Introduction

Emotional problems such as fear, anxiety, uncertainty, loss of control, and decreased self-esteem are possible in patients facing hospital entry and surgery. Preoperative anxiety symptoms are stress and discomfort, and the sympathetic, parasympathetic and endocrine system are well-known factors in this situation (1). Despite the progress in surgery and anesthesia, anxiety is an important problem for the majority of patients scheduled for surgery (2). Anxiety directly affects health care costs by increasing postoperative pain and analgesic consumption and prolonging hospital stay (3). Various medications and patient trainings are recommended to control these disturbed states.

A self-assessment scale was developed by Beck et al. (4) in 1988 to determine the frequency of anxiety symptoms experienced by individuals. It is a likert type scale consisting of 21 questions scored between 0-3.

Anxiety is a common condition in patients requiring surgical treatment. While anxiety causes the development of unstable vital-hemodynamic symptoms in the patient, it increases postoperative pain and nausea-vomiting, thereby affecting prolonged recovery and hospital stay (5). For this reason, it may be important to identify sensitive individuals on this subject. The purpose of this study is to determine the level of preoperative anxiety specific to oral-maxillofacial surgery and the related risk factors.

Materials and Methods

This retrospective study’s sample was derived from the population of patients who presented to the Department of Oral and Maxillofacial Surgery at the University of Aydın Adnan Menderes, for underwent of general anesthesia between 2017-2019. Helsinki and the Local Ethics Committee of Adnan Menderes University (Aydın, Turkey) approved it with 2020/059 ethical number. Subjects eligible for study inclusion had impacted mandibular third molars which need to remove bone and/or tooth sectioning for extraction, age≥18 and consented to the study enrollment. Subjects were excluded for study enrollment if they had a history of psychiatric disease, anxiety-induced drug use, presence of systemic disease that affects cognitive functions and abnormal preoperative hemodynamic findings.

In order to examine the factors affecting preoperative anxiety, patients undergoing maxillofacial surgery between January 2017 and December 2019, aged 16-60 years, with American Society of Anaesthesiologists (ASA) physical status classification I-II were included in the study. Patients with ASA III and IV were excluded.

Beck anxiety inventory (BAI) scores taken from the patients’ files which were routinely evaluated before the operation, were recorded. It was named as low level anxiety between 8-15 points, moderate anxiety between 16-25, and high level anxiety between 26-63. BAI score of 0-7 means absence of anxiety.

Patients are grouped as age is below 25 and above 25, gender is female and male, systemic status as ASA I and ASA II, surgical type (invasive tissue cutting are major others minor), with previous surgical experience or not, educational status below 12 years and above 12 years, marital status as married and single, with or without pre-surgery information, job status as unemployed, low-wage  employee, high-wage employee or house wife, having health insurance or not, have at least one dependent child or not. These were identified as risk factors that may affect the presence of anxiety.

Statistical Analysis

The effect of potential risk factors on patients according to the presence of anxiety was evaluated by performing multivariete conditional regression analysis. Odds ratio, 95% confidence interval and Wald statistical values of each independent variable were measured (p<0.05: significant).

Results

Thirty seven patients were excluded from the study because of the psychiatric disease history, anxiety-related drug use, the presence of systemic diseases affecting cognitive functions and abnormal preoperative hemodynamic findings. The study was performed on 333 patients.

Based on BAI, the number of patients without anxiety anxiety was 49 (15%) and with anxiety was 284 (85%). Mild anxiety was found in 132 patients (40%), moderate anxiety in 91 (27%), and severe anxiety in 61 (18%).

Age and economic status of potential risk factors were not effective on anxiety. Female gender, ASA II (chronic disease), having major surgery, no experience of surgery, education status is over 12 years, to be married, no preoperative information, being housewife, absence of health insurance and having a child in need of care are factors affecting preoperative anxiety (p<0.05) (Tables 1, 2).

Discussion

Anxiety is a universal feature in the preoperative setting. The incidence of anxiety ranges from 8% to 80% (6-9). This variance in incidence is mainly explained by different tools and methods used to diagnose preoperative anxiety. For example, Malvania and Ajithkrishnan (10) used the Modified Dental Anxiety scale in their study in 2011 and calculated the ratio of dental anxiety as 46%. In our study, anxiety was diagnosed in 85% of patients according to BAI.

There are many evidence does not confirm age as a risk factor for preoperative anxiety (9,11,12). In also our study, it was confirmed that age had no effect on preoperative anxiety.

In their study in 2018, Jeddy et al. (13) found that although the majority of patients participating in their study were male, the presence of anxiety was statistically higher in women. In the studies of Cianetti et al. (14) in 2017, it was proved that female gender is more prone to dental anxiety than male gender. In our study, similar to these studies, it was found that dental anxiety was more common in women and the view that being a woman is a risk factor for preoperative anxiety was supported.

When anxiety is defined as the fear of losing the patient’s well-being, it is a natural consequence that patients with higher ASA scores who are closer to the possibility of losing good health have higher anxiety. In a study conducted by Facco et al. (15) in 2008, they found that patients with higher ASA scores had higher anxiety levels. As also evidenced in our study, higher ASA score should be evaluated as a predisposing factor in terms of anxiety.

Whether surgery is major or minor directly affects the patient’s level of anxiety for the procedure. The complexity of the procedure directly affects the anxiety level of the patient (16). The fact that patients have not previously experienced surgery causes a low level of knowledge which makes the person potentially anxious. In the study published by Sørlie et al. (17) in 2007, it was proved that the level of anxiety decreased statistically significantly in patients who were informed. In addition, Kazancioglu et al. (18) they supported the view that visual information supported by videos contributed positively to lowering the level of anxiety in 2017. In our study, the level of anxiety is higher in patients who will undergo major surgery and who were not informed, whereas in patients who have previously undergone surgery, the level of anxiety is lower. As can be seen from these results, the unknown triggers the patient’s anxiety. When the patient’s level of consciousness increases with surgical experience or informative methods, anxiety decreases.

However; although increasing the level of knowledge about the procedure to be performed causes anxiety to decrease, the high education level of the patients may be a predisposing factor for dental anxiety. Since the questioning skills of patients with higher education levels will be higher, the number of questions they cannot predict will be more. The desire of these patients to control what is happening leads them to anxiety. Hernández-Palazón et al. (19) and Perks et al. (12) showed that higher education level is a predisposing factor on surgical anxiety. In our study, supporting this view, it was found that patients with higher education level experienced more intense anxiety, supporting this view.

Surgical anxiety increases with the intensive consideration of the surgical procedure, rather than considering other factors that are important in the patient’s life. Parents who have children in need of care cannot concentrate on their own fears, as they care about their children before themselves. Having a job and unconscious thoughts about the job also prevent the patient’s thought intensity from concentrating on the process to be done. Furthermore, The patient’s lack of health insurance causes the patient to concentrate more on the economic aspects of the procedure to be performed. Since the surgical procedure will remain secondary in patients who need to think more other factors than themselves, low anxiety level is an inevitable result in these patients. In our study, the level of anxiety was found to be significantly low in patients with a child in need of care and in patients do not have health insurance. Moreover, the level of anxiety in housewives was significantly higher than patients who worked in any job.

Conclusion

This study contributes to the determination of factors affecting patients’ anxiety level against the surgical procedure. Although anxiety correlates negatively with the patients’ knowledge of the procedure, patients with higher education levels are more likely to have anxiety. In addition, if there is a more important factor in patients’ life than their own situation, it causes the level of anxiety to be lower than other patients because they think less about the surgical procedure. Further studies are needed to investigate patients’ fears for the surgical procedure.

Ethics

Ethics Committee Approval: Helsinki and the Local Ethics Committee of Aydın Adnan Menderes University (Aydın, Turkey) approved it with 2020/059 ethical number.

Informed Consent: Subjects eligible for study inclusion had impacted mandibular third molars which need to remove bone and/or tooth sectioning for extraction, age≥18 and consented to the study enrollment.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: Ö.K., Design: B.G., Supervision: B.G., Ö.K., Materials: U.K., Z.B.D., Data Collection or Processing: U.K., B.G., Analysis or Interpretation: Ö.K., Literature Search: B.G., Writing: B.G., U.K., Critical Review: Ö.K.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.