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Dental Anxiety and Pain Perception associated with the Use of Miniscrew
Implants for Orthodontic Anchorage

Article  in  The Journal of Indian Orthodontic Society · September 2014

DOI: 10.5005/jp-journals-10021-1238

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10.5005/jp-journals-10021-1238
Dental Anxiety and Pain Perception associated with the Use of Miniscrew Implants for Orthodontic Anchorage
Original research

Dental Anxiety and Pain Perception associated with the

Use of Miniscrew Implants for Orthodontic Anchorage
1
KC Prabhat, 2Sandhya Maheshwari, 3Sanjeev K Verma, 4ND Gupta, 5A Balamani, 6Mohd Tauseef Khan, 7Raj K Singh

ABSTRACT Received on: 23/4/13

Introduction: This study was done with the aim to examine
the pain experienced by patient after the miniscrew implant
place­ment and the dental anxiety that might influence the pain
experience.
Materials and methods: A total of 41 subjects (20 males and
21 females) with the age range of 12 to 30 years were recruited
for this study, based on the need of skeletal anchorage for their
orthodontic treatment. After 1 hour of the placement of the mini­
screw implant patients were asked to indicate their level of pain
on a 100 mm of visual analog scale (VAS). Dental anxiety was
measured before placing the miniscrew implants using dental
anxiety scale (DAS) consisting of seven questionnaires modi­
fied for orthodontic use.
Results: The mean anxiety score DAS for the whole study
sample was 16.31 ± 1.70. The mean VAS score for entire study
group was 27.62 ± 1.12. Both the mean VAS and DAS score
was found to be higher in females than males. There was a
signi­ficant positive correlation between the dental anxiety and
patient perception of pain with miniscrew implant placement as
evident by Pearson correlation coefficient (r = 0.688).
Conclusion: The study showed a positive linear relationship
between dental anxiety and patient pain experience following
miniscrew implants placement.
Keywords: Anxiety, Pain, Miniscrew, Anchorage.
How to cite this article: Prabhat KC, Maheshwari S, Verma SK,
Gupta ND, Balamani A, Khan MT, Singh RK. Dental Anxiety and
Pain Perception associated with the Use of Miniscrew Implants
for Orthodontic Anchorage. J Ind Orthod Soc 2014;48(3):163-167.
Source of support: Nil
Conflict of interest: None
1
Assistant Professor, 2-5
Professor, 6Ex. Assistant Professor
7
Ex. Resident
1
Department of Orthodontics and Dentofacial Orthopedics
Dental College, Regional Institute of Medical Sciences (Auto­
nomous Institute of Ministry of Health, Government of India), Imphal
Manipur, India
2,3,6,7
Department of Orthodontics and Dental Anatomy, Aligarh
Muslim University, Aligarh, Uttar Pradesh, India
4
Department of Periodontics, Aligarh Muslim University, Aligarh
Uttar Pradesh, India
5
Department of Orthodontics, Mahatma Gandhi Post Graduate
Institute of Dental Sciences, Puducherry, India
Corresponding Author: KC Prabhat, Assistant Professor, Depart­
ment of Orthodontics and Dentofacial Orthopedics, Dental College
Regional Institute of Medical Sciences (Autonomous Institute of
Ministry of Health, Government of India), Imphal, Manipur, India
e-mail: dr.prabhatkc@gmail.com
Accepted after Revision: 30/5/13
INTRODUCTION
Stedman’s medical dictionary defines the pain1 as ‘an
unpleasant sensation associated with actual or potential
tissue damage and mediated by specific nerve fibers to the
brain, where its conscious appreciation may be modified by
various factors.’ This definition recognizes that pain may
have a noxious transmission component, a psychological
component and a very important modulatory component.
Pain is not simply determined by the intensity of the
nociceptive stimulus. In the evaluation of the effect of the
fear and anxiety on the pain reactivity in humans, Rhudy and
Meagher2 found that emotional state modulate human pain
reactivity. Pain is as much cogitative and emotional construct
as it is a physiologic experience,3,4 and it depends on psycho­
logic factors, such as the emotional and motivational state
of the organism.2,5
Dental anxiety and dental fear are strong negative feelings
associated with orthodontic or dental treatment involving
surgical procedures. The concept of dental fear and dental
anxiety is often used interchangeably in the dental literature.
Dental anxiety was described by Klingberg and Broberg6 as
a state of apprehension that something dreadful is going to
happen in relation to dental treatment or certain aspects of
dental treatment.7 Dental anxiety is a multidimensional state
that consist of somatic, cognitive and emotional elements and
describes a general state that is not stimulus specific. It is well
documented that patient’s perceptions of pain and discomfort
associated with debridement differ. Patient’s perception of
pain and dental anxiety differ in different dental surgical
procedures.8 It also differs with individual characteristics,
such as gender, age, education levels, income, smoking and
the oral health status.
Recently, the psychological and emotional patterns of
the patients have been emphasized in orthodontic literature.
The pain experienced by patients have been evaluated
during orthodontic tooth movement,9 fixed orthodontic treat­
ment,10-12 after dental implants13,14 and miniscrew implants
surgeries.15 Hence, the aim of this study was to examine the
degree of pain experienced by patients after the miniscrew
implant placement and the dental anxiety that might

The Journal of Indian Orthodontic Society, July-September 2014;48(3):163-167 163

KC Prabhat et al
influence the experience of pain. It also evaluates differences
in the pain perception between the genders associated with
miniscrew implants placement.
MATERIALS AND METHODS
The present clinical study was conducted on 41 subjects
(20 males and 21 females) in the Department of Orthodontics
and Dental Anatomy, Aligarh Muslim University, Aligarh,
India, from February 2011 to December 2012. Before
initiating this research work, the study was approved by
board of research studies of our university, and a written
informed consent was obtained from each participant or their
parents before inclusion in this study. To be included in the
study, patients had to be between 12 and 30 years of age.
The patients with the different malocclusion were recruited
based on need of skeletal anchorage. Exclusion criteria
included refusal to give informed consent, a medical or
psychological disorder that might affect pain thresholds,
use of pain or anxiety medication, smoking habit and/or
alcoholism, presence of acute periodontal pain, pulpitis,
abscesses or other acute infections, attachment loss and/or
gingival recession, and/or root hypersensitivity that might
cause tooth sensitivity.
All procedures were performed by an experienced
orthodontist with patients sitting in the same dental chair.
Before the placement of miniscrew implant, advantages and
disadvantages were explained to each patient and his or her
parents when an implant anchorage was considered desirable
for orthodontic treatment. A recommended guideline was
followed for the insertion procedure of miniscrew implants.
The screw implants were placed at 30° to 40°angles to the
long axes of the teeth in the maxillary arch and at 10° to
20° angles in the mandibular posterior area according to
use. Topical anesthesia (Lidocaine Topical Aerosol USP
15% w/w, Midascare Pharmaceuticals Pvt Ltd, Aurangabad,
India) was applied before miniscrew implant placement.
Before the application of topical anesthesia, the mucosa of
the placement site was thoroughly dried with gauge square.
The anesthesia was applied with a cotton swab or cotton
roll for 2 to 3 minutes. Peak anesthesia was obtained in
5 to 10 minutes, as confirmed with a periodontal probe.
An advantage of topical anesthesia is ease of administration.
It effectively diffuses 2 to 3 mm into the mucosa (does not
result in pulpal anesthesia), hence, it allows the patient
to retain sensation and report any pressure or discomfort
during miniscrew implants placement. Another advantage
of topical anesthesia is that it avoids tissue ballooning,
which can make the miniscrew implants placement more
difficult. No analgesics or antibiotics were prescribed after
164
miniscrew implant placement. Postoperative discomfort
was checked for all patients. The patients were instructed to
gently massage the implant area and to keep it clean. A 0.2%
chlorhexidine rinse was prescribed for 7 to 14 days. After
1 hour of the placement of miniscrew implants, patients were
asked to indicate their level of pain on a 100 mm horizontal
visual analog scale (VAS) where zero meant ‘no pain and
discomfort’ and 100 meant ‘the worst possible pain and
discomfort’ (Fig. 1). Visual analog scale is considered to be a
robust, sensitive and reproducible method of expressing pain
severity.16 It is a simple, reliable and valid pain measurement
scale that has been used for evaluating dental pain,17 such
as in previous studies that evaluated pain from periodontal
therapies.18-20
Dental anxiety was measured by using two anxiety
measurement scales modified for orthodontic use. One of the
questionnaire was the Corah’s dental anxiety scale (DAS),
which consists of four questions to assess dental anxiety.21
It is probably the most well-known questionnaire designed
to assess dental anxiety.22 The other was the dental fear sur­
vey (DFS), which consists of 20 questions.23 Karadottir et al
evaluated the DAS and DFS and found that only three of the
20 DFS questions and all four DAS questions significantly
correlated with patients’ responses to instrumentation.24
Therefore, in the present study, the patients were asked to
complete a questionnaire consisting of only these seven ques­
tions modified for orthodontic use. The anxiety question­­­­naire
scores ranged from 7 to 35 (Table 1). After completing the
questionnaire, implant placement was done. Before initiating
the research work, one of the investigator cross checked the
relia­bility of these seven questions in evaluating the dental
anxiety associated with miniscrew implants placement by
describing the orthodontic treatment plan involving the
mini­screw implants for anchorage to the patient at different
occasions and asked the patient to fill the questionnaire
(test-retest reliability). The study showed that these seven
questions were reliable in assessing the dental anxiety
associated with miniscrew implants placement (r = 0.9).
Statistical Analysis
Statistical analyses were performed with the program SPSS
13.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive
statistical analysis including mean and standard deviation
were calculated for all variables with respect to the entire
group, for the males and females. The student’s independent
t-test was used to compare the gender differences between
the anxiety score and VAS. Pearson correla­tion coefficient
(r) was calculated to analyze the relation­ship between VAS
and anxiety score. The level of statistical significance was
set at < 0.05.
 JIOS

Dental Anxiety and Pain Perception associated with the Use of Miniscrew Implants for Orthodontic Anchorage

Table 2: Evaluation of dental anxiety scores (das) and visual

analog scale (vas) scores for each gender and the entire group
Scores Gender N Mean Std. p-value
deviation
Fig. 1: Hundred points of visual analog scale DAS Female 21 17.62 1.12 0
Male 20 14.95 1.00
Overall 41 16.31 1.70
Table 1: Dental anxiety questionnaire modified for orthodontic use VAS Female 21 30.10 2.77 0
Dental anxiety questionnaire sheet (questions 1 to 3 originate Male 20 24.80 1.15
from the DFS and questions 4 to 7 are from Corah’s DAS) Overall 41 27.51 3.41
How much anxiety/fear or discomfort does each of this cause
you? Please use the numbers from the scale for the first three
questions.
1. None at all 2. A little 3. Somewhat 4. Much 5. Very much
1. Being seated in dental chair.........................
2. You are informed that miniscrew implant is necessary for your
orthodontic treatment.................
3. All things considered, how fearful are you of having miniscrew
implant placed?
4. If you had to go to the orthodontists tomorrow, how would
you feel about it?
a. I would look forward to it as a reasonably enjoyable
experience
b. I would not care one way or another
c. I would be a little uneasy about it
d. I would be afraid that it would be unpleasant and painful
e. I would be very frightened of what the orthodontist might
do
5. When you are waiting in the orthodontist’s office for your turn
in the chair, how do you feel? Fig. 2: Correlation between DAS and VAS scores
a. Relaxed
b. A little uneasy
c. Tense were found between the males and females with regard to
d. Anxious mean age (p > 0.05). The anxiety score DAS ranged from
e. So anxious that I sometimes breakout in a sweat or almost 7 to 35, and the mean anxiety score for the entire study
feel physically sick
6. When you are waiting in the orthodontist’s chair while sample was 16.31 ± 1.70 (Table 2). The mean anxiety score
assistant gets the drill ready to begin working on your teeth, for females was 17.62 ± 1.12 and that of males was 14.95 ±
how do you feel?
1.00 (see Table 2). The mean anxiety score was found to be
a. Relaxed
b. A little uneasy higher in females as compared to the males (p = 0.000). The
c. Tense mean VAS score for the entire group was 27.51 ± 3.41 (see
d. Anxious
e. So anxious that I sometimes break out in a sweat or almost
Table 2). The mean VAS scores for females and males were
feel physically sick 30.10 ± 2.77 and 24.80 ± 1.15 respectively (see Table 2). The
7. You are in the orthodontist’s chair for the placement of differences in mean VAS scores between females and males
miniscrew implant. While you are waiting and the dental
assistant is getting out the instruments that the orthodontist’s
was statistically significant (p = 0.000). The correlation
will use to place miniscrew implants in your jaw, how do you between VAS and DAS scores was calculated by using
feel? Pearson correlation test, and significant positive correlation
a. Relaxed
b. A little uneasy (r = 0.688) was found (Fig. 2).
c. Tense
d. Anxious
e. So anxious that I sometimes break out in a sweat or almost Discussion
feel physically sick
The present study provides information about pain percep­
tion of patients and the level of dental anxiety during
Results
routine orthodontic treatment needed miniscrew implants
Forty-one patients (21 females and 20 males: mean age— for anchorage control. Pain measurement is inherently
19.85 ± 4.82 years, age range—14-30 years) needed mini­ difficult as it has both physical and psychological aspects.17
screw implants for their orthodontic treatment filled out Verbal scaling systems have been used in measurement of
the questionnaire. No statistically significant differences pain intensity, but verbal reporting may be distorted, both

The Journal of Indian Orthodontic Society, July-September 2014;48(3):163-167 165

KC Prabhat et al
purposefully and unwittingly. The VAS is one of the most
commonly used tool to assess pain intensity and has been
shown to be a valid and reliable method of measuring discrete
pain as well as being a sensitive, simple, reproducible of
asses­sing pain.25 Moreover, VAS can assess the relative
change in the magnitude of pain over-time on linear scale.26
Thus, the VAS was employed in the assessment of pain in
this study.
Pain is subjective and depends on individual’s perception.
Therefore, a standardized and controlled environment was
essential for pain assessment. In the study, one experienced
orthodontist placed all miniscrew implants in all patients in
the same dental chair using the same implant kit in a quiet,
distraction-free environment. To minimize interpatient
variability in the present study, medically healthy patients
were included, because systemic factors were also shown to
modify an individual’s response to noxious stimuli. Patients
with moderate to severe inflammation within the gingiva
were shown to increase pain during periodontal probing8,
and it probably would change the pain levels after implants
placement.
To reduce exaggerated responses and bias, patients were
asked to participate in this study after the topical application
of local anesthesia. Moreover, the patients were aware that
miniscrew implant placement had not ended; therefore, we
believe that they were not relieved of their anxiety or fear.
Often, use of miniscrew implants for orthodontic anchorage
is associated with high level of anxiety as patient expects
more pain with microimplant surgery. Anxiety is thought to
influence the effective component of pain.27Anxious people
tend to overestimate the intensity of aversive events, such as
fear and pain.28 Canakci et al noted that a patient with a high
Corah’s DAS score would be more likely to present a high
pain response than a patient with a lower DAS score.8 Other
studies have also reported that people with higher scores on
scales measuring dental anxiety and pain reported more pain
after dental treatment.4 Furthermore, Reiss suggested that
patients differed in their fear of pain because of their fear of
anxiety, fear of negative evaluation and/or fear of injury.29
Klages et al showed that subjects expected more pain than
they experienced; this effect was stronger in patients with
higher dental-anxiety scores.30 The study showed a positive
linear relation between the dental anxiety and patient
perception of pain with miniscrew implants placement.
It is suggested that the use of anxiolytic agents may help
to reduce the fearful expectations. The study support the
assumption that people who are predisposed to responding
fearfully to pain are at an increased risk of ending up in a
vicious circle of anxiety, fear of pain and avoidance of dental
treatment.28 This study emphasizes the psychodynamic
166
understanding of the orthodontist-patient interaction, which
is a two-person endeavor. It is the orthodontist working with
the patient and the patient being able to accept the treatment
provided by the orthodontist. This interaction requires
improved time and behavioral management skills, increased
awareness of patients’ concerns and anxieties, the ability to
readjust treatment plans and to provide patient-centred care.
The fear of pain during treatment has been identified as
a major factor in preventing patients from seeking dental
or orthodontic care. Therefore, delivering orthodontic care
with minimal patient discomfort should be an essential part
of a clinician’s skills to avoid noncompliance. Screening of
patients’ previous dental experiences and histories for more
information should be considered so that the orthodontist
may take additional precautions to improve the doctor-
patient relationship and, thus, the treatment results. With
the increasing demand for stress-free and painless therapy,
clinicians should have the ability to reduce patients’ fear,
discomfort and pain during miniscrew implants placement
for successful orthodontic treatment. On the basis of the
information provided by the study, it can be concluded
that dental anxiety (fear) and pain/discomfort associated
with miniscrew implants placement need to be further
investigated. Studies should include confounding factors,
such as different age groups, operator and subjective aspects
like emotional responses, social determinants and cultural
aspects with larger sample size.
Conclusion
Thus, this study found a positive linear relationship between
dental anxiety and patient pain experience following
miniscrew implants placement. The females were more
anxious than males and females experienced more pain as
compared to the males.
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