Gabrielė Gugytė
5 kursas 14 grupėANXIETY BEFORE THIRD MOLAR SURGICAL
EXTRACTION WITH LOCAL ANESTHESIA VERSUS
COMBINED
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Kaunas, 2020
LIETUVOS SVEIKATOS MOKSLŲ UNIVERSITETAS MEDICINOS AKADEMIJA
ODONTOLOGIJOS FAKULTETAS
VEIDO IR ŽANDIKAULIŲ CHIRURGIJOS KLINIKA
ANXIETY BEFORE THIRD MOLAR SURGICAL EXTRACTION WITH LOCAL ANESTHESIA VERSUS COMBINED
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Kaunas, 2019 metai
KLINIKINIO – EKSPERIMENTINIO BAIGIAMOJO MAGISTRINIO DARBO VERTINIMO LENTELĖ
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Recenzento pastabos:
TURINYS
SUMMARY ... 10
INTRODUCTION ... 12
1. LITERATURE REVIEW ... 15
1.1. Dental anxiety, what is it? ... 15
1.2. Etiology and Causes ... 15
1.3. What type of Population is affected? ... 17
1.4. Problems Relating to Patient-Dentist Relationship and Relation to Dental Extraction ... 18
1.5. Dental Anxiety Treatment ... 20
2. MATERIALS AND METHODS ... 22
2.1. Inclusion and Exclusion Criteria ... 22
2.2. Sample Size Determination ... 22
2.3. Statistical Methods Used ... 22
3. RESULTS... 23 4. DISCUSSION ... 28 5. SPECIAL THANKS ... 29 6. CONFLICTS OF INTEREST ... 29 7. CONCLUSION ... 30 8. RECOMMENDATIONS ... 31 REFERENCES ... 32 ADDITIONAL DOCUMENTS ... 36
LITHUANIAN DENTIST‘S KNOWLEDGE ABOUT MYOFASCIAL PAIN SYNDROME IN MASTICATORY MUSCLES DIAGNOSIS AND TREATMENT
SUMMARY
Relevance of the problem: Dental anxiety before third molar extraction is the highest compared to
all other dental procedures. It is especially important for the doctor to know if anesthesia method correlates with dental anxiety levels before surgical molar extraction, so the doctor can choose the treatment plan accordingly. Dental anxiety may affect the pain during the pain level for the patient during the procedure and affect the doctor’s confidence as well, resulting in a less than enjoyable experience for both doctor and patient, and may affect healing after surgery as well.
Purpose of the study: To evaluate level of anxiety the level of anxiety before the surgery in patients
undergoing third molar surgical extraction.
Material and methods: Permission to conduct a study was obtained from the Bioethics Center of
Lithuanian University of Health Sciences (No. BEC-OF-60). 50 respondents participated in the survey. 25 respondants were undergoing third molar extraction with local anesthesia and the other 25 respondants were undergoing extraction with combined anesthesia. STAI-S scale was used to evaluate state anxiety of each patient before surgery of third molars. For statistics evaluation, the degree of freedom df, Mann- Whitney, Independent T-test, Npar, Kronbach's alpha (Cronbach's α) tests were used. A statistically significant dependency is when the significance level p <0.05.
Results: Patients undergoing third molar extraction with local or combined anesthesia have
statistically similar levels of anxiety before the procedure in Kauno Klinikos Oral and Maxillofacial Department. Age of the patient did not correlate statistically with the level of anxiety before the procedure (p>0.5) Gender had a positive statistical correlation with level of anxiety (p<0.5). Women that participated in the study had more anxiety than men. Men had no differneces in anxiety when comparing each anesthesia group and the same results were calculated for women. (p>0.5). There was statistically significant differences in level of anxiety in the combined anesthesia group between men and women. Women had much higher anxiety before third molar surgical extraction in the combined anesthesia setting (p<0.5)
Conclusions: Patients undergoing surgical third molar extraction in Kauno Klinikos in the Oral and
Maxillofacial surgery department with local anesthesia versus combined have the same amount of anxiety levels before their procedures. Both groups of patients contain high anxiety levels. Age was
not a significant factor when it came to anxiety levels with patients in both groups of anesthesia used. Anxiety levels and age do not correlate. No corrrelation was found with younger age and higher anxiety, nor older age and lower anxiety. All ages contained similar anxiety levels in both anesthesia groups. Gender was found to be statistically significant, in which women undergoing third molar surgical extraction with either anesthesia method, had higher levels of anxiety. There was no difference in anxiety levels between men in both anesthesia groups. There was no difference in anxiety level for women in both anesthesia groups. In the local anesthesia group, men and women had similar anxiety levels. In the combined anesthesia group, women had higher levels of anxiety before the procedure than men.
INTRODUCTION
Anxiety affects cognitive, affective, physiological, and behavioral response system and is related to upcoming future events that the individual sees as a threat. Anxiety becomes pathological when there is a surplus of perceived threat. This may lead the individual to act out with an inappropriate response and view the future situation as a danger [1]. Anxiety not only affects present behavior and emotions, but can also cause future problems, such as slower health recovery and memory impairment [2]. Dental anxiety is a state of fear of the unknown that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control. There are many etiologies of dental anxiety and some of them are thought to be genetic vulnerability, anxiety vulnerability, Cognitive conditioning, Cognitive content, among others [3]. In severe cases, dental anxiety may prevent the patient from receiving dental care [4]. Dental anxiety is an overall indicator for anxiety and pain, across different types of dental procedures or treatment stages. It has a significant impact on pretreatment and during-treatment [5]. In addition, it is shown that anxiety is related to the perception and tolerance of pain. Therefore, it may provoke an unpleasant situation for the patient, and not only, but also stand in the way of the performance of the surgeon. For dentists, it is considered a success when patients are comfortable with the absence of pain during the procedure [6].
In several studies, it showed that females, younger patients, and patients already with anxiety traits report higher anxiety before third molar extraction than do others. Patients with knowledge of receiving sedation reported higher levels of anxiety before third molar extraction procedures [7]. Oral and maxillofacial surgery department patients undergoing procedures have the highest amount of anxiety compared to other departments. Extraction seems to be the procedure causing the most dental related anxiety [8]. Third molar extraction is a procedure that is common all around the world. There are many reasons as to why a patient is required to undergo surgery for third molar extraction. The reported reasons for third molar removal include the risk of impaction associated with caries, pericoronitis, periodontal defects in the distal surface of second molars, odontogenic cysts and dental crowding [9]. Third molar surgical extractions may involve teeth of varying difficulty. Patients may undergo the surgical procedure via local anesthesia or together with sedation. Furthermore, dentists must inform the patient that surgical complications after third molar removal are possible and may come in the days after surgery. About 10% of individuals who undergo third molar extraction need emergency post-surgical care [10,11]. The reasons can range from severe pain to alveolar osteitis. Hearing the complications alone may cause anxiety for the future procedure.
Therefore it is very important to evaluate patients anxiety before procedures to minimize postsurgical complications. Dental anxiety can be evaluated by self-rating scales, questionnares or psychological evaluation done by psychiatrist.
State Anxiety Inventory is a self-report questionnaire is one the most commonly used and reliable scales to measure dental anxiety. STAI-S which is commonly utilized in research to assess state anxiety. It consists of 20 questions asking about the individual’s state anxiety (4). Scores ranging from 20-35 indicate low anxiety levels, scores ranging from 36-44 indicates moderate anxiety, and scores 45-80 indicate high anxiety.
Aim of Research. To find out how the anxiety levels differ in subjects before third molar surgical
extraction with combined anesthesia versus local anesthesia.
Objectives:
1. To use created and acquired STAI-S to obtain information about anxiety levels in patients before undergoing third molar surgical extraction with combined versus local anesthesia. 2. To distribute and collect the data about anxiety levels in patients undergoing third molar surgical extraction with combined anesthesia versus local.
3. To evaluate the data and compare the data received from the questionnaires.
Hypothesis:
Patients undergoing surgical third molar extraction in the combined anesthesia setting will have less anxiety before the procedure than patients undergoing third molar extraction in local anesthesia setting.
Abbreviations:
STAI-S - State Anxiety Inventory is a self-report questionnaire Pic – picture
1. LITERATURE REVIEW
1.1. Dental anxiety, what is it?
Dental phobia is a persistent and excessive fear of dental stimuli and procedures that results in avoidance or significant distress. Dental phobia results in the upbringing of dental anxiety. In fact, looking at various adult studies, evidence suggests that most adults with dental anxiety developed their fear in childhood or adolescence [12,13]. With this in mind, it was estimated that about 15% of the adult population suffers from significant dental anxiety [13].
Key physical characteristics associated with dental fear and anxiety is increased heart rate and sweating. In one specific study [14], it was stated that increased heart rate was not due to increased sympathetic activity, but due to a decrease in parasympathetic vagal tone. Indeed, additional studies [15, 16,17] have found an increased interference to process relevant information (i.e.,difficulties in naming the color in which threat-related words were presented).
It is well-known that the dental condition of patients with dental anxiety is generally worse than the condition of those without dental anxiety [18]. With that being said, dental anxiety is a big reason as to why patients may avoid treatment all together [4]. It is important for the dental community of doctors and professionals to determine dental anxiety and find a solution to help patients overcome their fears and anxiety over various dental treatments.
1.2. Etiology and Causes
Many factors contribute to dental anxiety. Dental anxiety does not develop instantaneously, it is a conditioned response, a learned behavior, in which people may suffer through out many dental treatments throughout their lifetime. One study conducted concluded that that 47% of their adults with high dental anxiety reported direct conditioning experiences that lead to their anxiety and another 26% reported a mixture of both direct and indirect learning experiences [19]. Dental anxiety may become surfaced in many ways and may be existent through many dental procedures.
Another study found that 93% of adults with either current dental anxiety or a history of dental anxiety reported at least one painful dental experience in their lifetime; patients with no dental anxiety reported a lower percentage. To add on, individuals that had a highly painful dental experience had high dental anxiety, respectively [20]. Patients who did not experience a painful or traumatic dental event, reported barely any dental anxiety [13,15].
Furthermore, individuals who have had fewer pleasing dental treatments or events before their climactic triggering event, had a bigger risk of developing dental anxiety [15,20]. In all, it is clear that anxiety develops from earlier on in an individual’s life, but these studies show that dental anxiety uncovers when a patient is faced with fewer positive experiences. The patients that experience a bigger amount of pleasing dental treatments, than those that do not, may express no or less dental
anxiety, when faced with an unpleasing experience. In such cases, it is determined earlier on in one’s lifetime if dental anxiety will develop, especially at an early age.
In general, individuals who contain no dental anxiety or minor dental anxiety are less fearful to pain, including minor pain. Individuals who have dental anxiety have a fearfulness for pain. Along with that, those with dental anxiety also have a lower pain threshold, than those who do not have dental anxiety [20,21]. Such individuals with low pain thresholds and higher fearfulness to pain may be more physically attentive to the procedures sensation, thus resulting in higher pain occurrences [22]. This will be explained more in detail in the following sections. Thus, while it is true that experiences may condition the individual, as well as change the way they perceive the situation, the way the individual views future experiences may be independent of anxiety driven situations. Responses elated to pain are difficult to interpret and the source of pain threshold may not always be clear. Pain is not only a physiological matter, but very much so a psycho-emotional phenomenon as well; individuals who are more sensitive to pain and have a low threshold, become the victims of perceiving it in future experiences. Not only is this important for that patient to know, but it is important for the doctor to keep in mind.
Continuing forward, not only does having dental anxiety affect pain, it also can relate to a person’s expression of disgust. In one particular study, it stated that, individuals who were shown photos relating to dental procedures and that also had dental anxiety were most stricken by disgust than individuals who did not have dental anxiety. However oral disgust is what created such a response by the individuals being tested in this study [23]. This study also confirms, that heart deceleration occurs when there is a presentation of feeling of disgust, when vice versa, heart acceleration occurs when exposed to stimuli that produces a feeling of fear in dental anxiety individuals.
To add on, dental anxiety is a complex topic when considering the etiology and causes of the phenomenon. Finding the one true cause may be a difficult task. A big factor that may also influence dental anxiety is family. Studies have shown that there is a strong connection with family members and the occurrence of dental anxiety in youth [ pic. 1]. When members of the family show negative feeling towards dental related topics, the studies conclude that that this greatly affects the young individual by surfacing a fearful attitude towards dental stimuli [24]. These presented studies found evidence for a significant correlation between parent dental anxiety and child dental anxiety. This correlation to dental anxiety may be significant, but yet, it remains weak.
Pic 1.: Reproduced from Seligman LD, Hovey JD, Chacon K, Ollendick TH. Dental anxiety: An
understudied problem in youth. Clinical Psychology Review. 2017 Jul 1;55:25–40.
1.3. What type of Population is affected?
Dental anxiety may affect all types of people, but studies that shown may refrain to certain type of groups of individuals that are more likely to experience dental anxiety. It is observed that females are more influenced by dental anxiety and more likely to experience it [25]. It also mentions that age is not a factor, nor is the educational level of the patient. And as mentioned before, this study also confirms that dental anxiety is more likely to be experienced if an individual had a traumatic procedure in the past. Although the above mentioned study presents education as a non-significant factor for dental anxiety, a systematic review and meta-analysis disputes this factor and shows that the higher the education of a patient, the more likely the individual will experience dental anxiety during certain dental procedures [7]. The study also mentioned that marital status had a significant influence on dental anxiety. Single individuals were believed to be more vulnerable to dental anxiety than individuals who were divorced. To add on, social class status was an important factor as well. The higher the social class meant the higher the dental anxiety, creating a direct relationship between the two.
Furthermore, the way patients receive the information before certain dental procedures also impacted the level of anxiety. Patients who receive information about the future dental procedure in written or verbal form show no difference in anxiety levels. The patients who receive information about their procedure in audio-visual form, automatically have higher dental anxiety [26,27,28]. Not
only does the way information is received matters, but the type of procedure does as well. It is well observed that patients who are to be receiving dental treatment in the oral-maxillofacial department, have the highest dental anxiety when compared to other forms of dental care, such as root canal therapy or caries [8].
Anesthesia is a procedure used in many dental offices. Studies show that different types of anesthesia methods can affect an individual’s dental anxiety. Patients who receive infiltration anesthesia show less anxiety. On the other hand, patients who have to receive block anesthesia have a much larger amount in dental anxiety compared to infiltrative anesthesia [29]. Some dental procedures also require sedative methods to complete tasks in the dental office. In one study it showed that intravenous sedation had a big impact on dental anxiety. Those who were receiving intravenous sedation were more likely to experience anxiety [30].
In other populations tested, it was observed that individuals with higher caries levels and individuals who irregularly attended their healthcare dental professional, showed to contain higher dental anxiety [31]. Although higher caries levels and irregular visits could be the result of dental anxiety, it is an important factor that should not be ignored. Also, patients who have a diagnosis of generalized anxiety disorder and/or major depressive disorder are more likely to experience anxiety in the dental office. Not only that, but these individuals may avoid regular visitation to dental offices and dental healthcare professionals as well [32]. One study also showed that there is no difference in where the patient is geographically located. Individuals who live either live in industrialized cities or country side areas, both showed no statistically significant difference when it came to anxiety levels [33].
1.4. Problems Relating to Patient-Dentist Relationship and Relation to Dental Extraction
As already mentioned above, dental anxiety may have a critical impact on the individuals oral health and visitation to the oral healthcare professional [31,32]. In other cases, individuals may fail to appear or avoid the overall scheduling of certain types of appointments, for example, root canal therapy or surgery. Patients may ignore the necessity of the procedure and the symptoms being felt from the oral problem they are experiencing due to the fear engulfing them and resulting in avoidance of the appointment [34]. This results in patients making unreasonable decisions relating to appointments and dental procedures, even if the oral healthcare professional recommends otherwise. Financial issues may come into the picture when dentists charge fees for being late or missing appointments due to the patient being too anxious to show up. Not only does this increase the cost for the patient, but it also may increase the amplitude of the problem, by worsening the already poor oral health condition. This may not only negatively impact the patient, but increase the complexity of the procedure for the dentist.
Pic. 2: Reproduced from Armfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear:
exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health. 2007;7:
Pain is also a phenomenon that may be highly affected when it comes to anxiety. When individuals are struck with dental anxiety during dental procedures, the level of pain
perception for the patient may increase [6]. Also, the way the patient perceives information may be disrupted, in essence, meaning that the patient may not receive the information and fully digest it, as the person without dental anxiety might [15,16,17]. It is key to remember when dealing with
anxious patients, that these differences can cause different outcomes and it is key to avoid any disruptions while performing dental and oral care. [ Pic.2]
As already mentioned above, dental extraction is one of the most anxiety related procedures in the dental office [6]. Patients have more anxiety during this procedure than root canal treatment or caries treatment. Although many factors predispose the patient to have anxiety during these procedures [7,25,26,27,28,29,30,31], it is not to be ignored that extraction wins first place. It is reported that patients who are undergoing extraction for a mandibular tooth contain more dental anxiety than patients who are undergoing extraction for a maxillary tooth. Another fact not to be ignored, is that patient who undergoes removal of two teeth in one appointment other than one, have more anxiety as well [29]. Patients that undergo tooth extraction with infiltrative anesthesia versus block or sedative methods, have lower anxiety levels [30].
1.5. Dental Anxiety Treatment
When it comes to treatment of dental anxiety, there are various options. These treatments may include pharmacological methods, non-pharmacological methods or both, in one specialized treatment plan for the patient. It is important to identify the problem and apply an appropriate evidence based treatment for the individual undergoing dental care. Such patients should be identified through assessment of blood pressure and pulse rate, as well as patient interviews [35]. Anxiety scales may be used. Sometimes, the patient may self-report on his/hers dental anxiety, in which further planning should go on from that moment. The patient’s dental anxiety may even start at the first encounter at the receptionist, so it is essential to keep in mind various triggers.
1.5.1 Dental Anxiety Non-Pharmacological Treatment
When considering how environment affects a patient with dental anxiety, certain changes can be made to the dental office to provide more comfort and care. One study claims that patients were more comfortable in a dental office when it was decorated with posters and pictures and available books and magazines to read. Also, temperature of the room was important, as the patients preferred a cooler setting. Soft lighting and soft calm music increased the comfort of the waiting room itself [36]. The waiting time was an important factor, in which shorter waiting time correlated with less anxiety [37].
Contuining to patient-doctor interaction, it is essential for the doctor to remain peaceful and calm. It is important not to seem judgmental, to properly introduce themselves and to be a good listener when the patient is talking [38]. Being friendly and sensitive seems to decrease the anxiety levels [39]. Taking time to understand the patient and avoiding rapid movements is key when making the patient feel calm. When in the midst of performing a dental procedure, letting the patient have a break during a serious treatment may be useful to let the patient have time to calm down before continuing to more complicated steps of treatment [40]. While the procedure is being performed, having background music playing or a television set on, may distract the patient from the procedure itself. This results in the patient being less anxious by being distracted [41].
When approaching and while treating the patient, it is important to remember the importance of positive reinforcement. Positive reinforcement may bring a calming and soothing effect. Reminding the patient by complimenting him/her may bring a sense of calm to the treatment [42].
Of course, the most important and easily done anxiety relieving procedure is diaphragmatic breathing. This not only reduces tension in the chest, but also provides more oxygen for the body [43]. There are different groups of muscles working during inhaling and exhaling, and the patient should be told to use them, accordingly. In relation to controlled diaphragmatic breathing, cognitive control is just of equal importance. It is essential to focus the patient on positive thoughts and push any negative cognitions aside. There are various techniques, as mentioned above, such as through guided imagery and positive encouragement, this can be easily achieved [44].
1.5.2 Pharmacological Treatment of Dental Anxiety
There are various pharmacological treatments in dentistry when it comes to anxiety control. Conscious sedation is one that is chosen frequently. The routes of oral sedation are inhalational, intravenous (IV), oral, sublingual, intranasal, intramuscular, or rectal. It is essential to collect all the patient’s medical history and dental history before considering conscious sedation. The state of health they are in and the types of medications being used by the patient are just a few of the details the doctor needs to know before administration. Sedation only should be used when there is a true indication that there is dental anxiety present [45].
A common inhaled sedative used is nitrous oxide (N2O). Nitrous oxide not only does it sedate the patient, but also gives a large anxiolytic effect. This stimulates muscle relaxation and analgesia both directly and indirectly. Nitrous oxide contains a quick onset and rapid recovery with minimal irritation to the lung tissue. It is costly luxury to have for patients with anxiety, but with the right tools and knowledge, it is easily possible to achieve a positive effect.
Oral sedation is also another technique used in pharmacological treatment of mild-moderate dental anxiety. It may be mixed with other methods of dental anxiety treatment for the severely anxious patients. The drug of choice is enteral and absorbed in the gastro-intestinal tract. The class drug of chose is commonly benzodiazepines. These drugs have various effects not only on the anxiety of the patient, but also respiratory, gastrointestinal, and many others. In these cases the doctor needs to be well read on dosage and indications when prescribing patients such medications.
Lastly, intra-vascular sedation may also be used when being faced with a patient who has dental anxiety. The use IV medications has many advantages, like having big control over duration of the sedation and fast onset. IV sedation has higher efficacy than oral or inhalation methods. It is important for the doctor to remember that this form of sedation requires high skill and knowledge. Open access for reversal agents is necessary in the case of complications. Common drugs used for IV sedations are benzodiazepines and opioids [35].
1.5.3 Anxiety evaluation
Denatal anxiety can be evaluated by several methods. In difficult cases usually it is done by psychiatrics or psychologists. More common way to evaluate dental anxiety is by self rating scales or questionnaires. These methods for researcher does not require special education and results can be rated by previously created evaluation scales and rates. [10,12,17]
2. MATERIALS AND METHODS
2.1. Inclusion and Exclusion Criteria
In 2019, the month of November, questionnare was created that contained in total 23 questions and a consent form. In the questionnare itself, contains the purchased STAI-S scale. The copyright is included. (Documemt Nr.1). The bioethics center confirmed and gave permission to continue the study (Nr. BEC-OF-60) (Document Nr.2). The duration of the study was from 2019 December to 2020 Febuarary. There was randomely selected a total of 50 participants: 25 partipants were undergoing third molar surgical extraction with local anesthesia only and the other 25 participants were undergoing third molar extraction with combined anesthesia. The inclusion criteria included ASA I class patients with no diagnosed psychological disorders ranging from ages 18-45. Exclusion criteria included ASA II-VI paients and patients who had a diagnosed psychological disorder. The questionnares were anonymous and were given out to patients after the procedure was described to them by the operating doctor. The patients were divided into two groups; patients undergoing extraction with local anesthesia and the other group patients undergoing extraction with combined anesthesia.
2.2. Sample Size Determination
According to statistical methods for the data to be statisticaly proven 50 randomly selected patients is enough undergoing third molar surgical extraction procedures.
2.3. Statistical Methods Used
Using the IBM SPSS Statistics 23.0 program, the statistical data analysis and statistical significance was calculated. df, Mann-Whitney, Independent T-test, Npar, Cochrane alfa (Cronbach‘s α) tests were used. A statistically significant dependency is when the significance level p <0.05.
The calculated information was represented in tables and diagrams using SPSS 23.0 and Excel 2016 programs.
3. RESULTS
During the trial, a total of 50 quetionnares were given out. 50 out of the 50 questionnares were answered fully. 25 were answered from individuals undergoing surgical extraction with local anesthesia only and the 25 others were answered by patients undergoing third molar extraction with combined anesthesia.
Table Nr. 1. Shows the distribution of patients during questionnare.
The second question was aimed at age. The age group included in this study was from 18-45 years.
Table Nr. 2. Shows the distribution of age of questionnares.
Youngest patients was 18 year old, the oldest 45. Age mean 25.8 – allowing to state that more young patients had third molar extraction, making probability that their social and emotional status is positive. Table Nr 3, Statistics amzius 50 0 25,80 ,932 24,00 24 6,593 27 18 45 21,00 24,00 30,00 Valid Miss ing N Mean Std. Error of Mean Median Mode Std. Deviation Range Minimum Maximum 25 50 75 Percentiles Local anethesia Combined Anesthesia Total
Table Nr 3. Shows percentage (%) of different age groups that participated in the study.
Third question was related to the gender of the participants included. There was 32% of men in the study and 68% of women.
Table Nr. 4. Gender of the participants and the percentage (%).
It was very importat to evaluate the STAIS-S questionnare eligibility with a conctent of 20 selected questions. As the Cronabach‘s alpha test show test is realiable with value 0.946. The STAI-S scale has a total of 20 questions with answers ranging rom 1-4. The lowest score possible to achieve is 20 meaning low anxiety and 80 meaning high anxiety.
amzius 4 8,0 8,0 8,0 1 2,0 2,0 10,0 5 10,0 10,0 20,0 3 6,0 6,0 26,0 5 10,0 10,0 36,0 5 10,0 10,0 46,0 7 14,0 14,0 60,0 2 4,0 4,0 64,0 3 6,0 6,0 70,0 1 2,0 2,0 72,0 1 2,0 2,0 74,0 2 4,0 4,0 78,0 3 6,0 6,0 84,0 1 2,0 2,0 86,0 1 2,0 2,0 88,0 1 2,0 2,0 90,0 2 4,0 4,0 94,0 1 2,0 2,0 96,0 1 2,0 2,0 98,0 1 2,0 2,0 100,0 50 100,0 100,0 18 19 20 21 22 23 24 25 26 27 29 30 31 34 35 36 37 40 42 45 Total Valid
Frequency Percent Valid Percent
Cumulative Percent Lytis 16 32,0 32,0 32,0 34 68,0 68,0 100,0 50 100,0 100,0 1 vyrai 2 moterys Total Valid
Frequency Percent Valid Percent
Cumulative Percent
Table Nr. 5. Shows general statistical values, regarding how many individuals received a certain
score for the questionnares. The mean STAI-S anxiety score was 45.06. While the minimum was 20 and maximum 71. The mode in this study was 60.
The statistical analysis showed no correlation between anxiety levels before extraction procedure and the type of anesthesia used. Using Independent Samples t-test, the p-value was calculated (p>0.5). Therefore thid might have happend due to young patients age.
We tried to calculate the statistical significance between different type of anesthesia used. There was no stastical significance correlating age and the level of anxiety before third molar extraction in both types of anesthesias used (p>0.5). as shown in table nr. 6
The next stastical analysis was aimed at gender and levels of anxiety. It was calculated that there is a statistically significant correlation between gender and levels of anxiety. Women in this
Statistics 50 50 0 0 45,06 2,2530 1,956 ,09781 45,50 2,2750 60 3,00 13,832 ,69160 51 2,55 20 1,00 71 3,55 35,00 1,7500 45,50 2,2750 57,25 2,8625 Valid Miss ing N Mean Std. Error of Mean Median Mode Std. Deviation Range Minimum Maximum 25 50 75 Percentiles Suma Klausimyno balø suma SumoVid Klausimyno balø sumo vidurkis
Independent Samples Test
,103 ,750 -,640 48 ,525 -2,520 3,936 -10,434 5,394 -,640 47,965 ,525 -2,520 3,936 -10,434 5,394 ,103 ,750 -,640 48 ,525 -,12600 ,19680 -,52170 ,26970 -,640 47,965 ,525 -,12600 ,19680 -,52170 ,26970 Equal variances assumed Equal variances not assumed Equal variances assumed Equal variances not assumed Suma Klausimyno balø suma SumoVid Klausimyno balø sumo vidurkis
F Sig.
Levene's Test for Equality of Variances
t df Sig. (2-tailed)
Mean Difference
Std. Error
Difference Lower Upper
95% Confidence Interval of the
Difference t-test for Equality of Means
study had more anxiety than men (p<0.5). As shown in table nr.7 Shows the calculation of the p-value for gender correlation with denal anxiety.
The next test done was to compare if anxiety levels differed between men that were operated with local anesthesia versus combined anesthesia. Using the Mann-Whitney test, the results showed no significant statistical difference in anxiety levels table nr. 8
Next, using the Mann-Whitney test, statistical significance was calculated to compare the difference in anxiety in women in both anesthesia groups, because men did not show any difference and as shown in table nr. 9 there was no statistically significant difference in anxiety levels
between women before being operated with local or combined anesthesia.
Independent Samples Test
,014 ,908 -2,488 48 ,016 -9,923 3,987 -17,940 -1,905 -2,502 29,867 ,018 -9,923 3,966 -18,025 -1,821 ,014 ,908 -2,488 48 ,016 -,49614 ,19937 -,89701 -,09527 -2,502 29,867 ,018 -,49614 ,19831 -,90123 -,09105 Equal variances assumed Equal variances not assumed Equal variances assumed Equal variances not assumed Suma Klausimyno balø suma SumoVid Klausimyno balø sumo vidurkis
F Sig.
Levene's Test for Equality of Variances
t df Sig. (2-tailed)
Mean Difference
Std. Error
Difference Lower Upper
95% Confidence Interval of the
Difference t-test for Equality of Means
Te st Statisticsb,c 29,500 29,500 74,500 74,500 -,212 -,212 ,832 ,832 ,837a ,837a Mann-Whitney U Wilcoxon W Z
Asymp. Sig. (2-tailed) Exact Sig. [2 *(1-ta iled Sig.)] Su ma Klausimyno balø suma Su moVid Klausimyno balø sumo vidurkis
Not corrected for ties. a.
Grouping Va riable : VirsujeApacioje Virsuje/Apacioje b. Lytis = 1 vyrai c. Test Statisticsb,c 101,000 101,000 272,000 272,000 -1,485 -1,485 ,138 ,138 ,144a ,144a Mann-Whitney U Wilcoxon W Z
Asymp. Sig. (2-tailed) Exact Sig. [2*(1-tailed Sig.)] Suma Klausimyno balø suma SumoVid Klausimyno balø sumo vidurkis
Not corrected for ties. a.
Grouping Variable: VirsujeApacioje Virsuje/Apacioje b.
Lytis = 2 moterys c.
Using Mann-Whitney, the calculation was made for significance in anxiety levels between men and women in the local anesthesia group (p>0.5).. And using the same test, the calculation was made for significance in anxiety levels between men and women in the combined anesthesia group. Women had higher anxiety than men before third molar surgical extraction in the combined
anesthesia group as shown in table nr. 10
Shows statistically significant difference in anxiety levels before operation between men and women in the combined anesthesia group (p<0.5).
When we evaluated 95% PI value for statistically significant difference in anxiety levels between men and women in the combined anesthesia group. Women have higher levels of anxiety than men before the procedure.
Test Statisticsb,c 26,500 26,500 71,500 71,500 -2,578 -2,578 ,010 ,010 ,008a ,008a Mann-Whitney U Wilcoxon W Z
Asymp. Sig. (2-tailed) Exact Sig. [2*(1-tailed Sig.)] Suma Klausimyno balø suma SumoVid Klausimyno balø sumo vidurkis
Not corrected for ties. a.
Grouping Variable: Lytis b.
VirsujeApacioje Virsuje/Apacioje = 2 virðus c.
4. DISCUSSION
The study results show that out of the two sample size tests, with 25 patients in the local anesthesia group (50%) and 25 patients in the combined anesthesia group (50%), have no statistically significant difference in amount of anxiety levels. The mean score from the STAI-S questionnare from both groups showed that anxiety before the surgical extaction of both groups had a mean score of 45.06 (high anxiety levels have a 45-80 score from STAI-S).
This shows that patients undergoing extraction in Kauno Klinikos Oral and Maxilllofacial department have high anxiety levels, no matter the type of anesthesia used. A systematic review from 2018 authored by A. Astromaskaitė and other authors showed the data that concluded patients who are undergoing surgical extraction with anesthesia are more likely to experience higher anxiety levels [7].
To add on, the results show that gender was statisitically significant when comparing anxiety levels before the extraction procedure. Women had much higher anxiety levels than men in both anesthesia groups.
The study results also show that age did not have an important effect on anxiety levels before third molar surgical extraction. This could be due to the bigger population of younger participants in the sample - with more than (50%) of participants were under 24 and under and less than half (50%) were over the age of 24. More studies need to be done with a more diverse age to get a better idea of anxiety level differences.
In regard to men and anxiety levels in both anesthesia groups, there was no significant difference in anxiety. Regarding women in both anesthesia groups, there was no stastical significance found either. Both groups should be approached the same way when considering anxiety levels before extraction. This study contained higher amount of women than men. Women composed 68% of the participants of this study, while men composed only 32% of this study. Moreover, this could be an important factor to think about for next studies, to create a more equal gender amount population.
In conclusion, the results also showed that there was no statistically significant difference in anxiety levels in the local anesthesia group between men and women. In the combined anesthesia group, men and women had a statistically significant difference in anxiety levels. Women contained higher levels when compared to men. This is an important factor to keep in mind when approaching the female population for combined anethesia setting third molar surgical extractions.
5. SPECIAL THANKS
I would like to thank my supervisor during this research, asist. Jan Pavel Rokicki for the help and for giving so much of his time for this study to help me.
6. CONFLICTS OF INTEREST
7. CONCLUSION
1. Patients undergoing surgical third molar extraction in Kauno Klinikos in the Oral and Maxillofacial surgery department with local anesthesia versus combined have the same amount of anxiety levels before their procedures. Both groups of patients contain high anxiety levels.
2. Age was not a significant factor when it came to anxiety levels with patients in both groups of anesthesia used. Anxiety levels and age do not correlate. No corrrelation was found with younger age and higher anxiety, nor older age and lower anxiety. All ages contained similar anxiety levels in both anesthesia groups.
3. Gender was found to be statistically significant, in which women undergoing third molar surgical extraction with either anesthesia method, had higher levels of anxiety. There was no difference in anxiety levels between men in both anesthesia groups. There was no difference in anxiety level for women in both anesthesia groups. In the local anesthesia group, men and women had similar anxiety levels. In the combined anesthesia group, women had higher levels of anxiety before the procedure than men.
8. RECOMMENDATIONS
It is recommended for doctos to provide more attention to the problem of dental anxiety before third molar surgical procedures in Kauno Klinikos Maxillofacial Department. May it be with non-pharmocological treatment or pharmacological, it is important to assess and treat the patient‘s anxiety before continuing with the procedure.
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ADDITIONAL DOCUMENTS
Document Nr. 1
TIRIAMOJO ASMENS INFORMAVIMO FORMA
Lietuvos Sveikatos Mokslų Universiteto Veido ir Žandikaulių Chirurgijos fakulteto studentas magistrinio darbo rengimo metų atliks tyrimą, skirtą palyginti nerimos kiekį su pacientais kurie operuosis protinius dantis chirurgiškai su lokalią nejautrą priešiais kombinuotą nejautrą. Tyrimo dalyviai bus 18-45 metų žmones, kurie neturi rimtų bendrinių ligų. Tyrimas bus anonimiškas, jusu duomenys bus saugūs. Jeigu turite klausimų, prašau kontaktuokite- Gabriele Gugyte- 862340626, LSMU KAUNO KLINIKOS ORAL AND MAXILLOFACIAL DEPARTMENT.
The supervisor of research:
Lytis: Vyras ____ Moteris ____ Amžius: _____
Jei sergate bendriniomis ligomis, prašau išvardinkite:
________________________________________________________________________________ ________________________________________________________________________________ ______________
