored the effects of psychiatric medications on saliva 5 and some studies, like this one, have examined the psychological disorders directly affecting salivation. Although psychological processes that are independent of salivary secretion may be related to xerostomia, it is noteworthy that depression, by stimulation of anticholinergic mechanisms, can reduce salivary flow rate.
Therefore, psychological conditions might affect both salivary flow rate and xerostomia.
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Furthermore, it was observed that salivary cortisol levels increased during stress, followed by changes in the composition of saliva. Borhan et al, 5 in a study similar to the present study in relation to the groups but with smaller sample size, showed that stress and depression play a significant role in reducing the salivary flow rate and in increasing the incidence of xerostomia.
In this regard, Bergdahl and Bergdahl 21 evaluated individuals in three groups and similarly showed that unstimulated salivary flow rate under 0. In relation to depression, Scarablot et al 22 showed a significant relation between reduced salivary flow rates and depression and sleep disorders, consistent with our findings.
This study also revealed that women with depression have more burning sensation and xerostomia than men. Similarly, Hugo et al 23 reported that stress can result in salivary gland hypo-function, which will reduce salivary flow. Thirty-eight medical students were enrolled in their research, consistent with the results of this study and a study by Baharvand and Hemati.
Enzyme-linked immunosorbent assay was used to assess the physiological stress marker, cortisol. The researchers suggested other possible responses through salivary proteins that increase with the acute stress stimuli but acute stress public talk did not affect salivary flow rate. Such difference in the results might be attributed to various reasons, including the fact that salivary gland function might be influenced by age and gender. Furthermore, different levels of stress and the duration of stress have different effects on immune function.
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This is the reason for the difference between the results of this study and the latter two investigations. In another investigation Di Loreto 28 evaluated the effect of stressful events in two groups with and without anxiety. They found significant relationships between hyposalivation and rise of cortisol levels. Bergdahl and Bergdahl 21 in their study observed a significant relationship between psychological factors such as anxiety and xerostomia or taste disorders.
Both these researchers reported results similar to the present study. Given the results of this study, we suggest further research with larger sample sizes and other standard questionnaires or investigations into the relationship between stress acute or mild , anxiety and depression each one individually ; whole saliva or salivary flow rate also should be considered. Moreover, other factors affecting salivary flow rate such as age, gender, systemic disorders, medications, etc should be evaluated in separate investigations. Additionally, further research appears to be crucial to find other suitable criteria for evaluation of xerostomia.
Psychological variables such as anxiety, stress and depression have a significant effect on reducing salivary flow rate and on xerostomia. This article was derived from a thesis submitted by Behrous Hosseini Sabzvari for a doctorate degree in general dentistry in the School of Dentistry, Zanjan, Iran. NG was responsible for the concept or design of the work.
BHS collected data for the work. AR interpreted data. SS drafted the work and revised it critically for important intellectual content. All the authors participated in the literature review. This study was funded by Zanjan University of Medical Sciences. Before starting the study, all the subjects signed an informed consent form.