Pratima Chaurasia1, Sheela Kumar Gujjari2*, Srinath KM3
1Post Graduate Student, Department of Periodontology, JSS Dental College and Hospital, Mysuru, India
2Professor, Department of Periodontology, JSS Dental College and Hospital, Mysuru, India
3Professor, Department of General Medicine, JSS Dental College and Hospital, Mysuru, India
*Correspondence author: Sheela Kumar Gujjari, Professor, Department of Periodontology, JSS Dental College
and Hospital, Mysuru, India; E-mail: [email protected]
Published Date: 03-10-2024
Copyright© 2024 by Chaurasia P, et al. All rights reserved. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Abstract
Background: Gender imbalances persist in high-ranking leadership roles,
particularly in Aim: To evaluate theassociation between duration of Sleep and Body-Mass Index (BMI) as potential risk
factors with Periodontitis and other co morbidities in duty nurses.
Methodology: An observational study was carried out on 42 duty nurses working in hospital. Two Questionnaires (PSQI)
Pittsburgh Sleep Quality Index and (ESS) Epworth-Sleepiness Scale were subjectively filled. Study was conducted in 2
phases in the same duty nurses. Phase 1 Duty nurses in morning shift underwent evaluation for periodontal health, BMI
and Waist -Hip ratio was recorded. Blood Samples were drawn for analysis of C-Reactive protein, lipid profile and
Fasting Blood Sugar. Participants were asked to maintain sleep diary for 6 months. Phase 2: Same Duty Nurses working in
Night Shift after 6 months of sleep diary maintenance underwent evaluation of same parameters as phase 1. All-the data
were tabulated and sent for statistical-analysis.
Results: The result showed that, the association of duration of sleep to Periodontitis was statistically
significant inthe morning-shift and night-shift (p=0.001), although association of Body Mass Index to periodontitis
was statistically
significant in the night shift with p value=0.001 than in the morning-shift.
The association of Plaque Index and
Gingival-Index with duration of sleep and BMI was statistically significant.
The parameters taken to study the
co-morbidities showed statistical significant difference between the two shifts except WHR ratio, LDL, HDL,
Triglyceride, Plaque index.
Conclusion: There is an association of Duration of Sleep and Body Mass Index as a potential risk factor for
periodontitis and other co-morbidities (Cardiovascular disease and Diabetes) in duty nurses, however the association is
much stronger in duty nurses working in night shift than morning shift.
Keywords: Sleep Duration; Shift Workers; Periodontitis; Body Mass Index; Duty Nurses
Introduction
Periodontal disease, characterized by inflammation of the gingiva, alveolar bone and periodontal ligament, is
multifactorial, influenced by various lifestyle choices, systemic conditions and environmental factors. While
established risk factors like smoking, poor oral hygiene and diabetes are well-documented, emerging research is shedding
light on the role of sleep disturbances, stress, diet and obesity in periodontal health [1,2].
Inadequate sleep, defined as less than 7 hours per day, has been associated with a 1.34 times higher risk of
periodontitis [3]. Sleep deprivation compromises immunity and increases inflammation, akin to chronic periodontitis.
Conversely, both insufficient and excessive sleep have been linked to elevated risks of mortality, diabetes, obesity and
cardiovascular disease, suggesting a U-shaped correlation between sleep duration and health outcomes [5-9].
Disruption of circadian rhythms due to shift work, common among nurses, contributes to sleep deprivation and poor sleep
quality [11]. Nurses experiencing reduced sleep are susceptible to cognitive decline, fatigue and various health issues
[11]. Neglecting sleep may increase BMI and contribute to periodontitis, potentially indicating systemic inflammation
[12, 13].
Furthermore, among nurses working varying shifts, understanding the interplay between sleep duration, BMI and
Periodontitis is essential for addressing oral health disparities. Despite the growing body of evidence linking sleep
duration, BMI and Periodontitis, there is a paucity of research focusing on nurses, especially those engaged in shift
work. Therefore, This study aims to explore the association between sleep duration, BMI and their impact on
Periodontitis and comorbidities among duty nurses.
Methods
This cross-sectional observational study was conducted among 42 Duty nurses, working in JSS Medical Hospital, Mysuru.
Inclusion criteria for the study encompass duty nurses aged 30 to 45, employed at JSS Hospital, with 3 to 5 years of
professional experience and possessing a minimum of 20 teeth. Exclusion criteria include pregnant or lactating women,
smokers, recent medication use of certain drugs within three months, diagnosed medical conditions like diabetes,
arthritis, tuberculosis or gastritis, as well as liver diseases, fatty liver diseases or recent periodontal treatment.
In phase 1, participants with C-Reactive Protein (CRP) levels exceeding 10mg/dl were excluded.
Participants were given to fill two questionnaire: “Pittsburgh Sleep Quality Index” for sleep quality assessment in
which a total score of “5” or greater is indicative of poor sleep quality and “Epworth Sleepiness Scale“ was used to
measure the ‘daytime sleepiness’ for adults.
Every participants will undergo 2 phases of evaluation.
Phase 1: duty nurses working in morning shift
Phase 2: after 6 months of sleep diary maintainance, same duty nurses working in night shift
Phase 1: Duty Nurses Working In Morning Shift
The Periodontal status
of the participants were recorded by evaluating Probing Depth (PD) and Clinical Attachment Level
(CAL) and were categorized into gingivitis and Mild/Moderate/Severe periodontitis using the Centers for Disease Control
and Prevention American Academy of Periodontology (CDC/AAP) definitions of periodontal disease as described by Eke, et
al., (1) mild periodontitis, defined as two or more interproximal sites with CAL ≥3 mm and at least two interproximal
sites with PD ≥4 mm (not on the same tooth) or one site with ≥5 mm; (2) moderate periodontitis, defined as two or more
interproximal sites with CAL ≥4 mm (not on the same tooth) or two or more interproximal sites with PD ≥5 mm, also not on
the same tooth; (3) severe periodontitis, defined as two or more interproximal sites with CAL ≥6 mm (not on the same
tooth) and on more interproximal site(s) with PD >5 mm [14].
To evaluate the oral hygiene status “Plaque Index” (Silness and Loe), “Gingival Index” (Loe and Silness), were recorded
Body Mass Index (BMI) was recorded using objectively measured height (cm), weight (kg) and waist : hip ratio following
the guidelines of anthropometry procedure manual. BMI was categorized according to World Health Organisation (WHO)
Asian.
BMI Classification
Participants Venous blood Samples was drawn after a minimum of 8 hrs of overnight fasting for analysis of C-Reactive
protein, lipid profile (HDL, LDL, triglycerides) and Fasting Blood Sugar (FBS).
Participants maintained a sleep diary for 6 months, recording sleep and wake times daily during morning and night
shifts. Diary entries were reviewed weekly for accuracy and consistency. The duration of Sleep were then categorized
into 3 categories : 2-6 hours as sleep deficient, 7-8 hours as sleep adequate and 9-12 hours as sleep excessive.
Phase 2: After 6 Months Of Sleep Diary Maintainance, Same Duty Nurses Working In Night Shift
After 6 months of maintaining the sleep diary, during the night shift working schedule, again same duty nurses
periodontal status were recorded that is probing depth and clinical attachment loss. Oral hygiene Indicators-PI, GI were
recorded.
Body Mass Index was recorded and participants blood sample was collected after an overnight fasting period of 8 hours
for CRP, Lipid profile and (FBS) that were collected and analysed in the JSS Medical Hospital, Mysuru. Comparative Data
of the investigations done in morning shift and in night shift were analysed.
Statistics
All the data was collected and fed into an MS Excel sheet, categorized and analyzed using SPSS for Windows (Statistical
Package for Social Sciences, SPSS Inc.) Version 29.0. The values obtained from the examination was subjected to
Descriptive statistics and Chi square test statistical analysis. Chi- Square test was done for association of all the
parameters with morning and night shift with p-value set at 0.05.
Result
A total of 42 duty nurses gave consent, filled the questionnaire and underwent examination in 2 phases: in morning shift
and in night shift with a gap of 6 months of sleep diary maintenance. In analyzing the Pittsburgh Sleep Quality Index,
57.1% of duty nurses exhibited poor sleep quality, scoring above 5. Additionally, the Epworth Sleepiness Scale indicated
that 49.4% of duty nurses experienced average to excessive daytime sleepiness. Categories for poor sleep quality and
daytime sleepiness severity were determined based on PSQI and ESS scores, as detailed in Table 1.
| |
Score |
|
Frequency |
Percentage |
| PSQI |
0 – 4 |
Very good sleep quality |
18 |
42.90% |
| 05-Oct |
Moderate sleep disturbances |
11 |
26.20% |
| Nov-15 |
Poor sleep quality |
8 |
19.00% |
| 16 -21 |
Very poor sleep quality |
5 |
11.90% |
| ESS |
0 – 7 |
Unlikely that you are abnormally sleepy |
21 |
50.00% |
| 08-Sep |
Average amount of daytime sleepiness |
9 |
21.40% |
| Oct-15 |
Excessively sleepy depending on the situation |
4 |
9.50% |
| 16 – 24 |
Excessively sleepy and should consider seeking medical attention |
8 |
19.00% |
Table 1: Descriptive statistics of PSQI AND ESS questionnaire.
On analysis of the periodontal status, there was an increase in moderate Periodontitis in duty from 19% in duty while working in morning shift to 31% in night shift. Also, Severe Periodontitis increased from 0.00% in morning shift to 21.40% in night shift but there was an significant difference in the periodontal status of duty nurses in morning shift to night shift with p =0.001 given . Association of Plaque Index (PI) with Morning and Night shift groups showed no statistical significance whereas on Associating Gingival Index (GI) with Morning and Night shift groups showed statistical significance (p=0.011*) (Table 4).
The result showed that among the duty nurses working in the morning shift, 31% of duty nurses were sleep deficient which had increased to 50% of duty nurses while working in night shift but the difference was statistically not significant (Table 4).
The association of Duration of sleep with Plaque Index, Gingival Index and gingivitis/mild, moderate severe Periodontitis was statistically significance in night shift. In morning shift, gingival index didn’t show statistical significance with duration of sleep, Plaque Index and Gingivitis, mild/ moderate/severe Periodontitis showed statistical significance (Table 2).
| |
Average duration of sleep |
χ2 Value |
P Value |
| Sleep Deficient |
Sleep Adequate |
Sleep Excessive |
| N |
% |
N |
% |
N |
% |
| Morning Shift |
PLAQUE INEX (PI) |
Good |
3 |
23.10% |
16 |
72.70% |
6 |
85.70% |
10.752 |
0.005* |
| Fair |
10 |
76.90% |
6 |
27.30% |
1 |
14.30% |
| Poor |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
| GINGIVAL INDEX (GI) |
Mild |
11 |
84.60% |
18 |
81.80% |
7 |
100.00% |
1.452 |
0.484 |
| Moderate |
2 |
15.40% |
4 |
18.20% |
0 |
0.00% |
| Severe |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
| GINGIVITIS OR MILD / MODERATE / SEVERE PERIODONTITIS |
GINGIVITIS |
0 |
0.00% |
10 |
45.50% |
7 |
100.00% |
20.632 |
0.001* |
| MILD |
10 |
76.90% |
7 |
31.80% |
0 |
0.00% |
| MODERATE |
3 |
23.10% |
5 |
22.70% |
0 |
0.00% |
| Night Shift |
PLAQUE INEX (PI) |
Good |
3 |
14.30% |
12 |
80.00% |
5 |
83.30% |
19.02 |
0.001* |
| Fair |
16 |
76.20% |
3 |
20.00% |
1 |
16.70% |
| Poor |
2 |
9.50% |
0 |
0.00% |
0 |
0.00% |
| GINGIVAL INDEX (GI) |
Mild |
7 |
33.30% |
15 |
100.00% |
6 |
100.00% |
21 |
0.001* |
| Moderate |
6 |
28.60% |
0 |
0.00% |
0 |
0.00% |
| Severe |
8 |
38.10% |
0 |
0.00% |
0 |
0.00% |
| GINGIVITIS OR MILD / MODERATE / SEVERE PERIODONTITIS |
GINGIVITIS |
0 |
0.00% |
10 |
66.70% |
4 |
66.70% |
29.19 |
0.001* |
| MILD |
2 |
9.50% |
2 |
13.30% |
2 |
33.30% |
| MODERATE |
10 |
47.60% |
3 |
20.00% |
0 |
0.00% |
| SEVERE |
9 |
42.90% |
0 |
0.00% |
0 |
0.00% |
Table 2: Association of average duration of sleep to PI, GI and Periodontitis in morning and night shift.
On Association of BMI to Periodontitis in the Duty nurses while working in night shift showed statistical significance with p=0.001 while it showed no statistical significance in night shift with p=0.074. The oral Hygiene indicators, Pl and GI on association with BMI showed statistical significance both while working in morning and night shift (Table 3).
On Analyzing the BMI, the result showed that the percentage of overweight individuals increased from 23.80% to 38.10%, 7% to 11% in obese I category and from 0% to 4.8% in obese II category in the morning shift to night shift though there was no statistical difference of BMI in morning and night shift (p=0.113) (Table 4).
The Descriptive statistics of all the parameters in morning shift and night shift is given in Table 4.The result showed there was no statistically significant difference in Waist Hip Ratio, BMI, LDL, HDL, Triglyceride, Plaque Index, Average duration of sleep while other parameters like C-reactive protein, Fasting Blood sugar levels, duration of sleep, Gingival index and Gingivitis / Periodontitis had a statistically significiant difference in night shift than morning.
| |
BMI |
χ2 Value |
P Value |
| Normal Weight |
Over Weight |
Obese I |
Obese II |
| N |
% |
N |
% |
N |
% |
N |
% |
| Morning Shift |
PLAQUE INEX (PI) |
Good |
22 |
75.90% |
2 |
20.00% |
1 |
33.30% |
0 |
0.00% |
10.551 |
0.005* |
| Fair |
7 |
24.10% |
8 |
80.00% |
2 |
66.70% |
0 |
0.00% |
| Poor |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
| GINGIVAL INDEX (GI) |
Mild |
28 |
96.60% |
7 |
70.00% |
1 |
33.30% |
0 |
0.00% |
11.52 |
0.003* |
| Moderate |
1 |
3.40% |
3 |
30.00% |
2 |
66.70% |
0 |
0.00% |
| Severe |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
0 |
0.00% |
| GINGIVITIS OR MILD / MODERATE / SEVERE PERIODONTITIS |
GINGIVITIS |
16 |
55.20% |
1 |
10.00% |
0 |
0.00% |
0 |
0.00% |
8.517 |
0.074 |
| MILD |
9 |
31.00% |
6 |
60.00% |
2 |
66.70% |
0 |
0.00% |
| MODERATE |
4 |
13.80% |
3 |
30.00% |
1 |
33.30% |
0 |
0.00% |
| Night Shift |
PLAQUE INEX (PI) |
Good |
15 |
78.90% |
4 |
25.00% |
0 |
0.00% |
1 |
50.00% |
16.951 |
0.009* |
| Fair |
4 |
21.10% |
11 |
68.80% |
4 |
80.00% |
1 |
50.00% |
| Poor |
0 |
0.00% |
1 |
6.20% |
1 |
20.00% |
0 |
0.00% |
| GINGIVAL INDEX (GI) |
Mild |
19 |
100.00% |
9 |
56.20% |
0 |
0.00% |
0 |
0.00% |
35.044 |
0.001* |
| Moderate |
0 |
0.00% |
5 |
31.20% |
1 |
20.00% |
0 |
0.00% |
| Severe |
0 |
0.00% |
2 |
12.50% |
4 |
80.00% |
2 |
100.00% |
| GINGIVITIS OR MILD / MODERATE / SEVERE PERIODONTITIS |
GINGIVITIS |
11 |
57.90% |
3 |
18.80% |
0 |
0.00% |
0 |
0.00% |
33.865 |
0.001* |
| MILD |
5 |
26.30% |
1 |
6.20% |
0 |
0.00% |
0 |
0.00% |
| MODERATE |
3 |
15.80% |
9 |
56.20% |
1 |
20.00% |
0 |
0.00% |
| SEVERE |
0 |
0.00% |
3 |
18.80% |
4 |
80.00% |
2 |
100.00% |
Table 3: Association of BMI to PI, GI and Periodontitis in morning and night shift.
| |
Groups |
χ2 Value |
P-value |
| Morning Shift |
Night Shift |
| N |
% |
N |
% |
| WAIST – HIP RATIO |
Normal Range |
26 |
61.90% |
21 |
50.00% |
1.208 |
0.272 |
| High risk Range |
16 |
38.10% |
21 |
50.00% |
| BMI |
Normal Weight |
29 |
69.00% |
19 |
45.20% |
5.968 |
0.113 |
| Over Weight |
10 |
23.80% |
16 |
38.10% |
| Obese I |
3 |
7.10% |
5 |
11.90% |
| Obese II |
0 |
0.00% |
2 |
4.80% |
|
C-Reactive
Protein mg/L
|
Moderate |
34 |
81.00% |
24 |
57.10% |
5.57 |
0.018* |
| High risk |
8 |
19.00% |
18 |
42.90% |
| LDL mg/dL |
Normal |
1 |
2.40% |
1 |
2.40% |
4.509 |
0.342 |
| Borderline High |
19 |
45.20% |
10 |
23.80% |
| High |
13 |
31.00% |
18 |
42.90% |
| Very High |
5 |
11.90% |
6 |
14.30% |
| Extremely High |
4 |
9.50% |
7 |
16.70% |
| HDL mg/dL |
Poor |
5 |
11.90% |
11 |
26.20% |
2.871 |
0.238 |
| Better |
32 |
76.20% |
26 |
61.90% |
| Best |
5 |
11.90% |
5 |
11.90% |
| TRIGLYCERIDE mg/dL |
Normal |
5 |
11.90% |
4 |
9.50% |
1.37 |
0.504 |
| Borderline High |
26 |
61.90% |
22 |
52.40% |
| High |
11 |
26.20% |
16 |
38.10% |
|
FASTING BLOOD
GLUCOSE mg/dL
|
Normal |
3 |
7.10% |
0 |
0.00% |
8.696 |
0.013* |
| Prediabetic |
37 |
88.10% |
32 |
76.20% |
| Diabetic |
2 |
4.80% |
10 |
23.80% |
| PLAQUE INEX (PI) |
Good |
25 |
59.50% |
20 |
47.60% |
2.799 |
0.247 |
| Fair |
17 |
40.50% |
20 |
47.60% |
| Poor |
0 |
0.00% |
2 |
4.80% |
| GINGIVAL INDEX (GI) |
Mild |
36 |
85.70% |
28 |
66.70% |
9 |
0.011* |
| Moderate |
6 |
14.30% |
6 |
14.30% |
| Severe |
0 |
0.00% |
8 |
19.00% |
|
GINGIVITIS OR
MILD / MODERATE /
SEVERE
PERIODONTITIS
|
GINGIVITIS |
17 |
40.50% |
14 |
33.30% |
15.742 |
0.001* |
| MILD |
17 |
40.50% |
6 |
14.30% |
| MODERATE |
8 |
19.00% |
13 |
31.00% |
| SEVERE |
0 |
0.00% |
9 |
21.40% |
|
AVERAGE
DURATION
OF SLEEP
|
Sleep Deficient |
13 |
31.00% |
21 |
50.00% |
3.28 |
0.194 |
| Sleep Adequate |
22 |
52.40% |
15 |
35.70% |
| Sleep Excessive |
7 |
16.70% |
6 |
14.30% |
Table 4: The descriptive statistics of all the parameters in morning shift and night shift.
Discussion
Research conducted by Scott, et al., found that 65% of nurses working rotating shifts experienced poor sleep quality,
Also Healthcare workers who work night shifts are more likely to experience insomnia, sleep disorders and excessive
daytime sleepiness [15,17].) A large percentage of nurses were female and research on them revealed a link between sleep
disturbance and psychological distress, particularly depression. highlighting the widespread issue of sleep disturbances
in this population [18]. The outcome of the present study showed approximately overall 57.1% duty nurse had poor quality
sleep with a score above 5 based on the PSQI. This is in accordance with a study by Grandner, et al, who examined sleep
quality among shift workers using the PSQI and found that shift work was associated with poorer sleep quality and
increased sleep disturbances. A study by Girschik, et al., gave similar results [20]. Epworth Sleepiness Scale showed
that overall 49.4% duty nurses had average amount of daytime sleepiness to excessive daytime sleepiness. Chervin, et
al., found that rotating shift workers had higher daytime sleepiness compared to day workers using the ESS. Similarly,
Hayley, et al., reported increased daytime sleepiness among nurses on shift work, aligning with our study’s findings
[21,22]. Our study found a significant association between Gingival Index (GI) and shift groups (p=0.011*), but no
significance with Plaque Index (PI) (p=0.247). We observed that inadequate sleep was linked to poorer oral health among
morning shift workers, aligning with previous studies by Suvan, et al., (2020) also support our findings regarding the
impact of insufficient sleep on periodontal disease progression [23]. Our study found that among the 42 duty nurses
working in the morning shift, 31% were sleep deficient. This increased to 50% among those working in the night shift,
indicating a higher prevalence of sleep deficiency during night shifts compared to morning shifts (Table 4). This aligns
with findings from, Flo, et al., who also reported shorter sleep durations among nurses working night shifts compared to
those on day shifts [24]. Our study revealed significant differences in the periodontal status of nurses between morning
and night shifts (p = 0.001). Significant associations (p=0.001) were found between sleep duration and gingivitis/mild
or moderate periodontitis in both morning and night shifts. Similar conclusions were drawn in a systematic review by
Aljehani, indicating an increased risk of periodontal disease among healthcare professionals [25].
Chaput, et al., linked sleep deprivation to increased eating and obesity risk in shift workers due to hormone
dysregulation. Our study revealed, the association of BMI with gingivitis/periodontitis was not statistically
significant in th morning shift but a significant association between BMI and gingivitis/periodontitis was seen among
night shift nurses (Table 3). This aligns with findings from Al Amri, et al., El-Sayed, et al., and Zhang, et al.,
suggesting a link between shift work and increased BMI. Our study examined the impact of morning and night shift work on
health parameters, including Waist-Hip Ratio (WHR), Body Mass Index (BMI), C-Reactive Protein (CRP) and fasting blood
glucose levels. Night shift nurses showed a higher prevalence of elevated fasting blood sugar levels, with 76.2% falling
into the pre-diabetic range. Morning shift workers had significantly higher moderate CRP levels compared to night shift
workers (p = 0.018*), suggesting increased inflammation among them. Additionally, night shift workers had a higher
proportion of individuals in the high-risk CRP category, indicating a potential link between night shift work and
increased inflammation (Table 4). These findings align with previous research by Kim, et al., and Lin, et al., which
found elevated CRP levels in shift workers. Morning shift workers also exhibited a healthier metabolic profile, but
concerns regarding cardiovascular health arose as 50% of night shift workers fell into the high-risk range for Waist-Hip
Ratio [26-30].
Conclusion
In conclusion of the result of our study, there is an association of Duration of sleep and BMI as potential risk factors
for Periodontitis. However, this association was more profound in night shift than in the morning shift. Also to study
the co-morbidities the parameters like c-reactive protein, Fasting Blood Glucose, Gingival Index and Gingivitis/ mild,
moderate, severe periodontitis showed statistical significant difference. The other parameters like WHR ratio, LDL, HDL,
Triglyceride, Plaque index showed no statistically significant difference. These findings underscore the importance of
vigilance and proactive management strategies in maintaining oral health and systemic health especially among shift
workers.
Conflict of Interests
The authors have no conflict of interest to declare.
