Evaluation of Preoperative Salivary Cortisol Level in Patients Undergoing Major Maxillofacial Surgery.

AIM: The main purpose of the study was to compare the preoperative salivary cortisol levels 3 days before the major surgery under general anesthesia and to compare it with the patients undergoing extraction under local anesthesia.
MATERIALS AND METHODS: Forty-two patients were undergoing major surgery and 42 age- and sex-matched patients undergoing dental extraction were included and their salivary cortisol levels were analyzed before and after the dental procedure.
RESULTS: Results showed that there is a significant increase in the mean salivary cortisol concentration after extraction (23.7 ± 9.2) than before extraction (18.9 ± 23.7) in the study group (P = 0.015) as well as in the control group. The comparison between salivary cortisol in the study group before (18.9 ± 23.7) and after (23.7 ± 9.2) surgery was significantly higher than the control group (15.2 ± 5.5) (P = 0.013 and 0.005), respectively.
CONCLUSION: We have concluded from this study that the salivary cortisol level shows a significant increase on the day of surgery. Copyright:

INTRODUCTION

The dental practice has revolutionized itself since the past three decades; despite advances in treatment, dental anxiety is still prevalent. It is considered to be the fifth most common cause of stress.[1] Just a simple thought of visiting the dentist may lead to anxiety and discomfort to the patient. With anxiety comes fear, which results in a stress reaction in the form of fight or flight response. Thus, dental anxiety and fear are one of the primary reasons for dental neglect, and it affects the optimum utilization of health-care services. Various factors stimulating dental anxiety include sights of needles, the smell of eugenol, air-rotor sound, and the vibration caused by dental instruments in the dental setting.[23]

During stress situations, the hypothalamus–pituitary–adrenal axis leads to the release of the hormone known as cortisol. Cortisol is successfully employed as a biomarker for various stress-related studies.[4] Usually, cortisol levels are increased in the body during the morning than at night. However, when the person is under stress or anxiety, the hormonal and metabolic changes occur in the body, termed the stress response.[5] Stress is not the only due to cortisol release but also because of increased production of catecholamines such as adrenaline, noradrenaline (fight flight hormone), and activation of beta adrenergic receptors.

As a diagnostic tool, saliva offers several benefits such as easy sampling, noninvasive methods, less economic burden, and no laboratory dependency. Many studies prove that salivary cortisol levels are reliable indicators for assessing stress in both adults and children. It can be because cortisol is not bounded by carrier protein and diffuses freely into saliva.[6] Thus, measurements in saliva, for the most part, represent the free fraction of the hormone. In dentistry, the evaluation of salivary cortisol has been employed to determine the anxiety of dental treatment.[7]

Significant research had shown an increase in salivary cortisol concentrations during routine dental procedures, but limited papers show the stress evaluation during major oral and maxillofacial surgical procedures. Our search showed that limited studies are available in the literature about the presurgical levels of salivary cortisol in patients undergoing major maxillofacial surgery under general anesthesia. The levels were checked on the day of surgery. The purpose of the present study was to compare the preoperative salivary cortisol levels 3 days before the major surgery under general anesthesia and to compare it with the patients undergoing extraction under local anesthesia.

MATERIALS AND METHOD

The study was performed in the department of oral and maxillofacial surgery after taking the informed consent from the patients. The study was approved by the institutional ethical committee. A detailed and thorough history of the patient was taken, followed by a clinical examination and complete blood profile, viral markers, liver and renal function tests, and lipid profile of the patients.

Group 1 (study group)

The study consisted of 42 patients (34 males and 8 females) who underwent major surgeries in the under general anesthesia.

Inclusion criteria

The study includes the patients undergoing surgery for trauma, orthognathic surgery, and other pathologies such as marsupialization of a larger cyst or removal of tumor.

Exclusion criteria

Patients with the history of endocrinal disorder such as diabetes, thyroid, and Cushing disease and children were excluded from the study.

Group 2 (control group)

Age- and sex-matched controls undergoing routine dental extraction under local anesthesia were considered for the study; the exclusion criteria for the controls remain the same as that of the study group.

Procedure

Salivary samples were collected between 10.00 am and 2.00 pm to standardize the diurnal variations of the secretion of cortisol.

Plain water was used to rinse the mouth before sample collection. About 1 ml of the unstimulated saliva was collected from all patients. Disposable micropipettes and graduated polypropylene vials were used to collect and store the sample. Sample 1 was taken 3 days before the patient went for surgery. Sample 2 was taken on the same day of the surgery.

The samples were labeled and were freezed until analysis. Salivary cortisol ELISA research kit (DRG Internationals, USA) was used as per manufacturer protocol to determine the cortisol levels. The assessment was done at optical density of 450 nm.

The results obtained were statistically computed using paired t-test. SPSS (version 17.0, SPSS Inc., Chicago IL, USA) was used.

RESULTS

The study consists of 42 patients in the study group and age- and sex-matched individuals in the control group. Patients in the study group underwent major maxillofacial surgery under general anesthesia without any complications. The age range varies from 23 to 65 years, with the mean age of 43.26 ± 15.86. There were 34 males and 8 females in both groups. Table 1 shows that the levels of mean salivary cortisol were significantly higher after extraction (23.7 ± 9.2) than before extraction (18.9 ± 23.7) in the study group (P = 0.015) as well as in the control group as shown in Table 2. Table 3 shows the comparison between salivary cortisol in the study group before (18.9 ± 23.7) and after (23.7 ± 9.2) surgery which was significantly higher than the control group (15.2 ± 5.5) (P = 0.013 and 0.005), respectively.

Table 1

Salivary cortisol levels before and after surgery in Group I

	Mean levels 3 days before surgery, mean±SD	Mean cortisol levels on the day of surgery, mean±SD	P
Salivary cortisol levels (ng/ml)	18.9±7.1	23.7±9.2	0.015

SD: Standard deviation

Table 2

Salivary cortisol levels before and after surgery in Group II

	Control group		P
	Mean±SD	n
Before extraction	15.2±5.5	42	0.005
After extraction	18.6±6.9

SD: Standard deviation

Table 3

Comparison of salivary cortisol levels before and after surgery between both the groups

	Study group		Control group		P
	Mean±SD	n	Mean±SD	n
Before extraction	18.9±7.1	42	15.2±5.5	42	0.013
After extraction	23.7±9.2	42	18.6±6.9	0.005

SD: Standard deviation

Graph 1 shows the mean values of salivary cortisol of the males and females before and after surgery. It was seen that males have high-stress levels even before surgery (19.9 ng/ml) as compared to females (15 ng/ml), but after surgery, the values were almost the same with 23.9 ng/ml and 23 ng/ml for males and females, respectively. Graph 2 shows the category of surgery performed, in which trauma (74%) showed more elevated levels than any other surgery.

Graph 1

Mean salivary cortisol values in males and females

Graph 2

Distribution of pathologies for which surgery was performed

DISCUSSION

Anxiety and fear are the two essential components of dental neglect in patients.[8] Prolonging dental treatments might lead to huge problems that require a more complex and complicated dental procedure. The body in a stressed condition produced the hormone known as stress hormone or cortisol. Cortisol is a glucocorticoid that has multiple roles regulating the metabolism of carbohydrate, protein, fat, and water. It also affects the nervous system's sensitivity, maintains vascular reactivity, regulates blood cell percentage, and regulates the stress response.[9] Cortisol has a low molecular weight and is lipophilic; due to this reason, the biologically active unbound cortisol enters the cells by passive diffusion. This cortisol can be determined, making it possible to measure the free cortisol fraction in all bodily fluids.

Various methods, such as excellent communication, behavioral modification, systemic desensitization, hypnosis, and guided relaxation, are employed to reduce patients' dental anxiety. In patients in whom these techniques fail, sedation and anti-anxiety premedication are used.[8] Drugs such as lorazepam, alprazolam, diazepam, and clonazepam can be used to reduce anxiety.[5] The present study has been conducted to evaluate presurgical salivary cortisol levels in patients undergoing major maxillofacial surgery under general anesthesia, with a sample size of 42 patients. The parameters considered were salivary cortisol levels on the day of admission and the day of surgery.

Table 1 of that the levels of mean salivary cortisol were significantly higher after extraction than before extraction in the study group. This could be due to the anxiety of patients before undergoing the operative procedure. Our results were per the study by Gadicherla et al.[10] that showed raised salivary cortisol levels in patients undergoing dental extraction. A study conducted by Miller et al.[9] showed that the stress associated with patients undergoing dental extraction is significantly higher than with other dental treatments. Our results were also consistent with the study by Aher et al.,[5] which showed an increase in the serum cortisol levels on admission. It was just 1 h before surgery, indicating anxiety toward the procedure.

Controls underwent simple dental extraction under local anesthesia, whereas in the study group, general anesthesia was used. General anesthesia produces more anxiety in patients than local anesthesia, as shown by salivary cortisol levels. The levels in controls were significantly less than those found for patients who underwent general anesthesia. Our results were in agreement with the study done by Greabu et al.,[4] which yields the same results. Hill and Walker,[11] in their research, investigated the salivary cortisol levels in patients who underwent extraction of wisdom tooth under general and local anesthesia. The results of their study showed that procedure performed under local anesthesia had less salivary cortisol levels than under general anesthesia.

Our results showed that after surgery, the cortisol levels remain the same in males and females hence showing no gender association, which was the same as shown by Kanegane et al.[12] in his study. However, in control, a significant difference was observed between the mean values of cortisol before and after.

The results of the present study signify the value of the noninvasive sampling in determining the psychological stress of the person. The reasons for elevated salivary cortisol levels can be due to hormone and metabolic changes occurring in the body following injury or trauma as seen in Graph 2; the major cause of surgery was trauma. Hence, it is basically a stress response of our body to the injury. Other reasons can be anxiety caused by the surgical operation or any previous bad dental experience. Our study shows that salivary cortisol assays are helpful in evaluating the stress response for surgical patients.

CONCLUSION

We have concluded from this study that the salivary cortisol level shows a significant increase on the day of surgery. The future study can focus on the comparison between increased levels of serum and salivary cortisol levels and the evaluation of the postoperative stresses in major maxillofacial surgery patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.