Online - 2455-3891

Vol 10, Issue 3, 2017 Print - 0974-2441

Research Article

RELATIONSHIP BETWEEN DENTAL ANXIETY AND PAIN EXPERIENCE DURING DENTAL

EXTRACTIONS

SANTHOSH KUMAR MP*

Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Chennai, Tamil Nadu, India.
Email: santhoshsurgeon@gmail.com
Received: 08 December 2016, Revised and Accepted: 22 December 2016

ABSTRACT

Objective: To assess the effects of anxiety on pain experienced during dental extractions.

Methods: A prospective study was conducted during the academic year July-September 2016, randomly among 60 dental patients who visited the
outpatient Department of Oral and Maxillofacial Surgery, Saveetha Dental College, Saveetha University, Chennai, for single tooth extraction. Anxiety
was measured using the Hamilton anxiety rating scale. The pain was measured using the pain visual analog scale (VAS) for the level of pain perceived
during extraction. Data collected were analyzed with Statistical Package for Social Sciences for Windows, Version 16.0 (SPSS Inc., Chicago, IL, USA)
and results obtained.

Results: From regression analysis, R2=0.605 which meant that the independent variable (anxiety) explained 60.50% of the variability of the dependent
variable (pain) with significant t-value. There was a statistically significant correlation between VAS and total anxiety score (p<0.05). This strongly
suggests that an increase in pain level is associated with an increase in anxiety level.

Conclusion: Pre-operative dental anxiety is a major predictor of pain experienced by patients during dental extractions. Hence, it is an important to
reduce anxiety before treatment to reduce pain during the treatment. Pharmacologic modalities like sedation can be used for reducing anxiety and
pain related to the treatment in indicated patients.

Keywords: Dental anxiety, Sedation, Anesthesia, Pain, Tooth extraction.

© 2017 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ajpcr.2017.v10i3.16518

INTRODUCTION department of oral and maxillofacial surgery, Saveetha Dental College,

Saveetha University, Chennai. This study was conducted randomly on
Dental extractions are the commonly performed procedures in dental 60 patients who required single tooth extraction for various reasons
clinics. An ideal tooth extraction is defined as painless removal of the such as pulpitis, mobility, root stump, periodontal disease, and fractured
whole tooth or tooth root with minimal trauma to the investing tissues teeth. Demographic details of the patients - such as age, sex, occupation,
so that the wound heals uneventfully and no post-operative prosthetic and educational qualification - were recorded.
problem is created. Dental anxiety and fear are common among patients,
and dental extractions are one of the most feared procedures. Klingberg For each patient anxiety and pain levels were measured using
and Broberg described dental anxiety as a state of apprehension that questionnaires with the help of patients. Anxiety was measured using
something dreadful is going to happen in relation to dental treatment the Hamilton anxiety rating scale:
or certain aspects of dental treatment [1]. Dental anxiety and fear are 0 - no anxiety
said to enhance pain during dental treatment. It may interfere with 1 - Mild anxiety
patients’ compliance during treatment resulting in poor dental and oral 2 - Moderate anxiety
health [2]. 3 - Severe anxiety
4 - Very severe anxiety.
Several factors may influence the perception of pain as it is a complex
process. Pain is not only determined by nociceptive stimulus but The pain was measured using the pain visual analog scale (VAS) graded
also by cognitive and emotional factors [3]. According to Rhudy and 0-10, the level of pain perceived during extraction:
Meagher emotional states highly modulate human pain reactivity [4]. Score 0/1/2: No pain
The positive relationship between anxiety and dental treatment Score 3/4: Moderate pain
pain as proven by several studies [5-9] state that major generators Score 5/6: Depressing pain
of anxiety are anesthetic injections and minor oral surgeries such as Score 7/8: Horrible pain
tooth extraction [10,11]. The rationale of this study was to estimate Score 9/10: Excruciating pain.
the anxiety and pain levels of patients during extraction and assess the
effects of anxiety on pain experienced during dental extractions done Extractions were done by a single dentist on all the patients, and data
in our college. were recorded. Data collected were analyzed with Statistical Package
for Social Sciences for Windows, Version 16.0 (SPSS Inc., Chicago, IL,
METHODS USA) and results obtained. To describe the data descriptive statistics
frequency analysis, percentage analysis was used for categorical
A prospective study was conducted during the academic year July- variables and the mean and standard deviation were used for continuous
September 2016 among the dental patients who visited the outpatient variables. To find the significance in categorical data, Chi-square test
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Asian J Pharm Clin Res, Vol 10, Issue 3, 2017, 458-461

was used. In the above statistical tool the probability value, p<0.05 is R2=0.605 which means that the independent variable (anxiety)
considered as significant level. explains 60.50% of the variability of the dependent variable (pain) with
significant t-value (Tables 9-13). This strongly suggests that an increase
RESULTS in pain level is associated with an increase in anxiety level.
In our study, 60 patients (29 males and 31 females) in the age range The relationship between patients’ pain responses to dental extraction
of 21-74 years participated and underwent single tooth extractions. indicated by the VAS and dental anxiety scores were evaluated by the
Various data were compiled and calculated as shown below in the Spearman’s rank correlation coefficient for total anxiety scores. There
following tables. Tables 1-3 give frequency distribution of values for was a statistically significant correlation between VAS and total anxiety
sex, anxiety, and pain, respectively. Tables 4-6 give descriptive statistics score (p<0.05).
age-wise and for males and females, respectively. Table 7 describes
correlation between anxiety and pain, and Table 8 gives results for Chi- DISCUSSION
square tests.
Anxiety can be defined as an unpleasant subjective bodily state
Regression analysis: Anxiety versus pain that acts as an alerting reaction and coping mechanism to some
Regression analysis was performed to obtain the relationship between impending event [12,13]. Gilhotra et al. [14] have elaborated various
pain and anxiety level. It is evident from the below tables that the neurochemicals involved in the pathology of anxiety. Anxiety is not
always detrimental to a person’s capabilities but often is normal and
necessary to help prepare for a crisis situation.
Table 1: Sex

Valid Frequency Percent Valid percent Cumulative Pain is an unpleasant sensory and emotional experience associated
percent with actual or potential tissue damage. Thakur and Srivastava [15] in
their review article elaboratively explains about the mechanisms of
Male 29 48.3 48.3 48.3
Female 31 51.7 51.7 100.0
Total 60 100.0 100.0 Table 6: Descriptive statisticsa

Sex N Minimum Maximum Mean Standard

Table 2: Anxiety deviation
Age 31 21 60 40.10 12.459
Valid Frequency Percent Valid percent Cumulative Valid N (list wise) 31        
percent a
Sex=Female
No anxiety 5 8.3 8.3 8.3
Mild 19 31.7 31.7 40.0
Table 7: Anxiety*pain cross tabulation
Moderate 23 38.3 38.3 78.3
Severe 13 21.7 21.7 100.0
Count
Total 60 100.0 100.0  
Anxiety Pain Total

Table 3: Pain 0 1 2 4 5 6 7 8
No anxiety 2 2 0 0 1 0 0 0 5
Valid Frequency Percent Valid percent Cumulative Mild 3 1 2 1 7 1 0 4 19
percent Moderate 0 1 0 0 10 2 5 5 23
Severe 0 0 1 0 0 0 2 10 13
0 5 8.3 8.3 8.3
Total 5 4 3 1 18 3 7 19 60
1 4 6.7 6.7 15.0
2 3 5.0 5.0 20.0 *Distribution=60
4 1 1.7 1.7 21.7
5 18 30.0 30.0 51.7 Table 8: Chi‑square tests
6 3 5.0 5.0 56.7
7 7 11.7 11.7 68.3 Parameters Value df Asymp.
8 19 31.7 31.7 100.0 significant (2‑sided)
Total 60 100.0 100.0
Pearson Chi‑square 48.257a 21 0.001
Likelihood ratio 51.944 21 0.000
Table 4: Descriptive statistics Linear‑by‑linear association 22.356 1 0.000
Number of valid cases 60    
Sex N Minimum Maximum Mean Standard a
28 cells (87.5%) have expected count<5. The minimum expected count is 0.08
deviation
Age 60 21 74 42.6 13.478 Table 9: Correlations
Valid N (list wise) 60
Sex: Male + Female Spearman’s rho Anxiety Pain
Anxiety
Table 5: Descriptive statisticsa Correlation coefficient 1.000 0.605**
Significant (2‑tailed) 0.000
N 60 60
Sex N Minimum Maximum Mean Standard
Pain
deviation Correlation coefficient 0.605** 1.000
Age 29 21 74 45.28 14.217 Significant (2‑tailed) 0.000
Valid N (list wise) 29 N 60 60
a
Sex=Male **Correlation is significant at the 0.01 level (2‑tailed)

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acute and chronic pain and the underlying peripheral as well as central Kain et al. [23] conducted a study to determine if post-operative
pathogenic mechanisms involved. Pain is usually associated to dental pain could be predicted based on pre-operative anxiety and their
treatment, and several factors may influence its perception because it is results showed positive correlations between the level of anxiety
a complex process [16]. and post-operative pain. Various other studies established the same
results [24,25]. Psychiatric and psychosomatic manifestation of
In terms of the effects of anxiety on the perception of pain, it can be increased pain from heightened anxiety is well established [26]. These
said that anxiety acts concomitantly with pain; as anxiety increases, so study results are in accordance to our study. In contrary, a study showed
does the likelihood of interpreting noxious stimuli as pain [17,18]. It no correlation between pre-operative anxiety and post-operative pain
is known that individuals who show general higher anxiety states in in patients undergoing major surgeries [27].
their daily lives tend to be more sensitive and reactive to pain than their
less anxious counterparts. In addition, during a situation of heightened Anxiety is thought to influence the effective component of pain [28].
anxiety, the pain threshold is lowered for all population. Therefore, Anxious people tend to overestimate the intensity of aversive events
lowering anxiety levels puts patients at ease and consequently helps such as fear and pain [29]. Canakçi and Canakçi noted that a patient
them tolerate their own subjective experience of pain. with a high Corah’s dental anxiety scale (DAS), score would be more
likely to present a high pain response than a patient with a lower DAS
Our study was conducted to assess the relationship between pain and score [30]. Other studies have also reported that people with higher
anxiety during dental extraction. The calculated value of (χ2) is greater scores on scales measuring dental anxiety and pain reported more pain
than the table value, so the null hypothesis is rejected. From the data, after dental treatment [3,31].
we can therefore conclude that there is association between pain and
anxiety level. The correlation between pain and anxiety is 0.605. It Klages et al. showed that subjects expected more pain than they
reveals that there is a high degree of positive correlation between these experienced and this effect was stronger in patients with higher dental
two variables. Hence, the pain level depends on anxiety level. If the anxiety scores [5]. It was also suggested that anxiety has an influence
anxiety level increases, the pain levels will be increased. on the expected pain but not on the experienced pain [32]. According
to Fagade and lIe-Lfe [33], if the anxiety scores are high, then there is
Relationship of anxiety to pain a corresponding significant increase in the pain VAS scores. Similarly,
While some studies have found a significant association between Vassend [34] reported that increased level of dental anxiety before dental
gender and level of dental anxiety, females being more anxious than treatment was associated with increased intra-operative pain perception,
males [19,20], others have not found this association [9,21]. In our thus suggesting a strong relationship between the patient’s anxiety state
study, we did not find any significant association between gender and before dental extraction and their perception of pain intraoperatively.
dental anxiety. Thomas et al. [22], from their study, concluded that high
prevalence of depression and anxiety produced a stress response, which Mehrstedt et al. in their study on oral health related quality of life in
triggered a cascade of events resulting in a series of changes in human patients with dental anxiety, found a close association between anxiety
vital physiological functions such as blood pressure, respiratory rate, and pain before during and after dental procedures. There was prevalence
and heart rate and they were significantly higher than normal values. of pain in patients with dental anxiety [35]. In another study, it was shown
that pain felt during dental injections was dependent on dental anxiety
levels [36]. Post-operative pain is also dependent on dental anxiety as
Table 10: Variables entered/removeda
shown by a study on pain after wisdom tooth removal [37]. Pain and
Model Variables entered Variables removed Method dental anxiety is intertwined, influencing each other substantially.
According to van Wijk and Hoogstraten people who are predisposed to
1 Anxietyb Enter responding fearfully to pain are at an increased risk of ending up in a
a
Dependent variable: Pain, bAll requested variables entered vicious circle of anxiety, fear of pain, and avoidance of dental treatment
which could, in turn, affect the dental treatment plan [36].
Table 11: Model summary
The fear of pain during treatment has been identified as a major factor
Model R R2 Adjusted R2 Standard error of in preventing patients from seeking dental care. Therefore, delivering
the estimate dental care with minimal patient discomfort should be an essential part
of a clinician’s skills to avoid noncompliance. Thus, there exists a need
1 0.616a 0.379 0.368 2.096 for the dentist to be aware of patient anxiety to effectively deal with
a
Predictors: (Constant), anxiety it. Hence, assessing the patient’s level of anxiety using a questionnaire
before dental treatment can lead to modification of the treatment plan
Table 12: ANOVAa as needed [38]. Clinicians should have the ability to reduce patients’
fear, discomfort and pain during dental extractions for successful
Model Sum of df Mean F Signification treatment which can be achieved using pharmacologic and/or non-
squares square pharmacologic therapies. Conscious sedation is a very useful tool
during dental extractions in anxious patients.
1
Regression 155.425 1 155.425 35.385 0.000b
CONCLUSION
Residual 254.758 58 4.392
Total 410.183 59   Pre-operative dental anxiety is a major predictor of pain experienced
a
Dependent variable: Pain, bpredictors: (constant), anxiety by patients during dental extractions. Hence, it is important to reduce

Table 13: Coefficientsa

Model Unstandardized coefficients Standardized coefficients t Signification

B Standard error Beta
1
(Constant) 2.256 0.591 3.814 0.000
Anxiety 1.804 0.303 0.616 5.949 0.000
a
Dependent variable: Pain, VAS: Visual analog scale

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