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The impact of preoperative anxiety on post-operative outcomes in patients undergoing third molar surgery

Q H. Fang*1 BHSc(Dent) MDent
P. Taneja2,3 BDS MJDF RCS (Eng) MOralSurg PG Cert (Clin Res) PG Dip PhD
1University of Newcastle, School of Medicine and Public Health, 77a Holden Street, Gosford NSW, 2250
2Sydney Dental Hospital, Department of Oral Surgery and Oral Medicine, 2 Chalmers Street, Surrey Hills NSW, 2010
3University of Sydney, School of Clinical Dentistry, 2 Chalmers Street, Surrey Hills, NSW, 2010
*Correspondence to: Dr. Qing Hui Fang
Email: qfang90@gmail.com
Fang Q H, Taneja P. The impact of pre-operative anxiety on post-operative outcomes in patients undergoing third molar surgery SAAD Dig. 2025: 41(I): 8-12

Abstract

Pre-operative anxiety refers to the psychological distress experienced by patients prior to treatment. There is emerging evidence demonstrating the relationship between pre-operative anxiety and post-operative complications. However, there is a dearth of knowledge in fully elucidating the relationship between pre-operative anxiety and post-operative pain, infection, oedema and trismus following third molar removal. Therefore, this review aims to investigate the impact of pre-operative anxiety on post-operative outcomes following lower third molar surgery (LM3).

Effective management strategies are essential to mitigate pre-operative anxiety and optimise surgical outcomes. Such strategies can be divided into non-pharmacological and pharmacological. Non-pharmacological interventions such as cognitive behavioural therapy and comprehensive patient education offer promising avenues for long term anxiety management. Pharmacological options such as benzodiazepines, provide rapid anxiety relief, albeit with varying efficacy and potential drawbacks.

This review identifies that pre-operative anxiety can induce a series of physiological stress responses that directly play a role in increasing the risk of post-operative pain, infection, oedema and trismus. A multi-modal approach to pre-operative anxiety management is paramount to address the multifaceted nature of anxiety and its impact on surgical outcomes. By integrating interventions that target both physiological and psychological aspects of anxiety, clinicians can help to minimise post-operative complications.

Key learning points

  1. Pre-operative anxiety specific to dentistry can be screened using standardised measurement questionnaires such as the Modified Dental Anxiety Scale (MDAS) prior to LM3 removal.
  2. Pre-operative anxiety has been linked to an increase in the risk of post-operative pain, infection, oedema and trismus in LM3 removal through inducing a series of physiological stress responses.
  3. Non-pharmacological interventions such as cognitive behavioural therapy should be the first line of treatment for managing anxiety as they are effective in reducing long term anxiety levels, though pharmacological options such as benzodiazepines are available when immediate anxiety relief is required.

Background

Lower third molar surgery (LM3) often involves elevating a mucoperiosteal flap, ostectomy and tooth division.1 Patients can therefore be concerned that the procedure may encompass pain and discomfort, particularly so if the patient suffers from dental anxiety.2

Dental anxiety is defined as anxiety associated with attending the dentist for preventive care or for a dental procedure.3 Such pre- operative anxiety poses a significant challenge in optimising patient comfort and surgical outcomes.4 For example, co-operation may be compromised by anxious patients who opt to undergo procedures, placing a greater stress on the operating surgeon and in turn, extending the overall surgical time and thereby the duration of the stressful event.4

Anxiety can be classified into state anxiety or trait anxiety. Trait anxiety is defined as an individual's predisposition to respond to situations they perceive as threatening with heightened anxiety and is often consistent with an individual’s personality and thinking.5 Conversely, state anxiety is a physiological transient reaction to an adverse situation at a specific moment.5 For example, an individual who has trait anxiety will constantly feel worried about their physical health even when there is no sign of illness, whereas someone who has state anxiety will only feel worried when there are symptoms associated with the illness. For pre-operative anxiety, particularly with LM3 removal, it is often considered as state anxiety since it is fear that varies in time and intensity depending on the presence of an anxiety-provoking stimulus such as surgery and an individual's stress coping mechanism.6

Pre-operative anxiety has been identified to begin at the time that the procedure is planned, peaking on the day of treatment.7 Such anxiety has been noted to be associated with physical changes such as tachycardic episodes, hypertension, increased body temperature and decreased immune response.8 These factors can contribute to the surgical outcome, post-operative recovery, as well as lead to an increased volume of anaesthetic required for the surgery, increasing the risk of adverse events and drug interactions.9

Specific to LM3 removal, there are a number of factors that contribute to the development of pre-operative anxiety. For example, an increased extraction difficulty; characterised by the patient's age, deep impaction of third molar, distal angulation and a close proximity of LM3 roots to the inferior alveolar canal.1 These factors can contribute to an increased operation time which can alter the patient’s behaviour pre- and peri-operatively due to the fear of potential complications arising from the surgery which may delay post-operative recovery.10 Other contributing factors that can increase pre-operative anxiety include the fear of anaesthetic injections, pain, post-operative complications and the lack of pre- operative information.11 Trauma responses related to previous surgical interventions,12 and past experiences, of physical, psychological, or sexual abuse are also important yet under-recognised contributors to anxiety in the medical setting.13 McCleane and Cooper9 demonstrated that patients who have higher anxiety scores require additional information compared to those who have a lower anxiety score.

Currently, there is growing evidence demonstrating the relationship between pre-operative anxiety and negative post- operative outcomes, both somatic and psychological, which can affect peri-operative anaesthesia, treatment outcome and post- operative recovery.14 However, there is a dearth of knowledge on the impact of pre-operative anxiety and post-operative morbidity following LM3 removal. Therefore, the present review aims to explore the relationship between pre-operative anxiety and its impact on post-operative pain, infection, oedema and trismus, as well as discuss potential management options to aid in reducing pre-operative anxiety, specific to LM3 removal.

Identifying and evaluating pre-operative anxiety

Pre-operative anxiety can be identified at the dental consultation from behavioural clues elicited by the patient.15,16 During this time, the practitioner is advised to use open-ended questions as they encourage the patient to steer the conversation towards their concerns.17 In addition, sufficient time should be given to allow the patient to communicate, and within quiet surroundings.17

Questionnaires have been developed to help identify and understand the causes and level of anxiety,18 allowing for a customised approach to its management.19 These tools are useful for gaining subjective insights, as discrepancies can often exist between patients' self-reported anxiety and the clinicians' evaluation.2

Several anxiety questionnaires are available, each with their own limitations, making it challenging for practitioners to determine the most suitable.17 A study by Newton and Buck20 aimed to identify the most reliable, valid and useful anxiety measures in dentistry. It was concluded that the Modified Dental Anxiety Scale (MDAS) was the most effective.21 The reason for this is that the scale accounts for patients' ratings of specific dental situations as well as providing a scoring system that allows the user to understand the patient’s degree of anxiety, hence, facilitating greater communication and allowing the clinician to provide a tailored intervention planning. Furthermore, the MDAS was noted for its ease of use and high levels of reliability and validity, with easy accessibility.15,21

Post-operative pain and pre-operative anxiety

Post-operative pain is a complex physiological reaction to tissue injury influenced by the patient’s autonomic, psychological and behavioural responses.22 Although there are improved management strategies for reducing acute post-operative pain following LM3 removal, the outcome can still vary largely between patients and particularly remains a problem for those who present with anxiety.3 This is because anxiety is linked to an increase in pain perception from a painful stimulus, resulting in greater experienced pain that lasts for longer than expected.3 This can be attributed to a physiological increase in endogenous inflammatory mediators and neurotransmitters which are induced by anxiety.23 For example, anxiety has been identified to increase serotonin (5-HT), of which 5-HT3 causes nociceptive excitation and 5-HT2 sensitises primary afferent fibres.24 Collectively, these result in peripheral sensitisation, hyperalgesia and spinal nociceptive processing which can extend the pain experience.25 Furthermore, there is an increase in prostaglandin E2 (PGE2), which is one of the primary inflammatory mediators that can cause acute local inflammation and promote excitability of the peripheral somatosensory system, resulting in inflammatory and neuropathic pain.26

Anxiety has also been found to cause a decrease in pre-synaptic gamma-aminobutyric acid (GABA) release. GABA has an inhibitory effect that dampens the anxiety response and pain perception. Therefore, a decrease in GABA release may result in pain and hyperalgesia.27

Attentional bias has also been found to play a role in acute post- operative pain.28 It refers to the tendency of patients to selectively focus their attention on pain-related information while ignoring others, often influenced by their emotional state.29 Patients who are attentionally biased towards positive experiences prior to surgery may lack the psychological preparation required to cope with post-operative pain in its acute phase following LM3 removal.29,30 Conversely, patients who have attentional bias towards pain-related stimuli or negative experiences prior to surgery are adapted at managing acute post-surgical pain due to their ability to timely manage and cope with the pain.29 However, patients are also more likely to develop chronic, postsurgical pain if they have sustained negative thoughts that extend beyond the preparation phase, due to their excessive focus on the sensation of pain which increases and prolongs the pain intensity.28 This phenomenon is known as pain catastrophizing and is found to be closely related with mood and personality variables, such as state and trait anxiety.31

The concern with pain catastrophising is its significance in both pain perception and analgesic consumption following LM3 removal. Altan, Akkoc, Erdil, Colak, Demir, and Altan32 identified that patients with greater scores on the pain catastrophising scale (PCS) reported higher levels of pain intensity and analgesic consumption. This poses a challenge for post-operative recovery, complicating overall patient outcomes. Therefore, comprehensive pain management strategies that address both the physiological aspects, such as inflammation and muscle tension, and psychological aspects of pain, including fear and anxiety, are crucial for improving recovery.33

Post-operative infection and preoperative anxiety

Post-operative infection following LM3 surgery has been reported to vary from 0.8% to 10.1% and is associated with pain, trismus and swelling.34,35 Post-operative infection has a complex interplay with pre-operative anxiety involving physiological, immunological and behavioural mechanisms.

Physiologically, pre-operative anxiety has been found to increase the release of endogenous stress hormones, primarily glucocorticoids and catecholamines.36 Glucocorticoids provide an anti-inflammatory and immunosuppressive effect as they decrease the production of pro-inflammatory cytokines, prostaglandins and leukotrienes which are crucial in mediating the innate and adaptive immune system to defend the body from foreign pathogens.37 Additionally, glucocorticoids also suppress the phagocytic ability of macrophages, inhibit neutrophil infiltration to the injurious site and T cells activation.37 These cells play a crucial role in mediating an inflammatory response to tissue injury and infection.38 By attenuating these critical immune responses, glucocorticoids foster an environment conducive to bacterial proliferation at the extraction site, thereby increasing the risk of post-operative infection following LM3 removal. In cases where patients have chronic anxiety, they may have a sustained high glucocorticoids concentration, which can persistently downregulate the cellular and humoral immunity resulting in a non-healing wound.39

Catecholamines, such as adrenaline, can cause wound hypoxia via vasoconstriction, decreasing vascular permeability and impairing angiogenesis.40 As a result, these combined effects create an environment conducive for bacterial growth, increasing the risk of bacterial infection and an impaired wound healing.36

It is well established that highly anxious individuals are more likely to adopt health damaging behaviours such as increased alcohol consumption or smoking.36 This is a result of a temporary sense of relaxation, by suppressing their anxiety symptoms, that accompanies the use of these substances.36 However, these behaviours can increase the likelihood of a post-operative infection following LM3 removal.36 Nonetheless, these behaviours are maladaptive in the long term as they do not address the underlying problem which can perpetuate patients’ anxiety and increase the risk of post-operative infection.41

Patients with heightened pre-operative state anxiety have been identified as more likely to neglect their oral hygiene practices, possibly due to their preoccupation with the upcoming surgery.42,43 For some of these patients with higher levels of anxiety, they may also perceive that refraining from brushing and flossing can help to alleviate pain following LM3 surgery, as it avoids direct contact with the surgical site thereby reducing mechanical irritation and minimising discomfort during the initial healing period.44 However, the potential result is that bacterial colonisation is promoted, and the lack of mechanical disruption to the oral biofilm that occurs with brushing may result in an infection.

  Oedema, trismus and pre-operative anxiety

In addition to pain and infection, preoperative anxiety can also increase the risk of postoperative oedema following LM3 surgery. The underlying mechanisms are similar to those explained for pain and infection, involving an intricate interplay of neuroendocrine pathways and inflammatory processes.45 This can increase the vascular permeability and cause vasodilation at the surgical site which allows plasma proteins and fluid to leak into the surrounding tissues, resulting in oedema formation. Additionally, the inflammatory response mediated by these cytokines can attract immune cells to the area, further exacerbating tissue swelling and oedema observed in LM3 removal.45

Trismus is defined as the reduction in jaw opening with equal to or less than 35 mm which usually occurs at day three post-operatively following LM3 surgery.46 For patients with pre-operative anxiety, the risk of trismus increases significantly due to the physiological increase in skeletal muscle activity via the ‘fight-or-flight’ response as a reflex reaction to stress.46 Anxiety can also distract patients from recognising the build-up of prolonged static tension in the overactive masticatory muscles following LM3 removal due to their preoccupation with excessive worry.47 This can cause muscle exhaustion which predisposes patients to developing painful muscle tension and spasm, contributing to trismus.47

Pharmacological and non- pharmacological management strategies for pre-operative anxiety

Pre-operative anxiety is a significant concern for patients undergoing LM3 removal as it can heighten pain perception, increase the risk of post-operative infection and oedema, all of which delay recovery and decrease quality of life.48 Therefore, it is imperative for clinicians to familiarise themselves with various management strategies so they can tailor their intervention to minimise post-operative complications and address any challenges posed by pre-operative anxiety. This ensures effective patient emotional control and optimal surgical outcomes to foster a positive patient experience. Management strategies specific to anxiety include both non-pharmacological and pharmacological approaches which can be adopted either independently or combined to manage the physical and psychological aspects of patient care, enhancing treatment outcomes.

Non-pharmacological interventions play a vital role in mitigating preoperative anxiety and promoting patient comfort during surgical procedures. They should be considered as the first line of treatment due to their ability to achieve longer-lasting benefits and lower relapse rates compared to pharmacotherapy.49 Such interventions include cognitive behavioural therapy, pre-operative education and relaxation techniques such as deep breathing and guided imagery.50

Pre-operative anxiety related to LM3 removal can be reduced by providing the patient with information on the procedure regarding the potential risks, benefits and post-operative care instructions,51 via a variety of methods including, written, verbal or video communication.52 Clinicians should ensure that they have accessible information for patients and guide them in understanding the procedure and the techniques available to alleviate their anxiety.

There is a risk that patients become over reliant and accustomed to pharmacotherapy if they are not allowed to acclimatise to the treatment via non-pharmacological interventions. Cognitive behavioural therapy (CBT) has emerged as a valuable non-pharmacological strategy which focuses on identifying and modifying negative thought patterns and behaviours associated with anxiety.53 Through techniques such as relaxation exercises, guided imagery and systematic desensitization, CBT helps patients develop coping skills to manage anxiety effectively.

Pharmacological interventions that aid in reducing pre-operative anxiety during LM3 removal can provide rapid and reliable anxiety relief.54 Benzodiazepines are common choices of anxiolytic medications in dentistry due to their efficacy in managing anxiety disorders and can be delivered in a number of forms, eg oral, intravenous and etc by dental practitioners (albeit with additional training).55 Their mechanism of action involves enhancing the inhibitory effects of GABA, the primary inhibitory neurotransmitter in the central nervous system.56 By binding onto GABA receptors, benzodiazepines potentiate GABAergic neurotransmission, resulting in anxiolytic, sedative and muscle relaxant effects.57

Pre-medication refers to the administration of a small dose of medication orally before a procedure. Its purpose is to reduce patient anxiety while allowing them to remain responsive to verbal commands and maintain normal physiological functions58. The calming effects of pre-medications have been reported by dentists to create a more relaxed environment for patients, facilitating better working conditions and enhancing the overall quality of care provided.59

Dentists can prescribe premedications, but a self-reported lack of confidence in this area combined with a preference for behavioural techniques for managing anxiety may lead to under prescribing.59 However, practitioners can communicate with the patient’s medical practitioner for guidance, as they will have the knowledge of the patients complete medical history and, on occasion, are known to prescribe without prior consultation with the dentist.59,60

Conclusion

Pre-operative anxiety in patients undergoing LM3 surgery presents significant implications for post-operative outcomes. This review elucidates that pre-operative anxiety induces a series of physiological stress responses, that directly play a role in increasing the risk of postoperative pain, infection, oedema and trismus. This connection underscores the importance of addressing pre- operative anxiety as part of patient care. Effective management strategies involve integrating both non-pharmacological and pharmacological interventions. In this way, a combined approach can be taken to address both short-term pre-operative anxiety and achieve long term outcomes in reducing anxiety levels. By approaching pre-operative anxiety through a multi-modal approach, clinicians can optimise surgical outcomes and enhance patient overall experience.

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