Association Between Preoperative Anxiety and Postoperative Pain Following Tooth Extraction: A Cross-Sectional Study

Association Between Preoperative Anxiety and Postoperative Pain Following Tooth Extraction: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association Between Preoperative Anxiety and Postoperative Pain Following Tooth Extraction: A Cross-Sectional Study Sami Mohammed Alshehry, Yaser Alqabbani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8920791/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 15 You are reading this latest preprint version Abstract Background Preoperative anxiety is a common psychological factor influencing patient experience in oral surgery. This study aimed to examine the association between preoperative anxiety levels and postoperative pain intensity following tooth extraction in Saudi Arabia. Materials and Methods A cross-sectional study was conducted among 229 adult patients undergoing tooth extraction. Anxiety levels were measured using the Dental Anxiety Scale (DAS), and postoperative pain intensity was assessed using a 10-point Visual Analog Scale (VAS). Data were analyzed using Spearman rank correlation and Fisher’s exact tests. Results Moderate to high preoperative anxiety was reported in 80.7% of participants. Higher anxiety levels were significantly associated with higher postoperative pain intensity (ρ = 0.448, p < 0.001). Conclusion Preoperative anxiety was positively associated with postoperative pain among oral surgery patients. Longitudinal or interventional studies are warranted to explore causal mechanisms and test anxiety-reduction strategies. dental anxiety pain intensity postoperative pain preoperative anxiety tooth extraction Figures Figure 1 Figure 2 Figure 3 1. Introduction Oral surgery encompasses a wide range of procedures targeting the oral and maxillofacial regions. These surgeries, including but not limited to tooth extractions, dental implants, and corrective jaw surgeries, are crucial for addressing various dental health issues [ 1 ]. However, they often provoke significant patient concerns, notably preoperative anxiety and the management of postoperative pain. The most commonly recognized definition of A complicated pattern of behavior linked to physiological activity, anxiety is triggered by both external (environmental) and internal (somatic and cognitive) stimuli. Patients may feel these stimuli prior to, during, or after oral surgery [ 2 ]. When it comes to oral surgery, fear and anxiety are often linked to poor oral health, a worse quality of life connected to dental health, and weakened psychosocial health, which includes reduced morale and low self-esteem [ 3 ]. Among common oral surgical procedures, tooth extraction—particularly third molar removal—is consistently associated with the highest patient anxiety levels [ 4 ]. Usually, the procedure results in soft tissue and bone trauma, which causes a range of morbidities. When patients feel anxious during oral surgery, they may not be able to cooperate with their surgeons. This might lead to longer and more complicated operations, which could result in unsatisfactory treatment outcomes [ 5 ]. Almost all oral and maxillofacial procedures are followed by the well-known occurrence of postoperative pain [ 6 ]. Pain is a painful feeling that is connected to actual tissue injury and is carried to the brain by certain nerve fibers. This definition demonstrates the multitude of psychological, moderating, and irritating transitional components that contribute to the pain [ 7 ]. Analgesics are often needed during the early postoperative phase, when pain is at its peak [ 8 ]. Anxiety and other psychological factors influence how patients perceive pain. Preoperative anxiety is often prevalent prior to lower third molar surgery [ 9 ]. Dentists believe that between 3% and 43% of people worldwide suffer from dental anxiety [ 10 ]. Research has shown that dental anxiety affects 4% to 20% of the general population, regardless of socioeconomic, cultural, or racial background, and that receiving better dental care does not lessen its prevalence [ 11 ]. The degree of patients' anxiety has been shown to impact the recovery process after third molar surgery [ 12 ]. Studies have shown that preoperative anxiety is linked to higher levels of postoperative pain and more prolonged surgical procedures [ 13 ]. Studies have shown a correlation between preoperative anxiety and the effectiveness of pain management after third molar surgery [ 14 ]. Throughout history, there has been a consistent connection between dental anxiety and the expectation of pain. However, dental anxiety is still quite common despite advancements in pain management, which prevents some people from seeking oral care [ 15 ]. In dental practice, patients who are fearful tend to become more nervous since they only seek treatment when they are in pain. This causes a vicious cycle of pain and anxiety, with both having a propensity to become worse [ 16 ]. Anxiety, according to several studies, is the cause of pain that is not alleviated by postoperative analgesics [ 14 , 16 ]. Anxiety may also activate stress responses, which include alterations in the cardiovascular, respiratory, metabolic, and hormonal systems. These alterations have the potential to impact the result of the surgery and lengthen the duration of the hospital stay. Extended postoperative pain is correlated with an increased likelihood of complications [ 17 ]. For assessing anxiety, the most widely used test is the State-Trait Anxiety Inventory (STAI) scale [ 18 ]. Current research indicates that variables, such as the kind of operation, anxiety, depression, and postoperative pain and the requirement for analgesics may be influenced by preoperative pain [ 19 ]. In several medical specialties, the relationship between postoperative pain and the pain threshold and tolerance to pressure have been evaluated. When it comes to postoperative pain management and the patient experience, the issue of preoperative anxiety in patients having oral surgery is an important challenge [ 20 ]. Preoperative anxiety, characterized by fear and apprehension before surgery, has been implicated in affecting the perception of pain, the recovery process, and the overall outcomes of pain management post- surgery. Despite the recognized importance of addressing preoperative anxiety to improve postoperative outcomes, there remains a critical gap in our understanding of how exactly preoperative anxiety influences postoperative pain management specifically in the context of oral surgery. Therefore, the present study aimed to investigate whether preoperative dental anxiety influences the severity of postoperative pain following surgical and non-surgical tooth extraction in adult patients. 2. Rationale of the Study Addressing this gap has the potential to significantly impact clinical practices by providing insights that could lead to the development of targeted interventions for reducing preoperative anxiety, thereby improving postoperative pain management [21]. Enhanced understanding of the anxiety-pain relationship in oral surgery could lead to better patient outcomes, including reduced pain levels, lower medication requirements, and overall improved quality of life post-surgery [22]. The proposed study seeks to advance knowledge in the field of oral health and surgery by exploring an under-investigated area. By specifically examining the correlation between preoperative anxiety and the treatment of postoperative pain in patients undergoing oral surgery, this research could contribute valuable insights that are applicable not only within the field of oral surgery but also in broader surgical and medical practices. The interdisciplinary benefits of this research could facilitate innovations in preoperative care and pain management, paving the way for improved patient care practices across various domains of healthcare [23]. 3. Hypothesis of the Study 3.1. Null Hypothesis (H₀): There is no association between preoperative anxiety and postoperative pain intensity among oral surgery patients. 3.2. Alternative Hypothesis (H₁): Higher preoperative anxiety levels are associated with higher postoperative pain intensity among oral surgery patients. 4. Methodology 4.1 Study Design The study employed a cross-sectional design, which is particularly suited for assessing and analyzing the association between preoperative anxiety levels and postoperative pain among patients undergoing a single-tooth extraction procedure during one visit. 4.2 Setting and Participants The study was conducted at the Dental College at Al-Imam Abdulrahman bin Faisal University (IAU), Dammam City. This setting was selected due to the high incidence of patients requiring surgical dental interventions, and data were collected between April 2025 and November 2025. Participants were patients admitted for tooth extraction, a common oral surgical procedure, ensuring a relevant and focused study population. 4.3 Eligibility criteria were defined based on clinical and demographic factors as shown in a Table. Inclusion Criteria Exclusion Criteria: Patients categorized under ASA (American Society of Anesthesiologists) classifications 1 and 2, indicating patients who are healthy or have mild systemic disease. Patients classified as ASA 3 and 4, representing individuals with severe systemic disease or life- threatening conditions, to avoid confounding effects on pain perception and anxiety levels. Adults aged ≥18 years. Pregnant or lactating women, and women regularly using oral contraceptives, to minimize physiological variations affecting anxiety or pain outcomes. Undergoing extraction of a single tooth. Patients on analgesics or anxiolytics within 24 hours. Capability to understand and comply with verbal and written instructions, ensuring reliable self-reported measures of anxiety and pain. Patients who refused participation or incomplete data. 4.4 Data Collection Methods Preoperative anxiety levels among patients were accurately measured using the Dental Anxiety Scale (DAS), a concise yet effective tool designed to evaluate anxiety specific to dental procedures. Postoperative pain intensity was categorized into three levels quantified using a ten-point Visual Analog Scale (VAS), allowing patients to self-assess their pain levels in both the immediate and late postoperative periods. A consecutive sampling technique was employed, including all eligible patients who met inclusion criteria during the study period. These instruments are chosen for their reliability and ease of use in clinical settings. 4.5 Ethical Considerations To guarantee compliance with ethical standards and the defense of participant rights, the study protocol was reviewed and approved by the Deanship of Scientific Research-Imam Abdulrahman bin Faisal University Institutional Review Board (IRB) (approval number: IRB-2025-02-0276) ( Approval Date : 13/04/2025). Each participant was given a detailed explanation of the study's goals, methods, possible dangers, and rewards before giving their informed consent. All participants were selected by random sampling. Confidentiality was strictly maintained, with data anonymized and securely stored to protect patient information. 4.6 Statistical analysis plan Descriptive statistics were used to summarize the characteristics of the study participants. Frequencies and percentages were calculated for categorical variables, while means and standard deviations were calculated for continuous variables. Age was treated as a continuous variable. Postoperative pain intensity was measured using the Visual Analog Scale (VAS) ranging from 1 to 10. For analytical purposes, VAS scores were categorized into three levels: mild pain (VAS 1–3), moderate pain (VAS 4–6), and severe pain (VAS 7–10), a categorization commonly used in pain research to facilitate clinical interpretation and group comparison [24]. Normality of continuous variables was assessed using the Shapiro–Wilk test. Due to non-normal distribution of the variables, non-parametric tests were applied. The association between categorical variables was evaluated using Fisher’s exact test to compare differences in proportions between groups. The correlation between continuous preoperative anxiety scores and postoperative pain intensity was assessed using Spearman’s rank correlation coefficient. To examine the association between preoperative anxiety and categorized postoperative pain severity, a multinomial logistic regression model was conducted using postoperative pain category (mild, moderate, severe) as the dependent variable and preoperative anxiety score as the independent variable. The number of teeth extracted was not included as an explanatory variable in the regression model because the study population predominantly underwent single-tooth extraction procedures, resulting in insufficient variability to support meaningful multivariable modelling. Statistical significance was set at p < 0.05 for all analyses. All statistical calculations were performed using IBM SPSS Statistics version 27.0.1 (IBM Corp., Armonk, NY, USA). 5. Results A total of 229 patients were included in the final analysis after applying the eligibility criteria. The study employed a cross-sectional design, and data were collected between April 2025 and November 2025. Baseline demographic and clinical characteristics of the participants are summarized in Table 1 in accordance with the CROSS-reporting guidelines. Table 1 : summarizes the demographic and clinical characteristics of the 229 participants. Most were females (n = 154, 67.2%) and Saudi nationals (n = 152, 66.4%). The largest age group was 36 years and older (n = 144, 62.9%). Regarding education, most had a university degree (n = 142, 62.0%). The most common reasons for tooth extraction were caries (n = 89, 38.9%) and wisdom teeth (n = 72, 31.4%) while extractions were most often performed on the upper right (n = 64, 27.9%) and upper left (n = 62, 27.1%) jaws. Table 1 Demographic and Clinical Characteristics of the Study Participants (n = 229) Variable: n (%) Gender Male 75 (32.8%) Female 154 (67.2%) Nationality Saudi 152 (66.4%) Non-Saudi 77 (33.6%) Age 18–25 years 54 (23.6%) 26–35 years 31 (13.5%) > 36 years 144 (62.9%) Education level Secondary 46 (20.1%) University 142 (62.0%) Postgraduate studies 36 (15.7%) Others 5 (2.2%) Reason for tooth extraction Caries 89 (38.9%) To install orthodontics 9 (3.9%) Tooth decay 32 (14.0%) Wisdom tooth 72 (31.4%) Others 27 (11.8%) Area of tooth extracted Lower jaw (left) 47 (20.5%) Lower jaw (right) 56 (24.5%) Upper jaw (left) 62 (27.1%) Upper jaw (right) 64 (27.9%) n: Frequency, %: Percentage Table 2 summarizes participants' general preoperative anxiety and perceptions. Over half of the participants reported moderate anxiety (n = 124, 54.1%), while 61 (26.6%) had high anxiety, and 44 (19.2%) reported low anxiety. The mean self-reported anxiety score on a 1–10 scale was 5.35 ± 2.87, ranging from 1 to 10. The most cited concern about tooth extraction was pain during or after the procedure (n = 85, 37.1%), followed by the anaesthesia needle (n = 45, 19.7%). Only 48.0% (n = 110) had been given a full explanation of the procedure steps prior to extraction. Regarding coping strategies, the most frequently used methods were deep breathing (n = 75, 32.8%), talking to a surgical expert (n = 55, 24.0%), and searching for information about the procedure (n = 44, 19.2%), among others. Table 2 Preoperative Anxiety: General Preoperative Anxiety and Perceptions Variable: n (%) Level of Anxiety Low 44 (19.2%) Moderate 124 (54.1%) High 61 (26.6%) Anxiety level about next tooth extraction (1–10 scale) Mean ± SD 5.35 ± 2.87 Range 1–10 Main concern about tooth extraction Anaesthesia needle 45 (19.7%) Method of tooth extraction 36 (15.7%) Pain during or after tooth extraction 85 (37.1%) Possible complications of tooth extraction 31 (13.5%) Side effects of tooth extraction 32 (14.0%) Explanation of tooth extraction steps received No 119 (52.0%) Yes 110 (48.0%) Method used to cope with anxiety Deep breathing training 75 (32.8%) Keeping the mind busy 5 (2.2%) Listening to music 6 (2.6%) Remembrance of God 14 (6.1%) Search for general information about the nature of tooth extraction. 44 (19.2%) Taking tranquilizers 22 (9.6%) Talk to a surgical expert 55 (24.0%) Others 8 (3.5%) n: Frequency, %: Percentage, SD: Standard deviation Figure 1 presents participants' situational anxiety levels during key phases of dental procedures. Anxiety peaks during anaesthesia injection, with 73 participants (31.9%) reporting high anxiety. Extreme stress during tooth extraction was reported by 31 participants (13.5%), who experienced physical symptoms of fatigue. While waiting for appointments, 108 participants (47.2%) felt mild anxiety, though 25 (10.9%) were so nervous and considered cancelling. Sitting in the dental chair induced high anxiety in 52 participants (22.7%). During gum numbness (particularly for upper extractions), 92 participants (40.2%) reported mild anxiety, while tool use caused mild anxiety in 84 participants (36.7%). Table 3 presents postoperative pain perception and management outcomes. The mean immediate post-extraction pain score was 5.0 ± 2.6. Nearly half (n = 107, 46.7%) reported their pain exceeded pre-operative anxiety expectations, while 100 (43.7%) found it matched expectations. Pain management effectiveness was rated as "average" by 101 (44.1%), though 45 (19.7%) found it very effective. Table 3 Postoperative Pain Perception and Pain Management Variable: n (%) Post-extraction pain level (1–10 scale) Mean ± SD 5.0 ± 2.6 Range 1–10 Actual pain during procedure vs pre-operative anxiety Yes 100 (43.7%) No 107 (46.7%) Not compatible (I didn't feel worried at all) 22 (9.6%) Effectiveness of post-operative pain management (medications) Above average effectiveness 41 (17.9%) Average effectiveness 101 (44.1%) Below average effectiveness 20 (8.7%) Ineffective 22 (9.6%) Very effective 45 (19.7%) n: Frequency, %: Percentage, SD: Standard deviation Figure 2 shows that for anxiety relief, some recommended receiving detailed explanations about the surgical procedure (n = 94, 41.0%), others preferred consulting a specialist doctor (n = 59, 25.8%). Pharmacological interventions like taking anxiety medications were suggested by 34 (14.8%) of respondents. Less common strategies included reviewing questionnaires from previous patients (n = 18, 7.8%) and requesting psychiatric consultation (n = 11, 4.8%). Table 4 and Fig. 3 To assess the relationship between preoperative anxiety and postoperative pain, both continuous and categorical analyses were performed. Using Spearman’s rank correlation, a statistically significant positive correlation was observed between preoperative anxiety scores and immediate postoperative pain intensity (ρ = 0.448, p < 0.001), indicating that higher levels of preoperative anxiety were associated with higher postoperative pain scores Table 4 Correlation between Preoperative Anxiety and Postoperative Pain Variables: Correlation coefficient p- value 95% CI Lower Upper Preoperative anxiety vs postoperative pain 0.448 < 0.001* 0.335 0.549 CI = confidence interval; ρ = Spearman’s rho; * p < 0.05 indicates statistical significance. Table 5 When both variables were analyzed categorically, Fisher’s exact test showed a statistically significant association between preoperative anxiety level and postoperative pain severity (p = 0.005). Patients with high preoperative anxiety experienced severe postoperative pain more frequently (41.0%) compared with those with moderate (16.9%) and low anxiety (20.5%). In contrast, mild pain was most commonly reported among patients with low preoperative anxiety (43.2%). No statistically significant associations were observed between postoperative pain level and other examined factors, including the main concern about tooth extraction (p = 0.569), receiving an explanation of the extraction steps (p = 0.710), or the coping method used for anxiety (p = 0.114). Table 5 Association of post-operative pain level and preoperative anxiety factors Variable: Mild pain Moderate pain Severe pain p-value # n (%) Level of Anxiety Low 19 (43.2%) 16 (36.4%) 9 (20.5%) 0.005* Moderate 41 (33.1%) 62 (50.0%) 21 (16.9%) High 16 (26.2%) 20 (32.8%) 25 (41.0%) Main concern about tooth extraction Anesthesia needle 16 (35.6%) 14 (31.1%) 15 (33.3%) 0.569 Method of tooth extraction 13 (36.1%) 15 (41.7%) 8 (22.2%) Pain during or after tooth extraction 26 (30.6%) 37 (43.5%) 22 (25.9%) Possible complications of tooth extraction 10 (32.3%) 15 (48.4%) 6 (19.4%) Side effects of tooth extraction 11 (34.4%) 17 (53.1%) 4 (12.5%) Explanation of tooth extraction steps received No 38 (31.9%) 54 (45.4%) 27 (22.7%) 0.710 Yes 38 (34.5%) 44 (40.0%) 28 (25.5%) Method used to cope with anxiety Deep breathing training 25 (33.3%) 31 (41.3%) 19 (25.3%) 0.114 Keeping the mind busy 1 (20.0%) 4 (80.0%) 0 (0.0%) Listening to music 3 (50.0%) 2 (33.3%) 1 (16.7%) Remembrance of God 7 (50.0%) 7 (50.0%) 0 (0.0%) Search for general information about the nature of tooth extraction. 11 (25.0%) 17 (38.6%) 16 (36.4%) Taking tranquilizers (medications) 5 (22.7%) 12 (54.5%) 5 (22.7%) Talk to a surgical expert 18 (32.7%) 23 (41.8%) 14 (25.5%) Others 6 (75.0%) 2 (25.0%) 0 (0.0%) n: Frequency, %: Percentage , # Fischer-Exact test, *p < 0.05, significant 6. Discussion At the outset of this study, the null hypothesis stated that there is no association between preoperative dental anxiety and the severity of postoperative pain following tooth extraction. Conversely, the alternative hypothesis posited that higher levels of preoperative dental anxiety would be associated with greater postoperative pain intensity. This study aimed to explore the association between preoperative anxiety levels and postoperative pain management in oral surgery patients in Saudi Arabia. Regarding preoperative anxiety, the findings reveal that over half of the participants (54.1%) reported moderate anxiety levels, while 26.6% experienced high anxiety, and 19.2% had low anxiety. The prevalence of moderate to high preoperative anxiety in this study aligns with global trends. A global meta-analysis by Abate et al. indicated a pooled prevalence of 48% among surgical patients [ 25 ]. Specifically, a Saudi study reported a high prevalence of preoperative anxiety among patients undergoing elective surgery, with factors such as female gender, younger age, and lower educational levels being associated with higher anxiety levels [ 26 ]. The primary concern among patients in this study was pain during or after the procedure, followed by fear of the anesthesia needle. This mirrors findings from other studies, where pain and fear of injections are prevalent concerns among dental patients [ 27 ]. Coping strategies employed by patients included deep breathing, seeking information about the procedure, and engaging in conversations with surgical experts. These methods align with those identified in previous research. A review emphasized that behavior-modification therapies, such as muscle relaxation and relaxation breathing, along with guided imagery and physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, are effective in managing anxiety due to dental procedures [ 28 ]. Furthermore, a study by Felszeghy et al. (2024) found that deep diaphragmatic breathing, combined with background music, helped reduce stress and anxiety in preclinical dental students during practice [ 29 ]. Our findings demonstrated a statistically significant moderate positive correlation between preoperative anxiety and postoperative pain intensity, indicating that higher levels of anxiety were associated with higher pain perception after tooth extraction. This result aligns with several studies in the literature. For instance, Gonçalves et al. (2024) reported a significant association between anxiety and pain outcomes in oral surgery under local anesthesia [ 32 ]. Similarly, another study showed that preoperative anxiety predicted higher postoperative pain and greater analgesic consumption [ 33 ]. However, contrasting evidence has also been reported. A cohort study conducted in Saudi Arabia found no significant association between preoperative dental anxiety and postoperative pain following third molar surgery [ 30 ]. Likewise, a Spanish study observed a significant relationship between preoperative and postoperative anxiety, but not between preoperative anxiety and postoperative pain scores [ 31 ]. Such discrepancies may be explained by differences in surgical procedures, pain assessment timing, population characteristics, and methodological variations across studies. The study concluded that 31.9% of participants felt high anxiety as the anesthetic was injected. This corroborates with the findings of an Indian study whereby considerable cardiovascular changes such as the rise of heart rate and blood pressure occurred at the time of administering local anesthesia to patients experiencing dental anxiety [ 34 ]. research of Zhang et al. (2024) in China also suggested that dental anxiety levels were associated with raised blood pressure during tooth extraction procedures [ 35 ]. Another study conducted in Iran revealed that 60.5% of subjects had moderate to severe dental anxiety with a positive correlation between high anxiety and anesthetic difficulties [ 36 ]. The importance of dealing with anxiety at this stage is thus emphasized to increase patient comfort and safety. Regarding tooth extraction, 31 participants (13.5%) felt extremely stressed and reported symptoms of fatigue. In contrast, in a Chinese study, only one patient who underwent third molar extraction exhibited dental phobia, which suggests a high level of anxiety [ 35 ]. While waiting for appointments, 108 participants (47.2%) felt mild anxiety, and 25 (10.9%) were so nervous and they considered canceling. This goes in line with findings from a study by Alenezi and Aldohkayel (2022), where 37.7% of participants reported dental fear, and a significant number delayed or avoided dental visits due to anxiety [ 37 ]. Tool use caused mild anxiety in 84 participants (36.7%). This is consistent with a study in the United Kingdom, where 36% of adults reported moderate dental anxiety, and a significant number experienced anxiety during dental treatments involving various tools [ 38 ]. Our study’s findings reveal a mean immediate post-extraction pain score of 5.0 ± 2.6 on a 1–10 scale, with nearly half of the participants (46.7%) reporting pain levels exceeding their preoperative anxiety expectations. This is in line with previous reports highlighting that postoperative pain and related complications following tooth extraction remain common clinical concerns that require appropriate preventive and management strategies [ 39 ]. Regarding pain management, 44.1% of participants rated the effectiveness of postoperative pain medications as average, while 19.7% found them very effective. These results align with the existing body of research on postoperative dental pain and its management. A systematic review and network meta-analysis by Miroshnychenko et al. (2023) assessed the effectiveness of various pharmacological treatments for acute postoperative pain following dental extractions. The study found that combinations of ibuprofen (200–400 mg) and acetaminophen (500–1,000 mg) were among the most effective interventions, followed by naproxen (400–440 mg), ibuprofen (400 mg) alone, and acetaminophen (650 mg) with oxycodone (10 mg). These treatments consistently outperformed placebo across multiple measures, including pain relief scales. In contrast, opioids such as oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo and were associated with higher rates of acute adverse events [ 40 ]. A substantial proportion of participants (41.0%) in this study indicated that receiving detailed explanations about the surgical procedure was their preferred method for anxiety relief. This is in agreement with the global research asserting that patient education is effective in reducing preoperative anxiety. For example, a study showed that preoperative education and psychosocial support may eliminate fear and misinformation, which results in low anxiety [ 41 ]. Bello et al. (2025) also pointed out that good preoperative consultations, particularly those by an anesthesiologist, help reduce anxiety, timing and content of these consultations are very important factors [ 42 ]. The second most sought out method was to consult specialist doctor (25.8%). This underscores how much patients appreciate the personalized interactions with the healthcare professionals. Preoperative anxiety, recovery from surgery, and patient satisfaction have been reduced by empathetic and patient-centered communication [ 41 ]. In this study, 14.8% of respondents suggested pharmacological interventions like taking anxiety medications. Most pharmacologic methods to deal with pre-operative anxiety (midazolam) have adverse effects, such as breathing problems, drowsiness and slower recovery. Therefore, non-pharmacological interventions are growing in demand [ 43 ]. In addition, effective non-pharmacological interventions, such as VR- based education have been demonstrated to prevent preoperative anxiety. For example, virtual reality interventions were shown to decrease anxiety levels in patients waiting for elective surgeries in a randomized clinical trial [ 44 ]. We found a moderately strong positive correlation (Spearman’s ρ = 0.448, p < 0.001) between preoperative anxiety and postoperative pain in our study, consistent with some recent studies. For instance, a cohort study conducted between 2019 and 2020 by Tadesse et al. (2022) revealed that patients with high preoperative anxiety experienced significantly increased postoperative pain at multiple time points, over 2, 4, 6, and 12 hours post-surgery, and required higher doses of analgesics such as tramadol [ 45 ]. Another similar study with elderly patients who underwent gastrointestinal cancer surgery showed a moderate positive correlation (r = 0.410, p < 0.001) between high preoperative anxiety and high postoperative pain, with preoperative anxiety being identified as an independent predictor for postoperative pain [ 46 ]. However, not all studies have shown a significant association between preoperative anxiety and postoperative pain. Shebl et al. (2025) conducted a meta-analysis, which found no significant association between preoperative anxiety and postoperative pain but there were associations with increased anesthetic and analgesic requirements and prolonged recovery time [ 47 ]. These inconsistencies may also be explained by variations in study designs, populations of patients, surgical procedures, and methods of anxiety and pain assessments. For example, differences in the time of pain assessment, the application of different pain scales, standardized pain management protocols, and other methodological issues could explain the observed relationships [ 47 ]. Furthermore, the multidimensionality of anxiety (state and trait components) may also account for some of these inconsistencies [ 47 ]. The present study investigates the association between preoperative anxiety levels and postoperative pain intensity among oral surgery patients. These findings show a statistically significant correlation (p = 0.005) of increased preoperative anxiety and more severe postoperative pain. Interestingly, patients who had high anxiety levels experienced severe postoperative pain at a rate of 41.0%, whereas only 20.5% of patients with low anxiety experienced severe pain. The relationship between preoperative anxiety and postoperative pain has been extensively studied globally in a variety of surgical disciplines. For instance, a narrative review by Ni et al. (2023) highlights that preoperative anxiety is correlated with adverse postoperative events such as increased pain perception [ 48 ]. A study of Kılıç et al. (2024) in the field of oral and maxillofacial surgery reported that preoperative educational interviews decreased preoperative anxiety level and postoperative discomfort such as pain. This implies that targeted preoperative interventions can reduce the detrimental effects of anxiety on postoperative pain outcomes. [ 49 ]. 7. Strengths and Future Directions This study contributes to the growing body of evidence regarding the psychological determinants of postoperative outcomes in oral surgery. A major strength of this work is the standardized use of validated measures for both dental anxiety and postoperative pain assessment, which enhances the reliability of the findings. Additionally, data were collected from a real clinical setting, increasing the ecological validity and generalizability of the results. Future studies should consider longitudinal designs to better capture temporal relationships between anxiety and postoperative pain beyond the immediate postoperative period. Further research is also warranted to examine the effectiveness of targeted preoperative interventions—both pharmacological and non-pharmacological—in reducing anxiety and improving postoperative pain outcomes among dental patients. 8. Limitations of the study This study’s cross-sectional design restricts the ability to establish causal association between preoperative anxiety and postoperative pain, as it captures data at a limited period of time. Since the DAS and the VAS are self-reported measures, there could be a possibility of biases, such as social desirability and recall biases in the assessment of anxiety and pain level. Moreover, the study’s single center setting in Saudi Arabia could hinder the generalizability of outcomes to other populations. In addition, the study did not take into consideration the influence of other psychological factors like physiological markers (e.g., heart rate, blood pressure, salivary cortisol) and procedural factors (duration of surgery, operator experience, anesthesia type) to validate anxiety responses. 9. Conclusion The findings of this study suggest a strong association between elevated preoperative anxiety levels and greater postoperative pain in oral surgery patients. This underscores the need to evaluate and manage anxiety prior to surgery as a means of improving pain management outcomes. Future research should adopt longitudinal study designs to examine association and include diverse populations to enhance generalizability. Additionally, integrating more elaborate psychological assessments and treatment approaches could explain additional mechanisms to relieve preoperative anxiety and provide insights into postoperative care interventions that might be more effective for pain management. Abbreviations -Dental Anxiety Scale (DAS) -Visual Analog Scale (VAS) - Patients categorized under ASA (American Society of Anesthesiologists) - Institutional Review Board (IRB) Declarations 10.2. Acknowledgments The authors would like to thank all participants who responded to the survey and the dentists who distributed the survey to their patients. 10.3. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 10.4. Author information - Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia, Dr. Sami Alshehry - College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, Dr.Yaser Alqabbani 10.5. Contributions Y.A. (Yaser Alqabbani) conceptualized the study, collected and analyzed the data, and drafted the manuscript. S.A. (Sami Alshehry) supervised the research process, provided guidance on study design and statistical interpretation, and critically revised the manuscript for important intellectual content. Both authors reviewed and approved the final version of the manuscript. 10.6. Conflict of Interest The authors declare no conflict of interest. 10.7. Ethical approval This study was approved by the Deanship of Scientific Research- Imam Abdulrahman bin Faisal University (IRB-2025-02-0276) (Approval Date: 13/04/2025). 10.8. Consent to participate Participation in the study was voluntary, and no incentives were offered to participate in the study to participants or to the dentists who distributed the survey to their patients. Participants were presented with an informed consent form with a preview of the study objectives. Data collection was performed in accordance with relevant guidelines and regulations of Deanship of Imam Abdulrahman bin Faisal university. 10.9. Consent for publication Not applicable. Survey completion implied consent for the use and publication of anonymized data in accordance of Deanship of Imam Abdulrahman bin Faisal university. 10.10. Competing interests The authors declare no competing interests. 10.11. Data availability The data can be provided by the corresponding author upon reasonable request. 10.12 . Declaration of Helsinki This study adhered to the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Deanship of Scientific Research-Imam Abdulrahman bin Faisal University Institutional Review Board (IRB) (Approval number: IRB-2025-02-0276) (Approval Date: 13/04/2025). All participants provided written informed consent before participation. References Shah A. Oral surgery. Prim Dent J 2022;11:2–3. https://doi.org/10.1177/20501684221118207. Maulina T, Djustiana N, Shahib MN. The Effect of Music Intervention on Dental Anxiety During Dental Extraction Procedure. Open Dent J 2017;11:565–72. https://doi.org/10.2174/1874210601711010565. López-Jornet P, Camacho-Alonso F, Sanchez-Siles M. Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: A prospective study. Br J Oral Maxillofac Surg 2014; 52:18–23. https://doi.org/10.1016/j.bjoms.2013.01.004. Sirin Y, Humphris G, Sencan S, Firat D. What is the most fearful intervention in ambulatory oral surgery? Analysis of an outpatient clinic. Int J Oral Maxillofac Surg 2012;41:1284–90. https://doi.org/https://doi.org/10.1016/j.ijom.2012.06.013. Kazancioglu H-O, Dahhan A-S, Acar A-H. How could multimedia information about dental implant surgery effects patients’ anxiety level? Med Oral Patol Oral Cir Bucal 2017;22:e102–7. https://doi.org/10.4317/medoral.21254. Cillo JE. Peri-Operative Pain Management in Maxillofacial Surgery BT - Perioperative Assessment of the Maxillofacial Surgery Patient: Problem-based Patient Management. In: Ferneini EM, Bennett JD, editors., Cham: Springer International Publishing; 2018, p. 145– 60. https://doi.org/10.1007/978-3-319-58868-1_11. Bailey E, Bailey E. Prevention and Management of Postoperative Pain in Oral Surgery. Prim Dent J 2018;7:57–63. https://doi.org/10.1177/205016841800700309. Sirintawat N, Sawang K, Chaiyasamut T, Wongsirichat N. Pain measurement in oral and maxillofacial surgery. 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Duarte-Rodrigues L, Miranda EFP, Souza TO, de Paiva HN, Falci SGM, Galvão EL. Third molar removal and its impact on quality of life: systematic review and meta-analysis. Qual Life Res 2018;27:2477–89. https://doi.org/10.1007/s11136-018-1889-1. González-Martínez R, Jovani-Sancho M del M, Cortell-Ballester I. Does Psychological Profile Influence Third Molar Extraction and Postoperative Pain? J Oral Maxillofac Surg 2017;75:484–90. https://doi.org/https://doi.org/10.1016/j.joms.2016.09.023. Humphris G, Crawford JR, Hill K, Gilbert A, Freeman R. UK population norms for the modified dental anxiety scale with percentile calculator: adult dental health survey 2009 results. BMC Oral Health 2013;13:29. https://doi.org/10.1186/1472-6831-13-29. Kyle BN, McNeil DW, Weaver B, Wilson T. Recall of Dental Pain and Anxiety in a Cohort of Oral Surgery Patients. J Dent Res 2016;95:629–34. https://doi.org/10.1177/0022034516631977. Doan L V., Blitz J. Preoperative Assessment and Management of Patients with Pain and Anxiety Disorders. Curr Anesthesiol Rep 2020;10:28–34. https://doi.org/10.1007/s40140- 020- 00367-9 Zsido AN, Teleki SA, Csokasi K, Rozsa S, Bandi SA. Development of the short version of the spielberger state—trait anxiety inventory. Psychiatry Res 2020;291:113223. https://doi.org/https://doi.org/10.1016/j.psychres.2020.113223. Astramskaitė I, Juodžbalys G. Scales used to rate adult patients’ psycho-emotional status in tooth extraction procedures: a systematic review. Int J Oral Maxillofac Surg 2017;46:886– 98. https://doi.org/https://doi.org/10.1016/j.ijom.2017.03.015. Kim S, Lee Y-J, Lee S, Moon H-S, Chung M-K. Assessment of pain and anxiety following surgical placement of dental implants. Int J Oral & Maxillofac Implant 2013;28:531– 5. https://doi.org/10.11607/jomi.2713. Álvarez-García C, Yaban ZŞ. The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis. Complement Ther Clin Pract 2020;38:101077. https://doi.org/https://doi.org/10.1016/j.ctcp.2019.101077. Lin C-S, Wu S-Y, Yi C-A. Association between Anxiety and Pain in Dental Treatment: A Systematic Review and Meta-analysis. J Dent Res 2016;96:153–62. https://doi.org/10.1177/0022034516678168. Bovaira M, Herrero Babiloni A, Jovaní M, Peñarrocha-Diago M, Peñarrocha-Diago M, González- Lemonnier S, et al. Preoperative Anxiety and Its Influence on Patient and Surgeon Satisfaction in Patients Receiving Dental Implant Surgeries Performed Under Intravenous Conscious Sedation. Int J Oral & Maxillofac Implant 2017;32:912–8. https://doi.org/10.11607/jomi.5712. Jensen MP, Chen C, Brugger AM. The measurement of clinical pain intensity: a comparison of six methods. Pain . 1999;83(2):157–162.mhttps://doi.org/10.1016/S0304-3959(99)00101-2 Abate SM, Chekol YA, Basu B. Global prevalence and determinants of preoperative anxiety among surgical patients: A systematic review and meta-analysis. International Journal of Surgery Open. 2020;25:6-16. https://doi.org/10.1016/j.ijso.2020.05.010 Almalki MS, Hakami OAO, Al-Amri AM. Assessment of preoperative anxiety among patients undergoing elective surgery. The Egyptian Journal of Hospital Medicine. 2017;69(4):2329-33. https://doi.org/10.12816/0041537 Berge KG, Agdal ML, Vika M, Skeie MS. High fear of Intra‐Oral injections: prevalence and relationship to dental fear and dental avoidance among 10‐to 16‐Yr‐Old children. European journal of oral sciences. 2016;124(6):572-9. https://doi.org/10.1111/eos.12305 Appukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, cosmetic and investigational dentistry. 2016:35-50. https://doi.org/10.2147/ccide.s63626 Felszeghy S, Kurki P, Liukkonen M, Suominen AL, Huhtela O. The combination of listening to background music and deep breathing as a stress reduction strategy during dental preclinical study. Journal of Dental Education. 2024;88(3):342-7. https://doi.org/10.1002/jdd.13424 Onwuka CI, Udeabor SE, Al-Hunaif AM, Al-Shehri WAK, Al-Sahman LA. Does preoperative dental anxiety play a role in postoperative pain perception after third molar surgery? Ann Afr Med . 2020;19(4):264–270. https://doi.org/10.4103/aam.aam_27_20 Reyes-Gilabert E, Luque-Romero LG, Bejarano-Avila G, Garcia-Palma A, Rollon-Mayordomo A, Infante-Cossio P. Assessment of pre and postoperative anxiety in patients undergoing ambulatory oral surgery in primary care. Med Oral Patol Oral Cir Bucal . 2017;22(6):e716–e722. https://doi.org/10.4317/medoral.21735 Gonçalves RCG, Cardoso RB, Bauer J, Santos VM, Jabur RO, Bortoluzzi MC. Exploring the relationship between anxiety, patient characteristics and pain outcomes in oral surgery under local anesthesia: the measurement problem. Dent Med Probl . 2024;61(4):515–523. https://doi.org/10.17219/dmp/189553 Qaddumi J, Arda AM, Alkhawaldeh A, Albashtawy M, Abdalrahim A, Albashtawy Sd, et al. Preoperative anxiety, postoperative pain tolerance and analgesia consumption: A prospective cohort study. Journal of Perioperative Practice. 2024. https://doi.org/10.1177/17504589241253489 Sharma A, Pant R, Priyadarshi S, Agarwal N, Tripathi S, Chaudhary M. Cardiovascular changes due to dental anxiety during local anesthesia injection for extraction. Journal of maxillofacial and oral surgery. 2019;18:80-7. https://doi.org/10.1007/s12663-018-1085-4 Zhang D, Li S, Zhang R. Effects of dental anxiety and anesthesia on vital signs during tooth extraction. BMC Oral Health. 2024;24(1):632. https://doi.org/10.1186/s12903-024-04404-5 Xu JL, Xia R. Influence factors of dental anxiety in patients with impacted third molar extractions and its correlation with postoperative pain: a prospective study. Medicina Oral, Patología Oral y Cirugía Bucal. 2020;25(6):e714. https://doi.org/10.4317/medoral.23293 Alenezi AA, Aldokhayel HS. The impact of dental fear on the dental attendance behaviors: A retrospective study. Journal of Family Medicine and Primary Care. 2022;11(10):6444-50. https://doi.org/10.4103/jfmpc.jfmpc_1030_22 Grossman S. The Surgical Dental Anxiety Scale (SDAS). British Dental Journal. 2024;237(12):935-7. https://doi.org/10.1038/s41415-024-7846-1 Dignam P, O’Connell B, et al. Prevalence and factors influencing post-operative complications following tooth extraction: a narrative review. Dentistry Journal . 2024;12(6):187. https://doi.org/10.3390/dj12060187 Miroshnychenko A, Ibrahim S, Azab M, Roldan Y, Martinez J, Tamilselvan D, et al. Acute postoperative pain due to dental extraction in the adult population: a systematic review and network meta-analysis. Journal of Dental Research. 2023;102(4):391-401. https://doi.org/10.1177/00220345221139230 Stucky C, Vortman R. Nurse-led strategies to decrease preoperative patient anxiety. Nursing2025. 2022;52(12). Bello CM, Eisler P, Heidegger T. Perioperative Anxiety: Current Status and Future Perspectives. Journal of Clinical Medicine [Internet]. 2025; 14(5). https://doi.org/10.3390/jcm14051422 Wang R, Huang X, Wang Y, Akbari M. Non-pharmacologic approaches in preoperative anxiety, a comprehensive review. Frontiers in public health. 2022;10:854673. https://doi.org/10.3389/fpubh.2022.854673 Chiu PL, Li H, Yap KY-L, Lam K-mC, Yip P-lR, Wong CL. Virtual Reality–Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery: A Randomized Clinical Trial. JAMA Network Open. 2023;6(10):e2340588-e. https://doi.org/10.1001/jamanetworkopen.2023.40588 Tadesse M, Ahmed S, Regassa T, Girma T, Hailu S, Mohammed A, et al. Effect of preoperative anxiety on postoperative pain on patients undergoing elective surgery: Prospective cohort study. Annals of medicine and surgery. 2022;73:103190. https://doi.org/10.1016/j.amsu.2021.103190 Liu Q, Li L, Wei J, Xie Y. Correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery. BMC Anesthesiology. 2023;23. https://doi.org/10.1186/s12871-023-02036-w Shebl MA, Toraih E, Shebl M, Tolba AM, Ahmed P, Banga HS, et al. Preoperative anxiety and its impact on surgical outcomes: A systematic review and meta-analysis. Journal of Clinical and Translational Science. 2025;9(1):e33. https://doi.org/10.1017/cts.2025.6 Ni K, Zhu J, Ma Z. Preoperative anxiety and postoperative adverse events: a narrative overview. Anesthesiology and Perioperative Science. 2023;1(3):23. https://doi.org/10.1007/s44254-023-00019-1 Kocaturk S, Gur ZB, Gursoytrak B. Can Verbal Interview Decrease Preoperative Anxiety and Postoperative Discomfort in Oral and Maxillofacial Surgery Patients?: A Randomized Clinical Trial. Journal of Oral and Maxillofacial Surgery. 2024;82(11):1425-32. https://doi.org/10.1016/j.joms.2024.06.178 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8920791","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":599583661,"identity":"8a69d6ba-e1fd-43a3-89d1-5c9db1f922a7","order_by":0,"name":"Sami Mohammed Alshehry","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYHACxgOMDQwJDMzMBw6A+QeI0APVwpZAqhYGHgMGorTITzv84ODPHTZ55u08Hw/8bGOQ47uRwPzhBx4tBrfTDA7znkkrljnMu+FgbxuDseSNBDbJHnxapBMMDjO2HU6cwcy74QBvG0PiBqAWBh58Dpud/uHgz7b/QC08Dw7+bWOoB2ph/vgHn2du5xgADT8A0sJwGGhLgsGNBAZpfLYY3M4pAKpMBmphMzgsc07CcOaZh23SMvgdtvHhzza7xBn8hx9/fFNmI893PPnwxzf4HIYGJIAYGE2jYBSMglEwCigDAEWGVoMChUoCAAAAAElFTkSuQmCC","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":true,"prefix":"","firstName":"Sami","middleName":"Mohammed","lastName":"Alshehry","suffix":""},{"id":599583662,"identity":"c05e1c97-7b5e-4abd-be01-78a9b9d6b81d","order_by":1,"name":"Yaser Alqabbani","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":false,"prefix":"","firstName":"Yaser","middleName":"","lastName":"Alqabbani","suffix":""}],"badges":[],"createdAt":"2026-02-19 20:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8920791/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8920791/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104177825,"identity":"b9bbd8d8-ad11-456e-a9e1-8231def39499","added_by":"auto","created_at":"2026-03-08 16:50:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64104,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipants’ response about situational anxiety during dental procedures\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8920791/v1/36b27d6b3ae86ada2193df96.png"},{"id":104177827,"identity":"d98e9456-f7a5-4155-b2c0-8b25ccf5c8d4","added_by":"auto","created_at":"2026-03-08 16:50:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26915,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStrategies for pre-operative anxiety relief\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8920791/v1/71ed7c0526513a35e60b4fb6.png"},{"id":104177826,"identity":"dd0b28da-1219-448e-9bcf-eb3d13bb79a1","added_by":"auto","created_at":"2026-03-08 16:50:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74868,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between Pre-operative Anxiety and Postoperative Pain\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8920791/v1/3f7295256a9964f141a38d00.png"},{"id":104403895,"identity":"5263cd84-8659-4be0-a3d4-2c34c8fc5711","added_by":"auto","created_at":"2026-03-11 12:19:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1098794,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8920791/v1/53a0b91f-77ce-4054-9e64-a1e824249871.pdf"},{"id":104177828,"identity":"6796def3-9461-40b9-a8d2-b9b88c300ef9","added_by":"auto","created_at":"2026-03-08 16:50:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1247471,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8920791/v1/899eedb9d7e703dbc91aa096.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Preoperative Anxiety and Postoperative Pain Following Tooth Extraction: A Cross-Sectional Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOral surgery encompasses a wide range of procedures targeting the oral and maxillofacial regions. These surgeries, including but not limited to tooth extractions, dental implants, and corrective jaw surgeries, are crucial for addressing various dental health issues [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, they often provoke significant patient concerns, notably preoperative anxiety and the management of postoperative pain. The most commonly recognized definition of A complicated pattern of behavior linked to physiological activity, anxiety is triggered by both external (environmental) and internal (somatic and cognitive) stimuli. Patients may feel these stimuli prior to, during, or after oral surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When it comes to oral surgery, fear and anxiety are often linked to poor oral health, a worse quality of life connected to dental health, and weakened psychosocial health, which includes reduced morale and low self-esteem [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among common oral surgical procedures, tooth extraction\u0026mdash;particularly third molar removal\u0026mdash;is consistently associated with the highest patient anxiety levels [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Usually, the procedure results in soft tissue and bone trauma, which causes a range of morbidities. When patients feel anxious during oral surgery, they may not be able to cooperate with their surgeons. This might lead to longer and more complicated operations, which could result in unsatisfactory treatment outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlmost all oral and maxillofacial procedures are followed by the well-known occurrence of postoperative pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Pain is a painful feeling that is connected to actual tissue injury and is carried to the brain by certain nerve fibers. This definition demonstrates the multitude of psychological, moderating, and irritating transitional components that contribute to the pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Analgesics are often needed during the early postoperative phase, when pain is at its peak [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Anxiety and other psychological factors influence how patients perceive pain. Preoperative anxiety is often prevalent prior to lower third molar surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Dentists believe that between 3% and 43% of people worldwide suffer from dental anxiety [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Research has shown that dental anxiety affects 4% to 20% of the general population, regardless of socioeconomic, cultural, or racial background, and that receiving better dental care does not lessen its prevalence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe degree of patients' anxiety has been shown to impact the recovery process after third molar surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Studies have shown that preoperative anxiety is linked to higher levels of postoperative pain and more prolonged surgical procedures [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Studies have shown a correlation between preoperative anxiety and the effectiveness of pain management after third molar surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Throughout history, there has been a consistent connection between dental anxiety and the expectation of pain. However, dental anxiety is still quite common despite advancements in pain management, which prevents some people from seeking oral care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In dental practice, patients who are fearful tend to become more nervous since they only seek treatment when they are in pain. This causes a vicious cycle of pain and anxiety, with both having a propensity to become worse [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Anxiety, according to several studies, is the cause of pain that is not alleviated by postoperative analgesics [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Anxiety may also activate stress responses, which include alterations in the cardiovascular, respiratory, metabolic, and hormonal systems. These alterations have the potential to impact the result of the surgery and lengthen the duration of the hospital stay. Extended postoperative pain is correlated with an increased likelihood of complications [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor assessing anxiety, the most widely used test is the State-Trait Anxiety Inventory (STAI) scale [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Current research indicates that variables, such as the kind of operation, anxiety, depression, and postoperative pain and the requirement for analgesics may be influenced by preoperative pain [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In several medical specialties, the relationship between postoperative pain and the pain threshold and tolerance to pressure have been evaluated.\u003c/p\u003e \u003cp\u003eWhen it comes to postoperative pain management and the patient experience, the issue of preoperative anxiety in patients having oral surgery is an important challenge [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Preoperative anxiety, characterized by fear and apprehension before surgery, has been implicated in affecting the perception of pain, the recovery process, and the overall outcomes of pain management post- surgery. Despite the recognized importance of addressing preoperative anxiety to improve postoperative outcomes, there remains a critical gap in our understanding of how exactly preoperative anxiety influences postoperative pain management specifically in the context of oral surgery. Therefore, the present study aimed to investigate whether preoperative dental anxiety influences the severity of postoperative pain following surgical and non-surgical tooth extraction in adult patients.\u003c/p\u003e"},{"header":"2. Rationale of the Study","content":"\u003cp\u003eAddressing this gap has the potential to significantly impact clinical practices by providing insights that could lead to the development of targeted interventions for reducing preoperative anxiety, thereby improving postoperative pain management [21]. Enhanced understanding of the anxiety-pain relationship in oral surgery could lead to better patient outcomes, including reduced pain levels, lower medication requirements, and overall improved quality of life post-surgery [22].\u003c/p\u003e\n\u003cp\u003eThe proposed study seeks to advance knowledge in the field of oral health and surgery by exploring an under-investigated area. By specifically examining the correlation between preoperative anxiety and the treatment of postoperative pain in patients undergoing oral surgery, this research could contribute valuable insights that are applicable not only within the field of oral surgery but also in broader surgical and medical practices. The interdisciplinary benefits of this research could facilitate innovations in preoperative care and pain management, paving the way for improved patient care practices across various domains of healthcare [23].\u003c/p\u003e"},{"header":"3. Hypothesis of the Study","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003e3.1.\u0026nbsp;Null Hypothesis (H₀):\u003c/strong\u003e There is no association between preoperative anxiety and postoperative pain intensity among oral surgery patients.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e3.2.\u0026nbsp;Alternative Hypothesis (H₁):\u003c/strong\u003e Higher preoperative anxiety levels are associated with higher postoperative pain intensity among oral surgery patients.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"4. Methodology","content":"\u003cp\u003e\u003cstrong\u003e4.1 Study Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe study employed a cross-sectional design, which is particularly suited for assessing and analyzing the association between preoperative anxiety levels and postoperative pain among patients undergoing a single-tooth extraction procedure during one visit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Setting and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at the Dental College at Al-Imam Abdulrahman bin Faisal University (IAU), Dammam City. This setting was selected due to the high incidence of patients requiring surgical dental interventions, and data were collected between April 2025 and November 2025. Participants were patients admitted for tooth extraction, a common oral surgical procedure, ensuring a relevant and focused study population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Eligibility criteria\u003c/strong\u003e were defined based on clinical and demographic factors as shown in a Table.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion Criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eExclusion Criteria:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePatients categorized under ASA (American Society of Anesthesiologists) classifications 1 and 2, indicating patients who are healthy or have mild systemic disease.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePatients classified as ASA 3 and 4, representing individuals with severe systemic disease or life- threatening conditions, to avoid confounding effects on pain perception and anxiety levels.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eAdults aged \u0026ge;18 years.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePregnant or lactating women, and women regularly using oral contraceptives, to minimize physiological variations affecting anxiety or pain outcomes.\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eUndergoing extraction of a single tooth.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePatients on analgesics or anxiolytics within 24 hours.\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eCapability to understand and comply with verbal and written instructions, ensuring reliable self-reported measures of anxiety and pain.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003ePatients who refused participation or incomplete data.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Data Collection Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ePreoperative anxiety levels among patients were accurately measured using the Dental Anxiety Scale (DAS), a concise yet effective tool designed to evaluate anxiety specific to dental procedures. Postoperative pain intensity was categorized into three levels quantified using a ten-point Visual Analog Scale (VAS), allowing patients to self-assess their pain levels in both the immediate and late postoperative periods. A consecutive sampling technique was employed, including all eligible patients who met inclusion criteria during the study period. These instruments are chosen for their reliability and ease of use in clinical settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Ethical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eTo guarantee compliance with ethical standards and the defense of participant rights, the study protocol was reviewed and approved by the Deanship of Scientific Research-Imam Abdulrahman bin Faisal University Institutional Review Board (IRB) (approval number: IRB-2025-02-0276) ( Approval Date : 13/04/2025). Each participant was given a detailed explanation of the study\u0026apos;s goals, methods, possible dangers, and rewards before giving their informed consent. All participants were selected by random sampling. Confidentiality was strictly maintained, with data anonymized and securely stored to protect patient information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.6 Statistical analysis plan\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Descriptive statistics were used to summarize the characteristics of the study participants. Frequencies and percentages were calculated for categorical variables, while means and standard deviations were calculated for continuous variables. Age was treated as a continuous variable. Postoperative pain intensity was measured using the Visual Analog Scale (VAS) ranging from 1 to 10. For analytical purposes, VAS scores were categorized into three levels: mild pain (VAS 1\u0026ndash;3), moderate pain (VAS 4\u0026ndash;6), and severe pain (VAS 7\u0026ndash;10), a categorization commonly used in pain research to facilitate clinical interpretation and group comparison [24].\u003c/p\u003e\n\u003cp\u003eNormality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. Due to non-normal distribution of the variables, non-parametric tests were applied. The association between categorical variables was evaluated using Fisher\u0026rsquo;s exact test to compare differences in proportions between groups. The correlation between continuous preoperative anxiety scores and postoperative pain intensity was assessed using Spearman\u0026rsquo;s rank correlation coefficient.\u003c/p\u003e\n\u003cp\u003eTo examine the association between preoperative anxiety and categorized postoperative pain severity, a multinomial logistic regression model was conducted using postoperative pain category (mild, moderate, severe) as the dependent variable and preoperative anxiety score as the independent variable. The number of teeth extracted was not included as an explanatory variable in the regression model because the study population predominantly underwent single-tooth extraction procedures, resulting in insufficient variability to support meaningful multivariable modelling.\u003c/p\u003e\n\u003cp\u003eStatistical significance was set at p \u0026lt; 0.05 for all analyses. All statistical calculations were performed using IBM SPSS Statistics version 27.0.1 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"5. Results","content":"\u003cp\u003eA total of 229 patients were included in the final analysis after applying the eligibility criteria. The study employed a cross-sectional design, and data were collected between April 2025 and November 2025. Baseline demographic and clinical characteristics of the participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e in accordance with the CROSS-reporting guidelines.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: summarizes the demographic and clinical characteristics of the 229 participants. Most were females (n\u0026thinsp;=\u0026thinsp;154, 67.2%) and Saudi nationals (n\u0026thinsp;=\u0026thinsp;152, 66.4%). The largest age group was 36 years and older (n\u0026thinsp;=\u0026thinsp;144, 62.9%). Regarding education, most had a university degree (n\u0026thinsp;=\u0026thinsp;142, 62.0%). The most common reasons for tooth extraction were caries (n\u0026thinsp;=\u0026thinsp;89, 38.9%) and wisdom teeth (n\u0026thinsp;=\u0026thinsp;72, 31.4%) while extractions were most often performed on the upper right (n\u0026thinsp;=\u0026thinsp;64, 27.9%) and upper left (n\u0026thinsp;=\u0026thinsp;62, 27.1%) jaws.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Characteristics of the Study Participants (n\u0026thinsp;=\u0026thinsp;229)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e154 (67.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSaudi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (66.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Saudi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77 (33.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (23.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;36 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e144 (62.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142 (62.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eReason for tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo install orthodontics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTooth decay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWisdom tooth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eArea of tooth extracted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower jaw (left)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (20.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower jaw (right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper jaw (left)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper jaw (right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (27.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003en: Frequency, %: Percentage\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003esummarizes participants' general preoperative anxiety and perceptions. Over half of the participants reported moderate anxiety (n\u0026thinsp;=\u0026thinsp;124, 54.1%), while 61 (26.6%) had high anxiety, and 44 (19.2%) reported low anxiety. The mean self-reported anxiety score on a 1\u0026ndash;10 scale was 5.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87, ranging from 1 to 10. The most cited concern about tooth extraction was pain during or after the procedure (n\u0026thinsp;=\u0026thinsp;85, 37.1%), followed by the anaesthesia needle (n\u0026thinsp;=\u0026thinsp;45, 19.7%). Only 48.0% (n\u0026thinsp;=\u0026thinsp;110) had been given a full explanation of the procedure steps prior to extraction. Regarding coping strategies, the most frequently used methods were deep breathing (n\u0026thinsp;=\u0026thinsp;75, 32.8%), talking to a surgical expert (n\u0026thinsp;=\u0026thinsp;55, 24.0%), and searching for information about the procedure (n\u0026thinsp;=\u0026thinsp;44, 19.2%), among others.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative Anxiety: General Preoperative Anxiety and Perceptions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (54.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (26.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnxiety level about next tooth extraction (1\u0026ndash;10 scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMain concern about tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnaesthesia needle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethod of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain during or after tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (37.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePossible complications of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSide effects of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExplanation of tooth extraction steps received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119 (52.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110 (48.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eMethod used to cope with anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeep breathing training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeeping the mind busy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eListening to music\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemembrance of God\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch for general information about the nature of tooth extraction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaking tranquilizers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTalk to a surgical expert\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (24.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003en: Frequency, %: Percentage, SD: Standard deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents participants' situational anxiety levels during key phases of dental procedures. Anxiety peaks during anaesthesia injection, with 73 participants (31.9%) reporting high anxiety. Extreme stress during tooth extraction was reported by 31 participants (13.5%), who experienced physical symptoms of fatigue. While waiting for appointments, 108 participants (47.2%) felt mild anxiety, though 25 (10.9%) were so nervous and considered cancelling. Sitting in the dental chair induced high anxiety in 52 participants (22.7%). During gum numbness (particularly for upper extractions), 92 participants (40.2%) reported mild anxiety, while tool use caused mild anxiety in 84 participants (36.7%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003epresents postoperative pain perception and management outcomes. The mean immediate post-extraction pain score was 5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6. Nearly half (n\u0026thinsp;=\u0026thinsp;107, 46.7%) reported their pain exceeded pre-operative anxiety expectations, while 100 (43.7%) found it matched expectations. Pain management effectiveness was rated as \"average\" by 101 (44.1%), though 45 (19.7%) found it very effective.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Pain Perception and Pain Management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-extraction pain level\u003c/p\u003e \u003cp\u003e(1\u0026ndash;10 scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eActual pain during procedure\u003c/p\u003e \u003cp\u003e\u003cb\u003evs\u003c/b\u003e\u003c/p\u003e \u003cp\u003epre-operative anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot compatible\u003c/p\u003e \u003cp\u003e(I didn't feel worried at all)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eEffectiveness of post-operative pain management (medications)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove average effectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage effectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (44.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow average effectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIneffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003en: Frequency, %: Percentage, SD: Standard deviation\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that for anxiety relief, some recommended receiving detailed explanations about the surgical procedure (n\u0026thinsp;=\u0026thinsp;94, 41.0%), others preferred consulting a specialist doctor (n\u0026thinsp;=\u0026thinsp;59, 25.8%). Pharmacological interventions like taking anxiety medications were suggested by 34 (14.8%) of respondents. Less common strategies included reviewing questionnaires from previous patients (n\u0026thinsp;=\u0026thinsp;18, 7.8%) and requesting psychiatric consultation (n\u0026thinsp;=\u0026thinsp;11, 4.8%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003eTo assess the relationship between preoperative anxiety and postoperative pain, both continuous and categorical analyses were performed. Using Spearman\u0026rsquo;s rank correlation, a statistically significant positive correlation was observed between preoperative anxiety scores and immediate postoperative pain intensity (ρ\u0026thinsp;=\u0026thinsp;0.448, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that higher levels of preoperative anxiety were associated with higher postoperative pain scores\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between Preoperative Anxiety and Postoperative Pain\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCorrelation coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep- value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLower\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eUpper\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative anxiety vs postoperative pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.549\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCI\u0026thinsp;=\u0026thinsp;confidence interval; ρ\u0026thinsp;=\u0026thinsp;Spearman\u0026rsquo;s rho; * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003c/p\u003e \u003cp\u003eWhen both variables were analyzed categorically, Fisher\u0026rsquo;s exact test showed a statistically significant association between preoperative anxiety level and postoperative pain severity (p\u0026thinsp;=\u0026thinsp;0.005). Patients with high preoperative anxiety experienced severe postoperative pain more frequently (41.0%) compared with those with moderate (16.9%) and low anxiety (20.5%). In contrast, mild pain was most commonly reported among patients with low preoperative anxiety (43.2%). No statistically significant associations were observed between postoperative pain level and other examined factors, including the main concern about tooth extraction (p\u0026thinsp;=\u0026thinsp;0.569), receiving an explanation of the extraction steps (p\u0026thinsp;=\u0026thinsp;0.710), or the coping method used for anxiety (p\u0026thinsp;=\u0026thinsp;0.114).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of post-operative pain level and preoperative anxiety factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMild pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSevere pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003csup\u003e\u003cem\u003e#\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLevel of Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (20.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.005*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e25 (41.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMain concern about tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnesthesia needle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (35.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (31.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethod of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (36.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (22.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain during or after tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePossible complications of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (48.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSide effects of tooth extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (34.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExplanation of tooth extraction steps received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (45.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eMethod used to cope with anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeep breathing training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeeping the mind busy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eListening to music\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemembrance of God\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch for general information about the nature of tooth extraction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (38.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaking tranquilizers (medications)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTalk to a surgical expert\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (32.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (41.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003en: Frequency, %: Percentage\u003c/em\u003e, \u003csup\u003e\u003cem\u003e#\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eFischer-Exact test, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, significant\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"6. Discussion","content":"\u003cp\u003eAt the outset of this study, the null hypothesis stated that there is no association between preoperative dental anxiety and the severity of postoperative pain following tooth extraction. Conversely, the alternative hypothesis posited that higher levels of preoperative dental anxiety would be associated with greater postoperative pain intensity.\u003c/p\u003e \u003cp\u003e This study aimed to explore the association between preoperative anxiety levels and postoperative pain management in oral surgery patients in Saudi Arabia. Regarding preoperative anxiety, the findings reveal that over half of the participants (54.1%) reported moderate anxiety levels, while 26.6% experienced high anxiety, and 19.2% had low anxiety. The prevalence of moderate to high preoperative anxiety in this study aligns with global trends. A global meta-analysis by Abate et al. indicated a pooled prevalence of 48% among surgical patients [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Specifically, a Saudi study reported a high prevalence of preoperative anxiety among patients undergoing elective surgery, with factors such as female gender, younger age, and lower educational levels being associated with higher anxiety levels [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary concern among patients in this study was pain during or after the procedure, followed by fear of the anesthesia needle. This mirrors findings from other studies, where pain and fear of injections are prevalent concerns among dental patients [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Coping strategies employed by patients included deep breathing, seeking information about the procedure, and engaging in conversations with surgical experts. These methods align with those identified in previous research. A review emphasized that behavior-modification therapies, such as muscle relaxation and relaxation breathing, along with guided imagery and physiological monitoring using biofeedback, hypnosis, acupuncture, distraction, positive reinforcement, stop-signaling, and exposure-based treatments, are effective in managing anxiety due to dental procedures [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, a study by Felszeghy et al. (2024) found that deep diaphragmatic breathing, combined with background music, helped reduce stress and anxiety in preclinical dental students during practice [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings demonstrated a statistically significant moderate positive correlation between preoperative anxiety and postoperative pain intensity, indicating that higher levels of anxiety were associated with higher pain perception after tooth extraction. This result aligns with several studies in the literature. For instance, Gon\u0026ccedil;alves et al. (2024) reported a significant association between anxiety and pain outcomes in oral surgery under local anesthesia [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, another study showed that preoperative anxiety predicted higher postoperative pain and greater analgesic consumption [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, contrasting evidence has also been reported. A cohort study conducted in Saudi Arabia found no significant association between preoperative dental anxiety and postoperative pain following third molar surgery [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Likewise, a Spanish study observed a significant relationship between preoperative and postoperative anxiety, but not between preoperative anxiety and postoperative pain scores [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Such discrepancies may be explained by differences in surgical procedures, pain assessment timing, population characteristics, and methodological variations across studies.\u003c/p\u003e \u003cp\u003eThe study concluded that 31.9% of participants felt high anxiety as the anesthetic was injected. This corroborates with the findings of an Indian study whereby considerable cardiovascular changes such as the rise of heart rate and blood pressure occurred at the time of administering local anesthesia to patients experiencing dental anxiety [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. research of Zhang et al. (2024) in China also suggested that dental anxiety levels were associated with raised blood pressure during tooth extraction procedures [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Another study conducted in Iran revealed that 60.5% of subjects had moderate to severe dental anxiety with a positive correlation between high anxiety and anesthetic difficulties [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The importance of dealing with anxiety at this stage is thus emphasized to increase patient comfort and safety. Regarding tooth extraction, 31 participants (13.5%) felt extremely stressed and reported symptoms of fatigue. In contrast, in a Chinese study, only one patient who underwent third molar extraction exhibited dental phobia, which suggests a high level of anxiety [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. While waiting for appointments, 108 participants (47.2%) felt mild anxiety, and 25 (10.9%) were so nervous and they considered canceling. This goes in line with findings from a study by Alenezi and Aldohkayel (2022), where 37.7% of participants reported dental fear, and a significant number delayed or avoided dental visits due to anxiety [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Tool use caused mild anxiety in 84 participants (36.7%). This is consistent with a study in the United Kingdom, where 36% of adults reported moderate dental anxiety, and a significant number experienced anxiety during dental treatments involving various tools [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study\u0026rsquo;s findings reveal a mean immediate post-extraction pain score of 5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 on a 1\u0026ndash;10 scale, with nearly half of the participants (46.7%) reporting pain levels exceeding their preoperative anxiety expectations. This is in line with previous reports highlighting that postoperative pain and related complications following tooth extraction remain common clinical concerns that require appropriate preventive and management strategies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Regarding pain management, 44.1% of participants rated the effectiveness of postoperative pain medications as average, while 19.7% found them very effective. These results align with the existing body of research on postoperative dental pain and its management. A systematic review and network meta-analysis by Miroshnychenko et al. (2023) assessed the effectiveness of various pharmacological treatments for acute postoperative pain following dental extractions. The study found that combinations of ibuprofen (200\u0026ndash;400 mg) and acetaminophen (500\u0026ndash;1,000 mg) were among the most effective interventions, followed by naproxen (400\u0026ndash;440 mg), ibuprofen (400 mg) alone, and acetaminophen (650 mg) with oxycodone (10 mg). These treatments consistently outperformed placebo across multiple measures, including pain relief scales. In contrast, opioids such as oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo and were associated with higher rates of acute adverse events [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA substantial proportion of participants (41.0%) in this study indicated that receiving detailed explanations about the surgical procedure was their preferred method for anxiety relief. This is in agreement with the global research asserting that patient education is effective in reducing preoperative anxiety. For example, a study showed that preoperative education and psychosocial support may eliminate fear and misinformation, which results in low anxiety [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Bello et al. (2025) also pointed out that good preoperative consultations, particularly those by an anesthesiologist, help reduce anxiety, timing and content of these consultations are very important factors [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The second most sought out method was to consult specialist doctor (25.8%). This underscores how much patients appreciate the personalized interactions with the healthcare professionals. Preoperative anxiety, recovery from surgery, and patient satisfaction have been reduced by empathetic and patient-centered communication [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In this study, 14.8% of respondents suggested pharmacological interventions like taking anxiety medications. Most pharmacologic methods to deal with pre-operative anxiety (midazolam) have adverse effects, such as breathing problems, drowsiness and slower recovery. Therefore, non-pharmacological interventions are growing in demand [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In addition, effective non-pharmacological interventions, such as VR- based education have been demonstrated to prevent preoperative anxiety. For example, virtual reality interventions were shown to decrease anxiety levels in patients waiting for elective surgeries in a randomized clinical trial [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found a moderately strong positive correlation (Spearman\u0026rsquo;s ρ\u0026thinsp;=\u0026thinsp;0.448, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between preoperative anxiety and postoperative pain in our study, consistent with some recent studies. For instance, a cohort study conducted between 2019 and 2020 by Tadesse et al. (2022) revealed that patients with high preoperative anxiety experienced significantly increased postoperative pain at multiple time points, over 2, 4, 6, and 12 hours post-surgery, and required higher doses of analgesics such as tramadol [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Another similar study with elderly patients who underwent gastrointestinal cancer surgery showed a moderate positive correlation (r\u0026thinsp;=\u0026thinsp;0.410, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between high preoperative anxiety and high postoperative pain, with preoperative anxiety being identified as an independent predictor for postoperative pain [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, not all studies have shown a significant association between preoperative anxiety and postoperative pain. Shebl et al. (2025) conducted a meta-analysis, which found no significant association between preoperative anxiety and postoperative pain but there were associations with increased anesthetic and analgesic requirements and prolonged recovery time [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These inconsistencies may also be explained by variations in study designs, populations of patients, surgical procedures, and methods of anxiety and pain assessments. For example, differences in the time of pain assessment, the application of different pain scales, standardized pain management protocols, and other methodological issues could explain the observed relationships [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Furthermore, the multidimensionality of anxiety (state and trait components) may also account for some of these inconsistencies [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study investigates the association between preoperative anxiety levels and postoperative pain intensity among oral surgery patients. These findings show a statistically significant correlation (p\u0026thinsp;=\u0026thinsp;0.005) of increased preoperative anxiety and more severe postoperative pain. Interestingly, patients who had high anxiety levels experienced severe postoperative pain at a rate of 41.0%, whereas only 20.5% of patients with low anxiety experienced severe pain. The relationship between preoperative anxiety and postoperative pain has been extensively studied globally in a variety of surgical disciplines. For instance, a narrative review by Ni et al. (2023) highlights that preoperative anxiety is correlated with adverse postoperative events such as increased pain perception [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. A study of Kılı\u0026ccedil; et al. (2024) in the field of oral and maxillofacial surgery reported that preoperative educational interviews decreased preoperative anxiety level and postoperative discomfort such as pain. This implies that targeted preoperative interventions can reduce the detrimental effects of anxiety on postoperative pain outcomes. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e"},{"header":"7. Strengths and Future Directions","content":"\u003cp\u003eThis study contributes to the growing body of evidence regarding the psychological determinants of postoperative outcomes in oral surgery. A major strength of this work is the standardized use of validated measures for both dental anxiety and postoperative pain assessment, which enhances the reliability of the findings. Additionally, data were collected from a real clinical setting, increasing the ecological validity and generalizability of the results.\u003c/p\u003e \u003cp\u003eFuture studies should consider longitudinal designs to better capture temporal relationships between anxiety and postoperative pain beyond the immediate postoperative period. Further research is also warranted to examine the effectiveness of targeted preoperative interventions\u0026mdash;both pharmacological and non-pharmacological\u0026mdash;in reducing anxiety and improving postoperative pain outcomes among dental patients.\u003c/p\u003e"},{"header":"8. Limitations of the study","content":"\u003cp\u003eThis study\u0026rsquo;s cross-sectional design restricts the ability to establish causal association between preoperative anxiety and postoperative pain, as it captures data at a limited period of time. Since the DAS and the VAS are self-reported measures, there could be a possibility of biases, such as social desirability and recall biases in the assessment of anxiety and pain level. Moreover, the study\u0026rsquo;s single center setting in Saudi Arabia could hinder the generalizability of outcomes to other populations. In addition, the study did not take into consideration the influence of other psychological factors like physiological markers (e.g., heart rate, blood pressure, salivary cortisol) and procedural factors (duration of surgery, operator experience, anesthesia type) to validate anxiety responses.\u003c/p\u003e"},{"header":"9. Conclusion","content":"\u003cp\u003eThe findings of this study suggest a strong association between elevated preoperative anxiety levels and greater postoperative pain in oral surgery patients. This underscores the need to evaluate and manage anxiety prior to surgery as a means of improving pain management outcomes. Future research should adopt longitudinal study designs to examine association and include diverse populations to enhance generalizability. Additionally, integrating more elaborate psychological assessments and treatment approaches could explain additional mechanisms to relieve preoperative anxiety and provide insights into postoperative care interventions that might be more effective for pain management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e-Dental Anxiety Scale (DAS)\u003c/p\u003e\n\u003cp\u003e-Visual Analog Scale (VAS)\u003c/p\u003e\n\u003cp\u003e- Patients categorized under ASA (American Society of Anesthesiologists)\u003c/p\u003e\n\u003cp\u003e- Institutional Review Board (IRB)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e10.2.\u0026nbsp;Acknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all participants who responded to the survey and the dentists who distributed the survey to their patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.3.\u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.4.\u0026nbsp;Author information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia, Dr. Sami Alshehry\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, Dr.Yaser Alqabbani\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.5.\u0026nbsp;Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.A. (Yaser Alqabbani) conceptualized the study, collected and analyzed the data, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eS.A. (Sami Alshehry) supervised the research process, provided guidance on study design and statistical interpretation, and critically revised the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eBoth authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.6.\u0026nbsp;Conflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.7.\u0026nbsp;Ethical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Deanship of Scientific Research- Imam\u003c/p\u003e\n\u003cp\u003eAbdulrahman bin Faisal University (IRB-2025-02-0276)\u0026nbsp;(Approval Date: 13/04/2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.8.\u0026nbsp;Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipation in the study was voluntary, and no incentives were offered to\u003c/p\u003e\n\u003cp\u003eparticipate in the study to participants or to the dentists who distributed the\u003c/p\u003e\n\u003cp\u003esurvey to their patients. Participants were presented with an informed consent\u003c/p\u003e\n\u003cp\u003eform with a preview of the study objectives. Data collection was performed in\u003c/p\u003e\n\u003cp\u003eaccordance with relevant guidelines and regulations of Deanship of Imam\u003c/p\u003e\n\u003cp\u003eAbdulrahman bin Faisal university.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.9.\u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. Survey completion implied consent for the use and publication\u003c/p\u003e\n\u003cp\u003eof anonymized data in accordance of Deanship of Imam Abdulrahman bin\u003c/p\u003e\n\u003cp\u003eFaisal university.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.10.\u0026nbsp;Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;10.11.\u003c/strong\u003e \u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data can be provided by the corresponding author upon reasonable\u003c/p\u003e\n\u003cp\u003erequest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10.12\u003c/strong\u003e.\u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adhered to the ethical principles of the Declaration of Helsinki. Ethical approval was\u003c/p\u003e\n\u003cp\u003eobtained from the Deanship of Scientific Research-Imam Abdulrahman bin Faisal University\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board (IRB) (Approval number: IRB-2025-02-0276) (Approval Date: 13/04/2025). All participants provided written informed consent before participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eShah A. Oral surgery. Prim Dent J 2022;11:2\u0026ndash;3. https://doi.org/10.1177/20501684221118207.\u003c/li\u003e\n \u003cli\u003eMaulina T, Djustiana N, Shahib MN. The Effect of Music Intervention on Dental Anxiety During Dental Extraction Procedure. Open Dent J 2017;11:565\u0026ndash;72. https://doi.org/10.2174/1874210601711010565.\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez-Jornet P, Camacho-Alonso F, Sanchez-Siles M. Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: A prospective study. 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Exploring the relationship between anxiety, patient characteristics and pain outcomes in oral surgery under local anesthesia: the measurement problem. \u003cem\u003eDent Med Probl\u003c/em\u003e. 2024;61(4):515\u0026ndash;523. https://doi.org/10.17219/dmp/189553\u003c/li\u003e\n \u003cli\u003eQaddumi J, Arda AM, Alkhawaldeh A, Albashtawy M, Abdalrahim A, Albashtawy Sd, et al. Preoperative anxiety, postoperative pain tolerance and analgesia consumption: A prospective cohort study. Journal of Perioperative Practice. 2024. https://doi.org/10.1177/17504589241253489\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/li\u003e\n \u003cli\u003eSharma A, Pant R, Priyadarshi S, Agarwal N, Tripathi S, Chaudhary M. Cardiovascular changes due to dental anxiety during local anesthesia injection for extraction. Journal of maxillofacial and oral surgery. 2019;18:80-7. https://doi.org/10.1007/s12663-018-1085-4\u003c/li\u003e\n \u003cli\u003eZhang D, Li S, Zhang R. Effects of dental anxiety and anesthesia on vital signs during tooth extraction. BMC Oral Health. 2024;24(1):632. https://doi.org/10.1186/s12903-024-04404-5\u003c/li\u003e\n \u003cli\u003eXu JL, Xia R. Influence factors of dental anxiety in patients with impacted third molar extractions and its correlation with postoperative pain: a prospective study. Medicina Oral, Patolog\u0026iacute;a Oral y Cirug\u0026iacute;a Bucal. 2020;25(6):e714. https://doi.org/10.4317/medoral.23293\u003c/li\u003e\n \u003cli\u003eAlenezi AA, Aldokhayel HS. The impact of dental fear on the dental attendance behaviors: A retrospective study. Journal of Family Medicine and Primary Care. 2022;11(10):6444-50. https://doi.org/10.4103/jfmpc.jfmpc_1030_22\u003c/li\u003e\n \u003cli\u003eGrossman S. The Surgical Dental Anxiety Scale (SDAS). British Dental Journal. 2024;237(12):935-7. https://doi.org/10.1038/s41415-024-7846-1\u003c/li\u003e\n \u003cli\u003eDignam P, O\u0026rsquo;Connell B, et al. Prevalence and factors influencing post-operative complications following tooth extraction: a narrative review. \u003cem\u003eDentistry Journal\u003c/em\u003e. 2024;12(6):187. https://doi.org/10.3390/dj12060187\u003c/li\u003e\n \u003cli\u003eMiroshnychenko A, Ibrahim S, Azab M, Roldan Y, Martinez J, Tamilselvan D, et al. Acute postoperative pain due to dental extraction in the adult population: a systematic review and network meta-analysis. Journal of Dental Research. 2023;102(4):391-401. https://doi.org/10.1177/00220345221139230\u003c/li\u003e\n \u003cli\u003eStucky C, Vortman R. Nurse-led strategies to decrease preoperative patient anxiety. Nursing2025. 2022;52(12).\u003c/li\u003e\n \u003cli\u003eBello CM, Eisler P, Heidegger T. Perioperative Anxiety: Current Status and Future Perspectives. Journal of Clinical Medicine [Internet]. 2025; 14(5). https://doi.org/10.3390/jcm14051422\u003c/li\u003e\n \u003cli\u003eWang R, Huang X, Wang Y, Akbari M. Non-pharmacologic approaches in preoperative anxiety, a comprehensive review. Frontiers in public health. 2022;10:854673. https://doi.org/10.3389/fpubh.2022.854673\u003c/li\u003e\n \u003cli\u003eChiu PL, Li H, Yap KY-L, Lam K-mC, Yip P-lR, Wong CL. Virtual Reality\u0026ndash;Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery: A Randomized Clinical Trial. JAMA Network Open. 2023;6(10):e2340588-e. https://doi.org/10.1001/jamanetworkopen.2023.40588\u003c/li\u003e\n \u003cli\u003eTadesse M, Ahmed S, Regassa T, Girma T, Hailu S, Mohammed A, et al. Effect of preoperative anxiety on postoperative pain on patients undergoing elective surgery: Prospective cohort study. Annals of medicine and surgery. 2022;73:103190. https://doi.org/10.1016/j.amsu.2021.103190\u003c/li\u003e\n \u003cli\u003eLiu Q, Li L, Wei J, Xie Y. Correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery. BMC Anesthesiology. 2023;23. https://doi.org/10.1186/s12871-023-02036-w\u003c/li\u003e\n \u003cli\u003eShebl MA, Toraih E, Shebl M, Tolba AM, Ahmed P, Banga HS, et al. Preoperative anxiety and its impact on surgical outcomes: A systematic review and meta-analysis. Journal of Clinical and Translational Science. 2025;9(1):e33. https://doi.org/10.1017/cts.2025.6\u003c/li\u003e\n \u003cli\u003eNi K, Zhu J, Ma Z. Preoperative anxiety and postoperative adverse events: a narrative overview. Anesthesiology and Perioperative Science. 2023;1(3):23. https://doi.org/10.1007/s44254-023-00019-1\u003c/li\u003e\n \u003cli\u003eKocaturk S, Gur ZB, Gursoytrak B. Can Verbal Interview Decrease Preoperative Anxiety and Postoperative Discomfort in Oral and Maxillofacial Surgery Patients?: A Randomized Clinical Trial. Journal of Oral and Maxillofacial Surgery. 2024;82(11):1425-32. https://doi.org/10.1016/j.joms.2024.06.178\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"dental anxiety, pain intensity, postoperative pain, preoperative anxiety, tooth extraction","lastPublishedDoi":"10.21203/rs.3.rs-8920791/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8920791/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Preoperative anxiety is a common psychological factor influencing patient experience in oral surgery. This study aimed to examine the association between preoperative anxiety levels and postoperative pain intensity following tooth extraction in Saudi Arabia.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted among 229 adult patients undergoing tooth extraction. Anxiety levels were measured using the Dental Anxiety Scale (DAS), and postoperative pain intensity was assessed using a 10-point Visual Analog Scale (VAS). Data were analyzed using Spearman rank correlation and Fisher\u0026rsquo;s exact tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eModerate to high preoperative anxiety was reported in 80.7% of participants. Higher anxiety levels were significantly associated with higher postoperative pain intensity (ρ\u0026thinsp;=\u0026thinsp;0.448, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Preoperative anxiety was positively associated with postoperative pain among oral surgery patients. Longitudinal or interventional studies are warranted to explore causal mechanisms and test anxiety-reduction strategies.\u003c/p\u003e","manuscriptTitle":"Association Between Preoperative Anxiety and Postoperative Pain Following Tooth Extraction: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 16:49:59","doi":"10.21203/rs.3.rs-8920791/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T06:35:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T11:21:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86553461686073473967023494538185390060","date":"2026-03-18T06:45:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T15:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186643801266113019755344762904327123638","date":"2026-03-14T17:51:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T15:28:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334140116928436602868826314775641489361","date":"2026-03-14T12:38:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-10T01:18:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208370634830154749157199048713918828601","date":"2026-03-07T21:37:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293044490634449074102896580165530013164","date":"2026-03-07T14:30:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25891908350275425165232979956139796215","date":"2026-03-02T21:43:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-02T08:23:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T23:54:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T23:53:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-02-19T20:37:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"319055e7-7afc-4d8e-8482-a98e190267e6","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T06:41:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 16:49:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8920791","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8920791","identity":"rs-8920791","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}