Physiology & Behavior 211 (2019) 112676

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Physiology & Behavior

journal homepage: www.elsevier.com/locate/physbeh

Influence of lavender oil inhalation on vital signs and anxiety: A randomized T

clinical trial
⁎
Nazife Begüm Karan
Recep Tayyip Erdoğan University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Rize, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To investigate the effectiveness of lavender oil (Lavandula angustifolia Mill) inhalation on anxiety,
Anxiety mood, and vital signs (blood pressure, respiratory rate, heart rate, and saturation) of patients undergoing oral
Clinical trial surgery. Vital signs were considered as primary outcome measures. Paired anxiety tests were used as secondary
Inhalation outcome measures.
Lavender
Methods: Patients who had dental anxiety according to the Dental Anxiety Questionnaire (DAQ) were enrolled in
Oral surgery
the study. One hundred twenty-six patients who were undergoing wisdom tooth removal under local anaesthesia
Wisdom tooth
were randomly assigned to the lavender oil and control groups. Paired anxiety tests (Modified Dental Anxiety
Scale and State-Trait Anxiety Inventory–State Scale were performed. Vital signs were noted pre-, intra-, and post-
operatively. Visual analogue scale (VAS) results were assessed. The patients' degree of satisfaction was noted.
Results: Pre-operative anxiety levels were similar in both groups. Significant changes in blood pressure were
observed in the lavender oil group post-operatively (p < .05). Most (79.4%) of the patients in the lavender oil
group enjoyed the scent, 89.68% were satisfied with their experience, and 97.62% of the patients stated that
they would prefer the same protocol when needed.
Conclusion: Inhalation of lavender oil, which is one of the most powerful anxiolytic essential oils, reduces peri-
operative anxiety and can be prospectively considered in future studies for its potential sedative characteristics
in patients undergoing surgical procedures under local anaesthesia.
Trial registration number:NCT03722771 (Influence of Lavender Oil on Vital Signs in Oral Surgery Patients)
https://clinicaltrials.gov/ct2/show/NCT03722771

1. Introduction
Dental anxiety is one of the most common global obstacles to dental
care, especially for patients who need oral surgery [1,2]. This prevents
patients from visiting dental offices and leads to further health pro-
blems [3,4].
There are many products with sedative effects used in patients with
anxiety prior to surgery. General anaesthesia or sedation may be re-
commended for patients with dental fear; however, it should be borne
in mind that these procedures may carry some risks. Additionally, some
patients have allergies or other contraindications for general anaes-
thesia. Aromatherapy is a preferred option for patients with anxiety
who are scheduled to undergo surgical procedures under local anaes-
thesia [5–8].
Several aromatherapy oils have been used for centuries for curing
various diseases. Lavender oil is one of the most effective and most
preferred oils. Extracts derived from the genus of lavender have been
used in folk medicine since ancient times. Lavender oil has also been
used as an anti-inflammatory, antiseptic, mucolytic, and carminative
phytotherapeutic agent for the treatment of minor health problems
[9,10].
Lavenders are mostly native to the Mediterranean region and
Southern Europe. > 30 species of lavenders are known and used in
cosmetics, the food industry or as scents [9–11]. The sedative properties
of this oil have been demonstrated widely on animals [12–16]. One of
the components in lavender oil, linalool, was found to have an in-
hibitory effect on the limbic system and autonomic neurotransmission,
which ultimately lead to a drop in blood pressure [14]. This systemic
effect is associated with gamma-aminobutyric acid (GABA-A) receptors,
which are known to play an important role in reducing anxiety levels
[12,15,17]. Lavender oil is known to be one of the most effective es-
sential oils for relieving anxiety disorders, and it is regarded as an ac-
cessible and safe option compared with anti-psychotic medications (e.g.
alprazolam, lorazepam, and diazepam) [5–8,10,13,18]. It has been

⁎
Corresponding author.
E-mail address: nazifebegum.karan@erdogan.edu.tr.

https://doi.org/10.1016/j.physbeh.2019.112676
Received 20 June 2019; Received in revised form 15 August 2019; Accepted 5 September 2019
Available online 07 September 2019
0031-9384/ © 2019 Elsevier Inc. All rights reserved.
N.B. Karan
shown to have effects similar to lorazepam in anxiety disorders, which
has been used as a licensed treatment protocol in recent years [19,20].
Oral surgical procedures have been proven to be the greatest con-
cern among dental practices for patients [21,22]. To the best of our
knowledge, limited randomized clinical trials have demonstrated evi-
dence-based results of lavender oil, despite being the most effective
essential oil for anxiety and stress. A reduction of blood pressure with
the scent of lavender or linalool has been shown in studies; however, no
studies have demonstrated its effects on vital signs during an entire
stressful intervention.
In both dentistry and medicine, it is necessary to prevent anxiety in
order to comfortably treat patients. Empathy with the patient, the right
approach, and alternative therapies enable smart use of anxiolytic
drugs, reserving sedation and general anaesthesia for serious condi-
tions. A patient's anxiety poses major management problems for the
dental team because more treatment time will be required for an an-
xious patient who is very likely to miss appointments. The hypothesis of
the present study was that the inhalation of lavender oil prior to oral
surgical procedures would reduce anxiety and affect intra and post-
operative vital signs (blood pressure, respiratory rate, heart rate, and
saturation).
2. Material and methods
A randomized controlled clinical trial providing lavender oil as an
inhalation agent was conducted in the Oral & Maxillofacial Surgery
Department of XXX University. Power analysis was performed using the
G-Power software package to predict the number of patients (80.4%
power, two-sided 5% significance level) and a previous study was used
to calculate the sample size [23]. It was determined that at least 63
patients (126 in total) were required in each group (α = 0.05, 91.4%
power). Vital signs were considered as primary outcome measures.
Anxiety test results served as secondary outcome measures. Those who
were involved in the conduct and analysis of the results of the study
were blinded to group allocation.
The protocol of the present study was approved by the Ethics
Committee of XXX University (Approval No.: 2016/87, Protocol
No.:106).
2.1. Recruitment and exclusion criteria
Patients with a baseline Dental Anxiety Questionnaire (DAQ) score of
at least 2 were enrolled in the study. One hundred twenty-six patients
who were systemically healthy according to the American Society of
Anaesthesiologists (ASA) classification (ASA I), aged 18 to 37 years
were recruited between September and December 2017. Patients aged
under 18 years, those taking psychotropic medication or psychiatric
treatment, those with systemic health problems or allergies, and preg-
nant women were excluded. All patients were informed about the
procedure of wisdom tooth extraction in a separate room prior to sur-
gery. Written informed consent was obtained for the described protocol.
This protocol allowed patients to drop out of the study at any stage
without having to provide any explanation.
2.2. Paired anxiety tests and other scales
The DAQ, Modified Dental Anxiety Scale (MDAS), State-Trait Anxiety
Inventory–State Scale (STAI-S) tests were used pre-and post-operatively
in the anxiety survey. The DAQ test is a single-item measure that asks
patients if they are anxious about going to the dentist. DAQ has 4
grades, 1–4 (1-No; 2- slight; 3-Yes; 4-Yes, a lot). [24] Higher values
indicate higher anxiety for all used tests.
The MDAS and STAI-S tests are the most commonly used measures
to evaluate mood and dental anxiety. MDAS evaluates the level of an-
xiety that may arise against dental practice; therefore, the questionnaire
reflects the views of patients about their future concerns. It is a 5-
2
Physiology & Behavior 211 (2019) 112676
question test with a total score of 5 to 25. STAI-S measures an in-
dividual's immediate response to a threatening situation, and designates
the current anxiety [5,25]. The STAI-S consists of 20 items and scores
range from 1 (almost never) to 4 (almost always) [26].
Pain intensity was measured using a Visual Analogue Scale (VAS) in
both groups. VAS scores range from 0 (no pain) to 10 (unbearable pain).
Patients in the lavender oil group were also asked to complete the two-
item Satisfaction Questionnaire Test. The first question asked patients to
identify their experiences ranging from 1 (low satisfaction) to 5 (high
satisfaction). The second question determined if they would prefer the
same protocol (yes or no) when needed.
2.3. Randomization of the groups
A simple randomization was performed by a nurse by which pa-
tients were randomly assigned to the groups according to the last digit
of their hospital number. The numbers are issued by the hospital and
the last digit can be even or odd. Even numbers were assigned to the
lavender oil (experimental) group and odd numbers were assigned to
the control group. Patients in the experimental group inhaled 100%
pure, high-strength lavender oil in a separate room for 3 min prior to
surgery. Med patches were used for the inhalation protocol and skin
contact was avoided. The control group was allowed no lavender ex-
posure.
2.4. Aromatic oil used in the study
The natural essential oil of lavender (100% pure Lavandula angusti-
folia Mill. NU13950, lot number 9133, Code APE 7490B), which is
marketed for clinical use, was obtained from NU-KA Defne Essencia
(Antalya, TURKEY). The country of origin of the lavender herb used
was France.
2.5. Anxiety monitoring
Nurses checked and recorded the vital signs (blood pressure, re-
spiratory rate, heart rate, and saturation) during the course the inter-
ventions. The level of the vital signs was noted pre-operatively, im-
mediately after the maximum pressure applied to elevate the wisdom
tooth, and post-operatively. The surgical duration was also noted.
2.6. Statistical analyses
The data obtained in the present study were analysed using the IBM
SPSS Statistics for Windows software (Version 20 IBM Corp, Armonk,
NY, USA). The Kolmogorov–Smirnov test was used to determine the
normality of the distribution. The distributions of all scales were con-
sidered significant at levels of p < .05.
The Chi-square test was used to evaluate the differences in socio-
cultural variables and the effects of previous oral surgical history
(Table 1). Differences in pain level were evaluated using the Man-
n–Whitney U test. The duration of the procedures in both groups was
also assessed using the Mann–Whitney U test (Table 2).
Correlations among the three anxiety measures (DAQ, MDAS, and
STAI-S) were assessed using the Pearson product-moment correlation
coefficient.
Differences between paired tests (STAI-S, MDAS) were analysed
using the Wilcoxon and Mann–Whitney U tests, both within and across
all groups (Table 3).
Friedman's two-way analysis of variance (ANOVA) test was used to
analyse differences in vital signs at different time intervals (Table 4).
Additionally, differences between the groups were analysed using the
Mann–Whitney U test. In the presence of a significant difference, in-
tergroup comparisons (post hoc analysis) were made using Bonferroni
correction.
N.B. Karan Physiology & Behavior 211 (2019) 112676

Table 1 3. Results
Differences in personal details.
Variable Control group Lavender oil Total p value No enrolled participants dropped out of the study. The demographic
% (n) group % (n) features of the patients (126 in total) showed no significant differences
% (n) between the groups. All selected patients were similar in age, height,
weight, and socio-cultural variables. Seventy-six per cent of the parti-
Sex (F/M) 79/21 (50/ 73/27 (46/17) 76/24 (96/ 0.530
13) 30)
cipants were females. Forty-four per cent of the patients had graduated
Educational level 0.490 from high school and 38% were university graduates. Of all patients in
Literate 3 (2) 5 (3) 4 (5) both groups, 62% had no history of wisdom tooth extraction (Table 1).
Elementary 3 (2) 0 (0) 1 (2) There were no statistically significant differences between the two
Middle school 15 (9) 11 (7) 13 (16)
groups in terms of pain levels. The differences between the durations of
High school 38 (24) 49 (31) 44 (55)
University 41 (26) 35 (22) 38 (48) the procedures were also statistically insignificant (Table 2).
Income 0.192 Statistical analysis showed a high degree of correlation among the
(Turkish Lira)⁎ anxiety questionnaires (DAQ, MDAS, STAI-S) for the assessment of the
< 1000 17 (7) 11 (11) 14 (18)
patients' stress levels. All patients showed moderate anxiety levels in all
1000–2500 67 (36) 57 (42) 62 (78)
2500–5000 13 (17) 27 (8) 20 (25)
tests applied both before and after the surgical procedures. According to
> 5000 3 (3) 5 (2) 4 (5) the paired test (MDAS, STAI-S) comparisons, there was no statistically
Place of residence 0.267 significant difference between the groups in terms of initial and final
City 45 (34) 54 (28) 49 (62) anxiety levels when analysed using the Mann–Whitney U test. However,
County 30 (20) 32 (19) 31 (39)
post-operative results showed a significant decrease compared with pre-
Village 25 (9) 14 (16) 20 (25)
Health Insurance 0 (4) 6 (0) 3 (4) 0.080 operative results when the groups were assessed within themselves
None using the Wilcoxon test. Nevertheless, a statistically insignificant de-
Social security 97 (54) 86 (61) 91 (115) crease in post-operative anxiety levels was detected in the lavender oil
Free medical care 2 (3) 5 (1) 3 (4) group (p < .05) (Table 3).
Private insurance 1 (2) 3 (1) 3 (3)
Previous wisdom
Most (79.4%) of the patients in the lavender oil group enjoyed the
Tooth extraction scent, 89.68% were satisfied with their experience, and 97.62% of the
History patients stated that they would prefer the same protocol when needed.
Very good 2 (6) 10 (1) 5 (7) No adverse effects were detected.
Good 3 (4) 6 (2) 5 (6) 0.267
In-group vital sign evaluations were made using Friedman's two-
Not bad 24 (11) 17 (15) 21 (26)
Bad 8 (3) 5 (5) 6 (8) way ANOVA test. A statistically significant decrease in post-operative
Severe 1 (0) 0 (1) 1 (1) systolic blood pressure was observed in the lavender oil group com-
No history 62 (39) 62 (39) 62 (78) pared with the pre-operative and intra-operative measurements (post
hoc 82% power). A statistically significant decrease in post-operative
Chi square test.
⁎ heart rate was detected in the control group compared with the pre-
10 Turkish Lira = roughly $US 5.60.
operative and intra-operative measurements (p < .05).
n = number of patient. F = female. M = male.
p < .05 = statistically different. Group comparisons were also made using the Mann-Whitney U test
and a significant decrease in intra-operative respiratory rate was found
Table 2 in the lavender oil group. In contrast, a significant increase in intra-
Differences of pain level and operation time between groups. operative respiratory rate was observed in the control group (post hoc
96% power) (p < .05). No other significant differences were observed
Control group Lavender oil group p value
in the between-group comparisons (Table 4).
Mean ± SD Mean ± SD

Degree of pain 1.62 ± 1.83 1.6 ± 2.63 0.212 4. Discussion

Duration of the 16.32 ± 9.51 16.78 ± 9.22 0.641
procedure
According to previous studies, it was determined that demographic
Mann-Whitney U Test.
characteristics such as sex, age, socio-cultural status, and education
SD, Standard deviation. level could affect anxiety levels [3,4]. All demographic characteristics
p < .05, Statistically different. of the patients were similar in the current study. In addition, the
duration of the procedures was similar. Post-operative MDAS and STAI-
Table 3 S results showed a significant decrease in anxiety levels in both groups;
Differences of anxiety scores within groups according to the time of the surveys. however, there was no significant difference between the initial and
final anxiety levels between the groups. Post-operative pain scores were
Questionnaires Pre-operative Post-operative p value
Mean ± SD Mean ± SD
also similar in both groups. These findings may be related to good
doctor-patient communication and the explanation of the procedures
Lavender oil group prior to the operations. It has been shown that MDAS is sensitive for the
MDAS 11.37 ± 4.58 9.98 ± 4.16 0.007⁎ identification of differences in dental anxiety resulting from manip-
STAI 41.16 ± 10,97 33.86 ± 11.03 0.001⁎
Control group
ulations in behavioural interventions [5]. The results of the present
MDAS 11.06 ± 3.66 10.17 ± 3.63 0.006⁎ study support this finding and the reduction of the anxiety levels in
STAI 42.22 ± 9.95 36.71 ± 10.56 0.001⁎ both groups could again be attributed to good care and communications
of all those involved in the procedure.
SD, Standard deviation. In terms of vital signs, however, there were systemic differences
p < .05, Statistically different.
between the control and the experimental groups. The intra- and post-
Wilcoxon Test.
⁎ operative vital signs of the patients were better in the lavender oil
The bold “p-value” indicates significant reduction in post-operative anxiety
levels compared to pre-operative measurements.
group. A statistically significant decrease in post-operative systolic
blood pressure was observed in the lavender group, which was in-
dicative of a decrease on anxiety levels. In addition, the low intra-

3
N.B. Karan Physiology & Behavior 211 (2019) 112676

Table 4
The median (min-max) scores at “vital signs” according to the time of the surveys.
Vital signs Pre-operative Intra-operative Post-operative Chi square p value

Median(min-max) Median(min-max) Median(min-max)

Lavender oil group Blood pressure (systolic) 110 (90–200) 110 (80–180) 105 (80–170) 8.691 0.013⁎
Blood pressure (diastolic) 60 (50–100) 70 (40–100) 60 (50–86) 2 0.368
Pulse/heart rate 89 (53–125) 90 (55–135) 86 (60–116) 4.769 0.092
Respiratory rate per minute 24 (20–36) 24 (16–28)a 24 (16–36) 3.138 0.204
Saturation 99 (96–100) 99 (91–-99) 99 (96–99) 1.14 0.566
Control group Blood pressure (systolic) 110 (80–140) 110 (80–150) 100 (80–140) 4.952 0.084
Blood pressure (diastolic) 60 (40–90) 70 (50–-90) 60 (50–-90) 3.191 0.203
Pulse /heart rate 87 (61–128) 86 (60–130) 86 (57–118) 11.139 0.004⁎⁎
Respiratory rate per minute 24 (20–28) 24 (16–-32)b 24 (20–−32) 5.574 0.062
Saturation 99 (97–99) 99 (90–99) 99 (94–99) 1.505 0.471

p < .05, Statistically different.

Differences within groups were analysed by Friedman's two-way ANOVA test.
Differences between groups were analysed using the Mann-Whitney U test.
⁎
The bold “p-value” indicates significant reduction in post-operative systolic blood pressure compared with pre-operative and intra-operative measurements in the
lavender oil group.
⁎⁎
The bold “p-value” indicates a significant reduction in post-operative heart rate compared with the pre-operative and intra-operative measurements in the
control group.
a
Significant decrease in intra-operative respiratory rate was found in the lavender oil group. (p < .05).
b
Significant increase in intra-operative respiratory rate was found in the control group. (p < .05).

operative respiratory rate shows the relaxation of the patients. On the
other hand, a significant heart rate drop was found in the control group.
An accelerated heart rate during anxiety is a well-known systemic re-
action, but the reason behind the slow heart rate is not very clear. A
slow heart rate can cause more distress, which may cause the patient to
faint. Anxiety or panic attacks during emotional stress may cause de-
terioration of the autonomic nervous system. The autonomic nervous
system is in charge of maintaining a regular heart rhythm and normal
blood pressure. During times of stress, the nervous system stops its
influence. Increased blood pressure and stress can cause vagal nerve
stimulation. As a result, the stimulation of this nerve can reduce the
heart rate and, in extreme cases, cause syncope, shock, and asystole
[27,28].
Systolic blood pressure gradually decreased in the lavender group.
However, in the control group, the pre-operative values increased intra-
operatively and then decreased. A significant decrease in pulse rate in
combination with blood pressure fluctuation was seen in the control
group, which may create syncope in patients. In contrast, the gradual
reduction of the blood pressure and the steady-state monitoring of the
pulse in the lavender oil group allows the patient to be treated more
comfortably. As a result of the current study, due to the positive
(calming) effects of lavender oil inhalation, we may suggest that it can
be used as a soothing scent, especially in patients with high tension.
It is known that odours have different effects and can change moods
[17]. They can also alter heart rate [23,29,30]. In a double-blind,
randomized controlled study, it was observed that the sedative effect of
imipramine was increased when used with lavender in the treatment of
depression [31]. Lin concluded that lavender oil could be preferred over
medications in vulnerable patients for the alleviation of anxiety levels
[32]. The use of lavender oil on animals revealed the sedative effects of
lavender oil inhalation, yielding a similar impact on behaviours as
benzodiazepines [16]. These drugs act as GABA receptor agonists;
however, they have adverse effects such as fatigue, ataxia, and pro-
longed sedation [18]. Considering the positive psychiatric effects
without adverse reactions, the application of lavender oil preparations
was investigated in animal studies. As a result, the injection of lavender
oil created diazepam-like dose-dependent sedative effects [15]. Dose-
dependent positive sedative effects of lavender oil similar to anxiolytic
agents have been shown and anxiolytic effects have even been attained
with intermediate doses [16,33]. Lavender supplements (oral, olfac-
tory, topical) are also used for the treatment of agitated behaviour in
severe dementia and anxiety disorders [34,35]. Silexan, which is
derived from lavender oil, is used as a licensed treatment protocol for
anxiety in Germany. In studies, supplements of lavender oil were found
to have positive effects comparable to anxiolytic drugs, as well as
having fewer adverse effects [19,20]. Similar effects of lavender oil
application were observed in the current study by inhalation.
Numerous useful (e.g. anti-inflammatory and analgesic) effects of
lavender oil use have been reported in the literature. However, the
mechanisms underlying its anxiolytic effects still remain unknown. It is
known that volatile molecules of lavender oil diffuse into the blood
rapidly after entering the lungs and eventually reach the brain by the
circulation. Brain activation occurs also by olfactory receptors [10,36].
Additionally, some studies have shown that lavender oil induces alpha
waves in the cortex, which causes relaxation. Linalool, one of the main
components of lavender oil, has been proven to reduce beta brain wave
activity, which has a significant effect on vigilance and awareness [16].
In recent studies, the anxiolytic effect of linalool was linked to the dose-
dependent action potential-blockage of sodium channels [37,38]. Other
researchers attributed the underlying neurochemical mechanism of li-
nalool to the inhibitory effect on glutamate binding in central nervous
system membranes [38,39]. However, sustained stimulation causes ig-
norance in the central nervous system and eventually becomes no
longer responsive to any stimuli after a certain time. Several sugges-
tions for the duration of oil applications have been made [37]. The
anticipated effects in the present study might have been obtained by the
reduction of the adaptation mechanism in the brain with the preferred
protocol (3 min of application).
Beside the positive effects, some adverse reactions such as induced
estrogenic activity have been reported, especially following repeated
topical applications of some essential oils. A case report showed the
correlation of estrogenic and anti-androgenic activities with the topical
use of lavender and tea tree oil, which is thought to be the cause of
gynecomastia in pre-pubertal boys. However, gynecomastia was re-
solved when the use of the preparations was discontinued [29]. Po-
tential allergic skin reactions with the application of lavender oil on
wounds have been reported. With this concern, lavender oil was tested
and found to be cytotoxic on human skin cells in an in-vitro study. In
addition, linalyl acetate, one of the major components of this oil,
showed maximum cytotoxic damage [40]. Conversely, some re-
searchers observed beneficial effects of lavender oil application on soft
tissue lesions and chronic wounds. Woollard et al. [41] Vakilian et al.
[42] and Marzouk et al. [43] proved that, a sitz bath with lavender oil
had a positive effect on episiotomy wounds and provided better healing

4
N.B. Karan
in comparison with povidone-iodine. Nevertheless, skin contact was
also avoided in the present study.
There are some limitations to the study. Double-blinded randomi-
zation could not be obtained because the odour of the lavender oil
could not be masked or controlled for by another scent; however; those
involved in the randomization of the study and those assessing the
outcomes were blinded. Future studies should consider inclusion of a
control scent in replicating the current study. In addition, different
scents can be employed on the same patients in similar procedures at
different times.
5. Conclusion
The current study demonstrated the sedative effects of lavender oil
inhalation on patients based on the assessment of vital measurements
and anxiety tests. The initial hypothesis that inhalation of lavender oil
prior to oral surgical procedures would reduce anxiety and conse-
quently affect intra- and post-operative vital signs is supported. In
conclusion, lavender oil may be beneficial in patients with dental an-
xiety who cannot receive general anaesthesia, and it can reduce the use
of anti-psychotic medications. Lavender oil can be considered as a
calming agent and preferred especially in patients with anxiety-related
tension, and used routinely in dental practice as an alternative form of
therapy or premedication.
Both herbal and cognitive therapies can be used to provide a better
approach in future studies because there is still no standard treatment
for dental anxiety.
Ethical considerations
The present study was conducted according to the principles of the
Helsinki Declaration. The protocol was approved by the Ethics
Committee of XXX University. Written, informed consent can be pro-
vided. The present study was conducted by the voluntary contributions
of the participants.
Funding
None.
Declaration of Competing Interest
None.
Acknowledgements
The author would like to thank Prof.Dr.Zihni YAZICI and
Assoc.Prof.Dr.Tolga MERCANTEPE for technical writing assistance.
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