Anxiety and pain during dental injections
Introduction
The use of dental injections as a model for studying the relation between anxiety and pain in dentistry seems useful for several reasons. First, for any type of invasive dental procedure, patients routinely receive anesthesia. In other words, dental procedures are usually painless other than in the case of failed local anesthesia.1 Although third molar extraction also forms an excellent model of pain for testing analgesic effects,2 this always concerns postoperative pain in which anxiety (as an anticipatory process) may be less relevant. Second, dental injections are an important aspect of dental treatment (at least in the perception of patients) which can induce dental anxiety or fear in children3 and forms a source of distress or a compelling reason to avoid dental treatment altogether4, 5 in adults. So, dental injections provide a painful stimulus as well as a reason for anxiety and are provided at that point in time where anxiety may be hypothesized to be at its maximum for the patients. Third, dental injections are so common that data is easily accessible for researchers. Moreover, injections are of a short duration, allowing researchers to assess individual experiences directly afterwards, and minimizing potential bias such as memory effects.
A number of procedural factors are possibly associated with pain felt during dental injections, such as type of anesthetic fluid, amount of injected anesthetic fluid, injection rate, location of injection, expertise of the dentist, use of surface anesthesia, and methods of injection. Psychological factors play an important role in the perception of pain as well, most notably anxiety or fear. A recent study6 investigated anxiety and pain using a clinically relevant sample and stimulus (i.e. injections). Results showed that highly anxious dental patients report pain of a higher intensity and of longer duration than normal patients. In a comment to this study,7 it was suggested that future studies should also focus on the degree of invasiveness of the procedure following the injection, since anticipation of such invasiveness can translate into elevated levels of anxiety.
The aim of this study is to investigate the relationship between anxiety and pain in a sample of ‘normal’ patients about to undergo ‘invasive’ dental treatment. Specifically, we wanted to know to what extent anxiety and pain during dental injections are related, taking into account procedural and psychological factors. It was hypothesized that; (I) anxious patients will report more pain (higher intensity) and of longer duration than less anxious patients; (II) type of dental procedure is related to pre-treatment anxiety levels; and (III) the use of surface anesthesia patients will reduce pain intensity.
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Subjects
Participants were 258 patients treated either at a private clinicb (specialized in implantology, endodontology and prosthetics) or in one of the major government hospitals,c both located in Istanbul. Inclusion criteria were a minimum age of 17 years, being able to read and willingness to participate. All participants signed an informed consent form. Except for one hospital patient, all patients
Descriptive statistics
Six patients were excluded from the dataset because they were younger than 17 years. This resulted in a total sample of 252 patients which consisted of 115 males (mean age = 48.6, S.D. = 15.5) and 137 females (mean age = 40.9, S.D. = 13.3). The male patients were significantly older (7.1 years) than the female patients, t (250) = 3.93, p < 0.001. In total, 70 patients were treated at the private clinic and 182 at the hospital.
Anxiety and pain
Two multiple stepwise regression analyses were performed. Independent variables
Discussion
Results showed that anxious dental patients experience pain of higher intensity and of longer duration. For duration of pain, about 28% of variance could be accounted for by fear of dental pain, the use of surface anesthesia and gender. For the intensity of pain, 22% of variance was accounted for by anxiety for the injection (NRS) and dental anxiety (s-DAI score). This forms a starting point for further research. For instance, rate of injection was not included in the present study but may be
Conclusions
Results clearly show that anxious patients feel more pain and of longer duration than less anxious patients. 28% of variance on the duration of pain felt could be accounted for by fear of dental pain, the use of surface anesthesia and gender. 22% of the variance on the intensity of pain felt could be accounted for by anxiety felt for the injection and dental anxiety. Unexpectedly, the use of surface anesthesia was associated with longer pain duration. However, this could be explained by the
Acknowledgements
The authors would like to express their gratitude towards Mehmet Siddik Aksit, who kindly facilitated the data collection procedure, Duygu Kara for translating the questionnaires into Turkish, and Zeynep Yaramic and Ismihan Egilmez for the data collection.
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