Effect of Audiovisual Treatment Information on Relieving Anxiety in Patients Undergoing Impacted Mandibular Third Molar Removal

DENTOALVEOLAR SURGERY

Effect of Audiovisual Treatment Information on Relieving Anxiety in Patients Undergoing Impacted Mandibular Third Molar Removal Sung-Hwan Choi, DDS, MS,* Ji-Hoon Won, DDS, MS,y Jung-Yul Cha, DDS, PhD,z and Chung-Ju Hwang, DDS, PhDx Purpose:

The authors hypothesized that an audiovisual slide presentation that provided treatment information regarding the removal of an impacted mandibular third molar could improve patient knowledge of postoperative complications and decrease anxiety in young adults before and after surgery. A group that received an audiovisual description was compared with a group that received the conventional written description of the procedure.

Materials and Methods:

This randomized clinical trial included young adult patients who required surgical removal of an impacted mandibular third molar and fulfilled the predetermined criteria. The predictor variable was the presentation of an audiovisual slideshow. The audiovisual informed group provided informed consent after viewing an audiovisual slideshow. The control group provided informed consent after reading a written description of the procedure. The outcome variables were the State-Trait Anxiety Inventory, the Dental Anxiety Scale, a self-reported anxiety questionnaire, completed immediately before and 1 week after surgery, and a postoperative questionnaire about the level of understanding of potential postoperative complications. The data were analyzed with c2 tests, independent t tests, Mann-Whitney U tests, and Spearman rank correlation coefficients.

Results:

Fifty-one patients fulfilled the inclusion criteria. The audiovisual informed group was comprised of 20 men and 5 women; the written informed group was comprised of 21 men and 5 women. The audiovisual informed group remembered significantly more information than the control group about a potential allergic reaction to local anesthesia or medication and potential trismus (P < .05). The audiovisual informed group had lower self-reported anxiety scores than the control group 1 week after surgery (P < .05). Conclusion:

These results suggested that informing patients of the treatment with an audiovisual slide presentation could improve patient knowledge about postoperative complications and aid in alleviating anxiety after the surgical removal of an impacted mandibular third molar. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-6, 2015

Impacted mandibular third molar extraction is a common surgical procedure for young adults and adolescents. Dental anxiety is most commonly provoked by the surgery. It is typically triggered by the needles

used for local anesthetic injection and drills that exhibit high-frequency vibration.1,2 Dental anxiety makes it more difficult to provide treatment, because patients with high levels of anxiety might not be

Received from the College of Dentistry, Yonsei University, Seoul,

mity, College of Dentistry, Yonsei University, 50-1, Yonsei-ro

Korea.

Seodaemun-gu, Seoul 120 752, Republic of Korea; e-mail: hwang@

*Fellow, Department of Orthodontics.

yuhs.ac

yPostgraduate Student, Department of Oral and Maxillofacial

Received March 20 2015

Surgery, Oral Science Research Center. zAssociate Professor, Department of Orthodontics, The Institute

Ó 2015 American Association of Oral and Maxillofacial Surgeons

of Cranial-Facial Deformity.

0278-2391/15/00912-X

Accepted June 25 2015

xProfessor, Department of Orthodontics, The Institute of Cranial-

http://dx.doi.org/10.1016/j.joms.2015.06.175

Facial Deformity. Address correspondence and reprint requests to Dr Hwang: Department of Orthodontics, The Institute of Cranial-Facial Defor-

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AUDIOVISUAL TREATMENT INFORMATION AND ANXIETY

cooperative during the procedure. This situation might cause stress to the operating surgeon, which could substantially decrease productivity and lead to longer operation times.3,4 Studies have shown that a lack of information about the surgical procedure and postoperative complications is the third strongest anxiety-inducing factor that occurs before the operation. It is stronger than the fear of feeling pain during the surgery.4,5 In the postoperative period, problems such as swelling and difficulty eating might be related to dental anxiety levels 1 week after surgery.4 Among the many methods of informing patients about a treatment, a written informed consent form is, without a doubt, the method most often used by surgeons. However, most of these documents describe complex concepts in unfamiliar language, and the explanations are easily forgotten.6 Many health providers have sought to improve methods for communicating medical information to increase patient understanding when providing consent.7,8 Although audiovisual treatment information methods might have little or no influence on the willingness to participate, these interventions might improve knowledge or understanding, which might lead to higher satisfaction.9 The present study aimed to determine whether providing treatment information with an audiovisual slide presentation could improve patient knowledge of postoperative complications and decrease anxiety before and after the surgical removal of impacted mandibular third molars. This study compared young adults who received the audiovisual presentation with those who received the conventional written informed consent form (control group). The authors hypothesized that, compared with the control group, the audiovisual informed group would have a better understanding of postoperative complications and, in consequence, would exhibit less anxiety before and after surgery.

surgical procedures simultaneously and those with histories of anxiety episodes or anxiolytic treatment were excluded. Participation was voluntary. Initially, 55 patients were enrolled; however, owing to missing questionnaire data, 4 participants were excluded. Thus, 51 patients 18 to 27 years of age were included in the study. This study followed the guidelines set forth by the Declaration of Helsinki regarding medical protocols and ethics, and it was approved by the regional ethics review board of the Capital Defense Command. The patients were randomly distributed into 2 groups. The first group received the Korean Dental Association Informed Consent document with a verbal explanation of the surgical procedure and the potential postoperative complications (control group). Eight postoperative complications were explained (Table 1). The second group of patients received the same document and then viewed a slideshow (audiovisual informed group). The narrated slideshow presentation included simple illustrations created with PowerPoint (2013; Microsoft Office PowerPoint, Microsoft, Redmond, WA) by personnel at the Korean Academy of Dental Science. Audio and visual cues were included to describe the surgical procedure and the 8 postoperative complications, and a clear explanation was provided in nontechnical language. All questions from the patients in the 2 groups were answered by the surgeons. To minimize possible confounding effects, such as differences in background training, the surgical procedure was standardized. Two surgeons treated all patients and used the standardized surgical procedures. The surgeons were trained in the content and proper delivery of the information to the patients.

Materials and Methods PATIENTS AND GROUPING

The present prospective, randomized, clinical trial recruited young adults who required surgical removal of an impacted mandibular third molar and were treated at the dental department of the health services of the Capital Defense Command (Seoul, Republic of Korea) from December 2014 through March 2015. Patients were eligible for the study when they met the following criteria: 1) were older than 18 years and 2) had no neurologic deficits that precluded cognition of information related to the procedure. To prevent possible confounding effects from unrelated conditions or medications, patients who required other

Table 1. POSTOPERATIVE COMPLICATIONS ASSOCIATED WITH SURGICAL EXTRACTION OF AN IMPACTED MANDIBULAR THIRD MOLAR

1. Allergic reactions from local anesthesia or medication; symptoms: dizziness, chills, and dyspnea 2. Paresthesia or dysesthesia of the inferior alveolar nerve and lingual nerve; symptoms: tingling, tickling, or numbness in half the lower lip, tongue, and chin on the operative side 3. Facial edema on the side of the extraction, which reaches a peak within 48 hr 4. Pain: dry socket accompanied by intense pain and odor 5. Bleeding at surgical site 6. Postoperative infections owing to poor hygiene or habits 7. Trismus, ie, limited mouth opening owing to bruising and swelling on the operative side 8. Temporomandibular joint pain owing to maintaining an open mouth for an extended period Choi et al. Audiovisual Treatment Information and Anxiety . J Oral Maxillofac Surg 2015.

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CHOI ET AL PATIENT-BASED ASSESSMENTS

On the day of treatment, the surgeon informed the patient about the surgical procedure and the postoperative complications; then, according to group designation, the slideshow was or was not presented. Subsequently, each patient was directed to a waiting area and asked to complete the State-Trait Anxiety Inventory (STAI)10 and the Corah Dental Anxiety Scale (DAS).11 Patients also were asked to rate their anxiety level based on a visual analog scale (self-reported anxiety). Each patient provided sociodemographic information (gender, age, and educational level) and any history of third molar extractions. The STAI is the most widely used scale for evaluating patient anxiety. State anxiety (STAI-S) refers to a provisional state or temporary emotional condition related to a specific situation. In contrast, trait anxiety (STAI-T) is defined as a relatively stable personality characteristic.2 The Korean version of the STAI-S and STAI-T sections of this questionnaire each contained 20 questions with 4 possible answers that produced total scores ranging from 20 to 80. The DAS was comprised of 4 items to determine how the patient would feel in a given dental situation. The possible answers ranged from ‘‘no anxiety’’ (score, 1) to ‘‘extreme anxiety’’ (score, 5). The total scores ranged from 4 (no anxiety) to 20 (maximum anxiety). For the DAS, a cutoff of 13 is conventionally used to distinguish patients with anxiety from those without anxiety.11 Self-reported anxiety was rated based on a visual analog scale. The patients were asked to score their anxieties for various situations on a scale from 0 (no anxiety at all) to 10 (maximum anxiety). One week after the operation, when the patients returned for suture removal, they were asked what they remembered from the information provided before surgery about the potential postoperative complications inherent to the surgery. Their recall was recorded on a questionnaire form (open questions). Each patient was asked to complete the STAI, DAS, and self-reported anxiety questionnaire. DATA ANALYSIS

The Shapiro-Wilk test was applied to verify the normality of data distributions. Descriptive statistics, including means and standard deviations, were used to describe each anxiety parameter analyzed in the study. Differences in baseline characteristics between the 2 groups were analyzed with c2 tests. Differences in variable scores before and after the surgical procedure were analyzed with independent t tests and Mann-Whitney U tests. Spearman rank correlation coefficients were used to explore the relations between the postoperative selfreported anxiety scores and other variables, including

the sociodemographic factors, histories of third molar extraction, and type of treatment information. Regarding assessments of the strengths of the correlations, an r value higher than 0.40 was taken to indicate a moderate to strong correlation, and an r value less than 0.40 was taken to indicate a weak correlation. All statistical analyses were performed with IBM SPSS 21.0 for Windows (IBM Korea Inc, Seoul, Korea).

Results Complete data were recorded for 51 young adults with a mean age of 22.4 years (standard deviation, 0.9 yr). Gender was not evenly distributed among the participants (40 men; 80.4%). Most patients (80.4%) reported a background of postsecondary education. Forty-two patients (82.4%) had no history of third molar extractions. The c2 tests showed no statistical differences between the 2 groups for gender, age, education level, or history of third molar extractions (Table 2). Apart from 4 patients (2 patients in each group), all patients remembered at least 1 postoperative complication (92.2%). The audiovisual informed group was significantly more likely to remember the complications of allergic reaction to local anesthesia or medication and trismus compared with the control group (P < .05). Facial edema (51.0%) and paresthesia of the inferior alveolar nerve (43.1%) were the complications most often remembered in this study (Table 3). Table 2. SUMMARY OF SOCIODEMOGRAPHIC FACTORS AND HISTORY OF THIRD MOLAR EXTRACTIONS

Variable Gender, n (%) Men Women Age (yr), mean  SD Education level, n (%) Up to secondary education Postsecondary education History of third molar extraction, n (%) No Yes

Written Informed Group

Audiovisual Informed P Group Value*

21 (80.8) 5 (19.2) 22.5  1.1

20 (80.0) 5 (20.0) 22.3  0.7

4 (15.4)

6 (24.0)

22 (84.6)

19 (76.0)

.34

.66 .41

.52

21 (80.8) 5 (19.2)

21 (84.0) 4 (16.0)

Abbreviation: SD, standard deviation. * By c2 test. Choi et al. Audiovisual Treatment Information and Anxiety . J Oral Maxillofac Surg 2015.

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AUDIOVISUAL TREATMENT INFORMATION AND ANXIETY

Table 3. POTENTIAL POSTOPERATIVE COMPLICATIONS DESCRIBED IN THE INFORMATION PROVIDED BEFORE SURGERY THAT WAS REMEMBERED BY THE PATIENTS 1 WEEK AFTER SURGERY

Complication Allergic reactions, n (%) Paresthesia of IAN, n (%) Edema, n (%) Pain, n (%) Bleeding, n (%) Infections, n (%) Trismus, n (%) TMJ pain, n (%)

Table 4. MEANS AND STANDARD DEVIATIONS OF THE ANXIETY PARAMETERS FOR THE 2 GROUPS

Variable

Written Informed Group

Audiovisual Informed Group

P Value*

2 (7.7)

8 (32.0)

<.05

10 (38.5)

12 (48.0)

.427

13 (50.0) 3 (11.5) 4 (15.4) 4 (15.4) 3 (11.5) 3 (11.5)

13 (52.0) 7 (28.0) 4 (16.0) 4 (16.0) 9 (36.0) 3 (12.0)

.837 .172 .939 .939 <.05 .948

Abbreviations: IAN, inferior alveolar nerve; TMJ, temporomandibular joint. * By c2 test. Choi et al. Audiovisual Treatment Information and Anxiety . J Oral Maxillofac Surg 2015.

One week after the surgical procedures, there were substantial decreases in all anxiety parameters compared with baseline in the 2 groups. No differences between the 2 groups were found in the STAIS, STAI-T, or DAS before and after surgery. However, the postoperative self-reported anxiety scores of the audiovisual informed group were significantly lower than those of the control group (P < .05; Table 4). As presented in Table 5, Spearman correlation coefficients indicated a weak negative correlation between postoperative self-reported anxiety score and receiving audiovisual information (P < .05). In addition, the self-reported anxiety score was positively correlated with the STAI and DAS scores after surgery (correlation coefficient range, 0.394 to 0.434; Table 5).

Discussion The present study sought to determine whether the use of an audiovisual slide presentation of treatment information would improve patient knowledge of postoperative complications and lessen anxiety before and after the removal of an impacted mandibular third molar compared with a control group that did not receive the slideshow presentation. The authors hypothesized that the audiovisual informed group would better understand the postoperative complications and exhibit less anxiety before and after surgery compared with the control group. The results of the present study confirmed the hypothesis that treatment information presented in an

Written Audiovisual Informed Informed P Group Group Value

STAI-S score, mean (SD)* Immediately before 43.3 (8.5) surgery 1 wk after surgery 31.1 (5.8) STAI-T score, mean (SD)* Immediately before 39.1 (6.4) surgery 1 wk after surgery 33.2 (7.2) DAS score, mean (SD)y Immediately before 10.8 (2.9) surgery 1 wk after surgery 9.0 (3.0) Self-reported anxiety score, mean (SD)y Immediately before 4.3 (2.9) surgery 1 wk after surgery 2.5 (1.8)

42.5 (9.4)

.754

29.2 (7.4)

.344

37.2 (7.6)

.404

32.3 (6.5)

.406

10.7 (2.3)

.948

8.0 (2.4)

.421

3.9 (2.6)

.665

0.7 (1.2) <.05

Abbreviations: DAS, Dental Anxiety Scale; SD, standard deviation; STAI-S, Spielberger State Anxiety Inventory; STAI-T, Spielberger Trait Anxiety Inventory. * By Independent t test. y By Mann-Whitney U test. Choi et al. Audiovisual Treatment Information and Anxiety . J Oral Maxillofac Surg 2015.

audiovisual slideshow could decrease patient anxiety after surgery for an impacted mandibular molar. The self-reported anxiety scores of the audiovisual informed group were lower than those of the control group after surgery (Table 4). Sociodemographic factors and history of third molar extractions were not correlated with self-reported anxiety scores after surgery. Although the STAI and DAS scores were not statistically different between groups, the scores were moderately positively correlated with self-reported anxiety after surgery (Table 5). The results were consistent with those from a previous study that showed that decreasing the ambiguity of a situation could lessen the anxiety experienced by patients.5 In this study, the slideshow viewed preoperatively by patients materially improved the understanding of potential postoperative complications. The audiovisual informed group remembered the complications involving allergic reactions, owing to local anesthesia or medication, and trismus much more frequently than the control group (Table 3). Delfino12 reported that, in general, patients want to know about all aspects of a procedure, including the effects of anesthesia and the anesthetic modalities that are available. Muglali and Komerik4 reported that, to decrease a patient’s anxiety, the patient’s

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CHOI ET AL

Table 5. CORRELATION COEFFICIENTS BETWEEN POSTOPERATIVE SELF-REPORTED ANXIETY SCORE AND OTHER VARIABLES

Variables

Postoperative self-reported anxiety

Gender

Age

Education Level

History of Third Molar Extraction

0.116

0.181

0.171

0.223

Type of Informed Consent Format

Postoperative STAI-S

Postoperative STAI-T

Postoperative DAS

0.345*

0.394*

0.398y

0.434y

Abbreviations: DAS, Dental Anxiety Scale; STAI-S, Spielberger State Anxiety Inventory; STAI-T, Spielberger Trait Anxiety Inventory. * P < .05. y P < .01. Choi et al. Audiovisual Treatment Information and Anxiety . J Oral Maxillofac Surg 2015.

understanding of factors, such as jaw fatigue, should be taken into account during surgery under local anesthesia. Provisional information about postoperative recovery details, surgical procedure details, and expected postoperative recovery could considerably decrease self-reported anxiety in patients throughout the procedure.5 Vallerand et al13 reported that increasing the quantity of information and ensuring understanding about postoperative complications could substantially increase pain relief and the resultant satisfaction with pain control, without increasing analgesic consumption. However, other studies have reported that preoperative information provided in audiovisual presentations fail to lessen patient anxiety before or after third molar extraction. Kazancioglu et al14 reported that watching a movie about third molar extractions led to increased anxiety and pain during the postoperative period. Torres-Lagares et al15 reported that information presented in a video format increased patient anxiety and did not provide advantages for dental treatment of patients. Videos that show the details of the surgical procedure, including the incision of the gingiva, tooth grinding, and bone removal, could provoke dental fear and anxiety, and this effect seems to offset the anxiety-ameliorating effect produced by improved knowledge or understanding of the situation.14 In the present study, a slideshow was used, rather than a movie, for the audiovisual presentation. This slideshow was designed to improve communication, because the conventional informed consent form typically used in clinical medicine is written in language that requires a reading level above grade 8. Reading at this level can substantially contribute to poor recall and comprehension in patients.16 To facilitate better comprehension, the slideshow used standardized illustrations, bullets, large font sizes, and nontechnical lan-

guage. The present study showed that it was possible to alter a patient’s appraisal of a stressful situation with improved understanding of the preoperative information, and that understanding could lessen the anxiety related to third molar removal surgery. It can be argued that supplementing any written information with an audiovisual presentation would be time consuming and add expense owing to the time required for the surgeon or staff to administer the informed consent process.17 However, the authors would argue the additional time required to view the slideshow would to be a small price to pay for achieving an understanding between the surgeon and patient, given that a considerable proportion of lawsuits result from a lack of understanding between the surgeon and patient, rather than errors in treatment.18 In addition, patients are more satisfied with the contact they have with their surgeon when they are supplied with and understand information about their treatment, although most patients do not recall much of the information they are given during the informed consent process. There were several limitations in this study that should be considered when interpreting the data. First, the present study used a convenience sample, rather than a random population-based sample, and the sample was quite small. Previous related studies had much larger samples.14,15 A larger cohort of patients might provide sufficient statistical power to detect a correlation between the history of third molar extraction and self-reported anxiety after extraction.19 Second, the gender ratio was skewed; the study included more men (80.4%) than women. Gender might influence the other factors analyzed, because young women more frequently report feeling anxious than men.14,20 Third, the patient population was not evenly distributed in education level; 80.4% of patients reported postsecondary educational

6 backgrounds; however, educational level was previously reported to be a minor factor.14 In conclusion, the present study suggested that an audiovisual slide presentation could improve patient knowledge of the potential postoperative complications involved in surgical removal of an impacted mandibular third molar. This improved knowledge decreased dental anxiety compared with knowledge gained from conventional written information. Additional studies are needed to evaluate the relation between anxiety and the method of delivering treatment information in the informed consent process. Larger patient samples are recommended to validate the results of the present study.

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AUDIOVISUAL TREATMENT INFORMATION AND ANXIETY 8. Campbell FA, Goldman BD, Boccia ML, et al: The effect of format modifications and reading comprehension on recall of informed consent information by low-income parents: A comparison of print, video, and computer-based presentations. Patient Educ Couns 53:205, 2004 9. Synnot A, Ryan R, Prictor M, et al: Audio-visual presentation of information for informed consent for participation in clinical trials. Cochrane Database Syst Rev 5:CD003717, 2014 10. Iwata N, Mishima N, Shimizu T, et al: The Japanese adaptation of the STAI Form Y in Japanese working adults—The presence or absence of anxiety. Ind Health 36:8, 1998 11. Corah NL, Gale EN, Illig SJ: Assessment of a dental anxiety scale. J Am Dent Assoc 97:816, 1978 12. Delfino J: Public attitudes toward oral surgery: Results of a Gallup poll. J Oral Maxillofac Surg 55:564, 1997 13. Vallerand WP, Vallerand AH, Heft M: The effects of postoperative preparatory information on the clinical course following third molar extraction. J Oral Maxillofac Surg 52:1165, 1994 14. Kazancioglu HO, Tek M, Ezirganli S, et al: Does watching a video on third molar surgery increase patients’ anxiety level? Oral Surg Oral Med Oral Pathol Oral Radiol 119:272, 2015 15. Torres-Lagares D, Heras-Meseguer M, Azcarate-Velazquez F, et al: The effects of informed consent format on preoperative anxiety in patients undergoing inferior third molar surgery. Med Oral Patol Oral Cir Bucal 19:e270, 2014 16. Philipson SJ, Doyle MA, Gabram SG, et al: Informed consent for research: A study to evaluate readability and processability to effect change. J Investig Med 43:459, 1995 17. Kang EY, Fields HW, Kiyak A, et al: Informed consent recall and comprehension in orthodontics: Traditional vs improved readability and processability methods. Am J Orthod Dentofacial Orthop 136:488 e1, 2009 18. Ferrus-Torres E, Valmaseda-Castellon E, Berini-Aytes L, et al: Informed consent in oral surgery: The value of written information. J Oral Maxillofac Surg 69:54, 2011 19. Brasileiro BF, de Braganca RM, Van Sickels JE: An evaluation of patients’ knowledge about perioperative information for third molar removal. J Oral Maxillofac Surg 70:12, 2012 20. Garip H, Abali O, Goker K, et al: Anxiety and extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 42:551, 2004