Saudi Journal of Oral Sciences

: 2019  |  Volume : 6  |  Issue : 2  |  Page : 60--64

The impact of dental anxiety on the salivary cortisol and alpha-amylase levels of children undergoing dental treatment

Majed AlMaummar1, Huda Othman Althabit2, Sharat Chandra Pani3,  
1 Department of Pediatric Dentistry, National Guard Health Affairs, Riyadh, Saudi Arabia
2 Saudi Board in Pediatric Dentistry, Saudi Arabia
3 Department of Preventive Dental Sciences, Riyadh Elm University, Riyadh, Saudi Arabia

Correspondence Address:
Dr. Sharat Chandra Pani
Department of Preventive Dental Sciences, Riyadh Elm University, PO Box 84891, Riyadh 11681
Saudi Arabia


Background and Aim: The purpose of this study was to assess the salivary cortisol and salivary alpha-amylase levels in children aged between 6 and 9 years immediately prior to dental treatment. Methodology: A total of 183 patients aged between 6 and 9 years who were awaiting dental treatment were administered the Arabic version of the Children's fear survey – dental subscale and accordingly allocated to one of three groups: phobic patients, anxious patients, and control group. Patients' heart rate in the waiting area, salivary cortisol, and salivary amylase were compared among the groups. Results: The results of the study showed that amylase and cortisol levels had a significant association with the level of dental fear. The phobic patients had the highest levels of salivary amylase and salivary cortisol levels with no significant associations observed with either heart rate. Control and anxious patients had significantly lower amylase levels when compared to phobic patients. There was no significant difference between the salivary cortisol levels of anxious and phobic patients. Conclusions: Within the limitations of this study, we can conclude that salivary amylase is a good indicator of acute stress that can differentiate between anxiety and dental fear, while salivary cortisol is a good indicator of the phobia induced by a flight or fight response.

How to cite this article:
AlMaummar M, Althabit HO, Pani SC. The impact of dental anxiety on the salivary cortisol and alpha-amylase levels of children undergoing dental treatment.Saudi J Oral Sci 2019;6:60-64

How to cite this URL:
AlMaummar M, Althabit HO, Pani SC. The impact of dental anxiety on the salivary cortisol and alpha-amylase levels of children undergoing dental treatment. Saudi J Oral Sci [serial online] 2019 [cited 2019 Sep 16 ];6:60-64
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Dental fear remains a significant challenge to obtaining good oral health care with multiple studies showing an association between dental fear and reduced dental visits.[1],[2],[3] The Diagnostic and Statistical Manual for Mental Disorders recognizes dental phobia as a specific disorder and places it as a subtype of blood injection and injury type of phobia.[4] While the theoretical difference between anxiety and fear has been reported in literature, a practical differentiation remains hard to estimate.[5]

Given that the cognitive process of a child is a continually developing process, there is evidence in literature to support the idea that children at different ages exhibit different patterns of fear,[6],[7],[8] with agreement on the relationship between dental fear and the cognitive development of individuals.[9],[10] The age between 6 and 9 years has been documented previously as a good starting point to measure the development of the cognitive process, and therefore by extension, a good time to study phobias and behavioral problems.[11],[12]

Cortisol is a hormone secreted by the adrenal glands and is a documented marker of the “fight or flight” response of humans. For this reason, cortisol has been used as a marker of both stress and anxiety for over five decades.[13] In dentistry, salivary cortisol has been used to measure the role of stress in the anxiety of dental treatment in both adults and children.[14],[15] Salivary alpha-amylase has been recently established as a complimentary diagnostic tool to salivary cortisol.[16],[17],[18] However, the exact mechanism of alpha-amylase in dental fear and anxiety in children remains poorly understood.

While biomarkers are a useful indicator of long-term stress, heart rate is a far more useful indicator of immediate fear, anxiety, and stress.[19] While there have been studies that use salivary markers as biomarkers for dental fear, phobia as a specific condition has received less attention. The aim of this study was to evaluate the salivary cortisol and alpha-amylase levels in children aged 6–9 years and correlate the levels of these hormones to the heart rate and their score on the Arabic version of the Child Fear Survey-Dental Subscale (CFSS-DS).


Ethical approval

The study was registered with the research centers of the King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia and the Institutional Review Board of the Riyadh Elm University, Riyadh, Saudi Arabia. Ethical approval was obtained from the Institutional Review Board of the KAIMRC (RC15-007). Informed consent was obtained from all parents and assent obtained from all children before including them in the study.

Source of patients

The sample comprised children who had completed a first dental visit and were awaiting dental treatment at the Dental University Hospital of the Riyadh Elm University and the Dental Clinics of the National Guard Health Affairs, Riyadh. A total of 183 children whose parents consented to examination and who assented to examination were included in the study. The children were divided into three groups:

Control Group (Group A) – Comprised patients who had been given a Frankl score of positive (+) or definitely positive (++) on the first dental visit were administered an Arabic version of the CFSS-DS. Patients who scored lower than 20 on the recall visit were assigned to this group.

Anxious patients (Group B) – Comprised patients who had been given a Frankl score of negative (−) or definitely negative (−−) on the first dental who scored higher than 32 on the Arabic version of the CFSS-DS.

Phobic patients (Group C) – Comprised patients who had been given a Frankl score of definitely negative (−−) on two separate occasions and were referred for dental treatment under general anesthesia. These patients scored above 32 on the CFSS-DS in the recall visit were classified as phobic patients using previously proposed criteria.

Sample size and power

The sample power was calculated using the G power Sample Size Calculator (Universitat Kiel, Keil Germany). Multiple sample power protocols were calculated for the one-way ANOVA and the Kruskal–Wallis test. The protocol showed that the minimum required subjects for an alpha of 0.05 with (1-β) of 0.95 and effect size of 0.5 (large effect size) was 66. The final sample achieved (n = 183) gave an actual power of 0.987.

Data collection

Collection and analysis of saliva

Stimulated saliva was collected using the passive drool method [20] into sterile collection tubes (Greiner Bio-One GmbH, Austria). These tubes were stored in a vaccine box (Apex International, Uttar Pradesh, India) at ≈5°C for half an hour before being transferred to a deep freezer at −80°C where they were stored until analysis. Early morning saliva was collected 3 h after the patient has woken up, noon saliva was collected at 12 pm, and evening saliva was collected at 8 pm. The saliva cortisol and amylase levels were then normalized for diurnal variation using standard protocols.[13],[21] The salivary cortisol was measured using commercially available chemoimmunoluminescence assay kits for salivary amylase and salivary cortisol (Cobas integra400 plus, Roche Diagnostics, Risch-Rotkreuz, Switzerland) and analyzer (Cobas e411, Roche Diagnostics, Risch-Rotkreuz, Switzerland).

Monitoring of the heart rate

Heart rate was measured using a pulse oximeter (Beurer, PO30, Beurer GmbH, Uttenweiler, Germany). Heart rate was recorded in the waiting room prior to the commencement of treatment. Heart rate was recorded over a 5-min period at 30 s intervals and the mean heart rate was used for the analyses.

Administration of questionnaire and data collection

The demographic data of the child was collected by administering a questionnaire to the father and the mother. The questionnaire contained questions regarding the age, sex, and taking other medication, the next part of a questionnaire filled by the dentist during the clinical examination contained behavior management, pulse rate, number of carious teeth, number of recurrent carious teeth, plaque accumulation, number of stainless steel crowns (SSC), and recall visit by month. The last part consisted of the CFFS-DS questionnaire that was administered to the child. The CFSS-DS is a subjective measure of dental fear that has been validated in Arabic and has been found to be useful in the measurement of fear in children.[22] The tool has been previously used to differentiate between fearful and phobic dental patients. The questionnaire also served as a means of obtaining informed consent.

Statistical analysis

Given the predisposition of salivary biomarkers to exhibit skew, an analysis of skew was done on the cortisol and amylase values of the population. No significant skew was found in the distribution of either cortisol (skew = 0.12) or amylase (skew = 0.09), thus allowing for the use of parametric statistics. The values of salivary cortisol and amylase were compared between the groups using a one-way ANOVA and Tukey's post hoc test. Gender differences were analyzed using the t-test. All statistical analyses were carried out using the SPSS version 21 data processing software (IBM Corp., Armonk, NY, USA).


There were 87 girls and 96 boys with a mean age of 7.43 (standard deviation [SD] =1.2). The patients were aged between 6 and 9 years, and though the males were slightly older than the females, there was no significant difference in age between the genders (P = 0.089). Although there were more males than females, the Chi-square test showed these differences to be statistically insignificant.

The average heart between different groups was 97.3 (SD = 13.77) with the highest heart rates observed with anxious patients. The one-way ANOVA showed these differences to be significant at both the 3 months and the 1-year findings [Table 1]. The Tukey's post hoc test showed that significant differences existed between the control and the anxious patients (P < 0.05). Interestingly, no significant differences existed between the control and anxious patients. Similarly, no statistically significant difference between the anxious and the phobic patients was observed [Table 1].{Table 1}

When the salivary amylase levels between the different groups were tabulated, it was observed that the phobic patients had the highest levels of salivary amylase, followed by the anxious patients with the control group having the lowest levels of salivary amylase. The one-way ANOVA found that these differences were statistically significant (P = 0.029) [Table 2]. When the differences between groups were compared using the Tukey's honestly significant difference (HSD) post hoc test, it was observed that phobic patients had significantly higher amylase levels when compared to control and anxious patients. No significant differences were observed between the anxious patients and the control patients.{Table 2}

The salivary cortisol levels varied significantly across groups. The control group had the lowest levels of salivary cortisol, while the patients classified as phobic had the highest levels of salivary cortisol [Table 3]. The one-way ANOVA showed that there was a significant difference among the groups at both 3 months and 1-year posttreatment [Table 3]. The Tukey's HSD post hoc demonstrated that the cortisol levels of the control group were significantly lower than those of the anxious and phobic patients (P < 0.05) [Table 3].{Table 3}


Child dental fear is one of the major problems that the dentist face in practice and has been linked to poor dental health.[1],[6],[7] Previous studies have shown that dental fear and the behavioral problems it causes are linked to the age of the child.[23],[24],[25] It is therefore reasonable that any study that aims to study dental fear must focus on a fixed age group. The age group 6–9 years has been used by several previous authors and has been proposed as an age where cognitive development begins to manifest itself.[26]

Demographically, this study found more females than males in the anxious group, a finding that is supported by previous studies.[27],[28] This is, however, contrary to other studies done on schoolchildren which have reported no difference in anxiety between girls and boys.[23],[24],[25] This study found no significant difference in age across which could be attributed to the strong age matching that was done during the stage of cross-matching. The fact that we found no age difference in fear among the different groups of this study seems to validate our rationale of choosing the age of 6–9 years as a homogenous study group.

The rationale for choosing heart rate as an indicator was based on previous studies which have demonstrated its usefulness in measuring the degree of stress and anxiety in patients undergoing dental treatment.[29],[30],[31] Our findings of significant differences in measurements of heart rate between the control and the anxious patients, in the waiting area prior to dental treatment, seem to confirm that patients who are anxious face increases in heart rate even when not in the dental chair. Interestingly, the patients classified as phobic using the CFSS-DS did not have a significantly higher heart rate than the control group. These findings need to be interpreted with caution, as the current study only observed the dentist's perception of the child's behavior and not the actual subjective feelings of the child. Furthermore, the current study measured heart rate in the waiting area, unlike the study by Wannemueller et al. which looked at the heart rate in response to a specific stimulus.[32]

Our results demonstrated that the cortisol levels of the control group were significantly lower than those of the anxious and phobic patient. However, we found no significant difference between the salivary cortisol levels of anxious and phobic patients. This further validates the theory that expression of fear is a result of the activation of the sympathetic response.[32]

In using the CFFS-DS as a tool for measuring the extent of fear and phobia, we were building on the work of El-Housseiny et al.[22] and ten Berge et al.[24] The salivary biomarker findings of this study indicate that there is some merit to classifying patients as anxious or phobic based on their fear score. The amylase and cortisol levels seen in our patients seem to demonstrate that not only is dental phobia distinct from dental fear and/or anxiety, but it also manifested differently in terms of biomarkers secreted. There is a need to view the stability of these findings, and a follow-up study spanning at least 1 year would be a field of further research.


Within the limitations of the study, we can conclude that in children aged between 6 and 9 years:

There is a definite relationship between dental fear and assays of salivary cortisol and salivary amylase which confirms the use of these biomarkersSalivary cortisol can serve as an assay of dental fear but cannot differentiate between patients who are anxious and those who are phobicSalivary amylase has poor correlation with anxiety scores but is effective at detecting dental phobia.


This study was supported by grant number RC15-007 of the KAIMRC, National Guard Health Affairs, Kingdom of Saudi Arabia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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