- Email: [email protected]
Postoperative recovery after removal of a lower third molar: role of trait and dental anxiety
Postoperative recovery after removal of a lower third molar: role of trait and dental anxiety Lucía Lago-Méndez, DDS, PhD,a Márcio Diniz-Freitas, DDS, PhD,a Carmen Senra-Rivera, PhD,b Gloria Seoane-Pesqueira, PhD,c José Manuel Gándara-Rey, MD, DDS, PhD,d and Abel García-García, MD, PhD,e Santiago de Compostela, Spain ORAL SURGERY AND ORAL MEDICINE UNIT, DENTAL SCHOOL, UNIVERSITY OF SANTIAGO DE COMPOSTELA
Objective. The aim of this study was to evaluate trait and dental anxiety influence on postoperative recovery after lower third molar surgery and to determine the effect of anxiety on surgery duration. Study design. A prospective study was performed of 145 patients who underwent lower third molar extractions. Dental anxiety was evaluated using the Corah Dental Anxiety Scale (DAS), Kleinknecht Dental Fear Survey (DFS), and the state anxiety scale of the State-Trait Anxiety Inventory (STAI). Trait anxiety was measured with the trait anxiety scale of the STAI. Surgery duration, postoperative pain, swelling, and trismus were also recorded. Results. Patients with high trait anxiety showed more pain according to all of the postoperative measures and to a significant degree in the last 2 postoperative days evaluated. Patients with high dental anxiety had greater trismus according to the DAS and to the dental stimuli dimension of the DFS. The average surgery time was higher in patients with high anxiety, for all of the measures used, although this difference was not statistically significant. Conclusion. Patients with high trait or dental anxiety may tend to require longer surgery times and have poorer postoperative recovery. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:855-860)
Although dental treatment has improved steadily over the years, it still causes psychologic stress in a considerable number of patients, and may, in some cases, develop into an anxiety syndrome.1,2 Although the use of anesthesia makes the removal of lower third molars a relatively painless procedure, the intervention often leads to manifestations of anxiety with different clinical implications.3 Anxiety before lower third molar surgery may have negative consequences, such as the avoidance of consultation or postponed treatment, leading to a worsening of a patient’s dental, and even general state of health.4 It has also been shown that dental anxiety can exert influence on the perceived pain threshold,
a
Oral Surgery and Oral Medicine Unit, Dental School, University of Santiago de Compostela, Santiago de Compostela, Spain. b Professor, Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, Santiago de Compostela Spain. c Professor, Department of Methodology, University of Santiago de Compostela, Santiagode Compostela, Spain. d Professor of Oral Medicine, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. e Professor of Oral Surgery, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. Head of Section, Department of Maxillofacial Surgery, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain. Received for publication May 11, 2009; returned for revision Jul 19, 2009; accepted for publication Jul 19, 2009. 1079-2104/$ - see front matter © 2009 Published by Mosby, Inc. doi:10.1016/j.tripleo.2009.07.021
resulting in the patient’s experiencing more than the inevitable discomfort; this increase in pain sensitivity amplifies anxiety and establishes a feedback cycle of anxiety and pain.5 In addition, the fact that an apprehensive patient may be uncooperative during surgery may complicate the operation procedures. Trait anxiety is a relatively stable tendency toward the kind of anxiety that anyone can suffer when facing situations perceived as threatening.6 State anxiety is felt as a transitory emotional condition of the human body, characterized by subjective and consciously perceived strain and apprehension feelings and by hyperactivity of the autonomic nervous system. State anxiety also includes dental anxiety, an anxious state in a patient caused by dental treatment.7 Taking into account the above-mentioned circumstances, the purpose of the present research was to study the influence of trait and dental anxiety in postoperative recovery from surgical removal of a lower third molar and to determine the role of anxiety in the duration of the procedure. MATERIAL AND METHODS Patient selection Between January 2003 and June 2004, we performed a prospective study of a consecutive series of 145 patients who underwent lower third molar extractions. We excluded patients who did not comply with the formal requirements of the study and those who had 855
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previously undergone this surgery. The final sample was composed of 81 patients undergoing a lower third molar removal for the first time (43 left and 38 right), 51 (63%) of whom were women and 30 (37%) men. Patient mean age was 26.67 ⫾ 7.25 years. All patients were healthy, with no serious medical conditions or blood dyscrasias. None of the patients had acute pericoronitis or severe periodontal disease at the time of surgery. Evaluation of trait and dental anxiety An initial dental consultation was carried out a week before surgery. Before being provided with any information about the operation, patients were asked to complete the Spielberger State-Trait Anxiety Inventory—Trait (STAI-T).6 This 20-item self-evaluation questionnaire is scored using a 4-level frequency scale, ranging from “almost never” to “almost always,” reflecting different degrees of anxiety about situations that subjects perceive as threatening. The patients were subsequently informed about the surgery and postoperative recovery. After information and disclosure of possible risks associated with a minor oral surgical procedure, each patient signed a informed consent form and volunteered to participate in this study. The next appointment took place on the day of the operation. Before entering the treatment room, patients, by themselves and in a quiet “nondental” room, filled out the Spielberger State-Trait Anxiety Inventory— State (STAI-S6) and 2 dental anxiety questionnaires: the Corah Dental Anxiety Scale (DAS)8 and the Kleinknecht Dental Fear Scale (DFS).9 The STAI-S6 is a 20-item self-evaluation questionnaire, scored using a 4-level frequency scale ranging from 0 to 3, that assesses transient emotional state or condition as characterized by subjective feelings of tension and apprehension that can fluctuate in time and intensity. The DAS,8 through a short 4-item questionnaire consisting of multiple-choice questions with only 1 possible answer, assesses the degree of anticipatory anxiety generated by a dental treatment. The DFS9 consists of 20 items grouped into 3 dimensions of avoidance, physiologic reactions, and specific dental stimuli, and according to which a patient’s dental anxiety is assessed by means of a Likert scale of intensity ranging from 1 (no fear) to 5 (extreme fear). Surgical procedure All interventions were performed by postgraduate students at the University of Santiago de Compostela (Spain). Surgery was in all cases performed under local nerve-block anesthesia of the inferior dental nerve, lingual nerve, and buccal nerve with 2 1.8-mL capsules
Table I. Visual analog scale pain data obtained during monitoring period Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Median Minimum Maximum
28 0 100
22 0 100
17 0 100
11 0 82
10 0 83
4 0 78
1 0 71
of 4% articaine with 1:200,000 epinephrine (Articaine; Inibsa, Barcelona, Spain). In cases in which forceps proved to be insufficient, a mucoperiosteal flap was raised, generally by incision distal to the lower second molar along the length of the anterior border of the ascending ramus of the mandible, with another incision mesial to the same molar. Osteotomy, coronal section, or root section was then performed as required, and the wound was closed with 3/0 silk. A piece of folded gauze was applied to the wound to aid hemostasis. Duration was recorded from start of exodontia procedure to last suture. All patients received an antibiotic (amoxicillin 500 mg/8 h for 7 days, starting the day before surgery), an antiinflammatory/analgesic agent (ibuprofen 600 mg/8 h for 4 days, starting after surgery), and an antiseptic (chlorhexidine 0.12%, 3 mouth rinses daily for 7 days, starting the day after surgery). Patients were also given appropriate instructions and recommendations regarding the postoperative recovery period. The sutures were removed 1 week later. Evaluation of postoperative swelling and trismus Facial measurements were made to control and monitor inflammation and trismus. To evaluate swelling we used 3 facial measures: 1) distance between lateral corner of the eye and angle of the mandible (DV); 2) distance between tragus and outer corner of the mouth (DHC); and 3) distance between tragus and soft tissue pogonion (DHS). Trismus was measured, using a sliding caliper, as the maximum interincisal distance (ID, measured in mm) between the upper and lower right central incisor. Data were recorded immediately before the surgical intervention and on postoperative days 3 and 7. Postoperative pain evaluation To evaluate postoperative pain, patients completed a 10-point visual analog scale (VAS)13 at home each day (at approximately the same time of day as the operation) until day 6 after surgery, when the sutures were removed. Statistical analysis Descriptive statistics were obtained for all of the variables of interest. Student t tests were used for independent samples to compare the means of 2 groups,
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Table II. Data for several inflammation measures DHS
DHC
DV
Day
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
0 3 7
14.4 14.7 14.6
⫾0.8 ⫾0.9 ⫾0.9
16.4 17.3 16.5
13.0 13.0 13.1
10.4 10.6 10.5
⫾0.7 ⫾0.7 ⫾0.7
12.2 12.3 12.3
9.0 9.4 9.2
10.8 10.9 10.8
⫾0.8 ⫾0.8 ⫾0.7
14.0 12.9 12.9
9.6 9.0 9.3
DHS, Distance between tragus and soft tissue pogonion; DHC, distance between tragus and outer corner of the mouth; DV, distance between lateral corner of the eye and angle of the mandible.
Table III. Descriptive scores for different state anxiety measures STAI-S
DAS
DFS
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
18.89
⫾8.14
39
6
8.85
⫾3.28
19
4
35.56
⫾12.82
89
20
STAI-S, State-Trait Anxiety Inventory—State; DAS, Dental Anxiety Scale; DFS, Dental Fear Scale.
and the same tests were used for the related samples to contrast the means of 2 variables in a single group. For all of the analyses, statistical significance was set for P ⱕ .05. All analyses were done using SPSS for Windows (SPSS, Chicago, IL). RESULTS Mean reported pain (as evaluated on the VAS) was highest on the day of surgery, at a median of 28 (on a 0-100 scale) and declined progressively in the following days (Table I). The inflammation measures showed a 0.02 ⫾ 0.03 cm average increase for DHS, 0.03 ⫾ 0.05 cm for DHC, and 0.01 ⫾ 0.05 cm for DV. At the time of suture removal, DHS was basically equal to its initial value (0.01 ⫾ 0.04 cm); however, for the DHC and DV a slight increase was produced: 0.08 ⫾ 0.03 cm and 0.02 ⫾ 0.04 cm, respectively (Table II). The ID on postoperative day 3 showed a mean reduction of 0.25 ⫾ 0.23 cm, declining to 0.13 ⫾ 0.17 cm on day 7. Trait anxiety (STAI-T) Trait anxiety values are given in Table III. To analyze the influence exerted by trait anxiety on inflammation (DHS, DHC, and DV), trismus (reflected in ID), and pain, the sample was divided into a lower quartile (low anxiety, ⬍12; n ⫽ 22) and an upper quartile (high anxiety, ⬎21; n ⫽ 21) according to STAI-T scores. The groups were compared for all 3 postoperative measures using Student t tests. The results showed significant differences only in the pain variable. As can be seen from Fig. 1, pain scores were higher in individuals with high trait anxiety, although differences were only statistically significant for the data recorded on postoperative days 5 and 6 (Fig. 1).
Fig. 1. Descriptive data and t test scores for subjects with high and low trait anxiety during the monitoring period.
Specific anxiety measures (STAI-S, DAS, DFS) As in the preceding section, the sample was divided into low- and high-anxiety groups that were compared for all 3 postoperative measures using the Student t test.
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Table IV. Surgery duration: t test data for low and high anxiety level groups Surgery duration Anxiety measure STAI-T STAI-S DAS DFS DFS: dimension 2* DFS: dimension 3*
Anxiety level
Mean
SD
t
Low High Low High Low High Low High Low High Low High
27.45 31.05 27.68 30.48 27.83 29.30 27.55 30.82 28.25 30.27 28.86 31.57
10.29 23.13 16.81 16.82 12.22 19.00 9.44 19.60 15.92 19.32 11.35 19.50
⫺.66 ⫺.65 ⫺.54 ⫺.54 ⫺.31 ⫺.31 ⫺.70 ⫺.70 ⫺.48 ⫺.44 .017 .021
STAI-T, State-Trait Anxiety Inventory-Trait; other abbreviations as in Table III. *DFS dimensions are: 2) physiologic reactions; and 3) dental stimuli.
The results showed that significant differences in the postoperative period occurred only with the DAS and in the dental stimuli dimension of the DFS. More specifically, it was observed that patients with high scores for these measures had a greater limitation on mouth opening on postoperative day 3 (t ⫽ ⫺2.15; P ⱕ .05; and t ⫽ ⫺2.04; P ⱕ .05; respectively). Regarding pain and inflammation, there were no significant differences between groups with low and high anxiety regarding any of the specific measures of anxiety. Anxiety and surgery duration The effect of anxiety on surgery duration was analysed using Student t tests for independent samples applied to the groups with low and high scores on the anxiety scales. Although the results revealed no significant differences (Table IV), the average surgery time was always higher for the group with the higher anxiety levels for all measures implemented. DISCUSSION Surgery and the subsequent recovery period can be a source of stress and physical trauma to patients. Psychologic discomfort arises when patients anticipate the pain they may suffer during surgery. Although there are few doubts that physical trauma can affect the postoperative period,10 little attention has been paid to the influence of psychologic factors despite their importance to recovery. It has been shown that psychologic stress can have many physical effects, ranging from increased sympathetic-adrenergic activity to illness susceptibility.11 Stress may even adversely affect physical recovery after surgery. Several studies report a
relationship between psychologic factors and postsurgical recovery; however, the results are neither clear nor compelling.12-16 Seymour et al.17 stated that there is a significant variation in pain perception between patients, with painkiller requirements after surgery depending on various psychologic factors. For this reason, we decided to assess to what extent anxiety could affect postoperative recovery of patients. We observed that patients with high compared with low trait anxiety reported more pain in all phases of the study, reaching significant levels in the last 2 postoperative days evaluated. Therefore, although the level of perceived pain during the first 5 days was higher in patients with high trait anxiety, the difference compared with patients with low trait anxiety was not significant, because all patients experienced the inevitable consequence of the operation in that period. However, as postoperative time went on and the physiologic discomfort lessened, patients with high trait anxiety not only continued to show pain but also a significantly more intense perception of pain. These findings are consistent with those obtained of George et al.,10 who concluded that high levels of trait anxiety were associated with a poorer recovery. Hoogenboom and Vielvoye-Kerkmeer18 suggested that the use and effect of painkillers administered after third molar extraction depended on the level of anxiety. Taenzer et al.19 subsequently confirmed that high levels of trait anxiety meant an increased perception of pain, as described for other types of surgeries.16,20 Vallerand et al.21 stated even that trait anxiety was an accurate predictor of postoperative pain and oral surgery recovery. Scott et al.22 also showed that high preoperative anxiety was related to an increase in pain, although Johnston and Carpenter23 did not confirm this result. In 2005, Okawa et al.24 found that patients with higher trait anxiety tended to experience greater propensity to feel pain. Feinmann et al.25 pointed out that although the influence of psychologic variables on postoperative pain perception was obvious, it was not the same in the case of analgesic consumption. Those authors also noted that trait anxiety predicted persistent postoperative pain and that this could be the cause of increased anxiety. Moreover, anxiety did not feature strongly in the 2 other postoperative complications, inflammation and trismus, possibly owing to the objective way in which these measures were recorded. In this regard, Earl26 reported that the STAI-T was an unreliable predictor of the development of postoperative symptoms. Vassend,27 among others, has shown that anxiety as a consequence of pain expectation or dental procedures expected to be painful is an obstacle to seeking treatment. Following this line of reasoning, it is assumed
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that pain overestimation and a fear of pain is manifested by people with high dental anxiety.28 In the present study, there were no significant relationships between specific measures of anxiety and pain, unlike trait anxiety and pain. Taenzer et al.19 stated that state anxiety, unlike trait anxiety, was not significantly associated with most measures of pain and did not help predict pain levels. However, Vallerand et al.21 found the same behavior patterns for both state and trait anxiety: both were accurate predictors of postoperative pain and oral surgery recovery. Scott et al.22 also concluded that low state anxiety predicted a favorable result. Maggirias and Locker,29 using 2 of the same specific measures of dental anxiety (DFS and DAS) as used in the present study, noted that anxiety related to dental treatment increased the probability of pain. More recently, Klages et al.30 found that patients with high dental anxiety expected and experienced more pain than those with low anxiety. Referring to the 2 other postoperative complications (inflammation and trismus), both the DAS and the dental stimuli dimension of the DFS detected significantly greater limitations on mouth opening on postoperative day 3. These results could have a methodologic explanation, with the inflammation measures used in this study failing to reveal any differences between patients with high and low dental anxiety. Of the 3 postoperative variables measured, trismus is better able to reflect changes, because it is a more accurate and objective measure. The fact that these changes seem to be significant according to the DAS and the dental stimuli dimension of the DFS could be due to the more specific aspects of dental anxiety. Manso et al.31 also assessed pain, inflammation, and trismus after the removal of lower impacted third molars, using facial measurements based on a DHS and DV algorithm as an inflammation gauge, finding more inflammation within the first 24 hours using the DFS as a measure of anxiety. Manso et al.31 showed that anxiety is not only directly associated with postoperative inflammation, but also with operation duration. Filewich et al.32 demonstrated that anxious compared with calm patients required approximately 20% more time for routine canal obturation, owing to breaks and additional explanations (because the time required to make the cavity was the same). According to Manso et al.,31 interruptions and/or explanations led to greater inflammation within the first 24 hours. In the present work, average surgery time was always higher for the group of patients with high anxiety according to all of the measures used, although there were no significant differences compared with the group with low anxiety. These results
Lago-Méndez et al. 859
may not be statistically significant, because, although the role of anxiety in surgery duration is important, other factors play a role, such as the difficulty of the intervention, the surgeon’s experience, etc. It seems reasonable to suppose that an increase in surgery duration may indirectly lead to an increase in perceptions of pain or in inflammation values.33 Unlike patients in general surgery, dental patients are active during surgery, and recovery to a great extent depends on them. From a psychologic point of view, it is important to give patients the tools that will help them deal with this type of surgery, especially when anxiety is involved, so that the intervention takes place with a minimum of discomfort and recovery is as fast and complete as possible. With the present research, we have tried to emphasize the importance of psychologic factors in assessing and, even better, predicting postoperative recovery after the removal of lower third molars. REFERENCES 1. Agras S, Silvestre D, Oliveau D. The epidemiology of common fears and phobia. Compr Psychiatry 1969;10:151-6. 2. Calatayud J. Study of anxiety and fear in dental patients. PhD Thesis. Department of Medical Stomatology and Periodontics, Faculty of Medicine, Complutense University of Madrid. 1988. ¨ , Garip Y. Anxiety and 3. Garip H, Abali O, Göker K, Göktürk U extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 2004;42:551-4. 4. Abrahamsson KH, Bergrren U, Hakeberg M, Carlsson SG. Phobic avoidance and regular dental care in fearful dental patients. Acta Odontol Scand 2001;59:273-9. 5. Cramer EH, Szmyd L. Identifying the overly anxious patient in impacted third molar surgery. Tech Doc Rep SAMTDR USAF Aerosp Med (SAM-TDR) 1962;62-90:1-5. 6. Spielberger CD, Gorsuch RL, Lushene RE. STAI. Manual for the State-Trait Anxiety Inventory (self evaluation questionnaire). 4th ed. Madrid: TEA; 1970. 7. Eli LL. Oral psychophysiology. Stress, pain and behavior in dental care. Boca Raton (FL): CRC Press; 1992. 8. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48;596. 9. Kleinknecht RA, Keplac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1984;109: 247-51. 10. George JM, Scoct DS, Turner SP, Gregg JM. The effects of psychological and physical trauma on recovery from oral surgery. J Behav Med 1980;3:291-310. 11. Holmes TH, Masuda M. Life change and illness susceptibility. In: Dohrenwend BS, Dohrenwend BP, editors. Stressful life events: their nature and effects. New York: Wiley; 1974. 12. Johnson JE, Dabbs JM, Leventhal H. Psychosocial factors in the welfare of surgical patients. Nursing Res 1970;19:18-28. 13. Wolfer JA, Davis CE. Assessment of surgical patients’ preoperative emotional condition and postoperative welfare. Nursing Res 1970;19:402-14. 14. Auerbach SM. Trait-state anxiety and adjustment to surgery. J Consult Clin Psychol 1973;40:264-71. 15. Cohen F, Lazarus RS. Active doping processes, doping dispositions and recovery from surgery. Psychosom Med 1973;35: 375-89.
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16. Martinez-Urrutia A. Anxiety and pain in surgical patients. J Consult Clin Psychol 1975;43:437-42. 17. Seymour R, Meechan JG, Blair GS. An investigation into postoperative pain after third molar surgery under local analgesia. Br J Oral Maxillofac Surg 1985;23:410-8. 18. Hoogenboom LJ, Vielvoye-Kerkmeer APE. Relief of pain due to surgical extraction of the third molar. Pain 1984;18:109S. 19. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986;24:331-42. 20. Chapman CR, Cox GB. Anxiety pain and depression surrounding elective surgery. A multivariate comparison of abdominal surgery patients with kidney donors and recipients. J Psychosom Res 1977;21:7-15. 21. Vallerand WP, Vallerand AH, Heft M. The effects of postoperative preparatory information on the clinical course following third molar extraction. J Oral Maxillofac Surg 1994;52: 1165-70. 22. Scott LE, Clum GA, Peoples JB. Preoperative predictors of postoperative pain. Pain 1983;15:283-93. 23. Johnston M, Carpenter L. Relationship between preoperative anxiety and postoperative state. Psychol Med 1980;10:361-7. 24. Okawa K, Ichinole T, Yuzuru K. Anxiety may enhance pain during dental treatment. Bull Tokyo Dent Coll 2005;46:51-8. 25. Feinmann C, Ong M, Harvey W, Harris M. Psychological factors influencing post-operative pain and analgesic consumption. Br J Oral Maxillofac Surg 1987;25:285-92. 26. Earl P. Patient=s anxieties with third molar surgery. Br J Oral Maxillofac Surg 1994;32:293-7.
27. Vassend O. Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther 1993;31:659-66. 28. Van Wijk J, Hoogstraten J. Experience with dental pain and fear of dental pain. J Dent Res 2005;84:947-50. 29. Maggirias J, Locker D. Psychological factors and perceptions of pain associated with dental treatment. Community Dent Oral Epidemiol 2002;30:151-9. 30. Klages U, Kianifard S, Ulusoy Ö, Wehrbein H. Anxiety sensitivity as predictor of pain in patients undergoing restorative dental procedures. Community Dent Oral Epidemiol 2006;34: 139-45. 31. Manso FJ, Calatayud J, Carrillo JS, Barbería E, Zaragoza JR. Anxiety, inflammation and intervation duration. Is there any interrelation? Av Odontoestomatol 1989;1:31-3. 32. Filewich RJ, Jackson E, Shore H. Effects of dental fear on efficiency of routine dental procedures. J Dent Res 60 1981;533. Abstract. 33. Lago-Méndez L, Diniz-Freitas M, Senra-Rivera C, GudeSampedro F, Gándara-Rey JM, García-García A. Relationships between surgical difficulty and postoperative pain in lower third molar extractions. J Oral Maxillofac Surg 2007;65:979-83. Reprint requests: Dr. Marcio Diniz-Freitas Facultad de Odontologia Calle Entrerrios s/n 15706 Santiago de Compostela Spain [email protected]
Objective. The aim of this study was to evaluate trait and dental anxiety influence on postoperative recovery after lower third molar surgery and to determine the effect of anxiety on surgery duration. Study design. A prospective study was performed of 145 patients who underwent lower third molar extractions. Dental anxiety was evaluated using the Corah Dental Anxiety Scale (DAS), Kleinknecht Dental Fear Survey (DFS), and the state anxiety scale of the State-Trait Anxiety Inventory (STAI). Trait anxiety was measured with the trait anxiety scale of the STAI. Surgery duration, postoperative pain, swelling, and trismus were also recorded. Results. Patients with high trait anxiety showed more pain according to all of the postoperative measures and to a significant degree in the last 2 postoperative days evaluated. Patients with high dental anxiety had greater trismus according to the DAS and to the dental stimuli dimension of the DFS. The average surgery time was higher in patients with high anxiety, for all of the measures used, although this difference was not statistically significant. Conclusion. Patients with high trait or dental anxiety may tend to require longer surgery times and have poorer postoperative recovery. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:855-860)
Although dental treatment has improved steadily over the years, it still causes psychologic stress in a considerable number of patients, and may, in some cases, develop into an anxiety syndrome.1,2 Although the use of anesthesia makes the removal of lower third molars a relatively painless procedure, the intervention often leads to manifestations of anxiety with different clinical implications.3 Anxiety before lower third molar surgery may have negative consequences, such as the avoidance of consultation or postponed treatment, leading to a worsening of a patient’s dental, and even general state of health.4 It has also been shown that dental anxiety can exert influence on the perceived pain threshold,
a
Oral Surgery and Oral Medicine Unit, Dental School, University of Santiago de Compostela, Santiago de Compostela, Spain. b Professor, Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, Santiago de Compostela Spain. c Professor, Department of Methodology, University of Santiago de Compostela, Santiagode Compostela, Spain. d Professor of Oral Medicine, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. e Professor of Oral Surgery, School of Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain. Head of Section, Department of Maxillofacial Surgery, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain. Received for publication May 11, 2009; returned for revision Jul 19, 2009; accepted for publication Jul 19, 2009. 1079-2104/$ - see front matter © 2009 Published by Mosby, Inc. doi:10.1016/j.tripleo.2009.07.021
resulting in the patient’s experiencing more than the inevitable discomfort; this increase in pain sensitivity amplifies anxiety and establishes a feedback cycle of anxiety and pain.5 In addition, the fact that an apprehensive patient may be uncooperative during surgery may complicate the operation procedures. Trait anxiety is a relatively stable tendency toward the kind of anxiety that anyone can suffer when facing situations perceived as threatening.6 State anxiety is felt as a transitory emotional condition of the human body, characterized by subjective and consciously perceived strain and apprehension feelings and by hyperactivity of the autonomic nervous system. State anxiety also includes dental anxiety, an anxious state in a patient caused by dental treatment.7 Taking into account the above-mentioned circumstances, the purpose of the present research was to study the influence of trait and dental anxiety in postoperative recovery from surgical removal of a lower third molar and to determine the role of anxiety in the duration of the procedure. MATERIAL AND METHODS Patient selection Between January 2003 and June 2004, we performed a prospective study of a consecutive series of 145 patients who underwent lower third molar extractions. We excluded patients who did not comply with the formal requirements of the study and those who had 855
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previously undergone this surgery. The final sample was composed of 81 patients undergoing a lower third molar removal for the first time (43 left and 38 right), 51 (63%) of whom were women and 30 (37%) men. Patient mean age was 26.67 ⫾ 7.25 years. All patients were healthy, with no serious medical conditions or blood dyscrasias. None of the patients had acute pericoronitis or severe periodontal disease at the time of surgery. Evaluation of trait and dental anxiety An initial dental consultation was carried out a week before surgery. Before being provided with any information about the operation, patients were asked to complete the Spielberger State-Trait Anxiety Inventory—Trait (STAI-T).6 This 20-item self-evaluation questionnaire is scored using a 4-level frequency scale, ranging from “almost never” to “almost always,” reflecting different degrees of anxiety about situations that subjects perceive as threatening. The patients were subsequently informed about the surgery and postoperative recovery. After information and disclosure of possible risks associated with a minor oral surgical procedure, each patient signed a informed consent form and volunteered to participate in this study. The next appointment took place on the day of the operation. Before entering the treatment room, patients, by themselves and in a quiet “nondental” room, filled out the Spielberger State-Trait Anxiety Inventory— State (STAI-S6) and 2 dental anxiety questionnaires: the Corah Dental Anxiety Scale (DAS)8 and the Kleinknecht Dental Fear Scale (DFS).9 The STAI-S6 is a 20-item self-evaluation questionnaire, scored using a 4-level frequency scale ranging from 0 to 3, that assesses transient emotional state or condition as characterized by subjective feelings of tension and apprehension that can fluctuate in time and intensity. The DAS,8 through a short 4-item questionnaire consisting of multiple-choice questions with only 1 possible answer, assesses the degree of anticipatory anxiety generated by a dental treatment. The DFS9 consists of 20 items grouped into 3 dimensions of avoidance, physiologic reactions, and specific dental stimuli, and according to which a patient’s dental anxiety is assessed by means of a Likert scale of intensity ranging from 1 (no fear) to 5 (extreme fear). Surgical procedure All interventions were performed by postgraduate students at the University of Santiago de Compostela (Spain). Surgery was in all cases performed under local nerve-block anesthesia of the inferior dental nerve, lingual nerve, and buccal nerve with 2 1.8-mL capsules
Table I. Visual analog scale pain data obtained during monitoring period Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Median Minimum Maximum
28 0 100
22 0 100
17 0 100
11 0 82
10 0 83
4 0 78
1 0 71
of 4% articaine with 1:200,000 epinephrine (Articaine; Inibsa, Barcelona, Spain). In cases in which forceps proved to be insufficient, a mucoperiosteal flap was raised, generally by incision distal to the lower second molar along the length of the anterior border of the ascending ramus of the mandible, with another incision mesial to the same molar. Osteotomy, coronal section, or root section was then performed as required, and the wound was closed with 3/0 silk. A piece of folded gauze was applied to the wound to aid hemostasis. Duration was recorded from start of exodontia procedure to last suture. All patients received an antibiotic (amoxicillin 500 mg/8 h for 7 days, starting the day before surgery), an antiinflammatory/analgesic agent (ibuprofen 600 mg/8 h for 4 days, starting after surgery), and an antiseptic (chlorhexidine 0.12%, 3 mouth rinses daily for 7 days, starting the day after surgery). Patients were also given appropriate instructions and recommendations regarding the postoperative recovery period. The sutures were removed 1 week later. Evaluation of postoperative swelling and trismus Facial measurements were made to control and monitor inflammation and trismus. To evaluate swelling we used 3 facial measures: 1) distance between lateral corner of the eye and angle of the mandible (DV); 2) distance between tragus and outer corner of the mouth (DHC); and 3) distance between tragus and soft tissue pogonion (DHS). Trismus was measured, using a sliding caliper, as the maximum interincisal distance (ID, measured in mm) between the upper and lower right central incisor. Data were recorded immediately before the surgical intervention and on postoperative days 3 and 7. Postoperative pain evaluation To evaluate postoperative pain, patients completed a 10-point visual analog scale (VAS)13 at home each day (at approximately the same time of day as the operation) until day 6 after surgery, when the sutures were removed. Statistical analysis Descriptive statistics were obtained for all of the variables of interest. Student t tests were used for independent samples to compare the means of 2 groups,
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Table II. Data for several inflammation measures DHS
DHC
DV
Day
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
0 3 7
14.4 14.7 14.6
⫾0.8 ⫾0.9 ⫾0.9
16.4 17.3 16.5
13.0 13.0 13.1
10.4 10.6 10.5
⫾0.7 ⫾0.7 ⫾0.7
12.2 12.3 12.3
9.0 9.4 9.2
10.8 10.9 10.8
⫾0.8 ⫾0.8 ⫾0.7
14.0 12.9 12.9
9.6 9.0 9.3
DHS, Distance between tragus and soft tissue pogonion; DHC, distance between tragus and outer corner of the mouth; DV, distance between lateral corner of the eye and angle of the mandible.
Table III. Descriptive scores for different state anxiety measures STAI-S
DAS
DFS
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
18.89
⫾8.14
39
6
8.85
⫾3.28
19
4
35.56
⫾12.82
89
20
STAI-S, State-Trait Anxiety Inventory—State; DAS, Dental Anxiety Scale; DFS, Dental Fear Scale.
and the same tests were used for the related samples to contrast the means of 2 variables in a single group. For all of the analyses, statistical significance was set for P ⱕ .05. All analyses were done using SPSS for Windows (SPSS, Chicago, IL). RESULTS Mean reported pain (as evaluated on the VAS) was highest on the day of surgery, at a median of 28 (on a 0-100 scale) and declined progressively in the following days (Table I). The inflammation measures showed a 0.02 ⫾ 0.03 cm average increase for DHS, 0.03 ⫾ 0.05 cm for DHC, and 0.01 ⫾ 0.05 cm for DV. At the time of suture removal, DHS was basically equal to its initial value (0.01 ⫾ 0.04 cm); however, for the DHC and DV a slight increase was produced: 0.08 ⫾ 0.03 cm and 0.02 ⫾ 0.04 cm, respectively (Table II). The ID on postoperative day 3 showed a mean reduction of 0.25 ⫾ 0.23 cm, declining to 0.13 ⫾ 0.17 cm on day 7. Trait anxiety (STAI-T) Trait anxiety values are given in Table III. To analyze the influence exerted by trait anxiety on inflammation (DHS, DHC, and DV), trismus (reflected in ID), and pain, the sample was divided into a lower quartile (low anxiety, ⬍12; n ⫽ 22) and an upper quartile (high anxiety, ⬎21; n ⫽ 21) according to STAI-T scores. The groups were compared for all 3 postoperative measures using Student t tests. The results showed significant differences only in the pain variable. As can be seen from Fig. 1, pain scores were higher in individuals with high trait anxiety, although differences were only statistically significant for the data recorded on postoperative days 5 and 6 (Fig. 1).
Fig. 1. Descriptive data and t test scores for subjects with high and low trait anxiety during the monitoring period.
Specific anxiety measures (STAI-S, DAS, DFS) As in the preceding section, the sample was divided into low- and high-anxiety groups that were compared for all 3 postoperative measures using the Student t test.
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Table IV. Surgery duration: t test data for low and high anxiety level groups Surgery duration Anxiety measure STAI-T STAI-S DAS DFS DFS: dimension 2* DFS: dimension 3*
Anxiety level
Mean
SD
t
Low High Low High Low High Low High Low High Low High
27.45 31.05 27.68 30.48 27.83 29.30 27.55 30.82 28.25 30.27 28.86 31.57
10.29 23.13 16.81 16.82 12.22 19.00 9.44 19.60 15.92 19.32 11.35 19.50
⫺.66 ⫺.65 ⫺.54 ⫺.54 ⫺.31 ⫺.31 ⫺.70 ⫺.70 ⫺.48 ⫺.44 .017 .021
STAI-T, State-Trait Anxiety Inventory-Trait; other abbreviations as in Table III. *DFS dimensions are: 2) physiologic reactions; and 3) dental stimuli.
The results showed that significant differences in the postoperative period occurred only with the DAS and in the dental stimuli dimension of the DFS. More specifically, it was observed that patients with high scores for these measures had a greater limitation on mouth opening on postoperative day 3 (t ⫽ ⫺2.15; P ⱕ .05; and t ⫽ ⫺2.04; P ⱕ .05; respectively). Regarding pain and inflammation, there were no significant differences between groups with low and high anxiety regarding any of the specific measures of anxiety. Anxiety and surgery duration The effect of anxiety on surgery duration was analysed using Student t tests for independent samples applied to the groups with low and high scores on the anxiety scales. Although the results revealed no significant differences (Table IV), the average surgery time was always higher for the group with the higher anxiety levels for all measures implemented. DISCUSSION Surgery and the subsequent recovery period can be a source of stress and physical trauma to patients. Psychologic discomfort arises when patients anticipate the pain they may suffer during surgery. Although there are few doubts that physical trauma can affect the postoperative period,10 little attention has been paid to the influence of psychologic factors despite their importance to recovery. It has been shown that psychologic stress can have many physical effects, ranging from increased sympathetic-adrenergic activity to illness susceptibility.11 Stress may even adversely affect physical recovery after surgery. Several studies report a
relationship between psychologic factors and postsurgical recovery; however, the results are neither clear nor compelling.12-16 Seymour et al.17 stated that there is a significant variation in pain perception between patients, with painkiller requirements after surgery depending on various psychologic factors. For this reason, we decided to assess to what extent anxiety could affect postoperative recovery of patients. We observed that patients with high compared with low trait anxiety reported more pain in all phases of the study, reaching significant levels in the last 2 postoperative days evaluated. Therefore, although the level of perceived pain during the first 5 days was higher in patients with high trait anxiety, the difference compared with patients with low trait anxiety was not significant, because all patients experienced the inevitable consequence of the operation in that period. However, as postoperative time went on and the physiologic discomfort lessened, patients with high trait anxiety not only continued to show pain but also a significantly more intense perception of pain. These findings are consistent with those obtained of George et al.,10 who concluded that high levels of trait anxiety were associated with a poorer recovery. Hoogenboom and Vielvoye-Kerkmeer18 suggested that the use and effect of painkillers administered after third molar extraction depended on the level of anxiety. Taenzer et al.19 subsequently confirmed that high levels of trait anxiety meant an increased perception of pain, as described for other types of surgeries.16,20 Vallerand et al.21 stated even that trait anxiety was an accurate predictor of postoperative pain and oral surgery recovery. Scott et al.22 also showed that high preoperative anxiety was related to an increase in pain, although Johnston and Carpenter23 did not confirm this result. In 2005, Okawa et al.24 found that patients with higher trait anxiety tended to experience greater propensity to feel pain. Feinmann et al.25 pointed out that although the influence of psychologic variables on postoperative pain perception was obvious, it was not the same in the case of analgesic consumption. Those authors also noted that trait anxiety predicted persistent postoperative pain and that this could be the cause of increased anxiety. Moreover, anxiety did not feature strongly in the 2 other postoperative complications, inflammation and trismus, possibly owing to the objective way in which these measures were recorded. In this regard, Earl26 reported that the STAI-T was an unreliable predictor of the development of postoperative symptoms. Vassend,27 among others, has shown that anxiety as a consequence of pain expectation or dental procedures expected to be painful is an obstacle to seeking treatment. Following this line of reasoning, it is assumed
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that pain overestimation and a fear of pain is manifested by people with high dental anxiety.28 In the present study, there were no significant relationships between specific measures of anxiety and pain, unlike trait anxiety and pain. Taenzer et al.19 stated that state anxiety, unlike trait anxiety, was not significantly associated with most measures of pain and did not help predict pain levels. However, Vallerand et al.21 found the same behavior patterns for both state and trait anxiety: both were accurate predictors of postoperative pain and oral surgery recovery. Scott et al.22 also concluded that low state anxiety predicted a favorable result. Maggirias and Locker,29 using 2 of the same specific measures of dental anxiety (DFS and DAS) as used in the present study, noted that anxiety related to dental treatment increased the probability of pain. More recently, Klages et al.30 found that patients with high dental anxiety expected and experienced more pain than those with low anxiety. Referring to the 2 other postoperative complications (inflammation and trismus), both the DAS and the dental stimuli dimension of the DFS detected significantly greater limitations on mouth opening on postoperative day 3. These results could have a methodologic explanation, with the inflammation measures used in this study failing to reveal any differences between patients with high and low dental anxiety. Of the 3 postoperative variables measured, trismus is better able to reflect changes, because it is a more accurate and objective measure. The fact that these changes seem to be significant according to the DAS and the dental stimuli dimension of the DFS could be due to the more specific aspects of dental anxiety. Manso et al.31 also assessed pain, inflammation, and trismus after the removal of lower impacted third molars, using facial measurements based on a DHS and DV algorithm as an inflammation gauge, finding more inflammation within the first 24 hours using the DFS as a measure of anxiety. Manso et al.31 showed that anxiety is not only directly associated with postoperative inflammation, but also with operation duration. Filewich et al.32 demonstrated that anxious compared with calm patients required approximately 20% more time for routine canal obturation, owing to breaks and additional explanations (because the time required to make the cavity was the same). According to Manso et al.,31 interruptions and/or explanations led to greater inflammation within the first 24 hours. In the present work, average surgery time was always higher for the group of patients with high anxiety according to all of the measures used, although there were no significant differences compared with the group with low anxiety. These results
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may not be statistically significant, because, although the role of anxiety in surgery duration is important, other factors play a role, such as the difficulty of the intervention, the surgeon’s experience, etc. It seems reasonable to suppose that an increase in surgery duration may indirectly lead to an increase in perceptions of pain or in inflammation values.33 Unlike patients in general surgery, dental patients are active during surgery, and recovery to a great extent depends on them. From a psychologic point of view, it is important to give patients the tools that will help them deal with this type of surgery, especially when anxiety is involved, so that the intervention takes place with a minimum of discomfort and recovery is as fast and complete as possible. With the present research, we have tried to emphasize the importance of psychologic factors in assessing and, even better, predicting postoperative recovery after the removal of lower third molars. REFERENCES 1. Agras S, Silvestre D, Oliveau D. The epidemiology of common fears and phobia. Compr Psychiatry 1969;10:151-6. 2. Calatayud J. Study of anxiety and fear in dental patients. PhD Thesis. Department of Medical Stomatology and Periodontics, Faculty of Medicine, Complutense University of Madrid. 1988. ¨ , Garip Y. Anxiety and 3. Garip H, Abali O, Göker K, Göktürk U extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 2004;42:551-4. 4. Abrahamsson KH, Bergrren U, Hakeberg M, Carlsson SG. Phobic avoidance and regular dental care in fearful dental patients. Acta Odontol Scand 2001;59:273-9. 5. Cramer EH, Szmyd L. Identifying the overly anxious patient in impacted third molar surgery. Tech Doc Rep SAMTDR USAF Aerosp Med (SAM-TDR) 1962;62-90:1-5. 6. Spielberger CD, Gorsuch RL, Lushene RE. STAI. Manual for the State-Trait Anxiety Inventory (self evaluation questionnaire). 4th ed. Madrid: TEA; 1970. 7. Eli LL. Oral psychophysiology. Stress, pain and behavior in dental care. Boca Raton (FL): CRC Press; 1992. 8. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48;596. 9. Kleinknecht RA, Keplac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1984;109: 247-51. 10. George JM, Scoct DS, Turner SP, Gregg JM. The effects of psychological and physical trauma on recovery from oral surgery. J Behav Med 1980;3:291-310. 11. Holmes TH, Masuda M. Life change and illness susceptibility. In: Dohrenwend BS, Dohrenwend BP, editors. Stressful life events: their nature and effects. New York: Wiley; 1974. 12. Johnson JE, Dabbs JM, Leventhal H. Psychosocial factors in the welfare of surgical patients. Nursing Res 1970;19:18-28. 13. Wolfer JA, Davis CE. Assessment of surgical patients’ preoperative emotional condition and postoperative welfare. Nursing Res 1970;19:402-14. 14. Auerbach SM. Trait-state anxiety and adjustment to surgery. J Consult Clin Psychol 1973;40:264-71. 15. Cohen F, Lazarus RS. Active doping processes, doping dispositions and recovery from surgery. Psychosom Med 1973;35: 375-89.
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