Are Salivary Cortisol Levels Elevated in Periodontitis Patients Experiencing Stress Compared to Those without Stress? A Systematic Review and Meta-analysis.

Abstract

Aim and background: This meta-analysis aims to systematically assess the association between periodontitis and stress in relation to salivary cortisol levels.

Methods: Four major databases, the MEDLINE-PubMed, Google Scholar, EMBASE, and CENTRAL databases, were searched from January 2005 to August 2023 for prospective and retrospective clinical studies. The PECO guidelines followed were as follows: Population: Patients with periodontal disease; Exposure: depression, stress, or anxiety; comparison: No periodontal disease and no depression, stress, or anxiety; outcome: salivary cortisol level. The following variables were extracted from each study: author, study design, sample size, saliva cortisol level (mean), periodontal parameters, method of stress evaluation, and the outcome of the study. The risk of bias was evaluated using the Newcastle-Ottawa Scale. The statistical analysis involved calculating standardized mean differences (SMD) and their corresponding 95% confidence intervals (CI). The meta-analysis was conducted using comprehensive meta-analysis version 2.

Results: A total of 101 articles were identified, of which 73 articles were excluded after the first round of screening of titles and abstracts and 17 articles were excluded after full-text examination. Finally, 11 clinical studies comprising of 1,565 participants that satisfied the inclusion criteria for the systematic review were considered. While eight studies were included for meta-analysis in the first comparison group and seven studies were considered for analysis in the second comparison group. Of the 11 studies included in the present systematic review, seven were cross-sectional studies, three were case-control studies, and one was randomized double-blinded prospective study. The meta-analysis findings indicated a statistically significant increase in cortisol levels among patients with periodontitis compared to those without periodontitis (SMD = -1.424, CI: -2.107 to -0.740, p = 0.001, low-quality evidence). Moreover, a statistically significant increase in cortisol levels was observed in patients with periodontitis who experienced stress.

Conclusion: Overall studies included in the review demonstrate and confirm a positive association between elevated salivary cortisol levels and periodontitis with stress.

Clinical significance: The results of this study suggest that treatment for periodontitis patients could be tailored to consider both the clinical aspects of the condition and the patient's stress levels. Thus, clinicians should pay attention to stress management as part of comprehensive periodontal care. How to cite this article: Al‑Ak'hali MS, Al-Moraissi EA, Fageeh HN, et al. Are Salivary Cortisol Levels Elevated in Periodontitis Patients Experiencing Stress Compared to Those without Stress? A Systematic Review and Meta-analysis. J Contemp Dent Pract 2025;26(2):206-216.