Fear of Tooth Extraction among Patients Visiting a Tertiary Care Center

Introduction : Extraction


INTRODUCTION
Fear refers to an activated response to an unpleasant emotion caused by the threat of danger, pain, or harm. 1 Dental fear is fear of dentistry-related objects and treatment procedures.Dental fear-related behaviours have long been recognized as the most difficult aspect of patient management and can be a barrier to good care. 2 Fear of dental treatment was seen in 24.3% of the individuals, which was fourth after fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%) according to a study done in the Netherlands. 3Among dental treatments slow speed drilling(42%) was most feared followed by high speed drilling(33%), preparation of anaesthetic (33%), and extraction of tooth(25%) according to Berggren et al. 4 Extraction of teeth is one of the most commonly performed procedures in dentistry both by general dentists and oral and maxillofacial surgeons.Extraction of teeth is meant to be painless and this can be achieved by giving adequate amounts of local anaesthesia to the patient.Studies have shown that patients undergoing dental treatment have a great fear of injection of local anesthesia. 2,5xtraction of teeth is known to be in the top five most frightening procedures in dental practice. 5Although extraction of teeth is one of the most performed surgical procedures and is feared by patients, there is a lack of data to show its prevalence.Reasons for fear of extraction of teeth are certain to be multifactorial, pain has been hypothesised to be a central component. 6Anxiety is used to describe the emotional state and fear to describe an activated response to unpleasant stimuli.However, the two terms are usually used synonymously. 7These two terms are used together in this study for comparison of the study findings.
The objective of this study was to find out the prevalence of fear of tooth extraction, its association with gender, age, education, and previous extraction experience, and the ranking of the fear of tooth extraction among patients visiting Birat medical college and teaching hospital, in Nepal.

METHODOLOGY
This descriptive cross-sectional study was conducted among the patients visiting the Department of Dental Surgery at Birat Medical College and Teaching Hospital, Tankisinwari, Morang, Nepal for extraction of teeth from 1 st March 2023 to 31 st August 2023.Ethical approval was taken from the Institutional Review Committee (Reference number: IRC-PA-284/2078-79). Written informed consent was taken from the patients.Patients with age ≥ 18 years whose permanent teeth were to be extracted were included in the study.Patients with deciduous tooth extraction, surgical extraction, and extraction that had been attempted outside and referred were excluded.A convenience sampling method was used.The sample size of 278 patients was calculated based on the previous study. 4mographic data of the patients were entered in the designed proforma.Patients were seated in the dental chair and asked about their education level, fear of extraction, and previous extraction experience after the patients were planned for extraction of a tooth.Education level of the patient was categorised into three as illiterate, ≤ higher education level and ≥ bachelor level.Fear of extraction of tooth was asked in 'yes' and 'no' form only. Previous extraction experience of the patient was also asked in 'yes' and 'no' form; patients were not asked in detail about their past experience of tooth extraction.Fear of the extraction of tooth was evaluated based on the pain perceived by the patients and it included pain from injection of local anaesthesia, pain during extraction, and pain after extraction in the postoperative period.Patients were asked to rank the pain which they feared most according to the order before the extraction of tooth.All extractions were performed in the out patient department of Dental surgery under local anaesthesia by multiple practitioners.
Data were entered in Microsoft Excel 2013 and analysed using Statistical Package for Social Sciences version 22. Frequencies and percentages were used to represent data.The Chi-square test was applied to evaluate the association between the variables.

Fig 1: Fear of extraction in patients with previous extraction and non-extraction experience
The association of fear of tooth extraction with gender, age, and experience of previous extraction was found to be significant (p<0.05) using the chi-square test.(  3).

DISCUSSION
In this study, out of 278 patients who came for extraction of teeth, the prevalence of fear of tooth extraction was 219 (78.70%).This prevalence is high compared to other studies by Berggren et al (25%). 4The differences could be because of methodological issues as in our study patients who were seated in dental chair and were about to go under extraction of teeth were evaluated.However in the study by Berggren et al. patients were interviewed, an oral examination was done and no dental treatment was done.Also in the study by Berggren et al. 160  adult patients that had dental fear and avoidance of dental treatment that were referred for at a special clinic for dental fear treatment were investigated.][10][11][12][13][14][15] In the study by Heft et al. fear of extraction of tooth was 29.7% in females and 20.2% in males. 6Reasons for gender differences in fear of extraction are not clear however studies have shown that females tend to remember more pain, report negative experience after extraction than males.In general, men and women differ in communication styles in the healthcare settings, with women being more expressive regarding their problems and feelings. 16ccording to Pierce et al. traditional male gender role may lead men to express less fear than what they really feel. 17Wabnegger et al. pointed out that the grey matter volume in the cognitive regions that are activated during emotional regulation were found to be greater in females than males that might influence behaviour. 18ar of tooth extraction was highest in the age group of 18-27 years (n= 67;87.01%)as the age advanced there was a decrease in the fear of extraction.Explanation for the decrease in fear in older age is that older adults tend to use emotional coping skills, have more prolonged exposure and greater tolerance acquired over their life span. 19,202][23] This could be attributed to difficulty in adapting to the environment as well as accepting the treatment for younger patients 13 .
Education level wise proportion of fear was highest in ≥ bachelor level (n=30;83.33%)and least in illiterate patients(n=71;73.95%)however it was not statistically significant similar to other studies. 10,15,24Another study by Ekanayake et al. have demonstrated that increased educational levels result in decreased dental fear however it was not so in our study. 25his might be due to patient being more educated means they knew more about the procedure and its complications and were concerned leading to more fear.
The prevalence of fear of extraction among previously experienced extraction patients was 106 (69%) and 113 (90.4%) in non-experienced patients.It was statistically significant as in the other studies. 10,12The most likely reason for these differences might be that individuals may 'overestimate' the fear of pain of tooth extraction that they have not experienced, compared to those they have experienced in the past. 26Previous good experience reduces the fear and bad experience increases the fear. 7 this study, the most feared was pain during extraction (n=134;61.20%)which is in contrast to a study by Laskin et al.
where postoperative pain was ranked the most feared. 27In the study by Laskin et

CONCLUSION
The fear of extraction of teeth was seen in the majority of patients and was more prevalent in females, younger patients, and previous non-extraction patients.On ranking the fear of extraction by patients, the most feared was pain during extraction and the least was pain in the post-extraction period.

RECOMMENDATIONS
Fear of extraction of teeth has a high prevalence that could lead to avoidance of extraction leading to delay in proper care required for patients.Further studies that could evaluate the impact of delay in extraction due to fear of extraction would be of great value.

LIMITATION OF STUDY
This study was done at a single centre, Birat Medical College and Teaching Hospital, so the findings of the study cannot be generalised to all the people of Nepal.Fear of extraction was evaluated based on the pain only and other relevant factors were not assessed.Previous extraction experience was evaluated as 'yes' or 'no', further detailed evaluation was not done.

Table 2 )
Females had significantly more fear compared to males and similarly the 18-27 years of age group had more fear compared to other age groups.Fear of tooth extraction decreased as the age of the patient advanced.Fear was significantly more in previous non-extraction patients compared to experienced patients.The association of fear of extraction of tooth with level of education was found to be not significant (p>0.05).

Table 2 :
Association of fear of tooth extraction with gender, age, education level, and previous extraction * Statistically significant, Chi-square test applied

Table 3 :
Ranking of fear of tooth extraction (n=219) Fear of extraction in patients can be removed by assuring them that there will be minimal discomfort only during injecting local anaesthesia.Patients should be assured that there will be no pain during extraction, and extraction would not be done without achieving adequate amount of anaesthesia, these will help to remove the fear in patients.Post-extraction fear can be removed by effective pain management by giving required medications and post-extraction instructions.Preoperatively understanding the issues faced by patients and planning effective management accordingly will be key to manage fear of extraction in the patients.