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Table of Contents   
ORIGINAL RESEARCH  
Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 263-266
Evaluation of stress among dental undergraduates and postgraduates using salivary cortisol as a biomarker


Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Uthandi, Chennai, Tamil Nadu, India

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Date of Submission23-May-2021
Date of Decision13-Sep-2022
Date of Acceptance03-Oct-2022
Date of Web Publication17-Jan-2023
 

   Abstract 


Background: Stress is a non-specific response of the body to any demand. Professional education has a certain level of stress inherent in it. Dental students have been reported in the literature to experience more stress than medical students. Objective: To evaluate the stress levels of dental students: first-year undergraduates, house surgeons, and final-year postgraduates, using salivary cortisol as a stress biomarker. Materials and Methods: Dental students above 18 years of age and without any systemic illness were included in the study. Those students with a drug history of corticosteroids, anti-depressants, and oral contraceptives were excluded from the study. Female participants experiencing pre-menstrual symptoms, pregnancy, and familial stressor issues were excluded from the study. First-year undergraduates, house surgeons, and final-year postgraduates were enrolled in the study. Unstimulated whole saliva was collected in the morning and evening between 9:00 and 10:00 am and between 3:00 and 4:00 pm. Salivary cortisol levels were assessed by chemiluminescence immuno-assay (CLIA). Results: Paired sample t-test was used to compare the diurnal variation among morning and afternoon samples within the groups. The salivary cortisol levels were found to be significant within the groups. One-way ANOVA was used to compare the salivary cortisol levels between the groups. The salivary cortisol levels within the groups were not statistically significant. Conclusion: Salivary cortisol is a non-invasive biomarker of stress. Postgraduates had higher salivary cortisol levels than other study groups.

Keywords: Dental students, stress, salivary biomarker, salivary cortisol

How to cite this article:
Vasanthi V, Thavarajah R, Joshua E, Rao UK, Ranganathan K. Evaluation of stress among dental undergraduates and postgraduates using salivary cortisol as a biomarker. Indian J Dent Res 2022;33:263-6

How to cite this URL:
Vasanthi V, Thavarajah R, Joshua E, Rao UK, Ranganathan K. Evaluation of stress among dental undergraduates and postgraduates using salivary cortisol as a biomarker. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 5];33:263-6. Available from: https://www.ijdr.in/text.asp?2022/33/3/263/367882



   Introduction Top


Saliva is a biofluid that reflects the physiological and pathological conditions of the body. Salivary diagnostics is a dynamic and emerging field in the diagnosis of oral and systemic diseases. The favourable attributes of saliva over other biofluids are non-invasiveness, self-collection, safe-handling, economy, and easy storage. Microbial and molecular elements in saliva have led to the development of “Salivaomics”, emphasising the role of saliva to the entire physiological system.[1],[2]

Cortisol is a glucocorticoid hormone produced by the zona fasciculata of the adrenal gland, regulated by the hypothalamic pituitary axis (HPA). Up to 95% of the secreted cortisol is bound to large proteins [corticosteroid binding globulin (CBG) albumin] and transported in the blood with a small fraction of unbound free cortisol that is biologically active. Because of its low molecular weight and lipophilic nature, unbound cortisol enters cells by passive diffusion, making it possible to measure the free cortisol fraction in all bodily fluids – urine, serum, or saliva. The secretion of this hormone follows a defined diurnal rhythmic pattern with a sharp peak in the early morning and with the lowest levels in the late evenings and night. Salivary cortisol is used as a non-invasive biological marker of stress as free cortisol from saliva is not dependent on salivary flow rate.[3],[4]

The word stress is derived from a Latin word called “stringere”, meaning to draw tight. The term stress was described by Seyle, the founder of stress theory as “the non-specific response of the body to any demand”. Stress has now become an integral part of our existing lifestyle.[5]

Various elements such as gender differences, peer support, lack of confidence, linguistic barrier, performance pressure, financial resources, academic assessments, clinical training, and fear of unemployment contribute to the stress perceived by the dental students. The aim of the present study was to compare the stress levels among the first-year undergraduate dental students, house surgeons, and final-year postgraduate dental students and evaluate the role of salivary cortisol as a stress biomarker.


   Materials and Methods Top


The study was approved by the Institutional Ethics Committee (20160229). This cross-sectional study was conducted among the first-year undergraduate, house surgeon, and final-year postgraduate students. Informed consent was obtained from voluntary participants of the study. First-year undergraduates, house surgeons, and final-year postgraduates were categorized as Group I, II, and III, respectively. A total of 60 participants with 20 in each group were included in the study.

Students above 18 years of age and without any systemic illness were included in the study. Those students with a drug history of corticosteroids, anti-depressants, and oral contraceptives were excluded from the study. Female participants experiencing pre-menstrual symptoms, pregnancy, and familial issues were excluded from the study. The study was carried out 3 months prior to the academic assessment.

The participants were instructed to avoid intake of acidic drinks, milk, and solid food 60 minutes before the scheduled saliva sample collection. The participants were appropriately trained on the method of saliva collection. To follow the cicardian rhythm, unstimulated whole saliva was collected during the morning and evening hours between 9:00 and 10:00 am and between 3:00 and 4:00 pm, respectively. The participants were made to sit in an erect position with the head flexed forward and asked to accumulate saliva for 5 min. Saliva was collected by a spitting method into a collection device and stored at -20°C until processing. Salivary cortisol levels were assessed by the chemiluminescence immuno-assay (CLIA) method. Morning and evening levels of salivary cortisol less than 0.69μg/dl and 0.43μg/dl were considered as normal values, respectively.

The data were analysed using Statistical Package for Social Sciences version 16. P value less than 0.05 was considered significant. Paired sample t-test was used to compare the diurnal variation between morning and afternoon samples within each group. One-way ANOVA was used to compare the salivary cortisol levels between the three groups.


   Results Top


In our study population, 52% were males and 48% were females. 15% of males and 18% of females were between 18 and 20 years of age, 17% of both males and females were aged between 21 and 25 years, 15% of males and 5% of females belonged to 25–30 years of age, and 5% of males and 8% of females belonged to 31–35 years of age [Figure 1]. Of the 60 participants, 63% had normal salivary cortisol levels and 37% had increased salivary cortisol levels, of which 16% were males and 21% were females [Figure 2].
Figure 1: Distribution of age and sex among study participants

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Figure 2: Distribution of salivary cortisol levels among study groups

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The mean salivary cortisol level was compared within each group to reflect the diurnal variations. The mean of morning and evening salivary cortisol of Group I was 0.582 ± 0.223 and 0.364 ± 0.099, that of Group II was 0.648 ± 0.216 and 0.424 ± 0.126, and that of Group III was 0.720 ± 0.423 and 0.441 ± 0.248, respectively. The difference between the means of morning and evening salivary cortisol was statistically significant for each group (p = 0.00).

On comparing the mean of morning salivary cortisol levels, Group III students experienced higher levels of stress, followed by Group II and Group I. The difference was not statistically significant [Table 1] and [Figure 3]a.
Table 1: Comparison of morning salivary cortisol levels between the groups

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Figure 3: Comparison of morning (3a) and evening (3b) salivary cortisol levels among study groups

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When the difference in mean of evening levels of cortisol was compared, Group III students had higher levels, followed by Group II and Group I. The difference was not statistically significant between the means of evening salivary cortisol levels among Group I, II, and III [Table 2] and [Figure 3]b.
Table 2: Comparison of evening salivary cortisol levels between the groups

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   Discussion Top


Dental education is reported to be considerably more stressful than medical education.[6] In India, undergraduate dental education is a 4-year programme with an additional 1 year of internship training. Postgraduate training is a 3-year programme in the respective speciality. Each academic year in undergraduate and postgraduate dental training is indigenously designed to impart intellectual and clinical skills in students. It is understood that a considerable amount of stress is native to medical and allied health sciences training.[7] Analytes in saliva can be used as part of the evaluation of endocrine functions. The readily repeatable nature makes salivary cortisol an ideal tool for investigating the cortisol response to stress in a research setting, particularly when a measure of free cortisol is desired.

These groups were specifically selected as they serve as a model for different phases of dental education including entry and exit, expecting a better scope with great employment opportunities. The curriculum for first- and second-year undergraduate students is designed to expose them to basic medical sciences and pre-clinical procedures. Home sickness, peer pressure, fear of approaching faculty, pre-clinical workouts, and basic medical sciences curriculum open the door to anxiety. Third- and final-year undergraduates are taught the clinical skills to treat patients. This transition to clinical training is expected to create anxiety in students. Perhaps the satisfaction on completion of the clinical procedure alleviates the temporary fear and anxiety. On completion of 4 years, students are entitled to 1 year of compulsory rotatory residential internship. The way this crucial period is handled by the students makes them stand apart. With respect to postgraduates, discussions are scheduled with faculties to bring out their critical analysing, research, and intellectual expertise over a time period of 3 years.

As salivary cortisol is a biological marker of stress which activates the HPA axis, cortisol levels were compared between dental first-year undergraduates, house surgeons, and final-year postgraduates to evaluate the amount of stress.

Female students had higher scores compared to male students in our study. Our findings were consistent with Al-Saleh et al.[8] and Hayes et al.[9] This could be attributed to the psychological traits between genders. Females express their emotions and experiences more than males. This view is different from the findings of Pani et al.,[10] who reported higher levels of salivary cortisol levels among males than among females.

First-year undergraduates experienced comparatively lower levels of stress. Uraz et al.[11] also reported similar findings as the stress from performance pressure and academic factors was considerably less in the first year. This may be because of the fact that their minds are imbibed with the rules of their school and the excitement of starting their white coat journey. In our study, the salivary samples were collected 3 months before the exams to evaluate stress levels. The stress to attain good academic grades, knowledge, and professional skills is not much experienced during this time period. This was in contrast with the findings of Silverstein and Kritz-Silverstein,[12] who reported increased stress among first-year dental students.

The salivary cortisol levels of students doing internship were comparatively higher than those of first-year undergraduates but lower than those of final-year postgraduates in our study. Our findings were consistent with the findings of Abu-Ghazaleh et al.,[13] who reported that clinical years are more stressful than non-clinical years. Paudel et al.[14] reported that patient management and responsibilities contribute to stressors among fourth- and fifth-year dental students. Factors such as fear of wrong diagnosis, hurting patients, getting infected, and dealing with medical emergencies could contribute to the anxiety within them.[15] Imbalance between employment opportunities and the number of graduating dentists plays a vital role as it creates a feeling of insecurity towards opportunities. Shaik et al.[16] reported that stress could also be because of the uncertainty in being economically independent following graduation.

Postgraduates had a higher stress score than other study groups. Nettam et al.[17] reported higher levels of burnout in postgraduate dental students than in undergraduates. Gorter et al.[18] stated that increased burnout in postgraduates might be from the continuation of stress levels from undergraduation to postgraduation studies. Various sources of stress among postgraduates could include the lack of confidence as they are involved in more academic activities such as paper presentations, dissertations, and publications in addition to the comprehensive patient care.[19] This could also be supported by the fact that postgraduate students are influenced by the scope of their speciality and employment opportunities upon completion as they would no longer be dependent on their parents for financial support. The expectations from family and society are also quite high upon graduation. Dental students might also be recommended to attend various stress management activities such as deep breathing exercises and progressive muscle relaxation.[20]

A limitation of the study is that the present study is a single-centre study. Further studies representing students from multiple dental colleges would give a better insight on perceiving of stress among dental students.


   Conclusion Top


Salivary cortisol has been proven in the literature to be a stress biomarker as compared to serum. High levels of salivary cortisol were observed in postgraduate students. Self-assessment of stress levels by undergraduates and postgraduates at periodic intervals might improvise their academic performance. It is evident that a negligible amount of stress is inevitable to attain good academic grades, knowledge, and clinical skills in professional education.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Silverstein ST, Kritz-Silverstein D. A longitudinal study of stress in first-year dental students. J Dent Educ 2010;74:836-48.  Back to cited text no. 12
    
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Abu-Ghazaleh SB, Sonbol HN, Rajab LD. A longitudinal study of psychological stress among undergraduate dental students at the University of Jordan. BMC Med Educ 2016;16:1-6.  Back to cited text no. 13
    
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Paudel S, Subedi N, Shrestha A. Stress and its relief among undergraduate dental students in a tertiary health care centre in eastern Nepal. Dentistry 2013;3:157.  Back to cited text no. 14
    
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Kieser J, Herbison P. Clinical anxieties among dental students. N Z Dent J 2000;96:138-9.  Back to cited text no. 15
    
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Shaik PS, Pachava S, Palli CB. Factors affecting stress among students in dental colleges of neo-capital state in India. J Indian Assoc Public Health Dent 2019;17:41-7.  Back to cited text no. 16
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Nettam V, Mandava P, SankarSingaraju G, Ganugapanta VR, Yelchuri H, Revathi P. Comparison of stress, burnout and its association among postgraduate orthodontic and undergraduate students in India. Indian J Dent Sci 2018;10:66-71.  Back to cited text no. 17
    
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Correspondence Address:
Dr. V Vasanthi
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Uthandi, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.ijdr_498_21

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