Comparison of Preoperative and Postoperative Anxiety Levels in Patients Undergoing Tooth Extraction

Introduction

Anxiety is a condition that is generally accepted as an expression of a person’s struggle against stress, and has both psychological and physiological parameters [1]. Dental anxiety, in particular, is defined as an excessive negative emotional reaction to dental procedures, often triggered by a perceived or anticipated threat [2]. The prevalence of dental anxiety in adults has been reported in the literature to occur at highly variable rates (ranging from 4.2% to more than 50%), but it constitutes an important public health problem [3]. According to more recent data, the prevalence of dental anxiety is around 15.3%, with 12.4% experiencing high levels of anxiety and fear, and 3.3% experiencing severe anxiety [4]. In young children, the rate of dental anxiety is also quite variable, ranging from 4% to 98% [5]. Many factors can play a role in the emergence of dental anxiety. These include individual characteristics (age and sex), previous dental experiences, and environmental and socioeconomic conditions [6]. Some studies indicate that female patients tend to exhibit higher dental anxiety levels than male patients [7].

Tooth extraction can be a source of anxiety and fear for many patients. The use of surgical motors and hand tools and the application of dental anesthesia often cause fear and anxiety and discomfort in patients in the dental clinic. This anxiety can occur at different levels both before and after the procedure and can affect the general psychological state of the patients [8]. The most important factor in the development of dental anxiety has been reported as the fear of pain that may be felt during treatment. Many factors other than pain can also affect dental anxiety. Undoubtedly, anxiety is one of the main factors that contribute to the difficulty of dental patients’ treatments. Although patients feel anxiety at various levels before dental procedures, oral surgery procedures are associated with the highest level of anxiety [9]. Preoperative anxiety can be affected by various factors such as age, sex, and systemic health status. However, there is no clear consensus in the literature on this issue. While some studies have reported that female patients had higher anxiety levels, others have not found a significant difference between the sexes. Similarly, the effect of age on anxiety is also controversial [10,11]. While it has been suggested that younger individuals may experience higher anxiety due to lack of experience, some studies argue that increased systemic diseases and death anxiety may cause more general anxiety in older individuals [12,13]. These inconsistencies in the literature highlight the complexity of dental anxiety and underscore the need for further investigation.

Spielberger’s State-Trait Anxiety Inventory (STAI-S, STAI-T) is an assessment tool that measures “state” (transient, STAI-S) and “trait” (persistent, STAI-T) anxiety. While STAI-T measures trait anxiety that an individual carries as a personality trait, STAI-S is intended to determine the level of momentary anxiety. Both scales consist of 20 items evaluated with a 4-point Likert-type scoring system [14]. The Corah Dental Anxiety Scale (DAS) is one of the most commonly used scales for determining anxiety in dentistry [15]. Adapted to Turkish by Seydaoğlu et al [16], the scale is a 5-point Likert-type scale consisting of 4 items to measure how anxious and worried people feel during dental procedures.

Despite extensive research, the evidence remains inconclusive regarding the influence of demographic factors on dental anxiety. Moreover, while the prevalence and impact of dental anxiety have been well-documented, there is limited research specifically comparing preoperative and postoperative anxiety levels in patients undergoing routine tooth extraction, particularly across different age groups and sexes.

This study aims to evaluate and compare preoperative and postoperative dental anxiety levels among patients undergoing tooth extraction, with a focus on age and sex differences. By better understanding the patterns of anxiety in specific patient populations, targeted strategies can be developed to improve patient comfort and clinical outcomes during oral surgical procedures.

Material and Methods

ETHICS STATEMENT:

Before starting the study, ethics committee approval was obtained from Eskişehir Osmangazi University Interventional Clinical Research Ethics Committee (Decision Date: 19.11.2024, Decision No: 2024-06(01)) and the study was conducted in accordance with the ethical standards in the Declaration of Helsinki. A total of 400 patients who had undergone tooth extraction at the Eskişehir Osmangazi University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, between November and December 2024, were included in our study. All of these patients had received detailed information about the survey to be conducted in written and verbal form and had given informed consent to participate. For patients under 18 years of age, both parental/guardian consent and patient assent were obtained.

STUDY DESIGN:

This study was designed as a prospective observational study to evaluate the impact of dental anxiety on patients undergoing tooth extraction. Patients were assessed before and after the extraction procedure using validated anxiety measurement scales. Data were collected through structured questionnaires, and statistical analyses were performed to identify significant relationships between demographic variables and anxiety levels.

INCLUSION CRITERIA:

Patients aged 13 years and older, who were mentally fit to complete the questionnaire, and who required non-surgical simple tooth extraction (anterior or posterior teeth) were included.

Patients were only included who provided informed consent (and parental consent where applicable).

EXCLUSION CRITERIA:

Patients receiving antianxiety or antipsychotic medications; patients with a history of psychiatric illness; and patients requiring surgical or complicated extractions (eg, impacted teeth, flap elevation, root sectioning) were excluded.

Patients were recruited using a consecutive sampling method, during the study period. Extractions involved both maxillary and mandibular teeth, including anterior and posterior teeth. The indications for extraction included periodontal disease, orthodontic reasons, prosthetic rehabilitation, and severe caries. Mandibular block anesthesia was administered for mandibular extractions, and infiltrative local anesthesia was used for maxillary extractions according to clinical indications. The type of extraction (anterior vs posterior) was not standardized across patients, and this has been considered as a potential limitation.

OUTCOME MEASUREMENTS:

The primary outcome of this study was the change in anxiety levels before and after tooth extraction. Anxiety was measured using the STAI-S and STAI-T, along with the DAS.

The STAI-S (State Anxiety) assesses momentary anxiety levels at the time of measurement. The STAI-T (Trait Anxiety) measures long-term, general anxiety levels. The DAS evaluates anxiety specifically related to dental procedures.

Secondary outcomes included the influence of demographic factors (age and sex) on anxiety levels, as well as variations in anxiety responses between different age groups. To evaluate anxiety variation between age groups, patients were classified into 4 age ranges: 13–19 years (adolescent), 20–34 years (young adult), 35–49 years (middle-aged adult) and 50+ years (older adult).

DATA COLLECTION:

The questionnaire form filled out before and after the extraction included the DAS, STAI-S, and STAI-T. The DAS consists of 4 questions on a 5-point Likert-type scale to measure anxiety. Increasing scores indicate increasing levels of anxiety. Evaluation was done on the basis of the sum of the scores given to the 4 questions. Patients scoring 4–7 points were evaluated as having no anxiety, while those scoring between 8–20 points were evaluated as having anxiety.

The State-Trait Anxiety Inventory consists of 2 separate scales, each with 20 items, for a total of 40 questions. While the STAI-S consists of questions aimed at determining the current anxiety level, the STAI-T consists of questions used to measure a person’s longer-term anxiety level, encompassing their personality traits. All 20 items in both scales are scored on a 4-point scale. The total score ranges from 20 to 80. Scores between 20 and 37 are considered as individuals with no anxiety or low anxiety, scores between 38 and 44 as individuals with moderate anxiety, and scores between 45 and 80 as individuals with high anxiety.

SAMPLE SIZE:

Power analysis was conducted using G*Power, a well-established statistical software platform for determining sample size and statistical power. The analysis was based on the following parameters: significance level (α)=0.05, statistical power=0.95, and effect size (Cohen’s d)=0.2. The effect size was chosen based on conventions for detecting small clinical effects and is consistent with prior literature on dental anxiety studies. The analysis indicated a required minimum sample size of 327. To ensure sufficient power, 400 patients were included.

STATISTICAL ANALYSIS:

The SPSS 22.0 Windows (IBM Corporation, Armonk, NY, USA) program was used in the analysis of the data obtained in the study. The suitability of the variables for normal distribution was evaluated using the Shapiro-Wilk test. The results of the Shapiro-Wilk test indicated that the data were not normally distributed (P<0.05 for all variables, including DAS, STAI-S, and STAI-T, both preoperatively and postoperatively). Therefore, non-parametric statistical tests were applied. Kruskal-Wallis and Mann-Whitney U tests were used for comparative statistical evaluation in subgroups, and P<0.05 was accepted as statistically significant. Post-hoc pairwise comparisons were not performed after Kruskal-Wallis analysis.

Results

A total of 400 patients, aged between 13 and 77 years (mean 42.62±15.14), including 237 female patients (59.3%) and 163 male patients (40.8%), were included in the study.

Descriptive statistics regarding the DAS, STAI-S, and STAI-T scores before (T1) and after (T2) tooth extraction are presented in Table 1. In the overall sample, mean DAS scores decreased from 8.30±3.50 at T1 to 7.26±2.98 at T2, representing a 12.5% reduction. Mean STAI-S scores decreased from 35.92±9.71 at T1 to 34.06±9.72 at T2, corresponding to a 5.2% reduction. Mean STAI-T scores decreased slightly from 38.25±7.79 at T1 to 38.19±8.39 at T2, a negligible reduction of 0.15%.

When stratified by sex, female patients had significantly higher DAS, STAI-S, and STAI-T scores at both T1 and T2 compared with male patients (P<0.05) (Table 2). When stratified by age groups, adolescents had the highest DAS and STAI-S scores, while older adults had the lowest scores (P<0.05). No significant difference was observed across age groups for STAI-T scores (P>0.05) (Table 3).

Discussion

This study evaluated the changes in dental anxiety levels before and after tooth extraction, and examined differences across age groups and sexes. The proportion and distribution of patients with diagnosed dental anxiety varies across geographic regions. This difference may be due to differences in how individuals perceive dental care and oral surgery or to the variety of measurement tools used to assess dental anxiety [17]. In Turkish society, traditional tooth extraction is seen as a treatment method that causes anxiety and fear. In a study conducted with 160 people with dental phobia, tooth extraction was determined to be the fourth most frightening procedure among all dental treatments [18]. The scales used to assess dental anxiety vary and are not always easy to apply; this process can sometimes be laborious [19]. In addition to scales specific to dentistry, there are also some scales commonly used in general clinical psychology. One of the most frequently used tools in this field is the STAI scale, which has the capacity to measure both general and momentary anxiety. The most important advantage of the STAI is that it can assess the variable nature of anxiety over time and in response to situational factors [20]. For this reason, the STAI has become one of the most frequently preferred research tools for analyzing anxiety in patients. It is also widely used in the field of dentistry due to the suitability of its structure for the assessment of anxiety triggered by specific experiences such as oral surgery [21,22]. The DAS is an assessment tool known for its ease of application and satisfactory psychometric properties [23]. The STAI and DAS scales were used in this study because they provide reliable and clear information. Specifically, a 12.5% reduction in DAS and a 5.2% reduction in STAI-S scores were observed, emphasizing the immediate psychological relief following the procedure.

Anxiety scores were related to the age and sex of the patients. It has been observed that anxiety decreases with age; most patients were classified as mildly anxious, and only a few were considered extremely anxious. In terms of sex, male patients are generally not anxious or remain at a mild level of anxiety, while female patients are mostly mild to moderately anxious [24]. Selimovic et al [25] evaluated the preoperative and postoperative STAI and DAS scores in young patients with tooth extractions. They determined the presence of high levels of general anxiety, situational anxiety and dental anxiety in the preoperative period. Considering that the majority of patients with third molar extraction indications undergo this procedure at a young age, Selimovic et al reported that the values of the monitored parameters may be different in the older population. A prospective study was conducted by Tarazona et al [26] on 145 patients. The anxiety levels of patients scheduled for unilateral lower third molar extraction were measured using the STAI-S, STAI-T, and DAS. These measurements were compared in terms of sex, and STAI-S and DAS scores were found to be higher in female patients than in male patients. It was reported that there was no statistical difference in STAI-T scores. On the other hand, it was reported that trait anxiety (STAI-T) levels were higher with increasing age (P = 0.034). It is thought that this result may be due to the inadequacy of the measurement scale used (STAI-T). The part of Spielberg’s STAI scale measuring trait anxiety was designed to assess the patient’s persistent anxiety level and may not always be directly related to anxiety specific to a particular situation [14]. Therefore, according to the authors, the results they found on the effect of age are not considered reliable [26]. Hagglin et al [27] conducted a study in Sweden with 1622 female patients who were followed for 28 years. They observed that there was a decrease in dental anxiety as age increased. Participants were examined at the ages of 6, 12, 24, and 28. They reported that higher anxiety levels were reached at the first visit. According to the authors, dental anxiety and other specific phobias caused by the dentist were reported to decrease with age [27]. Egbor and Akpata [28] evaluated the anxiety of patients using the DAS scale in a study conducted between the ages of 18–50 years. They divided the age ranges into 4 groups: <20, 21–30, 31–40, and 41–50. They found the highest DAS scores in patients aged <20, while the lowest scores were found in patients aged 41–50. The authors also found that the total DAS score was higher in female patients than in male patients. The age groups were classified based on commonly used epidemiological divisions in previous studies by Plonski [29], to allow comparability with existing literature.

Dereci et al [17] also evaluated Modified Dental Anxiety Scale (MDAS) and Dental Fear Scale (DFS) scores in patients who underwent tooth extraction, and found these values to be higher in female patients. Research suggests that the differences in anxiety levels between the sexes may be due to the different pain thresholds between men and boys compared with women and girls, or that women and girls express their fears and worries more than men and boys [26]. Studies have shown that dental anxiety decreases with age. It has been suggested that this inverse relationship may be due to the ability of older individuals to better rationalize the situation and thereby decrease general anxiety levels with age [30]. The present study findings are consistent with previous studies showing that older individuals have the lowest levels of anxiety. The highest levels of anxiety were found in adolescents. This may be explained by the difficulty of adapting to the environment and difficulty accepting treatment. Adults, on the other hand, may have been more involved in the treatment process and may have shown marked changes in their anxiety levels.

Jornet et al [8] evaluated STAI, MDAS, and DFS scores in a study of 70 patients in which they evaluated the patients’ anxiety and fear. They conducted the evaluation immediately before extraction (T1), immediately after extraction (T2), and 1 week after extraction (T3). It was reported that STAI-T and MDAS scores at T2 were higher than at T1. They reported that the reason for the high results was that dental anxiety experienced immediately after tooth extraction could be affected by the operation techniques (type of anesthesia, duration of operation or position of the extracted tooth). Yamashita et al [31] also conducted a prospective study to inform the development of interventions to reduce dental phobia and anxiety. Data from 34 female patients (age, 28.23±1.05 years) who had undergone mandibular third molar extraction, were analyzed. Postoperative STAI-S values were found to be significantly lower than preoperative values [8]. In the study, when the values of both sex and age groups were compared at T1 and T2, in line with the literature, the scores at T2 were found to be lower. Only in adolescents were STAI-T scores found to be higher after the extraction. It is thought that emotional fluctuations and the underdevelopment of stress coping mechanisms during adolescence may cause anxiety levels to remain high.

This study has some limitations. First, the sample of the study is limited to patients who applied to a university hospital in a specific geographical region. Therefore, the findings may not be generalizable to societies with different socioeconomic or cultural structures. Second, the STAI-S, STAI-T, and DAS scales used for anxiety assessment provide subjective data. Since anxiety levels are measured based on the participants’ own reports, individual differences and the possibility of response bias should be taken into account. Third, although preoperative and postoperative anxiety levels were assessed in the study, long-term effects were not examined. How anxiety changes over time and its long-term effects on attitudes towards dental treatments were not determined. Finally, the study was limited to patients who underwent tooth extraction only. The effects of more complex surgical procedures or different dental procedures on anxiety were not investigated. Considering these limitations, it is recommended that future studies with larger participant groups and long-term follow-ups, including individuals from different regions, be conducted.

Conclusions

This study confirms that tooth extraction is a procedure associated with elevated anxiety levels, particularly among female and adolescent patients. Anxiety was observed to decrease with age, suggesting that younger individuals may require additional psychological support during dental procedures. While state anxiety (STAI-S) and dental-specific anxiety (DAS) scores varied significantly across age and sex, no significant differences were found in trait anxiety (STAI-T) scores, indicating that situational factors may play a more dominant role. These findings emphasize the importance of targeted anxiety-reduction strategies in clinical settings, especially for younger populations. Future studies should explore long-term psychological impacts and assess the effectiveness of such interventions.