|Year : 2015 | Volume
| Issue : 2 | Page : 94-99
Assessment of the changes in the stress-related salivary cortisol levels to the various dental procedures in children
Sharmila J Patil1, Preetam P Shah1, Jayakumar A Patil2, Anand Shigli1, Anil T Patil1, Sridevi B Tamagond1
1 Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sangli, Maharashtra, India
2 Department of Conservative and Endodontics, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sangli, Maharashtra, India
|Date of Web Publication||15-Apr-2015|
Dr. Anil T Patil
Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sangli - 416 414, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Fear and pain are the factors producing stress and there is evidence that dental fear acquired in childhood may persist to influence adult behavior. Dental treatment is often considered as anxiety producing and stressful. Aim: To assess the levels of stress displayed by the healthy children undergoing routine dental procedures like oral examination, restoration, and extraction by analyzing salivary levels of cortisol before, during, and after the procedures. Materials and Methods: Twenty healthy children aged between 4 and 8 years having their first dental visit and requiring at least one restoration and one extraction were selected. In each patient, three procedures were carried out: (i) Routine dental examination, (ii) restoration, and (iii) extraction. Unstimulated salivary samples were collected 10 min before, during the procedure, and 30 min after each procedure at three different visits for comparison of cortisol production in response to anxiety and stress over time. Total 180 samples were collected to determine salivary cortisol levels using UBI-MAGIWEL TM kit and the readings were noted. Statistical Analysis Used: Statistical Package for Social Sciences (SPSS) software with paired t-test, two independent sample t-tests, and analysis of variance (ANOVA) were used to analyze the findings. Results: A correlation between salivary cortisol and stress in dental procedure was noticed. Cavity preparation is more stressful procedure in children, so alternative methods can be used in anxious children. Stress associated with extraction persists to a postoperative period. No correlation exists in between Corah's anxiety scale and salivary cortisol.
Keywords: Dental anxiety, pain, pediatric dentistry, salivary cortisol, stress
|How to cite this article:|
Patil SJ, Shah PP, Patil JA, Shigli A, Patil AT, Tamagond SB. Assessment of the changes in the stress-related salivary cortisol levels to the various dental procedures in children. J Indian Soc Pedod Prev Dent 2015;33:94-9
|How to cite this URL:|
Patil SJ, Shah PP, Patil JA, Shigli A, Patil AT, Tamagond SB. Assessment of the changes in the stress-related salivary cortisol levels to the various dental procedures in children. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Nov 13];33:94-9. Available from: http://www.jisppd.com/text.asp?2015/33/2/94/155116
| Introduction|| |
Dental treatment is often considered as anxiety producing and stressful, which has been related to fight or flight responsein children. Cortisol is a hormone secreted from the adrenal cortex and dispersed to all body fluids, that is, urine, serum, or saliva. The pioneering studies by Shannon et al.,  demonstrated increased 17-hydroxycorticosteroid (17-OHCS) serum levels before the administrations of local anesthesia and subsequent tooth extractions in healthy males, indicating that anticipation of dental treatment is an important stimulus to the adrenal cortex. Saliva is mirror of blood; especially in children sampling of saliva is easy, noninvasive. Very few studies have been conducted to evaluate relationship between stresses during dental treatment in children and unfortunately no quantitative measure exists which predict the amount of stress in children.
The amount of stress generated by different kind of dental procedures is variable. This study was done with the intent of determining the levels of stress displayed by the healthy children undergoing routine dental procedures like oral examination, restoration, and extraction by analyzing salivary levels of cortisol before, during, and after the procedures. After assessing salivary cortisol levels in dental procedures; dentist can modify various behavior techniques and help to reduce stress in children.
This study was designed and carried out with the aim to assess changes in the stress related salivary cortisol levels to the various dental procedures in children. Objectives of the study were to find out if any correlation exists between stress and salivary cortisol and to evaluate which step in a dental procedure is the most stressful.
| Materials and Methods|| |
Twenty healthy children aged between 4 and 8 years having their first dental visit and requiring at least one restoration and one extraction were selected from Department of Pedodontics and Preventive Dentistry, Bharati Vidyapeeth Dental College, Pune, India. Children having any history of systemic diseases, on corticosteroid therapy, having fever, or medically compromised were excluded from the study.
General medical history, dental history, marital status of parents, income of the parents, and educational qualification of the parents were recorded. Frankel's behavior rating scale was used to record the behavior of the child in the department. Simple translation of Corah's dental anxiety scale  in local language (i. e., Marathi) was done and anxiety in children was measured in the first dental visit. The study was explained to parents and written consent was obtained.
Collection of saliva samples
The children were called in the morning between 9am and 11am to participate in the present study. In each patient, three procedures were carried out, namely; (i) routine dental (including intraoral and extraoral) examination, (ii) restoration, and (iii) extraction. Salivary samples were collected 10 min before, during the procedure, and 30 min after each procedure at three different visits to allow for comparison of cortisol production in response to anxiety and stress over time. Total 180 samples were collected to determine salivary cortisol levels with the help of the UBI-MAGIWEL TM kit and laboratory and the readings were noted [Figure 1], [Figure 2], [Figure 3], [Figure 4]. After evaluation of anxiety in children, routine dental examination (including hard and soft tissue examination and radiograph as needed) was carried out and the child had undergone a tour and orientation to the complete clinic. The restorative procedure involving excavation of caries with rotary hand piece and placement of glass ionomer restorative material for the class I cavity of molar was done in the second dental visit. Teeth indicated for extraction were extracted in the third visit and the local anesthetic used was 2% lidocaine hydrochloride with 1:100,000 epinephrine. 
Unstimulated saliva, about 1-2 ml was collected from the child after rinsing mouth by half glass of a tap water at three intervals, as soon as child sits in the dental chair, during the procedure and 30 min after the completion of the procedure.  Unstimulated saliva was collected by asking the patient to expectorate into disposable plastic container. The sample from one child during restorative procedure contained insufficient quantity to assess; so it was not taken for analysis. The samples from three children undergoing dental extraction were contaminated with blood. These blood contaminated samples were excluded in the study because of likelihood of contamination with plasma cortisol. The disposable plastic containers containing the saliva samples were tightly closed and placed in gel bags and transported to the laboratory.
The salivary cortisol values were noted by using MAGIWEL TM kit. The data was tabulated and statistically analyzed byusing Statistical Package for Social Sciences (SPSS) software. Paired t-test, two independent sample t-tests, and analysis of variance (ANOVA) were used to find the significance for various parameters.
| Results|| |
Results were obtained from total 20 samples children in the first visit, 19 samples of children in the second visit, and 17 samples of children in the third visit. There was no significant difference between salivary cortisol levels at baseline and during the procedure as well as at baseline and after the procedure in the first visit as seen in [Table 1].
|Table 1: Comparison of salivary cortisol levels (μg/dl) at baseline, during the procedure, and after the procedure in the first visit (where routine dental examination was carried out)|
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[Table 2] shows statistically increased (P = 0.039) salivary cortisol levels at baseline and during the procedure in the second visit, where restoration was done. [Table 3] shows significant increase (P = 0.021) in salivary cortisol levels at baseline and after the procedure in the third visit, where extraction was carried out. Although there was no significant difference between salivary cortisol levels during the procedure at first, second, and third visit; the raised values of salivary cortisol were noticed in cavity preparation [Table 4]. [Table 5] shows there was significant increased salivary cortisol levels after the procedure at first, second, and third visit (P = 0.534). There was no correlation between average salivary cortisol levels at first visit with respect to anxiety grade [Table 6].
|Table 2: Comparison of salivary cortisol levels (μg/dl) evaluated at baseline, during the procedure, and after the procedure in the second visit (where restoration was carried out)|
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|Table 3: Comparison of salivary cortisol levels (μg/dl) evaluated at baseline, during the procedure, and after the procedure in the third visit (where extraction was carried out)|
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|Table 4: Comparison of salivary cortisol levels (μg/dl) evaluated during the procedure in the first, second, and third visit|
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|Table 5: Comparison of salivary cortisol levels evaluated (μg/dl) after the procedure at first, second, and third visit|
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|Table 6: Comparison of average salivary cortisol levels at first visit with respect to anxiety|
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| Discussion|| |
Dental anxiety is still prevalent, despite advances in treatment; therefore, it affects the utilization of healthcare services. Dental anxiety acquired in childhood through direct experience with painful treatment or vicariously through the parents, friends, or sibling may persist in adulthood. Pedodontist must be able to identify nervous children in quick and easy manner. Only few studies have measured physiologic stress induced by routine dental procedures.  The first serious studies on saliva were conducted by Pavlov, who demonstrated classic conditioning in a relationship to digestive activity. Miller and Carmona showed instrumental learning of salivation relative to thirst as water reward in dogs. 
Anticipation of the dental treatment is a significant stimulus for the adrenal cortex to release cortisol. The measurement of salivary concentration allows the determination of rapid changes in the adrenocortical activities.  Therefore, it has been suggested that salivary cortisol concentration may be related to the level of dental anxiety. Cortisol is the major glucocorticoid produced and secreted by the adrenal cortex. It affects the metabolism of protein, fat, and carbohydrates; the maintenance of muscle and myocardial integrity; and the suppression of inflammatory and allergic activities. Its systemic name is 11β, 17α, 21-trihydroxypregene-3, 20-dione and it is also known as 17-hydrocortisone.
Cortisol measurements in blood samples have been shown to result in higher values due to psychological stress of sample taking in children. Collection of serum is stressful; thereby, directly elevating free cortisol concentration and distorting the results of the tests. Collection of saliva is simple, noninvasive, stress free procedure. In contrast to serum; saliva collection and sample storage is very simple. Also it has been shown that, cortisol levels in saliva closely mirror serum free cortisol levels and are independent of flow rate. , In an animal study, Greenhood and Shutt  demonstrated that the salivary cortisol method was useful measure of stress. They found significant increase in free cortisol in saliva as a response to transportation of goats.
We have assessed stress in the participated children in terms of salivary cortisol level as response to 'stressor' like restoration and extraction procedures were selected. The importance of circadian rhythm of cortisol is emphasized in previous studies so considering this, saliva samples were collected from children at the same appointment hours. All procedures were scheduled for morning appointments, between 9.00am and 11.00 am. The similar study done by Mayer and Weber  used the same method of Serap et al.,  for sampling of saliva and found that, starting from the time that the child is seated in the dental chair, salivary cortisol increased rapidly during the cavity preparation and reached highest value during the placement of the base material. They reported that the stress and anxiety of the children decreased during the placement of restoration, and neared and beginning of treatment values at the end of the treatment.
Shinkai et al., determined cortisol levels in saliva by radioimmunoassay and found that salivary cortisol was an excellent measure for monitoring circadian rhythm variation in adrenal activity.  Salivary cortisol levels have been measured using an enzyme-linked immunoassay technique by (MAGIWEL TM cortisol kit). During estimation, all the salivary samples were stored at −20°C in a freezer before reading on the Alpha Prime LS auto reader. The results found in this study by using enzyme-linked immunosorbent assay (ELISA) kit with regards to salivary cortisol are informative of this method indicating that enzyme linked immunoassay can be used for estimation of salivary cortisol.
Consistent with behavior approach is the work of Corah who developed a scale designed to discriminate fearful and nonfearful patients for purpose of examining their relative reactions to dental procedures, both real and imagined. Corah's dental anxiety scale is composed of four items yielding a total anxiety score that he found to be reliable and valid  Although the value of such scale is readily apparent, its single score does not give information as to the variety of specific stimuli that may elicit fear or avoidance responses, nor does it tell us the patient's specific and unique response to those stimuli. Individuals react to stressful events indifferent ways. Similar study done by Brand  stated that salivary cortisol concentration did not correlate with either Visual Analog Score (VAS) or Disease Analog Score (DAS) score. The salivary cortisol levels and DAS scores did not correlate in our study. Explanation for this may be as some researchers do not allow obtaining direct viewpoint of very young children, since they are not able to fill out the questionnaires themselves or a sentence-completion task may be difficult for young children to manage. As young children encounter more problems with self-reports or in situations where the child is questioned or interviewed.
Salivary cortisol levels were increased during restorative procedure in the second dental visit between baseline salivary cortisol and during the procedure [Table 2]. These findings are suggestive of anticipation of the restorative procedure does produce stress and anxiety in children similarly stated by Serap et al.,  in their study.
There was significant difference of salivary cortisol between baseline and after the procedure at third visit [Table 3]. Regarding the data involving the patients undergoing extraction, the findings are worthy to notice similarly to those seen in the investigation done by Miller CS, Dembo JB.  We can say three findings worthy to notice; firstly apprehension can be a stimulus to adrenocortical secretion. This finding is based on the increase in the cortisol value at the point. Shannon et al.,  have reported that the anxiety of local anesthesia administration and oral surgery can cause elevations in cortisol in patients undergoing dental procedures. In contrast Banks  and Franksson and Gemzell  have reported that preoperative apprehension is not a stimulus to corticosteroid secretion. Secondly, the stress associated with extraction is greater than that associated with other dental procedures. This finding is based on the fact that salivary cortisol levels in children who received tooth extraction were higher than the mean levels during first and second dental visits. Third finding we found that the stress associated with extractions persists into the postoperative period. Rise in salivary cortisol levels after 30 min of extraction may be suggestive of loss of a tooth generated fear in children, several studies support this finding and in factelevated levels have been shown to remain elevated for about 4-7 h after surgery. , Only Hempenstall et al.,  reported that plasma cortisol decreased during the period after dental surgery. However, most studies have concluded that significant cortisol increases are not seen before or during minor operations but are increased in the postoperative period which is exactly similar to our findings. ,
The correlation between anxiety and salivary cortisol was found to be significant by McCartan et al.  In his study he also found that the Hospital Dental Anxiety (HAD) scores and salivary cortisol levels did not correlate. Our study result shows that salivary cortisol concentrations did not correlate with DAS score seen similarly in a study done by Brand.  A possible explanation is that the single question used to indicate self-perceived stress was perhaps too crude measure to assess stress. Respondents or children may underreport or exaggerate the nature of their stress. While an in-depth questionnaire may be useful.
| Summary and Conclusions|| |
Especially when dealing with children, it is important to predict child's behavior in dental treatment because there is evidence that dental fear acquired in childhood may persist to influence adult behavior. The salivary analysis of cortisol in children can measure dental anxiety very precisely.
There is a correlation between salivary cortisol and stress in dental procedure. Estimation of salivary cortisol in the dental operatory can be used as subjective measure of anxiety in children by using ELISA method. Hence, evaluation of a salivary cortisol is helpful in behavior modulation in children. Estimation of salivary cortisol is an easy, noninvasive procedure to grade anxiety. No correlation exists in between Corah's anxiety scale and salivary cortisol. Restorative procedure is more stressful in children, so alternative methods can be used in anxious children. Stress associated with extraction persists to a postoperative period.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]