Does giving brief information keep patients calm during different oral surgical procedures?

Does giving brief information keep patients calm during different oral surgical procedures?

MENA Dental Science

27. January 2019

Fatih Cabbar, Muammer Çağrı Burdurlu, Ceyda Özçakır Tomruk

Objectives: Dental anxiety may play a central role in the oral health status and treatment outcomes of oral surgical procedures. The study aimed to investigate the effect that brief written information has over patients undergoing oral surgical procedures and to evaluate factors that may cause anxiety. Method and Materials: A prospective study was performed on 38 mandibular third molar surgery patients (mean age 26.74±6.44 years) and 56 implant surgery patients (mean age 49.13±15.11 years). Each group was divided into two subgroups, and written information, explaining what they could expect and details about the procedure, was provided to study groups. The Spielberger State-Trait Anxiety Inventory was used to measure state (STAI-S) and trait anxiety (STAI-T). The visual analog scale (VAS) was used for pain scores preoperatively and on days 1, 3, 5, and 7. Demographic data and intraoperative behaviors of patients were recorded. Results: All groups had similar anxiety scores at baseline. Preoperative STAI-S and VAS scores were similar between study and control groups (P>.05). Study groups showed significantly lower mean intraoperative anxiety levels (P<.05). The implant group had a significantly lower VAS score (P<.05). STAI-T and preoperative STAI-S were not related to VAS. Postoperative STAI-S and VAS and recuperation were correlated (P<.05). Women showed significantly higher anxiety and VAS scores. Conclusion: The patients who received written information did not report lower anxiety scores. However, improved patient cooperation could be achieved with this method. Different surgical procedures may cause anxiety for different reasons.

Dental procedures are recognized as one of the most common causes of phobia development in humans, and dental patients commonly show anxiety and fear.1 Dental anxiety involves a complex situation of physiologic activation associated with external or internal stimuli before, during, or after dental treatment.2,3 Treatments related to oral surgery cause the highest anxiety levels in dental practice. Although oral surgical procedures are common, most are not life-threatening, and with shorter recovery periods than most surgeries of the body, the psychologic impact makes then an undesirable experience.2,4 It was reported that immediately before oral surgery, patients’ anxiety levels significantly increase.2,4

Anxiety is generally associated with somatic symptom patterns through to reflect autonomic nervous system activity. A beneficial response to the anxiety is the “fight or flight response,” where activation of both the hypothalamic pituitary adrenal axis and sympathetic nervous system prepares an organism to deal with a threat by increasing blood flow to the skeletal muscle, increasing heart rate, and elevating glucose metabolism.5 In regard to immunity, excessive stress might have a deleterious effect on immunity. Moreover, studies indicate that psychologic stress significantly prolongs wound-healing time, potentially through a mechanism involving the reduction of the cell-mediated inflammatory response at the wound site.6-8 In addition, patients with high anxiety could be regarded as uncooperative, problematic, or unreliable.9 As a result, dentists might think that these patients are difficult to treat and this might lead to ineffective dental treatment.9 During the surgery, the elevation of anxiety levels of the patient may give rise to anger or frustration and thus may cause the surgeon stress, which in turn may impair their performance and lead to a longer operation time.10 It was reported that longer operation times result in more swelling and pain in anxious subjects.11 Additionally, anxiety is often associated with poorer oral health and low quality of life and causes reduced morale and self-esteem.4,12 It has been reported that people with higher anxiety levels had significantly more missing, decayed teeth and fewer filled and sound teeth.13,14

It was shown that anxiety is significantly associated with both feeling and expectation of pain.4 However, some patients who experienced pain during surgery were not found to develop disabling anxiety.15 Moreover, the subject’s expectation of a given stimulus can influence the interpretation of the subject as non-painful or painful. Therefore, the felt sensation can be perceived as either painful or pleasurable depending on subjects’ expectancy.16 Therefore, improving patients’ knowledge before surgery may be useful in reducing situational anxiety. Several methods of informing patients about postoperative care and the healing period, such as written materials, videos, or verbal information, were found to be useful in reducing situational anxiety.2,17 Although operations performed under local anesthesia are generally painless and easy, and patients can return to their homes only hours later, for many people the prospect of having a conscious operation arouses fear and the thought of being conscious during surgery can make it worse.18,19 Even patients who are moderately anxious at the beginning of a procedure may become more anxious with time because of factors such as a sensation of pressure or the sound and vibration of rotary instruments.20 Hence, it is mandatory for the surgeon to control patients’ anxiety, reconstruct trust, and facilitate a healthy procedure.21

Dental anxiety may play a central role in the oral health status and treatment outcomes of oral surgical procedures, such as slower recuperation22 and increased risk of infection.23 Simple but sudden stimulants originating from the nature of the surgery, such as saline irrigation and bur vibration, could lead to an increase in anxiety and might result in loss of cooperation. Thus, this study aimed to investigate the effect of brief written information, given to the patients undergoing different oral surgical procedures, over anxiety levels, to observe their feedback during the surgery performed under local anesthesia and to evaluate the relation of anxiety levels with pain.

Method and Materials

Patient selection

The study was designed as a prospective and blind study. The study protocol complied with principles of the Helsinki Declaration and was approved by the university ethics committee (No. 580). All patients signed informed consent to participate in the study. The inclusion criteria were defined as indications for having mandibular third molar surgery with partial bone retention or having implant surgery in only one side of the jaw, healthy patients being ASA I or II, and being at least 18 years old. The exclusion criteria were defined as patients who declared that they have dental phobia or patients who were extremely anxious, patients who had any medication to manage anxiety or any sedative medication, patients who were not willing to participate in the study, and patients who had any previous oral surgeries or implant placement. Patients excluded from the study also include those who had surgeries on both sides of the jaws simultaneously, patients who had acute pericoronitis or any other oral infections at the time of surgery, patients who had not seen any videos about the procedure, and patients who cannot read and write. Patients who did not complete the formal requirements of the study, such as forgetting to complete the forms or not completing them properly, were also excluded. The sample size for the study was calculated utilizing the SPSS Statistics 22 (IBM) software. The sample size was estimated based on the probable number of participants that could be recruited in a reasonable time (a total of 141 patients in 3 months). The following formula was used for sample analyses:

 N is population size, d is deviation required according to the frequency of occurrence of the event, n is sample size, p is the proportion of sample elements that have a particular attribute, q is the proportion of sample elements that do not have a particular attribute, and t is the theoretical value from the t table at a certain degree of freedom and at a determined level of error.

A calculation of sample size revealed that at least 90 patients for all groups were needed to detect differences between results with statistical power (1-β value) of 80% allowing for a type I (α) error of .05. Of those 90 patients, 35 should be placed in the third molar surgery group (0.39), and 55 (0.61) should be placed in the implant group.

Study groups

Group 1 consisted of patients who received third molar surgery, and group 2 consisted of those patients who underwent dental implant surgery. In each group, two subgroups were also randomized by using block randomization.24 In one of the subgroups of the third molar surgery group, written information about the experience they were going to have during the surgical procedure was given to the patients. This group was named informed group 1 (Group 1-i). Basic information such as length of the operation was provided verbally to the other subgroup, but it was devoid of surgical details including operative procedures, and this group served as the control group for Group 1 (Group 1-c).

Written information was developed by the authors; each sentence was discussed considering operational details and clinical experiences, as below:

Third molar surgery is a routine procedure. It has been performed all over the world and in our clinic with confidence for many years.

The operation site will be anesthetized before starting the operation. The operation will not start without making certain of having achieved adequate anesthesia.

During the operation, it is possible to pause at any time you suggest. You can talk, cough and sneeze. There is no impediment to inhale and swallow during the operation.

At the operation site, you can sense the surgeon’s touches and pressure, you will feel the surgeon is doing something, but it is just the feeling of being touched. Pain has been neutralized with anesthesia, so you will not feel any pain.

A small amount of bleeding is typical during the operation. This bleeding will be immediately imbibed with highly powerful suction devices. Even though you might swallow some blood, there is no such harm on it.

While the surgeon is operating, the site is washed with sterile saline. The wash solution is also imbibed with suction devices. It is harmless, and there will be no problems in the case of swallowing it.

Dental rotary instruments will be used during the operation. These devices make sounds and vibration, which is a standard situation.

The same randomizations were performed for the dental implant surgery group, and group 2-i and group 2-c were identified similarly. The first sentence in the implant group was changed to “Dental implant surgery is a routine procedure, and it has been performed all around the world and in our clinic for many years. Dental implants are one of the most preferred and secure treatment options selected by patients.” The surgeons, patients, and other staff members were blinded to group allocation.

Evaluation of trait anxiety level and oral health

At the first appointment, patients, with the help of a nurse, were asked to complete the Spielberger State-Trait Anxiety Inventory-Trait (STAI-T), which was translated and validated in Turkish.25,26 This psychologic inventory is a 20-item self-evaluation questionnaire that is scored on a four-level scale, ranging from “almost never” to “almost always,” reflecting subjects’ anxiety levels about different kinds of situations that may be threatening. Subsequently, patients were examined by the surgeon and given information about the study protocol. If the patient volunteered to participate in the study, an informed consent form was provided to be signed. The demographic data of the patients such as age, sex, marital status, and education level were recorded. The oral health status of the patients was also recorded at the first visit by clinical examination. For assessing oral health status, the decayed, missing, and filled teeth (DMFT) index was used. The surgeon used clinical examinations and radiographs for this purpose, and the criteria for decayed teeth were manifest caries levels 3 to 5.27 The surgery was planned within 3 days.

Evaluation of trait anxiety and postoperative pain

On the day of the surgery, patients were taken by themselves into a quiet non-dental room and completed the Spielberger State-Trait Anxiety Inventory-State (STAI-S).25,26 Before completing the STAI-S inventory, the written information, as described above, was given to patients in group 1-i and group 2-i. Basic information was provided verbally to the control groups, excluding the operative procedures. STAI-S is a 20-item self-evaluation questionnaire, scored on a four-level scale, which assesses the anxiety level at the time of the evaluation. The score for each item in STAI-T and STAI-S ranges from 1 to 4. Therefore, the total score of the scale ranges from 20 to 80, with higher scores showing higher anxiety levels. Although the STAI scale has no established categories, a cut-off score of 38 was established as moderate anxiety, and 45 and higher was established as extreme anxiety.2

After the surgery, patients were given empty STAI-S forms and pain scores to complete during the healing process at days 1, 3, 5, and 7 at the same time of the day. A visual analog scale (VAS) was used to rate pain, and that scale ranged from no pain “0” to most pain imaginable “10.”

Surgical procedure

Three experienced surgeons, who had at least 3 years of professional experience after completing PhD degrees, performed all surgeries at Yeditepe University Dental Faculty Hospital. All surgeries were performed only after achieving adequate anesthesia by using 4% articaine with 0.006mg of epinephrine hydrochloride (Ultracaine, Sanofi). Third molar surgeries were performed under local anesthesia by blocking the inferior alveolar nerve block and buccal nerve. A mucoperiosteal flap was raised, and an osteotomy, coronal dissection, or root dissection was performed, if necessary. A 3/0 silk suture was used to suture a later extraction wound. Additionally, dental implant surgeries were performed under local infiltration anesthesia using the same anesthetic agent. During implant surgery, a mucoperiosteal flap was reflected, and an implant socket was prepared by using sequential drills according to the manufacturers’ instructions. After implant placement, a 3/0 silk suture was used to close the wound. A wet sponge was applied to all wounds for hemostasis. All patients were prescribed amoxicillin and clavulanic acid 1,000mg/12 hours for 5 days, diflunisal 500mg/12 hours for 4 days, and chlorhexidine 0.12% three times daily for 7 days. Cold packs were given to the patient immediately after surgery. Patients were also given both verbal and written information with appropriate recommendations about postoperative care.

Operating surgeon–completed measures

Operating surgeons also rated the patients during surgery as described previously by Heaton et al.28 Surgeons observed patients’ anxiety during the operation and rated their overall behavior, indicating the frequency, by using a VAS (“0” indicates that the patients did not show the behavior at all, while “100” indicates that a behavior was observed throughout the procedure). These intraoperative behavior patterns included showing muscle tension; increased perspiration rate/perspiring; showing facial signs of anxiety, such as becoming flushed or pale, shaking and trembling; speaking about anxiety; interrupting the procedure; and asking questions about the nature of the procedure, such as the expectation of pain. Additionally, surgeons were asked to complete a tenth overall anxiety VAS item, in which they rated the patients’ general levels of anxiety during the procedure. Then, each subject’s overall VAS anxiety score was calculated by averaging the surgeon’s ratings on all ten VAS items, which yielded the mean intraoperative VAS anxiety score. After the surgery, the operating surgeons reviewed the VAS measures with the principal investigator to ensure that a comprehensive list of behaviors in the VAS list was included. The principal investigator instructed the surgeons to consider each patient’s behavior during the entire procedure and complete the VAS scale regarding the mean number of behaviors observed during surgery. The principal investigator and surgeons discussed the behaviors exemplifying each VAS scale so that all assessments of the specific behaviors could be calibrated on each of the scales.28

Statistical analysis

Statistical analysis was performed using the NCSS (Number Cruncher Statistical System) 2007 Statistical Software package program. In addition to standard descriptive statistical calculations (mean and standard deviation), on variables that indicated a normal distribution, repeated one-way ANOVA was used in the comparison of time groups, Newman Keuls multiple comparison test was used in subgroup comparisons, and unpaired t test was used in a comparison of two groups. On variables that did not indicate a normal distribution, the Friedman test was used for time comparisons, Dunn’s multiple comparison tests for subgroup comparisons, Mann-Whitney U test for comparison of two groups, and the chi-square test was used for comparison of qualitative data. The Pearson correlation test was used to determine the relationships between the variables. The results were evaluated at a significance level of P<.05.


A sample of 123 patients gave consent to participate in the study. Twenty-nine patients were excluded from the study because of refusing or failing to attend follow-ups or not completing the study forms. Therefore, a total of 94 patients (32 males and 62 females) were included in the study. The main features of the groups, such as age, sex, marital status, education, STAI-S, and DMFT are shown in Table1. There were no statistically significant differences observed, either between the groups or the subgroups (P>.05), except for a younger age in group I than in group II and a higher DMFT index in group II than in group I (P<.05).

Table 1 Characteristics of included studies

Group I (n = 38) Group II (n = 56) P Group I-c (n = 19) Group I-i (n = 19) P Group II-c (n = 28) Group II-i (n = 28) P
Age (mean ± SD) 26.74 ± 6.44 49.13 ± 15.11 .0001* 27.42 ± 7.54 26.05 ± 5.24 .520* 46.57 ± 14.38 51.68 ± 15.64 .209*
Sex, n (%) Male 9 (23.7) 23 (41.1) .786† 3 (15.8) 6 (31.6) .252† 12 (42.9) 11 (39.3) .786†
Female 29 (76.3) 33 (58.9) 16 (84.2) 13 (68.4) 16 (57.1) 17 (60.7)
Spousal, n (%) Single 25 (65.8) 23 (41.1) .174† 12 (63.2) 13 (68.4) .732† 14 (50.0) 9 (32.1) .174†
Married 13 (34.2) 33 (58.9) 7 (36.8) 6 (31.6) 14 (50.0) 19 (67.9)
Education, n (%) Primary school 1 (2.6) 7 (12.5) .561† 0 (0.0) 1 (5.3) .424† 5 (17.9) 2 (7.1) .561†
High school 6 (15.8) 12 (21.4) 3 (15.8) 3 (15.8) 7 (25.0) 5 (17.9)
University 24 (63.2) 25 (44.6) 14 (73.7) 10 (52.6) 11 (39.3) 14 (50.0)
MSc 5 (13.2) 8 (14.3) 2 (10.5) 3 (15.8) 4 (14.3) 4 (14.3)
PhD 2 (5.3) 4 (7.1) 0 (0.0) 2 (10.5) 1 (3.6) 3 (10.7)
STAI-T (mean ± SD) 38.63 ± 3.77 38.95 ± 4.24 .713* 38.11 ± 4.16 39.16 ± 3.37 .397* 38.57 ± 4.65 39.32 ± 3.83 .513*
DMFT (mean ± SD) 5.45 ± 4.37 14.34 ± 7.07 .0001‡ 6.63 ± 5.38 4.26 ± 2.71 .360‡ 14.57 ± 7.63 14.11 ± 6.59 .863‡

DMFT, decayed, missing, filled teeth; Group I, third molar surgery group; Group II, implant surgery group; Group I-c, uninformed third molar surgery sub-group; Group I-i, informed third molar surgery group; Group II-c, uninformed implant surgery group; Group II-i, informed implant surgery group; STAI-T, State-Trait Anxiety Inventory- Trait.

*Unpaired t test.

†Chi-square test.

‡Mann-Whitney U test.

The preoperative trait anxiety scores (STAI-T) were positively correlated with state anxiety scores (STAI-S) for the entire group (r, 0.224; P=.03). The STAI-S scores, for the entire group and subgroups, preoperatively and at days 1, 3, 5, and 7, are shown in Tables2a and 2b. It was observed that preoperative STAI-S scores showed significantly higher values for all assessment times. For all groups, there was a significant decrease in state anxiety scores from preoperative assessments to assessments at days 1, 3, 5, and 7 (P<.05). However, there were no significant differences for state anxiety scores between informed groups and controls, and for group I and II (P>.05), except for group II-c and group II-i at day 7 (P<.05).

Table 2a The STAI-S score comparisons of the study groups

Group I (n = 38) (mean ± SD) Group II (n = 56) (mean ± SD) P* Group I-c (n = 19) (mean ± SD) Group I-i (n = 19) (mean ± SD) P* Group II-c (n = 28) (mean ± SD) Group II-i (n = 28) (mean ± SD) P*
STAI-S Pre-op 42.89 ± 13.50 39.18 ± 10.96 146 45.26 ± 14.05 39.53 ± 11.70 74 40.75 ± 10.76 37.61 ± 11.13 287
STAI-S Day 1 41.50 ± 12.30 37.41 ± 12.51 121 43.26 ± 13.90 39.74 ± 10.55 384 40.18 ± 12.23 34.64 ± 12.40 98
STAI-S Day 3 34.97 ± 12.05 36.88 ± 13.09 477 35.53 ± 13.43 34.42 ± 10.84 782 38.86 ± 12.24 34.89 ± 13.81 261
STAI-S Day 5 34.39 ± 11.62 34.70 ± 12.01 904 34.47 ± 13.42 34.32 ± 9.87 967 36.82 ± 11.98 32.57 ± 11.87 188
STAI-S Day 7 31.16 ± 10.62 32.34 ± 11.10 607 30.53 ± 11.22 31.79 ± 10.24 719 35.39 ± 12.04 29.29 ± 9.30 38
P† 1 1 1 19 2 2

Group I, third molar surgery group; Group II, implant surgery group; Group I-c, uninformed third molar surgery sub-group; Group I-i, informed third molar surgery group; Group II-c, uninformed implant surgery group; Group II-i, informed implant surgery group; STAI-S, State-Trait Anxiety Inventory-State.

*Unpaired t test.

†Repeated one-way ANOVA.

Table 2b The STAI-S score comparisons of the study groups

Newman Keuls multiple comparison test Group I (n = 38) (mean ± SD) Group II (n = 56) (mean ± SD) Group I-c (n = 19) (mean ± SD) Group I-i (n = 19) (mean ± SD) Group II-c (n = 28) (mean ± SD) Group II-i (n = 28) (mean ± SD)
Pre-op/1 day 584 248 218 763 782 199
Pre-op/3 day 7 125 7 299 205 306
Pre-op/5 day 4 1 2 311 7 39
Pre-op/7 day 1 1 1 31 1 1
1 day/3 day 1 561 23 9 367 828
1 day/5 day 1 9 13 8 59 64
1 day/7 day 1 1 2 15 15 33
3 day/5 day 595 14 546 939 108 67
3 day/7 day 46 2 87 309 13 36
5 day/7 day 104 23 187 358 66 92

As shown in Tables3a and 3b, VAS pain scores were the highest at day 1 and decreased significantly over time in all groups. VAS scores were significantly higher in group I than group II at days 1, 3, and 5 (P>.05). While there was no significant difference observed between controls (group I-c) and informed patients in the third molar surgery group (group I-i), controls of the implant surgery group (group II-c) had significantly lower VAS scores than informed implant patients (group II-i) at days 3 and 7 (P<.05).

Table 3a The VAS score comparisons of the study groups

Group I (n = 38) (mean ± SD) Group II (n = 56) (mean ± SD) P* Group I-c (n = 19) (mean ± SD) Group I-i (n = 19) (mean ± SD) P* Group II-c (n = 28) (mean ± SD) Group II-i (n = 28) (mean ± SD) P*
VAS Day 1 5.74 ± 2.77 2.5 ± 2.30 1 6.26 ± 3.07 5.21 ± 2.39 220 2.25 ± 2.27 2.75 ± 2.34 374
VAS Day 3 3.71 ± 2.71 1.73 ± 2.08 1 3.68 ± 2.98 3.74 ± 2.49 791 1.21 ± 1.83 2.25 ± 2.22 49
VAS Day 5 2.11 ± 2.18 1.02 ± 1.69 8 1.68 ± 2.03 2.53 ± 2.29 210 0.79 ± 1.40 1.25 ± 1.94 301
VAS Day 7 1 ± 1.64 0.46 ± 1.03 55 0.58 ± 0.90 1.42 ± 2.09 165 0.21 ± 0.79 0.71 ± 1.18 47
P† 1 1 1 1 1 1

Group I, third molar surgery group; Group II, implant surgery group; Group I-c, uninformed third molar surgery sub-group; Group I-i, informed third molar surgery group; Group II-c, uninformed implant surgery group; Group II-i, informed implant surgery group; VAS, visual analog scale.

*Mann-Whitney U test.

†Friedman test.

Table 3b The VAS score comparisons of the study groups

Dunn’s multiple comparison tests Group I (n = 38) (mean ± SD) Group II (n = 56) (mean ± SD) Group I-c (n = 19) (mean ± SD) Group I-i (n = 19) (mean ± SD) Group II-c (n = 28) (mean ± SD) Group II-i (n = 28) (mean ± SD)
1 day/3 day 1 1 5 6 1 174
1 day/5 day 1 1 1 1 1 1
1 day/7 day 1 1 1 1 1 1
3 day/5 day 1 1 1 16 16 2
3 day/7 day 1 1 1 1 2 1
5 day/7 day 1 2 2 8 11 48

When the relation of postoperative STAI-S scores was compared with VAS scores, it was observed that these scores were positively correlated for third molar surgery patients at all assessment times, but there was no significant correlation for implant patients at any time. STAI-T and preoperative STAI-S scores were also studied with VAS scores, but the results were not significant (P>.05).

Intraoperative behaviors of patients are shown in Table4. The mean anxiety levels between third molar surgery and implant patients were similar. However, there were significantly higher values observed for controls than informed patients in both subgroups (P<.05). There was no statistically significant difference observed between age and intraoperative behaviors in both third molar surgery and implant patients (P>.05).

Table 4 The differences in intraoperative behaviors of patients between groups

Group I (n = 38) (mean ± SD) Group II (n = 56) (mean ± SD) P* Group I-c (n = 19) (mean ± SD) Group I-i (n = 19) (mean ± SD) P* Group II-c (n = 28) (mean ± SD) Group II-i (n = 28) (mean ± SD) P*
Perspired more than was appropriate for the weather 7.61 ± 2.59 6.61 ± 2.68 76 8.16 ± 2.83 7.05 ± 2.27 193 6.79 ± 1.71 6.43 ± 3.41 623
Increased muscle tension 10.45 ± 3.37 11.93 ± 3.82 56 11.37 ± 4.13 9.53 ± 2.12 92 13.54 ± 2.65 10.32 ± 4.16 1
Increased respiration rate 9.53 ± 4.57 10.48 ± 3.88 278 10.63 ± 4.79 8.42 ± 4.18 138 11.21 ± 2.79 9.75 ± 4.66 159
Shaking and trembling 5.58 ± 2.32 4.66 ± 3.38 148 6.00 ± 2.24 5.16 ± 2.39 269 3.46 ± 1.35 5.86 ± 4.29 7
Showing facial signs of anxiety such as becoming flushed or pale 14.89 ± 3.52 14.89 ± 4.41 998 15.79 ± 3.99 14.00 ± 2.79 118 16.36 ± 3.72 13.43 ± 4.61 12
Showing vocal signs of anxiety 15.16 ± 4.35 13.14 ± 3.70 18 16.58 ± 5.11 13.74 ± 2.92 42 14.5 ± 3.21 11.79 ± 3.72 5
Speaking about anxiety 17.45 ± 6.05 14.57 ± 4.89 13 19.42 ± 6.88 15.47 ± 4.44 43 15.89 ± 4.48 13.25 ± 4.99 42
Asking questions about the nature of procedure such as expectation of pain 14.21 ± 7.86 13.54 ± 4.91 610 21.00 ± 4.90 7.42 ± 2.41 1 17.29 ± 2.54 9.79 ± 3.68 1
Interrupting procedure 15.71 ± 8.97 13.34 ± 5.94 126 23.53 ± 4.79 7.89 ± 3.70 1 18.18 ± 2.06 8.50 ± 4.38 1
General anxiety level scored by surgeon 19.39 ± 8.43 17.46 ± 7.98 263 27.26 ± 3.28 11.53 ± 2.14 1 24.61 ± 3.70 10.32 ± 3.19 1
Mean intraoperative anxiety level 13.00 ± 4.36 12.06 ± 3.57 258 15.97 ± 3.78 10.02 ± 2.45 1 14.18 ± 2.39 9.94 ± 3.31 1

Group I, third molar surgery group; Group II, implant surgery group; Group I-c, uninformed third molar surgery sub-group; Group I-i, informed third molar surgery group; Group II-c, uninformed implant surgery group; Group II-i, informed implant surgery group.

*Unpaired t test.

The relations of sex with STAI-T, preoperative STAI-S, STAI-S, and VAS scores were studied. Preoperative STAI-S scores were significantly higher for women (45.45±13.76) than for men (34.67±8.96) in third molar patients (P=.034). For implant patients, STAI-S scores at day 7 (men 28.57±7.08, women 34.97±12.64) and VAS scores at day 1 (men 1.48±1.97, women 3.21±2.26) were significantly higher in women (P<.05).

The correlation between gender and intraoperative behaviors is shown in Table5. In both groups, women were significantly more anxious during the procedure (P<.05).

Table 5 The difference of intraoperative behaviors between genders

Group I Group II
Male (mean ± SD) Female (mean ± SD) P* Male (mean ± SD) Female (mean ± SD) P*
Perspired more than was appropriate for the weather 6.11 ± 1.62 8.07 ± 2.69 46 5.87 ± 2.14 7.12 ± 2.92 86
Increased muscle tension 7.44 ± 2.40 11.38 ± 3.09 1 10.35 ± 3.82 13.03 ± 3.46 8
Increased respiration rate 6.56 ± 3.88 10.45 ± 4.43 23 9.13 ± 3.12 11.42 ± 4.11 28
Shaking and trembling 4.11 ± 1.62 6.03 ± 2.34 28 3.87 ± 2.40 5.21 ± 3.85 145
Showing facial signs of anxiety such as becoming flushed or pale 12.11 ± 1.36 15.76 ± 3.54 5 13.57 ± 4.67 15.82 ± 4.03 59
Showing vocal signs of anxiety 12.00 ± 2.00 16.14 ± 4.44 11 11.83 ± 3.87 14.06 ± 3.34 25
Speaking about anxiety 13.11 ± 2.42 18.79 ± 6.23 12 13.00 ± 5.09 15.67 ± 4.50 43
Asking questions about the nature of procedure such as expectation of pain 10.00 ± 5.83 15.52 ± 8.03 65 12.30 ± 5.28 14.39 ± 4.52 118
Interrupting procedure 11.00 ± 7.09 17.17 ± 9.10 71 12.87 ± 5.50 13.67 ± 6.30 626
General VAS anxiety level scored by surgeon 15.22 ± 7.36 20.69 ± 8.43 .089† 16.26 ± 7.81 18.30 ± 8.10 .351†
Mean intraoperative VAS anxiety score 9.77 ± 2.09 14.00 ± 4.41 .009† 10.90 ± 3.64 12.87 ± 3.34 .042†

Group I, third molar surgery group; Group II, implant surgery group.

*Unpaired t test (statistical significance P < .05).

†Mann-Whitney U test (statistical significance P < .05).

Regarding all patients included in the study, women had significantly higher scores for preoperative state anxiety scores (men 35.66±9.41, women 43.27±12.6; P=.03), VAS at days 1, 3, and 5 (P<.05), and mean intraoperative anxiety scores (P=.001).

Table6 shows the relation of perceived intraoperative anxiety with age, STAI-T and STAI-S levels. It was shown that intraoperative anxiety is mostly related to STAI-S scores (P<.05). There were no relevant relationships with age for all groups.

Table 6 The relation of mean intraoperative VAS anxiety scores with age and baseline STAI scores

Mean intraoperative VAS anxiety score* Age Preoperative STAI-S STAI-T
Group I r 54 22 781
p 747 896 1
Group II r −0.199 214 620
p 142 113 1
Group I-c r 140 61 831
p 568 804 1
Group I-i r −0.401 374 794
p 89 115 1
Group II-c r 250 109 630
p 199 580 1
Group II-i r −0.372 555 715
p 51 2 1

Group I, third molar surgery group; Group II, implant surgery group; Group I-c, uninformed third molar surgery sub-group; Group I-i, informed third molar surgery group; Group II-c, uninformed implant surgery group; Group II-i, informed implant surgery group; STAI-S, State-Trait Anxiety Inventory- State; STAI-T, State-Trait Anxiety Inventory-Trait; VAS, visual analog scale.

*Pearson correlation test.

There was no significant relation for STAI-T and DMFT index in any group. According to the marital status and education levels, no significant difference was observed in any group for all parameters that were studied (P>.05).


The results of this present study showed that patients who received written information prior to oral surgery did not report lower anxiety than controls, but were rated as less anxious during surgery than were patients who did not receive the written information. However, the standardization of surgical procedures in studies that investigates anxiety and pain in surgeries is challenging. To be able to standardize the present study, specific inclusion and exclusion criteria were established. Additionally, all comparable groups were similar in baseline variables such as STAI-T, preoperative STAI-S, sex, marital status, and education levels, and none of the patients had dental surgical procedures before, which reflected good standardization.

The patients’ perception of the operation, or propensity to anxiety, was reported as a significant factor in extraction procedures.29 It is also known that patients who have higher anxiety scores are more at risk of an increase in anxiety.30 The results of this study confirm that oral surgery causes dental anxiety and the participants were more anxious at preoperative measurements, which is consistent with the literature.4,10,29 None of the patients who participated in this study were regarded as highly anxious, and they had moderate anxiety scores. Moreover, the participants of this study had not undergone any previous oral surgical procedure, which can modify patients’ behaviors.

Although there are some conflicting reports,17,31 Lopez-Jornet et al2 reported a decrease in anxiety during the first 7 days of the postoperative healing period in tooth extraction procedures, which they explained with the absence of complications and a rapid recuperation. Muglali and Komerik31 suggested that the difficulty of the procedure does not influence anxiety immediately postoperatively, but it does so during the follow-up period, possibly as a result of postoperative complications. All the surgical wounds were healed uneventfully in the present study, and the trait anxiety scores were significantly decreased for both groups gradually, which was probably related with the decrease in pain levels and a healing process without complications.

There are studies suggesting that a negative feeling and pain interact with each other, and the increase in anxiety could cause pain to increase.32,33 However, only a few studies focused on the relation between anxiety and acute pain. Lago-Mendez et al34 reported that even days after third molar surgery and the physiologic discomfort lessened, patients with higher STAI-T scores not only continued to show pain significantly but also showed a more intense perception of pain than patients with lower STAI-T scores. Scott et al35 also showed an association between high preoperative anxiety and an increase in the amount of postoperative pain. In another study, Kazancioglu et al17 stated that providing written information before surgery influences pain perception positively, and pain control augmented without an increase in analgesic consumption. Unfortunately, the authors did not report the details of the written information. The findings of this study did not show any significant relation between pain and both STAI-S and preoperative STAI-T scores, whether the patients were informed or not. Some studies stated that while trait anxiety was significantly associated with pain and prediction of pain levels, this was not true for state anxiety.36 The findings of the present study showed that pain scores were significantly correlated with STAI-T scores for the third molar surgery patients but not for implant patients. This difference was thought to be a result of third molar surgery being significantly more painful for the patients. It seems that implant patients felt pain, but not as much as those that went through a third molar surgery, and it was probably not strong enough to make their anxiety specifically correlate with pain. Thus, the relationship of postoperative anxiety with pain could be based on an intensity dependent manner.

The relation of anxiety and gender were frequently assessed for tooth extraction procedures. While most of the studies reported a significant relationship,17,29,37 some others did not.17,38 Astramskaite et al37 reported in their systematic review that all the significant findings showed that women are more anxious than men in tooth extraction procedures. Some authors explain these contradictory results with cultural differences.39 According to Wabnegger et al,40 the grey matter volume in women’s brains was greater than that in men when the patient was emotionally activated. This might be a biologic influence on the gender-specific behavior for anxiety. Therefore, there might be a social influence that allows women to express their feelings more freely.4 The present findings suggest that women were not only significantly more anxious at preoperative assessment but also more nervous during the surgery according to surgeon-completed measures. Another interesting finding was that there was no significant difference observed for “interrupting procedure” and “general anxiety level scored by surgeon.” This result may imply that no matter how anxious female patients react to the surgery, they tolerate it as well as male patients. From the view of the operating surgeon, if a female patient did not interrupt the procedure, the surgeon did not score the general anxiety level any different than a male patient.

It was reported that there were different gender-oriented findings observed in the anxiety levels to the pain laboratory.41 In two studies conducted by Eli et al,4,42 conflicting findings were reported. In one study, there were no interactions between pain and gender,4 while another showed interactions.42 The authors explained this difference by the different surgical procedures performed and suggest that the high stress resulted from the implant operation and blurred the differences between genders.4 In the present study, both procedures were regarded as stressful and women showed significantly higher pain scores at most of the assessments, which indicates that gender has an effect on pain perception even in stressful operations.

Although there are some conflicting reports, dental anxiety has been shown to be more common in younger people.37,43 This result might be because older people, being more rational, do not fall into dental anxiety as easily.44 However, opposing results were also reported for the relationship between age and anxiety with STAI-T.38 Third molar surgery and implant surgery are different procedures. Therefore, a direct comparison of age between groups could be misleading. However, when the patients were evaluated for the third molar surgery group and the dental implant group separately, intraoperative behaviors were also found to be nonsignificant regarding age.

It has been suggested that giving detailed information about the procedure increases patients’ anxiety, by providing a better understanding of the difficulties of the surgery.17,45 Additionally, it might be even more frightening because of area incisions, seeing blood and other details of surgery, which might result in increased anxiety.17,37,45 The main reason for the information technique developed in this study was to relax patients before surgery. In line with the literature, the information was designed carefully to avoid giving redundant information about the surgery itself. Instead, its focus was to prepare the patients for the upcoming procedural experiences, such as saline irrigation, bur vibration, or feeling pressure, which may lead to a sudden increase in anxiety levels and result in the loss of the patient’s cooperation. Informing patients before the surgery about the procedure did not have any relaxing effect on the patient. However, informed patients were significantly more cooperative and had better intraoperative behaviors during the surgery, and the operating surgeons thought informed patients were less anxious. It seems that the given information was more effective on patients’ intraoperative behaviors than preoperative STAI-S levels.

In the present study, it was observed that preoperative STAI-S is significantly correlated with STAI-T, even though STAI-T reflects dispositional anxiety. This results support that trait anxiety acts as a moderator of the relationship between attentional orientation and state anxiety.46 On the other hand, while trait anxiety had no relation with intraoperative behaviors, state anxiety was positively correlated.

Anxiety related to dental implant surgery was evaluated in only one study.4 Unlike third molar surgery, dental implant surgery is an optional surgery that is not essential for the patients’ health, but it is strongly associated with quality of life. The decision to have implant surgery is completely up to the patient, and a medical necessity does not force it. Furthermore, the treatment date is mostly arranged according to the patient’s will. Under these conditions, it could be assumed that dental implant patients will have lower anxiety scores. In contrast, Eli et al4 reported high levels of anxiety for dental implant patients, and related anxiety with pain. The present results showed that while third molar surgery had a significantly more painful recuperation period than implant surgery, third molar surgery and implant surgery have similar STAI-S scores at all assessment times. Although third molar surgery can be regarded as a more traumatic and painful surgery than simple implant surgery, it is a more familiar operation for patients. However, implant treatment is a more complicated process for the patients, full of unknowns, and could be more stressful because of its mechanical nature and insertion of a foreign material into their jawbone. This might result in implant patients feeling as anxious as third molar surgery patients regardless of pain scores. These results suggest that different surgical procedures might cause anxiety for different reasons and might have different courses of anxiety development.

Three different surgeons performed the surgeries (two male, one female), which might be a limitation of the study. Although all the surgeons were experienced clinicians, some surgeons could build a closer relationship with the patient because of gender or behavioral differences, and this might have helped the patient relax during surgery. Additionally, those were different types of surgeries in their nature. Third molar surgery is that of extracting a body part, whereas implant surgery is an improvement by increasing function or esthetics.

In conclusion, better intraoperative patient cooperation could be achieved with this simple information method, which was directed to sudden stimulants originating from the nature of surgery. The provided written information was more effective on intraoperative behaviors than state anxiety levels. Although third molar surgery was more painful than dental implant surgery, patients had similar anxiety scores. Consequently, different surgical procedures may cause anxiety for different reasons. Many patients are anxious before operations and should be treated carefully; however, special care should be given to female patients since they are significantly more anxious during the procedures.


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Fatih Cabbar

1 Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Yeditepe, Istanbul, Turkey.

2 Associate Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Yeditepe, Istanbul, Turkey.

Correspondence: Assistant Professor Fatih Cabbar, Medical Director, Yeditepe Unv. Dis Hekimligi Fak. No:238 Bagdat Cd 34728 Goztepe, Istanbul, Turkey. Email:,