The aim of this study was to review scales used to assess anxiety, stress, and pain in dental patients undergoing a tooth extraction procedure and to propose a novel psycho-emotional rating scale based on the relevant literature and our own experience. An electronic literature search was conducted of the National Library of Medicine database MEDLINE (Ovid) and EMBASE databases between January 2005 and April 2016. Sequential screening at the title/abstract and full-text levels was performed. The review included all human prospective or retrospective follow-up studies and clinical trials, cohort studies, case–control studies, and case series that demonstrated at least one scale used to measure tooth extraction anxiety, stress, or pain. The search resulted in 32 articles meeting the inclusion criteria. None of the studies were found to be suitable in evaluating patient’s stress, pain, and fear at once. Also, no scales were found that included both the doctor’s and the patient’s rating. In a few studies, vital signs as psycho-emotional status indicators were rated. Guidelines for a suitable questionnaire that could be used for rating the psycho-emotional status of patients undergoing tooth extraction are listed in the present research. Further studies are required for verification and validation of offered scale.
The psycho-emotional status of patients undergoing various dental procedures is very important for patient–doctor comfort during the procedure . It was noted that three main factors should be identified before the treatment of patient to improve the quality of the treatment procedure: fear/anxiety, stress, and pain sensitivity . As long as different reactions are related to pain sensitivity, fear/anxiety and stress, it is important to evaluate which conditions affect the patient, so that it would be possible to reduce it .
Anxiety is known as an important part of the body’s responses and may help to solve specific life situations . However, often anxiety is found for no reason and it is an over-reaction to non-dangerous situations .
Many different types of fears and phobias are known, but dental care is at the top of the list of anxiety-provoking stimuli. According to different research in different populations, the prevalence of severe dental anxiety ranges from 3.9% to 11.7% . It was noted that from 3% to 43% of people have mild to severe dental anxiety, but it is not noticed every person and considered a pathological condition .
Moreover, not all the procedures in the dental surgery cause the same levels of anxiety. In previous studies, it was identified that dental surgery procedures were described as the most anxiety-provoking procedures out of a list of 67. Tooth extraction was at the top of the list . Third molar extraction was found to be the most anxiety-provoking procedure when only oral surgery procedures were tested as anxiety provoking triggers .
The other important factor is pain sensitivity, which is usually described as the patient feeling pain at the lowest stimulus and patient’s potential to maintain the highest pain level . Even though pain is usually described as the body’s response to injuries, it is highly correlated with a person’s psychology. A patient may have negative memories of past pain, which makes the patient more sensitive to pain when repeating the procedure . Also, patients may feel greater pain if they are expecting for pain beforehand . Physical methods alone are not always effective; therefore, it is important to observe and manage a patient’s psychological sensitivity to pain throughout . Tooth extraction is an invasive procedure, which produces pain during treatment and in post-treatment period; pain should therefore be carefully managed psychologically and physically.
Stress is usually described as the sympathetic nervous system’s reaction to a negative stimulus. It should be noted that anxiety and pain provoke stress in human bodies . It was assessed that even the thought of a negative stimulus, such as pain, increases adrenaline in the human body without any real stimulus . This shows that stress is also related to a psychological stimulus. Nowadays, stress is described as a process that arises as a reaction to a physical or psychological negative stimulus. Usually, psychological stress also reveals physiological reactions . Stress may be recognized because of nervous and endocrine system activation. A higher heart rate is an obvious sign of the presence of stress .
Nowadays, there are many medication and non-medication ways to ease anxiety, pain, and stress in dental surgery . Hypnosis, aromatherapy, musical therapy, or behavioural management could be used as non-medical ways to relax the patient . Conscious sedation and general anaesthesia are known to be effective and useful ways to improve a patient’s difficult psycho-emotional status during tooth extraction . Even so, before trying to affect a patient’s psycho-emotional status, you have to know if the problem is present in the situation experienced.
There are many different measurement scales to rate the psycho-emotional status in patients, such as the Spielberg State-Trait Anxiety Index, Corah’s Dental Anxiety Scale, Kleinknecht’s Dental Fear Survey. Therefore, the purpose of present article was to review scales used to assess anxiety, stress and pain in dental patients undergoing tooth extraction and to propose a novel psycho-emotional rating scale based on the relevant literature and own experience .
Material and methods
Protocol and registration
The methods and inclusion and exclusion criteria were determined in advance and documented in the protocol. The review was registered in PROSPERO, an international prospective register of systematic reviews.
The protocol can be accessed at www.crd.york.ac.uk/PROSPERO (registration number: CRD42015027778).
This systematic review adhered to the PRISMA (Preferred Reporting Item for Systematic Review and Meta-Analyses) statement .
The following focus question was developed according to the population, intervention, comparison, and outcome (PICO) study design: What are the advantages and disadvantages of scales that are used in measuring psycho-emotional status in adult patients undergoing a tooth extraction procedure?
Types of studies
The review included all human prospective or retrospective follow-up studies and clinical trials, cohort studies, case–control studies, and case series between January 2005 and April 2016 that demonstrated measurement of a patient’s psycho-emotional status undergoing tooth extraction using a specific scale.
Review studies were excluded.
The search strategy was based on electronic database examination. A search was carried out in the National Library of Medicine database MEDLINE (Ovid) and Embase.
The electronic search used the advanced search in the database. The electronic search was completed independently for each established part of psycho-emotional status. The keywords used in the primary search stages were as follows: “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”; “pain sensitivity tooth extraction” OR “pain sensitivity exodontia” OR “pain sensitivity oral surgery”; “stress before tooth extraction” OR “stress before exodontia” OR “stress before oral surgery”.
Keywords 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 conflict, consulting a third party if a consensus could not be reached. The third party was an experienced senior reviewer. At the title and abstract stage, one reviewer accepted the citations that appeared to meet the inclusion criteria and sent them for an to full-text review, with a second reviewer assessing only those citations and abstracts that the first reviewer deemed ineligible. For reviewing the full-text articles, a complete independent dual review was undertaken.
Inclusion and exclusion criteria
All prospective and retrospective studies, clinical trials, and cohort–control studies determining psycho-emotional status in tooth extraction assessed using a measurement scale in dental patients.
Adult patients (at least 16 years old) with no systematic disorders that may affect mental health (addiction to drugs, eating disorders, Down syndrome, etc.) and with no disorders that increase tooth extraction risks (diabetes mellitus, HIV, haemophilia).
Studies that could not be excluded before careful reading.
Studies that examined tooth extraction pain, stress or/and anxiety as a result of other occurrences.
Studies that included unclear data, with authors who could not be contacted in any way.
Sequential search strategy
The search strategy included three stages. In the first stage, title screening 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 questions. The third stage was reading full-text articles to confirm each study’s eligibility according to the inclusion and exclusion criteria.
The data were independently extracted from articles, according to the theme, purpose, and questions of the present review.
Data were collected from selected articles and arranged in the following fields:
‘Year’ – year of publication
‘Sample size’ – number of patients included in the study
‘Area’ – country in which the study was done
‘Follow-up’ – duration of outcome observation
‘Population feature’ – feature by which the included population was selected (nationality, age, gender, etc.)
‘Evaluation method’ – type of scale used to describe patient’s psycho-emotional status
‘Scale used’ – scale that was used to measure a patient’s stress, anxiety and/or pain level.
‘Interview features’ – specific features of interview (e.g., interview in non-dental rooms)
‘Interview method’ – method that was used to collect information from patients (self-reported, questionnaires at home, etc.)
Assessment of methodological quality
The quality of all included studies was evaluated during the full-text reading stage. During full-text reading, 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’s (Version 5.1.0) two-part tool for assessing risk of bias .
Synthesis of the results
Relevant data of interest in the previously stated variables were collected and organized into tables, based on the measurement used scales to rate anxiety, stress and pain sensitivity in tooth extraction patients. Diagrams showing the differences among the results of examined studies were made.
Owing to the heterogeneity of studies included in present review, data analysis was not performed. The kappa index was used to evaluate the level of agreement between the two researchers .
The initial search identified a total of 11,170 articles. Following the screening of the article titles, 3,166 potential relevant articles were identified. Independent screening of the abstracts resulted in a possible 47 articles for inclusion. One article from another source was also included in study as it followed the inclusion criteria. The inclusion and exclusion criteria were applied to 47 full-text articles. In total, 32 articles met the inclusion criteria and were selected for systematic review ( Fig. 1 ) .
The kappa values for inter-reviewer agreement for potentially relevant articles were 1 (titles and abstracts) and >0.9 (full-text articles), indicating an ‘almost perfect agreement’ between the two reviewers .
Exclusion of studies
The reasons for excluding studies after full-text assessment were as follows: full-text article in English unavailable ( n = 1); psycho-emotional status not specific to the tooth extraction procedure ( n = 11); conditions not related to psycho-emotional status examined ( n = 3).
The quality assessment ( Table 1 ) revealed a high risk of bias in the majority of the included studies. Six studies were classified as unclear risk of bias . Three articles had a low risk of bias in all contents .
|Sequence generation||Allocation concealment||Blinding of participants, personnel, and outcome assessors||Incomplete outcome data||Selective outcome reporting||Other sources of bias|
|Fagade et al. (2005)||+||+||?||+||+||+|
|Lago-Méndez et al. (2006)||?||?||+||+||+||+|
|Graziani et al. (2006)||+||+||+||+||+||+|
|Liau et al. (2008)||—+||?||+||+||+|
|Alemany-Martínez et al. (2008)||?||+||−||+||+||+|
|Wijk et al. (2008)||−||+||?||+||+||+|
|Jongh et al. (2008)||−||?||+||+||+||+|
|Muglali et al. (2008)||−||?||−||−||+||+|
|Lago-Méndez et al. (2009)||−||+||?||+||+||+|
|Rudin et al. (2010)||−||+||−||+||+||+|
|Kim et al. (2010)||+||?||+||+||+||+|
|Wijk et al. (2010)||−||+||−||+||+||+|
|Kim et al. (2011)||+||+||?||+||+||+|
|Mobilio et al. (2011)||−||?||−||+||+||+|
|McNeil et al. (2011)||−||+||−||+||+||+|
|Jongh et al. (2011)||−||?||?||+||+||+|
|Mehboob et al. (2011)||+||+||+||+||+||+|
|Sirin et al. (2012)||−||?||?||+||+||+|
|Seto et al. (2012)||−||+||?||+||+||+|
|Hierons et al. (2012)||+||+||?||+||+||+|
|Abdeshahi et al. (2013)||−||−||−||+||+||+|
|López-Jornet et al. (2013)||−||?||−||?||+||+|
|Martin et al. (2013)||−||+||−||+||+||+|
|Egbor et al. (2014)||−||?||−||+||+||+|
|Torres-Lagares et al. (2014)||−||+||+||+||+||+|
|Aznar-Arasa et al. (2014)||−||+||?||+||+||+|
|Torres-Lagares et al. (2014)||−||+||−||+||+||+|
|Hasheminia et al. (2014)||+||+||?||+||+||+|
|Arteagoitia et al. (2014)||+||+||+||+||+||+|
|Tarazona et al. (2015)||−||?||+||+||+||+|
|Glaesmer et al. (2015)||−||+||−||+||+||+|
|Kazancioglu et al. (2015)||−||+||+||?||+||+|
Types of studies
Twenty-three studies were prospective cohort studies, where the questionnaires were given to participants and different follow-up periods were observed. Eight reports were control trials in which different factors that may increase or decrease anxiety of tooth removal were examined . One article was a retrospective study, in which previously collected data were observed .
Measurement scales used
The main characteristics of the scales used in included studies can be viewed in Table 2 : Visual Analogue Scale (VAS), Corah’s Dental Anxiety Scale (DAS), Spielberg’s State-Trait Anxiety Scale (STAI), Kleinknecht’s Dental Fear Survey (DFS), Modified Dental Anxiety Scale (MDAS), Short version of Stouthard’s Dental Anxiety Index (S-DAI), Short Version of Fear of Dental Pain Questionnaire (S-FDPQ), Short Form of Fear of Pain Questionnaire (SF-FPQ), McGill Pain Questionnaire (SF-MPQ), The Amsterdam Preoperative Anxiety and Information Scale (APAIS), Hospital Depression and Anxiety Scale (HADS) . After careful revision some scales were found to have at least one item relating to tooth extraction. However, all of these scales were developed to measure a patient’s general state in an ordinary or in a dental office. None of the scales had been adapted to tooth extraction or oral surgery procedures before usage.
|Scale||Times used||Type of filling||Purpose of usage||Number of questions||Answer type||Items directed to tooth extraction procedure|
|Visual Analogue Scale (synonyms − Numerical Rating Scale; interval scale of anxiety response) (VAS)||22||Self-reported (SF)||To measure anxiety and pain||Linear rating with 100 mm long vertical or horizontal line; numerical 10-point or 100-point rating. Many modifications are possible.||Point on the line with start point at 0; rating in numbers||This is a universal scale, which can be fitted to any type of questions|
|Surgeon-reported||To measure patient’s behaviour|
|Corah’s Dental Anxiety Scale (DAS)||12||SF||To measure anxiety||4||5-point scale||None|
|Spielberger’s State-Trait Anxiety Inventory (STAI)||12||SF||To measure anxiety||40||4 multiple choices||None|
|Kleinknecht’s Dental Fear Survey (DFS)||7||SF||To measure fear||20||5-point scale||2 items about fear of anaesthetic injection|
|Modified Corah’s Dental Anxiety Scale (MDAS)||5||SF||To measure anxiety||5||5-point scale||1 item about fear of anaesthetic injection|
|Short version of Stouthard’s Dental Anxiety Index (S-DAI)||3||SF||To measure anxiety||9||5-point scale||1 item about fear of anaesthetic injection; 1 item about fear of tooth extraction|
|Short Version of Fear of Dental Pain Questionnaire (S-FDPQ)||1||SF||To measure fear of pain||5||5-point scale||1 item about fear of wisdom tooth extraction; 1 item about fear of tooth being pulled|
|Short Form of Fear of Pain Questionnaire (SF-FPQ)||1||SF||To measure fear of pain||9||5-point scale||1 item about fear of oral anaesthetic injection|
|McGill Pain Questionnaire (SF-MPQ)||1||SF||To measure pain||3 parts||5 multiple choices||Universal to all painful situations|
|The Amsterdam Preoperative Anxiety and Information Scale (APAIS)||1||SF||To measure anxiety||6||5-point scale||Universal to all types of surgeries and anaesthesia.|
|Hospital Depression and Anxiety Scale (HADS)||1||SF||To measure anxiety||14||4 multiple choices||None|
Anxiety as part of the psycho-emotional status was used the most often with various scales . For pain rating, the VAS was used most often; however, some authors chose the S-FDPQ, SF-FPQ, and SF-MPQ questionnaires ( Table 2 ). Stress was not discerned in any of the reviewed articles by using a specific scale.
All the scales are designed to be interpreted according to the sum of the total points gained.
Body responses monitoring
Six articles monitored body-responding reactions in the present review .
Plasma stress markers
Arteagoitia et al. assessed plasma stress markers, such as p-cortisol, p-prolactin, p-HVA, p-MHPG in patients undergoing tooth extraction. Only the p-cortisol marker was useful in assessing stress in young healthy people undergoing tooth extraction.
Three authors recorded vital signs (respiratory rate, heart rate, and blood pressure) while measuring a patient’s stress .
Pain sensitivity was tested twice before the procedure with a thermal stimulus . Rudin et al. used a heat pain threshold test to rate a patient’s pain sensitivity. Mobilio et al. chose a cold pressor test to evaluate the same indicator.