8/18/23, 10:16 PM Objective and subjective measurements for assessing dental fear in adolescents: a pilot study - Italian Journal

an Journal of Dental Me…

Objective and subjective measurements for

assessing dental fear in adolescents: a pilot
study
Redazione

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Diana Galamb1, Ágota Lenkey2, Anna Oláh2, János Máth3, Ildikó Márton1, Márta Alberth1
1 Department of Dentistry, University of Debrecen, Debrecen, Hungary
2 Department of Clinical Biochemistry and Molecular Pathology, University of Debrecen, Debrecen,
Hungary
3 Department of Psychology, University of Debrecen, Debrecen, Hungary

Abstract
Aim
The aim of the present study was to evaluate and compare the parameters for assessing dental fear in
adolescents through a multilateral approach in order to define the most eligible method for its evaluation.

Materials and methods

A sample of 40 adolescents (20 girls and 20 boys) were randomly selected for the study from students aged
12-14 years in the area of Debrecen (Hungary) having at least 2 decayed teeth. Subjects were administered
the Corah’s Dental Anxiety Scale questionnaire and asked to indicate their degree of anxiety (scores
ranging from 4 to 20). Patients with a DAS score above 13 were enrolled into the anxious group. Blood
pressure, pulse rate and sweating score were recorded, and salivary samples were taken to measure
salivary cortisol concentration and amylase activity before and 20 minutes after treatment. Data were
analyzed for statistical significance using the Chi-Square test in the case of categorical variables, while
Student’s t-test was applied for continuous variables. A p value less than 0.05 was considered significant.

Results
The change of objective parameters reflected the increasing or decreasing of dental fear during treatment,
so these changes were calculated and were used to compare the methods. Positive correlations were
observed between the parameters considered. No significant correlation between the DAS score and
results of objective methods was obtained in the present study when assessing dental fear, except for the
salivary cortisol level and the sweating score. Sweating is an indirect and reliable measurement of dental
fear; this was performed by measuring skin moisture based on the Corneometer® method (capacitance
measurement of a dielectric medium through a skin probe).

Conclusion
Measurement of salivary cortisol level, blood pressure, pulse rate and sweating score were valuable
objective methods to measure dental stress with high fidelity; however sweating scores reasonably well
reflected the parameters of the objective measurements and the use of the Corneometer® method proved
reliable and comfortable for the patients.

Adolescents, Dental Fear, Measurement of the skin moisture, Physical parameters.

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Introduction
Fear and anxiety is a common health care problem in adolescents, since treatment may be a stressful
situation because of a variety of potentially unpleasant stimuli. Therefore, the measurement of stress is
essential for the diagnosis of fear and allowing for the effective management of these subjects. Stress may
be short-term (acute) or long-term (chronic). Acute stress is the reaction to an immediate threat that can be
any situation experienced as a danger.

Since acute stress is a multifactorial phenomenon, it can be measured both subjectively and objectively.
The subjective methods are the age-specific direct scales and indirect questionnaires completed by the
parents.

The Corah’s Dental Anxiety Scale (DAS) is one of the most frequently applied questionnaires for evaluation
of dental anxiety (1). The questionnaires are suitable for measuring the overall fear in an appointment, but
the monitoring of fear during treatment is difficult by the use of questionnaires.

In a stressful situation the salivary cortisol and amylase concentrations are elevated (2), rate of respiration,
blood pressure, heart rate, muscle tension and sweat gland excretion (sweating) are increased, while skin
temperature and saliva production are reduced (3). Thus the objective measurement of stress may involve
the measurement of salivary cortisol concentration or alpha-amylase activity, in addition to measurement
of blood pressure, pulse rate, respiratory rate, muscle tone, skin temperature and sweating.

The aim of the present study was to evaluate and compare the parameters obtained using several
subjective and objective methods for assessing dental fear in adolescents. Using this multilateral approach
the most suitable method to monitor fear during treatment can be identified, as a quick, easily applicable,
reliable and harmless as well as comfortable for the patient.

Methods
For the study, which was approved by the Regional and Institutional Ethics Committee (Medical and Health
Science Center, University of Debrecen, Debrecen, Hungary), 500 students aged 12-14 years took part on a
dental screening. From the subjects having at least 2 decayed teeth, 40 adolescents (20 girls and 20 boys)
were randomly selected.

The procedures and possible discomforts were thoroughly explained to the adolescents and their parents,
and informed consent was obtained from the parents or guardians of the students, who served as
subjects.

In the first visit the oral health status was assessed using a dental mirror, probe and standard lighting. In
the second visit the patients had dental restorative treatment with local anaesthesia lasting approximately
for 30 minutes. The same pediatric dentist and dental assistant treated all patients. The visits were at a
fixed time between 8-9 a.m. Eight boys failed to come to the second visit.

Before the treatment the students were asked to fill the Corah’s Dental Anxiety Scale questionnaire
translated into Hungarian (4). Patients were asked to indicate their degree of anxiety in 4 dental treatment-
related situations using a five-point scale yielding total scores ranging from 4 to 20. The cut off value for
DAS was 13, above this value the patients were enrolled into the anxious group (5). Blood pressure, pulse
rate and sweating were recorded, and salivary samples were taken to measure salivary cortisol
concentration and amylase activity before and 20 minutes after the treatment. Blood pressure and pulse
rate were measured using a Pulsoxymeter Nonin® 8500M (Nonin Medical, Plymouth, MN, USA), sweating
(skin surface hydration) was measured using a Corneometer® CM 825 (Courage+Khazaka Electronics,
Cologne, Germany), applied always on the same point of the forehead. For salivary cortisol and amylase

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analysis, the patients were instructed to rinse their mouth with water, and to collect their saliva into two
plastic tubes before the treatment. This protocol was repeated 20 minutes after treatment. The samples
were free of any blood contamination and were stored in a freezer at -20 °C until used. After being thawed
the samples were centrifuged for 10 minutes at 1500 g to obtain clear supernatant (6). After 10 times
dilution with physiological saline, the amylase activity was measured using an enzymatic colorimetric EPS-2
method with Cobas Integra-800 analyzer (Roche Ltd, Mannheim, Germany). Salivary cortisol levels in the
undiluted samples were measured by means of a competitive radioimmunoassay kit (CORT-CT2, CIS bio
International, Gif-sur-Yvette, France). Analyses were performed in duplicate serial sets: 150 μl of standard,
control and salivary samples were dispensed, and 500 μl of 125 iodine-cortisol was added into each coated
tube. After incubation at 37 °C for 30 minutes, the supernatant was decanted, and the remaining
radioactivity bound to the tubes was measured by a gamma scintillation counter calibrated for 125 Iodine.
The reference interval was 6.2-38.1 nmol/l (7). The intraassay coefficient of variation (CV) of salivary cortisol
concentration and amylase activity determination was 7.06% and 1.4%, respectively. Arithmetic mean ±
standard deviation of the mean (SD) was determined. Data were analyzed for statistical significance using
Chi-Square test in the case of categorical variables, while Student’s t-test was applied for continuous
variables. A p value less than 0.05 was considered significant.

Results
In the present study the average DAS score was 10.84±3.25. The DAS did not show any significant
difference between genders, so the 32 students were considered one group statistically. There were 9
fearful students (28%), having DAS scores of 13 or higher. The change of objective parameters reflected the
increase or decrease of dental fear during treatment, so these changes were calculated and were used to
compare the methods.

Positive correlations were observed between the change of systolic pressure, pulse rate, sweating scores
and salivary cortisol concentration (Figure 1).

Figure 1 Correlation between changes of the systolic pressure, pulse rate, sweating score and salivary cortisol
concentration during treatment. Filled symbols represent cases where the parameter displayed on the abscissa
was greater after the treatment than its pre-treatment baseline value. In contrast, open symbols indicate data
where the parameter displayed on the abscissa increased during the treatment. A, B: Salivary cortisol
concentration plotted against the systolic pressure and pulse rate, respectively. C, D: Changes of sweating score
as a function of the systolic pressure and pulse rate. E: Correlation between changes of the sweating score and
salivary cortisol concentration. All the correlation shown were statistically significant (p<0.05)

The change of salivary cortisol concentration significantly correlated with the change of systolic pressure
(p=0.022) (Figure 1A) and pulse rate (p=0.018) (Figure 1B). Similarly, significant correlation was obtained
between the change of systolic pressure and sweating score (p=0.0019) (Figure 1C) and also between the
change of pulse rate and sweating score (p=0.0001) (Figure 1D). Finally, the change of sweating score

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showed significant correlation with the change of salivary cortisol level (p=0.006) (Figure 1E). However, the
change of salivary alpha-amylase activity failed to correlate significantly with any of the other parameters
studied, i.e. with systolic pressure (p=0.409), pulse rate (p=0.543), sweating score (p=0.763), or salivary
cortisol concentration (p=0.720). From the determined objective parameters only the change of salivary
cortisol concentration (p=0.0035) and sweating score (p=0.0022) showed significant correlation with the
score of the dental anxiety scale (Figure 2A, 2B).

Figure 2 Correlation between changes of the salivary cortisol concentration (A), sweating score (B) and results
obtained with the dental anxiety scale. Filled and open symbols represent cases where the parameter displayed on
the abscissa was higher or lower, respectively, than the respective parameter before the treatment. Correlations
were statistically significant (p<0.05).

Surprisingly, the change of pulse rate (p=0.079), systolic pressure (p=0.664) and salivary alpha-amylase
concentration (p=0.563) showed no correlation with dental anxiety scale. Significances of correlation are
summarized in Table 1 for the sake of better comparison.

Table 1 Correlation between the subjective and objective measuring methods of dental fear

According to our results, the students can be divided into two groups. In the first one, systolic pressure,
pulse rate, sweating score and salivary cortisol concentration decreased after the treatment compared to
baseline. In the second group these values increased after treatment. Those adolescents, whose salivary
cortisol concentration had increased after treatment, had significantly higher DAS scores, compared to
those showing decreased or unchanged salivary cortisol levels after treatment (p=0.02, Figure 3A). Similarly,
increased sweating scores were also associated with significantly higher DAS values (p=0.04) (Figure 3B).

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Figure 3 Patients were divided into two groups according to changes (elevation or reduction) in salivary cortisol
concentration (A) and sweating score (B) during treatment, and mean DAS scores of the two groups were
compared. Symbols and bars denote arithmetic means ± S.D. values. Differences were statistically significant
(p<0.05) in both cases

Discussion and conclusion

Several techniques are currently available for the measurement of fear, including subjective and objective
methods. Measurements of salivary cortisol concentration, salivary alpha-amylase activity, heart rate, and
rate of respiration, blood pressure, tension of skeletal muscles, skin temperature, and sweating are
considered objective, while the subjective methods are based on direct and indirect questionnaires. The
stress response is controlled by two primary neuroendocrine systems. In the first line there is an activation
of the autonomic sympathetic nervous system resulting in release of catecholamines from the adrenal
medulla. The second line involves the increased secretion of glucocorticoid hormones (mainly cortisol)
from the adrenal cortex due to activation of the limbic hypothalamic-pituitary-adrenal axis. Concentration
of cortisol in the serum, saliva, or urine can easily be determined, and is frequently applied as a peripheral
indicator of hypothalamic neural activity (8).

The determination of salivary cortisol is considered superior to the measurements from other sources (i.e.
plasma or urine), because the technique is non-invasive and collection of the sample is easy, especially in
children (9). Salivary cortisol increases with dental stress, strongly correlate with cortisol concentration in
blood (10). Salivary cortisol concentration is a valid measurement technique of fear. Corah’s Dental Anxiety
Scale is suitable to measure the overall dental fear. In the present study the mean DAS score was
10.84±3.25, a value comparable to data (10.7±3.7) previously reported by Fábián et al. (11), who studied
dental fear scores in Hungarian primary school children, although it was higher than data (8.4-9.3) obtained
by others (12). No significant correlation between the DAS score and results of objective methods was
obtained in the present study when assessing dental fear, except for the salivary cortisol level and the
sweating score. Earlier studies produced conflicting results.

In agreement with our findings, several investigators observed significant correlation between DAS score
and cortisol concentration (13, 14), although Brand (15) failed to explore the correlation between these
variables. Furthermore, similarly to the results of Krueger et al. (16), we found that patients with high
salivary cortisol level were more aroused and anxious and had significantly higher DAS scores, than those
with decreased cortisol concentration.

Based on previous results, salivary alpha-amylase concentrations were believed to be good predictors of
plasma catecholamine levels (particularly in the case of norepinephrine), since they were shown to highly
correlate with changes in the norepinephrine concentrations in response to stress (2). Thus salivary alpha-
amylase was supposed to be a useful indicator of stress, however, several factors (like smoking, caffeine,
tea, as well as the time elapsed from meals) are known to induce instability of alpha-amylase levels (6, 17).
Indeed, the vast majority of the most recent studies, in line with our present results, showed marked
individual differences in alpha-amylase, and these values failed to correlate with salivary cortisol
concentration during stress (2,18). Today it is a matter of debate whether salivary alpha-amylase may be an
indicator of sympathetic activity, or not. Our results, in accordance with those of Rohleder et al. (2), indicate

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that salivary alpha-amylase is not a specific marker of stress. Sweating is an indirect and reliable
measurement of dental fear (19, 20). Sweating is triggered (among other stimuli) by stress, fear and
anxiety. Measurement of the skin moisture is based on the internationally recognized Corneometer®
method. The measuring principle of the Corneometer® is based on the capacitance measurement of a
dielectric medium. Any change in the dielectric constant due to skin surface hydration variation alters the
capacitance as detected by a precision measuring capacitor. With the probe of the Corneometer® CM 825
single measurements as well as continuous monitoring are equally feasible. The software running under
Windows helps in all fields of application. The data can be stored, printed out and exported for statistical
use. In the present study sweating scores reasonably well reflected the parameters of the objective
measurements.

According to our results, measurement of salivary cortisol level, blood pressure, pulse rate and sweating
score were valuable objective methods to measure dental stress with high fidelity. The measurement of
salivary cortisol concentration is time consuming and restricted to specific laboratory background.
Furthermore, the measurement of salivary cortisol concentration and the subjective questionnaires are not
suitable to monitor the fear during the treatment. Monitoring of fear can help us to understand which the
most fearful point is during the treatment, and this is essential to help the patient to get through fear and
anxiety. The use of Pulsoxymeter Nonin® 8500M and Corneometer® CM 825 can be effective to measure
dental fear not just before and after the treatment, but also during it. Although the use of Pulsoxymeter is
a simple method, the adolescents are cognizant of the measurement, and felt this method uncomfortable.
On the contrary, the application of Corneometer® CM 825 can help us to measure dental fear within 1
second without causing any discomfort in patients. They do not even realize when the measurement is
taken, so Corneometer® monitoring is quite simple during the treatment, the dental assistant can do it as
well. Although this study was made in dentistry, Corneometer® CM 825 can also be used in general
practice, whenever it is necessary to monitor the change of anxiety during any type of treatments.

References

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