The association between Oral Health and Depression among university students in Makkah city: A web-based survey study

Background: Oral health encompasses a global health burden. Recently, a connection between oral health and depression was detected in many studies. Our study aimed to determine the association level between oral health and depression among university students in Makkah City. Methodology: A survey-based study was conducted via online social media channels utilizing two validated standardized tools: Oral Health Impact Profile-14 questionnaire and Patient Health Questionnaire (PHQ)-9. Results: 534 students were included in this survey; the Mean age was 21.3 with (SD=2.03) — most students aged 20 years old, 21.91%. Most participants had good levels of oral health, 94.19%, while most of the participants, on the other hand, had mild levels of depression, 38.58%. A statistically significant association was found between those with mild levels of depression and those with good levels of oral health (P-value, ˃ 0.001). Conclusion: This study demonstrated an association between oral health and depression among university students in Makkah City. More research is advised to support the results.


INTRODUCTION
It is now widely established that oral problems and diseases affect people's lives (Mulla, 2021;Dahl et al., 2012).Oral health-related pain can interfere with the ability of people to speak and decide what to eat, which lowers their quality of life (QoL) and has functional, emotional, and social implications term highlighting social and personal resources and physical capacities.It is a resource for daily life, not the goal of living (Mulla, 2021;Organization, 1984).
The general health of a person can be determined by their oral health (OH), which is closely related to both public health and health-related quality of life (HRQoL) (Thirunavukkarasu et al., 2022;Sabbah et al., 2019;Kieffer and Hoogstraten, 2008).A suitable metric for evaluating the general health of people and the impact of medical conditions on their quality of life is HRQoL (Thirunavukkarasu et al., 2022;Karimi and Brazier, 2016).Understanding oral health-related quality of life (OHRQoL) helps us better understand our overall health and quality of life (Thirunavukkarasu et al., 2022;Bennadi and Reddy, 2013).OHRQoL is the subjective perception of oral health-related symptoms that impact an individual's well-being (Thirunavukkarasu et al., 2022).
To determine how OH affects social, psychological, and functional well-being in daily life, the OHRQoL includes patientcentered outcome measures (Thirunavukkarasu et al., 2022;Bennadi and Reddy, 2013;Mehta and Kaur, 2011).Low self-esteem, sadness, lower performance in daily activities, a lack of social connection, and an increased cost on the healthcare system are only a few of the detrimental effects of poor OH and OHRQoL in persons (Thirunavukkarasu et Mitri et al., 2020).Only two studies have been done on the relationship between adult anxiety and dental health-related quality of life.These two investigations, however, did not clearly distinguish between anxiety and depression.Both studies Hajek and König, (2022), Moon et al., (2020), Hayashi et al., (2019) found a substantial correlation between anxiety/depressive symptoms and a lower quality of life linked to dental health.Our study aimed to emphasize the relationship between oral health and depression among students in Makkah City.This will help in the early determination of depression and increase awareness of other consequences among individuals with poor oral health and their quality of life.

METHODOLOGY
This web survey study was conducted at Umm Al-Qura University, Makkah City, in June 2023.This study was approved by the ethical committee of Umm Al-Qura University in 2023 Approval No. (HAPO-02-K-012-2023-08-1697), and a principle of the Declaration of Helsinki (DoH) was followed.We interviewed male and female students electronically, utilizing a web survey of Google platforms distributed via social media platforms.Male and female Students aged from 20 to 35 years old from Umm Al-Qura University were included in this survey, while those outside the university were excluded.Additionally, we excluded students who could not reach or communicate, were physically ill, or were rejected from participating in this survey.Umm Al-Qura University statistics show that the number of students was estimated to be 101931 in 2018.We utilized epi-info software to compute the sample size according to the previous population.As a result, we need at least 385 participants to achieve a CI of 95%.However, we collected 534 samples during data collection to overcome the incomplete participation.We structured our survey and categorized it into three different sections.We first gathered the social-demographical data of the participants.Then, we used the Arabic language of the Oral Health Impact Profile-14 questionnaire to evaluate oral health (Al-Habashneh et al., 2012).Lastly, we used the Arabic language of the Patient Health Questionnaire (PHQ)-9 to assess depression (Al-Qadhi et al., 2014; AlHadi et al., 2017).Our data was codded using MS Excel and then transferred into SPSS version 25.A descriptive analysis using mean and frequency was used for continuous variables.Then, we used an independent Chi-square test to determine the significance level and compared the categorical variable.
Variable related to the Oral Health Impact Profile-14 questionnaire was computed during analysis.The final score was categorized into the following: Those with less than 60% were classified as having good Oral health-related quality of life, while those with greater or equal to 60% were classified as having a poor Oral health-related quality of life (Al-Habashneh et al., 2012).

RESULTS
This is an electronic survey study that enrolled a total of 534 university students in Makkah City.The age mean of the participants was 21.3 (SD, 2.03); participants with 20 years old showed the most responses (n=117, 21.91%) (Figure 1).Males, Saudis, and single

ANALYSIS ARTICLE | OPEN ACCESS
Medical Science 27, e352ms3221 (2023) respondents responded the most (52.8%,84.3%, and 74%, respectively) (Table 1).Most participants show a very good level of dental care (50.7%), while about (1.7%) show very bad care on the contrary.Moreover, 24.5% of participants had a previous history of TMJ problems, and 18% had mouth-burning sensations (Table 1).Surprisingly, 94.19% of students show good oral health compared to poor oral health 5.81%.On the other hand, most participants had mild levels of depression, 38.58%.(Figure 2, 3) Tables 2 and 3 demonstrate participants' related oral health and depression profiles.Table 4 shows the relationship between oral health and depression.Participants with a mild level of depression corresponded significantly with good oral health (P-value, ˃0.001) (Table 4).

Limitation
It is essential to note some advantages and restrictions.Data were gathered for our study via a representative poll.The main variables-oral health-related quality of life-were measured using generally accepted and reliable techniques.It should be made clear that these are screening tools, in any case.Future study is therefore required to validate our findings.Our analysis also includes a cross-sectional design, which has known limitations in terms of causation.In this field, longitudinal research is mandatory.We cannot rule out the potential that non-responders have different characteristics from respondents, such as other health statuses.These potential variations, however, were impossible to calculate.

ANALYSIS ARTICLE | OPEN ACCESS
Medical Science 27, e352ms3221 (2023) Our study finds a significant relationship between oral health and depression among students in Makkah City.National awareness programs are recommended for the early diagnosis of depression to prevent serious consequences.Furthermore, future investigation is also required to identify relative causes and confirm the study's findings.
Furthermore, a variable related to Patient Health Questionnaire (PHQ)-9 was calculated as well during analysis; the final score was labeled as follows, those who earned a score between 0-4 were classified as none or minimal depression, from 5-9 mild, from 10-14 moderate, from 15-19 moderately severe, while those 20-27 classified as extremely severe (Al-Qadhi et al., 2014; AlHadi et al., 2017).

Figure 1 Figure 2
Figure 1 Age Frequency

Table 1
Demographic data

Table 2
Oral health profile

Table 3
Depression profile

Table 4
The association between oral health and depression