What is the most fearful intervention in ambulatory oral surgery? Analysis of an outpatient clinic


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.

Fear and anxiety about dental treatment are important clinical problems and occur in 40–50% of the general population. Direct traumatic experiences in childhood, influence of the family, general anxiety traits and social environment are associated with the onset of dental anxiety. Such individuals may avoid dental treatment or use dental services only for emergency purposes. In addition to demonstrating poor oral health status compared to the general population, they also report insufficient chewing ability and dissatisfaction with facial aesthetics. Different types of dental treatment can result in varied stress responses from these patients. Minor oral surgery under local anaesthesia is a common procedure with a relatively short recovery period, but its physical and psychological impact makes it a particularly stressful experience. The patient’s cognitive ability to process information before surgery has been shown to decrease, leading to preoperative communication problems. Adequate pain control and reassurance have been recommended as important factors in reducing the patient’s anxiety which, if not properly managed, may result in longer surgery duration, leading to increased facial swelling and poorer postoperative recovery. A prerequisite for building up new strategies to deal with this issue is the effective clinical assessment of the anticipated fearful response.

Self-administered dental fear and anxiety questionnaires are of clinical and scientific importance because they indicate the fear and present an assessment of the likely treatment outcome. To elucidate fearful behaviour, these scales are constructed around specifically designed questions. Any scale being used in a population other than that it was originally designed for should be validated for cultural and linguistic determinants. Such differences, if not recognized, may have an effect on the clinical use and interpretation. Some questionnaires are prepared to address different aspects of dental fear under various circumstances and predetermined sets of questions often refer to specific situations. It is also important to compare the distribution of the answers in a translated version with those of the original sample, to check for the presence of similar concepts which the original intended to examine. Since the final evaluation is based on the sum of scores according to the intensity of the fearful response, different interpretations of the items by the subjects can result in biased conclusions in a research study or in misinterpretation of a patient’s fearful attitude in the clinical setting.

The behavioural influence of oral surgery is a well known issue, but to the authors’ knowledge, no previous research has been carried out to examine its effects on a sample of routine clinical patients in daily practice, focussing specifically on different types of surgical interventions. The literature on this subject often disregards the fact that the perception of patients towards self-assessment instruments may differ from one cultural setting to another, thereby compromising interpretation of the original construct. The aim of this study was to investigate the levels of dental fear and anxiety in patients who have attended to an oral surgery outpatient clinic with various complaints by using questionnaires that were properly adjusted to the population characteristics involved.

Materials and methods

The study sample ( N = 700) was a combination of two different groups, described as clinical and non-clinical populations. To be included in this research project, the subjects had to be adult, consent to participate, be born, raised and educated within the national borders of Turkey, and have the cognitive skills and literacy to complete the study forms. The clinical treatment was conducted in the outpatient clinic of the Department of Oral surgery of the Faculty of Dentistry, Istanbul University which offers a routine daily walk-in service and accepts referrals from other cities. The clinical group included 500 consecutive patients ( n = 500) who were operated on under local anaesthesia. According to the characteristics of the treatment plan, these individuals were organized under one of the following entities: hard tissue group (HTG) ( n = 40); impacted third molar tooth group (TMG) ( n = 145); implantology group (IG) ( n = 32); soft tissue group (STG) ( n = 35); and tooth extraction group (TEG) ( n = 248). The HTG consisted of patients with radiographically well-demarcated benign, solid or cystic lesions with or without additional apicectomy, undergoing only apicectomy, removal of root remnants and alveoloplasty operations. The TMG was reserved for patients who required the surgical removal of their third molars. The IG included patients who will receive dental implants with or without guided bone regeneration procedures. The STG included patients with benign lesions limited to the oral mucosa with no bony component. The TEG included patients requiring teeth removal procedures for prosthetic, endodontic or periodontal causes with the exception of third molars. Patients with multiple surgery requirements were enrolled only in the corresponding group of their initial complaint. Individuals with acute pain, oedema or trismus were given the necessary care but were not enrolled in the study, since such clinical symptoms could have aggravating effects on the patients’ anxiety levels.

The non-clinical sample was contacted by mailing. This group of 200 subjects ( n = 200) comprised the families and relatives of the non-dental professional staff members of the faculty who met the inclusion criteria.

Three questionnaires were used in this study. The first was a demographic questionnaire consisting of open-ended and multiple choice questions that collected information about the age, gender, duration of education (less than 5 years, 5 years, 11 years, 15 years or more), marital status (single, married, widowed, divorced), monthly income (very low, low, moderate, high), age at first dental visit, presence of previous adverse experiences related to dentistry and the age when they occurred. The other two questionnaires were the previously validated translations of the Modified Dental Anxiety Scale (MDAS) and the Dental Fear Survey (DFS). The MDAS, which is based on Corah’s Dental Anxiety Scale (CDAS or DAS) , is a five item questionnaire with an answering scheme for each item ranging from ‘not anxious’ to ‘extremely anxious’. The original DFS consists of 20 items. The answers may differ from ‘not at all fearful’ to ‘very much afraid’, and the total score can range between 20 and 100. It was also designed to analyse three major factors of dental fear. The sum of the first two questions provides an estimate of the avoidance of dentistry (sub-scale 1), questions 3–7 report physiological arousal during dental treatment (sub-scale 2) and questions 8–20 estimate the fear of specific dental situations (sub-scale 3).

For the clinical group, an oral and maxillofacial surgeon consulted the patients at the first appointment and provided them with detailed verbal and written information concerning the procedure, such as the possibility of swelling, pain and use of medication. One week later, these patients returned for the appointment and completed the questionnaires before entering the surgery. Non-clinical participants were contacted by mail and were asked to complete the same documents, but they did not receive surgical instructions. 100 participants in each group were tested again after 1 week to determine the test–retest reliability of the MDAS and DFS.

Statistical analysis

SPSS ® 16.0 (IBM Statistical Package for Social Sciences, Chicago, IL, USA) was used in this study. Descriptive statistics were applied to examine the characteristics of the population. The χ 2 test was used for comparing frequencies or proportions. As the data were not normally distributed, the Mann–Whitney U -test was performed for the comparison of two groups using the ranked values of specified variables from each group. Cronbach’s alpha coefficient and two-way mixed intra-class correlation (ICC) methods were used to compute internal consistency and test–retest reliability, respectively. To discover the nature of the constructs influencing a set of responses, the exploratory factor analysis (EFA) was performed using the same software. An EFA procedure is a standard method to determine the underlying measurement structure of multiple questions comprising a self-reported rating scale. The confirmatory factor analysis (CFA) was performed in AMOS ® 18 (IBM Statistical Package for Social Sciences, Chicago, IL, USA) to support the previous analysis (EFA) and test the suitability of the final measurement model.

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Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on What is the most fearful intervention in ambulatory oral surgery? Analysis of an outpatient clinic
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