Self‐reported stress, coping ability, mental status, and periodontal diseases among police recruits

Abstract Objective This cross‐sectional study aimed to investigate self‐reported stress level and coping ability as well as mental status (anxiety and depression) via the 12‐item General Health Questionnaire (GHQ‐12) questionnaire and periodontal status among police academy recruits during their 8 months of training. Methods Eighty‐five consenting police recruits were examined at baseline during the first month of training and again during the last month of training. Full mouth plaque score (FMPS), full mouth bleeding score, basic periodontal examination, self‐reported stress level (scale of 1–10) and GHQ‐12 questionnaire (mental status) were recorded at both visits. Ability to cope (yes/no) with stress was recorded at the final visit. Periodontal diagnosis was derived based on clinical examination. t test and regression analyses (p < .05) were performed. Results High stress (odds ratio: 1.25) and inability to cope with stress (odds ratio: 1.31) were statistically significant (p < .05) predictors of high FMPS. Inability to cope with stress (odds ratio: 1.45) was also a statistically significant (p < .05) predictor for periodontitis compared to gingivitis. Mental status (anxiety and depression) may play a greater role in gingivitis (mean 1.75) as opposed to periodontitis (mean 1.00) as reflected by the higher mean GHQ‐12 (t test, p = .04). Conclusions In this study, both self‐reporting of stress level and ability to cope with stress were statistically significant predictors of higher plaque score (FMPS). Ability to cope with stress was also a statistically significant predictor of periodontitis compared to gingivitis. Recording of both self‐reported stress level and ability to cope may be valuable variables to note in the management of plaque and periodontal diseases.

The effect of exam stress on medical students was related to higher levels of plaque among those with exams as opposed to matched controls without exams (Deinzer et al., 2001). There was an increase in gingival inflammation as measured by bleeding on probing in students stressed by exams in comparison to matched controls without exams over a 4-week period (Deinzer, Rüttermann, Möbes, & Herforth, 1998). The psychological and immunological effects on stressed individuals may also have a time dissociation with the latter demonstrating a prolonged effect after the episode of stress (Deinzer, Kleineidam, Stiller-Winkler, Idel, & Bachg, 2000). Financial stress and also poor coping skills have been associated with an increased risk for periodontal diseases (Genco, Ho, Grossi, Dunford, & Tedesco, 1999).
Stress may produce changes in mental and psychological wellbeing to include signs of depression, anxiety, and altered self-esteem.
In an animal model, depression accelerated periodontal tissue breakdown and was reversed by antidepressive drug therapy (Breivik et al., 2006). However, whereas some human studies link anxiety and depression with periodontal diseases, others fail to show a relationship. A systematic review of stress and psychological factors as a risk factors for periodontal diseases revealed a positive outcome in 57%, equivocal results for 28%, and negative outcome for 14% involving 14 included studies (Peruzzo et al., 2007).
The General Health Questionnaire (GHQ) is a quantitative selfreported questionnaire method developed to determine risk for psychiatric disorders (Goldberg & Blackwell, 1970). The GHQ was reported as a commonly validated self-reported method in systematic reviews of anxiety or depression measures (Hewitt, Perry, Adams, & Gilbody, 2011;Meades & Ayers, 2011). The original version of 60 questions (GHQ-60) has been proposed in a shortened form for ease of applicability to 12 questions (GHQ-12) by Golderberg and Williams (1988) The GHQ-12 questionnaire excluded questions that were endorsed by the physically ill from the original GHQ-60 version. The GHQ-12 has been shown to have good reliability in the general population (Petkovska, Bojadziev, & Stefanovska, 2015) and further validity for measures of anxiety and depression (Baksheev, Robinson, Cosgrave, Baker, & Yung, 2011;Lundin, Hallgren, Theobald, Hellgren, & Torgén, 2016).
Many studies have employed structured questionnaires to measure stress and psychological status (Peruzzo et al., 2007). Additionally, comparisons are made with groups exposed to stress and those not exposed to stress rather than looking at the experience of all individuals within a group with similar environmental exposure (Deinzer et al., 1998;Deinzer et al., 2001). A simpler form of stress quantification such as the self-reported stress levels on a scale of 1-10 has ease of application to the clinical setting and has had little reporting in the literature. The relationship between stress and periodontal diseases continues to be an underscored area of study that requires further investigation.
Thus, the aim of this study was to investigate self-reported stress levels and coping ability as well as associated mental status (anxiety and depression) via the GHQ-12 questionnaire and periodontal status in a group of police academy recruits during their training programme.

| Study population and methodology
Ninety-six police recruits from the class of 2018, Police Academy, Trinidad and Tobago Police Service, were invited to participate in this cross-sectional study. All academy recruits were included without exclusion criteria once consent to participate was obtained to eliminate selection bias for stress, mental status, and periodontal disease.
Selection of police recruits also reduced confounding variables of systemic disease as these recruits were expected to be reasonably fit and healthy. The duration of the training course was a period of 8 months.
Ethical approval was obtained from the University of the West Indies Ethics Committee (Ref: CEC400/11/17).
This study composed of a demographic and health questionnaire that was completed by an interviewer and covered medical and dental histories to include self-reported anxiety (yes/no) and depression (yes/no) and temporomandibular complex problems (yes/no). Selfreported stress levels on a scale of 1-10 with 10 being the highest stress level were recorded. Psychological well-being or mental status was determined by the GHQ-12 questionnaire that was completed unaided by participants. The GHQ-12 consisted of six positive questions and six negative questions with a 4-point Likert scale response from always to never (see Figure 1). However, a binominal 0,0,1,1 scoring was applied from always to never for positive questions and never to always for negative questions. This was recommended to reduce the bias in response (Golderberg & Williams, 1988). Thus, there was a total maximum score of 12 for all questions indicating the worse mental well-being status.
The questionnaire was followed by a clinical dental examination that composed of a periodontal assessment via basic periodontal examination (BPE) scoring, full mouth plaque score (FMPS), and full mouth bleeding score (FMBS (Ainamo & Bay, 1975; The British Society of Periodontology (BSP), Council of the BSP, n.d.);). All patients were examined by one examiner who was a periodontologist. In the absence of dental radiological services, a tentative periodontal diagnosis in general terms of either healthy, gingivitis, or periodontitis was assigned based on clinical gingival presentation, FMPS, FMBS, BPE codes, interproximal recession, and attachment loss. In determining a diagnosis, care was taken to account for any false pockets (i.e., free gingival margin above the cementoenamel junction), and thus, patients with a true BPE of 4 were ascribed a periodontitis diagnosis. Additionally, patients with a BPE of 3 and interproximal recession were also assigned a diagnosis of periodontitis. In the periodontal diagnosis, RAMLOGAN ET AL. 118 further description of distribution or severity of the periodontal diseases was not attempted.
This first visit occurred within the first month of the training programme to determine the baseline scores of all recruits. All cases were coded via identification numbers to maintain confidentiality. The recruits were revisited within the last month of the training programme approximately 6 months later. At this final visit, the examiner was blind to the previously collected data. Self-reported stress levels, ability to cope with stress, GHQ-12 questionnaire, and repeat periodontal indices of FMPS, FMBS, and BPE were obtained at this final visit. Recruits were afforded individual feedback and group dental education only at this visit so as not to influence the outcome.
Self-reported stress levels were categorized as low for 1 to 5 and high for 6 to 10. Specific cohort-based GHQ-12 low and high categories were also derived based on a cut-off value established by the mean for the whole group (Goldberg, Oldehinkel, & Ormel, 1998).
IBM SPSS Statistics 24 statistical software (IBM Corporation, Armonk, NY, USA) was used in the analyses. t test (p < .05) comparisons of the mean periodontal indices of FMPS, FMBS, and highest BPE code in the (a) low stress and high stress level group, (b) inability to cope and ability to cope with stress groups, and (c) low and high GHQ-12 were derived. Regression analyses were conducted for the indices, which showed a statistical difference to account for confounding variables. t test (p < .05) comparisons of the mean stress level and mean GHQ-12 values as grouped by diagnoses were also derived.

| RESULTS
There were 85 recruits (88.5%) who consented to participate in this study out of a total class of 96 individuals. Seventy-four percent (n = 63) were male, and 26% (n = 22) were female. The mean age was 25.1 years (standard deviation: 4.4, range: 19-35 years). With regard to marital status, the majority of recruits were single at 69.4% (n = 59), and the remainder of 30.6% (n = 26) was in some form of relationship (married or partner). Only 1 (1.2%) of the 85 recruits was a current smoker. Nine (10.6%) recruits had some significant medical history (asthma, n = 6; high blood pressure, n = 2; minor heart condition, n = 1). There was an attrition rate of approximately 10% as eight recruits failed to return for the second visit due to study and training commitments.
All mean periodontal indices (FMPS, FMBS, and BPE) except the final mean BPE were higher for the high stress level group (stress: 6-10) compared with the low stress level group (stress: 1-4) for both the initial and final visits. There was no statistically significant difference between the periodontal indices for the stress level groups at the initial visit. The values are shown in Table 1  In comparison of mean periodontal indices with ability to cope with stress, all mean periodontal indices were higher for those who could not cope compared with those who could cope. The mean values were statistically significantly different for both FMPS and BPE (p = .03) but not for FMBS (Table 3).

| DISCUSSION
The mean FMPS was larger with statistical significance (t test, p = Coping with stress was only indicated at the final visit as a measure of the ability to manage the stress due to the training programme. Recruits who were not able to cope with stress had higher FMPS and BPE with statistical significance (p = .03 for both) compared with those who could cope. The authors recognize that the BPE scoring, a continuous limited number range index, does not measure similar equivalent increments as the FMPS and FMBS. However, it was included to reflect a gradation or measurement of increasing periodontal involvement. The lack of statistically significant difference for the FMBS between groups for coping with stress may be a reflection of the temporal limitations. Changes in bleeding may lag behind plaque accumulation. Another reason for the lack of difference with FMBS may be localization of changes and varying susceptibility of each recruit to periodontal disease. Additionally, looking at the low value of p = .08 for FMPS, it may also be postulated that the lack of significance may also be due to the low number of participants in this study with a larger population potentially revealing a significant result. Abbreviation: FMPS, full mouth plaque score; GHQ-12, 12-item General Health Questionnaire.

T A B L E 6 Regression model with dependent variable of FMPS
Initial GHQ-12 scores showed high correlation (Pearson's coefficient: .41; p < .01) with statistical significance with the initial stress level scores. Likewise, the high stress group had higher mean GHQ-12 scores compared with the lower stress group with statistical significance (p = .01) at the initial visit. These two findings were not demonstrated in the final visit. Further recruits reporting anxiety or depression had higher mean GHQ-12 scores with statistical significance (t test, p < .01) at the initial visit. Thus, although GHQ-12 may be a good measure of anxiety and depression, its relationship with stress may be more complex. Although there was good relationship at baseline between GHQ-12 and stress, this failed to remain true with the changes at the end of the training programme. It may be assumed that GHQ-12 may not be sensitive enough to reflect immediate or recent changes in stress. All periodontal indices were higher for high versus low GHQ-12 categories for both initial and final visits. However, these difference did not achieve statistical significance possibly due to drawbacks with scoring, selection of an accurate, or population specific cut-off point for high and low GHQ-12 categories and small study sample size.

GHQ
Overall recruits showed a decrease in GHQ-12 scores from initial to final visit, which achieved statistical significance (paired t test, p = .03).
Likewise, there were decrease in stress levels and periodontal indices of FMPS and FMBS from initial visit to final, but these changes did not achieve statistical significance. This study failed to show a relationship of GHQ-12 and periodontal indices or diagnosis by regression analyses. The reduction in GHQ-12 and stress levels at the end of the study was unexpected and may have been due to recruits having less burden of training and exams as the programme was coming to a close.
The impact on periodontal status and stress of the variables of smoking and even significant medical histories was limited due to the small numbers in the latter two groups. This was predictably expected due to the healthy status and requirements for entry into the police academy training programme. Those recruits who self-reported anxiety and depression were not clinically diagnosed with these conditions and thus were not on any medication to have had an impact on their oral status, stress level, or coping ability.  (Breivik et al., 2006;Deinzer et al., 1998;Deinzer et al., 2000;Deinzer et al., 2001;Genco et al., 1998;Genco et al., 1999;Goldberg & Blackwell, 1970;Peruzzo et al., 2007;Rozlog et al., 1999;Weik et al., 2008) and coping ability (yes/no) as well as associated mental status (anxiety and depression) via the GHQ-12 questionnaire and periodontal status in a group of stressed police academy recruits was undertaken.

| Principal findings
High stress (odds ratio: 1.25) and inability to cope with stress (odds ratio: 1.31) were statistically significant (p < .05) predictors of high plaque scores (FMPS). Inability to cope with stress (odds ratio: 1.45) was also a statistically significant (p < .05) predictor for periodontitis compared with gingivitis. Mental status (anxiety and depression) may play a greater role in gingivitis compared to periodontitis.

| Practical implications
Simple self-reporting of stress and ability to cope with stress in the clinical setting may be an efficient and quick method of recording factors that significantly impact on plaque scoring and by extension periodontal diseases. Unexpected changes in FMPS and periodontal diseases may be better managed by recognizing the role of stress in disease pathogenesis. Awareness of the level of these two factors (stress level and ability to cope) by both the clinician and the patient may be helpful in the successful management of periodontal diseases.