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 Table of Contents  
ORIGINAL RESEARCH
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 129-135

Salivary cortisol: a marker of anxiety in response to different dental treatment procedures: A cross sectional study


Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Submission30-Jul-2020
Date of Decision01-Dec-2020
Date of Acceptance30-Dec-2020
Date of Web Publication17-Apr-2021

Correspondence Address:
Dr. Purnima Seshadri
Impressions Dental Cosmetology Craniofacial Clinic, 84/1, Dr. Ranga Road, East Abhiramapuram, Mylapore, Chennai 600004, Tamil Nadu.
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_262_20

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  Abstract 

Aim: To evaluate and compare the levels of salivary cortisol prior to, during, and after different forms of dental treatment. Materials and Methods: An in-vivo cross-sectional study was designed to study saliva samples from a group of 70 subjects who reported to the Dental Outpatient Department for the estimation of salivary cortisol. The subjects were grouped into seven treatment groups and the sample size was estimated to be 10 per group (at 80% power and 5% α-error) based on the results from a previous study done by Carmen Benjamins, HenkAsscheman, and Albert H. B. Schuurs. All subjects were administered the Modified Dental Anxiety Scale. Unstimulated saliva was collected prior to, during, and at the end of the treatment procedure and assessed for salivary cortisol concentration by ELISA. Chi-square test was used to check for association between the independent variables and the mean salivary cortisol levels. ANOVA was used to estimate the variation in salivary cortisol levels across the three time periods in each of the treatment groups. Results: The mean salivary cortisol concentrations were highest in the prophylaxis group (12.16 ± 4.00) followed by extraction (9.77 ± 3.92) and the endodontics group (8.69 ± 7.81). ANOVA revealed that there was statistical significance for the mean cortisol levels across the time intervals in the examination, prophylaxis, and extraction group alone. Conclusion: The study reported maximum mean cortisol levels in the prophylaxis and extraction group. Also, maximum association between the time factor and cortisol concentrations was observed in the examination, extraction, and prophylaxis groups.

Keywords: Cortisol, cortisol stress, dental anxiety, salivary cortisol


How to cite this article:
Seshadri P, Ramani P. Salivary cortisol: a marker of anxiety in response to different dental treatment procedures: A cross sectional study. J Int Oral Health 2021;13:129-35

How to cite this URL:
Seshadri P, Ramani P. Salivary cortisol: a marker of anxiety in response to different dental treatment procedures: A cross sectional study. J Int Oral Health [serial online] 2021 [cited 2021 Jun 21];13:129-35. Available from: https://www.jioh.org/text.asp?2021/13/2/129/313842


  Introduction Top


Anticipation of dental treatment is a common source of anxiety and fear among patients.[1] Dental anxiety is often reported as a cause of irregular dental attendance, delay in acquiring dental care, or sometimes even the complete avoidance of dental care resulting in a poor oral health and related quality of life.[2] Despite advances in treatment, stress due to dental treatment procedures is still prevalent and it influences the quality of health-care services.

Anxiety is defined as the apprehension of danger and dread, accompanied by restlessness, tension, tachycardia, and dyspnea unattached to a clear, unidentifiable stimulus.[3] Little is understood of the natural history of dental anxiety.[4] Dental anxiety has been described by Klingberg and Broberg as a state of apprehension that something dreadful is going to happen in relation to dental treatment or certain aspects of dental treatment.[5] It has also been observed by investigators that those subjects experiencing high levels of dental anxiety are among those who are with the poorest health-related quality of life.[6] Helping patients overcome fear and anxiety may increase regular and scheduled dental visits and may help in improving the quality of life.[7]

A few studies have documented the stress response to minor general and oral surgical procedures with plasma hydrocorticosteroid as a measure of physiologic stress.[8],[9],[10] Previous studies have observed that the corticosteroid levels in patients before minor dental procedures was much higher than the patients not subjected to any dental treatment. Some studies also suggested that cortisol increase may not be seen before or during dental minor surgical procedures but may increase during the postoperative period.[9],[10],[11] The physiologic stress due to various dental treatment modalities may vary and many parameters have been tested to assess the stress specific to different procedures.

Several authors have proposed the use of salivary biomarkers as an easy and non-invasive method for assessing the stress levels induced by physical and psychological stressors. Among these, the most commonly studied are: salivary cortisol, alpha amylase, immunoglobulin A, and chromogranin A.[12]

Cortisol is a 21-carbon glucocorticoid secreted by the adrenal cortex that regulates carbohydrate, protein, fat, and water metabolism, maintains vascular reactivity, affects the sensitivity of the nervous system, regulates blood cell numbers, and affects the human stress response.[13] It is dispersed in all body fluids, and can be detected in urine, serum, or saliva. The concentration of cortisol in the blood averages 12 μg/100mL (average range: 10–20 micrograms per deciliter (mcg/dL)). The secretory rate averages 15–20 mg/day.[14]

Adrenocorticotropic hormone (ACTH) produced by the anterior pituitary gland regulates the secretion of cortisol, acting via the HPA axis. Inhibition of ACTH and subsequent decreased cortisol level tend to cause changes in the homeostasis of the body during stressful conditions. Stress and diurnal rhythm can upregulate the production of cortisol and adrenal insufficiency causes its decreased secretion. Secondary adrenal insufficiency results from chronic administration of exogenous corticosteroids, which disrupts the hypothalamic–pituitary–adrenal axis.[15],[16]

Many investigators have attempted to evaluate the adrenocortical status in dental patients by assessing the plasma levels of cortisol.[15] It was Shannon et al. who studied parotid saliva as a medium for the determination of human adrenocortical status.[17] The introduction of the immunoassay techniques by Walker and coworkers made it easier to sample salivary cortisol, being cost- effective and a sensitive method.[18] Salivary cortisol is a proven equivalent of serum cortisol for the determination of physiology stress.[19],[20],[21] Unfortunately, it is not possible to detect the risk of development of adrenal crisis during dental treatment procedures.[22]

This study was conducted with the aim of evaluating and comparing the salivary cortisol levels prior to, during, and after different forms of dental treatment procedures in healthy subjects. It was anticipated that the results obtained would be of significance in identifying the routine dental treatment procedures that often subject patients to increased stress levels and also understanding better, the susceptible individuals and their response to strenuous, but routine dental procedures. Our null hypothesis is that there is no association between the salivary cortisol levels and anxiety related to different dental procedures.


  Materials and Methods Top


The study was designed to examine the relationship between salivary cortisol and dental anxiety in response to various dental treatment modalities. An in vivo study was designed and conducted in various undergraduate postgraduate clinics in our dental hospital between August 2013 and October 2013. An in vivo cross-sectional study was designed to study saliva samples for the estimation salivary cortisol. Sample size was estimated to be 10 per group (seven treatment groups) (at 80% power and 5% α-error) based on the results from a previous study done by Carmen Benjamins, Henk Asscheman, and Albert H.B. Schuurs (1992).[23]

Sampling criteria

Inclusion Criteria were subjects in need of some dental treatment or routine dental examination, healthy subjects with no known underlying diseases, subjects between ages 20 and 60 years, non-smokers and non-alcoholics, and included females should be non-pregnant. Exclusion Criteria were subjects who had a previous history of smoking, subjects who did not maintain normal sleep pattern, subjects who had a history of taking androgens, corticosteroids or oestrogen, and subjects who were not willing to participate in the study, subjects who have been on any previous long-term medication.

The subjects were categorized into seven groups depending upon the treatment that they underwent. Each group comprised 10 individuals between the ages of 20 and 60 years.

  • Group 1: Dental examination


  • Group 2: Prophylaxis


  • Group 3: Restoration


  • Group 4: Endodontic therapy


  • Group 5: Extraction


  • Group 6: Impression (fixed or temporary partial dentures)


  • Group 7: Bracket placement or molar banding (fixed orthodontic therapy)


Collection of sample

Unstimulated saliva (2ml) was collected from the study group and the control group using the standard UCLA procedure. Donors were refrained from eating or drinking for at least 60min prior to each collection. The subjects were asked to rinse the mouth with drinking water and were supplied with a sterile container. Five minutes after the oral rinse, the subjects were asked to expectorate the unstimulated saliva into the sterile container. The samples were maintained in a freezer box and subsequently stored at -20ºC. The salivary cortisol ELISA was intended for quantitative determination of cortisol concentrations in the saliva. The sixpak human cortisol ELISA kit was used to analyze the salivary cortisol levels.

Calculation of results

The mean absorbance value for each set of reference standards, controls, and samples were calculated at 450 nm with the microtitre well reader. A standard curve was constructed by plotting the mean absorbance obtained for each reference standard against its concentration in ng/ml on the graph paper, with absorbance on the Y axis and concentration on the X axis. Using the mean absorbance value for each sample, the corresponding concentration of Cortisol in ng/ml was determined from the standard curve.

Statistical analysis

Data was entered in Microsoft Excel spread sheet and analyzed using SPSS (Statistical Package for the Social Sciences Software (version 21.0)). For test, a P-value of <0.05 was considered as statistically significant. Chi-square test was used to check for association between the independent variables and the mean salivary cortisol levels. ANOVA was used to estimate the variation in salivary cortisol levels across the three time periods in each of the treatment groups.


  Results Top


[Table 1] shows the distribution of study subjects according to gender and the modified dental anxiety scores. It was seen that in the high anxiety group, there were five males and no females and in the low anxiety group, there were 32 males and 33 females, Chi-square test showed a significant association between gender and the modified dental anxiety scores. [Table 2] shows the distribution of study subjects according to age and the modified dental anxiety scores. It was seen that in the high anxiety group, there were three subjects from the 20–30 years age group and in the low anxiety group, there were 29 subjects from the 20–30 years age group.
Table 1: Distribution of study subjects based on gender and Modified Dental Anxiety Scores

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Table 2: Distribution of study subjects based on age and Modified Dental Anxiety Scores

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Chi-square test showed no significant association between age and the modified dental anxiety scores.

[Figure 1] shows the association between modified dental anxiety scores and mean cortisol levels before the dental treatment procedure and the modified dental anxiety scores. No significant association was seen for the mean cortisol levels before the dental treatment procedure and the modified dental anxiety scores. [Figure 2] shows the mean (Mean ± SD) salivary cortisol levels in the different treatment groups. It was seen that the mean salivary cortisol concentrations were highest in the prophylaxis group followed by extraction and the endodontics group.
Figure 1: Association between modified dental anxiety scores and mean cortisol levels before the dental treatment procedure. *χ2 = 1.78, df = 3, P > 0.05

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Figure 2: Mean (Mean ± SD) salivary cortisol levels in the different treatment groups

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[Figure 3] shows the mean salivary cortisol levels in the different treatment groups across the three time intervals. It was seen that the mean salivary cortisol concentrations were highest in the prophylaxis group in the postoperative period followed by the extraction group, also in the post treatment period. [Table 3] depicts the mean salivary cortisol levels in all the seven treatment groups at the three time points. Statistical significance was found for the mean salivary cortisol levels across the three time interval in the prophylaxis, examination as well as the extraction groups.
Figure 3: Mean salivary cortisol in all the treatment groups prior, during and at the end of the procedure

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Table 3: Mean (±SD) salivary cortisol levels at the three time intervals in various groups

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  Discussion Top


Stress is an integral part of our lives. Stress causes certain changes in the structure and chemical composition of the body, which can be accurately appraised. Some of these changes are merely signs of damage, while others are manifestations of the body’s defensive adaptive reactions.[24] Despite advances in treatment, stress due to dental treatment procedures is still prevalent and it influences the quality of health-care services. Known alternatively as the “stress hormone,” cortisol is a useful marker in stress research offering the opportunity to indicate accurately the physiological stress levels experienced by subjects.[24] Even though salivary cortisol accounts for about 50–60% of the free cortisol in the plasma, several reports show that there is a high correlation between the two, and saliva, in fact, is an accurate determinant of cortisol levels.[1],[24],[25]

An extensive review of the literature revealed that there is a relative paucity of studies on the salivary cortisol levels in relation to dental treatment-related anxiety so as to establish the known treatment modalities that pose the patients at increased risk for dental anxiety. We anticipated that the present study could be of help in identifying the conditions that patients are subjected to and also understanding better, the susceptible individuals and their response to strenuous, but routine dental procedures.

The dental anxiety scale (DAS) is an instrument widely used in epidemiology and clinical research to assess the tendency to appraise dental treatment as fear provoking. Humphris et al. standardized the answering schemes and added a fifth item concerning anesthetic injection, which is of greatest concern for many people, and introduced the Modified Dental Anxiety Scale (MDAS).[26] This modified scale was validated and published in Portuguese in 2003.[26] This substantiates the use of the MDAS for the assessment of dental anxiety in our study. Although the study showed saliva as a new method to measure dental anxiety, it had no comparisons with the dental anxiety scale.[27] ELISA has been proven to be the gold standard for the estimation of salivary hormones and enzymes. Accordingly, we used a commercially available Cortisol Immunoassay from R and D Systems which is a competitive enzyme immunoassay designed to measure cortisol levels in cell culture supernates, serum, saliva, and urine.

Of the total 210 samples that were analyzed, the cortisol values ranged from 0.00 to 22.65ng/mL (some subjects revealed no cortisol levels at either of the three time intervals). Of the total 70 participants, 37 were males and 33 were females. There was a significant difference in the mean cortisol levels between males and females (P < 0.05), with males having a higher overall cortisol levels. Majority of studies have found higher prevalence rates for dental anxiety in females than males,[28],[29] with only few reports showing no significant relationship.[30],[31] A recently conducted study by McLean et al. concluded a preponderance of women among almost all anxiety disorders examined.[32] The unequal numbers of male and female participants in our study could be one factor contributing to this observation. Alternatively, it can be argued that males do not tend to express their stress or concerns. Our observations indicate that men may be as anxious about dental treatment as women or perhaps even more.

When considering the association between anxiety scores and mean salivary cortisol concentrations prior to the treatment procedure, it was found that although higher cortisol levels were observed in the high anxiety group, the difference was not statistically significant (P > 0.05). In the study by Brand, there were no significant differences in the salivary cortisol concentration between low DAS and high DAS groups.[1] In a study by Krueger et al., high anxiety patients showed a significant increase in salivary cortisol levels in educational sessions than low anxiety patients. However, the groups did not differ significantly in their salivary cortisol levels at the treatment session,[32] which was also the case in our study.

Among the different treatment groups, it was observed that mean cortisol concentration was found to be highest in the prophylaxis group (12.16 ± 4.00) followed by extraction (9.77 ± 3.92) and endodontic therapy (8.69 ± 7.81). The mean cortisol levels in the examination group was found to be 4.12 ± 3.07, in the restoration group it was 6.34 ± 4.01, in the impression group it was 6.12 ± 4.40, and in the orthodontic group was found to be 5.09 ± 3.29. Chamani reported highest cortisol concentrations in the examination, prophylaxis, and restoration groups.[33] Miller et al. observed that the mean salivary cortisol value for the extraction group was significantly different from the mean values of the examination, prophylaxis, root canal, and restoration groups.[22]

It was observed that differences among the mean cortisol levels within each treatment group at each time point were apparent. In general, the cortisol levels were found to be highest (6.33 ± 3.01) before commencement of the treatment procedure in the examination group alone. This is in agreement with the observation by Miller et al.[22] This is a very justifiable observation as the examination period is usually the first time when a patient reports to the dental office. As the patients are seated and questioned about their complaint and dental problems, they tend to become less anxious as indicated by the declining cortisol values during (2.31 ± 2.83) and at the end of the treatment procedure (3.73 ± 2.04). Statistical significance was found for the mean salivary cortisol levels across the three time intervals in the examination group (P < 0.05).

The prophylaxis, restoration, endodontics, and extraction group showed an increase in the cortisol concentrations between the pre and post treatment time intervals. But one-way ANOVA revealed statistical significance for the mean salivary cortisol levels across the three time periods only in the extraction (P < 0.05) and the prophylaxis groups (P < 0.05). Our findings for the restoration and endodontic groups are in contrast with those of Morse et al. who observed that pre-treatment and during treatment corticosteroid levels was higher that the post treatment levels.[12]

Also our observations regarding the prophylaxis and extraction group were in agreement with those of Miller et al. who found that the cortisol levels in the both these groups increased compared with the initial reading. This elevation in the extraction group can certainly be attributed to the more stressful procedure and also to the likelihood of pain being a contributing factor. Dembo and Falace[34] and Shannon et al.[17] have reported increased cortisol levels with higher levels of anxiety associated with administering local anesthetic injection and oral surgery, respectively. Miller et al. observed that the stress associated with extractions is greater than that associated with other dental treatments. Also in accordance with the findings of Banks[8] and Steer,[9] stress associated with extractions usually persists into the postoperative period as well. This could also explain the raised cortisol levels in the extraction group post the treatment period.

Regarding elevated cortisol levels in the prophylaxis group, Miller et al.[22] stated that elevations in this group could be attributed to discomfort experienced during the procedure or due to the contamination of blood. We feel that the latter reason could be a stronger contributing factor. Alternatively as patients would not expect to visualize bleeding from the gums during a routine prophylaxis, they might be under higher stress levels during the course of the procedure rather than prior to it.

Although variations in the salivary cortisol concentrations were apparent even in the impression and orthodontics group, they were not among the treatment groups that showed high mean cortisol levels. Also there was found to be no statistical significance in the cortisol levels of the impression and orthodontics group across the three time periods. Our study is the first to report variation in salivary cortisol levels in response to impressions and orthodontic treatment as well. Since many factors come to play their part in posing subjects at increased risk for dental anxiety such as the duration of the procedure, the frequency of dental attendance along with operator skills and previous dental experiences, it is difficult to identify specific reasons for the results observed.

In summary, it seems appropriate to conclude that salivary cortisol is indeed a reliable marker of dental treatment-related anxiety. Patients with higher anxiety levels exhibited higher salivary cortisol concentrations. Also subjects undergoing extraction, prophylaxis, and examination were found to be under higher stress levels as indicated by the significant increase in the cortisol levels.

Despite all our observations, it is not appropriate to conclude that patients reporting for other forms of dental treatment are exposed to less stress levels and do not need better intervention. As cortisol is a physiological parameter in the body fluids, variation could be attributed to various factors including socioeconomic status, day to day events, previous dental experiences, and other fear inducing factors.

From the evidence at hand, the salivary cortisol assay promises to be a useful tool in assessing dental anxiety. It also avoids the need for collection of blood and is a particularly important consideration in patients with adrenal insufficiency, especially if the lengthy treatment procedure poses the patients at increased anxiety levels and heightens their apprehension toward the procedure. Thus salivary diagnostic tests would provide an inexpensive and reliable testing so as to discover the subjects under increased stress levels, particularly those subjects who are on long-term corticosteroid therapy as there is no definite way of predicting the risk of adrenal crisis in response to the stress caused by various dental procedures.[35],[36],[37]

Further extensive studies and increasing the sample size could open a new horizon in this field. Including greater clinical parameters would broaden our vision towards scope for better research in the field of dental treatment related anxiety. Further research must be directed to evaluate variations in anxiety levels among individuals of different backgrounds, ethnicity, and medical conditions so as to ensure better quality of health-care services to concentrate on exploring the possibility of using salivary cortisol measurement as a tool for administering and modifying the routine dental treatment according to patients’ levels of anxiety. It could be of great help in assessing and curing patients on long-term corticosteroid as there is no definite way of predicting the risk of adrenal crisis in response to the stress caused by various dental procedures.


  Conclusion Top


The results of the present study revealed that salivary cortisol is indeed an effective indicator of the stress levels in subjects. The study reported maximum mean cortisol levels in the prophylaxis and extraction group. While the cortisol levels in highly anxious patients were observed to be higher than those in patients with low anxiety, the results were not statistically significant. Also, maximum association between the time factor and cortisol concentrations was observed in the examination, extraction, and prophylaxis groups. Our conclusions need to be substantiated with further research work especially with regard to subjects with underlying medical and/or drug histories, previous fearful dental experiences as well as subjects of a wider geographic distribution so as to understand better the role played by additional factors in driving the stress levels in subjects, thereby affecting their salivary cortisol levels.

Acknowledgement

The authors thank the management and departments of Saveetha Dental College and Hospitals for their support.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

Ethical policy and institutional review board statement

Prior to initiating the study, clearance was obtained from the Scientific Review Board (SRB) and ethical clearance was obtained from the Institutional Ethics Committee. (SRB/SDMDS11OMPS).

Patient declaration of consent

Informed written consent for participation in the study and publication of the data for research and educational purposes has been obtained.

Data availability statement

The data set used in the current study will be available on request from [email protected].

 
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    Figures

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    Tables

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