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Effect of Verbal and Written Information and Previous Surgical Experience on Anxiety During Third Molar Extraction
DENTOALVEOLAR SURGERY
Effect of Verbal and Written Information and Previous Surgical Experience on Anxiety During Third Molar Extraction € Kevser T€ ut€ unc€ uler Sancak, DDS,* and Umit Kıymet Akal, DDS, PhDy Purpose:
Third molar extraction is a quite common surgical procedure that causes dental anxiety. This procedure affects patients physiologically and mentally. The type of information provided to patients is important to determine the level of their anxiety regarding the surgical procedure. Patients’ experience is also a major determinant of dental anxiety. It is subjective and perceived only by the patient. Questionnaires are tools used to determine and assess patient anxiety. The present study evaluated the effect of verbal and written information and the previous surgical experience of patients on their anxiety before and after third molar extraction.
Patients and Methods:
A total of 66 patients who had been admitted for third molar extraction under local anesthesia were included. The patients were divided into 3 groups: group 1 was given verbal information, group 2 was given written information, and group 3 had had previous surgical experience. The Spielberger State Anxiety Inventory (STAI-S), Dental Fear Scale (DFS), Modified Dental Anxiety Scale (MDAS), and visual analog scale (VAS) were used pre- and postoperatively to evaluate dental anxiety.
Results:
The MDAS and VAS scores of all patients had decreased postoperatively (P = .012 and P < .001, respectively). The postoperative MDAS and VAS scores were lower than the preoperative scores in women (P = .007 and P < .001, respectively). The postoperative MDAS (P = .014 and P = .004, respectively) and VAS (P < .001 and P = .002) scores had decreased compared with the preoperative scores in groups 2 and 3. The preoperative and postoperative MDAS and VAS scores were similar in group 1. In addition, the preoperative and postoperative STAI-S and DFS scores were similar in all groups.
Conclusions: All patients should be adequately informed about the third molar extraction procedure, even if they have previous experience. Providing detailed information reduced the postoperative anxiety of the patients. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e7, 2019
Dental anxiety is general fear and anxiety related to dental treatment.1 It prevents patients from accepting dental treatment, resulting in delayed appointments.2 Just as for other procedures, third molar extraction causes fear and anxiety.3-5 Previous studies have shown that surgical procedures increase patients’
preoperative anxiety.4,5 Some studies have reported that 60 to 80% of patients were anxious preoperatively.4,6 Two factors will determine the amount of preoperative anxiety before third molar extraction: lack of information about the surgical process and undergoing surgery in an operating
Received from Department of Oral and Maxillofacial Surgery, Faculty
Received February 13 2019
of Dentistry, Ankara University, Ankara, Turkey.
Accepted May 22 2019
*Research Assistant. yProfessor.
Ó 2019 American Association of Oral and Maxillofacial Surgeons
Conflict of Interest Disclosures: None of the authors have any
https://doi.org/10.1016/j.joms.2019.05.014
0278-2391/19/30545-2
relevant financial relationship(s) with a commercial interest. Address correspondence and reprint requests to Dr Sancak: Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University, Ankara, Turkey; e-mail: [email protected]
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1.e2 room.4 The prevalence of dental anxiety has been reported to be 4 to 23.4%. Dental anxiety can also result from previous dental experience.7 Previous dental treatment and the lack of communication between the dentist and patient can cause anxiety and should be considered before treatment.7,8 Various studies have shown that psychological support and the provision of detailed information about the procedure beforehand will reduce patients’ preoperative anxiety.7,9 The level of patients’ preoperative anxiety has varied depending on the type of information (written vs verbal).4 The most effective method for giving information to patients and, hence, decreasing their preoperative anxiety level remains controversial. Reported studies have recommended verbal, written, or video communication, or a combination of these, for delivering information to patients.4,10 Determining the levels of dental anxiety among patients who visit a dental surgeon will help dental surgeons take precautions and reduce patient anxiety.11 Anxiety among patients scheduled to undergo surgical procedures is subjective and perceived only by the patient.12 Several scales are available to determine and assess dental anxiety among patients. Questionnaires are the most reliable form because they are easy to use.13 Anxiety can be measured on a scale from severe anxiety to no anxiety.14 The present study evaluated the effect of verbal and written information provided to patients who had been admitted for third molar extraction on their preoperative and postoperative anxiety levels.
Patients and Methods The present prospective study included 66 patients who had undergone third molar extraction under local anesthesia in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University from September to November 2018. The Ankara University ethical committee approved the research protocol (approval no. 36290600/69). The Spielberger State Anxiety Inventory (STAI-S), Dental Fear Scale (DFS), Modified Dental Anxiety Scale (MDAS), and visual analog scale (VAS) have been commonly used to assess patients’ dental anxiety. In the present study, all 4 were used together before and immediately after surgery to obtain better results. In addition, the participants’ age and gender were queried. The inclusion criteria were as follows: adults aged 18 to 80 years, American Society of Anesthesiologists physical status score I and II, and the absence of any systemic disease and regular medication use. The exclusion criteria were the inability to read and understand Turkish, the presence of significantly impaired eyesight or hearing, the presence of an existing psychiatric disorder, and age younger than 18 years.
ANXIETY DURING THIRD MOLAR EXTRACTION
After their panoramic radiographs had been examined, the patients who had undergone extraction were grouped into Class 1 or II and position A or B using the Pell-Gregory classification15 and a mesioangular or vertical position using the Winter classification.16 Each patient was examined by the investigators. The patients were informed about the procedure, and the patients’ preoperative assessment clinic provided the written informed consent form. If a patient had additional questions, they were included as a part of the study. The patients were divided into 3 groups: Group 1: patients were given only the basic information verbally Group 2: patients were given detailed written information about the preoperative, intraoperative, and postoperative periods Group 3: patients with previous experience and knowledge about third molar extraction and to whom the basic information was given verbally Whether the patients had previous experience of third molar extraction was determined before they completed the questionnaires. The patients were asked whether they had had any negative or unfavorable experiences during a previous third molar extraction procedure. Those who answered yes were not included in the present study. The patients were randomly assigned to group 1 or 2 using an online random allocation software program (available at: www.randomization.com). Information on completing the questionnaires was provided. The STAI-S, MDAS, DFS, and VAS were supplied to all patients in the waiting room 15 minutes before their surgery. The demographic data section (age and gender) on the form was completed by 1 of us (K.T.S.). The surgery was performed with the patient under local anesthesia, with no pharmaceutical premedication or sedation provided. The surgical procedure was performed by a single experienced surgeon in the oral-maxillofacial surgery clinic. After the surgery had been completed, the patients were taken to the waiting room, and the prescribed medications were given. The patients again completed the STAI-S, MDAS, DFS, and VAS questionnaires 20 minutes after the surgery in the waiting room. The questionnaires were given in the same room and at same table as preoperatively. QUESTIONNAIRES
Spielberger State Anxiety Inventory The STAI-S is one of the most frequently used scales in anxiety research, although it is not a specific scale for dental anxiety.17 The inventory has 2 scales, each
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Table 1. DEMOGRAPHIC PATIENT CHARACTERISTICS
Characteristic Age (years) Gender Female Male
Group 1 (n = 22)
Group 2 (n = 22)
Group 3 (n = 22)
P Value
25.5 9.0
23.3 8.5
27.5 10.7
.328* .561y
15 (68.2) 7 (31.8)
18 (81.8) 4 (18.2)
17 (77.3) 5 (22.7)
Data presented as mean standard deviation or n (%). * One-way analysis of variance test. y Pearson c2 test. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
with 20 items showing the state and trait anxiety levels. STAI-state is used to determine a patient’s current anxiety level, and STAI-trait is used to determine a patient’s underlying (ongoing/personality) anxiety level. All 20 items are rated using a 4-point scale. The total score obtained ranges from 20 to 80. STAI scores are commonly classified as no or low anxiety (score, 20 to 37), moderate anxiety (score, 38 to 44), and high anxiety (score, 45 to 80).4,18 Dental Fear Scale The DFS, developed by Kleinknecht et al,19 is used to determine a patient’s dental fear in different dimensions. It is a Likert-type scale with a score of 1 to 5. It has 20 items examining the levels of fear in terms of dentist avoidance, somatic symptoms of fear, and fear of various applications in dentistry practice.19-21 Modified Dental Anxiety Scale The MDAS was developed by Humphris et al13 by adding a question to Corah’s Dental Anxiety Scale related to injection. The scale consists of a 5-point Likert-type rating with 5 options. The total score in the scale ranges from 5 to 25.22,23
Visual Analog Scale The VAS is ideal for evaluating situations that cannot be measured using digital and oral information.24 In the present study, a scale with a 100-mm closed-end line was used to measure patients’ anxiety level. One end of the scale was labeled ‘‘no anxiety’’ and the other end as ‘‘maximum anxiety imaginable.’’ STATISTICAL ANALYSIS
The data were analyzed using SPSS for Windows, version 17 (IBM Corp, Armonk, NY). The results are presented as frequencies, percentages, and the mean standard deviation. A P value < .05 was considered to indicate statistical significance. The power analysis revealed a probability of < .05 with 80% power for 66 patients in the present study. The Student t test was used to determine the significance of the difference in the mean values between the groups when the number of independent groups was 2. The significance of the difference between more than 2 independent groups was evaluated using 1-way analysis of variance. The difference between the preoperative and postoperative STAI-S scores in the groups was determined using the paired samples t test. Statistically
Table 2. PRE- AND POSTOPERATIVE QUESTIONNAIRE SCORES FOR ALL PATIENTS
Score Questionnaire
Preoperative
Postoperative
P Value
Variation
STAI-S DFS MDAS VAS
40.1 10.0 38.5 (20-96) 10 (5-25) 4.6 (0.6-10)
39.6 10.0 40 (21-100) 9 (5-21) 2.7 (0.1-9)
.655* .371y .012yz <.001yz
0.5 9.3 0 (27 to 19) 0.5 (10 to 5) 1.7 (9.4 to 3.5)
Data presented as mean standard deviation or median (range). Abbreviations: DFS, Dental Fear Scale; MDAS, Modified Dental Anxiety Scale; STAI-S, Spielberger State Anxiety Inventory; VAS, visual analog scale. * Dependent sample t test. y Wilcoxon signed rank test. z Statistically significant. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
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ANXIETY DURING THIRD MOLAR EXTRACTION
significant changes among the DFS, MDAS, and VAS scores were investigated using the Wilcoxon signed rank test. However, Bonferroni correction was performed to check for type I error in all possible multiple comparisons.
Results No statistically significant difference was found between the groups in terms of mean age (P = .332). The distribution of men and women was also similar among the groups (P = .561; Table 1). No statistically significant difference was found in the postoperative STAI-S and DFS scores among the groups (P = .655 and P = .371, respectively). The postoperative VAS and MDAS scores for all the patients had decreased compared with the preoperative scores (P < .001 and P = .012, respectively; Table 2). No statistically significant differences were observed in the preoperative and postoperative STAIS, DFS, MDAS, and VAS scores among the groups (P = .236, P = .642, P = .107, and P = .094 and P = .859, P = .210, P = .279, and P = .527, respectively). The postoperative MDAS scores (P = .014 and P = .004, respectively) and VAS scores (P < .001 and P = .002, respectively) had decreased in groups 2 and 3 (Figs 1, 2). The preoperative and postoperative MDAS and VAS scores were similar in group 1. Furthermore, in all groups, the preoperative and postoperative STAI-S and DFS scores were similar for all patients (Table 3). No statistically significant difference was found in the preoperative STAI-S scores between the men and women (P = .400). The postoperative MDAS and VAS scores were lower than the preoperative scores for the women (P = .007 and P < .001, respectively). The postoperative MDAS score had significantly decreased for all patients (P = .009). Also, the postop-
FIGURE 1. Changes in postoperative (Post-op) Modified Dental Anxiety Scale (MDAS) scores compared with preoperative (Preop) scores. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
FIGURE 2. Changes in postoperative (Post-op) visual analog scale (VAS) scores compared with preoperative (Pre-op) scores. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
erative MDAS score had significantly decreased in group 2 (P = .012). The responses to each question in the DFS were statistically analyzed in detail. In the present study, the options related to injection and burring had the highest scores. The questions in the DFS questionnaire were evaluated one by one.
Discussion Dental treatment causes stress, fear, anxiety, and excitement among patients.25 Therefore, all dimensions of dental fear and anxiety should be evaluated correctly. The presence of fear and anxiety in a patient can be determined using specially developed scales. Completing these scales before dental treatment will not have a negative effect on the fear and anxiety level of the patients.13 Providing preoperative information has been found to be effective in reducing anxiety during dentoalveolar surgery. Brasileiro et al9 reported that all patients should be informed about third molar extraction. Laskin et al26 suggested that it would be useful to determine the effects of providing information to patients in advance of the procedure. High and very high anxiety levels before oralmaxillofacial surgical procedures are not surprising because oral-maxillofacial surgery has been reported to cause the greatest level of anxiety among all dental procedures. Muglali and Komerik7 reported less anxiety after surgical procedure using different measurement tools. Reyes-Gilabert et al27 reported that the preoperative STAI-S, STAI-T, and MDAS scores were higher than the postoperative scores. In the present study, the postoperative anxiety levels were significantly lower than the preoperative anxiety levels. In clinical studies, 1 or more scales have been used to evaluate dental anxiety to ensure the reliability of the data.28 Schuurs and Hoogstraten29 compared 6 different scales and determined that these scales
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Table 3. PREOPERATIVE AND POSTOPERATIVE QUESTIONNAIRE SCORES
Questionnaire STAI-S Group 1 Group 2 Group 3 P value DFS Group 1 Group 2 Group 3 P value MDAS Group 1 Group 2 Group 3 P value VAS Group 1 Group 2 Group 3 P value
Preoperative
Postoperative
P Value
Variation
42.5 10.2 40.5 11.3 37.4 7.8 .236y
39.7 11.2 40.4 7.8 38.7 11.1 0.859y
.212* .967* .396* NA
2.8 10.1 0.1 10.3 1.3 7.1 0.339y
36.5 (21-95) 38.5 (20-96) 39 (22-86) .642{
33 (21-94) 45 (21-98) 38.5 (22-100) .210{
.048z .532{ .337z NA
2.5 (13 to 12)xk 3 (27 to 19)x 1 (12 to 17)k .002{#
9 (5-21) 11.5 (5-25) 9.5 (5-21) .107{
7.5 (5-21) 10.5 (5-20) 6.5 (5-18) .279{
.232z .014z# .004z# NA
0 (6 to 3) 1.5 (10 to 4) 0 (6 to 5) .104{
3.9 (0.6-10) 5.8 (1.8-10) 3.4 (1.1-10) .094{
1.9 (0.1-9) 3.2 (0.4-7.8) 0.6 (0.4-7.9) .527{
.021z <.001z# .002z# NA
1.3 (9.4 to 3.5) 2.3 (7.2 to 2)** 1 (3.9 to 3.5)** .048{#
Data presented as mean standard deviation or median (range). Abbreviations: DFS, Dental Fear Scale; MDAS, Modified Dental Anxiety Scale; NA, not applicable; STAI-S, Spielberger State Anxiety Inventory; VAS, visual analog scale. * Dependent sample t test. y One-way analysis of variance test. z Wilcoxon signed rank test. x Statistically significant difference between groups 1 and 2 (P < .001). k Statistically significant difference between groups 1 and 3 (P = .012). { Kruskal-Wallis test. # Statistically significant. ** Statistically significant difference between groups 2 and 3 (P = .007). Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
were not sufficient to evaluate the findings. Hence, multiple scales should be used to measure dental anxiety. Four different scales were used in the present study to better analyze the results. The VAS and MDAS were preferred because the techniques are highly practical and easily adaptable to patients, suitable for frequent use and reuse, and suitable for statistical studies. When the patients were not sure how to respond, they could give an average response and avoid extreme responses, which might be attributed to the central tendency bias.4 This might be the reason the STAI and DFS and the MDAS and VAS surveys yielded different results. The MDAS and VAS are short-term evaluation tools, the STAI contains general terms, and the DFS is a 20-question survey. Patients completing the MDAS and VAS surveys might be easier to assess than those who might have provided more accurate answers. The MDAS has a simplified response design and includes an additional question about the local anesthetic injection.22 The VAS is ideal for
scoring situations that cannot be measured by digital and oral expression.24 Kvale et al30 found that the DFS was as reliable as the STAI-S for measuring dental anxiety. However, other studies found no significant relationship between the 2 scales.31,32 Considering previous findings,3,7,33-36 more attention should be given to reduce the anxiety among female patients. Although no statistically significant differences were found between the scores of the women and men in the present study, the scores of the women were higher. However, the postoperative MDAS and VAS scores for the women were significantly lower than their preoperative scores. When patients start a new treatment, their previous dental experience will affect their reaction in terms of their anxiety level. A poor previous experience with dental procedures will result in greater anxiety. Muglali and Komerik7 found that patients’ previous dental experiences will contribute to their anxiety. Yusa et al35 observed that patients who had undergone a 20-year dental extraction procedure had lower
1.e6 anxiety levels. Caumo et al37 reported that a history of surgery did not change patients’ level of anxiety. Earl38 found that 43% of 105 patients who had previously undergone third molar extraction had more fear when the procedure was repeated. L opez-Jornet et al39 found no difference in the anxiety levels between patients with previous experience and other patients after completion of the STAI-S, DFS, and MDAS before and after the dental extraction procedure. Although experience is a mixed concept, it is an impressive feature. However, it should not be considered alone. Negative experiences have been observed to be related to fear but no relationship was found between positive experiences and reductions in fear. In fact, a positive relationship between remembering positive memories and increased dental anxiety has been found.40 Therefore, we included only patients who had not had a negative experience. In the present study, even if the patients had previous experience, that experience had not provided them with enough information to reduce their preoperative anxiety. The MDAS and VAS scores were lower in the experienced group than in the other groups but without statistically significant differences. Important symptoms of dental anxiety include continuously avoiding dental treatment, delaying dental appointments, and canceling the appointment once the appointment has been made.41 In the present study, the response to the first question of the DFS ‘ the frequency of going to the dentist: ( ) none ( ) sometimes ( ) when there is a complaint ( ) every 6 months ( ) every one year’’ was evaluated. We found that most patients went to the dentist when they had the maximum number of complaints. Kleinknecht et al19 found the highest anxiety scores for the injection and drilling. These processes caused more anxiety compared with other processes in terms of both image and sound.38 In the present study, the questions in the DFS were evaluated one by one showing that the options related to injection and drilling had the highest scores. Determining how patients feel before the procedure and their expectations from the treatment process affect the course of treatment and postoperative patient satisfaction.42,43 Interactive animation videos and written information can be useful during the preoperative period.44 Although written information is the most effective method to inform patients, they could perceive it differently.4 Some studies have shown that the preoperative anxiety levels of patients who were informed in detail during the preoperative period were lower. Also, the pain and anxiety levels were lower during the postoperative period and the recovery was faster.45,46 In the present study, the postoperative VAS and MDAS scores of the patients
ANXIETY DURING THIRD MOLAR EXTRACTION
provided with written information were significantly lower than the preoperative scores. All patients should be adequately informed about the third molar extraction procedure even if some have had previous experience. Providing patients with detailed information will reduce postoperative anxiety. The postoperative MDAS and VAS scores were lower than the preoperative scores for the women. The use of multiple questionnaires has been preferred in studies evaluating patient anxiety. The present study had limitations regarding the design of the experienced group, and the group was not evaluated as either positive and negative. The effect of negative and positive experiences on anxiety is a complicated subject. In some studies, no difference was observed between those with a negative experience and control groups.3,47 However, in some studies, negative experiences were observed to be related to increased anxiety.40,48 This subject requires research and discussion in future studies.
References 1. Ayer W Jr, Domoto P, Gale E, et al: Overcoming dental fear: Strategies for its prevention and management. J Am Dent Assoc (1939) 107:18, 1983 2. Wisløff T, Vassend O, Asmyhr O: Dental anxiety, utilisation of dental services, and DMFS status in Norwegian military recruits. Community Dent Health 12:100, 1995 3. Stabholz A, Peretz B: Dental anxiety among patients prior to different dental treatments. Int Dent J 49:90, 1999 4. Jlala H, French J, Foxall G, et al: Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 104: 369, 2010 5. Karayagız F, Altuntas¸ M, G€ uc¸l€ u Y, et al: Cerrahi servisinde yatan hastalarda g€ or€ ulen anksiyete dagılımı. Smyrna Tıp Dergisi 1:22, 2011 6. Tas¸demir A, Erakgun A, Deniz MN, C ¸ ertug A: Preoperatif bilgilen€ncesi ve sonrası anksiyete dirme yapılan hastalarda ameliyat o d€ uzeylerinin state-trait anxiety inventory test ile kars¸ılas¸tırılması. Turk J Anaesth Reanim 41, 44, 2013 7. Muglali M, Komerik N: Factors related to patients’ anxiety before and after oral surgery. J Oral Maxillofac Surg 66:870, 2008 8. Thomson WM, Locker D, Poulton R: Incidence of dental anxiety in young adults in relation to dental treatment experience. Community Dent Oral Epidemiol 28:289, 2000 9. Brasileiro BF, de Braganc¸a RMF, Van Sickels JE: An evaluation of patients’ knowledge about perioperative information for third molar removal. J Oral Maxillofac Surg 70:12, 2012 10. Obled S, Melki M, Coelho J, et al: Patient information for liver biopsy: Impact of a video movie. Gastroenterol Clin Biol 31:274, 2007 11. Johansson P, Berggren U: Assessment of dental fear: A comparison of two psychometric instruments. Acta Odontol Scand 50: 43, 1992 12. Pritchard MJ: Using the Hospital Anxiety and Depression Scale in surgical patients. Nurs Stand 25:35, 2011 13. Humphris G, Clarke H, Freeman R: Does completing a dental anxiety questionnaire increase anxiety? A randomised controlled trial with adults in general dental practice. Br Dent J 201:33, 2006 € L-G, Skaret E: Cognitive Behavioral Therapy for 14. Ost L-G, Ost Dental Phobia and Anxiety. Hoboken, NJ, John Wiley & Sons, 2013
SANCAK AND AKAL 15. Pell GJ: Impacted mandibular third molars: Classification and modified techniques for removal. Dent Digest 39:330, 1933 16. Winter GB: Principles of Exodontia as Applied to the Impacted Mandibular Third Molar. St Louis, MO, American Medical Book Company, 1926 17. Spielberger CD: Manual for the State-Trait Anxiety Inventory STAI (Form Y) ("Self-Evaluation Questionnaire"). Palo Alto, CA, Consulting Psychologists Press, 1983 18. Ruffinengo C, Versino E, Renga G: Effectiveness of an informative video on reducing anxiety levels in patients undergoing elective coronarography: An RCT. Eur J Cardiovasc Nurs 8:57, 2009 19. Kleinknecht RA, Klepac RK, Alexander LD: Origins and characteristics of fear of dentistry. J Am Dent Assoc 86:842, 1973 20. Bodrumlu E, S€ umer AP, S€ umer M, K€ opr€ ul€ u H: Ondokuz Mayıs € niversitesi Dis¸hekimligi Fak€ U ultesine bas¸vuran bireylerde dental korkunun degerlendirilmesi. Hacettepe Dis¸hekimligi Fak€ ultesi Dergisi 1:51, 2006 21. Lago-Mendez L, Diniz-Freitas M, Senra-Rivera C, et al: Dental anxiety before removal of a third molar and association with general trait anxiety. J Oral Maxillofac Surg 64:1404, 2006 22. Tunc EP, Firat D, Onur OD, Sar V: Reliability and validity of the Modified Dental Anxiety Scale (MDAS) in a Turkish population. Community Dent Oral Epidemiol 33:357, 2005 23. Ilg€ uy D, Ilg€ uy M, Dinc¸er S, Bayirli G: Reliability and validity of the Modified Dental Anxiety Scale in Turkish patients. J Int Med Res 33:252, 2005 24. Aitken RC: A growing edge of measurement of feelings using visual analogue scales. Proc R Soc Med 62:989, 1969 25. Hakeberg M, Berggren U, Gr€ ondahl HG: A radiographic study of dental health in adult patients with dental anxiety. Community Dent Oral Epidemiol 21:27, 1993 26. Laskin DM, Priest JH, Alfaqih S, Carrico CK: Does viewing a third molar informed consent video decrease patients’ anxiety? J Oral Maxillofac Surg 76:2515, 2018 27. Reyes-Gilabert E, Luque-Romero L-G, Bejarano-Avila G, et al: Assessment of pre and postoperative anxiety in patients undergoing ambulatory oral surgery in primary care. Med Oral Patol Oral Cir Bucal 22:e716, 2017 28. Hakeberg M, Berggren U: Dimensions of the Dental Fear Survey among patients with dental phobia. Acta Odontol Scand 55:314, 1997 29. Schuurs AH, Hoogstraten J: Appraisal of dental anxiety and fear questionnaires: A review. Community Dent Oral Epidemiol 21: 329, 1993 30. Kvale G, Berg E, Raadal M: The ability of Corah’s Dental Anxiety Scale and Spielberger’s State Anxiety Inventory to distinguish between fearful and regular Norwegian dental patients. Acta Odontol Scand 56:105, 1998
1.e7 31. Schuurs AH, Duivenvoorden HJ, Makkes PC, et al: Personality traits of patients suffering extreme dental anxiety. Community Dent Oral Epidemiol 16:38, 1988 32. Okawa K, Ichinohe T, Kaneko Y: Anxiety may enhance pain during dental treatment. Bull Tokyo Dent Coll 46:51, 2005 33. Jaakkola S, Rautava P, Alanen P, et al: Dental fear: one single clinical question for measurement. Open Dent J 3:161, 2009 oker K, et al: Anxiety and extraction of third 34. Garip H, Abalı O, G€ molars in Turkish patients. Br J Oral Maxillofac Surg 42:551, 2004 35. Yusa H, Onizawa K, Hori M, et al: Anxiety measurements in university students undergoing third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:23, 2004 lvarez P, Pe~ 36. Tarazona B, Tarazona-A narrocha-Oltra D, et al: Anxiety before extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal 20:e246, 2015 37. Caumo W, Schmidt AP, Schneider CN, et al: Risk factors for preoperative anxiety in adults. Acta Anaesth Scand 45:298, 2001 38. Earl P: Patients’ anxieties with third molar surgery. Br J Oral Maxillofac Surg 32:293, 1994 39. L opez-Jornet P, Camacho-Alonso F, Sanchez-Siles M: Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: A prospective study. Br J Oral Maxillofac Surg 52:18, 2014 40. Risløv Staugaard S, Jøssing M, Krohn C: The role of negative and positive memories in fear of dental treatment. J Pub Health Dent 77:39, 2017 41. Berggren U, Meynert G: Dental fear and avoidance: Causes, symptoms, and consequences. J Am Dent Assoc (1939) 109: 247, 1984 42. Muglalı M, Komerik N: Oral surgery and anxiety. J Dent Cumhuriyet University 8:83, 2005 43. Eli I, Schwartz-Arad D, Baht R, Ben-Tuvim H: Effect of anxiety on the experience of pain in implant insertion. Clin Oral Implants Res 14:115, 2003 44. Oshodi TO: The impact of preoperative education on postoperative pain: Part 1. Br J Nurs 16:790, 2007 45. Weis O, Weintraub M, Sriwatanakul K, Lasagna L: Reduction of anxiety and postoperative analgesic requirements by audiovisual instruction. Lancet 321:43, 1983 46. Tou S, Tou W, Mah D, et al: Effect of preoperative twodimensional animation information on perioperative anxiety and knowledge retention in patients undergoing bowel surgery: A randomized pilot study. Colorectal Dis 15:e256, 2013 47. de Jongh A, Van Wijk AJ, Lindeboom JA: Psychological impact of third molar surgery: A 1-month prospective study. J Oral Maxillofac Surg 69:59, 2011 48. Sirin Y, Yucel B, Firat D, Husseinova-Sen S: Assessment of dental fear and anxiety levels in eating disorder patients undergoing minor oral surgery. J Oral Maxillofac Surg 69:2078, 2011
Effect of Verbal and Written Information and Previous Surgical Experience on Anxiety During Third Molar Extraction € Kevser T€ ut€ unc€ uler Sancak, DDS,* and Umit Kıymet Akal, DDS, PhDy Purpose:
Third molar extraction is a quite common surgical procedure that causes dental anxiety. This procedure affects patients physiologically and mentally. The type of information provided to patients is important to determine the level of their anxiety regarding the surgical procedure. Patients’ experience is also a major determinant of dental anxiety. It is subjective and perceived only by the patient. Questionnaires are tools used to determine and assess patient anxiety. The present study evaluated the effect of verbal and written information and the previous surgical experience of patients on their anxiety before and after third molar extraction.
Patients and Methods:
A total of 66 patients who had been admitted for third molar extraction under local anesthesia were included. The patients were divided into 3 groups: group 1 was given verbal information, group 2 was given written information, and group 3 had had previous surgical experience. The Spielberger State Anxiety Inventory (STAI-S), Dental Fear Scale (DFS), Modified Dental Anxiety Scale (MDAS), and visual analog scale (VAS) were used pre- and postoperatively to evaluate dental anxiety.
Results:
The MDAS and VAS scores of all patients had decreased postoperatively (P = .012 and P < .001, respectively). The postoperative MDAS and VAS scores were lower than the preoperative scores in women (P = .007 and P < .001, respectively). The postoperative MDAS (P = .014 and P = .004, respectively) and VAS (P < .001 and P = .002) scores had decreased compared with the preoperative scores in groups 2 and 3. The preoperative and postoperative MDAS and VAS scores were similar in group 1. In addition, the preoperative and postoperative STAI-S and DFS scores were similar in all groups.
Conclusions: All patients should be adequately informed about the third molar extraction procedure, even if they have previous experience. Providing detailed information reduced the postoperative anxiety of the patients. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e7, 2019
Dental anxiety is general fear and anxiety related to dental treatment.1 It prevents patients from accepting dental treatment, resulting in delayed appointments.2 Just as for other procedures, third molar extraction causes fear and anxiety.3-5 Previous studies have shown that surgical procedures increase patients’
preoperative anxiety.4,5 Some studies have reported that 60 to 80% of patients were anxious preoperatively.4,6 Two factors will determine the amount of preoperative anxiety before third molar extraction: lack of information about the surgical process and undergoing surgery in an operating
Received from Department of Oral and Maxillofacial Surgery, Faculty
Received February 13 2019
of Dentistry, Ankara University, Ankara, Turkey.
Accepted May 22 2019
*Research Assistant. yProfessor.
Ó 2019 American Association of Oral and Maxillofacial Surgeons
Conflict of Interest Disclosures: None of the authors have any
https://doi.org/10.1016/j.joms.2019.05.014
0278-2391/19/30545-2
relevant financial relationship(s) with a commercial interest. Address correspondence and reprint requests to Dr Sancak: Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University, Ankara, Turkey; e-mail: [email protected]
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1.e2 room.4 The prevalence of dental anxiety has been reported to be 4 to 23.4%. Dental anxiety can also result from previous dental experience.7 Previous dental treatment and the lack of communication between the dentist and patient can cause anxiety and should be considered before treatment.7,8 Various studies have shown that psychological support and the provision of detailed information about the procedure beforehand will reduce patients’ preoperative anxiety.7,9 The level of patients’ preoperative anxiety has varied depending on the type of information (written vs verbal).4 The most effective method for giving information to patients and, hence, decreasing their preoperative anxiety level remains controversial. Reported studies have recommended verbal, written, or video communication, or a combination of these, for delivering information to patients.4,10 Determining the levels of dental anxiety among patients who visit a dental surgeon will help dental surgeons take precautions and reduce patient anxiety.11 Anxiety among patients scheduled to undergo surgical procedures is subjective and perceived only by the patient.12 Several scales are available to determine and assess dental anxiety among patients. Questionnaires are the most reliable form because they are easy to use.13 Anxiety can be measured on a scale from severe anxiety to no anxiety.14 The present study evaluated the effect of verbal and written information provided to patients who had been admitted for third molar extraction on their preoperative and postoperative anxiety levels.
Patients and Methods The present prospective study included 66 patients who had undergone third molar extraction under local anesthesia in the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University from September to November 2018. The Ankara University ethical committee approved the research protocol (approval no. 36290600/69). The Spielberger State Anxiety Inventory (STAI-S), Dental Fear Scale (DFS), Modified Dental Anxiety Scale (MDAS), and visual analog scale (VAS) have been commonly used to assess patients’ dental anxiety. In the present study, all 4 were used together before and immediately after surgery to obtain better results. In addition, the participants’ age and gender were queried. The inclusion criteria were as follows: adults aged 18 to 80 years, American Society of Anesthesiologists physical status score I and II, and the absence of any systemic disease and regular medication use. The exclusion criteria were the inability to read and understand Turkish, the presence of significantly impaired eyesight or hearing, the presence of an existing psychiatric disorder, and age younger than 18 years.
ANXIETY DURING THIRD MOLAR EXTRACTION
After their panoramic radiographs had been examined, the patients who had undergone extraction were grouped into Class 1 or II and position A or B using the Pell-Gregory classification15 and a mesioangular or vertical position using the Winter classification.16 Each patient was examined by the investigators. The patients were informed about the procedure, and the patients’ preoperative assessment clinic provided the written informed consent form. If a patient had additional questions, they were included as a part of the study. The patients were divided into 3 groups: Group 1: patients were given only the basic information verbally Group 2: patients were given detailed written information about the preoperative, intraoperative, and postoperative periods Group 3: patients with previous experience and knowledge about third molar extraction and to whom the basic information was given verbally Whether the patients had previous experience of third molar extraction was determined before they completed the questionnaires. The patients were asked whether they had had any negative or unfavorable experiences during a previous third molar extraction procedure. Those who answered yes were not included in the present study. The patients were randomly assigned to group 1 or 2 using an online random allocation software program (available at: www.randomization.com). Information on completing the questionnaires was provided. The STAI-S, MDAS, DFS, and VAS were supplied to all patients in the waiting room 15 minutes before their surgery. The demographic data section (age and gender) on the form was completed by 1 of us (K.T.S.). The surgery was performed with the patient under local anesthesia, with no pharmaceutical premedication or sedation provided. The surgical procedure was performed by a single experienced surgeon in the oral-maxillofacial surgery clinic. After the surgery had been completed, the patients were taken to the waiting room, and the prescribed medications were given. The patients again completed the STAI-S, MDAS, DFS, and VAS questionnaires 20 minutes after the surgery in the waiting room. The questionnaires were given in the same room and at same table as preoperatively. QUESTIONNAIRES
Spielberger State Anxiety Inventory The STAI-S is one of the most frequently used scales in anxiety research, although it is not a specific scale for dental anxiety.17 The inventory has 2 scales, each
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Table 1. DEMOGRAPHIC PATIENT CHARACTERISTICS
Characteristic Age (years) Gender Female Male
Group 1 (n = 22)
Group 2 (n = 22)
Group 3 (n = 22)
P Value
25.5 9.0
23.3 8.5
27.5 10.7
.328* .561y
15 (68.2) 7 (31.8)
18 (81.8) 4 (18.2)
17 (77.3) 5 (22.7)
Data presented as mean standard deviation or n (%). * One-way analysis of variance test. y Pearson c2 test. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
with 20 items showing the state and trait anxiety levels. STAI-state is used to determine a patient’s current anxiety level, and STAI-trait is used to determine a patient’s underlying (ongoing/personality) anxiety level. All 20 items are rated using a 4-point scale. The total score obtained ranges from 20 to 80. STAI scores are commonly classified as no or low anxiety (score, 20 to 37), moderate anxiety (score, 38 to 44), and high anxiety (score, 45 to 80).4,18 Dental Fear Scale The DFS, developed by Kleinknecht et al,19 is used to determine a patient’s dental fear in different dimensions. It is a Likert-type scale with a score of 1 to 5. It has 20 items examining the levels of fear in terms of dentist avoidance, somatic symptoms of fear, and fear of various applications in dentistry practice.19-21 Modified Dental Anxiety Scale The MDAS was developed by Humphris et al13 by adding a question to Corah’s Dental Anxiety Scale related to injection. The scale consists of a 5-point Likert-type rating with 5 options. The total score in the scale ranges from 5 to 25.22,23
Visual Analog Scale The VAS is ideal for evaluating situations that cannot be measured using digital and oral information.24 In the present study, a scale with a 100-mm closed-end line was used to measure patients’ anxiety level. One end of the scale was labeled ‘‘no anxiety’’ and the other end as ‘‘maximum anxiety imaginable.’’ STATISTICAL ANALYSIS
The data were analyzed using SPSS for Windows, version 17 (IBM Corp, Armonk, NY). The results are presented as frequencies, percentages, and the mean standard deviation. A P value < .05 was considered to indicate statistical significance. The power analysis revealed a probability of < .05 with 80% power for 66 patients in the present study. The Student t test was used to determine the significance of the difference in the mean values between the groups when the number of independent groups was 2. The significance of the difference between more than 2 independent groups was evaluated using 1-way analysis of variance. The difference between the preoperative and postoperative STAI-S scores in the groups was determined using the paired samples t test. Statistically
Table 2. PRE- AND POSTOPERATIVE QUESTIONNAIRE SCORES FOR ALL PATIENTS
Score Questionnaire
Preoperative
Postoperative
P Value
Variation
STAI-S DFS MDAS VAS
40.1 10.0 38.5 (20-96) 10 (5-25) 4.6 (0.6-10)
39.6 10.0 40 (21-100) 9 (5-21) 2.7 (0.1-9)
.655* .371y .012yz <.001yz
0.5 9.3 0 (27 to 19) 0.5 (10 to 5) 1.7 (9.4 to 3.5)
Data presented as mean standard deviation or median (range). Abbreviations: DFS, Dental Fear Scale; MDAS, Modified Dental Anxiety Scale; STAI-S, Spielberger State Anxiety Inventory; VAS, visual analog scale. * Dependent sample t test. y Wilcoxon signed rank test. z Statistically significant. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
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ANXIETY DURING THIRD MOLAR EXTRACTION
significant changes among the DFS, MDAS, and VAS scores were investigated using the Wilcoxon signed rank test. However, Bonferroni correction was performed to check for type I error in all possible multiple comparisons.
Results No statistically significant difference was found between the groups in terms of mean age (P = .332). The distribution of men and women was also similar among the groups (P = .561; Table 1). No statistically significant difference was found in the postoperative STAI-S and DFS scores among the groups (P = .655 and P = .371, respectively). The postoperative VAS and MDAS scores for all the patients had decreased compared with the preoperative scores (P < .001 and P = .012, respectively; Table 2). No statistically significant differences were observed in the preoperative and postoperative STAIS, DFS, MDAS, and VAS scores among the groups (P = .236, P = .642, P = .107, and P = .094 and P = .859, P = .210, P = .279, and P = .527, respectively). The postoperative MDAS scores (P = .014 and P = .004, respectively) and VAS scores (P < .001 and P = .002, respectively) had decreased in groups 2 and 3 (Figs 1, 2). The preoperative and postoperative MDAS and VAS scores were similar in group 1. Furthermore, in all groups, the preoperative and postoperative STAI-S and DFS scores were similar for all patients (Table 3). No statistically significant difference was found in the preoperative STAI-S scores between the men and women (P = .400). The postoperative MDAS and VAS scores were lower than the preoperative scores for the women (P = .007 and P < .001, respectively). The postoperative MDAS score had significantly decreased for all patients (P = .009). Also, the postop-
FIGURE 1. Changes in postoperative (Post-op) Modified Dental Anxiety Scale (MDAS) scores compared with preoperative (Preop) scores. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
FIGURE 2. Changes in postoperative (Post-op) visual analog scale (VAS) scores compared with preoperative (Pre-op) scores. Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
erative MDAS score had significantly decreased in group 2 (P = .012). The responses to each question in the DFS were statistically analyzed in detail. In the present study, the options related to injection and burring had the highest scores. The questions in the DFS questionnaire were evaluated one by one.
Discussion Dental treatment causes stress, fear, anxiety, and excitement among patients.25 Therefore, all dimensions of dental fear and anxiety should be evaluated correctly. The presence of fear and anxiety in a patient can be determined using specially developed scales. Completing these scales before dental treatment will not have a negative effect on the fear and anxiety level of the patients.13 Providing preoperative information has been found to be effective in reducing anxiety during dentoalveolar surgery. Brasileiro et al9 reported that all patients should be informed about third molar extraction. Laskin et al26 suggested that it would be useful to determine the effects of providing information to patients in advance of the procedure. High and very high anxiety levels before oralmaxillofacial surgical procedures are not surprising because oral-maxillofacial surgery has been reported to cause the greatest level of anxiety among all dental procedures. Muglali and Komerik7 reported less anxiety after surgical procedure using different measurement tools. Reyes-Gilabert et al27 reported that the preoperative STAI-S, STAI-T, and MDAS scores were higher than the postoperative scores. In the present study, the postoperative anxiety levels were significantly lower than the preoperative anxiety levels. In clinical studies, 1 or more scales have been used to evaluate dental anxiety to ensure the reliability of the data.28 Schuurs and Hoogstraten29 compared 6 different scales and determined that these scales
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Table 3. PREOPERATIVE AND POSTOPERATIVE QUESTIONNAIRE SCORES
Questionnaire STAI-S Group 1 Group 2 Group 3 P value DFS Group 1 Group 2 Group 3 P value MDAS Group 1 Group 2 Group 3 P value VAS Group 1 Group 2 Group 3 P value
Preoperative
Postoperative
P Value
Variation
42.5 10.2 40.5 11.3 37.4 7.8 .236y
39.7 11.2 40.4 7.8 38.7 11.1 0.859y
.212* .967* .396* NA
2.8 10.1 0.1 10.3 1.3 7.1 0.339y
36.5 (21-95) 38.5 (20-96) 39 (22-86) .642{
33 (21-94) 45 (21-98) 38.5 (22-100) .210{
.048z .532{ .337z NA
2.5 (13 to 12)xk 3 (27 to 19)x 1 (12 to 17)k .002{#
9 (5-21) 11.5 (5-25) 9.5 (5-21) .107{
7.5 (5-21) 10.5 (5-20) 6.5 (5-18) .279{
.232z .014z# .004z# NA
0 (6 to 3) 1.5 (10 to 4) 0 (6 to 5) .104{
3.9 (0.6-10) 5.8 (1.8-10) 3.4 (1.1-10) .094{
1.9 (0.1-9) 3.2 (0.4-7.8) 0.6 (0.4-7.9) .527{
.021z <.001z# .002z# NA
1.3 (9.4 to 3.5) 2.3 (7.2 to 2)** 1 (3.9 to 3.5)** .048{#
Data presented as mean standard deviation or median (range). Abbreviations: DFS, Dental Fear Scale; MDAS, Modified Dental Anxiety Scale; NA, not applicable; STAI-S, Spielberger State Anxiety Inventory; VAS, visual analog scale. * Dependent sample t test. y One-way analysis of variance test. z Wilcoxon signed rank test. x Statistically significant difference between groups 1 and 2 (P < .001). k Statistically significant difference between groups 1 and 3 (P = .012). { Kruskal-Wallis test. # Statistically significant. ** Statistically significant difference between groups 2 and 3 (P = .007). Sancak and Akal. Anxiety During Third Molar Extraction. J Oral Maxillofac Surg 2019.
were not sufficient to evaluate the findings. Hence, multiple scales should be used to measure dental anxiety. Four different scales were used in the present study to better analyze the results. The VAS and MDAS were preferred because the techniques are highly practical and easily adaptable to patients, suitable for frequent use and reuse, and suitable for statistical studies. When the patients were not sure how to respond, they could give an average response and avoid extreme responses, which might be attributed to the central tendency bias.4 This might be the reason the STAI and DFS and the MDAS and VAS surveys yielded different results. The MDAS and VAS are short-term evaluation tools, the STAI contains general terms, and the DFS is a 20-question survey. Patients completing the MDAS and VAS surveys might be easier to assess than those who might have provided more accurate answers. The MDAS has a simplified response design and includes an additional question about the local anesthetic injection.22 The VAS is ideal for
scoring situations that cannot be measured by digital and oral expression.24 Kvale et al30 found that the DFS was as reliable as the STAI-S for measuring dental anxiety. However, other studies found no significant relationship between the 2 scales.31,32 Considering previous findings,3,7,33-36 more attention should be given to reduce the anxiety among female patients. Although no statistically significant differences were found between the scores of the women and men in the present study, the scores of the women were higher. However, the postoperative MDAS and VAS scores for the women were significantly lower than their preoperative scores. When patients start a new treatment, their previous dental experience will affect their reaction in terms of their anxiety level. A poor previous experience with dental procedures will result in greater anxiety. Muglali and Komerik7 found that patients’ previous dental experiences will contribute to their anxiety. Yusa et al35 observed that patients who had undergone a 20-year dental extraction procedure had lower
1.e6 anxiety levels. Caumo et al37 reported that a history of surgery did not change patients’ level of anxiety. Earl38 found that 43% of 105 patients who had previously undergone third molar extraction had more fear when the procedure was repeated. L opez-Jornet et al39 found no difference in the anxiety levels between patients with previous experience and other patients after completion of the STAI-S, DFS, and MDAS before and after the dental extraction procedure. Although experience is a mixed concept, it is an impressive feature. However, it should not be considered alone. Negative experiences have been observed to be related to fear but no relationship was found between positive experiences and reductions in fear. In fact, a positive relationship between remembering positive memories and increased dental anxiety has been found.40 Therefore, we included only patients who had not had a negative experience. In the present study, even if the patients had previous experience, that experience had not provided them with enough information to reduce their preoperative anxiety. The MDAS and VAS scores were lower in the experienced group than in the other groups but without statistically significant differences. Important symptoms of dental anxiety include continuously avoiding dental treatment, delaying dental appointments, and canceling the appointment once the appointment has been made.41 In the present study, the response to the first question of the DFS ‘ the frequency of going to the dentist: ( ) none ( ) sometimes ( ) when there is a complaint ( ) every 6 months ( ) every one year’’ was evaluated. We found that most patients went to the dentist when they had the maximum number of complaints. Kleinknecht et al19 found the highest anxiety scores for the injection and drilling. These processes caused more anxiety compared with other processes in terms of both image and sound.38 In the present study, the questions in the DFS were evaluated one by one showing that the options related to injection and drilling had the highest scores. Determining how patients feel before the procedure and their expectations from the treatment process affect the course of treatment and postoperative patient satisfaction.42,43 Interactive animation videos and written information can be useful during the preoperative period.44 Although written information is the most effective method to inform patients, they could perceive it differently.4 Some studies have shown that the preoperative anxiety levels of patients who were informed in detail during the preoperative period were lower. Also, the pain and anxiety levels were lower during the postoperative period and the recovery was faster.45,46 In the present study, the postoperative VAS and MDAS scores of the patients
ANXIETY DURING THIRD MOLAR EXTRACTION
provided with written information were significantly lower than the preoperative scores. All patients should be adequately informed about the third molar extraction procedure even if some have had previous experience. Providing patients with detailed information will reduce postoperative anxiety. The postoperative MDAS and VAS scores were lower than the preoperative scores for the women. The use of multiple questionnaires has been preferred in studies evaluating patient anxiety. The present study had limitations regarding the design of the experienced group, and the group was not evaluated as either positive and negative. The effect of negative and positive experiences on anxiety is a complicated subject. In some studies, no difference was observed between those with a negative experience and control groups.3,47 However, in some studies, negative experiences were observed to be related to increased anxiety.40,48 This subject requires research and discussion in future studies.
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SANCAK AND AKAL 15. Pell GJ: Impacted mandibular third molars: Classification and modified techniques for removal. Dent Digest 39:330, 1933 16. Winter GB: Principles of Exodontia as Applied to the Impacted Mandibular Third Molar. St Louis, MO, American Medical Book Company, 1926 17. Spielberger CD: Manual for the State-Trait Anxiety Inventory STAI (Form Y) ("Self-Evaluation Questionnaire"). Palo Alto, CA, Consulting Psychologists Press, 1983 18. Ruffinengo C, Versino E, Renga G: Effectiveness of an informative video on reducing anxiety levels in patients undergoing elective coronarography: An RCT. Eur J Cardiovasc Nurs 8:57, 2009 19. Kleinknecht RA, Klepac RK, Alexander LD: Origins and characteristics of fear of dentistry. J Am Dent Assoc 86:842, 1973 20. Bodrumlu E, S€ umer AP, S€ umer M, K€ opr€ ul€ u H: Ondokuz Mayıs € niversitesi Dis¸hekimligi Fak€ U ultesine bas¸vuran bireylerde dental korkunun degerlendirilmesi. Hacettepe Dis¸hekimligi Fak€ ultesi Dergisi 1:51, 2006 21. Lago-Mendez L, Diniz-Freitas M, Senra-Rivera C, et al: Dental anxiety before removal of a third molar and association with general trait anxiety. J Oral Maxillofac Surg 64:1404, 2006 22. Tunc EP, Firat D, Onur OD, Sar V: Reliability and validity of the Modified Dental Anxiety Scale (MDAS) in a Turkish population. Community Dent Oral Epidemiol 33:357, 2005 23. Ilg€ uy D, Ilg€ uy M, Dinc¸er S, Bayirli G: Reliability and validity of the Modified Dental Anxiety Scale in Turkish patients. J Int Med Res 33:252, 2005 24. Aitken RC: A growing edge of measurement of feelings using visual analogue scales. Proc R Soc Med 62:989, 1969 25. Hakeberg M, Berggren U, Gr€ ondahl HG: A radiographic study of dental health in adult patients with dental anxiety. Community Dent Oral Epidemiol 21:27, 1993 26. Laskin DM, Priest JH, Alfaqih S, Carrico CK: Does viewing a third molar informed consent video decrease patients’ anxiety? J Oral Maxillofac Surg 76:2515, 2018 27. Reyes-Gilabert E, Luque-Romero L-G, Bejarano-Avila G, et al: Assessment of pre and postoperative anxiety in patients undergoing ambulatory oral surgery in primary care. Med Oral Patol Oral Cir Bucal 22:e716, 2017 28. Hakeberg M, Berggren U: Dimensions of the Dental Fear Survey among patients with dental phobia. Acta Odontol Scand 55:314, 1997 29. Schuurs AH, Hoogstraten J: Appraisal of dental anxiety and fear questionnaires: A review. Community Dent Oral Epidemiol 21: 329, 1993 30. Kvale G, Berg E, Raadal M: The ability of Corah’s Dental Anxiety Scale and Spielberger’s State Anxiety Inventory to distinguish between fearful and regular Norwegian dental patients. Acta Odontol Scand 56:105, 1998
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