Dental Anxietyand Pain Perceptionassociatedwiththeuseof Miniscrew Implantsfor Orthodontics An
Dental Anxietyand Pain Perceptionassociatedwiththeuseof Miniscrew Implantsfor Orthodontics An
Dental Anxietyand Pain Perceptionassociatedwiththeuseof Miniscrew Implantsfor Orthodontics An
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Dental Anxiety and Pain Perception associated with the Use of Miniscrew
Implants for Orthodontic Anchorage
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10.5005/jp-journals-10021-1238
Dental Anxiety and Pain Perception associated with the Use of Miniscrew Implants for Orthodontic Anchorage
Original research
Introduction: This study was done with the aim to examine Accepted after Revision: 30/5/13
the pain experienced by patient after the miniscrew implant
placement and the dental anxiety that might influence the pain INTRODUCTION
experience.
Materials and methods: A total of 41 subjects (20 males and
Stedman’s medical dictionary defines the pain1 as ‘an
21 females) with the age range of 12 to 30 years were recruited unpleasant sensation associated with actual or potential
for this study, based on the need of skeletal anchorage for their tissue damage and mediated by specific nerve fibers to the
orthodontic treatment. After 1 hour of the placement of the mini
brain, where its conscious appreciation may be modified by
screw implant patients were asked to indicate their level of pain
on a 100 mm of visual analog scale (VAS). Dental anxiety was various factors.’ This definition recognizes that pain may
measured before placing the miniscrew implants using dental have a noxious transmission component, a psychological
anxiety scale (DAS) consisting of seven questionnaires modi component and a very important modulatory component.
fied for orthodontic use.
Pain is not simply determined by the intensity of the
Results: The mean anxiety score DAS for the whole study
nociceptive stimulus. In the evaluation of the effect of the
sample was 16.31 ± 1.70. The mean VAS score for entire study
group was 27.62 ± 1.12. Both the mean VAS and DAS score fear and anxiety on the pain reactivity in humans, Rhudy and
was found to be higher in females than males. There was a Meagher2 found that emotional state modulate human pain
significant positive correlation between the dental anxiety and reactivity. Pain is as much cogitative and emotional construct
patient perception of pain with miniscrew implant placement as
evident by Pearson correlation coefficient (r = 0.688). as it is a physiologic experience,3,4 and it depends on psycho
Conclusion: The study showed a positive linear relationship logic factors, such as the emotional and motivational state
between dental anxiety and patient pain experience following of the organism.2,5
miniscrew implants placement. Dental anxiety and dental fear are strong negative feelings
Keywords: Anxiety, Pain, Miniscrew, Anchorage. associated with orthodontic or dental treatment involving
How to cite this article: Prabhat KC, Maheshwari S, Verma SK, surgical procedures. The concept of dental fear and dental
Gupta ND, Balamani A, Khan MT, Singh RK. Dental Anxiety and anxiety is often used interchangeably in the dental literature.
Pain Perception associated with the Use of Miniscrew Implants
for Orthodontic Anchorage. J Ind Orthod Soc 2014;48(3):163-167. Dental anxiety was described by Klingberg and Broberg6 as
Source of support: Nil
a state of apprehension that something dreadful is going to
happen in relation to dental treatment or certain aspects of
Conflict of interest: None
dental treatment.7 Dental anxiety is a multidimensional state
that consist of somatic, cognitive and emotional elements and
1
Assistant Professor, 2-5
Professor, 6Ex. Assistant Professor describes a general state that is not stimulus specific. It is well
7
Ex. Resident documented that patient’s perceptions of pain and discomfort
1
Department of Orthodontics and Dentofacial Orthopedics associated with debridement differ. Patient’s perception of
Dental College, Regional Institute of Medical Sciences (Auto
nomous Institute of Ministry of Health, Government of India), Imphal
pain and dental anxiety differ in different dental surgical
Manipur, India procedures.8 It also differs with individual characteristics,
2,3,6,7
Department of Orthodontics and Dental Anatomy, Aligarh such as gender, age, education levels, income, smoking and
Muslim University, Aligarh, Uttar Pradesh, India the oral health status.
4
Department of Periodontics, Aligarh Muslim University, Aligarh Recently, the psychological and emotional patterns of
Uttar Pradesh, India
the patients have been emphasized in orthodontic literature.
5
Department of Orthodontics, Mahatma Gandhi Post Graduate
The pain experienced by patients have been evaluated
Institute of Dental Sciences, Puducherry, India
during orthodontic tooth movement,9 fixed orthodontic treat
Corresponding Author: KC Prabhat, Assistant Professor, Depart
ment of Orthodontics and Dentofacial Orthopedics, Dental College ment,10-12 after dental implants13,14 and miniscrew implants
Regional Institute of Medical Sciences (Autonomous Institute of surgeries.15 Hence, the aim of this study was to examine the
Ministry of Health, Government of India), Imphal, Manipur, India degree of pain experienced by patients after the miniscrew
e-mail: dr.prabhatkc@gmail.com
implant placement and the dental anxiety that might
influence the experience of pain. It also evaluates differences miniscrew implant placement. Postoperative discomfort
in the pain perception between the genders associated with was checked for all patients. The patients were instructed to
miniscrew implants placement. gently massage the implant area and to keep it clean. A 0.2%
chlorhexidine rinse was prescribed for 7 to 14 days. After
1 hour of the placement of miniscrew implants, patients were
MATERIALS AND METHODS
asked to indicate their level of pain on a 100 mm horizontal
The present clinical study was conducted on 41 subjects visual analog scale (VAS) where zero meant ‘no pain and
(20 males and 21 females) in the Department of Orthodontics discomfort’ and 100 meant ‘the worst possible pain and
and Dental Anatomy, Aligarh Muslim University, Aligarh, discomfort’ (Fig. 1). Visual analog scale is considered to be a
India, from February 2011 to December 2012. Before robust, sensitive and reproducible method of expressing pain
initiating this research work, the study was approved by severity.16 It is a simple, reliable and valid pain measurement
board of research studies of our university, and a written scale that has been used for evaluating dental pain,17 such
informed consent was obtained from each participant or their as in previous studies that evaluated pain from periodontal
parents before inclusion in this study. To be included in the therapies.18-20
study, patients had to be between 12 and 30 years of age. Dental anxiety was measured by using two anxiety
The patients with the different malocclusion were recruited measurement scales modified for orthodontic use. One of the
based on need of skeletal anchorage. Exclusion criteria questionnaire was the Corah’s dental anxiety scale (DAS),
included refusal to give informed consent, a medical or which consists of four questions to assess dental anxiety.21
psychological disorder that might affect pain thresholds, It is probably the most well-known questionnaire designed
use of pain or anxiety medication, smoking habit and/or to assess dental anxiety.22 The other was the dental fear sur
alcoholism, presence of acute periodontal pain, pulpitis, vey (DFS), which consists of 20 questions.23 Karadottir et al
abscesses or other acute infections, attachment loss and/or evaluated the DAS and DFS and found that only three of the
gingival recession, and/or root hypersensitivity that might 20 DFS questions and all four DAS questions significantly
cause tooth sensitivity. correlated with patients’ responses to instrumentation.24
All procedures were performed by an experienced Therefore, in the present study, the patients were asked to
orthodontist with patients sitting in the same dental chair. complete a questionnaire consisting of only these seven ques
Before the placement of miniscrew implant, advantages and tions modified for orthodontic use. The anxiety questionnaire
disadvantages were explained to each patient and his or her scores ranged from 7 to 35 (Table 1). After completing the
parents when an implant anchorage was considered desirable questionnaire, implant placement was done. Before initiating
for orthodontic treatment. A recommended guideline was the research work, one of the investigator cross checked the
followed for the insertion procedure of miniscrew implants. reliability of these seven questions in evaluating the dental
The screw implants were placed at 30° to 40°angles to the anxiety associated with miniscrew implants placement by
long axes of the teeth in the maxillary arch and at 10° to describing the orthodontic treatment plan involving the
20° angles in the mandibular posterior area according to miniscrew implants for anchorage to the patient at different
use. Topical anesthesia (Lidocaine Topical Aerosol USP occasions and asked the patient to fill the questionnaire
15% w/w, Midascare Pharmaceuticals Pvt Ltd, Aurangabad, (test-retest reliability). The study showed that these seven
India) was applied before miniscrew implant placement. questions were reliable in assessing the dental anxiety
Before the application of topical anesthesia, the mucosa of associated with miniscrew implants placement (r = 0.9).
the placement site was thoroughly dried with gauge square.
The anesthesia was applied with a cotton swab or cotton Statistical Analysis
roll for 2 to 3 minutes. Peak anesthesia was obtained in Statistical analyses were performed with the program SPSS
5 to 10 minutes, as confirmed with a periodontal probe. 13.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive
An advantage of topical anesthesia is ease of administration. statistical analysis including mean and standard deviation
It effectively diffuses 2 to 3 mm into the mucosa (does not were calculated for all variables with respect to the entire
result in pulpal anesthesia), hence, it allows the patient group, for the males and females. The student’s independent
to retain sensation and report any pressure or discomfort t-test was used to compare the gender differences between
during miniscrew implants placement. Another advantage the anxiety score and VAS. Pearson correlation coefficient
of topical anesthesia is that it avoids tissue ballooning, (r) was calculated to analyze the relationship between VAS
which can make the miniscrew implants placement more and anxiety score. The level of statistical significance was
difficult. No analgesics or antibiotics were prescribed after set at < 0.05.
164
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Dental Anxiety and Pain Perception associated with the Use of Miniscrew Implants for Orthodontic Anchorage
purposefully and unwittingly. The VAS is one of the most understanding of the orthodontist-patient interaction, which
commonly used tool to assess pain intensity and has been is a two-person endeavor. It is the orthodontist working with
shown to be a valid and reliable method of measuring discrete the patient and the patient being able to accept the treatment
pain as well as being a sensitive, simple, reproducible of provided by the orthodontist. This interaction requires
assessing pain.25 Moreover, VAS can assess the relative improved time and behavioral management skills, increased
change in the magnitude of pain over-time on linear scale.26 awareness of patients’ concerns and anxieties, the ability to
Thus, the VAS was employed in the assessment of pain in readjust treatment plans and to provide patient-centred care.
this study. The fear of pain during treatment has been identified as
Pain is subjective and depends on individual’s perception. a major factor in preventing patients from seeking dental
Therefore, a standardized and controlled environment was or orthodontic care. Therefore, delivering orthodontic care
essential for pain assessment. In the study, one experienced with minimal patient discomfort should be an essential part
orthodontist placed all miniscrew implants in all patients in of a clinician’s skills to avoid noncompliance. Screening of
patients’ previous dental experiences and histories for more
the same dental chair using the same implant kit in a quiet,
information should be considered so that the orthodontist
distraction-free environment. To minimize interpatient
may take additional precautions to improve the doctor-
variability in the present study, medically healthy patients
patient relationship and, thus, the treatment results. With
were included, because systemic factors were also shown to
the increasing demand for stress-free and painless therapy,
modify an individual’s response to noxious stimuli. Patients
clinicians should have the ability to reduce patients’ fear,
with moderate to severe inflammation within the gingiva
discomfort and pain during miniscrew implants placement
were shown to increase pain during periodontal probing8, for successful orthodontic treatment. On the basis of the
and it probably would change the pain levels after implants information provided by the study, it can be concluded
placement. that dental anxiety (fear) and pain/discomfort associated
To reduce exaggerated responses and bias, patients were with miniscrew implants placement need to be further
asked to participate in this study after the topical application investigated. Studies should include confounding factors,
of local anesthesia. Moreover, the patients were aware that such as different age groups, operator and subjective aspects
miniscrew implant placement had not ended; therefore, we like emotional responses, social determinants and cultural
believe that they were not relieved of their anxiety or fear. aspects with larger sample size.
Often, use of miniscrew implants for orthodontic anchorage
is associated with high level of anxiety as patient expects Conclusion
more pain with microimplant surgery. Anxiety is thought to Thus, this study found a positive linear relationship between
influence the effective component of pain.27Anxious people dental anxiety and patient pain experience following
tend to overestimate the intensity of aversive events, such as miniscrew implants placement. The females were more
fear and pain.28 Canakci et al noted that a patient with a high anxious than males and females experienced more pain as
Corah’s DAS score would be more likely to present a high compared to the males.
pain response than a patient with a lower DAS score.8 Other
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