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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 1  |  Page : 14-17

Estimation of salivary cortisol level and psychological assessment in patients with oral lichen planus


1 Department of Oral Medicine and Radiology, KD Dental College and Hospital, Mathura, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, AECS Maruti Dental College, Bengaluru, Karnataka, India
3 Department of Oral Medicine and Radiolog, Vyas Dental College, Jodhpur, Rajasthan, India

Date of Submission16-Sep-2017
Date of Acceptance17-Feb-2018
Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Anuj Gaur
Department of Oral Medicine and Radiology, KD Dental College and Hospital, Mathura, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_98_17

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   Abstract 


Introduction: Oral lichen planus (OLP) is a relatively prevalent chronic inflammatory disease, which affects the skin and mucous membrane. The etiology of OLP is unknown and there is controversy over the role of stress as an etiologic factor of OLP. Aim: To assess the salivary cortisol levels and psychological factors in OLP patients. Material and Methods: This study investigated the salivary cortisol level in 30 clinically and histopathologically proven OLP patient and 30 healthy individual. Salivary cortisol levels were analyzed by enzyme-linked immunosorbent assay methods. The psychological factors of study and control groups were assessed by DASS 21questionnaire (depression anxiety stress scale). Salivary cortisol levels and psychological factors were compared by using student's t-test. Results: The mean salivary cortisol level among study group was 9.90 ± 3.09 ng/dL as compared to the 6.92 ± 2.21 ng/dL of the control group with P < 0.001 which was highly significant. Study showed significantly higher stress anxiety and depression levels when compared to controls. Conclusion: Hence, it is concluded that increased salivary cortisol levels and psychological factors showed positive results in development of OLP.

Keywords: Depression anxiety stress, oral lichen planus, salivary cortisol


How to cite this article:
Gaur A, Kumar C A, Kumar JS, R. Nair GK, Agrawal VM. Estimation of salivary cortisol level and psychological assessment in patients with oral lichen planus. J Indian Acad Oral Med Radiol 2018;30:14-7

How to cite this URL:
Gaur A, Kumar C A, Kumar JS, R. Nair GK, Agrawal VM. Estimation of salivary cortisol level and psychological assessment in patients with oral lichen planus. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2020 Aug 14];30:14-7. Available from: http://www.jiaomr.in/text.asp?2018/30/1/14/230903




   Introduction Top


Many systemic diseases manifest in the oral cavity. In some conditions, oral cavity provides the first sign for the detection of underlying systemic disease. Dermatological disorders are one such class of diseases that have oral manifestations. Thus, the dentist must be in a position to establish the diagnosis of a dermatologic disease before the cutaneous lesions becomes apparent. Lichen planus, pemphigus, and pemphigoid are a few examples of dermatologic diseases that have oral manifestations.[1]

Lichen planus is a chronic inflammatory mucocutaneous disease of unknown etiology affecting the skin and/or oral mucosa.[2]

Cortisol, which is also called as “stress hormone”, has been used as an indicator in the stress evaluation studies . Most studies consider salivary cortisol levels a reliable measure of hypothalamus-pituitary-adrenal axis (HPA) adaptation to stress.[1]

Salivary cortisol measurement is an indicator of free cortisol or biologically active cortisol in human serum and provides noninvasive and easy technique.[3] Taking all these aspects into consideration, a need was felt to evaluate the salivary cortisol levels in oral lichen planus (OLP) patient with psychological assessment.


   Materials and Methods Top


This study was conducted to estimate the levels of salivary cortisol and psychological assessment in patients with OLP, in the Department of Oral Medicine and Radiology, Kanti Devi Dental College and Hospital Mathura, Uttar Pradesh, after receiving approval from the ethical committee.

The study population included 60 patients (both male and female) from places in and around Mathura. The control groupconsisted of 30 normal healthy individual and diseased group consisted of 30 patients with OLP (clinically confirmed and histologically diagnosed) were included in the study. The patients with long-term systemic disorders and autoimmune disorders, patients who were previously diagnosed and treated for OLP and patients with any adverse habits of chewing areca nut, gutka, tobacco, and smoking were excluded from the study.

The patients were selected for saliva collection in morning hours between 9 am and 10 am to avoid diurnal variations. In each case approximately 2.0 mL of stimulated saliva was collected from the subject by drawing the saliva on test tubes and later passing it into a sterile glass centrifuge tube. The samples were immediately frozen at -20°C and maintained at the temperature until shortly before assay. The samples were thawed at 37°C, and then immediately centrifuged at 8,000 rpm for 10 min. The supernatant fluid, thus obtained, was used for assay of cortisol estimation using salivary cortisol enzymes linked immunosorbent assay (ELISA) kit. The following values of normal samples were used as the primary guidelines:

AM – 3–10 ng/mL

PM – 0.6–2.5 ng/mL

After the procedure of saliva collection, psychological evaluation was done with depression, anxiety, stress scale (DASS 21). This scale enclosed a self-assessment questionnaire of 21 questions. For purpose of benefit to the patient, the questionnaire was translated in regional language of “Hindi”.

The statistical analysis was presented as mean ± standard deviation (SD) for quantitative/continuous data, and number and percentages for categorical data. Student's t-test was used for comparing the means between the groups. Categorical data was analyzed by paired t-test and unpaired t-test. Regressions were performed for assessing the association of independent variables and their effect/interaction with OLP. For all the tests, a P value of <0.001 or less was considered for statistical significance.


   Results Top


The patients included in the current study were in the age range of 26–67 years. The mean age ± SD was found to be 45.50 ± 28.99 among OLP patients. Among these, 21 (70%) patients were females and 9 (30%) were males [Table 1] and [Table 2].
Table 1: Distribution of study samples

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Table 2: Age wise distribution of control and study group

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Among the study group, we found different clinical forms at multiple sites in most of the patients. Most common forms were reticular (17 patients, 56.67%), erosive (8 patients, 26.67%) plaque (1 patient, 3.33%), and atrophic (4 patient, 13.33%) patterns [Table 3].
Table 3: Clinical patterns of oral lichen planus

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The comparison of salivary cortisol levels were found higher in the study group which was 9.90 ± 3.09 as compared to control group which was 6.92 ± 2.21 [Table 4].
Table 4: Comparison of salivary cortisol between control and study samples

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The salivary cortisol levels in OLP patients were found to be increased in 18 subjects (60.0%), and 12 subjects (40.0%) had normal level, i.e., 3–10 ng/mL [Table 5].
Table 5: Variation in salivary cortisol levels in study samples

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We found increased levels of depression, anxiety, and stress, respectively among the study group, when compared to controls [Table 6].
Table 6: Comparison of psychological stress assessment between study samples

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All these psychological factors were increased in all forms of OLP, that is there was no statistical difference of psychological factors between the erosive and nonerosive groups [Table 7].
Table 7: Comparison of psychological factors and salivary cortisol levels in erosive and nonerosive groups

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In the present study, we found positive correlation between depression, anxiety, and stress with salivary cortisol levels. The analysis showed positive correlation between salivary cortisol levels and depression in control (0.23, HS), erosive (0.78, HS) and nonerosive (0.32, S), anxiety in control (0.18, S), erosive (0.74, S) and nonerosive (0.51, HS) and stress in control (0.24, S), erosive (0.56, S) and nonerosive (0.58, HS) [Table 8].
Table 8: Relationship between psychological factors and salivary cortisol

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   Discussion Top


OLP is a fairly common disease of adults and has a worldwide distribution. Among Indians, the prevalence is found to be 0.02–0.22%, as per recorded in 30,000 dental outpatients.[3]

It is very well-established in the literature that a rise in serum cortisol levels with psychological factors such as depression, anxiety, and stress is due to activation of HPA axis. Though there are changes in the cortisol level at different points of time during the day, a positive correlation was observed between the levels of salivary cortisol in the OLP patients. Secretion of cortisol in saliva is a passive one and it is a reliable indicator of serum levels. This is a noninvasive and easy procedure, for the measurement of salivary cortisol levels and psychological factors in OLP patient.[3]

Various scales were used in the psychological assessment of patients in previous studies some were self-reported and other assessed by a psychiatrist. In a current study, we used a self-reported scale called DASS-21, which can assess all the three parameters, i.e., depression, anxiety, and stress.[3]

Cortisol is the major glucocorticoid in humans and has a wide range of influences on metabolism, immune regulation, vascular responsiveness, cognition, and behavior. Salivary cortisol measurement is an indicator of free cortisol or biologically active cortisol in human serum and provides noninvasive and easy technique.

In the present study, themean salivary cortisol level among study group was 9.90 ± 3.09 ng/dL as compared to the 6.92 ± 2.21 ng/dL of the control group with P < 0.001 which was statistically highly significant. Our results are consistent with the studies by Koray et al.[4] (2003) and Shah [3] (2009).

In the present study, the mean salivary cortisol among study group was 10.24 ± 3.17 ng/dL in nonerosive as compared to the 8.99 ± 2.88 ng/dL of the erosive group with P < 0.05 which was statistically nonsignificant.

Although, the concentration of cortisol in saliva makes up only about 50–60% of the free cortisol in the plasma, numerous studies have shown that salivary cortisol is an accurate measure of adrenocortical function as an index for stress. Salivary cortisol concentrations are highly correlated with biologically active' free' fractions of the hormone in plasma, whereas 90% of circulating cortisol is bound to plasma proteins, particularly transcortin.[5],[6]

Few studies have reported no significant difference in the cortisol levels between controls and OLP patients. One of the research group conducted a study by determining the salivary cortisol levels under stressful conditions, while the other had conducted a study determining the average plasma cortisol and 24 h urine cortisol in OLP patients.[3]

The modern view of the etiopathogenesis of most of the disease suggest them to be influenced by multiple factors, hence requiring a simultaneous evaluation of factors concerned with various etiology. The new biopsychosocial medical model, which comprises of biological finding, psychological and social correlates were described by Eagle, this concept is true for OLP.[7]

Assessment of the etiologic role of psychological factors like anxiety, stress, and depression in patient with OLP (Shetty et al. and Chaudhary 2004, and Giradi et al. 2005) has shown higher levels of stress anxiety and depression in comparison with controls.[1],[8],[9]

Numerous studies have shown that significantly higher stress, anxiety, and depression levels were found in patients with OLP when compared to the controls. This feature was noticed in present study with lichen planus group showing significantly higher stress scores (19.26 ± 10.57), anxiety scores (8.20 ± 4.76), and depression scores (22.73 ± 8.11) when compared to the stress scores (6.06 ± 1.33), anxiety scores (4.93 ± 1.55), and depression scores (19.80 ± 2.94) of the control group with P < 0.001 which was statistically highly significant.

In the present study, we found positive correlation between depression, anxiety, and stress with salivary cortisol levels. The analysis showed positive correlation between salivary cortisol levels and depression in control (0.23, HS), erosive (0.78, HS) and nonerosive (0.32, S), anxiety in control (0.18, S), erosive (0.74, S) and nonerosive (0.51, HS) and stress in control (0.24, S), erosive (0.56, S) and no erosive (0.58, HS).

Our findings were consistent with the Lundqvist (2006), Shah (2009), and Shetty (2011). Severely depressed patients have high blood levels of cortisol caused by chronic stress. During period of active stress, cortisol promotes survival by mobilizing energy reserves. In addition to these short-term adaptive changes, cortisol is also involved in other long-term stress related adaptive changes such as shaping and regulating a number of physiological processes, including immune responsiveness and activation of sympathetic nervous system. In the depressed people, cortisol peaks early in the morning and does not decrease as the day progresses. Clinical studies suggested that elevated cortisol may induce clinical depression.[1],[3],[10],[11]


   Conclusion Top


Due to inconsistent literature regarding the cortisol pattern associated with psychological factors in the OLP patients, it is difficult to compare across the available cortisol studies with different methodologies among diverse populations and parameters.

Future recommendation

The present study necessitates further larger longitudinal studies, equal number of male and female, equal number of subjects in different demographic groups. Different geographical area should be included, national data should be prepared using other parameters and techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Shetty VS, Thomas P, Chatra L, Shenai P, Rao P, Babu S. An association between serum cortisol levels in erosive and nonerosive oral lichen planus patients. Webmed Central 2010;1:1-19.  Back to cited text no. 1
    
2.
Hellhammer DH, Wüst S, Kudielka BM. Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology 2009;34:163-71.  Back to cited text no. 2
    
3.
Shah B, Ashok L, Sujatha GP. Evaluation of salivary cortisol and psychological factors in patients with oral lichen planus. Indian J Dent Res 2009;20:288-92.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Koray M, Dülger O, Ak G, Horasanli S, Uçok A, Tanyeri H, et al. The evaluation of anxiety and salivary cortisol levels in patients with oral lichen planus. Oral Dis 2003;9:298-301.  Back to cited text no. 4
    
5.
Umeda T, Hiramatsu R, Iwaoka T, Shimada T, Miura F, Sato T. Use of saliva for monitoring unbound free cortisol levels in serum. Clin Chim Acta 1981;110:245-53.  Back to cited text no. 5
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6.
Miller CS, Dembo JB, Falace DA, Kaplan AL. Cortisol response to dental treatment of varying stress. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:436-41.  Back to cited text no. 6
[PUBMED]    
7.
Kaur B, Sunil MK, Trivedi A, Singla N, Garg S, Goyal N, et al. Salivary cortisol as a doagnostic markerin oral lichen planus. J Int oral Health 2015;7:43-8.  Back to cited text no. 7
    
8.
Chaudhary S. Psychosocial stressors in oral lichen planus. Aust Dent J. 2004;49:192-5.  Back to cited text no. 8
    
9.
Giradic C, Luz C, Cherubini K, Figueiredo MA, Nunes ML, Salum FG, et al. Salivary cortisol and dehydroepiandrostrone (DHEA) levels psychological factors in patient with oral lichen planus. Arch Oral Biol 2011;56:864-8.  Back to cited text no. 9
    
10.
Lundqvist EN, Wahlin YB, Bergdahl M, Bergdahl J. Psychological health in patients with genital and oral erosive lichen planus. J Eur Acad Dermatol Venereol 2006;20:661-6.  Back to cited text no. 10
[PUBMED]    
11.
Hosseini FA, Moosavi MS, Affser MS, Salivary cortisol and salivary flow rate in clinical types of oral lichen planus. Skinmed 2016;28:78-8.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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