Medical and Dental Consultantsí Association of Nigeria
Home - About us - Editorial board - Search - Ahead of print - Current issue - Archives - Submit article - Instructions - Subscribe - Advertise - Contacts - Login 
  Users Online: 650   Home Print this page Email this page Small font sizeDefault font sizeIncrease font size

  Table of Contents 
Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 409-414

Factors affecting anxiety-fear of surgical procedures in dentistry

1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Yuzuncu Yil University, Kampus, Van 65080, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Selçuk University, Alaaddin Keykubat Kampus, Konya 42250, Turkey

Date of Acceptance20-Nov-2015
Date of Web Publication13-Apr-2017

Correspondence Address:
Dr. C N Eroglu
Yuzuncu Yil University, Faculty of Dentistry, Kampus, 65080, Van
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.181371

Rights and Permissions

Aim: To compare dental anxiety and fear during procedures performed under local anesthesia either in the operating room or in the clinic as well as to investigate the potential factors that might influence this psychological condition. Subjects and Methods: Patients who were admitted to the Department of Oral and Maxillofacial Surgery of the universities in two cities, which have a different sociocultural patient profile, were enrolled. In addition to the State-Trait Anxiety Inventory (STAI), Dental Anxiety Scale (DAS), and Dental Fear Scale (DFS), the patients were asked to answer the questions concerning previous dental experience, education level, and previous psychiatric therapy. Statistical Analysis Used: The results of STAI were analyzed by Mann–Whitney U-test and results of DAS and DFS were analyzed by one-way analysis of variance test. Results: Two hundred patients, of whom 76 were enrolled in the first center and 124 were enrolled in the second center. A statistically significant difference was observed in state anxiety levels of the patients between the two centers, whereas the difference in trait anxiety levels was not significant. The results of DAS, DFS, and STAI-trait (STAI-T) displayed a significant difference between genders; the levels of anxiety and fear were higher in females than in males (DAS P = 0.025, DFS P = 0.017, STAI-T P = 0.045). Comparison between the patients with and without previous dental experience revealed a statistically significant difference regarding the results of STAI. Conclusions: The study found that sociocultural structure and gender are the significantly effective factors on dental anxiety and fear.

Keywords: Dental Anxiety Scale, Dental Fear Scale, gender, sociocultural structure, state-trait anxiety

How to cite this article:
Eroglu C N, Ataoğlu H, Küçük K. Factors affecting anxiety-fear of surgical procedures in dentistry. Niger J Clin Pract 2017;20:409-14

How to cite this URL:
Eroglu C N, Ataoğlu H, Küçük K. Factors affecting anxiety-fear of surgical procedures in dentistry. Niger J Clin Pract [serial online] 2017 [cited 2022 Oct 1];20:409-14. Available from:

   Introduction Top

Patient compliance in clinical practice is of great importance for the dentist. However, some patients develop a psychological condition called treatment anxiety, which hinders the compliance of the patient, might be predictive of the occurrence of complications during clinical procedure and response to therapy from likely complications during clinical procedures to the response to therapy.[1]

Treatment in oral and maxillofacial surgery clinics frightens patients more than the clinical interventions performed in the other conservative sciences.[2] Based on the degree of difficulty of procedure, different states of anxiety and fear may develop among patients treated in the oral and maxillofacial surgery clinics. Even the word “operating room” or “surgical procedure” causes emotional stress in the patient. Serious levels of stress and fear that the patient feels before or over the course of the procedure trigger psychosomatic diseases in the patient and cause alterations in blood pressure.[3] In case of preexisting cardiac ischemia, complications can be encountered during or after surgery.[4],[5]

The most powerful stress factors that underlie the development of anxiety and fear are fear of pain, treatment cost, needle and injections, surgeon's failure, and fear of catching a treatment-related infectious disease.[1] In addition, age, gender, socioeconomic status, education level, and personal differences are other personal factors that could alter the degree of anxiety.[6] Some patients are successful in bypassing the development of anxiety although they feel pain.[7],[8] In some previous reports, the level of anxiety decreased and patients could cope with anxiety much more easily as socioeconomic and education levels increased.[9],[10],[11],[12],[13],[14]

Severe anxiety and fear not only lead to misdiagnosis by jeopardizing patient-doctor relationship but also may prevent receiving treatment.[15] Hence, some tests have been developed to provide necessary psychological support before the procedure by determining the anxiety and fear level of the patients. State-Trait Anxiety Inventory (STAI), widely used to measure treatment anxiety, is a questionnaire developed in 1970 by Spielberger et al.; it consists of short sentences and discrimination between event-specific and continuous anxiety is made by the patient.[16] Emotional state of the patients can be rapidly scored via this questionnaire without wasting patient's time. As STAI is a more general questionnaire, Corah's Dental Anxiety Scale (DAS) and Kleinknecht's Dental Fear Scale (DFS) were developed, which are more specific to dentistry in measuring anxiety and fear. [17,18] This study evaluated whether sociocultural differences, history of previous dental procedure, psychiatric therapy, age, and gender differences are associated with the level of treatment anxiety and fear among patients waiting for simple clinical procedures and for surgical procedures.

   Subjects and Methods Top

This study is a two-center study and consisted of patients with different socioeconomic status and education, who were admitted to Selçuk University Faculty of Dentistry, Department of Maxillofacial Surgery (A) in Konya province and to Yüzüncü Yil University Faculty of Dentistry, Department of Maxillofacial Surgery (B) in Van province. The study was approved by the Ethics Committee of the Yüzüncü Yil University Faculty of Medicine, and informed consent of the patients was obtained. The patients were asked to complete STAI, DAS, and DFS as well as to answer the questions concerning previous dental experience, education level, and previous psychiatric therapy. The patients were divided into two groups as clinical group who were waiting for simple clinical procedures (tooth extraction, temporomandibular joint diseases, postoperative dressing and suture removal, surgical examination, abscess drainage, reimplantation, biopsy, and treatment of alveolitis) and surgery group who were waiting for surgical procedures (extraction of impacted tooth, apical resection, enucleation of small cysts and tumors not requiring general anesthesia, and implant procedures).

The STAI tests measure state and STAI-trait (STAI-T) anxiety levels, and each of them consists of 20 questions rated on a four-point scale, with scores between 20 and 80. State anxiety defines psychological stress related to the individual's current state, whereas trait anxiety depends on the personal characteristics and is unrelated to the current state. Scores between 20 and 37 indicate minimum or no anxiety, 38–44 indicates moderate anxiety, and 45–80 indicates high anxiety levels.[6]

DAS that consists four items rated on a five-point Likert scale defines the patient's mood before dental treatment, and total score changes between four and 20, where a score of 13–14 indicates the presence of an anxiety problem and a score of 15 and higher indicates high levels of anxiety.[17],[19]

DFS consists of 20-questions rated on a five-point-scale, and it is used to measure the severity of emotions and reactions against certain conditions in dentistry. Scores between 21 and 60 indicate that the patient is fearful, whereas scores between 61 and 100 indicate that the patient has intense fear.[20]

   Analysis Top

Data including age, gender, interventional methods of treatment, sociocultural effect, and experienced dental procedure, as well as the results of STAI, were analyzed by Mann–Whitney U-test, which is a nonparametric statistical method; whereas results of DAS and DFS were analyzed by one-way analysis of variance (ANOVA) test (SPSS, Inc., Chicago, IL, USA, Version 12.0 for Windows program, P < 0.05).

   Results Top

In this study, 76 (38%) patients from 200 patients were enrolled in center A and the remaining 124 (62%) patients were enrolled in center B. Of these patients, 121 (60.5%) were in the clinical group (Konya n = 72% 36, Van n = 49% 24.5) and 79 (39.5%) were in the surgery group (Konya n = 52% 26, Van n = 27% 13.5) [Table 1]. A statistically significant difference was observed in state anxiety levels of the patients between the two centers, whereas the difference in trait anxiety levels was not significant. The patients in center A had a higher sociocultural level than that of the patients in center B, and anxiety levels of the patients in center A were lower than that of the patients in center B (P < 0.05, one-way ANOVA, Mann–Whitney U-test).
Table 1: Demographic characteristics of the patients enrolled in the study

Click here to view

Results of DAS, DFS, and STAI-T displayed a statistically significant difference between genders; accordingly, levels of anxiety and fear were higher in females in comparison to males (DAS P = 0.025, one-way ANOVA; DFS P = 0.017, one-way ANOVA; and STAI-T P = 0.045, Mann–Whitney U-test) [Table 2]. Comparison between the patients with and without previous dental experience revealed a statistically significant difference regarding the results of STAI (P < 0.05, Mann–Whitney U-test). Level of anxiety was higher among those who had a previous dental procedure when compared to those who did not. No statistically significant relationship was determined between the level of anxiety and history of previous psychological treatment, age, and type of intervention (P > 0.05, Mann–Whitney U-test). There was a significant difference between the clinical and surgery groups in terms of gender; the rate of females was significantly higher in the surgery group (P = 0.027, Mann–Whitney U-test). There was also a significant difference between the clinical and surgery groups regarding previous dental treatment; the rate of the presence of previous dental treatment was significantly higher in the clinical group (P = 0.019, Mann–Whitney U-test) [Table 3].
Table 2: Comparison of variables according to DAS, DFS, STAI-T - STAI-S

Click here to view
Table 3: Comparison of the clinical and surgery groups

Click here to view

There was a significant difference between Konya and Van provinces in terms of previous dental treatment and the presence of a psychological problem. The rate of patients receiving previous dental treatment was significantly higher in Konya province than in Van province (P = 0.001, Mann–Whitney U-test). The rate of patients with the psychological problem was significantly higher in Van province (P = 0.025, Mann–Whitney U-test) [Table 4].
Table 4: Comparison of Konya and Van provinces

Click here to view

   Discussion Top

The hypothesis of this study was that level of anxiety would be different in patients waiting to undergo procedures requiring an operating room in comparison to that of patients waiting to undergo simple clinical procedures; and additionally, sociocultural level, gender, and the presence of a history of psychiatric treatment would influence the level of anxiety. Results of the study indicated that nature of the surgical procedure was not associated with the level of anxiety. Hermes et al. conducted a study in quite a large group of patients from different medical departments undergoing general anesthesia, sedation, and local anesthesia.[21] They concluded that anxiety is a personal issue and is not changed in different surgical fields. Nevertheless, Hermes et al.[21] did not include the patients who would undergo operations for more invasive procedures due to trauma and tumor considering that psychological states of such patients might not be suitable. In this study, we did not make such discrimination, and the questionnaire was utilized in all voluntary patients waiting for surgery. From this aspect, the study objectively reveals that the nature of surgical intervention does not play an important role on the level of anxiety and fear [Table 2]. A difference could have been observed in the level of anxiety and fear if a general anesthesia group had been included in the study groups; because general anesthesia and sedation could substantially improve anxiety considering that some patients want to get through treatment steps unconsciously – although there is no indication.

As compared to an inexperienced individual, anxiety level during the next procedure is expected to be higher in patients with a previous unfavorable experience. If a painless procedure has been performed in a short period of time not causing stress on the patient, and if no serious problem has been encountered in the postoperative period, this may have an improving effect on the level of anxiety for the further procedures. In a study that seems to corroborate this theory, López-Jornet et al., found the level of anxiety significantly low over the course of a 7-day follow-up in the patients who had undergone tooth extraction and had no problems during or after the procedure.[6] Nevertheless, it should be taken into account that a bad treatment experience and specific conditions would not leave a bright impression concerning anxiolytic effect and patient expectations.[21] Moreover, although it seems that it is possible to much more reduce anxiety by informing the patients about the procedure, information may trigger the development of additional stress in the individuals. In literature, there are numerous studies in which different authors have reached different conclusions about the effect of explaining the procedure or previous experiences on the level of anxiety and fear.[3],[22],[23],[24],[25] In this study, it was observed that previous experiences caused an increase in the level of anxiety; thereby, not having information about the procedure or not having had a previous experience can be regarded as an advantage as previous experiences, regardless of being good or bad, trigger the emotional state.

Fear and anxiety in dentistry can be directly associated with poor oral hygiene that results from poor socioeconomic conditions, lack of self-confidence, psychological problems, and low morale.[26] Other factors include age, gender, education level, and personality of the patient. McGrath and Bedi reported a high level of anxiety among people with a low standard of living.[27] Moreover, it was reported that low level of education together with low socioeconomic status results in poor outcomes for anxiety.[28] However, there is no consensus on this subject, and there are authors[29] defending that dental anxiety is higher among well-educated people.

In this study, which was conducted in two different centers in two different cities having significantly different patient profiles in terms of socioeconomic status and level of education, the difference in the level of anxiety and fear was statistically significant. Incomes of the patients who were admitted to these two centers are different [Table 4]. However, it was concluded that rather than the economic conditions, education, and cultural level are more important in the development of treatment anxiety and fear, since social health security provides equal rights for everyone in this country.

In the study, gender was found to be an effective factor on the level of anxiety and fear [Table 3]. In general, it is argued that preoperative anxiety is higher in females and that females display more anxious behaviors as compared to males.[23] From this aspect, the result of this study is consistent with literature.

While the history of previous psychological treatment suggests that patients would be psychologically more sensitive, the result, in fact, was not consistent with our theory. Although there are authors[25],[30] who claim that a previous sad life event that required psychological treatment increases psychological stress during subsequent traumatic event, there was no consistent finding in this study and no relationship was determined between the presence of a history of psychological treatment and the level of dental anxiety and fear. Of the patients that completed the questionnaire, 10% stated that they had received psychological treatment previously. However, although the number of patients who seek psychiatric treatment for any psychological problem appears to be low in the population, the ratio, in fact, increases when the individuals that keep on living without treatment are taken into account. Getting knowledge about the previous psychological trauma by including detailed questions in the questionnaires used in this study would have led to a different result on this subject.

We explored whether there was a difference between anxiety levels of patients in decades of age groups; it was observed that anxiety level shows a decrease from the 10 to 20 year age group to the age group over 50 years. The level of anxiety decreases with increasing age, as the number of medical experiences increases with increasing age. The likelihood of having an experience less or more on the procedure increases with increasing age. From this aspect, the results concerning age and previous experiences are conflicting in this study. Anxiety decreases as the age increases but having an experience on the procedure enhances anxiety. This can be explained by the following points: The probability of having more hospital experience and accordingly coping with more serious problems than dental interventions are higher for older individuals as compared to young individuals. Whatever the nature of dental interventions is they do not create much anxiety or expectation in the elderly patient group. However, dental interventions are so important that they may cause serious trauma in the young patient group. Any previous bad experience enhances anxiety in the early ages.

   Conclusion Top

Results of this study reveal that gender, sociocultural differences, and previous bad experiences of the patients are the major factors that can lead to problems in the future procedures. Therefore, solving the fears at first and considering gender-based differences would be of help for the patient and the dentist in the periods during and after therapy. Although physicians do not have much effect on sociocultural structure, it would be advantageous to inform patients about expectations and likely outcomes before starting treatment in a way that they can understand.


The authors thank to Sadi Elasan from Yüzüncü Yil University Faculty of Medicine Department of Biostatistics, who contributed to the statistical analysis of this study.

Financial support and sponsorship


Conflicts of Interest

There are no conflicts of interest.

   References Top

Delfino J. Public attitudes toward oral surgery: Results of a Gallup poll. J Oral Maxillofac Surg 1997;55:564-7.  Back to cited text no. 1
Desjardins PJ. Patient pain and anxiety: The medical and psychologic challenges facing oral and maxillofacial surgery. J Oral Maxillofac Surg 2000;58:10 Suppl 21-3.  Back to cited text no. 2
Garip H, Abali O, Göker K, Göktürk U, Garip Y. Anxiety and extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 2004;42:551-4.  Back to cited text no. 3
Cawson RA. Essentials of Dental Surgery and Pathology 5th edLondon: Churchill Livingstone; 1991.  Back to cited text no. 4
Manso Platero FJ, Calatayud Sierra J, Carrillo Baracaldo JS, Barbería Leache E, Zaragoza Rubira JR. Anxiety, inflammation and duration of operation: Is there a relationship?. Av Odontoestomatol 1989;5:31-4.  Back to cited text no. 5
López-Jornet P, Camacho-Alonso F, Sanchez-Siles M. Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: A prospective study. Br J Oral Maxillofac Surg 2014;52:18-23.  Back to cited text no. 6
Ng SK, Chau AW, Leung WK. The effect of pre-operative information in relieving anxiety in oral surgery patients. Community Dent Oral Epidemiol 2004;32:227-35.  Back to cited text no. 7
McNeil DW, Helfer AJ, Weaver BD, Graves RW, Kyle BN, Davis AM. Memory of pain and anxiety associated with tooth extraction. J Dent Res 2011;90:220-4.  Back to cited text no. 8
van Wijk A, Lindeboom J. The effect of a separate consultation on anxiety levels before third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:303-7.  Back to cited text no. 9
Eli I, Baht R, Kozlovsky A, Simon H. Effect of gender on acute pain prediction and memory in periodontal surgery. Eur J Oral Sci 2000;108:99-103.  Back to cited text no. 10
Settineri S, Tati F, Fanara G. Gender differences in dental anxiety: Is the chair position important?. J Contemp Dent Pract 2005;6:115-22.  Back to cited text no. 11
de Jongh A, van Wijk AJ, Lindeboom JA, Psychological impact of third molar surgery: A 1-month prospective study. J Oral Maxillofac Surg 2011;69:59-65.  Back to cited text no. 12
de Jongh A, Olff M, van Hoolwerff H, Aartman IH, Broekman B, Lindauer R, et al., Anxiety and post-traumatic stress symptoms following wisdom tooth removal. Behav Res Ther 2008;46:1305-10.  Back to cited text no. 13
Muglali M, Komerik N. Factors related to patients' anxiety before and after oral surgery. J Oral Maxillofac Surg 2008;66:870-7.  Back to cited text no. 14
Milgrom P, Coldwell SE, Getz T, Weinstein P, Ramsay DS. Four dimensions of fear of dental injections. J Am Dent Assoc 1997;128:756-66.  Back to cited text no. 15
Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto (CA): Consulting Psycologists Press; 1970.  Back to cited text no. 16
Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978;97:816-9.  Back to cited text no. 17
Peretz B, Efrat J. Dental anxiety among young adolescent patients in Israel. Int J Paediatr Dent 2000;10:126-32.  Back to cited text no. 18
Öner N, LeCompte A. State-Trait Anxiety Inventory Handbook. Istanbul: Bogazici University Publishing House; 1985.  Back to cited text no. 19
Schuurs AH, Hoogstraten J. Appraisal of dental anxiety and fear questionnaires: A review. Community Dent Oral Epidemiol 1993;21:329-39.  Back to cited text no. 20
Hermes D, Matthes M, Saka B. Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-center trial. J Craniomaxillofac Surg 2007;35:316-21.  Back to cited text no. 21
Earl P. Patients' anxieties with third molar surgery. Br J Oral Maxillofac Surg 1994;32:293-7.  Back to cited text no. 22
Nishimori M, Moerman N, Fukuhara S, van Dam FS, Muller MJ, Hanaoka K, et al., Translation and validation of the Amsterdam preoperative anxiety and information scale (APAIS) for use in Japan. Qual Life Res 2002;11:361-4.  Back to cited text no. 23
Yusa H, Onizawa K, Hori M, Takeda S, Takeda H, Fukushima S, et al. Anxiety measurements in university students undergoing third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:23-7.  Back to cited text no. 24
Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999;49:90-4.  Back to cited text no. 25
Hägglin C, Hakeberg M, Ahlqwist M, Sullivan M, Berggren U. Factors associated with dental anxiety and attendance in middle-aged and elderly women. Community Dent Oral Epidemiol 2000;28:451-60.  Back to cited text no. 26
McGrath C, Bedi R. The association between dental anxiety and oral health-related quality of life in Britain. Community Dent Oral Epidemiol 2004;32:67-72.  Back to cited text no. 27
Locker D, Poulton R, Thomson WM. Psychological disorders and dental anxiety in a young adult population. Community Dent Oral Epidemiol 2001;29:456-63.  Back to cited text no. 28
Ekanayake L, Dharmawardena D. Dental anxiety in patients seeking care at the University Dental Hospital in Sri Lanka. Community Dent Health 2003;20:112-6.  Back to cited text no. 29
Seymour RA, Simpson JM, Charlton JE, Phillips ME. An evaluation of length and end-phrase of visual analogue scales in dental pain. Pain 1985;21:177-85.  Back to cited text no. 30


  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 The Comparison of Dental Anxiety between Patients Treated with Impacted Third Molar Surgery and Conventional Dental Extraction
Omur Dereci,Nesrin Saruhan,Gorkem Tekin,Vincenzo Grassia
BioMed Research International. 2021; 2021: 1
[Pubmed] | [DOI]
Oleg Ya. Mokryk,Davyd S. Avetikov,Ivan S. Sorokivskyi,Solomiya T. Havryltsiv,Nataliia ?. Sorokivska
Wiadomosci Lekarskie. 2021; 74(4): 906
[Pubmed] | [DOI]
3 Factors Responsible for Delayed Presentation at the Dental Clinic of the Federal Medical Centre, Birnin Kebbi, Nigeria
W. Olawole,K. Kanmodi
Medical University. 2019; 2(1): 12
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
   Subjects and Methods
    Article Tables

 Article Access Statistics
    PDF Downloaded560    
    Comments [Add]    
    Cited by others 3    

Recommend this journal