678168

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JDRXXX10.1177/0022034516678168Journal of Dental ResearchDental Anxiety and Pain

Clinical Review
Journal of Dental Research
2017, Vol. 96(2) 153162
Association between Anxiety and Pain International & American Associations
for Dental Research 2016

in Dental Treatment: A Systematic Reprints and permissions:

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Review and Meta-analysis DOI: 10.1177/0022034516678168

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C.-S. Lin1, S.-Y. Wu1,2, and C.-A. Yi2

Abstract
Accumulating evidence has revealed that dental anxiety (DA), as a dispositional factor toward the dental situation, is associated with the
state anxiety (SA) and pain related to dental procedures. However, conclusions from individual studies may be limited by the treatment
procedures that patients received, the tools used to assess DA, or the treatment stages when anxiety or pain was assessed. It is unclear
whether DA, at the study level, accounts for the variance in pretreatment SA. The impact of DA and SA on pain at different treatment
stages has not been systematically investigated. To address these questions, we present novel meta-analytical evidence from 35 articles
(encompassing 47 clinical groups) that investigated DA in a clinical group. Subgroup analyses revealed that the studies of surgical and
nonsurgical procedures did not significantly differ in either DA or pretreatment SA. Furthermore, metaregressions revealed DA as a
significant predictor that explained the variance in SA assessed before and during treatment but not after treatment. The findings suggest
that patient DA has a significant impact on patient SA. Metaregressions revealed DA as a significant predictor that explained the variance
in expected pain, pain during treatment and posttreatment pain. In contrast, pretreatment SA was a significant predictor that explained
the variance in expected pain. The findings reveal that DA has a consistent impact on pain through the entire period of dental treatment.
Altogether, the findings highlight the role of DA as an overall indicator for anxiety and pain, across different types of dental procedures
or treatment stages. We conclude 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.

Keywords: metaregression, dental anxiety, dental care, fear, oral health, pain management

Introduction (1) What is the association between DA and SA in dental treat-

Dental anxiety (DA), originally defined as the patients
response to the stress specific to the dental situation (Corah et al.
1978), is a worldwide challenge in oral healthcare (Milgrom
et al. 1988; Newton et al. 2012). In adult patients, higher DA is
associated with a deteriorated quality of life and oral health,
and an increased avoidance of future treatment (Armfield and
Ketting 2015; Carlsson et al. 2015). Anxiety is a future-
oriented state responding to an anticipated threat, which is dif-
ferent from fear, a present-oriented, emotional state responding
to an immediate threat (Keogh and Asmundson 2004). In the
dental context, DA is a more cognitively involved emotional
response to stimuli or experiences associated with dental treat-
ment (McNeil and Randall 2014). State anxiety (SA), in con-
trast, refers to anxiety at the present moment (Kyle et al.
2016), a response that is specific to each stage of treatment.
Accumulating evidence has revealed that DA is associated
with SA and pain of dental procedures (Klages et al. 2004; van
Wijk et al. 2010; McNeil et al. 2011). However, the conclu-
sions from the individual studies could be limited by the treat-
ment procedures that patients received, by the tools for
assessing DA, or by the treatment stages when anxiety or pain
was assessed. At present, 2 key questions regarding the asso-
ciation between DA, SA and pain have remained unanswered.
ment? As a complicated multifaceted experience, DA was con-
ceived as trait DA (Klages et al. 2004; McNeil et al. 2011),
which reflects the individual dispositional affect toward den-
tistry (Dailey et al. 2002) shaped by the prior experience of
dental treatment (Locker, Liddell, Dempster, et al. 1999). In
contrast, SA may reflect the situation-specific emotional expe-
rience towards a specific dental procedure, and it may fluctuate
at different treatment stages (Locker, Liddell, and Shapiro
1999). While several factors would account for the variance in
pretreatment SA (e.g., the type of treatment procedures or the
patients prior experience), it has remained unclear if patients
1
Department of Dentistry, School of Dentistry, National Yang-Ming
University, Taipei, Taiwan
2
Division of Family Dentistry, Department of Stomatology, Taipei
Veterans General Hospital, Taipei, Taiwan
A supplemental appendix to this article is available online.
Corresponding Author:
C.-S. Lin, Department of Dentistry, School of Dentistry, National Yang-
Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11221 Taiwan
(ROC).
Email: winzlin@ym.edu.tw
154 Journal of Dental Research 96(2)
DA levels would predetermine their pretreatment SA. (2) Is
DA or SA a better predictor of the pain experience of dental
treatment? Some studies concluded that the high-DA patients
reported more pain, compared to the low-DA patients (van
Wijk and Makkes 2008; McNeil et al. 2011). Others found that
SA showed a stronger association with pain (Eli et al. 2003;
Mehrstedt et al. 2007; Eli et al. 2008; van Wijk et al. 2010).
Notably, throughout the entire period of dental treatment, pain
would fluctuate at different treatment stages (Klages et al.
2004; van Wijk et al. 2010; McNeil et al. 2011). Therefore, the
predictability of DA and SA on pain may vary depending on
the treatment stage. Based on previous experimental evidence
on anxiety and pain expectation (Atlas and Wager 2012), we
reasoned that SA would predict the patients pain at each spe-
cific stage. In contrast, DA would predict the patients pain
through the entire period (i.e., before, during and after) of
treatment.
The current study aimed to adopt meta-analytical methods
to investigate the above-mentioned questions at the study level
by pooling individual research evidence. We aimed to test the
following hypotheses. For the first research question, we rea-
soned that DA, as a dispositional factor, is insensitive to the
stress related to treatment procedures. Two subgroup analyses
were performed to test the hypotheses that 1) at the study level,
DA would not significantly differ between surgical procedures,
which were considered more stressful (Klages et al. 2004), and
nonsurgical procedures. In contrast, we hypothesized that 2)
pretreatment SA, as a situation-specific factor, would show a
significant between-subgroup difference. Subsequently, to
investigate the impact of DA on SA at different treatment
stages, we performed metaregressions to test the hypotheses
that DA would be a significant predictor that would explain the
study-wise heterogeneity of SA, at the stage before (3), during
(4), and after (5) treatment.
For the second research question, to investigate the impact
of DA and SA on pain at different treatment stages, we per-
formed metaregressions to test the hypotheses, at the study
level, that: (6) pretreatment SA would be a significant predictor
of expected pain, (7) during-treatment SA would be a signifi-
cant predictor of pain during treatment, and (8) posttreatment
SA would be a significant predictor to post-treatment pain.
Finally, DA would be a significant predictor of pretreatment
(9), during-treatment (10), and posttreatment (11) pain.
Materials and Methods
The review and meta-analysis were conducted according to the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA, see Appendix Table 1 for the checklist)
(Moher et al. 2009). All meta-analyses were performed using
the statistical software Comprehensive Meta-Analysis 2 (Biostat).
Eligibility Criteria
Original research articles were selected based on the following
criteria:
(a) Participants: The study sample needed to be drawn from
a clinical group, i.e., dental patients who were about to
receive a treatment procedure. Both surgical and nonsur-
gical procedures were included. The studies regarding
DA of a community-based sample or survey with tele-
phone or mail (e.g., Heft et al. 2007) were excluded.
(b) Interventions: Both observational and experimental stud-
ies were included. However, we excluded studies in which
a pharmacological or equipment intervention was used to
modify anxiety or pain (e.g., Moore et al. 1997; Yesilyurt
et al. 2008). If a study presented the data of both the
experimental and the control (i.e., intervention-free)
groups, we included only the data from the control group.
(c) Outcomes: Because our primary aim focused on DA and
pain, we only included the studies that reported the out-
come variables DA and pain. Additionally, the outcomes
regarding SA would be extracted if available. It should be
noted that the outcomes of DA, SA and pain, are critically
related to the choice of assessment tools (Armfield
2010a). The common assessments for DA and SA include
the Corahs Dental Anxiety Scale (CDAS) (Corah 1969),
the Modified Dental Anxiety Scale (MDAS) (Humphris
et al. 1995), the short-version Dental Anxiety Inventory
(sDAI) (Aartman 1998), the Dental Fear Survey (DFS)
(Kleinknecht et al. 1973), and the state-anxiety scale of
the State-Trait Anxiety Inventory (STAI-s) (Spielberger
1989); these tools are summarized in Table 1.
Search Strategy and Study Selection
Detailed search strategy and results are documented in the
Appendix Results and Appendix Table 2. Based on the eligibility
criteria, we manually screened the original articles and excluded
studies with the following characteristics (Fig. 1): (a) included
children, parents or dentists in the study sample, (b) included a
nonclinical group (e.g., a community-based survey) in the study
sample, (c) used drugs or behavioral methods to manipulate
anxiety or pain (except for regular local anesthesia), (d) focused
on brain neuroimaging of anxiety or pain, (e) did not report DA
or pain scores, (f) only reported categorical outcomes of DA or
pain (e.g., the proportion of painful patients), (g) inability to
obtain the full-text article, and (h) other reasons (see Appendix
Table 3). The assessment of eligibility and study selection were
independently performed by all 3 authors (C.-S.L., S.-Y.W.,
C.-A.Y.), who reached a consensus on final inclusion.
Data Collection and Extraction of Data Items
Printed or electronic full texts of all the included studies were
retrieved. The following data items were manually extracted
independently by the 3 authors:
(A) Demographic and clinical characteristics (4 items, see
Table 2): (1) the first author and year of publication, (2)
the treatment procedure, (3) the number of participants,
and (4) the mean and standard deviation (SD) of the par-
ticipants ages (mean [SD]).
Dental Anxiety and Pain 155

Table 1. Definition of Key Concepts in the Review and the Relevant Assessment Tools.

Definitions of Key Concepts

Anxiety A future-oriented state responding to an anticipated threat (Keogh and Asmundson 2004).
SAa A concept that refers to anxiety at the present moment (Kyle et al. 2016).
Assessment Tools Psychometric Properties
STAI-state subscale Reliability = 0.89b
Good construct validity (Spielberger et al. 1970)
Visual analog scale (VAS) The VAS can be recommended as the self-report part of anxiety
Numerical rating scale (NRS)c measurement in trials which are assessing changes in anxiety levels
under different circumstances within the one session (Luyk et al. 1988)
DA Dental care-related anxiety refers to a more cognitively involved emotional response to stimuli or experiences associated with
dental treatment (McNeil and Randall 2014).
Assessment Tools Psychometric Properties
CDAS Good reliability and validity (Corah et al. 1978)
MDAS Reliability = 0.89b
Good construct validity (Humphris et al. 2000)
sDAI Reliability = 0.88b
Good construct validity (Aartman 1998)
DFS Good reliability and validity (Schuurs and Hoogstraten 1993)
Fear A present-oriented state responding to an immediate threat (Keogh and Asmundson 2004).
Dental Fear A concept that refers to trait dental fear and DA (Kyle et al. 2016)
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of
such damage (IASP Task Force on Taxonomy 1994).
a
It should be noted that, in the settings of dental treatment, the patients are facing a specific, spatially and temporally proximal threat (e.g., the sound of
drilling), which may result in a strong tendency of avoidance. Therefore, the emotional status may be considered as the state-specific fear.
b
The internal consistency coefficients (Cronbach alphas).
c
The NRS or VAS assesses anxiety based on a continuum formed by numbers (in NRS) or a line (in VAS), with the endpoint of 0 defining no anxiety,
and 10 (or 100) as extreme anxiety. For an example, see McNeil et al. 2011.

(B) Methodological characteristics (6 items, see Table 3):
(1) the regions where the study sample was collected; (2)
study design; tools for assessing (3) DA, (4) SA, and (5)
pain; and (6) other psychological or physiological
assessments related to anxiety and pain.
(C) Outcomes (11 items, for detailed results see Appendix
Table 4): (1) mean (SD) DA scores; (2 to 5) mean (SD)
SA scores at different treatment stages (SApreTX,
SAduringTX,SApostTX, and SAF/U), and (6 to 11) mean (SD)
pain scores (P) at different treatment stages (PpreTX,
Pexpected, PduringTX, PpostTX, PF/U, and Precalled). Here preTX,
duringTX, postTX, and F/U indicate outcomes collected
before treatment, during treatment, immediately after
treatment, and in the follow-up stage (i.e., 1 wk to 10 d
after treatment), respectively. Pexpected indicates the pain
experience that one anticipated about the treatment.
Precalled indicates the memory about pain during treat-
ment that one recalls weeks later.
Assessment of Bias
Within-study and across-studies biases were assessed using a
customized scale (for detailed item descriptions, see Table 4)
and the Eggers regression test (Egger et al. 1997). For detailed
methods and results, please see Appendix Results.
Data Synthesis
Before the meta-analyses, we normalized the DA, SA and pain
scores, as assessed by different scales, to a 0 to 1 scale. The
normalized scores were then used as an estimate of the effect
size (ES) of DA, SA and pain. This method of normalization
has been used in a previous review for a study-wise compari-
son of pain (Pak and White 2011). For example, a score of 16
from the CDAS, which ranges from 4 to 20, was normalized to
(164)/(204) = 0.75. We estimated the overall DA across all
the studies using a random-effects model because of the sub-
stantial study-wise heterogeneity (I2 > 75%) (Higgins and
Green 2011). Because the participants ages and the tools of
DA assessment could be a potential source of heterogeneity,
we performed an ad hoc metaregression to evaluate the impact
of the participants ages on DA, and a subgroup analysis to
investigate the difference in DA between the studies using dif-
ferent assessment tools. Both analyses showed nonsignificant
results (see Appendix Results).
Subgroup Analysis
To test Hypotheses (1) and (2), we performed 2 subgroup analy-
ses by adopting the type of dental procedures (surgical vs. non-
surgical) as a categorical moderator, and DA and pretreatment
SA (SApreTX) as the dependent variables (DVs). Extraction,
implant surgery, crown lengthening, and root canal treatment
were classified as surgical procedures. Restorations and peri-
odontal scaling were classified as nonsurgical procedures. The
studies that did not explicitly address the dental procedures that
the patients received were excluded from the analyses. Between-
group differences were considered significant if the group-wise
heterogeneity Q was statistically significant (P < 0.05).
156 Journal of Dental Research 96(2)
Figure 1. Flowchart of study selection and the results of screening.
Metaregression
To test Hypotheses (3), (4), and (5), we modeled DA as the
continuous covariate (i.e., the modifier) and SApreTX, SAduringTX,
and SApostTX as the DV. To test Hypotheses (6), (7), and (8), we
modelled SApreTX as the covariate and Pexpected as the DV,
SAduringTX as the covariate and PduringTX as the DV, and SApostTX
as the covariate and PpostTX as the DV, respectively. Finally, to
test Hypotheses (9), (10), and (11), we modeled DA as the
covariate and Pexpected, PduringTX, and PpostTX, respectively, as the
DV. Because of study-wise heterogeneity, all metaregressions
were performed using the random-effects model estimated by
method of moments (Knapp and Hartung 2003). We consid-
ered the impact of the covariate on the DV to be significant if
the slope of regression, evaluated by a z-test, was statistically
significant (P < 0.05).
Results
Results of Search and Study Selection
Our search yielded 302 articles, including 294 articles from
PubMed and 56 articles from CINAHL. Forty-eight articles
were screened out for redundancy, thus yielding 302 articles
for screening. Based on the eligibility criteria, a total of 35
articles were screened in the review (Fig. 1). Because an article
may include more than one study of different clinical groups,
we analyzed the outcome based on these individual studies.
For example, the article by Eli and others (Eli et al. 1997) was
considered as 4 studies, because there were 4 independent clin-
ical groups. In total, 47 studies were included in the subsequent
analysis (for a full list of the included studies, please see
Appendix Results).
Demographic, Clinical, and Methodological
Characteristics of the Included Studies
Table 2 shows the demographic and clinical characteristics of
the included studies. The data consisted of 3,184 patients,
including 1,368 males and 1,686 females (note that some stud-
ies only gave the total number of patients instead of listing
female and male patients separately). The mean age ranged
from 21.0 to 58.7 years old (study-wise median of mean age,
33.3). Nineteen studies focused on the anxiety and pain of
tooth extraction, 11 on periodontal treatment, and 5 on implant
surgery. Table 3 shows the methodological characteristics of
the included studies. Among the 35 included articles, 25 pre-
sented an observational research and 10 were related to experi-
mental interventions. All the experimental research articles
reported randomization across study groups or study condi-
tions. Among the 47 studies, 29 reported the results of SA, pre-
dominantly using the numerical rating scale (NRS, n = 10), the
visual analog scale (VAS, n = 9), and the STAI-s (n = 8). All
studies reported the results of treatment-related pain, predomi-
nantly using the VAS/NRS, at different stages of treatment. For
the DA assessment tools, most studies adopted the original or
the language-revised version of CDAS (n = 24), the Revised
Dental Anxiety Scale (DAS-R, n = 3), or the MDAS (n = 6).
These were followed by the short Dental Anxiety Inventory
(sDAI, n = 10), the DFS (n = 3), the Hierarchical Anxiety
Questionnaire (HAQ, n = 1) and a nonstandard scale that com-
bined both the CDAS and part of the DFS (n = 2). The psycho-
metric properties of the tools (Spielberger et al. 1970; Corah et al.
1978; Luyk et al. 1988; Schuurs and Hoogstraten 1993; Aartman
1998; Humphris et al. 2000) are summarized in Table 1.
Descriptive Analysis
Figure 2A descriptively presents SA and pain at different treat-
ment stages. Both SA and pain gradually decreased through the
whole treatment period. A substantial decrease in anxiety was
found from the pretreatment stage to the treatment stage. For
detailed methods and results, please see Appendix Results.
Subgroup Analysis
For Hypothesis (1), the overall DA between the studies of sur-
gical treatment and the studies of nonsurgical treatment was
nonsignificant. For Hypothesis (2), the overall SApreTX between
the studies of surgical treatment and the studies of nonsurgical
treatment was also nonsignificant. For detailed results, please
see Appendix Results.
Metaregression
Based on the review procedure, we analyzed 24, 10, and 13
studies for the metaregression analyses (Hypothesis (3), (4),
Dental Anxiety and Pain 157

Table 2. Demographic and Clinical Characteristics of the Included Studies.

First Author / Number of Mean

ID Publication Year Treatment Characteristics Patientsa Age (SD)

1 Chang 2016 Anesthetic injection 31/20/11 51.4 (8.1)

2 Hofer 2016 Dental hygiene appointment 46// 51.6 (17.2)
3 Kyle 2016 Extraction 157/87/70 38.0 (13.7)
4 Tanidir 2016 Extraction, with dubbed video instruction 43/25/18 26 (7)
5 Extraction, with silent video instruction 44/28/16 23 (4)
6 Extraction, without video instruction 42/27/15 26 (8)
7 Kazancioglu 2015 Extraction, impacted molar, with detailed instruction 95/50/45b 25.4 (2.1)
8 Extraction, impacted molar, with verbal and video 102/50/52b 26.2 (3.7)
instruction
9 Extraction, impacted molar, with conventional instruction 103/53/50b 22.4 (6.9)
10 Santuchi 2015 Full-mouth disinfection 41//
11 Almoznino 2014c High DA patients 67/24/43 28.5 (9.3)
12 Patients with an exacerbated gag reflex 54/19/35 28.4 (9.3)
13 Fatima 2014 Periodontal scaling 44/44/0 27 ()
14 Wilson 2014 Extraction 27// 30.5 (11.9)
15 Kim 2013 Implant surgery 89/38/51 51.2 (13.2)
16 de Jongh 2011 Extraction, impacted molar 71/35/36 25.0 (6.0)i
17 Kim 2011 Extraction, impacted molar 113/50/53 f
18 McNeil 2011 Extraction, emergent visit 79/44/35 37.0 (12.0)
19 Mobilio 2011 Extraction, lower molar 23/16/7 28.9/7.9
20 Sanikop 2011 Periodontal ultrasound scaling 100/52/48 38.4/6.6
21 Lindeboom 2010 Implant surgery, conventional procedure 8// 58.7/7.2
22 Implant surgery, flapless procedure 8// 54.6/2.9
23 van Wijk 2010 Extraction, impacted molar 160/72/88 30.5/14.2i
24 de Jongh 2008 Extraction, lower molar 34/21/13 26.3/6.0
25 Eli 2008 Implant surgery 66/42/24 51.7/12.8
26 Guzeldemir 2008 Periodontal ultrasound scaling 113/72/41 35.6/9.3
27 Hakeberg 2008 Periodontal ultrasound scaling 385/230/155e 47.6/16.7
28 Muglali 2008 Minor oral surgery 120/80/40 27.6/10.5
29 van Wijk 2008 Extraction, lower molar, with separate consultation 21/13/8 25.6/8.4d
30 Extraction, lower molar, with simultaneous consultation 29/15/14
31 van Wijk 2008 Anesthetic injection, high DA patients 23/14/9 39.5/13.4
32 Anesthetic injection, low DA patients 57/21/36 38.2/15.2
33 Klages 2006 Restorative treatment, high DA patients 42// 30.1/11.8d
34 Restorative treatment, low DA patients 48//
35 Fagade 2005 Extraction 122/69/53 33.9/15.2
36 Ozaka 2005 Periodontal debridement 20/20/0 38.0/19.1
37 van Wijk 2005g Periodontal probing 60h/36/24 44.8/i
38 Klages 2004 Extraction / Endodontic treatment 97/42/55 38.8/12.5
39 Eli 2003 Implant surgery 60/35/25 42.0/14.6
40 Eli 2000 Periodontal crown lengthening 37/22/15 33.7/11.4i
41 Sullivan 1999 Periodontal scaling 80/54/26 22.0/5.0
42 Eli 1998 Calculus removal 23// 28.0/8.7d
43 Restorative treatment 23//
44 Root canal treatment 25//
45 Extraction 21//
46 Sullivan 1998 Periodontal scaling 78/46/32 42.2/15.3
47 Tripp 1998 Periodontal ultrasound scaling 53/35/18 21.0/4.3

DA, dental anxiety; means data not available. For a full list of the included studies, please see Appendix Results.
a
Number of total patients/female patients/male patients.
b
Number of female/male participants was recorded in Table 1 of the study.
c
Control group was not analyzed due to lack of DA data.
d
Mean age of participants from all subgroups.
e
Number of participants was recorded in Table 1 of the study.
f
Patients ages were reported as categorical data.
g
Control group was not a clinical group; the DA group was not analyzed because of a lack of pain data.
h
Only 56 participants completed all questionnaires.
i
Overall mean age was calculated based on the mean age of male and female participants.
158 Journal of Dental Research 96(2)

Table 3. Methodological Characteristics of the Included Studies.

Major Assessment Tool

ID Region Design DA SA Paind Other Assessment

a
1 South Korea R CDAS VAS/100 PSS
2 Switzerland OSb, CS HAQ STAIe VAS/100 MDMQ
3 US OSb DFS NRS 100 NRS/100 CESD-R, PANAS
4 Turkey R MDAS STAIe VAS/10 STAI-trait, DAQ
5 Turkey MDAS STAIe VAS/10 STAI-trait, DAQ
6 Turkey MDAS STAIe VAS/10 STAI-trait, DAQ
7 R CDAS STAIe VAS/10
8 CDAS STAIe VAS/10
9 CDAS STAIe VAS/10
10 Brazil R CDAS VAS/10 DFS
11 Israel OSb CDAS NRS/10 PSQI
12 Israel CDAS NRS/10 PSQI
13 India OSb CDAS VAS/100
14 US OSb, PT DFS NRS/100 NRS/100
15 South Korea OSb CDAS VAS/10 VAS/10
16 The Netherlands OSb, PT sDAI sDAI VAS/100 LOE-DEQ
17 South Korea R CDAS CDAS NRS/5f BP, RR, HR
18 US OSb DFS NRS/100 NRS/100 SF-FPQ
19 Italy OSb MDAS VAS/100
20 India OSb CDAS+DFS VAS/100
21 The Netherlands R sDAI NRS/100 NRS/100 IES-R, OHIP14
22 The Netherlands sDAI NRS/100 NRS/100 IES-R, OHIP14
23 The Netherlands OSb sDAI NRS/10 NRS/10 ASI, FDPQ
24 The Netherlands OSb, PT sDAI VAS/100 VAS/100 LOE-DEQ
25 Israel Rc CDAS VAS/100 VAS/100
26 Turkey OSb CDAS+DFS VAS/100
27 Sweden OSb, CS CDAS NRS/5g
28 Turkey OSb CDAS STAIe VAS/10
29 The Netherlands R sDAI NRS/10 NRS/10 sFDPQ
30 The Netherlands sDAI NRS/10 NRS/10 sFDPQ
31 The Netherlands OSb sDAI NRS/10 NRS/10
32 The Netherlands sDAI NRS/10 NRS/10
33 Germany OSb CDAS NRS/100 ASI, PES(APS/SPS)
34 Germany CDAS NRS/100 ASI, PES(APS/SPS)
35 Nigeria OSb CDAS VAS/10
36 Turkey Rc CDAS VAS/100
37 The Netherlands OSb sDAI NRS/10 FPQ-III
38 OSb CDAS VAS/100 PSI, PES
39 Israel OSb CDAS VAS/100 VAS/100
40 Israel OSb CDAS VAS/100 VAS/100
41 Canada R DAS-R NRS/10 PCS
42 OSb CDAS VAS/100 NRS/4h STAI
43 CDAS VAS/100 NRS/4 STAI
44 CDAS VAS/100 NRS/4 STAI
45 CDAS VAS/100 NRS/4 STAI
46 Canada OSb DAS-R NRS/10 PCS
47 Canada OSb DAS-R NRS/10 PCS

ASI, anxiety sensitivity index; BR, blood pressure; CESD-R, Center for Epidemiologic Studies Depression Scale Revised; CS, a cross-sectional
design; CDAS, Corahs Dental Anxiety Scale; DAQ, Dental Anxiety Questionnaire; DAS-R, Revised Dental Anxiety Scale; DFS, Dental Fear Survey;
FPQ-III, Fear of Pain Questionnaire; HR, heart rate; IES-R, Impact of Events Scale - Revised; LOE-DEQ, the Level of Exposure-Dental Experiences
Questionnaire; MDAS, Modified Dental Anxiety Scale; MDMQ, Multidimensional Mood Questionnaire; , not applicable; NRS, numerical rating scale;
OHIP, Oral Health Impact Profile; OS, observational study; PANAS, Positive and Negative Affect Schedule; PCS, Pain Catastrophizing Scale; PES, the
Geissners Pain Experience Scale (Affective Pain Scale/Sensory Pain Scale); PSI, the Pain Sensitivity Index; PSQI, Pittsburgh Sleep Quality Index; PSS,
Perceived Stress Scale; PT, a prospective design; R, a study design with randomization between study groups or study conditions; RR, respiratory rate;
sDAI, short-version Dental Anxiety Inventory; sFDPQ, short-form Fear of Dental Pain Questionnaire; SF-FPQ, The Fear of Pain Questionnaire-Short
Form; STAI, State-Trait Anxiety Inventory; VAS, visual analog scale.
a
A randomized split-mouth design.
b
An observational study without experimental intervention.
c
A randomized cross-over design.
d
Number denotes the maximal value of the scale.
e
Only the subscale of SA was used.
f
Pain was assessed using a VAS, range 0 to 5.
g
Pain was assessed using a verbal rating scale, range 1 to 5.
h
Pain was assessed using a NRS, range 1 to 4.
Dental Anxiety and Pain 159

Table 4. Results of Risk of Bias (RoB) Assessment.

Customized Assessment Item

Major Domain of Assessment Scoring:
from Newcastle-Ottawa Scale 0 = Related information is explicitly disclosed in the study. Number of Studies
(Wells et al. 2000) 1 = Related information is missing/unclear. Showing RoB (%)

Representativeness
Confounding factors
Outcome
(1) The study does not report the country/region from where the participants were recruited. 17%
(2) The study does not report the clinical setting (e.g., in hospital or in a clinic) where the 6%
participants received treatment.
(3) The study does not report whether patients were administered local anesthesia, sedation or 49%
medication, which may alter the participants pain or anxiety.
(4) The study does not report the inclusion/exclusion criteria of participant recruitment. 17%
(5) The study does not report the exclusion or evaluation of psychological factors (e.g., the 51%
presence of mental disorders or chronic pain) that may influence DA.
(6) The study does not adopt a standardized tool for assessing DA. 0%

and (5), respectively). We analyzed 15, 10, 11 studies for the
metaregression analyses (Hypothesis (6), (7), and (8),
respectively).
All analyses consisted of at least 10 studies, satisfying the
suggested minimal number for metaregression (Higgins and
Green 2011). For a detailed list of the studies included in each
analysis, please see Appendix Table 4.
For Hypotheses (3) and (4), the slope of the regression was
statistically significant. For Hypothesis (5), the result was sta-
tistically nonsignificant. The findings revealed that DA has a
significant impact on pretreatment and during-treatment SA
but not posttreatment SA (Fig. 2B, C). For Hypothesis (6), the
result was statistically significant. For Hypotheses (7) and (8),
the slope of regression was statistically nonsignificant. The
findings revealed that pretreatment SA has a significant impact
on expected pain (Fig. 2D). The impact of SA on pain at the
other stages was not significant. Finally, for Hypotheses (9),
(10), and (11), the slopes of regression were all statistically
significant. The findings revealed that DA has a consistent
impact on pain at all different treatment stages (Fig. 2EG).
For detailed results, please see Appendix Results.
Discussion
Here, we provide meta-analytical evidence of the association
between DA, SA and pain related to dental treatment during
different treatment stages. For our first research question, we
found a nonsignificant difference in both DA and SApreTX
between surgical and nonsurgical procedures. Furthermore, we
found that DA was a significant predictor that could explain
part of the variance in pretreatment and during-treatment SA.
The findings suggest that DA has a significant impact on their
pretreatment SA. For our second research question, we found
that DA and SA have a distinct impact on pain at different treat-
ment stages: DA would predict pain through the entire period
of treatment, whereas SA would predict expected pain only.
We found that DA did not significantly differ between sur-
gical and nonsurgical procedures. We show that DA, as a dis-
positional factor, would be a situation (treatment procedure/
stage)-insensitive experience. The findings supported the
notion of train DA (Dailey et al. 2002; Klages et al. 2004;
McNeil et al. 2011), which can be considered as an individual
propensity or attitude toward dental situations shaped by nega-
tive dental experience (Locker et al. 1996; Locker, Liddell,
Dempster, et al. 1999). It is also consistent with the findings of
a significant association between DA and trait anxiety (Fuentes
et al. 2009). In contrast, we considered pretreatment SA as a
situation-sensitive experience, which can be assessed by ask-
ing about the participants current anxiety prior to treatment.
We hypothesized that pretreatment SA would differ between
surgical and non-surgical procedures. The hypothesis was not
supported by our results. The metaregression revealed DA as a
significant predictor that accounted for the variance in SApreTX.
Therefore, these findings suggest that before treatment, the dis-
position to feeling anxious, as quantified by DA, plays a key
role in SA. The findings implied that a high-DA patient would
perceive stronger anxiety before treatment, regardless of the
nature of the dental procedure. Consistently, studies have
revealed a positive correlation between current anxiety and
sDAI scores (van Wijk and Lindeboom 2008) and DFS scores
(McNeil et al. 2011) in patients undergoing third molar extrac-
tion. Notably, such an association between DA and SA was not
strong when the treatment was completed, as the metaregres-
sion revealed that DA was a nonsignificant predictor for
SApostTX. Our findings suggest that SA would be an index more
sensitive to the changes in the time-course of a treatment pro-
cedure (i.e., stage-sensitive), rather than an index sensitive to
the treatment procedure.
Furthermore, we found that DA could predict the pain expe-
rience either before, during or after treatment. Consistently, the
results from the individual studies have shown a positive cor-
relation between the 2 factors, in the context of not only a
stressful surgical treatment but also a regular dental hygiene
treatment (Sullivan and Neish 1998). The findings implied that
a high-DA patient may consistently perceive stronger pain,
regardless of the treatment stages. Altogether, the findings
highlight the role of DA as an overall indicator for anxiety and
pain, across different types of dental procedures or treatment
stages.
Accumulating evidence has shown that pain experience
fluctuates at different treatment stages. Notably, patients
expectations of pain during treatment was higher than that
160 Journal of Dental Research 96(2)

and pain may be stage-sensitive: during

and after treatment, a patient may per-
ceive a substantial decrease in pain due
to the therapeutic effect or local anesthe-
sia. However, SA may remain for a
period, because it is more relevant with a
persons trait DA. These findings were
consistent with the results of the descrip-
tive analysis (Fig. 2A) and previous
findings (McNeil et al. 2011) showing
that changes in anxiety could be less
stage-sensitive.
The findings presented here should
be interpreted within the following limi-
tations. First, for the subgroup analysis,
we classified all treatment procedures
into surgical or nonsurgical groups.
Such a categorization may be clinically
over-simplified. Notably, we found rela-
tively more studies that investigated
pain and anxiety for tooth extraction and
fewer studies focused on the less-stressful
treatment (e.g., restorative treatment).
Such an imbalance in the study number
made it difficult to perform an analysis
based on each type of dental procedure.
Second, a metaregression is more likely
to generate false-positive results due to
the presence of study-wise heterogene-
ity, especially when the study number is
small (Higgins and Thompson 2004). It
Figure 2. Results of data synthesis. (A) Estimated effect size (ES) of state anxiety (SA) and pain should be noted that the study-level
by different treatment stages (pretreatment, during treatment, posttreatment, and during follow- association does not guarantee an indi-
up). The y-axis denotes the overall normalized SA or pain estimated by a random-effects model. vidual-level association (Thompson and
The horizontal bar denotes the 95% CI. (BG) Results of metaregression. The x-axis denotes the
covariate and the y-axis denotes the dependent variable (DV), which is the overall ES estimated Higgins 2002). Though our metaregres-
by the random-effects model. Each circle denotes a study. The size of the circle represents the sion results were generally consistent
studys weight in the model estimation. DA, normalized dental anxiety score. with the conclusions from previous
studies, we did not aim to test the valid-
perceived (Klages et al. 2006; McNeil et al. 2011), and anxiety ity of regression models at the individual level, which others
may play a key role in such an over-expectancy of pain have reported (for an example, see McNeil et al. 2011). Third,
(Atlas and Wager 2012). We confirmed the hypothesis that we noticed that, from the results of the RoB assessment, more
before treatment, pretreatment SA would predict expected than half of the previous studies did not consider the presence
pain. The result echoed the findings from other studies that of mental disorders (e.g., major depression or generalized anx-
showed a positive correlation between the 2 ratings in the iety) as an inclusive/exclusive criterion, and only a few studies
patients receiving periodontal surgery (Eli et al. 2000), third investigated other factors relevant to anxiety and pain (for an
molar extraction (Muglali and Komerik 2008; van Wijk and example, see van Wijk et al. 2010). Therefore, our results can-
Lindeboom 2008), or restorative treatment and dental scaling not exclude the potentially confounding effects from these psy-
(Eli et al. 1997). It should be noted that DA also had a signifi- chological factors. Finally, it is noteworthy that the tendency to
cant impact on Pexpected (Fig. 2E). The findings suggest that, avoid dental treatment (Armfield and Ketting 2015) is associ-
instead of DA assessment (which would require a standard ated with a strong anxiety or fear, and the study sample from
questionnaire), a simple assessment of SA based on NRS or the current review comprised clinical patients. Therefore, we
VAS would help to predict the expected pain during treatment. cannot exclude the possibility that the anxiety level based on
In contrast to our hypotheses, we found a nonsignificant impact these clinical groups underestimates levels of the public, par-
of SA on pain both during and after treatment. The findings ticularly avoiders, who have strong anxiety or fear.
could be confounded by a smaller study number for metare- Our findings highlight the following clinical considerations.
gression. Still, they revealed that the association between SA First, we argue that an interpretation of anxiety scores should
Dental Anxiety and Pain 161
be based on the content of the assessment items. For example,
psychometric analyses have revealed that the first 2 items (e.g.,
. . . treatment tomorrow) of the CDAS/MDAS are associated
with anticipatory DA (ADA), and the other items (e.g., . . .
were about to have a tooth drilled) are associated with treatment-
related DA (TDA) (Yuan et al. 2008). Based on the framework
of emotional psychology (Table 1), ADA would relate to the
concept of trait DA, the emotion likely to be experienced
when facing an anticipatory and uncertain event. In contrast,
TDA would relate to the concept of SA, which reflects anxiety
about a specific treatment procedure or stage. Therefore, the
CDAS/MDAS score may partly reflect SA. Second, from a
clinical perspective, anxiety and fear are different experiences
(Keogh and Asmundson 2004; McNeil and Randall 2014)
(also see Table 1). This view is supported by experimental evi-
dence showing that anxiety and fear have divergent effects on
pain (Rhudy and Meagher 2000; Lin et al. 2014). For future
studies, the use of multiple tools to assess these relevant con-
structs, for example, the Fear of Dental Pain Questionnaire for
pain-related fear (van Wijk and Hoogstraten 2005), the STAI
for trait anxiety, or the Center for Epidemiologic Studies
Depression Scale for depression (Kyle et al. 2016), would bet-
ter characterize the emotional experience of patients. Third,
from the perspective practicing, our findings imply that anxi-
ety assessment should be a critical step, not only in anxiety
management for high-DA patients, but also in pain control for
all dental patients. Since most of the tools of DA assessment
are short in length, they can be easily completed by the patients
themselves. An assessment of pretreatment SA, which could
be easily performed with an NRS or a VAS, would quickly
indicate the expected pain, which plays a key role in dental
avoidance (Armfield 2010b). These assessments could be
included as part of the initial evaluation of the patients condi-
tion, and its ratings at different treatment stages could provide
critical information for dentists to evaluate treatment
outcomes.
Author Contributions
C.-S. Lin, contributed to conception, design, data acquisition,
analysis, and interpretation, drafted and critically revised the man-
uscript; S.-Y. Wu and C.-A. Yi, contributed to conception, data
acquisition, and analysis, critically revised the manuscript. All
authors gave final approval and agree to be accountable for all
aspects of the work.
Acknowledgments
This study was funded by the Ministry of Science and Technology
of Taiwan (103-2314-B-010-025-MY3). The authors declare no
potential conflicts of interest with respect to the authorship and/or
publication of this article.
References
Aartman IH. 1998. Reliability and validity of the short version of the dental
anxiety inventory. Community Dent Oral Epidemiol. 26(5):350354.
Armfield JM. 2010a. How do we measure dental fear and what are we measur-
ing anyway? Oral Health Prev Dent. 8(2):107115.
Armfield JM. 2010b. Towards a better understanding of dental anxiety and fear:
cognitions vs Experiences. Eur J Oral Sci. 118(3):259264.
Armfield JM, Ketting M. 2015. Predictors of dental avoidance among australian
adults with different levels of dental anxiety. Health Psychol. 34(9):929
940.
Atlas LY, Wager TD. 2012. How expectations shape pain. Neurosci Lett.
520(2):140148.
Carlsson V, Hakeberg M, Wide Boman U. 2015. Associations between dental
anxiety, sense of coherence, oral health-related quality of life and health
behaviora national swedish cross-sectional survey. BMC Oral Health.
15:100.
Corah NL. 1969. Development of a dental anxiety scale. J Dent Res. 48(4):596.
Corah NL, Gale EN, Illig SJ. 1978. Assessment of a dental anxiety scale. J Am
Dent Assoc. 97(5):816819.
Dailey YM, Humphris GM, Lennon MA. 2002. Reducing patients state anxi-
ety in general dental practice: a randomized controlled trial. J Dent Res.
81(5):319322.
Egger M, Davey Smith G, Schneider M, Minder C. 1997. Bias in meta-analysis
detected by a simple, graphical test. BMJ. 315(7109):629634.
Eli I, Baht R, Kozlovsky A, Simon H. 2000. Effect of gender on acute pain pre-
diction and memory in periodontal surgery. Eur J Oral Sci. 108(2):99103.
Eli I, Bar-Tal Y, Fuss Z, Silberg A. 1997. Effect of intended treatment on anxi-
ety and on reaction to electric pulp stimulation in dental patients. J Endod.
23(11):694697.
Eli I, Schwartz-Arad D, Baht R, Ben-Tuvim H. 2003. Effect of anxiety on the
experience of pain in implant insertion. Clin Oral Implants Res. 14(1):115
118.
Eli I, Schwartz-Arad D, Bartal Y. 2008. Anxiety and ability to recognize clini-
cal information in dentistry. J Dent Res. 87(1):6568.
Fuentes D, Gorenstein C, Hu LW. 2009. Dental anxiety and trait anxiety: an
investigation of their relationship. Br Dent J. 206(8):E17.
Heft MW, Meng X, Bradley MM, Lang PJ. 2007. Gender differences in reported
dental fear and fear of dental pain. Community Dent Oral Epidemiol.
35(6):421428.
Higgins JP, Thompson SG. 2004. Controlling the risk of spurious findings from
meta-regression. Stat Med. 23(11):16631682.
Higgins JP, Green S. 2011. Cochrane handbook for systematic reviews of inter-
ventions. The Cochrane Collaboration. www.cochrane-handbook.org.
Humphris GM, Freeman R, Campbell J, Tuutti H, DSouza V. 2000. Further
evidence for the reliability and validity of the modified dental anxiety scale.
Int Dent J. 50(6):367370.
Humphris GM, Morrison T, Lindsay SJ. 1995. The modified dental anxiety
scale: validation and United Kingdom norms. Community Dent Health.
12(3):143150.
IASP Task Force on Taxonomy. 1994. Merskey H, Bogduk N, editors.
Classification of chronic pain. Seattle (WA): IASP Press.
Keogh E, Asmundson GJ. 2004. Negative affectivity, catastrophising and
anxiety sensitivity. In: Asmundson GJ, Vlaeyen J, Crombez G, editors.
Understanding and treating fear of pain. Oxford (UK): Oxford University
Press, USA.
Klages U, Kianifard S, Ulusoy O, Wehrbein H. 2006. Anxiety sensitivity as
predictor of pain in patients undergoing restorative dental procedures.
Community Dent Oral Epidemiol. 34(2):139145.
Klages U, Ulusoy O, Kianifard S, Wehrbein H. 2004. Dental trait anxiety and
pain sensitivity as predictors of expected and experienced pain in stressful
dental procedures. Eur J Oral Sci. 112(6):477483.
Kleinknecht RA, Klepac RK, Alexander LD. 1973. Origins and characteristics
of fear of dentistry. J Am Dent Assoc. 86(4):842848.
Knapp G, Hartung J. 2003. Improved tests for a random effects meta-regression
with a single covariate. Stat Med. 22(17):26932710.
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):629634.
Lin CS, Hsieh JC, Yeh TC, Niddam DM. 2014. Predictability-mediated pain
modulation in context of multiple cues: an event-related fMRI study.
Neuropsychologia. 64:8591.
Locker D, Liddell A, Dempster L, Shapiro D. 1999. Age of onset of dental
anxiety. J Dent Res. 78(3):790796.
Locker D, Liddell A, Shapiro D. 1999. Diagnostic categories of dental anxiety:
a population-based study. Behav Res Ther. 37(1):2537.
Locker D, Shapiro D, Liddell A. 1996. Negative dental experiences and their
relationship to dental anxiety. Community Dent Health. 13(2):8692.
Luyk NH, Beck FM, Weaver JM. 1988. A visual analogue scale in the assess-
ment of dental anxiety. Anesthesia Prog. 35(3):121123.
McNeil DW, Helfer AJ, Weaver BD, Graves RW, Kyle BN, Davis AM. 2011.
Memory of pain and anxiety associated with tooth extraction. J Dent Res.
90(2):220224.
162 Journal of Dental Research 96(2)
McNeil DW, Randall CL. 2014. Dental fear and anxiety associated with oral
health care: conceptual and clinical issues. In: Mostofsky DI, Forgione AG,
Giddon DB, editors. Behavioral dentistry. 2nd ed. Ames (IA): John Wiley.
p. 165192.
Mehrstedt M, John MT, Tonnies S, Micheelis W. 2007. Oral health-related
quality of life in patients with dental anxiety. Community Dent Oral
Epidemiol. 35(5):357363.
Milgrom P, Fiset L, Melnick S, Weinstein P. 1988. The prevalence and practice
management consequences of dental fear in a major US city. J Am Dent
Assoc. 116(6):641647.
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. 2009. Preferred
reporting items for systematic reviews and meta-analyses: the PRISMA
statement. PLoS Med. 6(7):e1000097.
Moore PA, Finder RL, Jackson DL. 1997. Multidrug intravenous sedation:
determinants of the sedative dose of midazolam. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 84(1):510.
Muglali M, Komerik N. 2008. Factors related to patients anxiety before and
after oral surgery. J Oral Maxillofac Surg. 66(5):870877.
Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. 2012. The man-
agement of dental anxiety: time for a sense of proportion? Br Dent J.
213(6):271274.
Pak JG, White SN. 2011. Pain prevalence and severity before, during, and after
root canal treatment: a systematic review. J Endod. 37(4):429438.
Rhudy JL, Meagher MW. 2000. Fear and anxiety: divergent effects on human
pain thresholds. Pain. 84(1):6575.
Schuurs AH, Hoogstraten J. 1993. Appraisal of dental anxiety and fear
questionnaires: a review. Community Dent Oral Epidemiol. 21(6):
329339.
Spielberger CD. 1989. State-trait anxiety inventory: bibliography. Palo Alto
(CA): Consulting Psychologists Press.
Spielberger CD, Gorsuch RL, Lushene RE. 1970. Test manual for the state trait
anxiety inventory. Palo Alto (CA): Consulting Psychologists Press.
Sullivan MJ, Neish NR. 1998. Catastrophizing, anxiety and pain during dental
hygiene treatment. Community Dent Oral Epidemiol. 26(5):344349.
Thompson SG, Higgins JP. 2002. How should meta-regression analyses be
undertaken and interpreted? Stat Med. 21(11):15591573.
van Wijk A, Lindeboom J. 2008. The effect of a separate consultation on anxi-
ety levels before third molar surgery. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 105(3):303307.
van Wijk AJ, de Jongh A, Lindeboom JA. 2010. Anxiety sensitivity as a predic-
tor of anxiety and pain related to third molar removal. J Oral Maxillofac
Surg. 68(11):27232729.
van Wijk AJ, Hoogstraten J. 2005. Experience with dental pain and fear of
dental pain. J Dent Res. 84(10):947950.
van Wijk AJ, Makkes PC. 2008. Highly anxious dental patients report more
pain during dental injections. Br Dent J. 205(3):E7; discussion 142143.
Wells G, Shea B, OConnell D, Peterson J, Welch V, Losos M, Tugwell P.
2000. The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-
randomised studies in meta-analyses. [accessed 2016 Oct 17]. http://www
.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Yesilyurt C, Bulut G, Tasdemir T. 2008. Pain perception during inferior alveo-
lar injection administered with the wand or conventional syringe. Br Dent
J. 205(5):E10; discussion 258259.
Yuan S, Freeman R, Lahti S, Lloyd-Williams F, Humphris G. 2008. Some psy-
chometric properties of the Chinese version of the modified dental anxiety
scale with cross validation. Health Qual Life Outcomes. 6:22.
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