Factors determining tooth extraction anxiety and fear in adult dental patients: a systematic review

Abstract

The aim of this study was to review previous studies and to identify reliable factors determining anxiety in adult patients undergoing tooth extraction procedures. An electronic literature search was conducted of the MEDLINE, ScienceDirect, SpringerLink, and Wiley Online Library databases covering the period January 2005 to May 2015. Sequential screening was performed at the title/abstract and full-text level. The review included all human prospective and retrospective follow-up studies and clinical trials, cohort studies, case–control studies, and case series that demonstrated at least one factor determining tooth extraction anxiety and/or fear and used specific scales for measurement. The search identified 16 articles meeting the inclusion criteria. Factors related to tooth extraction in patients were assessed: propensity to anxiety ( P < 0.05), pain experience or expectations ( P < 0.05), level of disturbance during the procedure ( P < 0.001), difficulty of the procedure ( P = 0.034), marital status ( P = 0.003), social class ( P = 0.012), and type of local anaesthesia ( P = 0.008). Using a video as the method of providing information ( P < 0.05) and having had a previous negative dental experience ( P < 0.05) led to an increase in patient anxiety level. Due to disagreements between studies, further investigations into the other factors are required to clarify the results. However, the absence of a single and appropriate scale that includes both the patient’s evaluation and that of the doctor, hinders the rating of patient anxiety.

Fear and anxiety are known psychological responses to uncomfortable or unpleasant stimuli. Armfield and Heaton suggested using ‘anxiety’ as a term to describe the emotional state and ‘fear’ to describe an activated response to unpleasant, fearful stimuli. However, the two terms are usually used synonymously. These terms are used together in the present review to increase the number of studies included in order to make the results as objective as possible. A third term also related to negative psychological attitudes is ‘phobia’, which is more a diagnosis set by a psychotherapist than a psychological state or feeling.

These negative psychological conditions are common in patients seen in the field of dentistry. In a long list of fears and phobias, dental fear ranked fourth by prevalence, and research performed in Australia showed that only 52.7% of respondents indicated no or low dental anxiety. Deeper examination has revealed that not all dental procedures cause the same level of anxiety. Dental surgery, and particularly having a tooth extracted, is known to be in the top five most frightening procedures in dental practice. Patients feel more anxious about tooth removal than perceiving a pain or feeling helpless. It is interesting that pain is not the only aspect that makes this procedure unpleasant–people report that the fact of losing a tooth is also an important anxiety-provoking stimulus. Despite the negative effect on the patient’s psychology and feelings, doctors also find it difficult to deal with anxious patients, such that special preparation and mood modification are required.

It is thus clear that anxiety and fear in the dental office should be controlled as much as possible. In order for this to happen, it is important to identify the factors causing dental fear using existing anxiety measurement scales. However, there are many different types of scale using combinations of different criteria. It is still unknown which scales and criteria are most reliable in the evaluation of tooth extraction anxiety. Because of these uncertainties, the present review was conducted to identify reliable factors that have been assessed in previous studies using specific measurement scales that could help a doctor to predict the patient’s anxiety during the tooth extraction procedure.

Materials and methods

Protocol and registration

The methods and inclusion and exclusion criteria were determined in advance and documented in the protocol. This review was registered in PROSPERO, an international prospective register of systematic reviews. The protocol can be accessed at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024250 (registration number CRD42015024250).

This systematic review adhered to the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Focused question

The following focused question was developed according to the population, intervention, comparison, and outcome (PICO) study design: What are the main factors causing anxiety/fear, which can be measured using specific rating scales, in adult patients undergoing a tooth extraction procedure?

Types of studies

The review included all human prospective and retrospective follow-up studies and clinical trials, cohort studies, case–control studies, and case series published between January 2005 and May 2015 that demonstrated at least one factor determining tooth extraction anxiety and/or fear and used specific scales for measurement. Review studies were excluded.

Information sources and search strategy

The search strategy was based on an electronic database examination. A search was implemented in the National Library of Medicine database (MEDLINE) through its online site (PubMed), ScienceDirect, SpringerLink, and Wiley Online Library.

The electronic search explored an advanced search in every database separately. The key words used in the primary search stage were “dental fear” OR “dental phobia” OR “dental anxiety” OR “odontology fear” OR “odontology phobia” OR “odontology anxiety” OR “tooth extraction fear” OR “tooth extraction phobia” OR “tooth extraction anxiety” OR “exodontia fear” OR “exodontia phobia” OR “exodontia anxiety”. Key words were selected in order to collect all possible relevant data.

Selection of studies

All studies were selected by two separate reviewers according to the inclusion and exclusion criteria. The reviewers compared decisions and discussed any arising conflicts, consulting a third party if a consensus could not be reached. The third party was an experienced senior reviewer.

Inclusion criteria were the following: (1) all prospective and retrospective studies, clinical trials, cohort studies, case–control studies, and case series determining at least one factor that may predict tooth extraction anxiety/fear in dental patients and that used a measurement scale for assessment; (2) adult patients (at least 16 years old) who did not have any systemic disorders that may affect mental health (eating disorders, Down syndrome) and with no disorders that increase tooth extraction risks (diabetes mellitus, HIV, haemophilia); and (3) studies that could not be excluded before careful reading.

Exclusion criteria were the following: (1) studies that examined tooth extraction anxiety/fear as a factor of other occurrences; and (2) studies that included unclear data, with authors who could not be contacted in any way.

The search strategy comprised three stages. In the first stage, a screening of titles took place to exclude all irrelevant publications, case reports, reviews, and animal studies. In the second stage, the abstracts were read to see if the aim of the study met the systematic review question. The third stage was reading the full-text articles to confirm the eligibility of each study according to the inclusion and exclusion criteria.

Data extraction

The data were independently extracted from articles according to the theme, purposes, and questions of the present review. The following data items were collected from the selected articles: (1) year (year of publication); (2) area (country in which the study was performed); (3) population features (features by which the population was selected, including nationality, age, sex, etc.); (3) factors examined (factors that may cause tooth extraction anxiety/fear examined); (4) evaluation method (type of scale used to describe patient anxiety or the impact of factors); (5) interview features (specific features of the interview, e.g. interview in a non-dental room); (6) interview method (method that was used to collect information from the patients, e.g. self-reported, questionnaires at home, etc.).

Assessment of methodological quality

The quality of all included studies was evaluated during the full-text reading stage. All methodological elements that may influence the outcomes of the study were marked and evaluated.

The risk of bias in every study was evaluated according to the Cochrane Collaboration (version 5.1.0) two-part tool for assessing risk of bias.

Synthesis of the results and statistical analysis

Relevant data of interest for the previously stated variables were collected and organized into tables, based on the determination of tooth extraction fear/anxiety of the factor assessed.

A meta-analysis integrates the quantitative findings from separate but similar studies and allows the evaluation of the numerical results of the overall effect of interest. Meta-analyses were performed for studies that reported comparable outcomes of factors that may affect patient anxiety related to tooth extraction. Some of the factors in the studies could not be compared with numerical values because of insufficient data in the studies or an insufficient number of studies assessing the same factor. The data were analyzed using the Student t -test, and the 95% confidence interval (CI) was calculated where possible. The kappa index was used to evaluate the level of agreement between the two researchers.

Results

Study selection

The initial search identified a total of 6202 articles ( Fig. 1 ). Following the screening of article titles, 1753 potentially relevant articles were identified. Independent screening of the abstracts resulted in 33 possible articles for inclusion. Following the application of the study inclusion and exclusion criteria to the 33 full-text articles, 16 articles were finally selected for the systematic review.

Fig. 1
Procedural flow of the literature search and selection process.

The kappa value for inter-reviewer agreement for potentially relevant articles was 1 for titles and abstracts and >0.9 for full-text articles, indicating almost perfect agreement between the two reviewers.

Exclusion of studies

The reasons for the exclusion of studies after full-text assessment were as follows: full-text article not available in English ( n = 1), dental anxiety not specific to tooth extraction anxiety ( n = 12), dental anxiety as a factor of other occurrences ( n = 1), and psychological conditions other than anxiety examined ( n = 3).

Quality assessment

The quality assessment ( Table 1 ) of the studies included revealed that the majority had a high risk of bias. Two studies were classified as having an unclear risk of bias. None of the studies had a low risk of bias in all categories.

Table 1
Quality assessment. a
Ref. Sequence generation Allocation concealment Blinding of participants, personnel, and outcome assessors Incomplete outcome data Selective outcome reporting Other sources of bias
Lago-Méndez et al. (2006) ? ? + + + +
van Wijk et al. (2008) + ? + + +
de Jongh et al. (2008) ? + + + +
Muglali and Komerik (2008) ? + +
Kim et al. (2010) + ? + + + +
van Wijk et al. (2010) + + + +
McNeil et al. (2011) + + + +
de Jongh et al. (2011) ? ? + + +
Seto et al. (2012) + ? + + +
Abdeshahi et al. (2013) + + +
López-Jornet et al. (2013) ? ? + +
Egbor and Akpata (2014) ? + + +
Torres-Lagares et al. (2014) + + + + +
Tarazona et al. (2015) ? + + + +
Glaesmer et al. (2015) + + + +
Kazancioglu et al. (2015) + + ? + +

a ‘+’, low risk of bias; ‘?’, unclear risk of bias; ‘−’, high risk of bias.

Types of studies

Ten studies were prospective cohort studies in which questionnaires were given to participants and different follow-ups were observed. Six studies were controlled trials in which different factors that may increase or decrease the anxiety of tooth removal were examined ( Table 2 ).

Table 2
Basic information for the studies included.
Study Country Participants Age, years Procedure Rating scale a Times rated Factors examined Results
Lago-Méndez et al. (2006) Spain 70 18–60 Removal of a single third molar DAS, STAI, DFS 2 1. Gender
2. Trait anxiety
1. Females showed higher anxiety scores
Trait anxiety (STAI-T) is a significant predictor of dental anxiety (DAS)
van Wijk et al. (2008) Netherlands 50 >18 Removal of third molar S-DAI, S-FDPQ, NRS 2 1. Gender
2. Separate consultation
3. Pain
1. Females showed higher anxiety scores
2. No significant differences were found
Significant correlation between pain and anxiety was found
de Jongh et al. (2008) Netherlands 34 16–45 Invasive surgical removal of mandibular third molar S-DAI, VAS 4 1. Gender
2. Previous traumatic dental events
3. Levels of disturbance during treatment
4. Time after the procedure
5. Treatment duration; number of anaesthetic injections; extent of surgery
1. No significant differences were found
2. Significant association with dental trait anxiety
3. Significant association with anxiety level
4. There were no significant differences between S-DAI scores prior to treatment and at 4 weeks after treatment
No significant differences
Muglali and Komerik (2008) Turkey 120 ? 95 removal of third molars; 6 removal of impacted premolars; 10 removal of residual roots; 4 apical resections; 2 cyst enucleations; 1 alveoloplasty DAS, STAI 3 1. Gender
2. Age and education
3. Previous dental procedures experience
4. Positive pain history
5. Procedure difficulty
6. Pain expectations
7. Time after the procedure
1. Females showed higher anxiety scores
2. No significant associations
3. Positive correlations with preoperative dental anxiety, state anxiety, and pain expectation
4. Correlation with preoperative dental anxiety
5. Correlation with state anxiety
6. Correlation with preoperative anxiety
DAS scores 1 week after and immediately after the procedure were significantly lower than before the procedure
Kim et al. (2010) Korea 219 20–59 Removal of impacted third molar DAS 2 1. Gender, age, and education
2. Previous dental procedures experience
3. Time after the procedure
1. No significant differences found
2. Patients with previous dental procedures experience showed higher anxiety in postoperative period, but no significant differences were found before the procedure
Preoperative anxiety significantly affected postoperative anxiety
van Wijk et al. (2010) Netherlands 160 ? Third molar extraction ASI, S-DAI 4 1. Gender
2. Anxiety sensitivity
3. Number of teeth removed
1. Females showed higher anxiety scores at first three measurements, but no significant differences were found at 1-week follow-up
2. Modest correlation with expected anxiety during treatment and preoperative state anxiety; stronger correlation with dental anxiety
Patients with more (2) molars removed were more anxious just before the surgery and during treatment
McNeil et al. (2011) USA 79 ? Emergency tooth extraction NRS, DFS 3 1. DFS scores group
2. Pain
1. High dental anxiety group showed higher pre-extraction state anxiety, expected anxiety, recalled anxiety
Significant correlation with anxiety
de Jongh et al. (2011) Netherlands 71 ? Removal of impacted mandibular third molar S-DAI 4 1. Gender
2. Time after the procedure
3. Previous dental procedures experience
1. Females showed higher anxiety scores
2. Dental anxiety was significantly higher just before the procedure than immediately after it and higher than anxiety 1 week and 1 month after
Patients with many negative dental experiences reported a significantly higher level of state anxiety and trait anxiety during all stages of measurement
Seto et al. (2012) Japan 111 ? Removal of third molar STAI 2 Knowledge of being sedated There were no significant differences in state and trait anxiety scores between initial visit and operation day in the group without sedation; in the sedation group, state anxiety scores were significantly higher on initial visit than on the day of operation; combined anxiety scores were significantly higher in the sedation group
Abdeshahi et al. (2013) Iran 24 18–30 Removal of two third molars STAI 1 Hypnosis No significant difference was found between hypnosis and control groups
López-Jornet et al. (2013) Spain 70 >18 Removal of a tooth STAI, MDAS, DFS 3 1. Previous dental procedures experience
2. Variable types of local anaesthesia
3. Duration of operation
4. Position of tooth extracted
5. Education
6. Number of injections
7. Time after the procedure
1. No significant correlations found
2. Immediately after extraction, patients requiring block type of local anaesthesia showed higher anxiety (STAI-T)
3. Immediately after extraction (STAI-T, MDAS, DFS) and 1 week later (DFS), patients requiring more than 10 min procedure showed higher anxiety
4. Immediately after extraction and 1 week later, patients requiring mandibular tooth removal showed higher anxiety (STAI-T)
5. Significant difference in the standard of education in extreme anxiety and extreme fear was found (MDAS, DFS) immediately after the procedure and 7 days later
6. No significant differences
STAI-T scores were significantly higher 1 week after the procedure than immediately after the procedure; MDAS scores were significantly higher immediately after the procedure than before the procedure; DFS scores were significantly higher immediately after the procedure than before the procedure and significantly lower after 1 week than immediately after the procedure
Egbor and Akpata (2014) Nigeria 93 18–50 Intra-alveolar extraction DAS-R 1 1. Age
2. Gender
3. Area of residence
4. Marital status
5. Education
6. Social class b
7. Times visited before
1. The highest DAS scores were in those aged <20 years; patients >40 years had lowest mean anxiety score
2. Females showed higher anxiety scores
3. No significant differences
4. Single patients showed highest mean DAS scores
5. Patients with secondary school education had the highest mean DAS; the lowest DAS score was seen in those with primary school education
6. Social class IV showed the lowest mean anxiety score and class V had the highest mean anxiety score
No significant differences
Torres-Lagares et al. (2014) Spain 91 14–64 Removal of mandibular third molar STAI 2 Type of information provided Patient anxiety after receiving information in all groups showed no significant difference; oral and written information decreased patient anxiety levels and video recorded information increased patient anxiety levels in a significant way
Tarazona et al. (2015) Spain 125 >18 Removal of single third molar STAI, DAS, APAIS 2 1. Age
2. Gender
1. Higher trait anxiety (STAI-T) with increasing age; no significant differences were found with other measurement scales
Females showed higher anxiety rates (STAI-T, DAS, APAIS)
Glaesmer et al. (2015) Germany 102 >18 Removal of a tooth VAS 3 1. Time after the procedure
2. Hypnosis
1. Level of anxiety decreased from ‘before the procedure’ to ‘during the procedure’ and ‘after the procedure’
During treatment, patients undergoing tooth removal with hypnosis showed significantly lower anxiety; before and after the procedure, the difference was not significant
Kazancioglu et al. (2015) Turkey 300 18–25 Removal of impacted mandibular third molar DAS, STAI 3 1. Type of information provided
2. Gender
3. Age, surgery time, education level
4. Time after the procedure
1. Patients who were informed using video information were more anxious before the procedure and immediately after the procedure than patients who were informed verbally with and without details
2. Females showed higher anxiety rates
3. No significant differences
Anxiety scores were significantly lower immediately after the procedure and 1 week later than before the procedure

a DAS, Corah’s Dental Anxiety Scale; STAI, Spielberger’s State-Trait Anxiety Inventory (STAI-T and/or STAI-S); DFS, Kleinknecht’s Dental Fear Survey; S-DAI, short version of the Dental Anxiety Inventory; S-FDPQ, short version of the Fear of Dental Pain Questionnaire; NRS, numerical rating scale; VAS, visual analogue scale; ASI, Anxiety Sensitivity Index; MDAS, Modified Corah’s Dental Anxiety Scale; DAS-R, Corah’s Dental Anxiety Scale Revised; APAIS, Amsterdam Preoperative Anxiety and Information Scale.

b Determined according to the classification of Opeodu and Arowojolu .

Measurement scales used

Different types of measurement scale were used to identify the anxiety level ( Table 2 ). Most studies ( n = 7) used only one specific measurement scale. Five studies used two different measurement scales and four used three different types of measurement scale.

Significant factors

Several factors were found to be significantly associated with tooth extraction anxiety without any conflicts amongst the different studies: propensity to anxiety ( P < 0.05), pain experience or expectations ( P < 0.05), level of disturbance during the procedure ( P < 0.001), and the difficulty of the procedure ( P = 0.034).

When the impact of marital status was assessed, the highest anxiety scores were found in single respondents (Corah’s Dental Anxiety Scale (DAS) 9.41 ± 2.24) and the lowest in divorced respondents (DAS 6.00 ± 0.00) ( P = 0.003). Also, the examination results revealed that there was a significant difference ( P = 0.012) in anxiety level among the various social classes of subjects, with social class determined according to the classification of Opeodu and Arowojolu. The lowest mean anxiety score was reported for social class IV (DAS 6.5 ± 2.42); in contrast, the highest mean anxiety score was reported for class V (DAS 9.18 ± 2.87).

The preoperative information provided to the patient also showed a significant effect on patient anxiety. Anxiety levels in patients receiving verbal or written information did not differ, but information in the form of a video/movie increased patient anxiety significantly ( P < 0.05) ( Table 3 ). It is interesting to note that even knowledge of being sedated significantly increased patient anxiety ( P < 0.05).

Table 3
Type of information provided as a factor predicting tooth extraction anxiety.
Study Scale used Verbal group Wr./Verb + D a Video group Outcomes P -value
Torres-Lagares et al. (2014) VAS (1–5) 0.97 ± 1.21 b 0.29 ± 0.97 b −0.57 ± 1.43 b Patient anxiety levels decreased after the provision of verbal 1 and written 2 information, and increased in the video 3 group; the difference was statistically significant P 1–3 = 0.000
P 2–3 = 0.022
Kazancioglu et al. (2015) DAS 11.34 ± 2.433 9.21 ± 2.02 16.11 ± 3.74 Video information patients were significantly more anxious before the procedure than patients in the verbal and written information groups P < 0.05
Kazancioglu et al. (2015) STAI-S 33.54 ± 34.41 30.01 ± 22.45 48.54 ± 34.41 Video information patients were significantly more anxious before the procedure than patients in the verbal and written information groups P < 0.05
VAS, visual analogue scale; DAS, Dental Anxiety Scale; STAI-S, State-Trait Anxiety Inventory.

a Written information in Torres-Lagares et al.; verbal information with details in Kazancioglu et al.

b Mean change scores.

In the assessment of the impact of a previous negative experience related to a dental procedure on patient anxiety, a positive correlation with dental anxiety in tooth removal patients was unanimously agreed. However Egbor and Akpata and López-Jornet et al. did not show statistically significant correlations ( P = 0.209 and P > 0.05, respectively), while the other authors did.

Some aspects of the procedure were also identified as important factors. Significant differences were found between patients having a mandibular tooth removed and those having a maxillary tooth removed, as determined using the State-Trait Anxiety Inventory (STAI-T) scale immediately after ( P = 0.003) and 1 week after the procedure ( P = 0.01), with higher anxiety scores in patients who had a mandibular tooth removed. However, no significant difference was found with the STAI-S, Dental Fear Survey (DFS), or Modified Dental Anxiety Scale (MDAS) measurement scales. The results revealed that patients who had two molars removed were significantly more anxious just before ( P < 0.016) and during ( P < 0.001) surgery than those who had one molar removed.

The specific type of anaesthetic injection was found to affect patient anxiety, with patients who required specific block type local anaesthesia reporting significantly higher anxiety immediately after the procedure (STAI-T; P = 0.008) than those who had infiltration anaesthesia; however, the difference disappeared ( P = 0.41) over the 7 days of follow-up. In contrast, with the STAI-S, MDAS, and DFS measurement scales, no significant differences were found ( P = 0.4, P = 0.627, P = 0.36 immediately after surgery, and P = 0.98, P = 0.99, P = 0.49 at the 7-day follow-up).

Conflicting results

Some of the results were identified as conflicting, since different findings were obtained in different reports. Disagreement between significant and non-significant differences were obtained for the following factors: gender ( Table 4 ), level of education, duration of the procedure, and the effect of hypnosis.

Table 4
Gender as a factor predicting tooth extraction anxiety.
Study Scale used a Males (mean ± SD) Females (mean ± SD) Outcomes P -value
Lago-Méndez et al. (2006) DAS 8.68 ± 2.996 9.47 ± 3.334 NSD >0.05
Kim et al. (2010) DAS 13.32 ± 2.98 13.24 ± 2.98 NSD 0.846
Tarazona et al. (2015) DAS 7.4 ± 2.09 10.5 ± 2.75 Females showed significantly higher DAS scores 0.006
Egbor and Akpata (2014) DAS 7.37 ± 1.88 8.76 ± 2.84 Females showed significantly higher DAS scores 0.00
Muglali and Komerik (2008) DAS N/A N/A Females showed significantly higher DAS scores <0.001
Kazancioglu et al. (2015) DAS N/A N/A Females showed significantly higher DAS scores <0.05
Total DAS 10.377 ± 3.877 11.083 ± 3.474 Females showed significantly higher DAS scores 0.0311
van Wijk et al. (2010) S-DAI 16.69 ± 7.34 22 ± 9.93 Females showed significantly higher S-DAI scores <0.05
de Jongh et al. (2011) S-DAI 16.6 ± 7 21.1 ± 9.4 Females showed significantly higher S-DAI scores <0.05
de Jongh et al. (2008) S-DAI N/A N/A NSD N/A
van Wijk et al. (2008) S-DAI N/A N/A Females showed significantly higher S-DAI scores <0.05
Total S-DAI 16.664 ± 7.243 21.706 ± 9.769 Females showed significantly higher S-DAI scores <0.0001
Lago-Méndez et al. (2006) STAI-T 15.2 ± 7.555 20.16 ± 8.421 Females showed significantly higher STAI-T scores <0.05
Tarazona et al. (2015) STAI-T 16.47 ± 6.94 18.79 ± 9.3 NSD 0.41
Kazancioglu et al. (2015) STAI-T N/A N/A NSD N/A
Total STAI-T 16.063 ± 7.167 19.317 ± 8.997 Females showed significantly higher STAI-T scores 0.0081
Lago-Méndez et al. (2006) STAI-S 18.68 ± 7.459 19.53 ± 8.722 NSD >0.05
Muglali and Komerik (2008) STAI-S N/A N/A Females showed significantly higher STAI-S scores 0.013
Tarazona et al. (2015) STAI-S 20.62 ± 10.35 25.17 ± 12.51 Females showed significantly higher STAI-S scores 0.05
Kazancioglu et al. (2015) STAI-S N/A N/A Females showed significantly higher STAI-S scores <0.05
Total STAI-S 19.998 ± 9.562 23.001 ± 11.537 NSD 0.0585
Tarazona et al. (2015) APAIS 12.25 ± 4.27 18.70 ± 3.68 Females showed significantly higher APAIS scores 0.00
Lago-Méndez et al. (2006) DFS 33.28 ± 13.532 36.38 ± 13.063 NSD >0.05
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Dec 15, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Factors determining tooth extraction anxiety and fear in adult dental patients: a systematic review
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