Tooth extraction: factors affecting anxiety and fear


A 2014 review (Beaton et al) suggests that almost of third of the population exhibit some degree of dental anxiety with 12 % suffering from extreme dental fear. It is also known that some dental procedures cause more anxiety than others.

The aim of this review was to examine factors determining fear and anxiety in adult patients undergoing tooth extraction.


Searches were conducted in the Medline, Science direct, Springer link and Wiley online library from 2005-2015. Prospective and retrospective studies, clinical trials, cohort studies, case-control studies, and case series determining at least one factor that may predict tooth extraction anxiety/fear in dental patients and that used a measurement scale for assessment were considered.

Two reviewers selected studies and abstracted data independently, with study quality being assessed using the Cochrane risk of bias tool. Meta-analyses were performed for studies that reported comparable out- comes of factors that may affect patient anxiety related to tooth extraction.


  • 16 studies (10 prospective cohorts, 6 controlled trials) were included.
  • A majority of the studies had a high risk of bias.
  • Several factors were significantly associated with tooth extraction anxiety:-
    • Propensity to anxiety (P<0.05),
    • Pain experience or expectations (P<0.05),
    • Level of disturbance during the procedure (P<0.001),
    • Difficulty of the procedure (P=0.034),
    • Marital status (P=0.003),
    • Social class (P=0.012),
    • Type of local anaesthesia (P=0.008)
    • Using a video as the method of providing information (P<0.05)
    • Having had a previous negative dental experience (P<0.05)
  • Disagreements between significant and non-significant differences were found for the following factors:-
    • Gender
    • Level of education
    • Duration of procedure
    • Effect of hypnosis
    • Age
    • Time after procedure


The authors concluded: –

Due to disagreements between studies, further investigations into the other factors are required to clarify the results. However, the absence of a single and appropriate scale that includes both the patient’s evaluation and that of the doctor hinders the rating of patient anxiety.


This review addresses and important issue and while a number of databases have been searched it would have also been interesting to include the PsychINFO database which includes which specifically focuses on psychology and the behavioral and social science. The reviewers have rightly decided to include a broad range of study designs as one would anticipate that observation studies would be helpful in this area. As the review does include these type of studies a more appropriate tool to assess study quality might have been the Newcastle Ottawa scale or the Cochrane ROBINS-I tool previously called A Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBATNRSI).

While the review does suggest an number of relevant factors which seem to be associate with tooth extraction anxiety A key issue identified by the reviewers was the marked heterogeneity in the measurement scales used. This together with concerns over the quality of the included studies means that the findings should be interpreted with care.


Primary paper

Astramskaitė I, Poškevičius L, Juodžbalys G. Factors determining tooth extraction anxiety and fear in adult dental patients: a systematic review. Int J Oral Maxillofac Surg. 2016 Jul 16. pii: S0901-5027(16)30141-2. doi: 10.1016/j.ijom.2016.06.019. [Epub ahead of print] Review. PubMed PMID: 27436789.

Other references

Original review protocol on PROSPERO database

Beaton L, Freeman R, Humphris G. Why are people afraid of the dentist? Observations and explanations. Med Princ Pract. 2014;23(4):295-301. doi: 10.1159/000357223. Epub 2013 Dec 20. Review. PubMed PMID: 24356305.

Cochrane (ROBINS-I tool) Risk Of Bias In Non-randomized Studies – of Interventions tool


Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+