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Year : 2020  |  Volume : 23  |  Issue : 10  |  Page : 1407-1413

Evaluation of the effects of the surgical removal of impacted third molars on the emotional state of individuals with Beck depression inventory

1 Private Practice, Sakarya, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziosmanpasa University, Sivas, Turkey
3 Sivas Dental Health Hospital, TR Ministry of Health, Sivas, Turkey
4 Labour Economics and Industrial Relations, Faculty of Political Sciences, Sakarya University, Turkey

Date of Submission01-Nov-2019
Date of Acceptance23-Apr-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. M S Demirsoy
Arabacialani Mahallesi, Mert Sokak, No: 25, Sakarya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_603_19

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Aims: In this study, using Beck depression inventory (BDI), we aimed to determine alterations in the emotional state of patients who had impacted third molars (M3) extracted owing to postoperative pain, edema, and trismus.In this prospective clinical trial, which was conducted at Tokat Gaziosmanpasa University, Faculty of Dentistry, Department of Maxillofacial Surgery Clinic, we studied 60 patients (30 males and 30 females), who were 18–47 years old (the mean of 25.6 years of age). The patients with M3 with moderate preoperative pain intensities, edema, and maximal mouth opening (MMO) data were recorded, and BDI was applied to determine their emotional states. The patients were re-evaluated using BDI to detect alterations in their emotional state owing to pain intensity, edema, and trismus on postoperative second and seventh day. Subjects and Methods: Descriptive statistical analysis, Chi-square, and independent t-test were utilized to interpret the obtained data. Results: According to our findings, a statistically significant relationship was observed between BDI scores and gender on the second postoperative day (P = 0.004), and between MMO and BDI scores on the second and seventh postoperative day (P = 0.012, P = 0.045). Pain intensity scores on the postoperative sixth hour and seventh day were significantly correlated with BDI scores on the postoperative second and seventh day (P = 0.000/ P = 0.000/P = 0.002/P = 0.004/P = 0.010/P = 0.017/P = 0.001/P = 0.000).Conclusions: Our results suggest that the pain and trismus owing to the M3 surgery were significantly correlated with an increase in the postoperative BDI scores.

Keywords: Complications, depression, emotional state, third molar surgery

How to cite this article:
Demirsoy M S, Tumer M K, Erdil A, Ozkan Y. Evaluation of the effects of the surgical removal of impacted third molars on the emotional state of individuals with Beck depression inventory. Niger J Clin Pract 2020;23:1407-13

How to cite this URL:
Demirsoy M S, Tumer M K, Erdil A, Ozkan Y. Evaluation of the effects of the surgical removal of impacted third molars on the emotional state of individuals with Beck depression inventory. Niger J Clin Pract [serial online] 2020 [cited 2022 Dec 8];23:1407-13. Available from:

   Introduction Top

The surgical removal of impacted teeth is one of the most commonly performed procedures in maxillofacial surgery.[1–4]

Third molar teeth (M3) are the most likely teeth to become impacted. M3 cannot erupt in a regular pattern, and approximately half of M3 teeth do not attain the vertical position and remain mesioangularly impacted.[1],[4],[5]

The incidence rates of postoperative complications after the surgical removal of M3 vary, and the general opinion is that a 10% rate is reasonable.[1],[3] However, recent studies have shown that incidence rates vary in the range of 3%–30%.[6],[7]

Swelling, pain, and trismus are considered to be predictable outcomes. Complications (e.g. inferior alveolar nerve disturbance, fracture of the mandible, alveolar osteitis, and infection) are seldom seen and have low incidence rates.[1]

Even though predictable outcomes are described as normal physiological responses, these complications reduce the individual's quality of life and cause inconvenience.

Depression also known as depressive disorder is a common chronic illness that can affect thoughts, mood, and physical health. It is characterized by low mood, lack of energy, sadness, insomnia, and an inability to enjoy life.[8] Depressive disorders affecting 121 million people worldwide are a significant cause of disability. Depression ranks 4th in the global disease burden list by the World Health Organization (WHO).[9] There is an interaction between the course and outcome of medical and dental treatments in the community and the presence of psychological disorders. Especially during these treatments, people's moods can be affected and cause anxiety. Physical trauma affects the postoperative condition, but increased psychological stress has been associated with many physical effects, from adrenergic sympathetic activity to disease susceptibility.[10]

Beck depression inventory (BDI) was obtained from the clinical observations of prevailing attitudes and symptoms in both depressive and nondepressive psychiatric patients. Eventually, 21 items were identified and graded in the range of 0–3 according to their severity. The obtainable minimum score is 0, and the maximum score is 63. A higher total score indicates higher symptom severity. BDI is one of the most widely used and empirically validated questionnaires for screening depression. The BDI was initially developed to provide a quantitative assessment of the intensity of depression. Because it is designed to reflect the depth of the depression, it can monitor changes over time and provide an objective measure for judging improvement and the effectiveness or otherwise of treatment methods.[11–14]

The objectives of this study are to radiographically determine the surgical extraction difficulties according to anatomical positions of M3, to recruit patients with a moderate difficulty (difficulty scores between 4 and 7), to determine the postoperative pain intensity, swelling, and trismus amounts for each individual, and to follow up and detect alterations in the emotional state of the patients using BDI. A study hypothesis was formed stating that “the predictable outcomes of surgical removal of M3 alter the emotional state of individuals in a significant manner which can be observed by BDI.”

   Subjects and Methods Top

Study design

We designed a prospective, observational clinical trial. The operating surgeon (MSD) evaluated preoperative emotional states of the involved patients using BDI and the surgical difficulty of M3, and performed the surgeries. Postoperative BDI and clinical parameter evaluations were performed by another researcher (AE) who was unaware of surgical difficulties and preoperative BDI scores. This study received approval from the Tokat Gaziosmanpasa University Clinical Trials Ethics Committee (18-KAEK-042), and the study protocol complied with the guidelines of the Declaration of Helsinki. All volunteer patients signed informed consent for agreeing to participate in this study. A total of 60 subjects (the male: female ratio of 1:1) between 18 and 47 years of age (the mean of 25.6 years of age), who required the extraction of one mandibular M3 and presented between March and December 2018, were recruited. The patients between 18 and 65 years of age, with a score of 0–20 during the preoperative BDI assessment, and without obstacles for the surgical removal of M3 were included. Patients under the age of 18 and older than 65 years, who were diagnosed with chronic diseases (e.g. diabetes mellitus or hypertension), autoimmune diseases and malignancy, or who were pregnant or lactating were excluded.

Surgical protocol

Before surgery, BDI scores, maximal mouth opening (MMO), facial dimensions, and pain intensity scores were recorded. The study's enrolled teeth were evaluated on panoramic radiographs (taken within the last 6 months) in terms of surgical difficulty and were given a score based on angulation, depth of impaction, and available space according to Freudlsperger et al.[15] Total extraction scores between 3 and 4 were noncomplex, scores between 5 and 7 were moderate, and scores between 8 and 10 were considered difficult. Teeth with a moderate difficulty score were extracted at Tokat Gaziosmanpasa University, Faculty of Dentistry, Department of Maxillofacial Surgery Clinic. All patients were administered 2 mL of local anesthesia containing 40 mg/mL articaine and 0.005 mg/mL epinephrine (Maxicaine DS, VEM Pharmaceuticals). Surgeries were conducted with a standardized technique described by Alcantara et al.[16] All surgeries were performed under similar conditions with identical instruments, and flaps were closed primarily with 3/0 silk sutures.

Patients were prescribed an oral analgesic (i.e. 25 mg of dexketoprofen trometamol taken every 8–12 h if needed), an oral antibiotic (i.e. amoxicillin/clavulanic acid 825 mg/125 mg, one tablet every 12 h), and a mouth rinse (i.e. 0.12% chlorhexidine gluconate every 8 h).

   Follow-Up Period Top

Assessment of pain Intensity

Pain intensities were self-evaluated by patients using a visual analog scale (VAS) at preoperative, postoperative 6th hour, and day 1–7 timelines. VAS was printed on follow-up forms as a 10-cm line, and patients were instructed to mark a point that indicates their intensity of the pain (0 = absence of pain, 5 = moderate pain, 10 = intolerable pain). The obtained VAS scores of each patient were classified as mild (scores of 0–3), moderate (3.1–6.9), and severe (7–10).

Maximal Mouth Opening (MMO)

The MMO values of the patients were obtained preoperatively and postoperatively on the 2nd and 7th day. The distance between the incisal edges of maxillary and mandibular central incisors was measured in millimeters. The reduction rates of distances were classified as mild (<20%), moderate (20%<<40%), and severe (>40%).

Assessment of Edema

Line measurements from the corner of the mouth to the middle point of the tragus and from the outer cantus of the eye to the angle of the mandible were performed on the operated sites. The measurements were averaged and recorded in millimeters preoperatively and postoperatively on days 2 and 7.

The increase rates were classified as mild (<10%), moderate (5%<<10%), and severe (10%<).

Beck Depression Inventory (BDI) evaluation

Preoperative BDI scores were compared with postoperative days 2 and 7 scores to determine the alterations in the emotional state owing to predicted outcomes. BDI scores were classified as no depression (scores 0–10), mild depression (11–16), clinical depression (17–20), moderate depression (21–30), severe depression (31–40), and intense depression (>41).[17]

Statistical analysis

Statistical analyses were performed using SPSS (Version 25.0, SPSS Inc., Chicago, USA). Descriptive analyses were conducted to identify the general characteristics of the study groups. The data of continuous variables were expressed as the mean ± standard deviation; categorical variables were presented as n (%). An independent sample t-test was used to compare the mean of the quantitative variables between the groups. Cross-tables and Chi-square tests were used to evaluate the relationship between qualitative variables and BDI. The probabilities of < 0.05 were considered to be significant.

   Results Top

The obtained results were presented as four headings. T-test was utilized to determine the relationships between BDI scores and gender, pain intensity, edema, and trismus. The Chi-square test was utilized to show the relationships between BDI scores, gender, pain intensity classification, increase in edema (%), and trismus (%).


The mean BDI scores of males and females on day 2 were 11.87 ± 5.83 and 14.53 ± 4.06, respectively. On day 7, the scores decreased to 7.53 ± 6.42 for males and 10.43 ± 5.06 for females. A statistically significant relationship was detected between an increase in the BDI scores and genders on day 2 (P = 0.045). There was a significant relationship between alterations in emotional state and gender on day 2 (P = 0.029). Thus, both BDI scores and alterations of the emotional state were higher in females than in males, and only variances for females on day 2 were statistically significant [Table 1].
Table 1: The data revealing relationships between genders and BDI scores on days 2 and 7

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BDI-Pain Intensity (VAS)

There was a strong correlation between preoperative pain and BDI scores (P = 0.000). Out of the 42 patients with mild preoperative pain, eight patients had scores >10. Out of the 16 patients with moderate preoperative pain, the scores of 11 patients were >10. The two patients with severe preoperative pain also had BDI scores >10. The mean preoperative VAS score was 2.11 ± 2.37.

The postoperative 6th hour VAS scores reached the highest levels (mean = 6.39 ± 2.75), and a decrease was observed during the follow-up period.

There was a significant correlation between variances of the VAS score on the postoperative 6th hour, days 1, 2, 3, and 4 and alterations of emotional state on postoperative day 2. However, significance was observed between the variances of VAS scores on days 5, 6, and 7 and alterations of emotional state on postoperative day 7. There were similar correlations between pain intensity classifications and BDI scores [Table 2] and [Table 3].
Table 2: Pain intensity and depression symptoms (student t-test)

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Table 3: Pain intensity classification and depression symptoms (Chi-square Test)

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There was no statistically significant relation between mean edema measurements and alterations of emotional state on days 2 and 7 (P = 0.904, P = 0.627). Nevertheless, the relation between quantitative edema increase in patients with BDI scores below 10 (5.04 ± 2.39 mm) and above 10 (8.08 ± 4.23 mm) on day 2 was statistically significant (P = 0.002). Contrary to these findings, edema increases in patients with BDI scores below 10 (2.08 ± 2.13 mm) or above 10 (2.94 ± 2.57 mm) on day 7 were not significantly associated with alterations of emotional states. Due to edema severity classification, no significant association was found between edema severity and BDI scores on days 2 (P = 0.062) and 7 (P = 0.382).


The preoperative mean MMO value was 46.40 ± 6.20 mm, whereas the mean values on days 2 and 7 were 28.40 ± 8.68 and 37.37 ± 8.74, respectively. There were significant correlations between decreased MMO rates and BDI scores on days 2 and 7 (P = 0.012, P = 0.045).

Due to the relationship between trismus classification and BDI scores on day 2, any significant differences were not observed (P = 0.149).

On day 7, out of 29 patients with symptoms, 8 had mild trismus, 17 had moderate trismus, and 4 had severe trismus. Thus, the association between trismus rates and BDI scores on day 7 was significant (P = 0.023) [Table 4].
Table 4: Edema severity and depressive symptoms

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   Discussion Top

Many researchers emphasized the necessity to manage pain, edema, and trismus after an M3 surgery. These predictable outcomes, postoperative wounds, and physiological sequelae significantly impair the quality of life.[10],[18] According to the World Health Organization data, depression affects 350 million people; it is considered to be a cause of disability and is one of the leading diseases in the global burden of disease list.[9],[19]

Validity and reliability studies indicate that BDI is a convenient and easily rated instrument that can be used to assess depressive symptoms and depression level.[20] Richter et al.[21] have stated that there may be a significant change in BDI scores even within at least one week. This feature allowed us to examine alterations in the emotional state during one week after the impacted lower M3 surgery by BDI.

According to our literature review, it has been observed that there have been no studies performed to determine whether M3 surgery increases BDI scores. Therefore, our study is the first to investigate whether complications caused by M3 surgery cause alterations in emotional state and which complications are responsible for the alterations. Colorado-Bonin et al.[22] and Avellaneda-Gimeno et al.[23] have investigated the impact of lower M3 surgery on an individual's quality of life in postoperative 2–3 days. The authors stated that the essential factor affecting the quality of life was the loss of chewing ability (up to 80%). Similar results were obtained in our study. VAS scores reached maximum levels between postoperative 6th hour and day 3, and the mean MMO decreased to 38.8% on day 2. These variables were correlated with an increase in the BDI scores.

Aznar-Arasa et al.[24] have investigated the association between impacted M3 surgery and anxiety levels of 102 patients. Their results revealed that the patients with deeply impacted M3, who required bone removal or coronectomy, had high preoperative anxiety levels. In our study, patients with impacted M3 with moderate difficulty were enrolled; therefore, bone removals were performed for all patients. Thus, we could not determine the impact of bone removal on pre- and postoperative outcomes. In addition, this fact is a limitation of our study and should be further researched in other studies owing to various surgical difficulties.

González-Martínez et al.[10] have studied the postoperative anxiety levels and wound healing processes of patients who underwent lower M3 surgery with IV sedation. Eventually, patients with psychological disorders had considerable preoperative anxiety. Similarly, in our study, out of 21 patients with preoperative BDI scores >10, 19 patients had preoperative pain. Wang et al.,[25] using Dental Anxiety and Fear Index, have evaluated 119 patients, who had undergone horizontally impacted M3 surgery, and reported a significant correlation between the postoperative increment of pain intensities and fear–anxiety levels. We observed the highest VAS and BDI scores on day 2, and these scores gradually declined until day 7. However, on day 7, BDI scores remained high for patients without a VAS score reduction. Thus, our results agree with those of Wang et al.; specifically, higher pain intensities have a more significant adverse effect on an individual's emotional state.

Phillips et al.[26] have evaluated the impact of predictable outcomes on the health-related quality of life (HRQoL) after an M3 surgery. They determined that the recovery period required for females (35%) was more extended than that for males (22%); postoperative complications and oral functions of females improved twice as late as those of males. In our study, the mean amount of trismus on days 2 and 7 for female (25.90 ± 7.51/35.03 ± 7.06) MMO was more restricted than that of males (30.10 ± 9.15/39.70 ± 9.49). There was a correlation between the amount of limitation in MMO and BDI. In terms of pain intensities on days 2 and 7, the VAS scores of females (3.88 ± 2.46/1.25 ± 2.11) were higher than those of males (3.77 ± 2.74/1.06 ± 1.66), and the scores were correlated with BDI.

Within the limitations of our study, impacted M3 surgery was found to cause alterations in the mood of patients. Nevertheless, in our study, patients with preoperative BDI scores <20 were examined. The effects of impacted M3 surgery on depression can be seen more clearly in studies conducted with participants who were diagnosed with depression by experts and whose BDI scores were >20. Besides, the effects of depression on quality of life should be investigated in future studies as it affects factors such as lifestyle, thoughts, and stamina.

Although there was no one-to-one relationship between pain, edema, trismus, and gender, the combination of these factors resulted in a significant change in the patient's emotional state and a correlated relationship between BDI scores and gender. It was observed that the emotional state of females was affected more negatively after the surgery.

   Conclusion Top

The total effects of outcomes owing to impacted M3 surgery result in the alterations of the patients' emotional state. The effects of such surgical interventions should not be ignored in individuals who are susceptible to depression. However, in this study, there were no insistent complications. Therefore, it will be beneficial to evaluate these effects in further studies.

As stated in the guidelines by the National Institute for Health and Care Excellence,[27] one of the critical aspects is that inappropriate procedures cause excessive cost to healthcare providers and that sequelae in patients may cause undesired results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of Interest

There are no conflicts of interest.

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

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