According to the International Association for the Study of Pain (IASP), pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

Intensity of nociceptive stimulation is not the only factor to determine any pain [1] . Cognitive and emotional construct are as much important factors as is physiological experience in determining pain [2] . Rhudy et al. based on their study supported the fact that emotional states modulate human pain reactivity [3] .

Dental anxiety and dental fear are strong negative feelings associated with dental treatments and are often used interchangeably in the dental literature. According to Klingberg and Broberg, dental anxiety is a state of apprehension that something dreadful is going to happen in relation to dental treatment or certain aspects of dental treatment [1] .

Dental anxiety is a common phenomenon. In a recent Canadian survey, 5.5% of respondents reported being “very afraid or terrified” of dental visits, and a further 9.8% were “somewhat afraid” [4] . Dental anxiety prevalence of a clinical significance varies based on criteria used to measure it and the population studied. In general, worldwide estimates range from about 4% to over 20% [5] [6] .

Perception of pain varies among individuals because it is a multifaceted emotional and sensory experience that is associated and exaggerated with previous experience, expected stress, clinical situation and anxiety [7] - [9] . Fear of this pain represented by anxiety, is one of the most common factor related with dental fear, and 40% of the population has been reported to suffer from it [10] - [12] .

There had been numerous studies in the literature which told us patient’s pain perceptions, their degree of dental anxiety and their compliance, but most of these studies did not tell about clinical information. According to Erten et al. [13] , site of the dental injection needle and the feeling of being injected was the most fear producing stimuli.

Dental anxiety has been variously called dental phobia, odontophobia, dentophobia, or dental fear in the literature. Fear is aroused by a real, specific stimulus (i.e. needle), whereas anxiety can be thought of as anticipatory in nature. Regardless of classification, a person’s response is similar in both situations.

A negative dental experience is a strong predictor of dental anxiety. In a random general population sample, people who had a painful, embarrassing, and frightening dental experience were over 22 times more likely to have dental anxiety [14] . Extreme helplessness and a lack of control during dental treatment, and a lack of understanding from the dentist are highly correlated with dental anxiety [15] . Experiencing extreme pain after dental work is amongst the most prevalent distressing life experiences, and can trigger psychological trauma and a persistent fear of the dentist [16] . Similar to the anxiety disorders, dental fear has been found to be heritable [17] .

There were studies in the literature which had suggested that dental anxiety appeared to be gender specific phenomenon being significantly correlated with the female gender [18] . Patient’s perception to pain also varies with age, smoking and oral health status [1] .

Dental treatment influences patients by causing stress and reminding them of unpleasant memories, which often leads to the postponement of dental treatment [8] . Investigating the level of pain after extraction and the factors influencing pain could provide information that would help patients to have more harmonious communication with dentists and to have realistic expectations about the dental procedure [19] . Therefore, the purpose of this study was to investigate the change in 100 patients’ pain and anxiety following extraction and to evaluate the correlation among anxiety, pain, and influencing factors.

This clinical study was conducted at the department of oral and maxillofacial surgery from October 2013 to October 2014. Patients aged 18 years to 30 years who had required extraction of either 34 or 44 due to orthodontic treatment means were included in the study. With increasing age there is change of anxiety levels, to avoid this error we had included only younger age group in this study.

Exclusion criteria included a medical or psychological disorder that might affect pain threshold, use of pain or anxiety medication, acute periodontal pain, pulpitis, abscess or other acute infections.

The work was conducted in compliance with Institutional Review Board/Human Subjects Research Committee requirements.

In our study 100 dental patients (56 females and 44 males mean age 23.49 ± 6.16 years, age range 18 to 30 years) participated. No statistically significant differences were found between males and females with regard to mean age (P = 0.128) (Table 2).

The mean VAS score for the entire group was 16.23 ± 1.28 (range, 0 - 58) and the median interquartile range (IQR) was 14. The mean VAS score for the males were 13.52 ± 1.38 and the median value was 11. The mean VAS score for the females were 17.62 ± 2.12 and the median value was 15. The difference in mean VAS score between males and females were statistically significant (P = 0.005) (Table 3). VAS score were evaluated for the following age groups, 18 to 21 years, 22 to 25 years, 26 to 29 years and more than 29 years. There were no statistically significant differences in VAS scores among these age groups (P = 0.325) (Table 4).

The mean anxiety score for the entire study population was 10.64 ± 3.12 (range, 11 to 35). The median was 9. The mean anxiety score for the males were 9.32 ± 2.16 and the median value was 9.1. The mean anxiety score for the females were 12.12 ± 3.62 and the median value was 12. The difference in mean anxiety score between

S = Significant; NS = Not significant.

males and females was statistically significant (P = 0.005) (Table 3). There were no statistically significant differences in anxiety score among different age groups (P = 0.356) (Table 4).

The relationship between patient’s pain response to extraction indicated by the VAS and the anxiety scores were evaluated by the spearman’s rank correlation coefficient for total anxiety scores. There was a statistically significant correlation between VAS and total anxiety score. (P = 0.001) When VAS was evaluated for each question, there was significant correlation except for questions number 4, 8 and 9 in males. Question number 1 was having the maximum significant value in females (correlation coefficient = 0.695) while question number 7 was having maximum significant value in males (correlation coefficient = 0.592) (Tables 5-7).

Our study gives information about patient’s pain perception and level of dental anxiety during routine dental extraction for orthodontic means. There were studies in the literature which had assessed these parameters in patients undergoing for dental treatment [24] [25] .

In our study patients had experienced limited pain but VAS scores were highly variable. This can be attributed to the reason that pain measurement is subjective and individual, and the assessment and screening is more difficult because of its physical and psychological features.

In this study all the preventive measures were taken to reduce the individual and environmental discrepancies for the best results. Our patients had been treated in the same dental chair, with the same dental assistant, in the same separate noise free room to provide a standardized and controlled environment for the study. Medically healthy patients were included in this study to decrease interpatient variability because there were studies in which it has been shown that systemic factors could modify individual’s response to painful stimuli [26] .

Communication skills, individual psychological status and the social and cultural background of the patient affect the expression of experienced pain which may be further biased because patients may give socially acceptable responses.

Socioeconomic status has any role with the dental anxiety has not been clear but to prevent any bias we included patients who had passed at least tenth grade level of education and belonged to the same socioeconomic group [27] .

There were studies in the literature in which it has been shown that patient’s pain perception was related to the site of the disease [26] . To avoid this site specific bias we had selected identical sites in all the patients.

In the literature there were no studies identical to our study so we are comparing our study findings with the identical studies for different dental procedures. In our study the mean VAS score for the entire study group was 16.23 ± 1.28. Karadottir et al. [22] reported the mean VAS score for scaling and root planning of two different hygienists as 15.1 and 10.8 and according to Chung et al. [23] these score were 22.3 and 19.5. Sjogren et al. [28] and van Wijk et al. [29] reported a mean VAS of 17.61 and 21.3 respectively. The mean VAS score of our study was similar to the previous studies.

In our study there were significant differences in mean VAS scores between genders. Females pain responses were higher than males (P = 0.05) which is not in agreement with other studies [22] [30] [31] . This can be attributed to the fact that other studies had been done on the procedures which were supposed to be less painful and may be because of sexually dimorphic pain modulation systems or factors that activate these systems [3] .

In our study there were significant differences in dental anxiety scores between the genders. Females were having more dental anxiety than males which is in agreement with other studies [2] [13] [27] . According to Eli et al., males were more anxious than females [8] . This discrepancy may have been due to different definition of dental anxiety, differences in study design or different evaluation systems used.

S = Significant; NS = Not significant.

S = Significant; NS = Not significant.

S = Significant; NS = Not significant.

In our study a significant correlation existed between VAS and each question as well as the total dental anxiety scores except for the question number 4, 8 and 9 in males which is in agreement with other studies [32] . Anxiety, pain and fear are highly subjective and are affected by so many factors; a single question may not adequately assess all aspects. In our study these questions were correlated with pain for men and had a tendency to be significant for experiencing pain for women. Thus the more pain the subject experiences, the more fear the subject will have at the next visit. This is an important finding of which dentist should be aware, and the question could be informative for practitioner.

Anxiety is main component of pain [33] . It has been reported that a patient with high DAS score would be more likely to present a high pain response than a patient with lower DAS score [30] . It was also suggested that anxiety has an influence on the expected pain, but not on the experienced pain [34] .

The major limitation of this study was use of yet to validate questionnaires which we had developed to concentrate only on the factors related to extraction of teeth compared to validated scales used in the literature. For the validation of this questionnaire further studies in future will be required.

Although most patients had experienced limited pain, there was a significant gender difference in pain and anxiety level. They were anxious because they expected pain, women being more anxious than men. The most provoking factor for anxiety and pain while going for extraction in females was “being seated in dental chair”, while in men the most provoking factor was “uncertainty about proper numbness before extraction”. An understanding of the presence of the anxiety can help dentists to understand what patients feel about dental treatment procedures and aid dentist efforts to improve patients care.

ShalenderSharma,KaberiMajumder,J. K. DayashankaraRao,VarunArya,VijaySiwach,SunilGulia, (2015) Assessment of Relationship between Pain and Anxiety Following Dental Extraction—A Prospective Study. Pain Studies and Treatment,03,23-30. doi: 10.4236/pst.2015.33003