|ORIGINAL ARTICLE - EVALUATIVE STUDY
|Year : 2018 | Volume
| Issue : 2 | Page : 247-253
Evaluation of anxiety, pain, and hemodynamic changes during surgical removal of lower third molar under local anesthesia
Vandana R Gadve1, Ramakrishna Shenoi2, Vikas Vats3, Amit Shrivastava4
1 Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, VSPM's Dental College and Research Centre, Digdoh Hills, Nagpur, Maharashtra, India
3 Consultant Oral & Maxillofacial Surgeon, Bhiwani, Haryana, India
4 Consultant Oral & Maxillofacial Surgeon, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||26-Dec-2018|
Dr. Vandana R Gadve
125, Jai Hind Society, Shyam Nagar, Somalwada, Nagpur, Maharashtra
Aim: The aim of this study are to determine the hemodynamic changes in healthy patients during the surgical removal of lower third molar and to evaluate whether these variations are attributable to patient anxiety and pain experienced during surgical procedure. Materials and Methods: Sixty healthy patients were evaluated (i) to determine the hemodynamic changes (systolic blood pressure [SBP], diastolic blood pressure [DBP], heart rate [HR], and oxygen saturation) at nine occasions: before starting the surgical procedure, 1 min and 4 min after local anesthetic injection, during the incision, at the time of ostectomy, at the completion of tooth removal, at the start and completion of suturing, and finally, after completion of surgery and (ii) to evaluate whether these variations are attributable to patient anxiety and pain experienced during the surgical procedure. Hemodynamic variables were compared between the gender and at different time points by performing two-way analysis of variance for repeated measures. Global mean values of hemodynamic variables were compared between male and female using unpaired t-test. Categorical variables were compared by Chi-square test. All the tests were two-sided. P < 0.05 was considered statistically significant. Results: SBP and DBP showed significant changes; the highest value was recorded at the time of ostectomy/tooth sectioning. Maximum HR was observed 4 min after local anesthetic injection and the lowest HR was recorded after completion of tooth extraction, i.e., during the suturing. In females, mean HR was significantly increased. Conclusion: The present study suggests that dental anxiety impacts the effect of delivery of local anesthesia on blood pressure and is significantly associated with increased HR.
Keywords: Anxiety, hemodynamic changes, pain
|How to cite this article:|
Gadve VR, Shenoi R, Vats V, Shrivastava A. Evaluation of anxiety, pain, and hemodynamic changes during surgical removal of lower third molar under local anesthesia. Ann Maxillofac Surg 2018;8:247-53
|How to cite this URL:|
Gadve VR, Shenoi R, Vats V, Shrivastava A. Evaluation of anxiety, pain, and hemodynamic changes during surgical removal of lower third molar under local anesthesia. Ann Maxillofac Surg [serial online] 2018 [cited 2019 Feb 16];8:247-53. Available from: http://www.amsjournal.com/text.asp?2018/8/2/247/248593
| Introduction|| |
The administration of local anesthetics and the performance of extensive dental procedures such as tooth extraction and minor surgical procedures may cause stress and systemic disturbances in medically compromised patients. To avoid potentially serious reactions, dentists are obligated to monitor continuously their medically challenged patients. Healthy patients are usually able to tolerate these physiologic responses which are due to stress; however, patients with hypertension, heart disease, cerebrovascular disease, or increased age may have a diminished tolerance to stress. Anxiety experienced during a dental visit may cause parasympathetic dominance, with bradycardia and/or syncope, or even cardiac arrhythmias. Some studies found an increase in blood pressure (BP) during dental surgery is common even in normotensive patients. This increase is influenced by many factors, such as psychological and physical stress, painful stimuli, and the action of catecholamines present in local anesthetics.,
The aims of this study are to determine the hemodynamic changes in healthy patients during the surgical removal of lower third molar and to evaluate whether these variations are attributable to patient anxiety and pain experienced during surgical procedure.
| Materials and Methods|| |
An observational study was made of the hemodynamic constants of normotensive patients subjected to surgical removal of mandibular third molar. The study sample consisted of 60 adults seen in our department from January 2013 to December 2014 for surgical removal of mandibular third molar. All mesioangularly impacted mandibular third molars (difficulty index 3–4) were included in the study. The difficulty of surgical extraction of the molars was assessed using Pederson's difficulty index. The patient distribution by gender was female 34 and male 26, with a mean age of 37 years (range, 20–53 years). Local anesthesia comprised 2% of lignocaine with vasoconstrictor (adrenaline 1:200,000). Patients below 18 years of age and medically compromised patients were excluded in the study.
Prior clinical history was compiled, a clinical examination was carried out, and a panoramic X-ray study was requested to evaluate buccodental health. In all 60 patients, surgical procedure was done by the same surgeon. The mean duration of the surgical procedure measured from the time of local anesthesia to the end of suturing was 35 min (range 20–50 min). During the procedure, patient position was reclined at an angle of 120°. Amount of local anesthetic solution used during the procedure was not more than 4 ml. Local anesthesia comprised 2% lignocaine with vasoconstrictor (adrenaline 1:200,000).
The patients were monitored for diastolic BP (DBP) and systolic BP (SBP) by Electronic BP Apparatus (OMRON SEM1), and the heart rate (HR) and oxygen saturation (SpO2) were recorded by pulse oximeter (BPL Cleo). These hemodynamic parameters were recorded on nine occasions: before starting the surgical procedure, 1 min and 4 min after local anesthetic injection, during the incision, at the time of ostectomy, at the completion of tooth removal, at the start and completion of suturing, and finally, after completion of surgery. All patients were informed of the purpose of the study, and signed consent was obtained in all cases. Tests of patient anxiety (Corah's dental anxiety scale and Kleinknecht dental fear scale [DFS]) were carried out to evaluate a patient's overall dental anxiety level, both real and imagined.
- 9–12 = Moderate anxiety
- 13–14 = High anxiety
- 15–20 = Severe anxiety.
Kleinknecht DFS has score total score ≤20–35 indicates low fear and >35 indicates high fear.
The degree of pain experienced during the surgical procedure was assessed by means of a visual analog scale (VAS).
Ethical approval has been received from the institutional ethical committee.
Hemodynamic parameters were presented as mean ± standard deviation (SD); categorical variables were expressed in frequencies and percentages. Hemodynamic variables were compared between genders and at different time points by performing two-way analysis of variance (ANOVA) for repeated measures. Global mean values of hemodynamic variables were compared between male and female using unpaired t-test.
Categorical variables were compared by Chi-square test. All the tests were two- sided. P < 0.05 was considered statistically significant. STATA version 10.0 was used for statistical analysis.
| Results|| |
The mean SBP, DBP, HR, and SpO2 values were recorded at each of the nine time points during surgical procedure, for the global sample [Table 1].
|Table 1: Mean blood pressure, heart rate, and oxygen saturation values at nine different time points during the surgical procedure|
Click here to view
Systolic blood pressure
The global mean SBP is 122.76 mmHg, with a SD of 12.09 mmHg [Table 2]. Distributed by gender, the mean SBP is 124.72 mmHg with SD of 9.49 mmHg in males versus 121.21 mmHg with SD of 13.63 mmHg in females. This difference is significantly high (P = 0.0008) [Table 3]. The SBP varied with surgical time (F = 1.99; d.f. = 8; P = 0.04) shows significant high value at the time of ostectomy. Variation in SBP shows a similar pattern in both genders [Table 4]a and [Table 4]b.
|Table 2: Global mean values of systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation|
Click here to view
Diastolic blood pressure
The global mean DBP is 79.68 mmHg, with a SD of 8.08 mmHg [Table 2]. Distributed by gender, the mean DBP is 78.43 mmHg with SD of 7.79 mmHg in male versus 79.87 mmHg with SD of 8.32 mmHg in female. This difference is not significant (P = 0.5299) [Table 3]. The DBP varied with surgical time (F = 2.88; d.f. = 8; P = 0.004) shows significant high value at the time of ostectomy and tooth extraction. Variation in DBP shows significant high values in female (F = 1.154; d.f. = 1, P = 0.026) [Table 5]a and [Table 5]b.
The global mean HR is 85.28 bpm with a SD = 12.04 bpm [Table 2]. Mean HR value in male is 81.62 with SD = 9.72 and in female is 88.19 with SD = 12.89 shows statistical significant variation (P = 0.0001) [Table 3].
HR varied with surgical time (F = 10.13, d.f. = 8, P = 0.0001) shows significant rise in HR values 4 min after local anesthesia. This variation is seen in female (F = 6.26; d.f. = 1; P = 0.036) [Table 6]a and [Table 6]b. The lowest HR was recorded after completion of tooth extraction, i.e., during the suturing [Table 6]a and [Table 6]b.
The global mean SpO2 is 98.61 with a SD = 0.87 [Table 2]. Mean SpO2 value in male is 98.66 with SD = 0.87 and in female is 98.58 with SD = 0.87. This difference is not statistically significant (P = 0.28) [Table 3].
SpO2 variation with surgical time (F = 1.695; d.f. = 8; P = 0.0974) and in gender (F = 3.256; d.f. = 1; P = 0.1088) is not statistically significant [Table 7]a and [Table 7]b.
Anxiety and fear
Mean anxiety level in male is 9.07 ± 2.68 and in female is 11.3 ± 2.81. The difference in DAS values is significant (P = 0.0029). The females show higher level of anxiety than male, but DAS values in females and males are <12 which shows anxiety level low [Table 8], [Table 9], [Table 10].
|Table 8: Mean Dental Anxiety Scale , Dental Fear Scale and Visual Analog Scale score|
Click here to view
|Table 9: Mean systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation values by dental anxiety scale score|
Click here to view
|Table 10: Mean systolic blood pressure, diastolic blood pressure, heart rate, and oxygen saturation values by dental fear survey score|
Click here to view
In anxious patients mean DBP and mean HR is significantly high [Table 9] whereas degree of fear does not show any significant effect on mean SBP, DBP, HR and SpO2 [Table 10].
In more anxious patients, DBP in female patients [Table 11] and HR in male patients increase [Table 12]. In more anxious males, SpO2 showed significant changes [Table 13].
|Table 11: Mean diastolic blood pressure in male and female by dental anxiety scale scores|
Click here to view
|Table 12: Mean heart rate in male and female by dental anxiety scale scores|
Click here to view
|Table 13: Mean oxygen saturation in male and female by dental anxiety scale scores|
Click here to view
Mean DFS in male is 35.37 ± 5.69 and in female is 43.09 ± 6.09. The difference in DFS values is highly significant (P = 0.0001) [Table 8]. The females show higher level of fear [Table 8].
Mean degree of dental anxiety was low and dental fear was significantly high, according to the DAS and DFS assessed before the surgical procedure [Table 8].
However, as compared to males, the degree of anxiety and fear in females was significantly high with significantly higher mean score.[Table 8].
Degree of pain experienced during the surgical procedure was low, equivalent to 1 which indicated hurts little bit with Wong–Baker FACES pain rating scale assessed at the end of the treatment [Table 8].
| Discussion|| |
More than any other of the health sciences, dentistry has been associated with anxiety, fear, and pain. The anticipation of forthcoming dental treatment induces a physiologic stress response in patients that manifests in corticosteroid release, BP change, and hemodynamic and cardiovascular reactions. Most dental treatments are performed with the use of local anesthesia, and an increase in BP is common even in normotensive patients. This increase is influenced by many factors, such as psychological and physical stress, painful stimuli, and action of catecholamines present in local anesthetics. The DAS is designed to evaluate a patient's overall dental anxiety level. On the other hand, the DFS helps the clinician to focus on a patient's autonomic responses, avoidance, and fear of specific stimuli during dental procedures. In this study, all patients have completed Corah's DAS questionnaire before receiving anesthetic injection for dental extraction. The overall mean DAS score was 10.3 ± 2.95. This mean DAS score was slightly higher than earlier studies in adult patients, which reported values in the range from 9.3 ± 2.5 in Taiwan dental patients, 8.6 ± 3.7 in German dental patients, 7.87 ± 3.5 in Norwegian patients, and 7.26 ± 2.7 in patients from Denmark. In the present study, women tended to be more anxious than men (females 11.3 ± 2.81 and males 9.07 ± 2.68); a finding consistent with ter Horst and de Wit and Settineri et al.'s studies on dental anxiety., This finding might be explained on the basis that women have higher levels of neuroticism than men and that anxiety is positively associated with neuroticism., In this study, the mean age of the patient was 37 years. Mean anxiety level was low. Several studies have shown that younger people tend to have more severe dental anxiety than elderly people., However, in contrast to that, the present study shows low anxiety level in young patients which supported the result of Erten et al.'s study which concluded that age was not a factor affecting the anxiety level. In the present study, mean anxiety score and mean VAS score both were low. The result indicates that females were more anxious than males (females 11.3 ± 2.81 and males 9.07 ± 2.68) and higher VAS score was noted in females than males. This result is in consonance with the study by Averbuch and Katzper, who reported that postoperative baseline pain was significantly greater in females than in males after a third molar extraction procedure. However, Slater reported that females could tolerate pain more than males, indicating that males tend to bottle up their anxiety but females express their anxiety. Pain threshold in the male patients appears lower than females.
In the present study, all the patients included were operated in the morning. As the explanation by Hansson et al. in their study, they had explained about diurnal variation in endogenous steroid and opioid concentration may be the reason for the result that showed low mean anxiety and mean VAS score in the present study.
In the present study, patients with high dental anxiety had increase in HR and DBP during the surgical procedure. HR increases after the administration of local anesthetic solution. This result supported the result of Liau et al. The increase of HR and the alterations in BP during the injection may have been partly due to endogenous epinephrine release as a result of the emotional stress and not from the effect of local anesthetic. A study by Taggart et al. suggests that a stronger anticipatory response to stressful events, which can be measured by DAS, may result in increased HR and DBP. The association of emotional stress with enhanced sympathetic activity, tachycardia with increased plasma concentrations of epinephrine or norepinephrine, or both are possible mechanisms which may explain these effects.
Several studies,, reported that pain causes an alarm reaction manifested by hypothalamic oriented vasoconstriction and dilatation as well as the release of more epinephrine and norepinephrine. This results in increased in systemic arterial pressure and pulse rate immediately after injection and after extraction. In addition, pain may cause BP to rise due to the release of endogenous catecholamine plus psychosomatic fear of injection and the extraction.
Anderson and Reagan as well as Lilienthal and Reynolds, reported that attempts to assess patient anxiety subjectively during preoperative sessions were not necessarily useful because patients who appeared calm or who claimed to be without anxiety, which may show signs of significant physiologic stress during dental procedures when monitored electronically.
These findings highlight the need for using an objective instrument such as Corah's DAS to assess anxiety. Corah DAS was proven to be popular among dental researchers to assess dental anxiety. It is a simple, easy to score, short, valid, and reliable test for dental visit-associated anxiety. The contribution of pain expectations to dental anxiety, and also to dental avoidance, suggests that this might usefully be a specific focus of intervention in programs to reduce dental anxiety.
In this study, HR significantly increases 4 min after local anesthesia and then gradually decreases. Lowest value was recorded after completion of extraction of the tooth. SBP and DBP significantly increase at the time of ostectomy and extraction of the tooth. These findings are consistent with the findings of Meyer and Vernale, who observed that increase in HR and alteration in BP before injection and during extraction are possibly an expression of an endogenous catecholamine release as a result of emotional stress and not pharmacological effect. These hemodynamic changes caused by emotional stress mask the alterations caused by exogenously active catecholamines. Fear, anxiety, and expectation or experience of pain are special stress factors in this situation. The study by Taggart et al. supports the present study concluding that emotional stress is conventionally considered to be associated with tachycardia and enhanced sympathetic activity. Salonen et al. supported the result of the present study showing increased HR after the injection of lidocaine with adrenaline but HR remained unaltered after plain lignocaine. They reported that the adrenaline concentration was higher during surgery than the baseline level. According to Silvestre et al. and James et al., the fact of using or not using a vasoconstrictor with local anesthetic solution exerts no effect upon BP in normotensive patients though a certain increase in SBP was noted at moment of tooth extraction and at the end of the procedure. This was attributed to increased patient anxiety during extraction, taking into account that the difference was comparatively greater between SBP at the start of the procedure and at the actual moment of extraction. In the present study, SBP and DBP significantly increase at the time of ostectomy and tooth extraction; these findings are consistent with the study by Brand and Yoshito Nakamura. As per Brand et al. and et al., changes in mean HR and mean SBP and DBP are induced in both the patient's anticipation of scheduled treatment and the actual dental treatment itself. Significant changes have been observed before application of a local anesthetic, during restorative treatment, and during extraction. These cardiovascular responses may vary according to the local anesthetic used and the choice of vasoconstrictor. The individual changes in HR and BP are affected by pain and such individual factors as age, gender, hypertension, dental experience, and psychological responses. The study by Silvestre et al. on the evaluation of hemodynamic changes in controlled hypertensive during extraction showed no significant hemodynamic changes attributable to anesthetic use with a vasoconstrictor.
For successful dental treatment, a gentle, supportive, professional, sympathetic, quiet, and more considerate approach should be followed when managing patients with dental anxiety. On their first visit, patients should be dealt with more sensitively to avoid increasing their anxiety and thus avoid their repulsion to dental care.
| Conclusion|| |
The present study suggests that dental anxiety impacts the effect of delivery of local anesthesia on BP and is significantly associated with increased HR. As the literature shows the cases of fainting, collapse, shock, coma, death during minor dental surgical procedures, monitoring the vitals during minor surgical procedures in the healthy as well as medically compromised patients helps the dentist detect acute medical emergencies or preventive measures that are rendered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fukayama H, Yagiela JA. Monitoring of vital signs during dental care. Int Dent J 2006;56:102-8.
Cioffi GA, Chernow B, Glahn RP, Terezhalmy GT, Lake CR. The hemodynamic and plasma catecholamine responses to routine restorative dental care. J Am Dent Assoc 1985;111:67-70.
Davenport RE, Porcelli RJ, Iacono VJ, Bonura CF, Mallis GI, Baer PN, et al.
Effects of anesthetics containing epinephrine on catecholamine levels during periodontal surgery. J Periodontol 1990;61:553-8.
Fernieini EM, Bennett JD, Silverman DG, Halaszynski TM. Hemodynamic assessment of local anesthetic administration by laser Doppler flowmetry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:526-30.
Miller RA, Siegelman LI. Dental anesthetic management of a patient with ventricular arrhythmias. Anesth Prog 1998;45:68-73.
Matsumura K, Miura K, Takata Y, Abe I, Fujishima M: Changes in blood pressure and autonomic nervous system in dental treatment with use of local anesthesia. Cardiovasc Rev Rep 2000;21:35-9.
Matsumura K, Miura K, Takata Y, Kurokawa H, Kajiyama M, Abe I, et al.
Changes in blood pressure and heart rate variability during dental surgery. Am J Hypertens 1998;11:1376-80.
Kleinknecht RA, Klepac RK, Alexander LD. Origins and characteristics of fear of dentistry. J Am Dent Assoc 1973;86:842-8.
Liau FL, Kok SH, Lee JJ, Kuo RC, Hwang CR, Yang PJ, et al.
Cardiovascular influence of dental anxiety during local anesthesia for tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:16-26.
Erten H, Akarslan ZZ, Bodrumlu E. Dental fear and anxiety levels of patients attending a dental clinic. Quintessence Int 2006;37:304-10.
Kunzelmann KH, Dünninger P. Dental fear and pain: Effect on patient's perception of the dentist. Community Dent Oral Epidemiol 1990;18:264-6.
Neverlien PO. Normative data for corah's dental anxiety scale (DAS) for the Norwegian adult population. Community Dent Oral Epidemiol 1990;18:162.
Schwarz E. Dental anxiety in young adult Danes under alternative dental care programs. Scand J Dent Res 1990;98:442-50.
ter Horst G, de Wit CA. Review of behavioural research in dentistry 1987-1992: Dental anxiety, dentist-patient relationship, compliance and dental attendance. Int Dent J 1993;43:265-78.
Settineri S, Tati F, Fanara G. Gender differences in dental anxiety: Is the chair position important? J Contemp Dent Pract 2005;6:115-22.
Freeman R. A psychodynamic theory for dental phobia. Br Dent J 1998;184:170-2.
Freeman R. The psychology of dental patient care 9. Communicating effectively: Some practical suggestions. Br Dent J 1999;187:240-4.
Elter JR, Strauss RP, Beck JD. Assessing dental anxiety, dental care use and oral status in older adults. J Am Dent Assoc 1997;128:591-7.
Locker D, Liddell AM. Correlates of dental anxiety among older adults. J Dent Res 1991;70:198-203.
Averbuch M, Katzper M. A search for sex differences in response to analgesia. Arch Intern Med 2000;160:3424-8.
Slater PJ. Patterns of access to public oral health care in Queensland by gender, indigenous status and rurality. Aust Dent J 2001;46:122-33.
Hansson P, Ekblom A, Thomsson M, Fjellner B. Pain development and consumption of analgesics after oral surgery in relation to personality characteristics. Pain 1989;37:271-7.
Taggart P, Hedworth-Whitty R, Carruthers M, Gordon PD. Observations on electrocardiogram and plasma catecholamines during dental procedures: The forgotten vagus. Br Med J 1976;2:787-9.
Hondrum SO. Hypertensive episode in the dental office. Gen Dent 1985;33:134-9.
Gortzak RA, Abraham-Inpijn L. Pain-induced hypertensive episode in the dental office. Gen Dent 1995;43:274-6.
Vernale CA. Cardiovascular responses to local dental anesthesia with epinephrine in normotensive and hypertensive subjects. Oral Surg Oral Med Oral Pathol 1960;13:942-52.
Anderson LD, Reagan SE. Local anesthetics and vasoconstrictors in patients with compromised cardiovascular systems. Gen Dent 1993;41:161-4.
Lilienthal B, Reynolds AK. Cardiovascular responses to intraosseous injections containing catecholamines. Oral Surg Oral Med Oral Pathol 1975;40:574-83.
Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
Savithri NV, Esa R. Dental fear and utilization behaviour among antenatal mothers in Seremban district. Ann Dent Univ Malaya 2008;15:27-32.
Meyer FU. Haemodynamic changes under emotional stress following a minor surgical procedure under local anaesthesia. Int J Oral Maxillofac Surg 1987;16:688-94.
Salonen M, Forssell H, Scheinin M. Local dental anaesthesia with lidocaine and adrenaline. Effects on plasma catecholamines, heart rate and blood pressure. Int J Oral Maxillofac Surg 1988;17:392-4.
Silvestre FJ, Verdú MJ, Sanchís JM, Grau D, Peñarrocha M. Effects of vasoconstrictors in dentistry upon systolic and diastolic arterial pressure. Med Oral 2001;6:57-63.
James O, Ladeinde AL, Ogunlewe MO. Hemodynamic response after injection of local anesthetics with or without adrenaline in adult Nigerian subjects undergoing simple tooth extraction. J Clin Sci 2015;12:90-5. [Full text]
Brand HS, Gortzak RA, Palmer-Bouva CC, Abraham RE, Abraham-Inpijn L. Cardiovascular and neuroendocrine responses during acute stress induced by different types of dental treatment. Int Dent J 1995;45:45-8.
Nakamura Y, Matsumura K, Miura K, Kurokawa H, Abe I, Takata Y, et al.
Cardiovascular and sympathetic responses to dental surgery with local anesthesia. Hypertens Res 2001;24:209-14.
Silvestre FJ, Salvador-Martínez I, Bautista D, Silvestre-Rangil J. Clinical study of hemodynamic changes during extraction in controlled hypertensive patients. Med Oral Patol Oral Cir Bucal 2011;16:e354-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]