Anxiety Levels During the First Clinical Tooth Extraction Experience Among Fourth-Year Dental Students: A Cross-Sectional Observational Study

Anxiety Levels During the First Clinical Tooth Extraction Experience Among Fourth-Year Dental Students: A Cross-Sectional Observational 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 Anxiety Levels During the First Clinical Tooth Extraction Experience Among Fourth-Year Dental Students: A Cross-Sectional Observational Study Emin Celalettin ÜN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9721499/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background/Objectives: The first clinical tooth extraction represents a pivotal and anxiety-provoking milestone in dental undergraduate education. The assessment of anxiety at this specific moment has important implications for curriculum design, student well-being, and patient safety. This study aimed to measure and characterise state and trait anxiety levels among fourth-year dental students performing tooth extraction on real patients for the first time. Methods A cross-sectional single-centre observational study was conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University, Turkey. All 74 fourth-year dental students (49 female, 25 male) participating in the first compulsory clinical extraction session were invited to complete the State–Trait Anxiety Inventory (STAI). State anxiety (STAI-S) was assessed immediately before the extraction procedure; trait anxiety (STAI-T) was assessed during a regular, non-clinical lecture session. Descriptive statistics, a one-sample t-test, a paired-samples t-test, Pearson correlation analysis, and effect size calculations (Cohen’s d, 95% CIs) were performed. Results The mean STAI-S score immediately preceding the first extraction was 53.54 ± 6.17 (range 38–66), which was significantly higher than the theoretical midpoint of 50 (t = 4.937, df = 73, p < 0.001, Cohen’s d = 0.574). The mean STAI-T score was 40.16 ± 6.22 (range 28–51), consistent with commonly reported normative ranges for non-clinical adult populations. State anxiety scores were significantly higher than trait anxiety scores (paired t = 21.339, p < 0.001, Cohen’s d = 2.181). A moderate positive correlation was found between state and trait anxiety (r = 0.621, p < 0.001). Most students (81.1%) showed moderate state anxiety; 17.6% showed high state anxiety. No statistically significant gender difference was found in either STAI-S or STAI-T scores (p = 0.441 and p = 0.939, respectively). Conclusion Fourth-year dental students experience significantly elevated situational anxiety immediately prior to their first real-patient tooth extraction, suggesting that the observed elevation was predominantly related to the situational demands of the clinical encounter. These findings support the potential value of structured psychological preparation and progressive clinical exposure in undergraduate dental curricula to optimise both student welfare and patient care outcomes. Dentistry student dental anxiety tooth extraction education dental clinical competence Figures Figure 1 1. INTRODUCTION Anxiety is a universal human response to perceived threat and is particularly prevalent in academic and professional training environments. In health professions education, clinical training inherently confronts students with situations characterised by high stakes, uncertainty, and the immediate welfare of another person. Dental education is widely recognised as one of the most stressful healthcare training programmes, owing to the complexity of manual skills required, the close physical proximity to patients, and the potential for irreversible procedural errors 1 , 2 . Anxiety and stress have been systematically documented across dental student cohorts globally, with clinical training consistently identified as a primary stressor, particularly during the transition from preclinical to patient-based practice 1 – 3 . Among the clinical procedures encountered during dental undergraduate training, tooth extraction occupies a distinctive position. It is perceived by students as an irreversible, consequential intervention that requires simultaneous competence in local anaesthesia administration, force control, anatomical knowledge, and patient communication. Earlier studies have documented that the prospect of performing tooth extractions elicits considerable apprehension among dental students, and that confidence in performing this procedure remains a recurring concern even among final-year cohorts 4 , 5 . Wrong-site extractions, post-operative complications such as dry socket, and the possibility of iatrogenic injury further contribute to the psychological burden carried by students approaching this procedure for the first time 6 – 8 . The first clinical extraction—performed on a real patient rather than a mannequin or phantom head—represents a particularly important transition point. Prior to this event, students have typically accumulated preclinical simulation training and have observed clinical procedures, but have not yet assumed primary responsibility for an irreversible surgical act on a human being. The psychological impact of this transition has not been adequately characterised in the literature. Most existing studies have assessed general or broadly defined clinical anxiety among dental students, without isolating the acute situational anxiety associated with a specific, defined first-time clinical procedure 9 – 12 . The State–Trait Anxiety Inventory (STAI), developed by Spielberger and colleagues, provides a validated, widely used psychometric instrument capable of distinguishing between state anxiety, a transient, situation-specific emotional response, and trait anxiety a stable personality disposition to perceive situations as threatening 13 . This distinction is particularly valuable in clinical education research because it allows investigators to determine whether elevated anxiety at a given moment reflects the situational demands of the clinical encounter or a pre-existing individual characteristic. To date, no published study appears to have employed the STAI to characterise both state and trait anxiety specifically at the moment of the first real-patient tooth extraction in an undergraduate dental cohort. The present study was therefore designed to fill this gap. The primary objective was to measure STAI state and trait anxiety scores in fourth-year dental students immediately before and independently of their first clinical tooth extraction, and to examine the relationship between these two dimensions of anxiety. We hypothesised that students would demonstrate significantly elevated state anxiety immediately before their first clinical tooth extraction compared with their stable trait anxiety levels, and that a positive association would be observed between state and trait anxiety within the cohort. The findings are intended to inform evidence-based decisions regarding the psychological preparation and support structures embedded in clinical dental education. 2. MATERIALS AND METHODS 2.1 Study Design This was a cross-sectional observational study conducted at Oral and Maxillofacial Surgery Clinic of the Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University, Nevşehir, Turkey. The study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. 2.2 Participants The study population consisted of all fourth-year dental students enrolled at Nevşehir Hacı Bektaş Veli University Faculty of Dentistry during the 2025–2026 academic year. Inclusion criteria were: (i) enrollment in the fourth year of the undergraduate dental programme; (ii) attendance at the first compulsory real-patient tooth extraction session; and (iii) provision of voluntary written informed consent. Students who had previously performed a tooth extraction on a real patient in any clinical setting, or who refused to participate, were excluded. Prior extraction experience was verified through self-report at the time of enrollment, cross-referenced with the faculty clinical logbook records maintained by the department. Students were asked to declare any extraction performed independently, whether during external clinical placements, elective rotations at other institutions, or any other clinical setting outside the faculty. While experience at other institutions could not be verified through internal records, no student declared prior external extraction experience, and this criterion was therefore effectively based on self-report for external settings. All 74 eligible students agreed to participate, yielding a 100% response rate (Fig. 1 ). Gender data were collected as grouped demographic information to enable subgroup analyses; the cohort comprised 49 female students (66.2%) and 25 male students (33.8%). 2.3 Ethical Approval The study protocol was reviewed and approved by the Ethics Committee of Nevşehir Hacı Bektaş Veli University (Decision No: 2025.12.22; Date: 29 December 2025). All procedures were conducted in accordance with the Declaration of Helsinki. Prior to data collection, all participants received a written information sheet and provided written informed consent. Students were assured that participation or non-participation would have no bearing on their academic assessment. 2.4 STAI Assessment Protocol State and trait anxiety were assessed using the Turkish version of the Spielberger State–Trait Anxiety Inventory (STAI) [13], adapted and validated by Öner and Le Compte [14]. The inventory consists of two 20-item subscales. The State Anxiety Scale (STAI-S) measures transient, situation-specific anxiety with response options ranging from (1) Not at all to (4) Very much so. The Trait Anxiety Scale (STAI-T) measures stable predispositions to anxiety, with response options from (1) Almost never to (4) Almost always. Both subscales yield scores ranging theoretically from 20 to 80, with higher scores reflecting greater anxiety. Scoring was performed according to the established algorithm. Items are classified as direct (reflecting negative affect) or reverse-scored (reflecting positive affect). For the STAI-S, ten items are reverse-scored (items 1, 2, 5, 8, 10, 11, 15, 16, 19, and 20); for the STAI-T, seven items are reverse-scored (items 21, 26, 27, 30, 33, 36, and 39). The total score is computed by subtracting the weighted sum of reverse-scored items from the weighted sum of direct items, then adding a fixed constant (50 for STAI-S; 35 for STAI-T). Forms on which more than three items were left unanswered were considered invalid and excluded. No forms required exclusion on this basis. The STAI-S was administered to each student individually in the Oral and Maxillofacial Surgery clinic immediately before the student performed their first tooth extraction on a real patient, defined as the moment after the patient had been seated and prepared but before the student began administration of local anaesthesia. This time point was selected to capture peak pre-procedural anxiety. The STAI-T was administered first, during a routine didactic lecture session on a day unrelated to any clinical activity, in order to capture trait anxiety under neutral, non-threatening conditions; this assessment preceded the clinical extraction session and the STAI-S administration by at least one week, ensuring that awareness of the upcoming procedure could not contaminate the trait anxiety measurement. Sessions were scheduled to avoid examination periods and days immediately preceding clinical rotations, minimising the influence of acute contextual stressors on trait anxiety measurement. The two assessments were thus conducted on different occasions in a predetermined order (STAI-T first, then STAI-S on the day of the first extraction) to prevent order effects and cross-contamination between state and trait responses. 2.5 Clinical Procedure Context All tooth extractions were performed under direct supervision of experienced clinicians within the Oral and Maxillofacial Surgery Clinic of the Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University. In accordance with the undergraduate curriculum at this institution, fourth-year dental students performing their first compulsory real-patient extraction are exclusively assigned simple (non-surgical) extractions. Surgical extractions are reserved for more advanced stages of clinical training. Accordingly, all 74 participants in this study performed a simple extraction as their first independent clinical procedure; no participant performed a surgical extraction. This uniform procedure type eliminates extraction complexity as a confounding variable and strengthens the internal consistency of the anxiety measurement. Prior to the session, all students had completed the relevant preclinical simulation training and had observed a minimum number of extractions as required by the faculty curriculum. The session constituted the student's first independent execution of the procedure on a live patient. 2.6 Statistical Analysis Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics; means, standard deviations (SD), medians, and ranges were computed for both STAI-S and STAI-T scores. Normality of distributions was assessed with the Shapiro–Wilk test. A one-sample t-test was used to compare the mean STAI-S score against the theoretical midpoint of the instrument scale (score of 50). This reference point was selected because it represents the neutral midpoint of the STAI-S response scale, dividing the instrument into below-average and above-average anxiety ranges; it does not imply clinical significance but serves as an internally anchored benchmark for group-level comparison, consistent with previous STAI-based studies in dental education contexts. Independent-samples t-tests were used to compare STAI-S and STAI-T scores between male and female students, with Cohen’s d and 95% CIs reported as effect size measures. A paired-samples t-test was used to compare STAI-S and STAI-T scores within participants. Effect sizes were calculated for all inferential tests: Cohen’s d was computed for t-tests (interpreted as small ≈ 0.20, medium ≈ 0.50, large ≥ 0.80), and r was used as the effect size index for the Pearson correlation. Ninety-five percent confidence intervals (95% CIs) were reported for all primary comparisons. The strength of association between state and trait anxiety was assessed using Pearson’s product-moment correlation coefficient. For descriptive categorisation of anxiety severity, scores were classified as low (20–39), moderate (40–59), or high (60–80), consistent with interpretive frameworks reported in the STAI literature. The significance threshold was set at α = 0.05. The study involved six inferential comparisons in total (one-sample t-test, paired t-test, Pearson correlation, two independent-samples t-tests for gender, and the Wilcoxon sensitivity test). No formal Bonferroni correction was applied, as the analyses were exploratory and hypothesis-generating rather than confirmatory; applying a correction of α = 0.008 would have substantially reduced power in a sample already limited to n = 74. Results for each comparison should nonetheless be interpreted with appropriate caution, as the family-wise Type I error rate across all six tests exceeds the nominal 0.05 threshold. The primary finding (state–trait dissociation, d = 2.181) is highly robust and would survive any conventional correction; the null gender comparison (p = 0.441 and p = 0.939) is equally unaffected by correction. Readers are advised to treat the correlation values as provisional pending replication in larger samples. Because the study aimed to include the entire accessible cohort of fourth-year students undertaking the first compulsory extraction session, formal a priori power calculation was not performed. Nevertheless, post hoc power estimation indicated that the sample size (n = 74) provided greater than 80% power to detect medium effect sizes (Cohen's d ≥ 0.50) at α = 0.05, supporting the adequacy of the sample for the primary comparisons performed. The expected effect size was informed by previous dental anxiety studies reporting moderate-to-large state–trait differences in clinical training contexts, where Cohen's d values between 0.50 and 1.00 have been commonly observed. 3. RESULTS 3.1 Descriptive Statistics A total of 74 fourth-year dental students participated in the study (n = 74; 100% response rate), comprising 49 female (66.2%) and 25 male students (33.8%). All completed questionnaires were valid. Descriptive statistics for STAI-S and STAI-T scores, overall and by gender, are presented in Table 1. Table 1. Descriptive statistics for State and Trait Anxiety Inventory (STAI) scores, overall and by gender, among fourth-year dental students (n = 74). ᵃ p-value from independent-samples t-test (male vs. female). ** p < 0.001. SD = Standard Deviation. Variable Overall (n=74) Female (n=49) Male (n=25) STAI-S: Mean ± SD 53.54 ± 6.17 53.14 ± 6.17 54.32 ± 6.22 STAI-S: Median (Range) 53.0 (38–66) 53.0 (38–64) 56.0 (42–66) STAI-S: High anxiety ≥60; n (%) 13 (17.6%) 9 (18.4%) 4 (16.0%) STAI-T: Mean ± SD 40.16 ± 6.22 40.12 ± 5.93 40.24 ± 6.89 STAI-T: Median (Range) 40.0 (28–51) 40.0 (28–50) 40.0 (28–51) State–trait correlation r 0.621** 0.552** 0.749** Gender comparison p-value (STAI-S / STAI-T) — — 0.441 / 0.939ᵃ The mean STAI-S score recorded immediately before the first real-patient tooth extraction was 53.54 ± 6.17 (median 53.0; range 38–66). The mean STAI-T score, assessed during a neutral lecture session, was 40.16 ± 6.22 (median 40.0; range 28–51). State anxiety scores were thus, on average, approximately 13 points higher than trait anxiety scores. 3.2 Distribution of Anxiety Categories The distribution of students across anxiety severity categories is presented in Table 2. Regarding state anxiety, the overwhelming majority of students fell within the moderate category (40–59): 60 students (81.1%). Thirteen students (17.6%) exhibited high state anxiety (scores ≥ 60), and only one student (1.4%) fell within the low anxiety category (score < 40). For trait anxiety, no student scored ≥ 60 (high category), 40 students (54.1%) were in the moderate range, and 34 students (45.9%) were in the low anxiety category. Table 2. Distribution of State Anxiety (STAI-S) and Trait Anxiety (STAI-T) scores across anxiety severity categories (n = 74). Anxiety Category Score Range State Anxiety n (%) Trait Anxiety n (%) Low 20–39 1 (1.4%) 34 (45.9%) Moderate 40–59 60 (81.1%) 40 (54.1%) High 60–80 13 (17.6%) 0 (0.0%) 3.3 Statistical Comparisons Results of all inferential statistical tests are summarised in Table 3. Shapiro–Wilk testing indicated that STAI-S scores followed a normal distribution (W = 0.978, p = 0.217). STAI-T scores showed a slight but statistically significant departure from normality (W = 0.957, p = 0.012); however, given the adequacy of the sample size (n = 74) and the robustness of t-tests to minor violations of normality, parametric analyses were retained. As a sensitivity check, a Wilcoxon signed-rank test was also performed for the paired comparison of STAI-S and STAI-T scores; results were consistent with those of the parametric test (Z = -7.48, p < 0.001), confirming the robustness of the findings. Gender-stratified Shapiro–Wilk tests confirmed approximately normal distributions across all four subgroup scores (male STAI-S: W = 0.956, p = 0.342; female STAI-S: W = 0.973, p = 0.330; male STAI-T: W = 0.943, p = 0.172; female STAI-T: W = 0.959, p = 0.082), supporting the use of parametric comparisons within gender subgroups. A one-sample t-test confirmed that the mean STAI-S score (53.54) was significantly higher than the scale midpoint of 50 (t(73) = 4.937, p < 0.001, Cohen’s d = 0.574, 95% CI for mean difference: [2.11, 4.97]), indicating a moderate effect and that students as a group experienced substantially elevated state anxiety in the pre-extraction period. Trait anxiety (mean 40.16 ± 6.22) remained in the lower-to-moderate range of the scale, consistent with commonly reported normative ranges for non-clinical adult populations. A paired-samples t-test demonstrated that state anxiety scores were significantly higher than trait anxiety scores within the same participants (t(73) = 21.339, p < 0.001, Cohen’s d = 2.181, 95% CI for mean difference: [12.15, 14.65]), representing a numerically very large effect size. It should be noted, however, that Cohen’s d derived from the comparison of two different subscale scores (STAI-S and STAI-T) may not be directly comparable to effect sizes derived from repeated measures of the same construct; the large d value partly reflects the structural difference between the two subscales in addition to the genuine state–trait elevation. The magnitude of the state–trait dissociation is nonetheless clinically meaningful: the raw mean difference of approximately 13 points represents 21.7% of the full instrument range (20–80), and the 95% CI [12.15, 14.65] confirms that this dissociation is estimated with considerable precision. Expressing the effect in these raw-score terms provides a more interpretable index of practical significance than the d value alone in this cross-subscale context. Finally, a moderate positive correlation was found between STAI-S and STAI-T scores (r = 0.621, p < 0.001, 95% CI: [0.47, 0.74]), suggesting that individuals with higher baseline trait anxiety tended to experience higher situational state anxiety in the pre-extraction context. Gender-stratified subgroup analyses revealed no statistically significant difference in STAI-S scores between female (mean 53.14 ± 6.17) and male students (mean 54.32 ± 6.22) (t(72) = -0.774, p = 0.441, Cohen’s d = 0.190, 95% CI [−4.21, 1.85]). Similarly, STAI-T scores did not differ significantly by gender (female: mean 40.12 ± 5.93; male: mean 40.24 ± 6.89; t(72) = -0.076, p = 0.939, Cohen’s d = 0.019, 95% CI [−3.19, 2.95]). The proportion of students in the high state anxiety category (≥60) was comparable between female (18.4%; 9/49) and male (16.0%; 4/25) students. State–trait correlations were moderate-to-strong in both genders: r = 0.552 (p < 0.001) in female students and r = 0.749 (p < 0.001) in male students. The numerically higher correlation in male students may reflect a stronger coupling between dispositional and situational anxiety in this subgroup under high-stakes procedural conditions; however, this interpretation must be treated with considerable caution given the small male subgroup (n = 25), which yields wide confidence intervals and reduces the reliability of the correlation estimate. The difference between the two correlation coefficients was not formally tested and should not be over-interpreted. These gender subgroup results are summarised in Table 1. Table 3. Inferential statistical results for STAI-S and STAI-T comparisons (n = 74). ᵃ Wilcoxon signed-rank test performed as a nonparametric sensitivity check given the marginal departure from normality in STAI-T scores (W = 0.957, p = 0.012). Statistical Test Statistic df p-value / Effect Size Shapiro–Wilk (State Anxiety) W = 0.978 — 0.217 Shapiro–Wilk (Trait Anxiety) W = 0.957 — 0.012 One-sample t-test (State vs. reference 50) t = 4.937 73 < 0.001; d = 0.574 (medium) Paired t-test (State vs. Trait) t = 21.339 73 < 0.001; d = 2.181 (large) Pearson correlation (State vs. Trait) r = 0.621 72 < 0.001; r = 0.621 (moderate) Wilcoxon signed-rank testᵃ (State vs. Trait — sensitivity) Z = -7.48 73 < 0.001 (consistent with parametric result) 4. DISCUSSION To the authors’ knowledge, and to the best of our literature review, this is among the first studies to employ the STAI to characterise both state and trait anxiety specifically at the moment of the first real-patient tooth extraction in an undergraduate dental student cohort. The principal finding is that fourth-year dental students experience significantly elevated situational anxiety immediately before this procedure, whereas their baseline trait anxiety remains within commonly reported normative ranges. This dissociation between state and trait anxiety has important implications for understanding the nature of clinical performance anxiety in dental education and for designing targeted educational interventions. The mean STAI-S score of 53.54 ± 6.17 observed in the present study reflects moderate-to-elevated state anxiety. To contextualise this finding, published normative data for the STAI-S in healthy adult non-patient populations typically cluster around 35–45. For Turkish adult populations specifically, Öner and Le Compte’s normative data indicate mean STAI-S values in the range of approximately 36–42 for non-clinical samples, against which the present mean of 53.54 represents a clinically meaningful elevation 14 . Values approaching or exceeding 50 are higher than commonly reported normative ranges and may be considered suggestive of substantial situational anxiety, though no universal cutoff exists for clinical interpretation. In the present cohort, 98.6% of students fell within the moderate or high anxiety categories, indicating that virtually no student approached this procedure in a relaxed or minimally anxious state. These data are consistent with, and extend, the broader literature documenting relatively elevated anxiety among dental students in clinical settings 11,12,15,16 . The significantly higher STAI-S compared with STAI-T (paired t = 21.339, p < 0.001) is a theoretically coherent finding. It demonstrates that the anxiety elevation observed prior to the extraction appears predominantly attributable to the situational demands of the clinical encounter including the irreversibility of the procedure, the immediate welfare of a real patient, and the scrutiny of supervisors rather than to a stable anxious personality. This distinction is clinically important: interventions aimed at reducing performance anxiety in this context should target situational preparation and clinical self-efficacy rather than the management of trait-level dispositional anxiety. Comparable observations have been reported in adjacent domains of dental undergraduate training. Grock and colleagues found that dental students performing emergency endodontic treatment for the first time demonstrated measurable anxiety elevations that were contextually linked to the clinical encounter 9 . Similarly, Wong and colleagues reported that preclinical local anaesthesia training reduced both performance anxiety and self-reported lack of confidence in subsequent clinical encounters, highlighting the protective role of structured preparation 10 . Gaballah and colleagues demonstrated that perceived confidence in tooth extraction, a construct inversely related to procedural anxiety, remains suboptimal even among dental students and newly qualified graduates, reinforcing the notion that extraction continues to be an anxiety-generating procedure throughout the early career trajectory 4 . The moderate positive correlation between state and trait anxiety (r = 0.621, p < 0.001) is consistent with established theoretical models of anxiety and with empirical findings in clinical education research. Spielberger's STAI model predicts that individuals with higher trait anxiety are more reactive to stressful situations, producing greater state anxiety elevations in response to equivalent objective stressors. In the present study, while all students displayed moderate-to-high state anxiety, those with greater dispositional anxiety tended to experience proportionally higher pre-procedural anxiety levels. This finding suggests that students with higher trait anxiety scores may benefit from targeted pre-clinical psychological support and enhanced graduated exposure to reduce the magnitude of state anxiety spikes at critical procedural milestones. The hypothesised anxiety transition model presented in Figure 1 contextualises these findings within the broader literature on clinical transition stress. Global reviews have consistently identified academic load, clinical performance demands, and patient management as principal sources of stress across dental schools worldwide 16-19 . Among clinical sources of stress, oral surgery and extraction procedures are frequently cited among the most anxiety-inducing 11,20,21 . The present study extends this evidence by providing what appears to be among the first precise quantitative STAI-based snapshots of anxiety at the exact moment of the first real-patient extraction. Few studies have specifically examined anxiety at this single defined procedural milestone, and existing evidence is largely retrospective or based on general clinical anxiety rather than the immediate pre-procedural state. The theoretical and practical concerns associated with tooth extraction; including wrong-site errors, inadequate anaesthesia, alveolar fractures, and post-operative complications represent objectively consequential outcomes that may contribute to the anxiety experienced 6-8 . The awareness of these potential adverse events, combined with the unprecedented nature of the procedure, creates a unique psychological context that differs substantially from preclinical simulation training. The ecological validity of the present study's design, capturing anxiety at the exact pre-procedural moment rather than prospectively or retrospectively, strengthens the interpretability of the findings. The present findings carry several potential implications for dental educational practice, though these must be understood as exploratory proposals given the single-centre, cross-sectional design. They are presented here in approximate order of existing evidence support. Most directly supported by adjacent literature is simulation-based pre-procedural training: systematic reviews in surgical and dental education indicate that progressive simulation exposure builds self-efficacy and can attenuate performance anxiety, though effects are context-dependent. Moderately supported, primarily on the basis of educational theory rather than controlled trials, are structured reflective debriefing after first procedures and staged exposure models (observe → assist → operate under supervision), which may reduce the novelty-driven component of first-procedure anxiety. More speculative, pending direct evaluation in dental extraction contexts, are peer mentoring programmes and formal pre-screening of trait anxiety for risk-stratified support. Procedural confidence should nonetheless be treated as an explicit curricular objective, with milestone-based competency feedback and normalisation of pre-procedural anxiety as a transient response. The identification of a high-anxiety subgroup (scores ≥ 60; 17.6%) supports pre-screening for targeted support, and the present findings suggest that this vulnerability is not confined to one gender: the proportion of high-anxiety students was comparable between female (18.4%) and male (16.0%) participants, with no statistically significant gender difference in either STAI-S or STAI-T scores. This finding is noteworthy given that the broader dental anxiety literature frequently reports higher anxiety scores among female students; the absence of a significant gender effect in the present study warrants careful interpretation. Several explanations merit consideration. First, a compression effect may be operating: when virtually all students (98.6%) cluster in the moderate-to-high anxiety range, the statistical space for a gender difference to emerge is severely constrained regardless of any underlying dispositional difference. Second, social desirability bias cannot be excluded; male students may underreport anxiety on self-report instruments. Third, the male subgroup (n = 25) may be underpowered to detect a gender difference of the magnitude typically reported (d ≈ 0.30–0.50). The null finding should therefore not be interpreted as strong evidence that gender is unrelated to first-extraction anxiety; rather, the universally high-stakes nature of this milestone may attenuate, but not necessarily eliminate, gender-related differences in situational anxiety. It must be emphasised that these recommendations extend beyond what the present single-centre cross-sectional data can directly support, and should be understood as speculative proposals informed by adjacent literature rather than conclusions derived from this study. The evidence base for many of these interventions remains limited in the dental extraction context specifically: while simulation-based training is widely advocated, systematic reviews report heterogeneous effects on clinical anxiety; peer mentoring and staged exposure have been evaluated primarily in terms of skill acquisition rather than anxiety reduction. Future interventional research should directly test the efficacy of these approaches in attenuating pre-procedural anxiety at defined surgical milestones. The present findings should also be considered in the context of patient safety. Elevated operator anxiety is theoretically linked to reduced procedural precision, attentional narrowing, and impaired decision-making; however, direct causal evidence for this relationship in undergraduate dental clinical settings remains limited, and the existing references cited here address stress and burnout in qualified dentists rather than procedural outcomes in student operators 22,23 . The present study does not provide evidence on procedural outcomes. The documented level of pre-procedural anxiety in this cohort nonetheless underscores the importance of close supervision and of creating a psychologically safe clinical environment in which students feel able to pause, seek guidance, or request assistance without fear of negative academic consequences. Whether and how this level of pre-procedural anxiety translates into measurable procedural performance differences is an important question that requires direct investigation in future research. If these findings are replicated in larger, multi-centre samples, dental schools may wish to consider a dual obligation: to protect the welfare of students experiencing performance anxiety, and to ensure that patient safety is not compromised by inadequately supervised high-anxiety encounters. Structured pre-procedural briefings, real-time faculty monitoring, and post-procedural debriefing may serve both goals simultaneously, though their efficacy in this specific context requires direct empirical evaluation. 5. CONCLUSIONS This cross-sectional study demonstrates that fourth-year dental students experience significantly elevated situational anxiety immediately prior to their first real-patient tooth extraction, with a mean STAI-S score of 53.54 ± 6.17 that is above commonly reported normative ranges. A moderate positive correlation between state and trait anxiety further suggests that students with greater dispositional anxiety may be particularly vulnerable during early clinical surgical experiences. These findings may support the incorporation of structured psychological preparation, progressive clinical exposure, and individualised support mechanisms into undergraduate dental curricula. Future longitudinal and multi-centre research should examine how anxiety evolves across repeated clinical extraction experiences and how educational interventions may modify this trajectory. 6. LİMİTATIONS Several limitations of the present study should be acknowledged. First, the cross-sectional single-institution design limits the generalisability of the findings to other dental schools, which may differ in terms of curriculum structure, supervision ratios, pre-clinical training intensity, and institutional culture. Second, although gender data were collected and subgroup analyses performed, the sample sizes within gender subgroups (female: n = 49; male: n = 25) may limit the statistical power of gender-stratified comparisons, particularly for the male subgroup. Future studies with larger, more balanced gender distributions would allow more robust evaluation of potential gender moderation effects. Third, the study assessed anxiety at a single time point. Longitudinal follow-up assessments after subsequent extraction sessions would allow characterisation of the learning-related trajectory of anxiety over time and could evaluate whether anxiety diminishes with repeated exposure. Fourth, anxiety was assessed solely through a self-report instrument; physiological measures (e.g., salivary cortisol, heart rate) were not included, and social desirability bias cannot be excluded. Fifth, procedural outcomes such as extraction difficulty, duration, or occurrence of complications were not systematically recorded, precluding an analysis of the relationship between anxiety level and clinical performance. Sixth, as the study was conducted exclusively at Nevşehir Hacı Bektaş Veli University Faculty of Dentistry with a single cohort of fourth-year students, the sample was necessarily limited to 74 participants. This restricts statistical power for subgroup analyses and limits generalisation to contexts with different institutional cultures, curriculum structures, or preclinical training intensities. Finally, the very large Cohen’s d reported for the paired state–trait comparison (d = 2.181) should be interpreted with caution, as this metric compares scores from two structurally distinct subscales; readers should weigh the raw mean difference and confidence intervals alongside the effect size estimate. Declarations Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Nevsehir Haci Bektas Veli University (Decision No: 2025.12.22; Date: 29 December 2025). Data Availability Statement: The data presented in this study are available on request from the corresponding author. Consent for Publication: Not applicable. No identifying images or personal/clinical details of individual participants are presented in this manuscript. Conflicts of Interest: The author declares no conflicts of interest. References Alzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH (2011) Stress amongst dental students: a systematic review. Eur J Dent Educ 15(1):8–18. https://doi.org/10.1111/j.1600-0579.2010.00640.x Botelho M, Joao Ferreira M, Hadad H, Proenca L, Vasconcelos M (2018) An analysis of clinical transition stresses experienced by dental students: A qualitative methods approach. Eur J Dent Educ 22(3):e564–e572. https://doi.org/10.1111/eje.12353 Correa-Beltrán G, Pereira Nunes MF, Medeiros-Fonseca B, Araújo M, Freitas SEM (2022) Stress amongst dental students in the transition from preclinical training to clinical training: A qualitative study. J Dent Educ 86(10):1319–1327. https://doi.org/10.1002/jdd.13052 Gaballah K, Ali K, Zahra D, Abou Neel E, Ibrahim E (2024) Perceived confidence of dental students and new graduates in performing tooth extractions—An exploratory study. Eur J Dent Educ 28(1):191–205 Gilmour ASM, Welply A, Cowpe JG, Bullock AD, Jones RJ (2016) The undergraduate preparation of dentists: Confidence levels of final year dental students at the School of Dentistry in Cardiff. Br Dent J 221(6):349–354 Jadu FM, Jan AM, Albenayan R, Alsharkawi D (2019) The prevalence and causes of wrong tooth extraction. Niger J Clin Pract 22(12):1706. http://dx.doi.org/10.4103/njcp.njcp_206_19 Adeyemo WL, Oderinu OH, Olojede ACO et al (2011) Experience of wrong-site tooth extraction among Nigerian dentists. Saudi Dent J 23(3):153–156 Rakhshan V (2018) Common risk factors of dry socket (alveolitis osteitis) following dental extraction: A brief narrative review. J Stomatol Oral Maxillofac Surg 119(6):407–411. http://dx.doi.org/10.1016/j.jormas.2018.04.011 Grock CH, Luz LB, Oliveira VF et al (2018) Experiences during the execution of emergency endodontic treatment and levels of anxiety in dental students. Eur J Dent Educ 22(4):e715–e723 Wong G, Apthorpe HC, Ruiz K, Nanayakkara S (2019) Student-to-student dental local anesthetic preclinical training: impact on students' confidence and anxiety in clinical practice. J Dent Educ 83(1):56–63 Malghani PG, Abbasi LS, Majeed S, Saleem T (2021) Level of anxiety in clinical settings and coping mechanisms used by dental undergraduate students to overcome it. J Dent Educ 85(11):1749–1755 Mikhail CRG, Ragab MH, Ahmed Y et al (2025) Clinical anxiety among a sample of dental students in South Sinai. BMC Oral Health 25(1):198 Spielberger CD (1983) Manual for the State-Trait Anxiety Inventory (Form Y). Consulting Psychologists, Palo Alto, CA Öner N, Le Compte A (1983) Durumluk-Sürekli Kaygı Envanteri El Kitabı [State-Trait Anxiety Inventory Manual]. Boğaziçi Üniversitesi Yayınları, Istanbul Azodo C, Omoaregba JO, James BO, Obarisiagbon A (2013) Clinical anxiety among final year dental students: The trainers and students perspectives. Sahel Med J 16(2):64. http://dx.doi.org/10.4103/1118-8561.115263 Elani HW, Allison PJ, Kumar RA et al (2014) A systematic review of stress in dental students. J Dent Educ 78(2):226–242 Alhajj MN, Khader Y, Murad AH et al (2018) Perceived sources of stress amongst dental students: A multicountry study. Eur J Dent Educ 22(4):258–271 Srivastava R, Jyoti B, Pradhan D et al (2020) Evaluating the stress and its association with stressors among the dental undergraduate students of Kanpur city, India: A cross-sectional study. J Educ Health Promot 9:56 Acharya S (2003) Factors Affecting Stress Among Indian Dental Students. J Dent Educ 67(10):1140–1148. http://dx.doi.org/10.1002/j.0022-0337.2003.67.10.tb03707.x Alazmah A, Almotiry K, Alolaywi A et al (2020) Level of Stress among Final Year Dental Students while Performing Paediatric Dentistry Procedures in Riyadh City—A Cross-sectional Study. J Clin Diagn Res 14(6):ZC01–ZC05. http://dx.doi.org/10.7860/jcdr/2020/44744.14275 Tangade PS, Mathur A, Gupta R, Chaudhary S (2011) Assessment of Stress Level among Dental School Students: An Indian Outlook. Dent Res J 8(2):95–101 Rada RE, Johnson-Leong C (2004) Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc 135(6):788–794 Alaujan AH, Alzahem AM (2004) Stress among dentists. Gen Dent 52(5):428–432 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryFiles.zip Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9721499","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":640691409,"identity":"f07360cf-4084-432d-96ab-be2c566ba5d8","order_by":0,"name":"Emin Celalettin ÜN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYDCCA0CcAMT8IE5CATFajkG1SDaAGAbEagEBgwNgkggdfPebj254uONwnvH51YkfHhgwyPOLHcCvRfIYW9qNxDOHi81uvN0sAXSY4czZCfi1GBzjMbuR2HY4cduNsxtAWhIMbhPUwv8NrGXzjLObfxCphYcNrGUDf+824myRPJYGclh64owbvNssEgwkCPuF7/DhZzd/tlkn9vef3XzzR4WNPL80AS0IIAFWKUGschDgP0CK6lEwCkbBKBhJAAB+GUz/esBTrgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0002-6481-4110","institution":"Nevsehir Haci Bektas Veli University, Faculty of Dentistry","correspondingAuthor":true,"prefix":"","firstName":"Emin","middleName":"Celalettin","lastName":"ÜN","suffix":""}],"badges":[],"createdAt":"2026-05-15 07:51:10","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9721499/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9721499/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109435342,"identity":"29de03e6-99ec-4265-b1f5-1762b8f23d7b","added_by":"auto","created_at":"2026-05-18 06:02:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102522,"visible":true,"origin":"","legend":"\u003cp\u003eSpeculative Conceptual Model of Anxiety Trajectory Across the Preclinical-to-Clinical Transition (Not Empirically Tested in the Present Study)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSpeculative conceptual model illustrating a hypothesised trajectory of state and trait anxiety across the preclinical-to-clinical training continuum, informed by the present findings and existing literature. This model was not empirically tested in the present study, which captured anxiety at a single time point only. The trajectory shown for subsequent exposures is based on theoretical inference and has not been directly observed.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9721499/v1/f8ba381519e352b7c1d017a4.png"},{"id":109435345,"identity":"1a45c011-0690-4fd0-9b69-d2ec6662b363","added_by":"auto","created_at":"2026-05-18 06:02:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":296367,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9721499/v1/746185b1-e045-4351-84d3-14c795bcb4a0.pdf"},{"id":109435343,"identity":"2e75d32b-d175-4887-b25b-2480a9f011f5","added_by":"auto","created_at":"2026-05-18 06:02:01","extension":"zip","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":84276,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiles.zip","url":"https://assets-eu.researchsquare.com/files/rs-9721499/v1/e6b073c0ca48a4744ad2ed5e.zip"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAnxiety Levels During the First Clinical Tooth Extraction Experience Among Fourth-Year Dental Students: A Cross-Sectional Observational Study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eAnxiety is a universal human response to perceived threat and is particularly prevalent in academic and professional training environments. In health professions education, clinical training inherently confronts students with situations characterised by high stakes, uncertainty, and the immediate welfare of another person. Dental education is widely recognised as one of the most stressful healthcare training programmes, owing to the complexity of manual skills required, the close physical proximity to patients, and the potential for irreversible procedural errors\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Anxiety and stress have been systematically documented across dental student cohorts globally, with clinical training consistently identified as a primary stressor, particularly during the transition from preclinical to patient-based practice\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmong the clinical procedures encountered during dental undergraduate training, tooth extraction occupies a distinctive position. It is perceived by students as an irreversible, consequential intervention that requires simultaneous competence in local anaesthesia administration, force control, anatomical knowledge, and patient communication. Earlier studies have documented that the prospect of performing tooth extractions elicits considerable apprehension among dental students, and that confidence in performing this procedure remains a recurring concern even among final-year cohorts\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Wrong-site extractions, post-operative complications such as dry socket, and the possibility of iatrogenic injury further contribute to the psychological burden carried by students approaching this procedure for the first time\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe first clinical extraction\u0026mdash;performed on a real patient rather than a mannequin or phantom head\u0026mdash;represents a particularly important transition point. Prior to this event, students have typically accumulated preclinical simulation training and have observed clinical procedures, but have not yet assumed primary responsibility for an irreversible surgical act on a human being. The psychological impact of this transition has not been adequately characterised in the literature. Most existing studies have assessed general or broadly defined clinical anxiety among dental students, without isolating the acute situational anxiety associated with a specific, defined first-time clinical procedure\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe State\u0026ndash;Trait Anxiety Inventory (STAI), developed by Spielberger and colleagues, provides a validated, widely used psychometric instrument capable of distinguishing between state anxiety, a transient, situation-specific emotional response, and trait anxiety a stable personality disposition to perceive situations as threatening\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. This distinction is particularly valuable in clinical education research because it allows investigators to determine whether elevated anxiety at a given moment reflects the situational demands of the clinical encounter or a pre-existing individual characteristic.\u003c/p\u003e \u003cp\u003eTo date, no published study appears to have employed the STAI to characterise both state and trait anxiety specifically at the moment of the first real-patient tooth extraction in an undergraduate dental cohort. The present study was therefore designed to fill this gap. The primary objective was to measure STAI state and trait anxiety scores in fourth-year dental students immediately before and independently of their first clinical tooth extraction, and to examine the relationship between these two dimensions of anxiety. We hypothesised that students would demonstrate significantly elevated state anxiety immediately before their first clinical tooth extraction compared with their stable trait anxiety levels, and that a positive association would be observed between state and trait anxiety within the cohort. The findings are intended to inform evidence-based decisions regarding the psychological preparation and support structures embedded in clinical dental education.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003e This was a cross-sectional observational study conducted at Oral and Maxillofacial Surgery Clinic of the Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University, Nevşehir, Turkey. The study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003eThe study population consisted of all fourth-year dental students enrolled at Nevşehir Hacı Bektaş Veli University Faculty of Dentistry during the 2025\u0026ndash;2026 academic year. Inclusion criteria were: (i) enrollment in the fourth year of the undergraduate dental programme; (ii) attendance at the first compulsory real-patient tooth extraction session; and (iii) provision of voluntary written informed consent. Students who had previously performed a tooth extraction on a real patient in any clinical setting, or who refused to participate, were excluded. Prior extraction experience was verified through self-report at the time of enrollment, cross-referenced with the faculty clinical logbook records maintained by the department. Students were asked to declare any extraction performed independently, whether during external clinical placements, elective rotations at other institutions, or any other clinical setting outside the faculty. While experience at other institutions could not be verified through internal records, no student declared prior external extraction experience, and this criterion was therefore effectively based on self-report for external settings. All 74 eligible students agreed to participate, yielding a 100% response rate (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Gender data were collected as grouped demographic information to enable subgroup analyses; the cohort comprised 49 female students (66.2%) and 25 male students (33.8%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Ethical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of Nevşehir Hacı Bektaş Veli University (Decision No: 2025.12.22; Date: 29 December 2025). All procedures were conducted in accordance with the Declaration of Helsinki. Prior to data collection, all participants received a written information sheet and provided written informed consent. Students were assured that participation or non-participation would have no bearing on their academic assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 STAI Assessment Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eState and trait anxiety were assessed using the Turkish version of the Spielberger State–Trait Anxiety Inventory (STAI) [13], adapted and validated by Öner and Le Compte [14]. The inventory consists of two 20-item subscales. The State Anxiety Scale (STAI-S) measures transient, situation-specific anxiety with response options ranging from (1) Not at all to (4) Very much so. The Trait Anxiety Scale (STAI-T) measures stable predispositions to anxiety, with response options from (1) Almost never to (4) Almost always. Both subscales yield scores ranging theoretically from 20 to 80, with higher scores reflecting greater anxiety.\u003c/p\u003e\n\u003cp\u003eScoring was performed according to the established algorithm. Items are classified as direct (reflecting negative affect) or reverse-scored (reflecting positive affect). For the STAI-S, ten items are reverse-scored (items 1, 2, 5, 8, 10, 11, 15, 16, 19, and 20); for the STAI-T, seven items are reverse-scored (items 21, 26, 27, 30, 33, 36, and 39). The total score is computed by subtracting the weighted sum of reverse-scored items from the weighted sum of direct items, then adding a fixed constant (50 for STAI-S; 35 for STAI-T). Forms on which more than three items were left unanswered were considered invalid and excluded. No forms required exclusion on this basis.\u003c/p\u003e\n\u003cp\u003eThe STAI-S was administered to each student individually in the Oral and Maxillofacial Surgery clinic immediately before the student performed their first tooth extraction on a real patient, defined as the moment after the patient had been seated and prepared but before the student began administration of local anaesthesia. This time point was selected to capture peak pre-procedural anxiety. The STAI-T was administered first, during a routine didactic lecture session on a day unrelated to any clinical activity, in order to capture trait anxiety under neutral, non-threatening conditions; this assessment preceded the clinical extraction session and the STAI-S administration by at least one week, ensuring that awareness of the upcoming procedure could not contaminate the trait anxiety measurement. Sessions were scheduled to avoid examination periods and days immediately preceding clinical rotations, minimising the influence of acute contextual stressors on trait anxiety measurement. The two assessments were thus conducted on different occasions in a predetermined order (STAI-T first, then STAI-S on the day of the first extraction) to prevent order effects and cross-contamination between state and trait responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Clinical Procedure Context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll tooth extractions were performed under direct supervision of experienced clinicians within the Oral and Maxillofacial Surgery Clinic of the Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University. In accordance with the undergraduate curriculum at this institution, fourth-year dental students performing their first compulsory real-patient extraction are exclusively assigned simple (non-surgical) extractions. Surgical extractions are reserved for more advanced stages of clinical training. Accordingly, all 74 participants in this study performed a simple extraction as their first independent clinical procedure; no participant performed a surgical extraction. This uniform procedure type eliminates extraction complexity as a confounding variable and strengthens the internal consistency of the anxiety measurement. Prior to the session, all students had completed the relevant preclinical simulation training and had observed a minimum number of extractions as required by the faculty curriculum. The session constituted the student's first independent execution of the procedure on a live patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics; means, standard deviations (SD), medians, and ranges were computed for both STAI-S and STAI-T scores. Normality of distributions was assessed with the Shapiro–Wilk test. A one-sample t-test was used to compare the mean STAI-S score against the theoretical midpoint of the instrument scale (score of 50). This reference point was selected because it represents the neutral midpoint of the STAI-S response scale, dividing the instrument into below-average and above-average anxiety ranges; it does not imply clinical significance but serves as an internally anchored benchmark for group-level comparison, consistent with previous STAI-based studies in dental education contexts. Independent-samples t-tests were used to compare STAI-S and STAI-T scores between male and female students, with Cohen’s d and 95% CIs reported as effect size measures. A paired-samples t-test was used to compare STAI-S and STAI-T scores within participants. Effect sizes were calculated for all inferential tests: Cohen’s d was computed for t-tests (interpreted as small ≈ 0.20, medium ≈ 0.50, large ≥ 0.80), and r was used as the effect size index for the Pearson correlation. Ninety-five percent confidence intervals (95% CIs) were reported for all primary comparisons. The strength of association between state and trait anxiety was assessed using Pearson’s product-moment correlation coefficient. For descriptive categorisation of anxiety severity, scores were classified as low (20–39), moderate (40–59), or high (60–80), consistent with interpretive frameworks reported in the STAI literature. The significance threshold was set at α = 0.05. The study involved six inferential comparisons in total (one-sample t-test, paired t-test, Pearson correlation, two independent-samples t-tests for gender, and the Wilcoxon sensitivity test). No formal Bonferroni correction was applied, as the analyses were exploratory and hypothesis-generating rather than confirmatory; applying a correction of α = 0.008 would have substantially reduced power in a sample already limited to n = 74. Results for each comparison should nonetheless be interpreted with appropriate caution, as the family-wise Type I error rate across all six tests exceeds the nominal 0.05 threshold. The primary finding (state–trait dissociation, d = 2.181) is highly robust and would survive any conventional correction; the null gender comparison (p = 0.441 and p = 0.939) is equally unaffected by correction. Readers are advised to treat the correlation values as provisional pending replication in larger samples. Because the study aimed to include the entire accessible cohort of fourth-year students undertaking the first compulsory extraction session, formal a priori power calculation was not performed. Nevertheless, post hoc power estimation indicated that the sample size (n = 74) provided greater than 80% power to detect medium effect sizes (Cohen's d ≥ 0.50) at α = 0.05, supporting the adequacy of the sample for the primary comparisons performed. The expected effect size was informed by previous dental anxiety studies reporting moderate-to-large state–trait differences in clinical training contexts, where Cohen's d values between 0.50 and 1.00 have been commonly observed.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e\u003cstrong\u003e3.1 Descriptive Statistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 74 fourth-year dental students participated in the study (n = 74; 100% response rate), comprising 49 female (66.2%) and 25 male students (33.8%). All completed questionnaires were valid. Descriptive statistics for STAI-S and STAI-T scores, overall and by gender, are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Descriptive statistics for State and Trait Anxiety Inventory (STAI) scores, overall and by gender, among fourth-year dental students (n = 74). ᵃ p-value from independent-samples t-test (male vs. female). ** p \u0026lt; 0.001. SD = Standard Deviation.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale (n=49)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale (n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTAI-S: Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.54 \u0026plusmn; 6.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.14 \u0026plusmn; 6.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.32 \u0026plusmn; 6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTAI-S: Median (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.0 (38\u0026ndash;66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.0 (38\u0026ndash;64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.0 (42\u0026ndash;66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTAI-S: High anxiety \u0026ge;60; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTAI-T: Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.16 \u0026plusmn; 6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.12 \u0026plusmn; 5.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.24 \u0026plusmn; 6.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTAI-T: Median (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.0 (28\u0026ndash;51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.0 (28\u0026ndash;50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.0 (28\u0026ndash;51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eState\u0026ndash;trait correlation r\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.621**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.552**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.749**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender comparison p-value (STAI-S / STAI-T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.441 / 0.939ᵃ\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eThe mean STAI-S score recorded immediately before the first real-patient tooth extraction was 53.54 \u0026plusmn; 6.17 (median 53.0; range 38\u0026ndash;66). The mean STAI-T score, assessed during a neutral lecture session, was 40.16 \u0026plusmn; 6.22 (median 40.0; range 28\u0026ndash;51). State anxiety scores were thus, on average, approximately 13 points higher than trait anxiety scores.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Distribution of Anxiety Categories\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe distribution of students across anxiety severity categories is presented in Table 2. Regarding state anxiety, the overwhelming majority of students fell within the moderate category (40\u0026ndash;59): 60 students (81.1%). Thirteen students (17.6%) exhibited high state anxiety (scores \u0026ge; 60), and only one student (1.4%) fell within the low anxiety category (score \u0026lt; 40). For trait anxiety, no student scored \u0026ge; 60 (high category), 40 students (54.1%) were in the moderate range, and 34 students (45.9%) were in the low anxiety category.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Distribution of State Anxiety (STAI-S) and Trait Anxiety (STAI-T) scores across anxiety severity categories (n = 74).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eState Anxiety n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrait Anxiety n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u0026ndash;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60 (81.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u0026ndash;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Statistical Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults of all inferential statistical tests are summarised in Table 3. Shapiro\u0026ndash;Wilk testing indicated that STAI-S scores followed a normal distribution (W = 0.978, p = 0.217). STAI-T scores showed a slight but statistically significant departure from normality (W = 0.957, p = 0.012); however, given the adequacy of the sample size (n = 74) and the robustness of t-tests to minor violations of normality, parametric analyses were retained. As a sensitivity check, a Wilcoxon signed-rank test was also performed for the paired comparison of STAI-S and STAI-T scores; results were consistent with those of the parametric test (Z = -7.48, p \u0026lt; 0.001), confirming the robustness of the findings. Gender-stratified Shapiro\u0026ndash;Wilk tests confirmed approximately normal distributions across all four subgroup scores (male STAI-S: W = 0.956, p = 0.342; female STAI-S: W = 0.973, p = 0.330; male STAI-T: W = 0.943, p = 0.172; female STAI-T: W = 0.959, p = 0.082), supporting the use of parametric comparisons within gender subgroups.\u003c/p\u003e\n\u003cp\u003eA one-sample t-test confirmed that the mean STAI-S score (53.54) was significantly higher than the scale midpoint of 50 (t(73) = 4.937, p \u0026lt; 0.001, Cohen\u0026rsquo;s d = 0.574, 95% CI for mean difference: [2.11, 4.97]), indicating a moderate effect and that students as a group experienced substantially elevated state anxiety in the pre-extraction period. Trait anxiety (mean 40.16 \u0026plusmn; 6.22) remained in the lower-to-moderate range of the scale, consistent with commonly reported normative ranges for non-clinical adult populations.\u003c/p\u003e\n\u003cp\u003eA paired-samples t-test demonstrated that state anxiety scores were significantly higher than trait anxiety scores within the same participants (t(73) = 21.339, p \u0026lt; 0.001, Cohen\u0026rsquo;s d = 2.181, 95% CI for mean difference: [12.15, 14.65]), representing a numerically very large effect size. It should be noted, however, that Cohen\u0026rsquo;s d derived from the comparison of two different subscale scores (STAI-S and STAI-T) may not be directly comparable to effect sizes derived from repeated measures of the same construct; the large d value partly reflects the structural difference between the two subscales in addition to the genuine state\u0026ndash;trait elevation. The magnitude of the state\u0026ndash;trait dissociation is nonetheless clinically meaningful: the raw mean difference of approximately 13 points represents 21.7% of the full instrument range (20\u0026ndash;80), and the 95% CI [12.15, 14.65] confirms that this dissociation is estimated with considerable precision. Expressing the effect in these raw-score terms provides a more interpretable index of practical significance than the d value alone in this cross-subscale context. Finally, a moderate positive correlation was found between STAI-S and STAI-T scores (r = 0.621, p \u0026lt; 0.001, 95% CI: [0.47, 0.74]), suggesting that individuals with higher baseline trait anxiety tended to experience higher situational state anxiety in the pre-extraction context. Gender-stratified subgroup analyses revealed no statistically significant difference in STAI-S scores between female (mean 53.14 \u0026plusmn; 6.17) and male students (mean 54.32 \u0026plusmn; 6.22) (t(72) = -0.774, p = 0.441, Cohen\u0026rsquo;s d = 0.190, 95% CI [\u0026minus;4.21, 1.85]). Similarly, STAI-T scores did not differ significantly by gender (female: mean 40.12 \u0026plusmn; 5.93; male: mean 40.24 \u0026plusmn; 6.89; t(72) = -0.076, p = 0.939, Cohen\u0026rsquo;s d = 0.019, 95% CI [\u0026minus;3.19, 2.95]). The proportion of students in the high state anxiety category (\u0026ge;60) was comparable between female (18.4%; 9/49) and male (16.0%; 4/25) students. State\u0026ndash;trait correlations were moderate-to-strong in both genders: r = 0.552 (p \u0026lt; 0.001) in female students and r = 0.749 (p \u0026lt; 0.001) in male students. The numerically higher correlation in male students may reflect a stronger coupling between dispositional and situational anxiety in this subgroup under high-stakes procedural conditions; however, this interpretation must be treated with considerable caution given the small male subgroup (n = 25), which yields wide confidence intervals and reduces the reliability of the correlation estimate. The difference between the two correlation coefficients was not formally tested and should not be over-interpreted. These gender subgroup results are summarised in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Inferential statistical results for STAI-S and STAI-T comparisons (n = 74). ᵃ Wilcoxon signed-rank test performed as a nonparametric sensitivity check given the marginal departure from normality in STAI-T scores (W = 0.957, p = 0.012).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistical Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value / Effect Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShapiro\u0026ndash;Wilk (State Anxiety)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eW = 0.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShapiro\u0026ndash;Wilk (Trait Anxiety)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eW = 0.957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOne-sample t-test (State vs. reference 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003et = 4.937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001; d = 0.574 (medium)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePaired t-test (State vs. Trait)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003et = 21.339\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001; d = 2.181 (large)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePearson correlation (State vs. Trait)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003er = 0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001; r = 0.621 (moderate)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWilcoxon signed-rank testᵃ (State vs. Trait \u0026mdash; sensitivity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZ = -7.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001 (consistent with parametric result)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eTo the authors\u0026rsquo; knowledge, and to the best of our literature review, this is among the first studies to employ the STAI to characterise both state and trait anxiety specifically at the moment of the first real-patient tooth extraction in an undergraduate dental student cohort. The principal finding is that fourth-year dental students experience significantly elevated situational anxiety immediately before this procedure, whereas their baseline trait anxiety remains within commonly reported normative ranges. This dissociation between state and trait anxiety has important implications for understanding the nature of clinical performance anxiety in dental education and for designing targeted educational interventions.\u003c/p\u003e\n\u003cp\u003eThe mean STAI-S score of 53.54 \u0026plusmn; 6.17 observed in the present study reflects moderate-to-elevated state anxiety. To contextualise this finding, published normative data for the STAI-S in healthy adult non-patient populations typically cluster around 35\u0026ndash;45. For Turkish adult populations specifically, \u0026Ouml;ner and Le Compte\u0026rsquo;s normative data indicate mean STAI-S values in the range of approximately 36\u0026ndash;42 for non-clinical samples, against which the present mean of 53.54 represents a clinically meaningful elevation\u003csup\u003e14\u003c/sup\u003e. Values approaching or exceeding 50 are higher than commonly reported normative ranges and may be considered suggestive of substantial situational anxiety, though no universal cutoff exists for clinical interpretation. In the present cohort, 98.6% of students fell within the moderate or high anxiety categories, indicating that virtually no student approached this procedure in a relaxed or minimally anxious state. These data are consistent with, and extend, the broader literature documenting relatively elevated anxiety among dental students in clinical settings\u003csup\u003e11,12,15,16\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe significantly higher STAI-S compared with STAI-T (paired t = 21.339, p \u0026lt; 0.001) is a theoretically coherent finding. It demonstrates that the anxiety elevation observed prior to the extraction appears predominantly attributable to the situational demands of the clinical encounter including the irreversibility of the procedure, the immediate welfare of a real patient, and the scrutiny of supervisors rather than to a stable anxious personality. This distinction is clinically important: interventions aimed at reducing performance anxiety in this context should target situational preparation and clinical self-efficacy rather than the management of trait-level dispositional anxiety.\u003c/p\u003e\n\u003cp\u003eComparable observations have been reported in adjacent domains of dental undergraduate training. Grock and colleagues found that dental students performing emergency endodontic treatment for the first time demonstrated measurable anxiety elevations that were contextually linked to the clinical encounter\u003csup\u003e9\u003c/sup\u003e. Similarly, Wong and colleagues reported that preclinical local anaesthesia training reduced both performance anxiety and self-reported lack of confidence in subsequent clinical encounters, highlighting the protective role of structured preparation\u003csup\u003e10\u003c/sup\u003e. Gaballah and colleagues demonstrated that perceived confidence in tooth extraction, a construct inversely related to procedural anxiety, remains suboptimal even among dental students and newly qualified graduates, reinforcing the notion that extraction continues to be an anxiety-generating procedure throughout the early career trajectory\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe moderate positive correlation between state and trait anxiety (r = 0.621, p \u0026lt; 0.001) is consistent with established theoretical models of anxiety and with empirical findings in clinical education research. Spielberger\u0026apos;s STAI model predicts that individuals with higher trait anxiety are more reactive to stressful situations, producing greater state anxiety elevations in response to equivalent objective stressors. In the present study, while all students displayed moderate-to-high state anxiety, those with greater dispositional anxiety tended to experience proportionally higher pre-procedural anxiety levels. This finding suggests that students with higher trait anxiety scores may benefit from targeted pre-clinical psychological support and enhanced graduated exposure to reduce the magnitude of state anxiety spikes at critical procedural milestones.\u003c/p\u003e\n\u003cp\u003eThe hypothesised anxiety transition model presented in Figure 1 contextualises these findings within the broader literature on clinical transition stress. Global reviews have consistently identified academic load, clinical performance demands, and patient management as principal sources of stress across dental schools worldwide\u003csup\u003e16-19\u003c/sup\u003e. Among clinical sources of stress, oral surgery and extraction procedures are frequently cited among the most anxiety-inducing\u003csup\u003e11,20,21\u003c/sup\u003e. The present study extends this evidence by providing what appears to be among the first precise quantitative STAI-based snapshots of anxiety at the exact moment of the first real-patient extraction. Few studies have specifically examined anxiety at this single defined procedural milestone, and existing evidence is largely retrospective or based on general clinical anxiety rather than the immediate pre-procedural state.\u003c/p\u003e\n\u003cp\u003eThe theoretical and practical concerns associated with tooth extraction; including wrong-site errors, inadequate anaesthesia, alveolar fractures, and post-operative complications represent objectively consequential outcomes that may contribute to the anxiety experienced\u003csup\u003e6-8\u003c/sup\u003e. The awareness of these potential adverse events, combined with the unprecedented nature of the procedure, creates a unique psychological context that differs substantially from preclinical simulation training. The ecological validity of the present study\u0026apos;s design, capturing anxiety at the exact pre-procedural moment rather than prospectively or retrospectively, strengthens the interpretability of the findings.\u003c/p\u003e\n\u003cp\u003eThe present findings carry several potential implications for dental educational practice, though these must be understood as exploratory proposals given the single-centre, cross-sectional design. They are presented here in approximate order of existing evidence support. Most directly supported by adjacent literature is simulation-based pre-procedural training: systematic reviews in surgical and dental education indicate that progressive simulation exposure builds self-efficacy and can attenuate performance anxiety, though effects are context-dependent. Moderately supported, primarily on the basis of educational theory rather than controlled trials, are structured reflective debriefing after first procedures and staged exposure models (observe \u0026rarr; assist \u0026rarr; operate under supervision), which may reduce the novelty-driven component of first-procedure anxiety. More speculative, pending direct evaluation in dental extraction contexts, are peer mentoring programmes and formal pre-screening of trait anxiety for risk-stratified support. Procedural confidence should nonetheless be treated as an explicit curricular objective, with milestone-based competency feedback and normalisation of pre-procedural anxiety as a transient response. The identification of a high-anxiety subgroup (scores \u0026ge; 60; 17.6%) supports pre-screening for targeted support, and the present findings suggest that this vulnerability is not confined to one gender: the proportion of high-anxiety students was comparable between female (18.4%) and male (16.0%) participants, with no statistically significant gender difference in either STAI-S or STAI-T scores. This finding is noteworthy given that the broader dental anxiety literature frequently reports higher anxiety scores among female students; the absence of a significant gender effect in the present study warrants careful interpretation. Several explanations merit consideration. First, a compression effect may be operating: when virtually all students (98.6%) cluster in the moderate-to-high anxiety range, the statistical space for a gender difference to emerge is severely constrained regardless of any underlying dispositional difference. Second, social desirability bias cannot be excluded; male students may underreport anxiety on self-report instruments. Third, the male subgroup (n = 25) may be underpowered to detect a gender difference of the magnitude typically reported (d \u0026asymp; 0.30\u0026ndash;0.50). The null finding should therefore not be interpreted as strong evidence that gender is unrelated to first-extraction anxiety; rather, the universally high-stakes nature of this milestone may attenuate, but not necessarily eliminate, gender-related differences in situational anxiety.\u003c/p\u003e\n\u003cp\u003eIt must be emphasised that these recommendations extend beyond what the present single-centre cross-sectional data can directly support, and should be understood as speculative proposals informed by adjacent literature rather than conclusions derived from this study. The evidence base for many of these interventions remains limited in the dental extraction context specifically: while simulation-based training is widely advocated, systematic reviews report heterogeneous effects on clinical anxiety; peer mentoring and staged exposure have been evaluated primarily in terms of skill acquisition rather than anxiety reduction. Future interventional research should directly test the efficacy of these approaches in attenuating pre-procedural anxiety at defined surgical milestones.\u003c/p\u003e\n\u003cp\u003eThe present findings should also be considered in the context of patient safety. Elevated operator anxiety is theoretically linked to reduced procedural precision, attentional narrowing, and impaired decision-making; however, direct causal evidence for this relationship in undergraduate dental clinical settings remains limited, and the existing references cited here address stress and burnout in qualified dentists rather than procedural outcomes in student operators\u003csup\u003e22,23\u003c/sup\u003e. The present study does not provide evidence on procedural outcomes. The documented level of pre-procedural anxiety in this cohort nonetheless underscores the importance of close supervision and of creating a psychologically safe clinical environment in which students feel able to pause, seek guidance, or request assistance without fear of negative academic consequences. Whether and how this level of pre-procedural anxiety translates into measurable procedural performance differences is an important question that requires direct investigation in future research. If these findings are replicated in larger, multi-centre samples, dental schools may wish to consider a dual obligation: to protect the welfare of students experiencing performance anxiety, and to ensure that patient safety is not compromised by inadequately supervised high-anxiety encounters. Structured pre-procedural briefings, real-time faculty monitoring, and post-procedural debriefing may serve both goals simultaneously, though their efficacy in this specific context requires direct empirical evaluation.\u003c/p\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eThis cross-sectional study demonstrates that fourth-year dental students experience significantly elevated situational anxiety immediately prior to their first real-patient tooth extraction, with a mean STAI-S score of 53.54 ± 6.17 that is above commonly reported normative ranges. A moderate positive correlation between state and trait anxiety further suggests that students with greater dispositional anxiety may be particularly vulnerable during early clinical surgical experiences. These findings may support the incorporation of structured psychological preparation, progressive clinical exposure, and individualised support mechanisms into undergraduate dental curricula. Future longitudinal and multi-centre research should examine how anxiety evolves across repeated clinical extraction experiences and how educational interventions may modify this trajectory.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"6. LİMİTATIONS","content":"\u003cp\u003eSeveral limitations of the present study should be acknowledged. First, the cross-sectional single-institution design limits the generalisability of the findings to other dental schools, which may differ in terms of curriculum structure, supervision ratios, pre-clinical training intensity, and institutional culture. Second, although gender data were collected and subgroup analyses performed, the sample sizes within gender subgroups (female: n = 49; male: n = 25) may limit the statistical power of gender-stratified comparisons, particularly for the male subgroup. Future studies with larger, more balanced gender distributions would allow more robust evaluation of potential gender moderation effects. Third, the study assessed anxiety at a single time point. Longitudinal follow-up assessments after subsequent extraction sessions would allow characterisation of the learning-related trajectory of anxiety over time and could evaluate whether anxiety diminishes with repeated exposure. Fourth, anxiety was assessed solely through a self-report instrument; physiological measures (e.g., salivary cortisol, heart rate) were not included, and social desirability bias cannot be excluded. Fifth, procedural outcomes such as extraction difficulty, duration, or occurrence of complications were not systematically recorded, precluding an analysis of the relationship between anxiety level and clinical performance. Sixth, as the study was conducted exclusively at Nevşehir Hacı Bektaş Veli University Faculty of Dentistry with a single cohort of fourth-year students, the sample was necessarily limited to 74 participants. This restricts statistical power for subgroup analyses and limits generalisation to contexts with different institutional cultures, curriculum structures, or preclinical training intensities. Finally, the very large Cohen’s d reported for the paired state–trait comparison (d = 2.181) should be interpreted with caution, as this metric compares scores from two structurally distinct subscales; readers should weigh the raw mean difference and confidence intervals alongside the effect size estimate.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Nevsehir Haci Bektas Veli University (Decision No: 2025.12.22; Date: 29 December 2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe data presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot applicable. No identifying images or personal/clinical details of individual participants are presented in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe author declares no conflicts of interest.\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlzahem AM, van der Molen HT, Alaujan AH, Schmidt HG, Zamakhshary MH (2011) Stress amongst dental students: a systematic review. Eur J Dent Educ 15(1):8\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1600-0579.2010.00640.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-0579.2010.00640.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotelho M, Joao Ferreira M, Hadad H, Proenca L, Vasconcelos M (2018) An analysis of clinical transition stresses experienced by dental students: A qualitative methods approach. 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Br Dent J 221(6):349\u0026ndash;354\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJadu FM, Jan AM, Albenayan R, Alsharkawi D (2019) The prevalence and causes of wrong tooth extraction. Niger J Clin Pract 22(12):1706. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.4103/njcp.njcp_206_19\u003c/span\u003e\u003cspan address=\"10.4103/njcp.njcp_206_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeyemo WL, Oderinu OH, Olojede ACO et al (2011) Experience of wrong-site tooth extraction among Nigerian dentists. Saudi Dent J 23(3):153\u0026ndash;156\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRakhshan V (2018) Common risk factors of dry socket (alveolitis osteitis) following dental extraction: A brief narrative review. J Stomatol Oral Maxillofac Surg 119(6):407\u0026ndash;411. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jormas.2018.04.011\u003c/span\u003e\u003cspan address=\"10.1016/j.jormas.2018.04.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrock CH, Luz LB, Oliveira VF et al (2018) Experiences during the execution of emergency endodontic treatment and levels of anxiety in dental students. Eur J Dent Educ 22(4):e715\u0026ndash;e723\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong G, Apthorpe HC, Ruiz K, Nanayakkara S (2019) Student-to-student dental local anesthetic preclinical training: impact on students' confidence and anxiety in clinical practice. J Dent Educ 83(1):56\u0026ndash;63\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalghani PG, Abbasi LS, Majeed S, Saleem T (2021) Level of anxiety in clinical settings and coping mechanisms used by dental undergraduate students to overcome it. J Dent Educ 85(11):1749\u0026ndash;1755\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikhail CRG, Ragab MH, Ahmed Y et al (2025) Clinical anxiety among a sample of dental students in South Sinai. BMC Oral Health 25(1):198\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpielberger CD (1983) Manual for the State-Trait Anxiety Inventory (Form Y). Consulting Psychologists, Palo Alto, CA\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;ner N, Le Compte A (1983) Durumluk-S\u0026uuml;rekli Kaygı Envanteri El Kitabı [State-Trait Anxiety Inventory Manual]. Boğazi\u0026ccedil;i \u0026Uuml;niversitesi Yayınları, Istanbul\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzodo C, Omoaregba JO, James BO, Obarisiagbon A (2013) Clinical anxiety among final year dental students: The trainers and students perspectives. Sahel Med J 16(2):64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.4103/1118-8561.115263\u003c/span\u003e\u003cspan address=\"10.4103/1118-8561.115263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElani HW, Allison PJ, Kumar RA et al (2014) A systematic review of stress in dental students. J Dent Educ 78(2):226\u0026ndash;242\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhajj MN, Khader Y, Murad AH et al (2018) Perceived sources of stress amongst dental students: A multicountry study. Eur J Dent Educ 22(4):258\u0026ndash;271\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrivastava R, Jyoti B, Pradhan D et al (2020) Evaluating the stress and its association with stressors among the dental undergraduate students of Kanpur city, India: A cross-sectional study. J Educ Health Promot 9:56\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcharya S (2003) Factors Affecting Stress Among Indian Dental Students. J Dent Educ 67(10):1140\u0026ndash;1148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1002/j.0022-0337.2003.67.10.tb03707.x\u003c/span\u003e\u003cspan address=\"10.1002/j.0022-0337.2003.67.10.tb03707.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlazmah A, Almotiry K, Alolaywi A et al (2020) Level of Stress among Final Year Dental Students while Performing Paediatric Dentistry Procedures in Riyadh City\u0026mdash;A Cross-sectional Study. J Clin Diagn Res 14(6):ZC01\u0026ndash;ZC05. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.7860/jcdr/2020/44744.14275\u003c/span\u003e\u003cspan address=\"10.7860/jcdr/2020/44744.14275\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTangade PS, Mathur A, Gupta R, Chaudhary S (2011) Assessment of Stress Level among Dental School Students: An Indian Outlook. Dent Res J 8(2):95\u0026ndash;101\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRada RE, Johnson-Leong C (2004) Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc 135(6):788\u0026ndash;794\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlaujan AH, Alzahem AM (2004) Stress among dentists. Gen Dent 52(5):428\u0026ndash;432\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"student,dental, anxiety, tooth extraction, education,dental, clinical competence","lastPublishedDoi":"10.21203/rs.3.rs-9721499/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9721499/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground/Objectives:\u003c/h2\u003e \u003cp\u003eThe first clinical tooth extraction represents a pivotal and anxiety-provoking milestone in dental undergraduate education. The assessment of anxiety at this specific moment has important implications for curriculum design, student well-being, and patient safety. This study aimed to measure and characterise state and trait anxiety levels among fourth-year dental students performing tooth extraction on real patients for the first time.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A cross-sectional single-centre observational study was conducted at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Nevşehir Hacı Bektaş Veli University, Turkey. All 74 fourth-year dental students (49 female, 25 male) participating in the first compulsory clinical extraction session were invited to complete the State\u0026ndash;Trait Anxiety Inventory (STAI). State anxiety (STAI-S) was assessed immediately before the extraction procedure; trait anxiety (STAI-T) was assessed during a regular, non-clinical lecture session. Descriptive statistics, a one-sample t-test, a paired-samples t-test, Pearson correlation analysis, and effect size calculations (Cohen\u0026rsquo;s d, 95% CIs) were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean STAI-S score immediately preceding the first extraction was 53.54\u0026thinsp;\u0026plusmn;\u0026thinsp;6.17 (range 38\u0026ndash;66), which was significantly higher than the theoretical midpoint of 50 (t\u0026thinsp;=\u0026thinsp;4.937, df\u0026thinsp;=\u0026thinsp;73, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.574). The mean STAI-T score was 40.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22 (range 28\u0026ndash;51), consistent with commonly reported normative ranges for non-clinical adult populations. State anxiety scores were significantly higher than trait anxiety scores (paired t\u0026thinsp;=\u0026thinsp;21.339, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;2.181). A moderate positive correlation was found between state and trait anxiety (r\u0026thinsp;=\u0026thinsp;0.621, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Most students (81.1%) showed moderate state anxiety; 17.6% showed high state anxiety. No statistically significant gender difference was found in either STAI-S or STAI-T scores (p\u0026thinsp;=\u0026thinsp;0.441 and p\u0026thinsp;=\u0026thinsp;0.939, respectively).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFourth-year dental students experience significantly elevated situational anxiety immediately prior to their first real-patient tooth extraction, suggesting that the observed elevation was predominantly related to the situational demands of the clinical encounter. These findings support the potential value of structured psychological preparation and progressive clinical exposure in undergraduate dental curricula to optimise both student welfare and patient care outcomes.\u003c/p\u003e","manuscriptTitle":"Anxiety Levels During the First Clinical Tooth Extraction Experience Among Fourth-Year Dental Students: A Cross-Sectional Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 06:01:57","doi":"10.21203/rs.3.rs-9721499/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6ccea42-f968-4a14-91ba-14685c476c8e","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":68174270,"name":"Dentistry"}],"tags":[],"updatedAt":"2026-05-18T06:01:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 06:01:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9721499","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9721499","identity":"rs-9721499","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}