Anxiety and pain during dental treatment


Dental Anxiety (DA) is a challenge to the provision of oral health care.  Corah defined it as ‘the patient’s response to the stress specific to the dental situation’ and it adults it is associated with poorer quality of life and oral health.  Evidence suggests that that DA is associated with state anxiety (SA) and pain of dental procedures. State anxiety refers to ‘anxiety at the present moment’ (Kyle 2016).

The aim of this review was to assess the association between DA and SA in dental treatment and to examine if DA or SA a better predictor of the pain experience of dental treatment.


Searches were conducted in the Medline and CINHAL databases.  Observational or interventional studies of dental patients who were about to undergo a clinical procedure were considered. Studies involving a pharmacological or equipment intervention to modify pain or anxiety were excluded as community based samples or postal or telephone surveys.  The main outcomes were DA and pain.

Three reviewers independently abstracted data and within and across study biases were assessed using a customized Newcastle-Ottawa Scale (NOS). Data from the different scales for DA,SA and dental pain were normalised prior to meta-analysis, which was conducted using a random effects model.  Subgroup analysis of surgical vs. non- surgical and DA and pre-treatment SA were undertaken.


  • 35 studies investigating 47 clinical groups were included.
  • The studies involved 3,184 patients (1,368 males; 1,686 females)
  • 19 studies involved tooth extraction, 11 periodontal treatment, and 5 implant surgery.
  • 10 of the studies were experimental the rest observational.
  • The included studies were considered to be at low to moderate risk of bias.
  • Subgroup analyses revealed that the studies of surgical and nonsurgical procedures did not significantly differ in either DA or pre-treatment SA.
  • Meta-regressions revealed DA as a significant predictor that explained the variance in SA assessed before and during treatment but not after treatment.
  • Findings suggest that patient DA has a significant impact on patient SA.
  • Meta-regressions revealed DA as a significant predictor that explained the variance in expected pain, pain during treatment and post-treatment pain.
  • Pre-treatment SA was a significant predictor that explained the variance in expected pain.
  • The findings suggest that DA has a consistent impact on pain through the entire period of dental treatment.


The authors concluded

that anxiety should be assessed as a critical step not only in anxiety management for high-DA patients, but also in pain control for all dental patients.


Despite only using two major databases a large number of studies were identified for this review which perhaps highlights the importance of DA as a problem.  It would have been interesting to have included the PsycINFO database in the search strategy as this may have increased the number of studies available. That said this is a large review running to 10 pages with a significant amount important detail only being available in the detailed online supplements .  The authors raise concerned regarding the way in which the studies have been grouped into surgical and non-surgical treatments and the fact that some of the primary studies may not have assessed important confounders.

There is also significant heterogeneity between the studies because of  both the variety of tools used to assess DA and SA and the range of procedures undertaken.  The authors also point out that meta-regression is more likely to generate false-positive results so they should be interpreted cautiously.


Primary paper

 Lin CS, Wu SY, Yi CA. Association between Anxiety and Pain in Dental Treatment. J Dent Res. 2017 Feb;96(2):153-162. doi:10.1177/0022034516678168.PubMed PMID: 28106507.

Other references

Corah NL, Gale EN, Illig SJ. 1978. Assessment of a dental anxiety scale. J Am Dent Assoc. 97(5):816–819.

Kyle BN, McNeil DW, Weaver B, Wilson T. 2016. Recall of dental pain and anxiety in a cohort of oral surgery patients. J Dent Res. 95(6):629–634.

Dental Elf – 9th Sept 2016

Tooth extraction: factors affecting anxiety and fear

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