Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial

doi:10.1016/j.jcms.2007.03.004

Journal of Cranio-Maxillofacial Surgery

Volume 35, Issues 6–7, September–October 2007, Pages 316-321

https://doi.org/10.1016/j.jcms.2007.03.004 Get rights and content

Summary

Background

Oral and Maxillofacial operations can be extremely frightening treatment situations. General data on this phenomenon should be acquired through a multi-centre trial.

Method

A 10-page questionnaire was developed which was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental and general practitioners/internal medicine patients. Twenty six medical practices and hospital departments in 11 German cities were involved in the trial.

Results

Both subjective anxiety assessment by patients and objective testing (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment situations. Oral and Maxillofacial Surgery (OMFS) patients’ scores were significantly higher than those of control groups. Especially younger and female patients, patients treated under local anaesthesia and out-patients showed intensive anxiety. Previous treatment experience in OMFS did not modify test results.

Conclusion

Managing perioperative anxiety is still a major challenge in OMFS. Irrespective of technical, pharmacological and surgical advances, developing and establishing stress-reducing and anxiolytic perioperative techniques is of considerable importance for both patients and surgeons.

Introduction

Treatment anxiety is an undesirable psychological phenomenon, whose multiple negative influences on patient compliance (Delfino, 1997) and treatment comfort (Scott et al., 1983; Hampf, 1989; Eli et al., 2003), surgical conditions and postoperative outcome (George et al., 1980; Hampf, 1989) are observable daily. Numerous studies from various surgical disciplines and especially dentistry (Kleinknecht et al., 1973; Meechan and Seymour, 1993; Coulter et al., 1995; Litt, 1996; Joehren and Sartory, 2002; Wolf et al., 2003) have investigated the problem in the past 50 years.

Clinically oral and maxillofacial treatment is an intensely frightening situation (Desjardins, 2000), however no survey can be found in the literature on individual and group-specific treatment anxiety of oral and maxillofacial patients.

Own investigations should gain information about subjective and objective intensity and content of treatment-related anxiety in oral and maxillofacial patients. Influence of demographic and surgical factors, and previous treatment experience of anxiety should be identified. Individual and group-specific data should be interpreted in comparison with control groups recruited from related medical disciplines (surgery, dentistry) and general practitioners/internal medicine patients.

Section snippets

Test instrumentary

A 10-page questionnaire was developed. All participants were asked first to rate their individual anxiety in cases of a dental, G.P./internal medicine, surgical or oral and maxillofacial surgery (OMFS) treatment situation by numeric rank scales (NRS; range 0 – 100). Any previous OMFS treatment experience was investigated by further multiple-choice and NRS questions.

Established anxiety tests such as the dental fear survey (DFS) evaluate individual treatment anxiety by calculating sum scores from

Oral and maxillofacial patient group

Three hundred and one female (50.2%) and 299 male patients (49.8%) between 16 and 84 years of age received OMFS treatment under out-patient (n=300) or in-patient (n=300) conditions. The majority of treatments were planned under local anaesthesia (51.2%; local anaesthesia sedation 9.83%; general anaesthesia 38%). Control groups (n=800) did not differ significantly concerning demographic variables.

Self-assessment of treatment anxiety in different medical disciplines

According to patient ratings OMFS treatment is associated with a comparatively high level of

Discussion

“Anxiety” (lat. angustus: narrow) is a state of mind characterised by an individually distinctive switch off of the intellectual and deliberate personality control. Non-object-referring, diffuse anxiety is distinguished from “Real Anxiety” caused by specific situations (Joehren and Sartory, 2002).

Anxious behaviour on specific stimuli can be interpreted as a physiological mechanism of adaptation in unknown situations (Joehren and Sartory, 2002). Nevertheless, multiple negative effects of such a

Conclusion

OMFS creates intense situative anxiety in patients. Treatment anxiety varies significantly depending on the patient's sex, age and surgical/anaesthesiological factors. Further variables linked to this phenomenon should be identified in subsequent studies.

Awareness of the problem and implementation of anxiety-reducing procedures in the surgical routine are of great importance to increase patient comfort, optimize surgical circumstances, minimize perioperative risks and cut down cost.

Acknowledgements

The authors would like to thank the staff of all departments and practices participating in this trial for their support.

References (24)

N.L. Corah et al.
Assessment of a dental anxiety scale
J Am Dent Assoc
(1978)
W.A. Coulter et al.
Dental anxiety and the absorption of orally administered erythromycin stearate
Oral Surg Oral Med Oral Pathol
(1995)
J. Delfino
Public attitudes toward oral surgery: results of a Gallup poll
J Oral Maxillofac Surg
(1997)
P.J. Desjardins
Patient pain and anxiety: the medical and psychological challenges facing oral and maxillofacial surgery
J Oral Maxillofac Surg
(2000)
D.J. Edwards et al.
Choice of anaesthetic and healthcare facility for third molar surgery
Br J Oral Maxillofac Surg
(1998)
R.A. Kleinknecht et al.
The assessment of dental fear
Behav Res
(1978)
M.D. Litt
A model of pain and anxiety associated with acute stressors: distress in dental procedures
Behav Res Ther
(1996)
J.G. Meechan et al.
The use of third molar surgery in clinical pharmacology
Br J Oral Maxillofac Surg
(1993)
L.E. Scott et al.
Preoperative predictors of postoperative pain
Pain
(1983)
A. Stabholz et al.
Dental anxiety among patients prior to different dental treatments
Int J Dent
(1999)

H. Yusa et al.

Anxiety measurement in university students undergoing third molar extraction

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

(2004)

H.S. Brandt et al.

Abraham-Inpijn L: Cardiovascular and endocrine responses during acute stress induced by different types of dental treatment

Int Dent J

(1995)

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Offering preoperative information is one option to help patients cope with the anxiety associated with oral and maxillofacial surgical procedures. Although this information is commonly delivered verbally, written information, audio recordings, and videos are also recommended. This study aimed to evaluate the effects of different preoperative information techniques on patients' anxiety levels before and after third molar tooth extraction.
A single-blind randomized controlled clinical trial with parallel groups was performed. 92 patients who fulfilled the inclusion criteria were randomly assigned to one of four groups. Group 1 was provided information via a silent video with subtitles. Group 2 was informed via a video with background audio. Group 3 was provided a written information brochure. Group 4, designated as the control group, was informed verbally. 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 the dental anxiety of patients. The primary predictor variable was the preoperative information method. The primary outcome variables were the scores of STAI-S, DFS, MDAS, and VAS. Gender was also set as a covariate variable. Data analysis was performed with the IBM SPSS Statistics 25.0 software program. Unless otherwise stated, P < .05 was considered statistically significant.
A total of 86 patients scheduled for impacted third molar extractions under local anesthesia were included in the study. There was no statistically significant difference among the groups in the mean age (P = .275) or distribution of gender (P = .070). Compared to preoperative values, the postoperative scores of MDAS and VAS were decreased significantly in group 1 (P = .002, P = .003, respectively) and group 3 (P = .007; P = .009, respectively). No statistically significant differences were found between the preoperative and postoperative scores of STAI-S, DFS, MDAS, and VAS in group 2 (P = .300, P = .028, P = .063, P = .038, respectively) and group 4 (P = .127, P = .587, P = .072, P = .016, respectively).
The findings indicate that visual or written material, without audio or oral delivery, substantially reduced the anxiety associated with oral and maxillofacial surgery. Therefore, clinicians should preferentially provide information via written methods to control patients' anxiety before impacted third molar surgery.
Palatal needle-free anesthesia for upper molars extraction. A randomized clinical trial
2020, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
The injection of local anesthetics into the palatal mucosa is considered one of the most painful experiences in dental practice due to the tight binding between the palatal mucosa and the underlying periosteum, and its extensive nervous supply (Kravitz, 2006). Alternative interventions have been also explored to promote comfort in dentistry treatments such as hypnosis (Abdeshahi et al., 2013) and anxiety reduction protocols (Dantas et al., 2017; Hermes et al., 2007). Furthermore, some advances in formulations and techniques for local anesthesia in the palatal mucosa, such as pressure-injection (Kravitz, 2006), palatal cooling (Harbert, 1989), low palatal injection rate (Meechan and Day, 2002), and computer-assisted anesthesia systems (Friedman and Hochman, 1997) are considered important (Sharma et al., 2014).
The aim of this study was to compare the ability of liposomal and non-liposomal lidocaine and prilocaine in hydrogel formulations to promote topical anesthesia in palatal mucosa during upper molar extractions.
In this randomized, cross over, triple-blinded clinical trial, a liposomal and a non-liposomal formulation of the eutectic mixture of local anesthetics, 2.5% lidocaine and 2.5% prilocaine, were used to promote palatal anesthesia without the local anesthetic infiltration during bilateral upper molars extractions.
From the total of 40 patients included in this study, the non-liposomal eutectic lidocaine-prilocaine formulation failed in 40% of cases, unlike the liposomal formulation, which was effective for all patients (Fisher's exact test, p < 0.0001). Furthermore, the liposomal formulation (26.75 ± 7,47 min) induced longer anesthesia duration (t-test, p < 0.0001) than the non-liposomal formulation (16.78 ± 4.75 min). No mucosal ulceration or discomfort was reported for both formulations.
The liposomal formulation was able to induce adequate anesthesia in palatal mucosa during dental extraction, avoiding the local anesthetic infiltration. For the first time, a topical formulation allowed upper molars surgical removal without injection of any local anesthetic agent into palatal mucosa in adults.
Does Psychological Profile Influence Third Molar Extraction and Postoperative Pain?
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Our purposes were to determine the influence of psychological profile on hemodynamic changes in patients who undergo surgical removal of the third molars under intravenous sedation and to evaluate the effect on patients' anxiety and postoperative recovery.
We performed a prospective study of 100 patients (American Society of Anesthesiologists classes I and II; aged ≥18 years) seen in the CIMIVClinic (Department of Oral Surgery, Casa de Salud University Hospital, Valencia, Spain) who underwent extractions of all third molars under intravenous sedation. All patients were administered the Symptom Checklist 90 Revised (SCL-90-R). The following parameters were monitored at different times during the surgical interventions: systolic blood pressure, diastolic blood pressure, oxygen saturation, and heart rate. Position and depth of impaction of the tooth (Pell and Gregory classification and Winter classification), surgery duration, and surgical technique also were recorded. Finally, the degree of pain experienced the week after the surgical intervention was measured using a visual analog scale.
Patients' anxiety levels preoperatively were significantly higher in patients with psychological distress (P = .023). Postoperative pain significantly decreased from the first day to the seventh day in healthy patients but not in patients with altered psychological conditions (P < .05). Nevertheless, the hemodynamic changes were not correlated with the psychological impairment.
Intravenous sedation enables the control of hemodynamic changes in all patients independently of their psychological profile. Patients with psychological distress present with higher levels of dental anxiety and postoperative pain. Future studies are needed to further clarify this interaction.
Changes in heart rate during third molar surgery
2016, International Journal of Oral and Maxillofacial Surgery
Anxiety is an undesirable psychological phenomenon. Patients are usually anxious when subjected to third molar surgery, but the pattern of anxiety is unknown. The aim of this study was to assess the intensity and course of anxiety during third molar surgery. This study included 48 consecutive patients (mean age 25 ± 6 years) who had a third molar removed surgically under local anaesthesia. The heart rate was monitored continuously during treatment as a measure of anxiety. Preoperative anxiety was scored with the Modified Dental Anxiety Scale. Each patient's anxiety level was assessed when in the waiting room, sitting down in the dental chair, during the application of local anaesthesia, application of surgical drapes, time-out procedure, incision, alveolotomy, removal of the third molar, and suturing, and at the end of the procedure. The lowest heart rates were recorded in the waiting room, in the dental chair, during anaesthesia, when applying surgical drapes, during suturing, and at the end of the procedure. The highest values were obtained during the time-out procedure, incision, and alveolotomy (P < 0.005). In conclusion, the intensity and course of anxiety has a specific pattern during third molar surgery, with the lowest levels of anxiety prior to surgery and directly postoperative and the highest during the time-out procedure and the actual surgery.
What is the most fearful intervention in ambulatory oral surgery? Analysis of an outpatient clinic
2012, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The idea of having an operation of any kind is a stress provoking event for patients. Oral and maxillofacial surgery candidates have been shown to have higher levels of anxiety when compared to individuals undergoing other types of operation, including those in the gastrointestinal system.20 This study was undertaken to evaluate the behavioural profiles of those attending an outpatient clinic who were about to undergo different oral surgery procedures.
The aim of this study was to evaluate the levels of fear and anxiety in patients undergoing different types of minor oral surgery procedures by using conventional rating scales adjusted to the population characteristics. A demographic form and translated versions of the Modified Dental Anxiety Scale (MDAS) and Dental Fear Survey (DFS) were completed by 500 patients having hard or soft tissue pathologies, third molar removal, implant placement, tooth extraction procedures and 200 non-clinical participants. MDAS and DFS were highly correlated (r = 0.79; P < 0.05). The structural properties of the MDAS were similar to the original, but the DFS required substantive changes to achieve comparable measurement properties. Anxiety levels decreased with age and were greater in females, those with higher education and following a previous unpleasant experience (P < 0.05 for all). The third molar group scored higher than most of the surgical categories in both questionnaires (P < 0.05 for each). DFS showed they tended to avoid surgical procedures and were more susceptible to environmental and chair-side effects (P < 0.05 for all). Regarding oral surgery, third molar patients should be targeted to increase overall comfort of the treatment. Assessments should be adjusted to cultural differences.
An evaluation of patients' knowledge about perioperative information for third molar removal
2012, Journal of Oral and Maxillofacial Surgery
Third molar removal is usually accompanied by a high degree of patient anxiety. Lack of knowledge about the procedure is a major contributor to this anxiety. The aim of this study was to investigate the perioperative perceptions of patients who underwent extraction of third molars to assess their concerns during the surgical experience.
Issues related to preoperative, intraoperative, and postoperative phases of the experience were assessed with the purpose of identifying the most frequent questions and misconceptions. Data were assessed to correlate the influence of previous experience with extraction(s) with the appropriate knowledge of third molar surgery, as well as knowledge variations as to the age and gender of the patients.
The sample was composed of 67 patients (43 female patients and 24 male patients) divided into 2 groups: The first had some previous experience with extractions (25 patients), and the second had no experience (42 patients). The most frequent questions regarded the number of teeth to be extracted (65.4%), and the most prevalent misconception was about medications before surgery (28.4%). Patients with a previous history of dental extractions had more questions about use of medication before surgery (P = .03). Patients without previous experience with extraction had more concerns about anesthesia techniques (P = .02) or the number of teeth that would be removed during the same procedure (P = .02). Other questions and misconceptions were not different between these groups.
Patients with a history of tooth extraction and those without it presented different patterns of knowledge about third molar surgery. Both groups of patients needed detailed perioperative instructions about the procedure. These results may provide oral and maxillofacial surgeons with useful information about patients' knowledge throughout the surgical process.

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View full text

Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial

Summary

Background

Method

Results

Conclusion

Introduction

Section snippets

Test instrumentary

Oral and maxillofacial patient group

Self-assessment of treatment anxiety in different medical disciplines

Discussion

Conclusion

Acknowledgements

J Am Dent Assoc

Oral Surg Oral Med Oral Pathol

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Behav Res

Behav Res Ther

Br J Oral Maxillofac Surg

Pain

Int J Dent

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Abraham-Inpijn L: Cardiovascular and endocrine responses during acute stress induced by different types of dental treatment

Int Dent J