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Year : 2021  |  Volume : 24  |  Issue : 10  |  Page : 1430-1437

The effect of dental anxiety on surgical time of mandibular third molar disimpaction

Department of Oral and Maxillofacial Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission10-Aug-2020
Date of Acceptance17-Jun-2021
Date of Web Publication16-Oct-2021

Correspondence Address:
Dr. A A Efunkoya
Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Aminu Kano Teaching Hospital, 2 Zaria Road, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_501_20

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Background: Dental treatment of anxious patients induces stress due to the patients' expectation of pain. This may prolong treatment due to such patients' inability to cooperate during treatment. Aim: The aim of the study was to determine the effect of dental anxiety on surgical time of mandibular third molar (M3) disimpactions at a Nigerian hospital. Subjects and Methods: A prospective study was conducted at the Oral Surgery clinic of Aminu Kano Teaching Hospital, Kano, between October 2016 and September 2017 to assess the effect of dental anxiety on surgical time of M3 disimpactions using the Modified Dental Anxiety Scale (MDAS). The Patients' biodata, clinical and M3 radiologic data were recorded. Surgical durations were also recorded. Data were analyzed with Statistical Package for Social Sciences for Windows (IBM statistics 23 software). Results: One hundred and sixteen subjects (64 males, 52 females) were studied. Forty-two subjects (36.2%) were mildly anxious, 67 (57.8%) were moderately anxious, and 7 (6.0%) were highly anxious. The females were more anxious and the overall surgical time (OST) of disimpaction correlated with the anxiety levels of the subjects. The OST increased by approximately 0.8 min with every unit rise in the anxiety score. Other factors that affected OST in the study were M3 depth, type of impaction, and root curvature. Conclusion: The patients' dental anxiety increased the surgical time of M3 disimpactions. Clinicians should consider the patients' anxiety among the factors that affect the surgical time of M3 disimpactions. Verbally soothing anxious patients and administering anxiolytic when necessary, may help to reduce the patients' anxiety, and hence, prevent surgical time prolongation.

Keywords: Dental anxiety, surgical disimpaction, third molar surgery, time

How to cite this article:
Suleiman A R, Efunkoya A A, Omeje K U, Amole I O. The effect of dental anxiety on surgical time of mandibular third molar disimpaction. Niger J Clin Pract 2021;24:1430-7

How to cite this URL:
Suleiman A R, Efunkoya A A, Omeje K U, Amole I O. The effect of dental anxiety on surgical time of mandibular third molar disimpaction. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 8];24:1430-7. Available from:

   Introduction Top

Dental anxiety (DA) has been defined as any psychological or physiological type of a strong feeling of fear due to a dental appointment or a stimulus (or stimuli) related to dental treatment.[1] DA is an important clinical problem with an estimated worldwide prevalence ranging from 3 to 43%.[2],[3] Patients who have high levels of DA have a higher probability of irregular dental attendance and are often uncooperative and difficult to manage on the dental chair making such patients an economic risk to dentists.[3],[4]

The degree of DA expressed by patients varies. At one end of the spectrum are patients who are not anxious while at the other end of the spectrum are those who are highly anxious.[4] There are various specific DA scales and general anxiety tools used for the measurement of DA. These include the Dental Anxiety Scale (DAS),[5] the Modified Dental Anxiety Scale (MDAS),[6] the Dental Fear Survey (DFS),[7] and the State Trait Anxiety Inventory (STAI)[3],[8] among others. The MDAS is one of the most popular DA scales and has been used in studies both locally and internationally because it is short, simple to use, can be easily translated into indigenous languages, and has shown high validity and reliability.[2]

The etiology of DA is multifactorial. The implicated factors vary between individuals, act in synergy to affect the expression of DA, and hence, the ability of people to cope with treatment.[3],[9] A number of demographic, behavioral, psychosocial, and clinical factors have been related to high DA in patients. These include a high level of the trait or general anxiety (the innate tendency of an individual to develop anxiety), female gender, lower and middle age groups, low socioeconomic status, negative previous dental experience, prolonged waiting period in the dental office, long periods since the last dental visit, fear of dental anesthetic injections, use and sounds of drills, and dental treatments involving tooth extractions[2] among others.[3],[4],[9],[10],[11],[12],[13]

Economically, improper utilization of a scheduled surgical time or prolongation of any treatment beyond its scheduled time interval adversely affects the clinic's income generation, increases the utilization of treatment consumables, and hence the clinical cost of carrying out the treatment.[14] It also increases subsequent patients' waiting time and the hours of work or school time missed by patients. Clinically, the surgical time in an experienced hand may serve as an indication of the surgical difficulty of M3 disimpaction.[8],[15],[16],[17] Factors such as gender, age, body mass index (BMI), weight, number, and morphology of the roots of M3, its depth of impaction, and angulation among other factors have been identified in different studies to influence the surgical time and hence the difficulty of M3 disimpaction which in turn influences the degree of the immediate postoperative sequalae of pain, trismus, and swelling.[8],[15],[16],[17],[18],[19]

While a number of studies have focused on clinical and radiologic factors relevant to M3 disimpaction,[15],[16],[17],[18],[19],[20] there is a dearth of literature on the influence of psychosocial factors such as anxiety on M3 disimpaction despite the increasing awareness among health professionals concerning the negative impact psychosocial issues may have on surgical treatment, wound healing, and the postoperative recovery in general.[21]

The aim of this study was to determine the effect of DA on the surgical time of M3 disimpactions performed at a Nigerian tertiary health care facility.

   Subjects and Methods Top

A prospective study of subjects presenting at the Oral Surgery clinic of Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria for disimpaction of M3 from October 2016 to September 2017 was undertaken. All patients from 18 to 50 years of age who consented to participate in the study were included. Patients being managed for emotional or anxiety disorders were excluded from the study. Also excluded were patients who required surgical disimpaction under conscious sedation or general anesthesia.

A minimum sample size of 106 subjects was calculated using the prevalence of DA reported in a previous Nigerian study.[22] The study protocol was approved by the AKTH ethics and research committee (NHREC/21/08/2008/AKTH/EC/1687). Sociodemographic, clinical, and radiologic data were collected according to the template used by Gbotolorun et al.[16] DA was assessed by asking the subjects to complete the MDAS[6] (appendix I) in a quiet non-operating office preoperatively.

The MDAS has five questions asking about anxiety toward different stimuli scored on a 5-point Likert scale (not anxious: 1, slightly anxious: 2, fairly anxious: 3, very anxious: 4, and extremely anxious: 5). The anxiety score for each subject was the sum of all the scores of the five questions (ranging from 5 to 25). Subjects with anxiety scores 5–9 were considered as mildly anxious, those with anxiety scores 10–18 were considered as moderately anxious, and those with a score of 19 or above were considered as highly anxious.[6],[23]

Surgical procedure and intraoperative data collection

All the surgical disimpactions were performed early in the morning of the scheduled days by a single operator under local anesthesia (LA). The buccal guttering technique was used for all disimpactions. Intraoperatively, with the aid of stopwatches, different surgical times and durations were noted. Local Anesthesia Administration Time (LAAT) was the time measured from the subject sitting on the dental chair to the completion of LA administration. Bone Guttering Time (BGT) was the time measured from the commencement of bone guttering to the completion of bone drilling including tooth sectioning (if needed). Overall Surgical Time (OST) was the time measured from when the patient sat on the dental chair to the placement of the last suture for wound closure. Durations of the time segments between LA administration and the commencement of bone drilling as well as that between the completion of bone drilling and placement of the last suture were recorded.

Data analysis

Data analysis was performed using Statistical Package for Social Sciences (SPSS) for Windows (IBM SPSS statistic version 23). One-way Analysis of Variance (ANOVA) was used to compare the mean surgical durations among the different levels of anxious subjects. The overall surgical time was classified as short (OST ≤ 25 min), average (OST 26–45 min), and prolonged (OST >45 min). Univariate analysis (Spearman's correlations and Chi-square tests) involving DA scores and other preoperative variables in association with OST were performed. All the significantly associated variables of the univariate analysis were further employed in multiple linear regression to ascertain the most important determinants of OST and their effects in the study. The level of statistical significance (P value) for the study was set at 0.05.

   Results Top

A total of 124 patients with impacted M3 were seen during the study period. Two male subjects declined participation in the study, two other subjects (1 male, 1 female) did not present to the clinic for their scheduled M3 disimpactions. Four subjects (1 male, 3 females) were excluded from the study based on the study exclusion criteria. A total of 116 patients (64 males, 52 females) participated in the study. The mean age of the study population was 28.36 ± 6.8 years.

Forty-two (36.2%) subjects were mildly anxious, 67 (57.8%) subjects were moderately anxious, and 7 (6.0%) subjects were highly anxious. The female subjects (mean anxiety score = 12.90 ± 3.7) were found to be more anxious than the male subjects (mean anxiety score = 10.14 ± 4.1). The MDAS yielded a Cronbach's alpha of 0.83.

Thirteen (11.2%) disimpactions had short OST, 80 (69.0%) disimpactions had average OST, and 23 (19.8%) disimpactions had prolonged OST. The OST ranged from 22.55 to 65.25 min with a total sample mean of 36.40 ± 9.9 min. [Table 1] shows the mean duration of the local anesthetic administration, bone guttering, and overall surgical time based on the level of anxiety among the patients studied. The patients who were highly anxious, moderately anxious, and mildly anxious had mean overall surgical times of 47.50 ± 15.6 min, 37.14 ± 9.8 min, and 33.34 ± 7.5 min, respectively. Generally, all the mean surgical durations increased as the levels of the patients' anxiety increased from mild to high. However, unlike the differences in the mean times of LA administration and the OST across the three levels of anxious subjects which were found to be statistically significant (P < 0.05), the difference in the mean times of the BGT of the various anxiety groups were not statistically significant (P > 0.05).
Table 1: Mean duration of intraoperative time segments during M3 disimpactions of the different levels of anxious patients

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[Table 2] shows the results of univariate analysis between preoperative variables and the OST. It shows that gender, ethnicity, depth of impaction, DA levels, type of impaction, root bulbousity, and root curvature were all significantly associated with OST levels (P < 0.05). [Table 3] presents the results of multiple regression (multivariate) analysis involving all the significant preoperative variables of univariate analysis at P ≤ 0.05. It shows that DA and three other variables (depth of impaction, root curvature, and angulation of impaction) had statistically significant effects on the OST.
Table 2: Results of univariate analysis between preoperative variables and OST

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Table 3: Multiple linear regression (multivariate analysis) results

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   Discussion Top

Oral surgical procedures, especially third molar surgery, have been reported to cause the highest level of anxiety among patients when compared to other dental as well as medical and surgical treatments.[2],[24],[25] Sirin et al.[25] found out that patients scheduled for M3 disimpactions had the highest anxiety scores among a sample of oral surgery patients and recommended that more efforts should be directed at the management of the third molar surgery patients since they are likely to be the most anxious patients. This underscores the need to investigate DA in third molar surgeries.

In the present study, the internal consistency of the MDAS as a measuring tool of anxiety was high and comparable with those of the previous studies.[26],[27] The mean MDAS score of the subjects in this study was comparable with the mean MDAS scores of other study samples.[26],[28],[29],[30]

Appukuttan et al.[28] reported lower percentages of patients with moderate and high DA levels in their study sample which is similar to our findings. The prevalence of high DA in our study is comparable with those of some other studies.[22],[31] In contrast, other studies from some industrialized nations reported a higher prevalence of high DA[8],[30],[32] despite the technological advancements in health care delivery, pain control, and relatively high levels of oral health awareness in these countries. The differences in the levels of anxiety in various studies could be due to geographical variations, differences in ethnocultural characteristics,[33] and quality of life of the study samples.

The duration of time utilized in the extraction of impacted M3 reported in the literature ranges from 7.57 to 105 min.[15] The mean OST of disimpaction in this present study was comparable with mean surgical times reported by Renton et al.[15] In several studies, various factors have been associated with the length of surgical time of M3 disimpactions. Unlike the previous studies,[15],[16],[17],[18],[19],[20],[34],[35] the present study considered DA among other previously studied preoperative variables and seven variables (gender, ethnicity, DA, depth of M3, M3 root curvature, M3 root bulbousity, and M3 type of impaction) were found to be associated with the surgical time when univariate analysis was conducted at 0.05 significance. It was not possible to eliminate the confounding variables of DA in the study which prompted the need for further multivariate regression analysis to determine the effect of dental anxiety scores on the OST while dental anxiety and other significantly associated variables of the univariate analysis interact.

In the present study, the depth of impacted M3 was significantly associated with surgical time both at the univariate and multivariate levels of analyses which is consistent with the finding of Akadiri and Obiechina[20] in a systematic review of several literatures on M3 disimpaction. The depth of impaction correlates with the amount of bone removal required to disimpact M3 and has been cited by Akinwande[18] as the single most important factor in the determination of surgical time of M3 disimpaction. Our study result supports this finding as the depth of impaction had the highest significant effect (i.e. highest beta value) on surgical time after a multivariate regression analysis.

Lago-Mendez et al.[36] suggested that M3 disimpaction may require a longer time in anxious patients. This opinion was confirmed by Aznar-Arasa et al.[7] who concluded that DA increases the difficulty and surgical time of M3 disimpactions. The present study aligns with Lago-Mendez et al.[36] and Aznar-Arasa et al.[7]

DA proved to be a significant factor at both univariate and multivariate levels of analysis in the present study. After the depth of impaction, it was the second most important factor (i.e., second highest beta value) in determining surgical time. A unit rise in the MDAS score increased the OST by approximately 0.8 min (i.e., B value in [Table 3]). This effect was reflected in the increase of the mean OST of the three groups of anxious subjects as the anxiety levels increased and statically significant differences in the OST (P < 0.05). As the level of anxiety increased among the study subjects, the mean durations of all the different time segments recorded during the M3 disimpactions increased [Table 1]. Except for the mean bone guttering times, all increases in the mean times were statistically significant and may cumulatively explain the impact of DA on the OST of the disimpactions.

LA injection is one of the common causes of anxiety among dental patients. Hermes, Matthes, and Saka[24] found that oral and maxillofacial patients treated under LA and on an outpatient basis had high levels of anxiety which may be due to the fear of injections by these patients. The M3 disimpactions in our study were done under LA on an outpatient basis. The results showed that anxiety toward LA significantly contributed to the prolongation of OST in the present study. The mean LA administration time increased as the level of patients' anxiety increased from mild to high and the differences in these mean times were statistically significant (P = 0.0001). The anxious subjects frequently displayed unfavorable behavior at the expectation of a dental syringe approaching the mouth. Such behavior includes moving the head away from the needle, holding the operator's hand, and covering the mouth, thus, hindering easy administration of LA. The behavioral displays and the time needed to reassure such anxious subjects may explain the prolongation of the local anesthesia administration times among the anxious patients. The authors, therefore, align with Sneha S, et al.[37] that patients' anxiety before dental treatments can provoke emotional unease and unfavorable behavior that can hinder the treatment.

The statistical significance in the increases of the mean durations of the period between the completion of LA administration and the commencement of bone drilling across the anxiety groups seems to agree with the assertion that DA can hinder the absorption and onset of action of drugs, cause unfavorable physiological changes such as decreasing the pain threshold, and hence, increasing the perception of pain during the treatment.[2] Though this time segment also includes the time to raise the access flap in the present study, it may be a reflection of the time needed to wait for the onset of LA action since the same access flap design was used for all the disimpactions. It was observed that the time of onset of action of the local anesthetic agent increased among the subjects as the levels of their anxiety increased. This could be attributed to a possibly lowered pain threshold of the subjects or the reduced efficacy of the anesthetic agent resulting from physiologic body responses to anxiety.[2] This could also be due to forced errors in the local anesthetic injection technique due to the patients' uncooperative behavior, thus, prompting the need to repeat the injection and further prolonging this time segment.

Aznar-Arasa et al.[8] found out that the patient's anxiety before the third molar surgery was related to the depth of impaction, and hence, the duration of time required for bone guttering and tooth sectioning. Though the bone guttering times in our study increased as the level of anxiety increased clinically, statistically, the differences in the durations of this time segment across different anxiety levels were not significant suggesting that anxiety was not important during bone guttering among our subjects. This contradicts the findings of Aznar-Arasa et al.[8] This difference in the result between our study in which only one surgeon carried out all the extractions and that of Aznar-Arasa et al.[8] might be related to the varied abilities of the different surgeons who participated in their own study to allay patients' anxieties prior to the procedure.

The mean times of the last time segment extending from the end of bone guttering to the completion of placement of the last suture were significantly prolonged among subjects who were more anxious when compared to their less anxious counterparts. This could have been due to the fear associated with the extraction of the teeth after bone guttering among anxious patients and fatigue by both patient and surgeon.

The third most important determinant factor of surgical time after multivariate analysis in the present study is angulation of the impacted M3. This finding concurs with the previous authors[20],[34],[35] who reported that angulation of M3 impacts significantly on the surgical time of M3 disimpaction. Though many other authors found associations between M3 angulation and surgical time at only the univariate analysis level,[20] this finding reemphasizes the need to consider M3 angulation during a patient assessment before M3 disimpactions.

The importance of the root curvature as a strong determinant of surgical time of M3 disimpaction was reported by Gbotolorun et al.[16] Divergent or mesially curved roots of M3 often impede easy elevation of the M3 which may increase the difficulty of disimpaction, and hence, increase the surgical time.[16] Though M3 root curvature was the least significant factor to influence OST in the present study, the P value (0.0001) of the association reiterates the finding of Gbotolorun et al.[16]

Extended surgical or operation times have been documented to have adverse economic effects on care providers especially when these extensions are unplanned. These effects range from the excessive use of treatment consumables and increased treatment cost to operator fatigue and loss of clinical time for the treatment of subsequent patients leading to reduced income generation for the care provider and possibly an increased payment by patients or health insurance agents.[14] A clinical effect of prolonged surgical times of third molar disimpactions as reported by Bello et al.[17] is worsened postoperative sequalae of pain, swelling, and trismus which may consequently increase the period of postoperative recovery, school or work hours missed by patients, and hence, reduce their productivity/income. Lago Mendez et al.[36] reported that high preoperative anxiety of patients before the third molar could also impact negative effects on postoperative sequalae thus prolonging recovery of patients after third molar disimpactions. It is, therefore, desirable to understand the predictive factors of surgical time in third molar studies and plan reduction or elimination of their negative effects on the surgery. This buttresses the need for the present study which investigated, among all other factors, the role of DA on surgical time, a scarcely studied subject area.

   Conclusion Top

DA increases the surgical time of impacted M3 disimpactions and can have negative clinical and economic consequences for both clinicians and patients. Patients' DA should, therefore, be considered along with the depth of M3, its angulation, and root curvature during the preoperative evaluation of surgical difficulty and planning for optimal surgical time utilization in M3 disimpactions. Patients' preoperative DA should be regularly assessed, anxious patients identified, and steps be taken to control their anxiety prior to the disimpaction surgery. Such steps to manage the anxiety of dental patients include trying to understand, encourage, and provide verbal support and comfort to the patient regarding the third molar disimpaction procedure. This may be augmented with the use of pharmacological agents such as anxiolytics when necessary. These steps should help reduce the difficulty of surgical disimpaction and improve time management during third molar surgical disimpactions in anxious patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the forms the patient(s) has/have given his/her/their consent for his/her/their 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.

   APPENDIX I: Modified Dental Anxiety Scale (MDAS) Top



1. If you went to your Dentist for TREATMENT TOMORROW, how would you feel?

Not Slightly Fairly Very Extremely

Anxious □ Anxious □ Anxious □ Anxious □ Anxious □

2. If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?

Not Slightly Fairly Very Extremely

Anxious □ Anxious □ Anxious □ Anxious □ Anxious □

3. If you were about to have a TOOTH DRILLED, how would you feel?

Not Slightly Fairly Very Extremely

Anxious □ Anxious □ Anxious □ Anxious □ Anxious □

4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel?

Not Slightly Fairly Very Extremely

Anxious □ Anxious □ Anxious □ Anxious □ Anxious □

5. If you were about to have a LOCAL ANESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?

Not Slightly Fairly Very Extremely

Anxious □ Anxious □ Anxious □ Anxious □ Anxious □

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  [Table 1], [Table 2], [Table 3]


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