Dental anxiety in patients undergoing oral surgery and its effects on blood pressure and heart rate

Objective: To assess dental anxiety in patients undergoing oral surgery, as well as its impact on blood pressure and heart rate. Material and Methods: A total of 233 patients answered a socio-demographic questionnaire and another one based on the Corah dental anxiety scale. Blood pressure and heart rate were assessed at three moments while: patients were in the waiting room, immediately before and after the procedure. Results: This study revealed a prevalence of anxiety of 77.3%. There was a statistically significant difference in mean systolic blood pressure and heart rate at the three moments of the evaluation. Anxiety was prevalent in the sample and was observed from the time in the waiting room until the time when local anesthesia was performed, causing variations in systolic blood pressure and heart rate, anxiety levels decreased after the end of the service. In conclusion, we observed that oral surgery is directly related to increased anxiety, and anxiety is mainly related to the change in heart rate.


Introduction
Dental anxiety is defined as an anticipation of suffering, which can result in dental treatment-related-distressing experiences. Surgical procedures are usually the most feared dental treatments in part of the population because they are usually associated with pain. High levels of anxiety during surgery are related with non-collaborative behavior or avoidance, as well as dissatisfaction with postoperative results, which subsequently affects oral health. (Armfield & Ketting, 2015;Wilson, McNeil, Kyle, Weaver, & Graves, 2014) This psychological disorder is easily recognized through some signs ranging from physical expressions, such as restlessness or crying, to physiological imbalance, such as increased heart rate and blood pressure. (Mento et al., 2014) According to (Matsumura, Miura, Kurokawa, Abe, & Takata, 2001) the elevation in blood pressure and heart rate during oral surgery modifies physiological and hemodynamic balance of the body and may trigger clinical emergencies. (Matsumura et al., 2001) Thus, the aim of this study was to evaluate dental anxiety in patients undergoing minor oral surgery in a Brazilian sample and its implications on blood pressure and heart rate.

Material and Methods
This was a cross-sectional, observational, quantitative study, with a convenience sample of 233 recruited patients who underwent closed or open dental extractions with osteotomy and, tooth section was performed when necessary. All surgical procedures were Development, v. 9, n. 8, e316985536, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i8.5536 5 2016) Patients who attained this pressure were referred for cardiac evaluation, and only those with diagnosis of anxiety were included in the study. Subjects excluded from the study were those affected by systemic diseases that directly influenced blood pressure such as hypertension, hyperthyroidism, and diabetes; administration of benzodiazepines in the preoperative period; and allergies to any of the medications or anesthetics used in the study.
Were also excluded from the study, pregnant patients or in lactation phase, those who had any contraindication for performing oral surgery in an outpatient setting, patients who had intraoperative complications or those who refused to participate or did not complete the questionnaires.
A prevalence of anxiety of 50% was used to calculate sample size, based on a pilot study with 40 patients. A probabilistic sampling, with a confidence level of 95% (Z = 1.96) and an error margin of 5% was used. This calculation was performed using a formula in the SPSS software program for Windows (version 22.0, SPSS Inc., Chicago, IL., USA), where n = sample size; N = population size, and p = the expected proportion in the population (0.5).
Thus, the minimum sample size after the calculation was 233 patients.

Research Tools
Two questionnaires were used, a sociodemographic one where gender, age, and level of education were determined, and another questionnaire based on the Corah dental anxiety scale. (Corah, 1969) This latter questionnaire is based on a scale used to assess the degree of anxiety before a dental treatment. The Corah dental anxiety scale was cross-culturally adapted to Brazilian Portuguese by (Hu, Gorenstein, & Fuentes, 2007), is composed of four questions with five alternatives related to reactions of the patient during visits to the dentist, and the answers are assigned scores ranging from 1 to 5 points; 1 for a state of tranquility and 5 for a condition of exaggerated anxiety. (Corah, 1969;Liau et al., 2008) After the sum of the total scores for the four questions, patients were classified as anxious or not anxious, based on the sum of these points. A sum above 5 points, indicated that the patient was not anxious, while a sum between Japan) was used by following the manufacturer's instructions and the calibration measures according to the VII Brazilian Guidelines for Hypertension (VII Diretrizes Brasileira de Hipertensão Arterial). (Malachias, 2016) Blood pressure and heart rate were measured by a single pre-calibrated examiner at three different moments: in the waiting room, in the dental chair before anesthesia, and immediately after surgery.
Blood pressure was categorized as normal, optimal, or hypertensive. The blood pressure was considered to be optimal when systolic pressure was less than or equal to 120 mmHg and diastolic blood pressure was less than or equal to 80 mmHg; normal when systolic pressure was between 120 and 139 mmHg and diastolic pressure was between 80 and 89 mmHg; and hypertensive when systolic pressure was higher than 140 mmHg and diastolic pressure was higher than 90 mmHg.(do Nascimento, da Silva Araújo, Gusmão, & Cimões,

2011)
Categorization of heart rate (HR) was performed in the same way. The HR was considered to be normal when between 60 to 100 beats per minute. Below this range, the HR was classified as bradycardia and above this range, it was classified as tachycardia. (do Nascimento et al., 2011)

Statistical analysis and risk factors
An epidemiological questionnaire was given to patients to obtain data to be used in the analysis of risk factors. The variables analyzed and their respective risk factors were: age groups (18 to 25 years, 26 to 35 years, 36 to 45 years, 46 to 55 years, and > 55 years), gender (female, male), level of education (illiterate, incomplete elementary school, complete elementary school, complete secondary school, incomplete secondary education, and higher education), last visit to the dentist (up to 6 months, from 6 to 12 months, from 13 to 36 months, from 37 months to 72 months, > 72 months and never went to the dentist), blood pressure in the waiting room (optimal, normal, and hypertensive), pre-anesthetic blood pressure (optimal, normal, and hypertensive), immediate postoperative blood pressure (optimal, normal, and hypertensive), heart rate in the waiting room (optimal, normal, and hypertensive), pre-anesthetic heart rate (optimal, normal, and hypertensive), immediate postoperative heart rate (optimal, normal, and hypertensive), and type of procedure (simple exodontia, and complex exodontia).
A uni-variable analysis using the chi-square test (p ≤ 0.2) was performed for the selection of variables. Significant variables were subjected to a multi-variable analysis using Research, Society and Development, v. 9, n. 8, e316985536, 2020 (CC BY 4. The comparison of the mean arterial pressure and HR at all times and the dental anxiety scale of Corah, blood pressure, and heart rate with the other variables was performed with a variance analysis using the Tukey test at 5% significance, using the Statistical Package for Social Sciences (SPSS for Windows, version 22.0, SPSS Inc., Chicago, IL., USA).

Results
Altogether 233 patients were assessed, 58.4% were female. The most frequent age ranged from 18 to 25 years (36.5%) and the majority had completed secondary education (45.5%). In accordance with the Corah dental anxiety scale, 77.3% of the cases were anxious while 22.7% were not. There was a statistically significant difference in mean of systolic blood pressure between the first and third verification moments (p = 0.000336) and between the second and third moments (p = 0.006409). A statistically significant difference were also found in the mean HR between the first and third moments of verification (p = 0.03454), and between the second and third moments (p = 0.000570) ( Table 1).  Table 1 indicated that the systolic blood pressure and heart rate increased from the moment the volunteers were in the waiting room to the time of measurement before local anesthesia, when they were already in the dentist's chair, falling soon after the end of the surgical procedure.

Moments
Means of systolic When related to the Corah dental anxiety scale a statistically significant number of patients were submitted to a complex extraction (p = 0.028). However, the differences related to blood pressure were not statistically significant.
Although without statistical significance, when comparing the level of anxiety with systolic blood pressure, 44% of patients who demonstrated anxiety during blood pressure measurement in the waiting room and 71% of patients who were anxious just before the anesthetic was administered were also hypertensive, but at the end of the surgery, when patients were assessed for the third time, 84% had normal blood pressure.
When related to anxiety assessed by the Corah dental anxiety scale, the HR was significantly different at the last moment of verification, showing normal post-surgery HR (p = 0.01), in agreement with the behavior of systolic pressure.
When age was correlated with anxiety level, a statistically significant difference was detected (p = 0.028), indicating that anxiety was more frequent in subjects in the lower age range, while this psychological state reduced with increasing age. Statistically significant results were not found with regards to the level of education and the anxiety level, (p = 0.098).
Individuals who never visited the dentist had a higher rate of dental anxiety (p = 0.002). While in the waiting room, these patients displayed hypertension (p = 0.012) but at other moments of verification there was no significant difference in either blood pressure or HR (Table 2) among these patients. No. and %= Number and percentage of individuals Source: Author. Table 2 shows the different variables of the patients included in this study, which shows that anxiety is present in a large portion of the population. With regards to the relationship between gender and anxiety, women were about 2.5 times (p = 0.003) more likely to be anxious than men (Table 3).  Table 3 shows the importance of targeting anxiety control in both genders, especially for women.
The high prevalence of anxiety among patients in the lowest age group may be justified by the high demand for extraction of third molars with orthodontic or preventive indications against the appearance of carious, periodontal, cystic and/or tumor lesions, in agreement with studies by (Liau et al., 2008) and (Tarazona, Tarazona-Álvarez, Peñarrocha-Oltra, Rojo-Moreno, & Peñarrocha-Diago, 2015). However, in contrast, (Hägglin, Berggren, Hakeberg, Hällstrom, & Bengtsson, 1999) observed a decrease in dental anxiety when increasing age in a longitudinal study of 28 years in a Swedish population of Gothenburg. (Armfield et al., 2006) and (Thomson, Stewart, Carter, & Spencer, 1996) observed that women demonstrated more anxiety disorder during dental treatment than men.
In fact, it is known that women are more fearful of needles and drills than men. (Holtzman, Berg, Mann, & Berkey, 1997) Regarding the level of education, in agreement with the findings of (Fayad, Elbieh, Baig, & Alruwaili, 2017) there were no statistical differences in relation to the levels of anxiety, unlike the results of other studies. (Bonafé & Campos, 2016;Locker et al., 2001) According to a medical study conducted by (Agras, Sylvester, & Oliveau, 1969), the thought of going to the dentist for preventive care and dental procedures was the fifth-leading cause of anxiety. This association is still frequently cited in the literature, and has therefore led to regular dental visits being postponed until cases become clinical emergencies.(al Absi the findings from the study of (Cheraskin & Prasertsuntarasai, 1959). The mean heart rate was significantly different between the 3 moments measured and its association with anxiety in the postoperative assessment was significant, corroborating the findings from the study of (Liau et al., 2008). The decrease in anxiety, heart rate and blood pressure at the end of the procedure, as observed in this study, can be changed if a patient feels pain during surgery or if the procedure time is too long.

Conclusion
In conclusion, we observed that oral surgery is directly related to increased anxiety, and anxiety is mainly related to heart rate.