Sec. Sci.Med.Vol. 35,No. 12,pp. 1511-1520,1992 Printedin Great Britain

0277-9536/92 $5.00+ 0.00 PergamonPressLtd

THE RELATIONSHIP BETWEEN WORK STRESS AND ORAL HEALTH STATUS WAGNERSEGURA MARCEN= and AUBREYSHEIHAM Department of Epidemiology and Public Health, University College London, 66-72 Gower Street, London WCIE 6EA Abstract-This study investigated whether oral health status is associated with work stress. 164 male workers aged from 35 to 44 years, equally distributed over four so&o-economic groups took part in the study. Three work characteristics related to stress were studied: mental demand, control and variety. Age, socio-economic status, sugar consumption, frequency of dental attendance, toothbrushing frequency, type of toothpaste used, years of residence in Belo Horizonte and marital quality were considered in the data analysis. The results of simple regression analysis (dental caries data) and simple logistic regression analysis (periodontal data) showed a significant relationship between periodontal health status and work-related mental demand (P < O.OOl), marital quality (P < 0.01) and socio-economic status (P < 0.05). Dental caries status was significantly associated with age (P < O.OOl),socio-economic status (P < 0.05), sugar consumption (P < 0.01) and marital quality (P < 0.0001). Socio-economic status did not remain significantly associated with dental caries after adjusting for all the variables studied. Key words-dental factors

caries, periodontal diseases, stress, work, social class, psychosocial factors, behavioural

INTRODUCTION Although much is known about the aetiological significance of biological and behavioural risk factors of both dental caries and periodontal disease, a significant proportion of the variation of the occurrence of these oral diseases is unexplained. This may be because important psycho-social risk factors such as stress, have rarely been seriously considered when investigating oral disease aetiology. There is very little data linking psycho-social factors to dental caries. Sutton [ 1] reported that patients with a history of recent mental stress experienced rapidly progressing caries, and Beck et al. [2] reported a positive association between negative life events and root caries in an elderly population. Evidence linking psycho-social factors to periodontal disease is more abundant. A number of studies have shown an association between the occurrence of acute necrotizing ulcerative gingivitis and negative life events [3-91 and stress arising from life situation [IO, 111. Also, a study based on clinical observation showed that periodontal disease was associated with psycho-social factors such as broken homes and marital problems [12]. The possible mechanisms whereby psycho-social factors relate to periodontal disease have also been investigated. Milgrom et al. [13], found a positive association between life events and changes in bacterial colony counts in a case study of one patient. Davies et al. [14], in a cohort study in young adult clinical patients who were regular dental attenders and had good oral hygiene found that stress and depression were associated with rapid periodontal destruction.

The findings from these studies may be questioned because they were based on small samples of students and clinic patients who are not representative of the general population. However, epidemiological studies do link psycho-social factors and oral diseases. Osterberg, Hedegard and Sater [ 151 reported clear differences in oral health status between married and unmarried individuals. Hunt et al. [16] reported that

married people consistently had lower rates of edentulism than did unmarried people. More recently, Marcenes and Sheiham [17] reported a lower prevalence of dental caries in families whose marital quality was good compared to those whose marital quality was not good. A finding which agrees with epidemiological research that has linked marital quality and physical and mental disease [l&25], as well as the clinical study conducted by Baker et al. [12]. It is not marriage per se, but the quality of marriage which is related to health. As Renne [18, 191, and Gove, Hughes and Style [24] reported, people who were dissatisfied with their marriages were more likely to be in poorer physical and psychological health than people that are single, widowed or divorced. In short, there is evidence that psycho-social factors are associated with dental caries and periodontal disease [26]. Sutton [27] postulated that stress would reduce the efficacy of the immune system, which would decrease the defence against bacterial attack, permitting the development of acute dental caries. This theory appears feasible, since immunological mechanisms are implicated in the pathogenesis of dental caries [28,29] and it can be affected by environmental factors such as stress

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[30-331. This theory also applies to periodontal disease [33]. Haavio-Mannila [34] showed that the major sectors of people’s life are family, work and leisure, and that among those, family is the most important to overall life satisfaction. Family environment has been shown to be associated with oral health [12, 15-171, but the effect of the work environment on oral health still has to be investigated. It can be hypothesized that if the work environment is an important factor in life, it may be associated with oral health. Certain characteristics of work (such as level of demand, monotony, control over work) are associated with stress and health. For example, organizational characteristics of work have been associated with mental health [35-371, gastrointestinal, respiratory and musculoskeletal problems [38], hospitalization [39], mortality [40-411 and cardiovascular disease [42-491. As stress has a relatively non-specific effect, in that it is associated with a wide variety of diseases [50], it is logical to speculate that there is a relationship between oral health status and work stress. In attempting to understand why an individual’s occupation or the organizational characteristics of his or her work might contribute to the development of disease, researchers have investigated the content of the daily experience of work-life. Garde11 [35] suggested that the main focus in the relationship between work and health is the extent to which an individual’s job fulfils his or her ego needs. Johansson [46] discussed work from sociological and psychosocial perspectives. He mentioned high mental demands, excessive work and time pressure as the traditional psychological stressors. He also identified lack of autonomy, understimulation, underutilization of skills, and infrequent opportunities to learn new things as important job stressors [46]. Karasek [36] postulated that work stress, and subsequent physiological illness, occurs when the psychological demands of the work are high and a person’s ability to deal with those demands is simultaneously low. The job strain model developed by Karasek [36] has been tested and confirmed by several other studies [39,47-491. An investigation to assess whether work stress and oral health status are associated was conducted. The following research questions were addressed: 1. Do individuals exposed to work conditions which are mentally adverse (high mental demand, low control and monotony) have worse oral health status than those not so exposed? 2. If work conditions are associated with oral health status, are they associated through riskrelated behaviour or do they affect oral health status by pathways other than the established risk factors?

METHODS The data used to test the hypothesis come from a family study conducted in Belo Horizonte, Brazil [51]. That study included 164 randomly selected families (father, mother and at least one 13-year-old child). Only the data relating to the fathers in each family were used in the present study. Thus, the sample was 164 males, all of whom were in paid work. The sample was selected by randomly selecting 164 13-year-old children from both private and state schools. Parents of the selected child were recruited into the study. Since oral health is strongly related to age [52], this variable was standardized. All fathers were 35-44 years old. This age group is the standard monitoring group for the oral health condition of adults [53]. As socio-economic status also plays an important role in the determination of health status [54] and oral health [52, 55-571, the families were equally distributed over four socio-economic groups: A, B, C and D [58]. To select the families according to socioeconomic status, the schools located in the city of Belo Horizonte were divided into two groups: those located in the central area (‘middle-class’) and those in the suburban area (‘poor’). The schools were then given a number and a draw established the order in which schools would be visited. All the schools selected agreed to participate in the study. The first 6 schools located in the ‘middle-class’ areas and the 3 schools in the ‘poor’ areas were sufficient for the sample. A total of 233 families were selected; 123 from the schools in ‘middle-class’ areas and 110 from those in the ‘poor’ areas. Information available at each selected school registrar’s office was used to list all 13-year-old students. The criterion adopted to divide Belo Horizonte into areas was developed by PLAMBEL [59]. Since there are some lower socio-economic group pockets located in the ‘middle-class’ areas, for example the slums, and some upper socio-economic group pockets located in the ‘poor’ areas, some children from the lower socioeconomic groups attended classes in the schools located in ‘middle-class’ areas and some children from upper socio-economic groups attended classes in schools located in ‘poor’ areas. Thus, some refinement of the socio-economic group distribution of the families was necessary. The ABA-ABIPEME criterion for socio-economic classification [58] was utilized for this purpose. It was also used to subdivide the middle-class and poor groups and distribute the families over the four socio-economic groups: A, B, C and D. The families were approached following the order established by the random selection of schools. Only when all 13-year-old children from one school were visited, was the next school included. Once a sufficient number in each of the 4 cells was obtained, the remaining families from the completed cell were not

Work stress and oral health status contacted. The response rate was just over 93%, considered all contacted participating. Data were collected through a clinical examination and a personal interview. Both took place in the participants’ home. The clinical examination recorded the number of decayed, missing and filled tooth surfaces-DMFS scores-[53], periodontal pockets [60] and the presence of gingival bleeding on probing. The consistency of examinations was assessed by reexamining 1 subject in 10. The result of the Cohen’s Unweighed Kappa Coefficient of Agreement between examinations was above 80% for both dental caries and periodontal disease, which indicate almost perfect agreement beyond chance. A questionnaire was used during the personal interview to collect psychosocial and behavioural data. Five psychosocial variables were included: work-related mental demand, work control, work variety, socio-economic status and marital quality. Sugar consumption, toothbrushing frequency, type of toothpaste and frequency of dental attendance were the behavioural risk-related factors studied. Years of residence in Belo Horizonte, a fluoridated city, was also included. Measures Psychosocial factors. Work stress was measured, based in the Karasek job strain model [36,43]. Karasek’s job strain model is composed of two dimensions: demands and decision. The ‘job demands’ dimension reflects the psychological stressors related to work load, unexpected tasks and personal conflict, but not physical job stressors. The ‘job decision’ dimension includes two indicators, which have different goals: intellectual discretion, defined as the intellectual possibility of developing work; and personal schedule freedom, defined as control over time, reflecting the individual’s control over his time schedule of participation in the work process [36,43]. Karasek [36] measured intellectual discretion by comparing the skill level required for the worker’s job and his evaluation of the work as repetitive and lacking variety. Karasek [36] assumed that after constant rehearsal of repetitive work, workers tend to lose the capacity for intellectual challenge. Moreover, he found that the great majority of repetitive job responses were from workers in jobs which require no formal training beyond elementary education [36]. This study measured the intellectual discretion dimension through workers’ evaluation of their lack of job variety and was named ‘work variety’. The dimension ‘personal schedule freedom’ was labelled ‘work control’ in this study. The questions used to measure each dimension are presented in Appendix 1 and were selected from the measure used by Karasek [36] and Karasek et al. [43], Coburn [42] and the Whitehall II study of British civil servants [61]. The calculation of the scores for each dimension was done adding each question’s value. The final

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scores for work-related mental demand, work variety and work control ranged from O-12,0-12 and O-16, respectively. Marital quality was measured by combining specific questions relating to pleasurable or stressful family experiences. The measure took into account couples rather than individuals, which differs from the majority of studies. One cannot make inferences and draw conclusions about married couples when only one of the spouses is studied. Four dimensions were evaluated: companionship, communication, satisfaction with marriage and satisfaction with children. Demonstration of affection and sexual enjoyment were initially included in the questionnaire but were excluded after the pilot test of the questionnaire because respondents felt embarrassed to answer such questions. The questions used to measure each dimension are presented in Appendix 2 and were selected from validated scales such as the Marital Adjustment Test [62], the Caring Relationship Inventory [63], the Dyadic Adjustment Scale [64], the Dyadic Trust Scale [65], the Dual-Career Family Scale [66], the Marital Satisfaction Scale: Form B [67], the Abbreviated Barrett-Lennard Relationship Inventory [68], the McMaster Family Assessment Device [69] and the Quality of Life Scale [70]. The calculation of the total score was carried out as follows. Answers were dichotomized and a value of 0 and 1 was given to unfavourable and favourable answers, respectively. Answers were considered favourable if respondents answered ‘always’ or ‘often’ to questions 1, 2 and 3 and ‘very satisfied’, ‘moderately satisfied’ or ‘a little satisfied’ to questions 4 and 5. Agreement between answers was also taken into account to calculate the final score. A value of 2 was given if both answered the question in a favourable way, 1 if only one of the partners answered favourably, and 0 if both answered in an unfavourable way. Since one dimension included 2 questions and the others 1 question, a weight of 2 was given to the other dimensions. A final score, which ranged from O-16, was calculated adding the scores of each dimension. Socio-economic status was measured using the ABA-ABIPEME criterion of socio-economic classification [58], which is based on a group of specific socio-economic indicators. These indicators can be divided into two categories: resources (TV, radio, bathroom, motorcar, maid, vacuum cleaner and washing machine) and education level (none, primary school (4 years), primary school (8 years), secondary school (12 years) and university). Points were assigned to each indicator and a final score, which defines the socio-economic groups, was given. Oral health related behavioural factors. Sugar consumption was measured using the 24-hr recall method. In an attempt to help participants remember the food consumed on the previous day, a list of items (adapted from Bagramian [71]) was used. A score was given counting the number of times a day an

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Table 1. Frequency distribution of socio-economic groups, frequency of dental attendance, type of toothpaste, and periodontal health status in sample: 164 male workers Variable

Response

Socio-economic

groups

A B C D

41 41 41 41

Type of toothpaste

Non fluoride Fluoride Do not know

104 (63.4)’ 54 (32.9) 6 (3.7)

Frequency

Every Once Once Only

24 (14.6) 29(17.7) 7 (4.3) 104 (63.4)

of dental attendance

Periodontal ‘Figures

health status

in parentheses

6 months a year every 2 years when in trouble

No bleeding no pockets With bleeding or Dockets

44 (28.4) 111 (71.61

are percentages

individual consumed products with sugar (hereafter called units a day). Toothbrushing frequency per day, type of toothpaste, frequency of dental attendance and years of residence in Belo Horizonte were also recorded. Frequency of dental attendance was recorded as ‘every 6 months’, ‘once a year’, ‘once every 2 years’ and ‘only when in trouble’. Type of toothpaste meant ‘with fluoride’ or ‘without fluoride’. Oral health indicators. For dental caries status, the DMFS index was adopted [53]. The DMFS index expresses the amount of successfully treated disease (filled and crowned surface), unsuccessfully treated disease (extracted teeth) and untreated disease (decayed surfaces). The DMFS scores were calculated by adding together the number of decayed, filled and missing surfaces. The calculations were based on 128 surfaces, since third molars was not included. For periodontal disease, the presence or absence of teeth either with gums bleeding on probing or with pockets was used. The indicator was labelled as ‘complete absence of teeth with gums bleeding on probing and with pockets’, and ‘presence of any tooth with gums bleeding on probing or pockets’. Shallow and deep pockets were not differentiated in the calculation since only one subject had deep pockets.

A detailed explanation of the development of the measures adopted is reported elsewhere [51]. Statistical

analysis

Assuming that oral health status may be affected by several factors, well known risk-factors such as age, socio-economic status, frequency of dental attendance, toothbrushing frequency, sugar consumption, and type of toothpaste were considered in the analysis. Years of residence in Belo Horizonte was also considered in the analysis because the water was fluoridated there in 1975. Since data were collected in 1988, all subjects were exposed to fluoride for less than 14 years. Individuals living in Belo Horizonte for more than 13 years were recorded as 14 years and if below 14, by the number of years they lived in the city. Marital quality was also included [17]. All variables were entered into the equation as scores, but not as categorical variables. Data analysis was carried out in order to assess the unique contribution of each independent variable. Correlations between all variables, simple linear regression analyses and multiple linear regression analysis was carried out for the dental caries data. Simple logistic regression and multiple logistic regression analysis were carried out for the periodontal data. Six workers were excluded from the dental caries data analysis due to missing values. Also, 15

Table 2. Mean, standard deviations, minimum, quartiles and maximum values of years of residence in Belo Horizonte, age, toothbrushing frequency, sugar consumption, marital quality, DMFS, proportion of teeth with gums bleeding after probing and proportion of teeth with pockets in sample: 164 male workers Variable

Mean

Years of residence Age Toothbrushing frequency Sugar consumption Work mental demand Work control Work variety Marital quality DMFS Bleeding Pockets ‘Figures

in parentheses

12.5 (3.2)’ 41.2 (2.2) 2.7 (1.2) 6.6 (4.5) 6.2 (3.9) 11.2 (4.8) 9 (3.3) 5.9 (4.1) 64.8 (31.2) 0.25 (0.31) 0.11 (0.24) are standard

deviations.

Minimum

25

Quartiles 50

3:

14 40 2 3 3 8 7 2 41 0 0

14 42 3 6 6 12 10 6 59 0.12 0

0 0 0 0 0 0 0 0 0

75 14 43 3 10 9 16 12 8 87.7 0.39 0.11

Maximum 14 44 6 23 12 16 12 16 128 1 1

Work stress and oral health status workers were not included in the periodontal data analysis, 6 due to missing values and 9 because they were edentulous. RESULTS

The sample population had a high level of dental caries and a low level of periodontal disease. The mean DMFT of all workers was 18.3, and the mean DMFS was 64.8. On average, workers had 7 teeth missing. By contrast, the level of periodontal disease was low: the mean proportion of teeth with gums bleeding after probing was 0.25, and the mean proportion of teeth with pockets was 0.11. Furthermore, 28.4% of workers had no teeth with periodontal disease. The mean sugar consumption reported was high, 6.6 units a day. Toothbrushing frequency reported was very high, on average 2.7 per day. Approximately two-thirds of the subjects said they used a non-fluoride toothpaste, and 63.4% reported going to the dentist only when in trouble. The frequency distribution of all variables studied is presented in Tables 1 and 2. Dental caries

Except for frequency of dental attendance and years of residence in Belo Horizonte, which were only slightly correlated, correlation coefficients between independent variables and DMFS scores were greater than 0.10 (Table 3). This means that grouping subjects in an age range within which they are similarly affected by caries status (35-44 years old) did not standardize that variable. The significance of correlation coefficients should be viewed with caution. Some of the variables did not present a normal distribution, which may distort the calculations. A linear regression analysis was carried out for each independent variable to check whether they were significantly associated with DMFS scores. Higher levels of marital quality (P < O.OOOl), lower sugar consumption (P < O.Ol), upper socio-economic status (P < O.OS),and younger age (P < 0.001) were significantly associated with lower DMFS scores. All other variables were found not to be significantly associated with DMFS scores (P > 0.05) (Table 4). The next step was to carry out a multiple linear regression analysis with all variables in the model. The results of multiple linear regression analysis showed that age, sugar consumption, and marital quality remained significantly associated with DMFS scores (Table 4). Socio-economic status did not remain significantly associated with DMFS scores (P > 0.05) after adjusting for the other variables studied. The model explained 3 1.8 % of the variation in DMFS scores. A search focused on residuals to check the assumptions of linearity and constant variance was carried out and showed that these assumptions were not

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Table 4. Linear regression of marital quality, toothbrushing frequency, sugar consumption, age, years of residence in Belo Horizonte, type. of toothpaste, frequency of dental attendance and so&-economic status on DMFS. Sample of 158 male workers Simple linear regression Regression coefficient

Variable Work mental demand Work control Work variety Marital quality Toothbrushing frequency Sugar consumption Age Years of residence Type of toothpaste Frequency dental attendance Socio-economic status ‘Figures

in parentheses

are standard

Multiple

Significant level coefficient 0.9469 0.6635 0.2051 < 0.0001 0.1207 0.0024 0.0004 0.2388 0.0731 0.3414 0.0151

0.43 (0.65)’ -0.23 (0.52) -0.96 (0.75) -3.12(0.56) - 3.43 (2.20) 1.65 (0.54) 3.94(1.09) 0.91 (0.77) -9.47 (5.25) 2.04 (2.14) -0.36(0.141

linear regression

Regression

Significant level

0.19 (0.56) 0.87 (0.53) -0.06 (0.77) -2.95 (0.54) -1.33(2.10) 1.22 (0.49) 3.92(1.01) 0.15 (0.68) - 5.46 (4.93) -1.57(2.12) -0.31 (0.171

0.7322 0.1027 0.9362 < 0.0001 0.5284 0.0140 0.0002 0.8240 0.2705 0.4608 0.0741

error.

violated. The plot of residuals against the predicted values of DMFS scores did not show any pattern. Interaction among the variables was also checked by calculating a two way interaction for all variables, carrying out a regression analysis adding the new variables to the model and checking whether they improved the model significantly. The partial F-test criterion using the level of significance of 5% suggested that there was no interaction, since the new variables did not improve the model significantly (P > 0.05).

demand and marital quality remained significant after adjusting for the other variables (P < 0.01) (Table 5). Work-related mental demand and marital quality were of clinical and statistical significance. The odds ratio for periodontal health status between those who experienced low (first quartile) and high levels (fourth quartile) of work-related mental demand and marital quality were, on average, 3.3 and 2.5, respectively after taking into account all variables studied (Table 5). DISCUSSION

Periodontal disease

The first step in analyzing the periodontal data was to carry out a logistic regression for each independent variable to check whether they were significantly associated with workers’ periodontal health status. Lower work-related mental demand (P < O.OOl), higher levels of marital quality (P < 0.01) and upper socio-economic status (P < 0.05) were significantly associated with better periodontal health status (Table 5). All other variables were found not to be significantly associated with periodontal health status

Two research questions were addressed in this paper. The first was whether workers exposed to work conditions which were mentally adverse had worse oral health status than those not so exposed. A significant association was found between workrelated mental demand and periodontal health status, a result that was consistent with a large body of medical epidemiological studies [36,39,45,47-49, 72,731 and gives support to the theory that stress has a relatively non-specific effect since it is associated with a variety of diseases [50] including periodontal disease. The association found between work-related mental demand and periodontal health status is not due to socio-economic status, since the association

(P > 0.05).

A logistic regression analysis was carried out with all variables in the model. The association between periodontal health status and work-related mental

Table 5. Logistic regression of marital quality, toothbrushing frequency, sugar consumption, age, years of residence in Belo Horizonte, type of toothpaste, frequency of dental attendance and so&-economic status on periodontal health status. Sample of 149 male workers Simple logistic Regression coefficient

Variable Work mental demand Work control Work variety Marital quality Toothbrushing frequency Sugar consumption Age Years of residence Type of toothpaste Frequency dental attendance So&-economic status ‘Figures

in parentheses

are standard

0.17 (0.05)’ -0.03 (0.04) -0.02 (0.06) -0.13 (0.05) -0.19(0.17) 0.01 (0.04) -0.09 (0.08) - 0.02 (0.06) 0.33 (0.39) 0.07(0.15) -0.03 (0.011 error

regression

Multiple

Significant level coefficient 0.0009 0.4323 0.6703 0.0058 0.2583 0.8562 0.3079 0.7480 0.4010 0.6374 0.0191

logistic

regression Significant

Regression level 0.0006

0.20 (0.06) -0.03 -0.01 -0.15 -0.22 -0.03 -0.06 -0.04

(0.05) (0.08) (0.06) (0.21) (0.05) (0.10) (0.07)

-0.12 -0.03

(0.19) (0.01)

0.5350 0.9534 0.0063 0.2876 0.5365 0.5675 0.5073 0.2904

0.49 (0.46)

0.5432

Work stress and oral health status

remained significant after adjusting for this variable. The results also showed that the association between work-related mental demand and periodontal health status is of clinical importance. Workers who experienced high levels of work-related mental demand were, on average, 3.3 times more likely to have teeth with gums bleeding after probing or with pockets than workers who experienced low levels of work-related mental demand. The lack of association between periodontal health status, work control and work variety may be explained by the presence of uncontrolled extraneous variables, which may interact with work-related mental demand, work control and work variety leading to a spurious interpretation. In fact, this study did not include several aspects of the work situation and disregarded one important variable that recent research has identified as being associated with health-the social support from co-workers [46]. Marmot and Theorell [74] reported that control over work process and social support in the work setting are the two major psychological resources that can serve to modify the potentially stressful demands and pressures of modern production systems. Moreover, Johnson [75] found that a combination of both high support and high control is necessary to alleviate the impact of work-related mental demands. The presence or absence of social support determined whether or not work control operated to reduce work stress and the risk of cardiovascular disease [75]. Thus, further research must include measures of social support. The most likely reason for the lack of significant association between dental caries status and workrelated mental demand, work control and work variety, is that work stress was measured at only one point in time, and the workers’ reports may reflect a temporary or recent phenomenon while the DMFS scores reflect present and past disease. Other possible explanations for the lack of association between periodontal health status, work control and work variety, as well as, between dental caries status and work-related mental demand, work control and work variety are lack of adequate measures of work characteristics, in-home interview or simply type 2 error. The second question addressed by this study was are work conditions associated with oral health status through risk-related behaviours or do they affect oral health status by pathways other than the established risk factors? The results suggest that work-related mental demand was associated with periodontal health status through other pathways than through the risk-related behaviours studieddental attendance, toothbrushing frequency, type of

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toothpaste and sugar consumption. Firstly, workrelated mental demand was not significantly correlated with those variables. Secondly, data analysis included these variables and the association between work-related mental demand and periodontal health status remained significant after adjusting for those variables. Thus, the possibility of work-related mental demand being associated with periodontal health status through the risk-related behaviour factors studied was excluded. It is tempting to hypothesize that psychosocial factors such as work-related mental demand may affect periodontal health through alterations in saliva flow and changes in the immunologic system. It is well known that anxiety, psychological stress and depression may decrease salivary flow, which may increase the occurrence and progression of periodontal disease [76]. Also, psychosocial factors, including work stress [45], affect the immune system [30, 32,331, and the immunologic system is an important defence against periodontal disease [29,77]. In fact, immunological mechanisms have been implicated in the pathogenesis of periodontal disease for over 25 years [33], and it is not unlikely that immunoenhancement by psychological processes can have a clinical significance in periodontology [78]. As Seymour [33] stated “despite the irrefutable evidence that plaque is the cause of chronic inflammatory periodontal disease, it must not be forgotten that the disease itself results from the interaction of the host’s defence mechanisms with micro-organisms in the plaque”. Besides work-related mental demand, significant associations were found between sugar consumption and dental caries [79,80], socio-economic status and dental caries [52, 56, 57,811, and frequency of dental attendance and dental caries [52]; as well as between periodontal health status and socio-economic status [82,83] and frequency of dental attendance [55]. The results of the present study are broadly in agreement with other studies in relation to wellknown risk factors, which gives greater validity to the findings in relation to work-related mental demand. In conclusion, this study has shown that there is a highly significant relationship between work-related mental demand and periodontal health status. The findings corroborate the theory that psychosocial factors may affect oral health status. It is important to bear in mind that the interplay between the human being and micro-organisms can result in disease or be compatible with the maintenance of health, depending upon the environmental circumstances under which the encounter between them takes place [84]. The concept that everyone will respond in the same way to the presence of plaque is far too simplistic [33].* REFERENCES

*Details of the questions used to measure work stress and to measure marital quality may be obtained from the author on request.

1.

Sutton P. R. N. The early onset of acute dental caries following mental stress. NY State Dent. J. 31,450-455, 1965.

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APPENDIX Questions Used to Measure

1 Work Stress

Work-related mental demand

How strongly do you agree or disagree with these statements? 1. In your job you have to work very fast. (a) strongly disagree (b) disagree (c) neither/nor (d) agree (e) strongly agree 2. In your job you have to work very hard. (a) strongly disagree (b) disagree (c) neither/nor (d) agree (e) strongly agree

WAGNER SEGURAMmmm

1520

3. How mentally demanding is your job? (a) not at all (b) a little (c) fair amount (d) quite a lot (e) a great deal

and

AUBREY S~IHAM

10. Your job requires you to take the initiative. (a) strongly disagree (b) disagree (c) neither/nor (d) agree (e) strongly agree.

APPENDIX

Work control measure

4. To what extent do you yourself decide on the way you do things in your job? (a) not at all (b) a little (c) fair amount (d) quite a lot (e) a great deal How strongly do you agree or disagree with statements? 5. You have a say in your own work speed. (a) strongly disagree (b) disagree Cc) neither/nor (dj agree ’ (e) strongly agree

these

6. You can decide when to take a break. (a) (b) (c) (d) ., (e)

strongly disagree disagree neither/nor agree strongly agree

7. Others take decisions concerning your work. (a) strongly agree (b) agree Cc) \ neither/nor (d) disagree (e) strongly disagree

Questions Communication

Used to Measure

2 Marital

Quality

dimension

1. Have you and your partner talked frankly to each other about your relationship during the last 12 months? (a) always/almost always (b) often (c) sometimes (d) seldom (e) never Companionship

dimension

2. Have you confided in your partner during the last 12 months? (a) (b) (c) (d) (e)

always/almost always often sometimes seldom never

3. Have you got support from your partner that helped you to face general problems during the last 12 months? (a) always/almost always (b) often (c) sometimes (d) seldom (e) never

I

Work variety measure

How strongly do you agree or disagree with these statements? 8. In your job, you have to do the same thing over and over again. (a) (b) (c) (d) (e)

strongly agree agree neither/nor disagree strongly disagree

9. Your job provides you with a variety of interesting things. (a) (b) (c) (d) (e)

strongly disagree disagree neither/nor agree strongly agree

Satisfaction

with marriage dimension

4. Everything considered, how satisfied or dissatisfied have you been with your marriage during the last 12 months? (a) very satisfied (b) moderately satisfied (c) a little satisfied (d) no feelings either way (e) a little d&satisfied (f) moderately dissatisfied (g) very dissatisfied Satisfaction

with children dimension

5. Everything considered, how satisfied or dissatisfied have

you been with your child (13-year-old child) during the last 12 months? (a) (b) (c) (d) (e) (f) (g)

very satisfied moderately satisfied a little satisfied no feelings either way a little dissatisfied moderately dissatisfied very dissatisfied.