- Email: [email protected]
Effect of Lavender Oil Inhalation on Reducing Presurgical Anxiety in Orthognathic Surgery Patients
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ANESTHESIA/TMJ DISORDERS/FACIAL PAIN
Q1
Effect of Lavender Oil Inhalation on Reducing Presurgical Anxiety in Orthognathic Surgery Patients Poyzan Bozkurt, DDS, PhD,* and C ¸ agıl Vural, MDy
Q19
Purpose:
We hypothesized that lavender oil inhalation, before orthognathic surgery, would have an anxiolytic effect on patients.
Materials and Methods:
We executed a single-blinded, randomized, prospective study. The study comprised 90 patients (43 men and 47 women) scheduled to undergo orthognathic surgery (bilateral sagittal split, Le Fort I, and bimaxillary osteotomies). The patients were exposed to different concentrations of lavender oil diffusions in 120 mL of water during a 1-hour period before surgery (group 1, 0.1mL oil diffusion; group 2, 0.3-mL oil diffusion; and group 3, no oil). The predictor variable was the State-Trait Anxiety Inventory (STAI). The STAI-2 was used to assess trait anxiety scores, and the STAI-1 was used to assess state anxiety scores at the time of admittance (STAI-1-A) and after 1 hour, before operating room transfer (STAI-1-OR). We performed a c2 analysis for categorical variables, 1-way analysis of variance for continuous variables, and paired-samples t test for patients’ state and trait anxiety levels. The P value was set at .05.
Results:
No significant differences were found between groups concerning gender, age, working status, educational background, and surgical operation to be performed. When the demographic data and STAI scores were compared, the STAI-2 scores of patients in group 3 aged between 18 and 30 years and high school graduates were significantly higher. The mean trait anxiety scores were significantly higher in group 2 than in group 1. The STAI-1-OR scores in all 3 groups were significantly higher than the STAI-1-A scores. However, no statistically significant difference was found between the groups.
Conclusions: The results of this study suggested that 1 hour of presurgical inhalation of 0.1-mL and 0.3-mL lavender oil diffusions in 120 mL of water did not have an anxiolytic effect on patients undergoing orthognathic surgery. Future studies will focus on different concentrations, different inhalation times, and higher study samples. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e7, 2019
Q4
Q3
The candidates for orthognathic surgery are likely to have pre-existing problems with their appearance, disrupting their adaptation to social life. In addition, orthognathic surgery results in changes in external appearance, and despite the advances in digital technologies, these changes mostly cannot be fully predicted or comprehended by the patients. These
factors increase the probability of experiencing difficult emotions before surgery, such as anxiety, panic, and aggression.1,2 Evaluating the presurgical mental health and emotional states of these patients and intervention will positively affect the treatment process because the obvious presurgical anxiety in these patients will
Received from Department of Oral and Maxillofacial Surgery, Faculty
Emniyet Mahallesi, I_ncitas¸ Sokak, Yenimahalle, Ankara, Turkey;
of Dentistry, Ankara University, Ankara, Turkey. *Instructor.
e-mail: [email protected] Received July 4 2019
ySpecialist, Anaesthesiology Section.
Accepted August 22 2019
Conflict of Interest Disclosures: None of the authors have any
Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral
relevant financial relationship(s) with a commercial interest.
and Maxillofacial Surgeons
Address correspondence and reprint requests to Dr Bozkurt: An€ niversitesi Dis¸ Hekimligi Fak€ kara U ultesi, Agız Dis¸ ve C ¸ ene Cerrahisi,
0278-2391/19/31047-X https://doi.org/10.1016/j.joms.2019.08.022
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LAVENDER OIL INHALATION AND ANXIETY
make it difficult for them to understand the presurgical training and instructions given and cause a decrease in patient satisfaction in the postsurgical period.1 A high rate of surgical patients, that is, 57%, try to relax before surgery using complementary medicine practices such as prayer, massage, and herbal products. Patients’ interest in these noninvasive practices is increasing day by day. More than 75% of patients report that they might prefer to use these methods for presurgical relief because of fewer side effects, effects similar to medicinal practice, and no detrimental effect on health.3 Examples of commonly used sedative and relaxant herbal products are oils of sandalwood, sweet marjoram, clary, and lavender.4 Lavender oil has been reported to be beneficial in treating anxiety, depression, and insomnia by both neuropharmacologic mechanisms and psychological effects.4 The anxiolytic effect of lavender oil on patients has been investigated for many interventions; however, its effect on the anxiety states of orthognathic surgery patients has not been investigated. Therefore, our study focused on whether lavender oil inhalation of different diffusion amounts reduces the presurgical anxiety of orthognathic surgery patients.
Materials and Methods The Institutional Ethical Review Board of Ankara University Faculty of Dentistry approved the study (No. 15/10; ClinicalTrials.gov identifier NCT03388736), and the study followed the Declaration of Helsinki on medical protocol and ethics. PATIENT POPULATION AND SELECTION CRITERIA
Q5
On the basis of the results of previous studies, under the assumption that the standard deviation of group means would be 3.40 and the standard deviation of anxiety values would be 10, with 80% power and a 5% error level, intergroup comparisons could be made with analysis of variance when a minimum of 29 patients were randomly assigned to each group. A total of 90 consecutive patients (43 men and 47 women) who were admitted to our clinic and scheduled to undergo orthognathic surgery (type 1, bilateral sagittal split osteotomy; type 2, Le Fort I osteotomy, or type 3, bimaxillary osteotomy) were enrolled in this single-blinded, randomized prospective study. The inclusion criteria were patients aged between 18 and 45 years who were nonsmokers and volunteered to fill out the following presurgical State-Trait Anxiety Inventory (STAI) tests: STAI-2 and STAI-1-A. Patients with a history of respiratory hypersensitivity or allergy, diagnosed psychiatric diseases such as panic disorder or major depression, and the use of psychotropic medications were excluded from the study. Patients were
randomly assigned to the study groups by use of a random number generator in the Microsoft Excel program (Microsoft, Redmond, WA). APPLICATION OF LAVENDER OIL
A commercially available lavender oil preparation consisting of Lavandula angustifolia miller (Herbaflora, Turkey) was used. An infuser device with a Q6 mist output of 30 mL/h and grading lines that could be set to 120 mL was used, and measurements of the amount of oil used were made with the preparation’s own graded dropper. Group 1 received inhalation of 0.1 mL of lavender oil diffused in 120 mL of water; group 2, 0.3 mL of lavender oil diffused in 120 mL of water; and group 3, 120 mL of water. The amount of lavender oil to be used was based on former studies.5-12 During admittance, demographic characteristics were collected and the patients were asked to fill out the STAI forms (STAI-2 and STAI-1-A [at the time of admittance]). The STAI index has 2 subheadings, STAI-1 (state index) and STAI-2 (trait index), with a total of 40 questions. The questions are rated on a 4-point scale from ‘‘almost never’’ to ‘‘almost always’’ and are scored. Higher scores indicate higher anxiety levels. The infuser device, prepared according to assigned group, was placed in the patient room (standardized 12-m2 room), underneath the patient bed, where the patient and attending relative could not see. The device was left running for half an hour before the patient and attending relative were allowed in the room. The patients were not informed about the study to avoid any impact of the psychological effects of the lavender smell on the results. While the operating Q7 room (OR) was being prepared, patients stayed in their rooms for 1 hour, with the door closed, and received standard nursing care during this time. None of the patients received preoperative sedative medication. After 1 hour, before OR transfer, patients were informed about the study and asked if they wanted to contribute. All patients gave consent and filled out the STAI-1 again before OR transfer (STAI1-OR). STATISTICAL ANALYSIS
Data were evaluated in the SPSS program (version 20; IBM, Armonk, NY). Normality was evaluated using the Shapiro-Wilk test. The scores obtained from the STAI questionnaires were found to be in compliance with the normal distribution. Variables were given as mean standard deviation or frequency (percentage). A c2 analysis was used to evaluate categorical variables. A 1-way analysis of variance test was used to compare continuous variables. A paired-samples t test was used to compare the patients’ trait and state anxiety levels. P < .05 was considered significant.
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Results
Q8
Demographic features are presented in Table 1. No significant differences were observed between groups. The relationships between demographic data and the distribution of STAI scores, according to group, are presented in Table 2. In group 3, the STAI-2 scores were significantly higher among patients aged between 18 and 30 years and high school graduates (P = .022 and P = .015, respectively). In group 2, the STAI-1-A score of female patients was higher (P = .044), whereas in group 1, both the STAI-1-A and STAI-1-OR scores of female patients were higher (P = .021 and P = .008, respectively). The distribution of the mean STAI scores between groups is presented in Table 3. No difference was found between the groups in terms of the mean STAI-1-A and STAI-1-OR scores (P = .584 and P = .357, respectively). However, the mean STAI-2 score was significantly higher in group 2 than in group 1 (P = .046). Relationships between STAI score changes in the groups are presented in Table 4. In group 2, the mean STAI-1-A score was significantly lower than the mean STAI-2 score (P = .022), and in group 3, the mean STAI-1-A score was significantly higher than the mean STAI-2 score (P = .005). In group 3, the mean STAI-1-OR score was significantly higher than the mean STAI-2 score (P = .001). In all groups, the mean STAI-1-OR scores were significantly higher than the mean STAI-1-A scores (P < .001 for each, Table 4). The increase in mean STAI-1 scores was highest in group 3 and lowest in group 2, although
the differences cant (Table 3).
were
not
statistically
signifi-
Discussion The feeling of anxiety is the combination of unpleasant feelings of agitation and nervousness. It is a common health care problem in patients who will undergo surgery.13 Different questionnaires and indexes have been used to assess patient anxiety. One of the most commonly used indexes is the selfreported Spielberger STAI.2,13 The Turkish version of the index has proven high validity and reliability in the Turkish subpopulation and has been used in our study to assess patient anxiety levels.2,13 Reduction of anxiety can be achieved by pharmacologic or nonpharmacologic/complementary methods. A complementary method used to reduce anxiety is an ancient method using essential oils. Today, the term ‘‘aromatherapy’’ is used and refers to the use of plantborne essential oils for physical and psychological health conditions. It was proposed by chemist ReneMaurice Gattefosse when his hand recovered from a burn after accidentally being dipped in lavender oil.4 Q9 Among 30 species—and even more subspecies— Lavandula angustifolia miller, formerly known as Lavandula officinalis, was used in this study. This species is grown in the Mediterranean habitat, and the leaves are used as herbal medicine. The chemical composition of lavender is very complex; the major chemical components are linalool, linalyl acetate, 1,8-cineole B-ocimene, terpinen-4-ol, and camphor.14,15 Linalool and linalyl acetate have been
Table 1. DEMOGRAPHIC FEATURES OF STUDY POPULATION
Gender, n (%) Male Female Age, mean SD, yr Educational background, n (%) High school graduate University graduate Working status, n (%) Unemployed Working Student Operation type, n (%) 1 2 3
Group 1 (n = 30)
Group 2 (n = 30)
Group 3 (n = 30)
11 (25.6) 19 (40.4) 25.2 9.0
15 (34.9) 15 (31.9) 26.6 12.0
17 (39.5) 13 (27.7) 25.0 8.15
19 (31.1) 11 (37.9)
24 (39.3) 6 (20.7)
18 (29.5) 12 (41.4)
4 (50.0) 13 (3.1.7) 13 (31.7)
4 (50.0) 12 (29.3) 14 (34.1)
0 (0) 16 (39.0) 14 (34.1)
20 (40.0) 6 (23.1) 4 (28.6)
13 (26.0) 10 (38.5) 7 (50.0)
17 (34.0) 10 (38.5) 3 (21.4)
P Value .287 .793 .207
.321
.335
Note: Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Operation Q13 Q14 type 1 was bimaxillary surgery; type 2, Le Fort I surgery; and type 3, bilateral sagittal split osteotomy. Abbreviation: SD, standard deviation. Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
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337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
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LAVENDER OIL INHALATION AND ANXIETY
Table 2. RELATIONSHIP BETWEEN DEMOGRAPHIC DATA AND DISTRIBUTION OF SCORES FROM STAI-1-A, STAI-1-OR, AND STAI-2
Q15
Group 1 Gender Male Female P value Age 18-40 yr >40 yr P value Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value Group 2 Gender Male Female P value Age 18-40 yr >40 yr P value Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value Group 3 Gender Male Female P value Age 18-40 yr >40 yr P value
STAI-1-A
STAI-1-OR
STAI-2
32.7 5.8 40.0 8.8 .021*
34.1 6.5 43.8 9.9 .008*
38.0 7.2 37.7 6.3 .918
37.8 8.2 33.0 12.1 .361
41.1 9.1 32.6 15.5 .163
37.5 6.6 40.6 6.6 .441
36.3 7.4 39.1 10.3 .386
39.7 10.6 41.1 8.8 .717
38.2 7.2 37.0 5.5 .646
33.0 11.1 37.0 7.0 39.0 9.3 .469
34.7 12.3 39.4 8.0 42.8 10.7 .343
41.0 6.2 38.0 4.9 39.0 9.3 .531
36.8 7.1 41.6 10.6 33.5 11.5 .469
40.2 9.0 43.5 8.1 35.7 16.3 .343
38.5 6.6 37.3 5.0 35.2 8.9 .531
34.2 10.4 41.7 8.8 .044*
36.6 13.4 41.9 9.7 .229
40.2 6.9 44.3 9.3 .185
38.4 10.6 36.0 8.7 .641
39.8 12.3 36.6 9.0 .585
43.4 8.3 36.8 5.8 .106
37.5 10.2 39.8 11.1 .632
39.5 12.5 38.5 9.1 .857
42.5 7.7 41.1 11.1 .716
39.5 5.6 39.0 11.3 36.7 10.6 .821
49.5 16.0 38.0 9.5 37.4 11.7 .181
41.5 7.2 40.5 7.6 44.0 9.2 .556
40.2 6.2 38.5 12.2 33.14 12.9 .342
42.9 13.2 37.4 8.3 35.2 13.0 .331
41.4 8.5 45.5 7.7 39.2 8.1 .292
37.8 10.1 42.4 8.8 .201
42.2 11.2 44.1 7.1 .594
38.5 7.3 38.8 6.2 .902
40.1 9.1 37.3 .647
43.7 9.1 36.6 13.0 .227
39.5 6.2 30.3 6.3 .022*
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Table 2. Cont’d
Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value
STAI-1-A
STAI-1-OR
STAI-2
40.6 10.3 38.6 8.9 .600
45.0 9.3 40.0 9.4 .166
41.0 6.9 35.0 4.9 .015*
— 38.7 9.3 41.0 10.2 .524
— 42.2 10.0 44.0 9.2 .625
— 36.8 6.1 40.7 7.0 .111
40.2 9.9 38.8 10.0 40.6 11.0 .922
42.7 10.1 44.7 9.1 39.3 9.0 .696
38.8 5.7 39.6 9.0 34.6 1.1 .555
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Operation type 1 was bimaxillary surgery; type 2, Le Fort I surgery; and type 3, bilateral Q16 sagittal split osteotomy. Q17 * Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
Q10
reported to be responsible for the relaxant and sedative effects.3,15 Lavender oil produces its effects by 2 mechanisms: psychological and pharmacologic. The psychological effects occur through emotional learning, conscious perception, belief, and expectation. The pharmacologic effects occur through modulating cyclic adenosine monophosphate activity (reduction of cyclic adenosine monophosphate results with sedation) and inhibiting glutamate binding (sedative effects).4 Lavender oil can be used orally, by inhalation, or by massage, and its use is considered safe, except for rare allergic reactions. Today, it offers a more acceptable and easy option than anxiolytic drugs for patients with anxiety disorders.14
The effects of lavender oil have been researched in different fields for various diseases and interventions, such as fragranced cleansing gel’s relaxation effect on health care personnel; the curative effect of lavender oil inhalation in patients with Alzheimer disease; the anxiolytic effect while patients are waiting for a scheduled dental appointment; the anxiolytic and pain-reducing effect during a gynecologic examination and during intrauterine device insertion; the effect on self-reported sleep and heart rate in midlife women with insomnia; and the reported beneficial effects on relaxation and anxiety, pain reduction, improvement in cognitive function and dementia, and improvement in sleep quality.5-12
Table 3. DISTRIBUTION OF STAI SCORES BETWEEN GROUPS AND CHANGE IN MEAN STATE ANXIETY SCORES
STAI-2 STAI-1-A STAI-1-OR Change in mean scores between STAI-1-A and STAI-1OR
Group 1
Group 2
Group 3
P Value
37.8 6.5* 39.8 9.7 43.0 9.5 2.9 6.0
42.3 8.3* 38.0 10.2 39.3 11.8 1.3 9.0
38.6 6.7* 37.3 8.5 40.3 9.9 3.2 6.3
.046y .584 .357 .558
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Abbreviation: STAI, State-Trait Anxiety Inventory. * Group 1 differed significantly from group 2. No significant difference was found between group 3 and either group 1 or Q18 group 2. y Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
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561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616
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Table 4. CHANGE IN STAI SCORES EVALUATING PATIENTS’ STATE AND TRAIT ANXIETY
STAI-1-A STAI-1-OR P value for STAI-1-A vs STAI-1OR STAI-1-A STAI-2 P value for STAI-1-A vs STAI-2 STAI-1-OR STAI-2 P value for STAI-1-OR vs STAI-2
Group 1
Group 2
Group 3
37.3 8.5 40.3 9.9 <.001*
38.0 10.2 39.3 11.8 <.001*
39.8 9.7 43.0 9.5 <.001*
37.3 8.5 37.8 6.5 .965 40.3 9.9 37.8 6.5 .565
38.0 10.2 42.3 8.3 .022* 39.3 11.8 42.3 8.3 .348
39.8 9.7 38.6 6.7 .005* 43.0 9.5 38.6 6.7 .001*
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Abbreviation: STAI, State-Trait Anxiety Inventory. * Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
Studies reporting the effects of lavender oil inhalation on surgical patients are rare. Bagheri-Nesami et al16 reported a reduction in pain on a visual analog scale during needle insertion into a fistula in patients undergoing hemodialysis, but they did not investigate the effect on anxiety. They used lavender oil diluted 1:10 with sweet almond oil for 3 consecutive sessions. The method of application was soaking a cotton ball with 3 drops (approximately 0.15 mL) of diluted lavender oil and keeping this cotton ball at a 5-cm distance for 5 minutes. In a study investigating ambulatory otolaryngology patients, Wotman et al17 instructed patients to place a lavender-scented patch over their gown in the abdominal area for a minimum of 30 minutes. They used a visual analog scale for evaluation of anxiety and reported a reduction after lavender oil inhalation. In a study investigating elective breast surgery patients, Franco et al18 directed patients to inhale 2 drops (approximately 0.10 mL) of lavender oil inside a plastic mask for 10 minutes with an oxygen flow rate of 2 L/minute in the preoperative holding area. They used the STAI for evaluations and concluded that lavender oil had beneficial effects on anxiety. In a study investigating heart and abdominal surgery patients, Fayazi et al19 instructed patients to inhale lavender oil from a handkerchief for 20 minutes. STAI evaluations showed that lavender oil inhalation significantly reduced presurgical anxiety. A review study by Braden et al3 also reported that studies investigating lavender oil inhalation during the presurgical phase observed significantly lower anxiety during OR transfer. With olfactory application, the effects of lavender oil are reported to have an immediate onset.3 In our study, the infuser device was turned on half an hour before the patient’s entrance and continued for 1 additional hour after OR transfer. The total amount of
lavender oil distributed in the room was 0.03 mL in group 1 and 0.11 mL in group 2. Studies investigating surgical patients all used inhalation of lavender oil with different methods of application and different timings. The method of application may have caused the conflicting results because the amount of oil distributed in the patient room was significantly lower than that in other studies; nevertheless, the inhalation time was greatly longer. The other varying factor compared with the literature was the surgical operation to be performed. The studies reported in the literature all investigated different surgical interventions, and the fact that extreme presurgical anxiety has been reported in orthognathic surgery patients may have influenced the conflicting results.1,2 Another factor may be whether patients were informed about the study. Unlike in other studies investigating surgical patients,16-19 in our study, the patients were unaware that they were in a lavenderscented room and were not informed until the OR transfer. Yet, none of the patients reported a state of awareness before OR transfer and the psychological effects were assumed to be eliminated. Baseline trait anxiety scores (STAI) also were evaluated. The studies by Franco et al18 and Fayazi et al19 using the STAI did not report baseline trait anxiety scores. In our study, the mean STAI-2 score in group 2 was significantly higher than that in group 1, whereas the mean STAI-1-A and STAI-1-OR scores did not differ between groups. Score changes did not show a relationship between STAI-1 and STAI-2 scores. Although this study detected a decrease in anxiety levels in orthognathic surgery patients inhaling lavender oil, this reduction was not statistically significant. The results of our study show promise for further investigation of this noninvasive method.
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673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707
One-hour inhalation of 0.1 mL and 0.3 mL of lavender oil, diffused in 120 mL of water, showed no anxiolytic effect on patients before orthognathic operations. Future studies investigating orthognathic surgery patients should test different types of diffusion, different methods of application, and different settings. Acknowledgments Q11 Q12
The authors thank Prof Dr Hakan A. Karasu for his generous help in carrying out the study.
References 1. Brucoli M, Baena RRY, Boffano P, Benech A: Psychological profiles in patients undergoing orthognathic surgery or rhinoplasty: A preoperative and preliminary comparison. Oral Maxillofac Surg 23:179, 2019 2. Erkilic E, Kesimci E, Soykut C, et al: Factors associated with preoperative anxiety levels of Turkish surgical patients: From a single center in Ankara. Patient Prefer Adherence 11:291, 2017 3. Braden R, Reichow S, Halm MA: The use of the essential oil lavandin to reduce preoperative anxiety in surgical patients. J Perianesth Nurs 24:348, 2009 4. Herz RS: Aromatherapy facts and fictions: A scientific analysis of olfactory effects on mood, physiology and behavior. Int J Neurosci 119:263, 2009 5. Field T, Diego M, Hernandez-Reif M, et al: Lavender fragrance cleansing gel effects on relaxation. Int J Neurosci 115:207, 2005 6. Jimbo D, Kimura Y, Taniguchi M, et al: Effect of aromatherapy on patients with Alzheimer’s disease. Psychogeriatrics 9:173, 2009 7. Kritsidima M, Newton T, Asimakopoulou K: The effects of lavender scent on dental patient anxiety levels: A cluster randomisedcontrolled trial. Community Dent Oral Epidemiol 38:83, 2010
8. Lehrner J, Marwinski G, Lehr S, et al: Ambient odors of orange and lavender reduce anxiety and improve mood in a dental office. Physiol Behav 86:92, 2005 9. Zabirunnisa M, Gadagi JS, Gadde P, et al: Dental patient anxiety: Possible deal with Lavender fragrance. J Res Pharm Pract 3:100, 2014 10. Tugut N, Demirel G, Baser M, et al: Effects of lavender scent on patients’ anxiety and pain levels during gynecological examination. Complement Ther Clin Pract 28:65, 2017 11. Shahnazi M, Nikjoo R, Yavarikia P, et al: Inhaled lavender effect on anxiety and pain caused from intrauterine device insertion. J Caring Sci 1:255, 2012 12. Chien LW, Cheng SL, Liu CF: The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evid Based Complement Alternat Med 2012: 740813, 2012 € : Validity and reliability of 13. Cetinkaya F, Kavuran E, Aslan Unal KSU the Amsterdam Preoperative Anxiety and Information Scale in the Turkish population. Turk J Med Sci 49:178, 2019 14. Koulivand PH, Khaleghi Ghadiri M, Gorji A: Lavender and the nervous system. Evid Based Complement Alternat Med 2013: 681304, 2013 15. Perry R, Terry R, Watson LK, Ernst E: Is lavender an anxiolytic drug? A systematic review of randomised clinical trials. Phytomedicine 19:825, 2012 16. Bagheri-Nesami M, Espahbodi F, Nikkhah A, et al: The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients. Complement Ther Clin Pract 20: 1, 2014 17. Wotman M, Levinger J, Leung L, et al: The efficacy of lavender aromatherapy in reducing preoperative anxiety in ambulatory surgery patients undergoing procedures in general otolaryngology. Laryngoscope Investig Otolaryngol 2:437, 2017 18. Franco L, Blanck TJ, Dugan K, et al: Both lavender fleur oil and unscented oil aromatherapy reduce preoperative anxiety in breast surgery patients: A randomized trial. J Clin Anesth 33: 243, 2016 19. Fayazi S, Babashahi M, Rezaei M: The effect of inhalation aromatherapy on anxiety level of the patients in preoperative period. Iran J Nurs Midwifery Res 16:278, 2011
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ANESTHESIA/TMJ DISORDERS/FACIAL PAIN
Q1
Effect of Lavender Oil Inhalation on Reducing Presurgical Anxiety in Orthognathic Surgery Patients Poyzan Bozkurt, DDS, PhD,* and C ¸ agıl Vural, MDy
Q19
Purpose:
We hypothesized that lavender oil inhalation, before orthognathic surgery, would have an anxiolytic effect on patients.
Materials and Methods:
We executed a single-blinded, randomized, prospective study. The study comprised 90 patients (43 men and 47 women) scheduled to undergo orthognathic surgery (bilateral sagittal split, Le Fort I, and bimaxillary osteotomies). The patients were exposed to different concentrations of lavender oil diffusions in 120 mL of water during a 1-hour period before surgery (group 1, 0.1mL oil diffusion; group 2, 0.3-mL oil diffusion; and group 3, no oil). The predictor variable was the State-Trait Anxiety Inventory (STAI). The STAI-2 was used to assess trait anxiety scores, and the STAI-1 was used to assess state anxiety scores at the time of admittance (STAI-1-A) and after 1 hour, before operating room transfer (STAI-1-OR). We performed a c2 analysis for categorical variables, 1-way analysis of variance for continuous variables, and paired-samples t test for patients’ state and trait anxiety levels. The P value was set at .05.
Results:
No significant differences were found between groups concerning gender, age, working status, educational background, and surgical operation to be performed. When the demographic data and STAI scores were compared, the STAI-2 scores of patients in group 3 aged between 18 and 30 years and high school graduates were significantly higher. The mean trait anxiety scores were significantly higher in group 2 than in group 1. The STAI-1-OR scores in all 3 groups were significantly higher than the STAI-1-A scores. However, no statistically significant difference was found between the groups.
Conclusions: The results of this study suggested that 1 hour of presurgical inhalation of 0.1-mL and 0.3-mL lavender oil diffusions in 120 mL of water did not have an anxiolytic effect on patients undergoing orthognathic surgery. Future studies will focus on different concentrations, different inhalation times, and higher study samples. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e7, 2019
Q4
Q3
The candidates for orthognathic surgery are likely to have pre-existing problems with their appearance, disrupting their adaptation to social life. In addition, orthognathic surgery results in changes in external appearance, and despite the advances in digital technologies, these changes mostly cannot be fully predicted or comprehended by the patients. These
factors increase the probability of experiencing difficult emotions before surgery, such as anxiety, panic, and aggression.1,2 Evaluating the presurgical mental health and emotional states of these patients and intervention will positively affect the treatment process because the obvious presurgical anxiety in these patients will
Received from Department of Oral and Maxillofacial Surgery, Faculty
Emniyet Mahallesi, I_ncitas¸ Sokak, Yenimahalle, Ankara, Turkey;
of Dentistry, Ankara University, Ankara, Turkey. *Instructor.
e-mail: [email protected] Received July 4 2019
ySpecialist, Anaesthesiology Section.
Accepted August 22 2019
Conflict of Interest Disclosures: None of the authors have any
Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral
relevant financial relationship(s) with a commercial interest.
and Maxillofacial Surgeons
Address correspondence and reprint requests to Dr Bozkurt: An€ niversitesi Dis¸ Hekimligi Fak€ kara U ultesi, Agız Dis¸ ve C ¸ ene Cerrahisi,
0278-2391/19/31047-X https://doi.org/10.1016/j.joms.2019.08.022
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LAVENDER OIL INHALATION AND ANXIETY
make it difficult for them to understand the presurgical training and instructions given and cause a decrease in patient satisfaction in the postsurgical period.1 A high rate of surgical patients, that is, 57%, try to relax before surgery using complementary medicine practices such as prayer, massage, and herbal products. Patients’ interest in these noninvasive practices is increasing day by day. More than 75% of patients report that they might prefer to use these methods for presurgical relief because of fewer side effects, effects similar to medicinal practice, and no detrimental effect on health.3 Examples of commonly used sedative and relaxant herbal products are oils of sandalwood, sweet marjoram, clary, and lavender.4 Lavender oil has been reported to be beneficial in treating anxiety, depression, and insomnia by both neuropharmacologic mechanisms and psychological effects.4 The anxiolytic effect of lavender oil on patients has been investigated for many interventions; however, its effect on the anxiety states of orthognathic surgery patients has not been investigated. Therefore, our study focused on whether lavender oil inhalation of different diffusion amounts reduces the presurgical anxiety of orthognathic surgery patients.
Materials and Methods The Institutional Ethical Review Board of Ankara University Faculty of Dentistry approved the study (No. 15/10; ClinicalTrials.gov identifier NCT03388736), and the study followed the Declaration of Helsinki on medical protocol and ethics. PATIENT POPULATION AND SELECTION CRITERIA
Q5
On the basis of the results of previous studies, under the assumption that the standard deviation of group means would be 3.40 and the standard deviation of anxiety values would be 10, with 80% power and a 5% error level, intergroup comparisons could be made with analysis of variance when a minimum of 29 patients were randomly assigned to each group. A total of 90 consecutive patients (43 men and 47 women) who were admitted to our clinic and scheduled to undergo orthognathic surgery (type 1, bilateral sagittal split osteotomy; type 2, Le Fort I osteotomy, or type 3, bimaxillary osteotomy) were enrolled in this single-blinded, randomized prospective study. The inclusion criteria were patients aged between 18 and 45 years who were nonsmokers and volunteered to fill out the following presurgical State-Trait Anxiety Inventory (STAI) tests: STAI-2 and STAI-1-A. Patients with a history of respiratory hypersensitivity or allergy, diagnosed psychiatric diseases such as panic disorder or major depression, and the use of psychotropic medications were excluded from the study. Patients were
randomly assigned to the study groups by use of a random number generator in the Microsoft Excel program (Microsoft, Redmond, WA). APPLICATION OF LAVENDER OIL
A commercially available lavender oil preparation consisting of Lavandula angustifolia miller (Herbaflora, Turkey) was used. An infuser device with a Q6 mist output of 30 mL/h and grading lines that could be set to 120 mL was used, and measurements of the amount of oil used were made with the preparation’s own graded dropper. Group 1 received inhalation of 0.1 mL of lavender oil diffused in 120 mL of water; group 2, 0.3 mL of lavender oil diffused in 120 mL of water; and group 3, 120 mL of water. The amount of lavender oil to be used was based on former studies.5-12 During admittance, demographic characteristics were collected and the patients were asked to fill out the STAI forms (STAI-2 and STAI-1-A [at the time of admittance]). The STAI index has 2 subheadings, STAI-1 (state index) and STAI-2 (trait index), with a total of 40 questions. The questions are rated on a 4-point scale from ‘‘almost never’’ to ‘‘almost always’’ and are scored. Higher scores indicate higher anxiety levels. The infuser device, prepared according to assigned group, was placed in the patient room (standardized 12-m2 room), underneath the patient bed, where the patient and attending relative could not see. The device was left running for half an hour before the patient and attending relative were allowed in the room. The patients were not informed about the study to avoid any impact of the psychological effects of the lavender smell on the results. While the operating Q7 room (OR) was being prepared, patients stayed in their rooms for 1 hour, with the door closed, and received standard nursing care during this time. None of the patients received preoperative sedative medication. After 1 hour, before OR transfer, patients were informed about the study and asked if they wanted to contribute. All patients gave consent and filled out the STAI-1 again before OR transfer (STAI1-OR). STATISTICAL ANALYSIS
Data were evaluated in the SPSS program (version 20; IBM, Armonk, NY). Normality was evaluated using the Shapiro-Wilk test. The scores obtained from the STAI questionnaires were found to be in compliance with the normal distribution. Variables were given as mean standard deviation or frequency (percentage). A c2 analysis was used to evaluate categorical variables. A 1-way analysis of variance test was used to compare continuous variables. A paired-samples t test was used to compare the patients’ trait and state anxiety levels. P < .05 was considered significant.
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Q2
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Results
Q8
Demographic features are presented in Table 1. No significant differences were observed between groups. The relationships between demographic data and the distribution of STAI scores, according to group, are presented in Table 2. In group 3, the STAI-2 scores were significantly higher among patients aged between 18 and 30 years and high school graduates (P = .022 and P = .015, respectively). In group 2, the STAI-1-A score of female patients was higher (P = .044), whereas in group 1, both the STAI-1-A and STAI-1-OR scores of female patients were higher (P = .021 and P = .008, respectively). The distribution of the mean STAI scores between groups is presented in Table 3. No difference was found between the groups in terms of the mean STAI-1-A and STAI-1-OR scores (P = .584 and P = .357, respectively). However, the mean STAI-2 score was significantly higher in group 2 than in group 1 (P = .046). Relationships between STAI score changes in the groups are presented in Table 4. In group 2, the mean STAI-1-A score was significantly lower than the mean STAI-2 score (P = .022), and in group 3, the mean STAI-1-A score was significantly higher than the mean STAI-2 score (P = .005). In group 3, the mean STAI-1-OR score was significantly higher than the mean STAI-2 score (P = .001). In all groups, the mean STAI-1-OR scores were significantly higher than the mean STAI-1-A scores (P < .001 for each, Table 4). The increase in mean STAI-1 scores was highest in group 3 and lowest in group 2, although
the differences cant (Table 3).
were
not
statistically
signifi-
Discussion The feeling of anxiety is the combination of unpleasant feelings of agitation and nervousness. It is a common health care problem in patients who will undergo surgery.13 Different questionnaires and indexes have been used to assess patient anxiety. One of the most commonly used indexes is the selfreported Spielberger STAI.2,13 The Turkish version of the index has proven high validity and reliability in the Turkish subpopulation and has been used in our study to assess patient anxiety levels.2,13 Reduction of anxiety can be achieved by pharmacologic or nonpharmacologic/complementary methods. A complementary method used to reduce anxiety is an ancient method using essential oils. Today, the term ‘‘aromatherapy’’ is used and refers to the use of plantborne essential oils for physical and psychological health conditions. It was proposed by chemist ReneMaurice Gattefosse when his hand recovered from a burn after accidentally being dipped in lavender oil.4 Q9 Among 30 species—and even more subspecies— Lavandula angustifolia miller, formerly known as Lavandula officinalis, was used in this study. This species is grown in the Mediterranean habitat, and the leaves are used as herbal medicine. The chemical composition of lavender is very complex; the major chemical components are linalool, linalyl acetate, 1,8-cineole B-ocimene, terpinen-4-ol, and camphor.14,15 Linalool and linalyl acetate have been
Table 1. DEMOGRAPHIC FEATURES OF STUDY POPULATION
Gender, n (%) Male Female Age, mean SD, yr Educational background, n (%) High school graduate University graduate Working status, n (%) Unemployed Working Student Operation type, n (%) 1 2 3
Group 1 (n = 30)
Group 2 (n = 30)
Group 3 (n = 30)
11 (25.6) 19 (40.4) 25.2 9.0
15 (34.9) 15 (31.9) 26.6 12.0
17 (39.5) 13 (27.7) 25.0 8.15
19 (31.1) 11 (37.9)
24 (39.3) 6 (20.7)
18 (29.5) 12 (41.4)
4 (50.0) 13 (3.1.7) 13 (31.7)
4 (50.0) 12 (29.3) 14 (34.1)
0 (0) 16 (39.0) 14 (34.1)
20 (40.0) 6 (23.1) 4 (28.6)
13 (26.0) 10 (38.5) 7 (50.0)
17 (34.0) 10 (38.5) 3 (21.4)
P Value .287 .793 .207
.321
.335
Note: Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Operation Q13 Q14 type 1 was bimaxillary surgery; type 2, Le Fort I surgery; and type 3, bilateral sagittal split osteotomy. Abbreviation: SD, standard deviation. Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
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337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
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LAVENDER OIL INHALATION AND ANXIETY
Table 2. RELATIONSHIP BETWEEN DEMOGRAPHIC DATA AND DISTRIBUTION OF SCORES FROM STAI-1-A, STAI-1-OR, AND STAI-2
Q15
Group 1 Gender Male Female P value Age 18-40 yr >40 yr P value Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value Group 2 Gender Male Female P value Age 18-40 yr >40 yr P value Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value Group 3 Gender Male Female P value Age 18-40 yr >40 yr P value
STAI-1-A
STAI-1-OR
STAI-2
32.7 5.8 40.0 8.8 .021*
34.1 6.5 43.8 9.9 .008*
38.0 7.2 37.7 6.3 .918
37.8 8.2 33.0 12.1 .361
41.1 9.1 32.6 15.5 .163
37.5 6.6 40.6 6.6 .441
36.3 7.4 39.1 10.3 .386
39.7 10.6 41.1 8.8 .717
38.2 7.2 37.0 5.5 .646
33.0 11.1 37.0 7.0 39.0 9.3 .469
34.7 12.3 39.4 8.0 42.8 10.7 .343
41.0 6.2 38.0 4.9 39.0 9.3 .531
36.8 7.1 41.6 10.6 33.5 11.5 .469
40.2 9.0 43.5 8.1 35.7 16.3 .343
38.5 6.6 37.3 5.0 35.2 8.9 .531
34.2 10.4 41.7 8.8 .044*
36.6 13.4 41.9 9.7 .229
40.2 6.9 44.3 9.3 .185
38.4 10.6 36.0 8.7 .641
39.8 12.3 36.6 9.0 .585
43.4 8.3 36.8 5.8 .106
37.5 10.2 39.8 11.1 .632
39.5 12.5 38.5 9.1 .857
42.5 7.7 41.1 11.1 .716
39.5 5.6 39.0 11.3 36.7 10.6 .821
49.5 16.0 38.0 9.5 37.4 11.7 .181
41.5 7.2 40.5 7.6 44.0 9.2 .556
40.2 6.2 38.5 12.2 33.14 12.9 .342
42.9 13.2 37.4 8.3 35.2 13.0 .331
41.4 8.5 45.5 7.7 39.2 8.1 .292
37.8 10.1 42.4 8.8 .201
42.2 11.2 44.1 7.1 .594
38.5 7.3 38.8 6.2 .902
40.1 9.1 37.3 .647
43.7 9.1 36.6 13.0 .227
39.5 6.2 30.3 6.3 .022*
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Table 2. Cont’d
Educational background High school graduate University graduate P value Working status Unemployed Working Student P value Operation type 1 2 3 P value
STAI-1-A
STAI-1-OR
STAI-2
40.6 10.3 38.6 8.9 .600
45.0 9.3 40.0 9.4 .166
41.0 6.9 35.0 4.9 .015*
— 38.7 9.3 41.0 10.2 .524
— 42.2 10.0 44.0 9.2 .625
— 36.8 6.1 40.7 7.0 .111
40.2 9.9 38.8 10.0 40.6 11.0 .922
42.7 10.1 44.7 9.1 39.3 9.0 .696
38.8 5.7 39.6 9.0 34.6 1.1 .555
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Operation type 1 was bimaxillary surgery; type 2, Le Fort I surgery; and type 3, bilateral Q16 sagittal split osteotomy. Q17 * Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
Q10
reported to be responsible for the relaxant and sedative effects.3,15 Lavender oil produces its effects by 2 mechanisms: psychological and pharmacologic. The psychological effects occur through emotional learning, conscious perception, belief, and expectation. The pharmacologic effects occur through modulating cyclic adenosine monophosphate activity (reduction of cyclic adenosine monophosphate results with sedation) and inhibiting glutamate binding (sedative effects).4 Lavender oil can be used orally, by inhalation, or by massage, and its use is considered safe, except for rare allergic reactions. Today, it offers a more acceptable and easy option than anxiolytic drugs for patients with anxiety disorders.14
The effects of lavender oil have been researched in different fields for various diseases and interventions, such as fragranced cleansing gel’s relaxation effect on health care personnel; the curative effect of lavender oil inhalation in patients with Alzheimer disease; the anxiolytic effect while patients are waiting for a scheduled dental appointment; the anxiolytic and pain-reducing effect during a gynecologic examination and during intrauterine device insertion; the effect on self-reported sleep and heart rate in midlife women with insomnia; and the reported beneficial effects on relaxation and anxiety, pain reduction, improvement in cognitive function and dementia, and improvement in sleep quality.5-12
Table 3. DISTRIBUTION OF STAI SCORES BETWEEN GROUPS AND CHANGE IN MEAN STATE ANXIETY SCORES
STAI-2 STAI-1-A STAI-1-OR Change in mean scores between STAI-1-A and STAI-1OR
Group 1
Group 2
Group 3
P Value
37.8 6.5* 39.8 9.7 43.0 9.5 2.9 6.0
42.3 8.3* 38.0 10.2 39.3 11.8 1.3 9.0
38.6 6.7* 37.3 8.5 40.3 9.9 3.2 6.3
.046y .584 .357 .558
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Abbreviation: STAI, State-Trait Anxiety Inventory. * Group 1 differed significantly from group 2. No significant difference was found between group 3 and either group 1 or Q18 group 2. y Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
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505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616
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LAVENDER OIL INHALATION AND ANXIETY
Table 4. CHANGE IN STAI SCORES EVALUATING PATIENTS’ STATE AND TRAIT ANXIETY
STAI-1-A STAI-1-OR P value for STAI-1-A vs STAI-1OR STAI-1-A STAI-2 P value for STAI-1-A vs STAI-2 STAI-1-OR STAI-2 P value for STAI-1-OR vs STAI-2
Group 1
Group 2
Group 3
37.3 8.5 40.3 9.9 <.001*
38.0 10.2 39.3 11.8 <.001*
39.8 9.7 43.0 9.5 <.001*
37.3 8.5 37.8 6.5 .965 40.3 9.9 37.8 6.5 .565
38.0 10.2 42.3 8.3 .022* 39.3 11.8 42.3 8.3 .348
39.8 9.7 38.6 6.7 .005* 43.0 9.5 38.6 6.7 .001*
Note: Data are presented as mean standard deviation. Group 1 received a 0.1-mL diffusion, group 2 received a 0.3-mL diffusion, and group 3 was the control group. Abbreviation: STAI, State-Trait Anxiety Inventory. * Statistically significant (P < .05). Bozkurt and Vural. Lavender Oil Inhalation and Anxiety. J Oral Maxillofac Surg 2019.
Studies reporting the effects of lavender oil inhalation on surgical patients are rare. Bagheri-Nesami et al16 reported a reduction in pain on a visual analog scale during needle insertion into a fistula in patients undergoing hemodialysis, but they did not investigate the effect on anxiety. They used lavender oil diluted 1:10 with sweet almond oil for 3 consecutive sessions. The method of application was soaking a cotton ball with 3 drops (approximately 0.15 mL) of diluted lavender oil and keeping this cotton ball at a 5-cm distance for 5 minutes. In a study investigating ambulatory otolaryngology patients, Wotman et al17 instructed patients to place a lavender-scented patch over their gown in the abdominal area for a minimum of 30 minutes. They used a visual analog scale for evaluation of anxiety and reported a reduction after lavender oil inhalation. In a study investigating elective breast surgery patients, Franco et al18 directed patients to inhale 2 drops (approximately 0.10 mL) of lavender oil inside a plastic mask for 10 minutes with an oxygen flow rate of 2 L/minute in the preoperative holding area. They used the STAI for evaluations and concluded that lavender oil had beneficial effects on anxiety. In a study investigating heart and abdominal surgery patients, Fayazi et al19 instructed patients to inhale lavender oil from a handkerchief for 20 minutes. STAI evaluations showed that lavender oil inhalation significantly reduced presurgical anxiety. A review study by Braden et al3 also reported that studies investigating lavender oil inhalation during the presurgical phase observed significantly lower anxiety during OR transfer. With olfactory application, the effects of lavender oil are reported to have an immediate onset.3 In our study, the infuser device was turned on half an hour before the patient’s entrance and continued for 1 additional hour after OR transfer. The total amount of
lavender oil distributed in the room was 0.03 mL in group 1 and 0.11 mL in group 2. Studies investigating surgical patients all used inhalation of lavender oil with different methods of application and different timings. The method of application may have caused the conflicting results because the amount of oil distributed in the patient room was significantly lower than that in other studies; nevertheless, the inhalation time was greatly longer. The other varying factor compared with the literature was the surgical operation to be performed. The studies reported in the literature all investigated different surgical interventions, and the fact that extreme presurgical anxiety has been reported in orthognathic surgery patients may have influenced the conflicting results.1,2 Another factor may be whether patients were informed about the study. Unlike in other studies investigating surgical patients,16-19 in our study, the patients were unaware that they were in a lavenderscented room and were not informed until the OR transfer. Yet, none of the patients reported a state of awareness before OR transfer and the psychological effects were assumed to be eliminated. Baseline trait anxiety scores (STAI) also were evaluated. The studies by Franco et al18 and Fayazi et al19 using the STAI did not report baseline trait anxiety scores. In our study, the mean STAI-2 score in group 2 was significantly higher than that in group 1, whereas the mean STAI-1-A and STAI-1-OR scores did not differ between groups. Score changes did not show a relationship between STAI-1 and STAI-2 scores. Although this study detected a decrease in anxiety levels in orthognathic surgery patients inhaling lavender oil, this reduction was not statistically significant. The results of our study show promise for further investigation of this noninvasive method.
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BOZKURT AND VURAL
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One-hour inhalation of 0.1 mL and 0.3 mL of lavender oil, diffused in 120 mL of water, showed no anxiolytic effect on patients before orthognathic operations. Future studies investigating orthognathic surgery patients should test different types of diffusion, different methods of application, and different settings. Acknowledgments Q11 Q12
The authors thank Prof Dr Hakan A. Karasu for his generous help in carrying out the study.
References 1. Brucoli M, Baena RRY, Boffano P, Benech A: Psychological profiles in patients undergoing orthognathic surgery or rhinoplasty: A preoperative and preliminary comparison. Oral Maxillofac Surg 23:179, 2019 2. Erkilic E, Kesimci E, Soykut C, et al: Factors associated with preoperative anxiety levels of Turkish surgical patients: From a single center in Ankara. Patient Prefer Adherence 11:291, 2017 3. Braden R, Reichow S, Halm MA: The use of the essential oil lavandin to reduce preoperative anxiety in surgical patients. J Perianesth Nurs 24:348, 2009 4. Herz RS: Aromatherapy facts and fictions: A scientific analysis of olfactory effects on mood, physiology and behavior. Int J Neurosci 119:263, 2009 5. Field T, Diego M, Hernandez-Reif M, et al: Lavender fragrance cleansing gel effects on relaxation. Int J Neurosci 115:207, 2005 6. Jimbo D, Kimura Y, Taniguchi M, et al: Effect of aromatherapy on patients with Alzheimer’s disease. Psychogeriatrics 9:173, 2009 7. Kritsidima M, Newton T, Asimakopoulou K: The effects of lavender scent on dental patient anxiety levels: A cluster randomisedcontrolled trial. Community Dent Oral Epidemiol 38:83, 2010
8. Lehrner J, Marwinski G, Lehr S, et al: Ambient odors of orange and lavender reduce anxiety and improve mood in a dental office. Physiol Behav 86:92, 2005 9. Zabirunnisa M, Gadagi JS, Gadde P, et al: Dental patient anxiety: Possible deal with Lavender fragrance. J Res Pharm Pract 3:100, 2014 10. Tugut N, Demirel G, Baser M, et al: Effects of lavender scent on patients’ anxiety and pain levels during gynecological examination. Complement Ther Clin Pract 28:65, 2017 11. Shahnazi M, Nikjoo R, Yavarikia P, et al: Inhaled lavender effect on anxiety and pain caused from intrauterine device insertion. J Caring Sci 1:255, 2012 12. Chien LW, Cheng SL, Liu CF: The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evid Based Complement Alternat Med 2012: 740813, 2012 € : Validity and reliability of 13. Cetinkaya F, Kavuran E, Aslan Unal KSU the Amsterdam Preoperative Anxiety and Information Scale in the Turkish population. Turk J Med Sci 49:178, 2019 14. Koulivand PH, Khaleghi Ghadiri M, Gorji A: Lavender and the nervous system. Evid Based Complement Alternat Med 2013: 681304, 2013 15. Perry R, Terry R, Watson LK, Ernst E: Is lavender an anxiolytic drug? A systematic review of randomised clinical trials. Phytomedicine 19:825, 2012 16. Bagheri-Nesami M, Espahbodi F, Nikkhah A, et al: The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients. Complement Ther Clin Pract 20: 1, 2014 17. Wotman M, Levinger J, Leung L, et al: The efficacy of lavender aromatherapy in reducing preoperative anxiety in ambulatory surgery patients undergoing procedures in general otolaryngology. Laryngoscope Investig Otolaryngol 2:437, 2017 18. Franco L, Blanck TJ, Dugan K, et al: Both lavender fleur oil and unscented oil aromatherapy reduce preoperative anxiety in breast surgery patients: A randomized trial. J Clin Anesth 33: 243, 2016 19. Fayazi S, Babashahi M, Rezaei M: The effect of inhalation aromatherapy on anxiety level of the patients in preoperative period. Iran J Nurs Midwifery Res 16:278, 2011
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