Date and place of thesis defense:
05.12. 2012, Zenica
Prof. dr. sc. Lejla Ibrahimagić-Šeper
Thesis title: Značaj prevencije anksioznosti i bola kod oralno-hirurškog zahvata i njihov utjecaj na vitalne parametre
After oral surgery, greater or lesser extent of trauma to surrounding tissue after the intervention, post-surgery complications will arise. Correlation between surgical removal of impacted third molars and potential complications is quite common. Complications were ranked as the expected and predictable, such as swelling, pain, trismus and serious and permanent complications, such as paresthesia n.alveolaris inferior of the n. lingualis and fracture of the mandible. Increasing incidence of complications and seriousness of complication are most directly associated with impaction depth and age of the patient. Removal of impacted teeth in elderly patients is associated with increased incidence of post-surgery complications, especially alveolar osteitis and inferior alveolar nerve anesthesia Removal of complete bone impaction is most widely associated with increased post-surgery pain and the increasing incidence of inferior alveolar nerve anesthesia.
Using the pharmacological volume control of inflammation, the intensity of post-surgery complications, pain in particular, can be significantly reduced. However, the mere knowledge of the existence of post-surgery complications, especially post-surgery pain, and uncertainty about the intensity of such complication and the outcome of the surgery, waiting times for the start of the intervention, is not encountered with same attitude in all patients who expect oral surgical procedure, and may produce the development of pre-surgery anxiety and post-surgery anxiety in a greater or lesser extent due to the surgery experience.
Modern techniques of oral surgery and current therapeutic approach to pain control make painless oral surgery practice a reality. Still, the results of many studies suggest that most people avoid oral surgical intervention for fear of pain. Increasing frequency of patients with the unpleasant experience is what a large number of oral surgeons and psychologists experience.
A large number of patients avoid another trip to the intervention due to experienced unpleasant oral surgery, although there are indications for surgery, which inevitably leads to worsening of health situation.
Oral surgery is undoubtedly a stressful situation and "stress", as a general term, means a reaction that involves psychological and physiological components.
Occurrence of syncope or collapse before or during oral surgical procedures is not a rare occurrence for patients who have not been prepared psychologically or patients who had an unpleasant experience and were sent for oral surgery again. In fact, the intensity of psychological reactions depends on the intensity of mental effort of the patient to cope with challenging situations, which oral surgical procedure inevitably brings.
Some studies suggest connection between anxiety caused by going to the dentist with the anxiety caused by oral surgery procedure, given the logic of association, since both interventions, dental and oral surgery are carried in the mouth.
Of course, change of the status of anxiety caused by the oral surgical procedure can lead to changes in vital parameters such as blood pressure, pulse and breathing rate.
The assessment of anxiety and anxiety disorders in clinical practice using the clinical interview and examination, anamnestic data and heteroanaemnestic data.
Clinical instruments for assessment of anxiety have been developed for the needs of objectification of the current clinical status, distinguishing between symptoms, assessment of their intensity and monitoring during treatment.
Clinical instruments are not present in everyday use, but their use for research (epidemiological, therapeutic, diagnostic studies) is unquestionable. Assessment of clinicians about the need to measure the presence and severity of symptoms depends on the clinical situation and interests, but also on the patient as a participant, i.e. participant in research study.
The most commonly used clinical instruments are scales, which can measure the intensity of symptoms, or the questionnaire, which are often for self-evaluation and reveal the presence of symptoms.
It is not always easy to choose the instrument of measurement that will meet the objectives of the test.
Known scales are usually used in the study, use of which has resulted in good experiences, but sometimes, if necessary, the scale can be constructed for a specific measurement in the study.
Reliability and sensitivity of the scale is significant in the selection of scale, as well as good psychometric properties, simplicity of application and time of application. Simplicity of data processing is critical for use of data. M
The aim of our study was to determine the level of anxiety in oral surgery and its impact on the value of vital parameters (blood pressure, pulse and breathing rate) during the three days of measurements (the day of examination, immediately before the intervention and 1 day after the intervention) and on pain measurement on the third day. We also evaluated dental anxiety and its impact on the level of pre-surgery and post-surgery anxiety in oral surgery, and determined the difference between men and women in all measured parameters provided by the research protocol
Place of study: Department of Oral Surgery of the Dental Department at the PI Institute Health Center Zenica in Zenica.
The study included 501 patients indicated for removal of maxillary and mandibular impacted third molars with fully completed growth and root development and mesio angular position. Same operative approach was applied with standard surgical instruments. Each patient was given adequate oral surgical pre-surgery and post-surgery therapy, which included analgesic, antibiotic and antiphlogistic medication.
Patients were divided into groups using different aspects. According to the location of surgical procedure in a group, surgical interventions on impacted teeth were carried out in the operating room and group where the surgery was conducted in the outpatient clinic. According to the protocol of Nakazata et. al., we created groups of patients based on grade scores for anxiety: patients with very high, high, moderate and low anxiety. Each group included patients of both genders, aged between 18-45 years of age without contraindications to medications and anesthetic that were planned for use in research.
Based on the protocol of Gedik et. al., we created age groups of patients: 18-20, 21-29, 30-39 and 40-45.
After the clinical examination and X-ray analysis of the corresponding images, which were developed using orthopantogram, each patient was diagnosed with impacted maxillary and mandibular third molar or molars.
Criteria for exclusion of patients included: kidney or liver disease, blood diseases, former and present gastric ulcers, heart disease, proven hypersensitivity, allergic reactions to some of the research medication, pregnancy and lactation. All elected candidates have been without pain and other inflammatory symptoms including swelling, hyperemia and decreased mouth opening at the time of surgery.
The study did not include patients who did not accept the pre-surgery measurements and post-surgery planned study protocol. With the prior consent after the patients were clearly informed about the upcoming intervention, impacted teeth of patients involved in the study were extracted, under local anesthesia using a dose of 4 cc 2% lidocaine with epinephrine (1: 80 000).
In this study, pre-surgery and post-surgery levels of patients’ anxiety after surgical removal of impacted third maxillary and mandibular molars, were assessed as follows: Day 1 (examination) - DAS scale, STAI Form (X1 and X2); Day 2 (just before the intervention) - STAI Form (X1 and X2) and Day 3 (the day after surgery) - STAI Form (X1 and X2)
Assessment of vital parameters, and measurement of blood pressure, heart rate, respiratory rate was carried out using a digital pressure gauge that measures the value of all three simultaneously. Each measurement was repeated five times, every two minutes. The data were entered in Table 1, 2.3 for all three days of measurements according to the study protocol.
In this study, the level of post-surgery patients’ pain after surgical removal of impacted third maxillary and mandibular molars, was assessed based on VAS (visual analogue scale)
Data from this study were statistically analyzed and presented in tables and graphs and compared with the results of research between research groups. In order to confirm the hypotheses and for a statistical analysis of data from the aspect of significance, we used the following statistical methods: Standard methods of descriptive statistics (measures of central tendency and dispersion) ANOVA, Tukey's F - test for testing of the variance between groups, t - test for significance of differences of characteristic patterns given are parameter form, Pearson's χ 2 - test to determine statistically significant differences between the characteristics of individual samples given in the non-parameter form. Level of significance was p <0.01.
For these analyzes we used computer software packages Microsoft Excel 2007, and IBM SPSS Realise 20.0.
To view the histogram frequency plots we used Columna, and cumulative frequency tables
Correlation of results for the above parameters on the first (DAS-R, X1 and X2), the second (X1 and X2) and third (X1 and X2) day of measurement was statistically significant; Table 30, 31, (p <0.01). Very high correlation coefficients between DASR and X1 and X2 in the first two measurements (the day of examination and immediately before surgery), and the mutual correlation between X1 and X2 in the first two measurements was somewhat less in correlation with the third measurement after surgeries. This means that during the third day of measurements there was a significant change in anxiety for some patients, and this was reflected in reduction of the coefficient of correlation, which is logical considering that there is a tendency for decrease of anxiety after oral surgery.
Statistically significant correlation between dental anxiety assessed with the DAS-R at the day of the patient examination and the correlation coefficient for the X1 and X2 estimated on the first, second and third day of measurement, suggests that patients with dental anxiety revealed correlating values for pre-surgery and post-surgery general and momentary anxiety.
Correlation of results for mentioned parameters for the first (DAS-R, KP1_S, KP1_D, PULS1 and DIS1), second (DAS-R, KP2_S, KP2_D, PULS2 and DIS2) and third (DAS-R, KP3_S, KP3_D, PULS3 and DIS3) day is statistically significant; Table 32, 34.36 (p <0.01). Results suggest that people with high dental anxiety had consequently correlating values of measured vital parameters, blood pressure, and pulse and respiration rate for all three days of measurements. At the same time there was a decrease in correlation coefficients for the third day of measurements, as well as the values of measured parameters provided in the research protocol, which is explained by the fact that oral surgical procedure was completed, so the psychological burden on patients and consequently “response” of organism was also lower.
Tables 39.40 and 41; (p <0.01) give values of the basic statistical parameters of pairs of X1 and X2 for days of measurements, their correlation coefficients and values of paired t-test parameters from which we can conclude that there are significant differences between pairs of parameters for different days and that the anxiety of patients decreased with the days of measurement, and patients became less anxious during the surgery and after surgery.
Tables 42.43 and 44; (p <0.01) give values of the basic statistical parameters of pairs of vital parameters for days of measurements, their correlation coefficients and values of paired t-test parameters from which we can conclude that there were significant differences between pairs of parameters according to days and that the value of vital parameters of patients on the first and second day of measurement decreased compared to the third day of measurement, i.e. after the surgery, which is logical. Increase in the value of the vital parameters on the second day of measurement compared to the first day of measurement was statistically insignificant, and elevated vital parameters measured immediately before oral surgical procedure were slightly elevated in comparison to the initial values that were measured on the day of examination.
Tables 49-64. give frequency and percentages of the monitored parameters during the study by gender. The value of Pearson χ 2 and the value α = 0.000 test, and p <0.01 indicate a statistically significant difference in the prevalence of parameters by gender.
In order to confirm the results of statistically significant differences between anxiety parameters and vital parameters we also performed testing with ANOVA test. The obtained values of the F-test according to ANOVA and comparison with the table values (with standard table values) can fully confirmed previously determined statistically significant difference of anxiety and vital parameters in men and women according to days of measurement; Table 65 and 66, p < 0.01. Generally it can be concluded that women are much more sensitive and values of all parameters were larger compared to men.
Based on analysis of data from tables 76 and 77, and cross tables, as well as the values of the F-test, we can conclude that there was no statistically significant difference between the parameter values according to location of the surgery.
Discussion analyses our results and those of other researchers.
Based on the results of research we came to the following conclusions for set objectives:
- Average value of the parameters of current and general anxiety estimated using Spielberg patterns X1 and X2 with respect to the total sample was:
for the first day of measurement X1 = 47.03; X2 = 50.99 (Table 8, 10,11,12,13)
for the second day of measurement X1 = 46.014, X2 = 50.11 (Table 15, 16:17)
for the third day of measurements X1 = 39.01; X2 = 41.91 (Table 19,20,21)
Average estimated value of the anxiety based on the Corah’s questionnaire for Dental anxiety was 14.32 (Table 8)
- The level of pain on the third day of measurements, assessed using VAS ranged from 2 to 3 for 23.4% of patients, 4 to 5 for 25.4% of patients and 6 to 9 for 50.6% of patients. (Table 23, 24 , 63.64)
- There was a statistically significant correlation between the intensity of anxiety assessed on the basis Spielberg’s forms X1, X2, and post-surgery pain levels (p <0.01) (Table 36), with a positive correlation between these parameters and a higher level of anxiety producing more pain and vice versa.
- There was a positive correlation and statistically significant connection between anxiety assessed with Spielberg’s forms X1 and X2 with the values of vital parameters (blood pressure, pulse and breathing rate) for all three days of measurement (p <0.01) (Table 33, 35, 37)
- There was a statistically significant connection between dental anxiety assessed using the DAS-R with pre-surgery anxiety and post-surgery anxiety using Spielberg’s forms X1 and X2 (p <0.01). Positive correlation indicates that the higher the R-DAS is followed with increased anxiety before and after oral surgery (Table 30)
- There was a statistically significant difference between female patients and male patients for dental anxiety estimated by DAS-R, which was higher for female patients (p <0.01) (Table 49, 50)
- There was a statistically significant difference between female patients and male patients for the current anxiety estimated by Spielberg form X1, which was higher for female patients on the first, second and third day of measurement (p <0.01) (Table 51, 52.55 , 56, 59.60)
- There was a statistically significant difference between female patients and male patients for general anxiety estimated using Spielberg’s form X2, which was higher for female patients on the first, second and third day of measurement (p <0.01) (Table 53, 54, 57, 58, 61, 62)
- There was a statistically significant difference between female patients and male patients for post-surgery pain assessed with VAS- on the third day of measurements which was greater for female patients (p <0.01) (Table 63, 64)
- There was a statistically significant difference between female patients and male patients in the intensity changes of vital parameters caused by different values of the intensity of pre-surgery and post-surgery anxiety, whose scores were higher for women for all three days of measurement (p <0.01) (Table 65, 66)
There was no statistically significant difference between the measured values for the parameters of anxiety and vital parameters from the study protocol provided for oral surgery procedures performed in the operating room and ambulatory surgery (p> 0.01) (Table 76, 77)
Key words: Prevention, anxiety, pain, oral surgery, vital parameters