The Impact of Anxiety on IV Sedation for Tooth Extraction

Third molar extraction is a common procedure that leads to dental anxiety and the physiologic sequelae of anxiety such as elevated heart rate and blood pressure. Higher anxiety levels have also been shown to be associated with longer recovery times as well as increased doses of medications.¹ It can be difficult to quickly and reliably assess patient anxiety prior to third molar surgery, and the ability to do so could have implications on medication dosing. The depression-anxiety stress scale (DASS) is a three part self-report measuring emotional states which can be assessed as a whole or in components.² The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The stress scale is sensitive to levels of chronic non-specific arousal such as difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable, and impatient. Characteristics of high scores on the DASS indicate apprehensive, tense, jumpy, and easily upset traits. It is used in many clinical and research applications to measure current state of anxiety or changes over time. The purpose of this study is to evaluate the relationship between preoperative level of stress and anxiety, doses of medication, degree of movement during procedure, and vital signs. Patients were included in the study if >18 years, ASA I or II, undergoing extraction of at least two impacted teeth or greater than three erupted teeth. Prior to the start of the procedure, informed consent was obtained and patients completed the anxiety and stress components of the DASS, to which investigators were blinded. Vital signs, intraoperative movement, the amount of each medication administered, and operative time were recorded during the procedure. After collecting data from fifty sedation procedures, a trend has emerged between the patient’s DASS classification for stress to the total dose of medication (mg/kg/min) administered during the procedure. It was also observed that there was an absence of correlation between the patient’s DASS classification for anxiety and the total medication dose administered during the procedure, as well as between the patient’s average level of intraoperative movement. This is part of an ongoing prospective evaluation and while statistical significance has not yet been achieved, a trend toward increased dose of medication with increasing DASS-stress score was noted. This may be an indication that a patient’s tendency to perceive a particular situation as stressful or anxiety-provoking has a greater impact on medication requirements. Given an absence of a trend relating medication doses to DASS-Anxiety may indicate that acute situational anxiety is less a factor in medication requirements than the overall tendency. Clinically, this could translate in to the assessment of how prone a patient is to perceive a situation as anxiety-provoking being more important than how anxious they feel in that moment. Those clinicians who choose to assess procedural anxiety and tailor anesthetic approach based on that assessment, should do so based on tendency toward anxiety and not an acute anxiety assessment. Caution may be appropriate when assessing acute level of anxiety and significantly increasing medication doses solely on that parameter as it may not correlate to an increase in need for medication. The goal of any sedation is to have maximum anxiolytic, amnestic, and analgesic effect at the lowest possible dose to facilitate the surgery and allow for quick recovery. Studies such as this help identify areas for evaluation and assessment to further the armamentarium we utilize to perform safe and effective sedation for dentoalveolar procedures. 

1. Osborn TM, Sandler NA. The effects of preoperative anxiety on intravenous sedation. Anesth Prog. 2004;51(2):46-51.
2. Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2^nd. Ed.) Sydney: Psychology Foundation.