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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 82-86

Anxiety in patients undergoing surgical extraction of mandibular third molars


1 Department of Oral and Maxillofacial Surgery, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
2 Private Practice, Shiraz, Iran

Date of Submission13-Oct-2019
Date of Decision31-Dec-2019
Date of Acceptance01-Jan-2020
Date of Web Publication22-Jul-2020

Correspondence Address:
Saeid Tavanafar
Department of Oral and Maxillofacial Surgery, School of Dentistry, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_36_19

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  Abstract 


Aim: The present study aimed to assess the amount of anxiety felt before and immediately after surgical removal of impacted mandibular third molars.
Materials and Methods: Patients' anxiety related to mandibular third molar surgery was prospectively measured before and after the procedure. Each patient level of anxiety was measured using a visual analog scale preoperatively and immediately postoperatively. Patients older than 18 years who were referred to the Oral and Maxillofacial Department of Shiraz University of Medical Sciences, Shiraz, Iran, for surgical removal of mandibular third molars were asked to participate in this study. Data including patient's demographic information, type of the third molar, and severity of surgical removal were recorded. The patient's age and gender and its relation to level anxiety were analyzed. Surgical removal of all third molars was performed by an experienced oral and maxillofacial surgeon under local anesthesia without sedation.
Results: Eighty-four patients participated in the present study, of which male participants were 36.7% and female patients were 64.3%. The mean age of participants was 42.07 ± 14.93 years and ranged from 18 to 70 years. The amount of anxiety preoperative compared to postoperative was statistically significant different (P < 0.00). No statistically significant differences observed between males and females patients before (P = 0.41) and after surgery (P = 0.11). Patients younger than 30 years old and older than 55 years old had significant reduction in anxiety postoperatively (P = 0.001 and P = 0.006, respectively).
Conclusion: The amount of anxiety related to surgical extraction of mandibular third molars was higher preoperatively than postoperatively, without any relation to the age and gender. Preoperative patients' reassurance and adequate explanation are recommended.

Keywords: Dental anxiety, oral surgery, third molar, tooth extraction, visual analog scale


How to cite this article:
Aliabadi E, Tavanafar S, Ghorbani F, Karimpour H. Anxiety in patients undergoing surgical extraction of mandibular third molars. J Oral Res Rev 2020;12:82-6

How to cite this URL:
Aliabadi E, Tavanafar S, Ghorbani F, Karimpour H. Anxiety in patients undergoing surgical extraction of mandibular third molars. J Oral Res Rev [serial online] 2020 [cited 2020 Sep 21];12:82-6. Available from: http://www.jorr.org/text.asp?2020/12/2/82/290506




  Introduction Top


Anxiety is a complex sequence of behaviors involving psychophysical activation in response to painful or unpleasant stimuli. The stimuli can be internal such as cognitive and somatic or external such as environment which patients may experience before, during, or after the third molar surgery.[1],[2],[3] Patients with fear and anxiety related to dentistry usually suffer from poor oral health-related quality of life and impaired psychological status such as reduced self-esteem and morale.[4],[5],[6] It is shown that there is a relation between the oral health-related quality of life and the level of dental anxiety.[7] People with higher degrees of dental fear and anxiety had more tooth decay and missing teeth and fewer sound or filled teeth than people with less dental fear.[8] Severe dental anxiety is more common among patients with more missing teeth.[4]

The complexity of dental anxiety is affected by different factors.[9],[10],[11],[12],[13] Pain, age, sex, level of education, and patient's personality trait can affect the amount of dental anxiety.[9],[10],[14],[15],[16] Pain is the most common etiologic factor in patients with dental anxiety, even though not all of the patients who experienced dental pain develop incapacitate dental anxiety and not all of the patients with disabling dental anxiety have experienced a specific confirmed previous dental pain.[14] The effect of patient academic education on dental anxiety is controversial, while some studies showed more anxiety with less educated people, others showed more dental anxiety in those with a higher level of education.[16],[17],[18]

Surgical removal of third molars is among the most stressful procedures in dentistry.[19] We hypothesized that the level of stress and anxiety associated with this procedure fluctuates once patients experience an inadvertent procedure without pain and discomfort. Successful assessment of dental anxiety can be measured using a simple self-reported scale. We aimed to monitor the degree of patients' anxiety related to surgical removal of third molars before and immediately after the procedure.


  Materials and Methods Top


Participants

This prospective study was planned in Oral and Maxillofacial Department of Shiraz University of Medical Sciences, and the study protocol was reviewed by the ethical committee (IR.SUMS.REC.1394.S9601). Patients over 18 years old of both sexes who were referred for surgical extraction of impacted mandibular third molar were asked to participate in the study. The sample size was estimated similar to the previous study.[20] Therefore, eighty-four patients participated over 4 month's period. Inclusion criteria were healthy patients without any severe medical conditions (American Society of Anesthesiologist I and II), level A, and class I impaction according to the Pell and Gregory Classification.[21] Exclusion criteria were patients with acute infection, unwilling to participate in the study, and known psychological or behavioral disorders or patients with language and cognitive problems, uncontrolled diabetes, hypertension, malignancies, and radiotherapy of the site.

Procedures were explained clearly for all of the patients, and written informed consent was obtained. The present prospective study consisted of two assessment points: before and immediately after the surgical removal of impacted mandibular third molars. Patients' medical status, demographic data, educational degree, type of third mandibular molar impaction,[21] and the severity of surgery were recorded.

Surgical procedure

All of the surgical procedures were performed by an experienced oral and maxillofacial surgeon with the help of an assistant, under local anesthesia only, without any premedication or sedation. A mucosal incision was made using No. 15c blade and mucoperiosteal elevators were used for reflecting the mucosal flap. Bone was removed using surgical bur under copious normal saline irrigation. The duration of operation was measured from the start of the anesthetic injection until the last suture. At the end of the procedure, patients were instructed verbally for postoperative care and these instructions were reinforced in writing.

Anxiety measurement

A simple form of visual analog scale was employed using a straight line with no distress at one end and unbearable distress at the other end of the line. The line was 10 cm in length and schematic faces indicating the feeling of the patients were used to guide patients per their level of anxiety from none to unbearable. The degree of anxiety was measured preoperatively and immediately postoperatively. Patients were asked to fill the questionnaire and mark the level of anxiety and stress before entering the operation room in a separate, quite non-dental room. Immediately after the operation, patients were asked again about the amount of anxiety they had. Patient answers were used to assess a patient's level of anxiety at the two points of time by measuring the distance on the line.

Statistical analysis

Normality of data was checked by Shapiro–Wilk test. Data were presented as means and number (%) for continuous and categorical variables, respectively. Data were analyzed through t-test, paired t-test, Spearman's rho, and one-way analysis of variance (one-way ANOVA). P < 0.05 considered as the significant level. All date were analyzed by SPSS for Windows, Version 16.0. Chicago, SPSS Inc Version 16.0, IBM Corp, Chicago, IL, USA.


  Results Top


The final sample consisted of 84 patients (36.7% male and 64.3% female). The mean age of participants was 42.07 ± 14.93 years and ranged from 18 to 70 years. The mean duration of operation was 38.8 ± 7.8 min. Patients were instructed to report any significant postoperative complications such as extensive swelling, excruciating pain, or malodor. There was no significant complication, and mild swelling was considered normal.

On a positive note, the present study observed a statistically significant decrease in mean anxiety levels among study subjects following the surgical procedure (before – 26.2; after – 14.7; P ≤ 0.001). Based on the gender, no statistically significant difference in anxiety levels was observed between males and females before (P = 0.417) or after (P = 0.118) the surgical procedures. However, when the mean anxiety levels that have changed before and after the procedure were considered, a statistically significant decrease in anxiety levels was observed among both males (P = 0.002) and females (P = 0.007). Age and duration of operation were categorized according to the quartile value. There were no statistically significant differences between age groups before (P = 0.085) and after the surgical procedure (P = 0.255), as well as a change of before and after surgical (P = 0.116). While according to the intragroup analysis, patients under 30 years old and those above 55 years old patients had significant decrease in anxiety level (P = 0.001 and P = 0.006, respectively), but the values were not significant in 30–40 years and 50–55 years which represents middle-aged patients [Table 1]. There was a significant correlation between anxiety before and after surgery and duration of surgery (spearman's rho = 0.229, P = 0.036). On the other hand, with increasing the duration of operation, the amount of reduction of anxiety decreased [Figure 1]. [Figure 1] shows the relation between two variables, the anxiety and duration of operation. It shows that the lesser the duration, more reduction in anxiety happens postoperatively. This result was confirmed by analyzing the intragroup analysis. When the operation duration were <32 min and 32–40 min' the level of anxiety was significantly low compared to others (P = 0.024 and P = 0.004, respectively). But in above of 40 the changes were not significant in to both groups [P = 0.214 and = 0.117, [Table 1].
Table 1: Mean of the patient's anxiety score before and after operation

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Figure 1: Scatterplot of anxiety change and duration of operation. Figure shows that with increasing the duration of operation, the reduction of anxiety decreased (see if change = 0)

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  Discussion Top


Surgical removal of impacted third molars is a commonly performed procedure in dentistry. It has relatively low postoperative life-threatening complications and short recovery time. However, it is associated with the highest level of stress and anxiety due to its physical and psychological impact.[16],[18] In the present study, we intended to identify variables that affect the level of anxiety concerning surgical removal of mandibular third molars.

It is shown that there is no statistically significant difference between a patient with the previous experience of dental extraction compared to those without earlier experiences in terms of level anxiety.[15],[21] Some authors suggested that prior experience with dental extraction might even reduce the amount of anxiety of patients. In a study, patients who were scheduled for two-stage surgical removal of third molars experienced a significant reduction in anxiety score for the second session of surgical extraction than for the first time.[3] In the present study, we found a statistically significant decrease in the level of anxiety after patients experienced the surgical procedure. It might be because of the unrealistic overestimation of discomfort that patients have before the surgery. Other factors such as trait anxiety should be considered, which can be an accurate prediction of the amount of pain and recovery after oral surgery. Some authors found increased pain experience in patients with high preoperative anxiety.[5]

Armfield et al.[2] stated that dental fear is multidimensional, and some of the contributing factors are personal and socioeconomic status and different aspects of oral health care. An indicator of previous traumatic dental experience could be the number of missing teeth, which varies among different age groups. However, in the present study, there were no statistically significant differences between the levels of anxiety at different ages of patients. Patients without painful dental experience may still experience a high level of anxiety based on indirect exposures.[17],[22],[23]

Factors such as patient's sex and dentally anxious relatives are shown to have a strong correlation with dental fear and anxiety.[9],[24] Others found that the patient's educational level can reduce fear and anxiety in the logistic regressional pattern, with higher educated patients experience less anxiety and fear.[20] Many studies have shown that women have more dental anxiety than men, but others found no statistically significant differences in general anxiety between the two genders.[1],[25],[26] In the present study, females' anxiety was higher than males, but it was not statistically significant. The differences in dental anxiety between the genders could be related to the different level of pain threshold between males and females.[27] Others believe that the differences are due to the fact that women express their fear and feelings more freely than men.[26]

Lopez-Jornet et al.[20] found that patients' anxiety immediately after tooth extraction and 1 week later in patients requiring more than 10 min procedure showed higher degree of anxiety. Although simple tooth extractions might be easier than mandibular third molar surgery, our results showed that shorter procedures (<40 min) are associated with a significantly lower level of anxiety postoperatively. Astramskaite et al.[28] systematically reviewed literature regarding influential factors of dental extraction anxiety and concluded that the duration of procedure is not significantly correlated with patient anxiety and suggested that more detailed studies are needed to confirm the significance of different factors affecting patients' anxiety.

Anxiety as an “aversive psychological construct” is an undesirable experience and always related to a specific incidence which takes time to be forgotten.[12] Our findings also support it, and the scores of the patients anxiety significantly decreased once the patient experienced an inadvertent surgical procedure. Rapid patient's re-cooperation after surgery without any significant complication could be one of the causes.

One of the limitations of the present study was the lack of a control group. Therefore, we should interpret the results cautiously. Another limitation was that the patient's anxiety was evaluated immediately after the surgical procedure without long-term follow-ups for the level of anxiety of patients. Even complicated procedures may not affect patient anxiety immediately after the operation but can do so during longer follow-ups, perhaps due to postoperative complications. Some of the complications might happen postoperatively over time, and the level of discomfort due to these complications might affect the patient's anxiety related to a specific procedure. In the present study, patients were instructed to contact the department in case any complications have occurred. None of the patients reported any significant complication in the present study.

The present data, however, showed that the immediate postoperative psychological impacts of surgical removal of mandibular third molar under local anesthesia were relatively lower than the preoperative level of anxiety, possibly because the procedure is simple to perform, and patients have less than expected level of discomfort. Reassurance and educating patients at consultation visits using visual information about the procedure might alleviate preoperative patient's anxiety, which needs further investigation.


  Conclusion Top


The present data showed that the immediate postoperative psychological impacts of surgical removal of mandibular third molar under local anesthesia were relatively lower than the preoperative level of anxiety, possibly because the procedure is simple to perform, and patients have less than expected level of discomfort. Reassurance and educating patients at consultation visits using visual information about the procedure might alleviate preoperative patient's anxiety, which needs further investigation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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