UNCLASSIFIED AD "DFFNSE DOCUMENTATION CENTER FOR SCIENTIFIC AND TECHNICAL INF;ORMATION CAMERON STATION, AIEXANDHIA. VIRGINIA UNCLASSHFIED

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1 UNCLASSIFIED AD "DFFNSE DOCUMENTATION CENTER FOR SCIENTIFIC AND TECHNICAL INF;ORMATION CAMERON STATION, AIEXANDHIA. VIRGINIA UNCLASSHFIED

2 NOTICE: When government or other drawings, specifications or other data are used for any purpose other than in connection with a definitely related government procurement operation, the U. S. Government thereby incurs no responsibility, nor any obligation whatsoever; and the fact that the Government may have formulated, furnished, or in any way supplied the said drawings, specifications, or other data is not to be regarded by implication or otherwise as in any manner licensing the holder or any other person or corporation, or conveying any rights or permission to manufacture, use or sell any patented invention that may in any way be related thereto. I'!

3 -rg ul 0.- Av. U -r I,,... CRSRSSI 00 ENAIATET STRESS IN DENTAL PATIENTS "Adrenocortical Responses in Patients Scheduled for Operative Dentistry and for Impaction Surgery TECHNICAL DOCUMENTARY REPORT NO. SAM-TDR February 1963 USAF School of Aerospace Medicine IBrooks Aerospace Medical Division (AFSC) Air Force Base, Texas r A S T z Task No 'U

4 Qualified requesters may obtain copies of this report from ASTIA. Orders will be expedited if placed through the librarian or other perron designated to request documents from ASTIA. When U. S. Government drawings, specifications, or other data are used for any purpose other than a definitely related government procurement operation, the government thereby incurs no responsibility nor any obligation whatsoever; and the fact that the government may have formulated, furnished, or in any way supplied the said drawings, specifications, or other data is not to be regarded by implication or otherwise, as in any manner licensing the holder or any other person or corporation, or conveying any rights or permission to manufacture, use, or sell any patented invention that may in any way be related thereto.

5 FOREWORD This report was prepared by the following personnel: IRA L. SHANNON, Major, USAF, DC* WALTER V. DAVIS, Major, USAF, DC* LUCIAN SZMYD, Lieutenant Colonel, USAF, DCt JOHN R. PRIGMORE, Major, USAF, MSC* (*Dental Sciences Division, USAF School of Aerospace Medicine; toral Surgery Department, USAF Hospital, Lackland AFB; tuniversity of Utah *Medical School.) I

6 ABSTRACT Serum free 17-hydroxycorticosteroid levels were determined for 1,700 systemically healthy, young adult males divided intoathe following groups: One thousand subjects were included in a physiologic baselitle study; one control group of 209 subjects was sampled over a 21-week period; a second control group of 248 participants was studied along with 97 patients scheduled for operative dentistry and 146 patients appointed for impaction surgery. All samples were collected between 7:30 and 8:00 a.m. In the baseline study a serum free 17-OHCS mean of (S.D. = 3.91) ug./100 ml. was found. The means for the two control groups were not significantly different. Variances for these groups did differ (P <.05). The anticipation of "having a tooth filled" was a signiftant (P <.05) stimulus to the adrenal cortex but an appointment for impaction surgery produced a significantly greater response (P <.001). This technical documentary report has been reviewed and is approved. ROBERT B. PAYNE Colonel, USAF, MSC Chief, Operations Division Uil

7 SREM U DMAL PAUMM AduKro Uca bquspo b Pdam Shdd fw Opevo Didr ad hnpaudn Suaoe 1. INTRODUCTION of the method, and efforts were made to recover measured amounts of steroid that were It has been previously reported that the added to pooled human sera. In the baseline anticipation of oral surgery produced a mild experiment, 1,000 subjects were sampled. Conyet significant hyperactivity of the adrenal -cortex (1, 2, 3). trol group 1 in the dental study was made up of 248 randomly selected subjects who were sampled over the same time period as the ex- The present study was designed to investigate this anticipatory response further by perimental subjects. Control group 2 included 209 subjects, 9 to 11 of whom were sampled on evaluating patients not scheduled for dental a particular day of each week. Collections operations of any type, those appointed for for this group were thus made over a prolonged operative dental procedures, and those antici- time period. Neither of these control groups pating the removal of an impacted lower third was scheduled for dental procedures of any molar. Two control groups were included to test the homogeneity of such groups in experitype. In the dental experimental groups, 97 of the subjects had known for at least 48 hours ments of this type. Further: a large group of that they were scheduled to "have a tooth normal subjects was sampled to provide physio- filled" on the morning of the experiment while, logic baselines for our experimental population, for 146 additional participants, conditions were Laboratory performance of the analytical pro- the same except that each expected to "have an cedure was also evaluated. imbedded wisdom tooth removed." 2. MATERIALS AND METHODS 3. RESULTS AND DISCUSSION Certain experimental conditions were common to all phases of this study. The subjects In analyzing the performance of the laborawere systemically healthy males between 17 tory method, a mean of ug./100 ml. was and 22 years of age whose environmental con- found for the 40 determinations on the 20 sera. ditions have been previously described (1, 2, 3). The average difference between duplicates was A venous blood sample was drawn from each 0.329,g./100 ml. and the standard deviation of participant at between 7:30 and 8:00 a.m. and this difference was pg./100 ml. The serum free 17-hydroxycorticosteroid (17- coefficient of variation of the method (S.D. x OHCS) concentration was determined by the 100 divided by mean) was found to be 5.8%/0. method of Peterson et al. (4), which utilized In the recovery study, measured amounts of the Porter-Silber (5) color reaction with hydrocortisone were added to pooled human phenylhydrazine-sulfuric acid. sera to produce theoretic steroid concentrations Duplicate steroid determinations were per- of 23.49, 29.74, 37.54, and ug./100 ml. formed on 20 sera to test the reproducibility Determined steroid values for these test preparations were 21.22, 27.35, 36.64, and Reeved for publcation on 20 November IN6. pzg./100 ml., respectively. 1

8 U! scm. ric wt-in (pwgmfi FIGURE 1 Frequency diatribution for serusm free 1 7-OHCS levels. For the 1,000 subjects in the baseline study, group 2 was significantly (P <.05) lower than a serum free 17-OHCS mean of (S.D. = that for control group 1. For this reason and 3.91),4./100 ml. was found. The frequency since the participants in control group 1 were distribution of these steroid values is shown in sampled during the same time interval as were figure 1. The 25th, 50th, and 75th percentiles the dental patients, this group was taken as for these measurements were 12.08, 14.59, and the true controls for comparison with the ex pg./100 ml., respectively. perimental subjects. Means and standard deviations for the two An analysis of variance was performed control and two experimental groups in the upon the data for the 248 subjects in the dental study are shown in figure 2. The means control group, the 97 patients who were achedfor the two groups were not significantly dif- uled for operative dentistry, and the 146 ferent, although the variance for control patients appointed for impaction surgery. The *2

9 2 It 10 I CONTROL CONTROL OPMTIVES IPNACTION,E2 CASES CASES FIGURE 2 Serum free 17-OHCS means as influenced by dental appointment.. variances for these three groups differed sig- seeming discrepancy except that the nature of nificantly (P <.01). Similar significant dif- the impaction procedure understandably proferences were also found for the group means. duces a much more marked anticipatory re- The operative patients had a significantly sponse than does the anticipation of having a (P <.05) higher steroid mean than did the tooth filled or, for that matter, of having a control group. Other intergroup differences, fully erupted tooth removed (3). With this controls vs. impactions and impactions vs. wider spread in preoperative values, the chance operative patients, were significant at the for differences within the group becomes more.001 level. pronounced. For these three groups, all the samples in The findings of the present study confirm each group were divided into first and second previous observations that the average dental halves, and means and variances were calcu- patient presents for treatment in a state of lated for each half group. The two estimates mild, yet significant, adrenocortical hyperof variance were not significantly different for activity and that the degree of this hyperfuncany of the groups. However, the means for tion is directly related to the severity of the the impaction cases differed at the.05 level, impending treatment procedure. No claim can No positive interpretation can be given for this be made that this mild form of stimulation is 3

10 of pathologic importance syster dcally, even ating the reaction of patients to dental procethough it is well established that prolonged dures. In this way the relative strain of adrenocortical hyperactivity can be damaging, different operations can be studied and, If Rather, this quite predictable patient response readjustment is indicated, therapeutic measis suggested as an objective method of evalu- ures may be instituted. REFERENCES 1. Shannon, I. L.,.. R. Prigmore, W. R. Heater, 3. Shannon, I. L., L. Sxmyd, and J. R. Prigmore. C. M. McCall, Jr., and G. M. Isbell. Stress in Stress in dental patients: Serum and urine dental patients: 1. Serum free 17-hydroxycorti- 17-hydroxycorticosteroid responses in impaction costeroids, sodium and potassium in subjects patients. USAF School of Aerospace Medicine undergoing local anesthesia and simple exodontic Report 62-59, Apr procedures. J. Oral Burg. 19:486 (191). 4. Peterson, R. E., A. Karrer, and S. L. Guerra. Evaluation of Silber-Porter procedure for deter- 2. Shannon, I. L., G. M. Isbell, J. R. Prigmore, and mination of plasma hydrocortisone. Anal. W. R. Hester. Stress in dental patients: Chem. 29:144 (1957). sponse 11. The in serum routinely free 17-hydroxycorticosteroid appointed patients under- re- 5 Porter, C. C., and R. H. Silber. A qugtntitative sponsenrouiex pointia O al ur- s 1color reaction for cortisone and related 17,21- going simple dihydroxy-20-ketosteroids. J. Biol. Chem. 185: 201 (1950). 4

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