RESEARCH REPORTS

Clinical

D.W. McNeil1,2*, A.J. Helfer1,3,

B.D. Weaver4, R.W. Graves4,
Memory of Pain and
B.N. Kyle1, and A.M. Davis1,5 Anxiety Associated
1
Department of Psychology, West Virginia University, 53
Campus Drive, PO Box 6040, Morgantown, WV 26506-6040,
with Tooth Extraction
USA; and 2Department of Dental Practice and Rural Health,
3
Division of Dental Hygiene, and 4Department of Oral and
Maxillofacial Surgery, West Virginia University School of
Dentistry; and 5Department of Psychology, University of
Alabama; *corresponding author, Daniel.McNeil@mail.wvu
.edu

J Dent Res 90(2):220-224, 2011

Abstract
Concerns regarding pain constitute a large compo-
nent of dental anxiety, and patients with high den-
tal anxiety are likely to have exaggerated memory
and prediction of dental pain. It remains to be
investigated, however, if memory of anxiety is
exaggerated in a manner similar to that of pain,
and if anxiety and pain assimilate in memory over
time. A sample of 79 patients presenting for emer-
gency extraction rated their anxiety and pain
before, during, and two weeks after the procedure.
Measures of trait dental anxiety and fear of pain
also were collected. All patients exaggerated their
recall of procedure pain, but only those high in
trait dental anxiety exaggerated their recall of
anxiety. Highly anxious patients reported more
pain prior to the procedure and expected more
pain; ratings of anxiety and pain for all participants
assimilated over time.
KEY WORDS: dental anxiety, pain, memory.
DOI: 10.1177/0022034510385689
Received December 10, 2008; Last revision July 7, 2010;
Accepted July 8, 2010
A supplemental appendix to this article is published elec-
tronically only at http://jdr.sagepub.com/supplemental.
© International & American Associations for Dental Research
Introduction
D espite advances in dental care, population-based dental fear and anxiety
have remained stable since the 1960s (Smith and Heaton, 2003). (Fear and
anxiety are different constructs, but for simplicity of expression, dental anxi-
ety will be used as the terminology in the present paper.) Approximately 6% of
the population reports severe dental anxiety, and high levels of dental anxiety
are associated with dental non-attendance (Gatchel et al., 1983; Maggirias and
Locker, 2002); if left untreated, dental anxiety can persist across decades of
life (Thomson et al., 2009). Individuals avoiding dental care have more oral
disease and experience greater negative impact on their daily life from poor
oral health (Abrahamsson et al., 2001).
Pain is often cited as both an etiological and a maintaining factor in
patients’ dental anxieties (Lautch, 1971; Bernstein et al., 1979; Wardle, 1982;
McNeil and Berryman, 1989). Yet, not all patients who experience pain dur-
ing dental procedures develop disabling dental anxiety (Davey, 1989), and not
all patients whose over-estimation of dental pain is disconfirmed necessarily
decrease their recall of past pain or prediction of future pain (Arntz et al.,
1990). In addition to the avoidance-promoting function of over-prediction and
recall of aversive stimuli intensity (Rachman and Bichard, 1988), one expla-
nation for inaccurate prediction and recall of pain in high-dental-anxiety
patients is that anxiety biases memory of prior pain, subsequently affecting
predictions of future pain (Wardle, 1984).
Research with dental patients supports the concept of a cycle of anxiety
and exaggerated expectation and recall of pain. In a general dental practice,
patients remembered more pain after 3 mos than they reported immediately
after the procedure, but highly dentally anxious patients had a greater increase
in remembered pain (Kent, 1985). Another study of patients undergoing root
canal therapy revealed that only experienced pain intensity predicted pain
intensity recalled after 1 wk (Gedney et al., 2003). For pain intensity recalled
after 18 mos and pain unpleasantness recalled after both 1 wk and 18 mos,
state anxiety immediately prior to treatment was a significant predictor.
Finally, the best predictor of pain expected before oral surgery, during sur-
gery, and recalled 4 wks later was state anxiety at the time of report (Eli et al.,
2003).
Other questions regarding the effect of anxiety on recall of dental pain,
however, remain unanswered. It is not known if memory of experienced
anxiety increases with time, as does memory of pain. An increase in recalled
anxiety could exacerbate recall of pain by increasing the recall of anxiety-
provoking aspects of the dental visit (e.g., pain). Additionally, it would be

220
J Dent Res 90(2) 2011 Memory of Pain and Anxiety   221
expected that reporting of the two aversive experiences would
become more closely related over time, especially as memory
becomes less accurate and specific. Yet, no study has examined
such a temporally dynamic relation between anxiety and pain
with dental patients.
This study examined reports of anxiety and pain over time
for oral surgery patients high and low in dental anxiety. It was
predicted that: (a) high-anxiety patients would expect and
remember, but not experience, more pain than low-anxiety
patients; (b) high-dental-anxiety patients would report greater
anxiety at all times; (c) high dental anxiety would be related to
greater fear of pain; (d) the relation between anxiety and pain
would strengthen with time for all patients; and (e) recalled pain
and anxiety would be significantly related, even after adjust-
ment for other relevant variables.
Materials & Methods
Participants
A final sample of 79 (n = 44 female) adult outpatients reporting
to the West Virginia University (WVU) Oral and Maxillofacial
Surgery Clinic for emergency extraction was included in this
study. Appendix A includes additional information about recruit-
ment and participants, who received $10 USD for study comple-
tion. Data were collected with approval from the WVU
Institutional Review Board.
Measures
Numerical Rating Scale
We used 2 numerical rating scales (NRS) to measure self-report
of anxiety and pain at the current moment on a continuum from
0 (no pain or anxiety) to 100 (extreme pain or anxiety). The
NRS has been used in previous research of pain and emotion
(Kyle et al., 2009), has demonstrated internal consistency mea-
suring pain (Price et al., 1994), is influenced by emotion in a
manner similar to other pain-rating scales (Kremer et al., 1981),
and can be administered in interview or questionnaire format.
Dental Fear Survey (DFS)
This scale is a 20-item measure of fears of a variety of situations
and stimuli associated with dentistry (Kleinknecht et al., 1973).
The DFS has been used globally and has a wealth of support
regarding its psychometric properties (e.g., McGlynn et al.,
1987).
Fear of Pain Questionnaire-III (SF-FPQ)
Developed by McNeil and Rainwater (1998), the Fear of Pain
Questionnaire-III (FPQ-III) assesses fear associated with differ-
ent painful situations. The FPQ has demonstrated reliability and
validity in clinical and community samples internationally (e.g.,
Osman et al., 2002), and has been used in oral health settings
(e.g., McNeil et al., 2001). The current study used the 9-item
FPQ short form (SF-FPQ).
Procedure
After entering the operatory and sitting in a dental chair prior to
treatment, participants were approached by a research assistant,
who gained informed consent, completed a demographic inter-
view, and recorded the patient’s NRS rating of pre-procedure
state anxiety and dental pain, as well as anxiety and pain
expected during extraction. Participants also completed the DFS
and SF-FPQ.
For all patients, local anesthesia was used. Immediately fol-
lowing extraction, participants completed NRS to rate maximal
pain and anxiety during the procedure. Follow-up NRS, asking
participants to rate maximal pain and anxiety remembered dur-
ing the extraction, were mailed to patients 2 wks later, and were
returned after an average of 25.2 (SD = 17.4) days.
Analysis Plan
DFS total scores were used to divide participants into high- and
low-dental-anxiety groups. A 2 (dental anxiety group) x 4 (rat-
ing time) multivariate analysis of variance (MANOVA) approach
to repeated measures was used to examine the effect of dental
anxiety on ratings of pain and anxiety over time. Tests for sim-
ple effects of dental anxiety on pain and anxiety at different
rating times were planned a priori. Pearson correlation coeffi-
cients were used to analyze the relation between dental anxiety
and fear of pain. Finally, hierarchical linear regression equations
examined the contributions of dental anxiety, fear of pain, and
ratings of pain and anxiety across time to the prediction of
recalled pain and anxiety. Age and gender, then fear of pain and
dental anxiety, were entered first and second to control for these
demographic and trait variables, respectively. Then anxiety and
pain ratings were entered in chronological order.
Results
Division of participants based on DFS total scores yielded a
low-dental-anxiety group of 40 participants (n = 22 female) and
a high-dental-anxiety group of 39 participants (n = 22 female).
Split half scores were calculated separately for males and
females to avoid confounding gender and dental anxiety, because
females tend to report more, and males less, dental anxiety
(Kleinknecht et al., 1973). Total DFS scores for the high- and
low-dental-anxiety groups matched well, respectively, to prior
scores for dental phobic individuals and an unselected student
sample (McGlynn et al., 1987; Moore et al., 1991; Johansson
and Berggren, 1992).
Trait Dental Anxiety and Pain
A 2 x 4 repeated-measures MANOVA revealed a significant
effect of time for ratings of pain, F(3, 75) = 4.06, p < 0.05, par-
tial η2 = 0.07 (Fig. 1). The main effect of the DFS group just
missed the standard level of statistical significance, F(1, 77) =
3.78, p = 0.06. The interaction of DFS group and time was not
significant, F(3, 75) = 0.96, p = 0.42. Comparison of marginal
 222  McNeil et al. J Dent Res 90(2) 2011
60
a, A High DFS
55
NRS Pain Rating
50 Low DFS
NRS Anxiety Rating
45 a, A, B
40 a, A
35 a, B a 45
30 b
a
25 a 35
20
state expected reported recalled
Rating Time
Figure 1.  Mean rating of pain across rating times for participants in
both DFS groups. Means that do not share upper-case subscripts differ
significantly across rating times, and means that do not share lower-
case subscripts differ significantly between groups. Each cell of data
for the low-dental-anxiety group represents 40 participants, and each
cell of data for the high-dental-anxiety group represents 39 participants.
Error bars represent the standard error of the mean. **p < 0.001.
means for the main effect of time revealed that, for all partici-
pants, pain reported immediately following extraction (M =
28.2, SD = 3.7) was significantly lower than pain prior to extrac-
tion (M = 43.7, SD = 4.0) and pain recalled several weeks later
(M = 35.2, SD = 3.9). Expected pain during extraction (M =
35.4, SD = 3.6) did not significantly differ from other rating
times.
A priori simple effects tests of the effects of dental anxiety at
each rating time were calculated as planned. The only time-
point yielding a significant difference was state pain before
extraction, F(1, 77) = 5.95, p < 0.05; participants in the high-
dental-anxiety group reported greater pain (M = 53.4, SD =
35.3) than participants in the low-dental-anxiety group (M =
33.9, SD = 35.8). Participants in the two groups did not signifi-
cantly differ on expected pain, F(1, 77) = 2.33, p = 0.13; pain
reported immediately following extraction, F(1, 77) = 0.06, p =
0.81; or recalled pain, F(1, 77) = 0.03, p = 0.87.
Trait Dental Anxiety and State Anxiety
A 2 x 4 repeated-measures MANOVA produced a significant
interaction between DFS group and time for ratings of anxiety,
F(3, 75) = 3.57, p < 0.05, partial η2 = 0.06 (Fig. 2). There also
were significant main effects for both DFS group, F(1, 77) =
25.21, p < 0.001, partial η2 = 0.25, and time, F(3, 75) = 5.70,
p < 0.01, partial η2 = 0.10.
Simple effects tests of DFS group at rating time revealed that
patients in the high-dental-anxiety group, compared with
patients in the low-dental-anxiety group, reported greater pre-
extraction state anxiety (M = 55.3, SD = 4.6 vs. M = 14.8, SD =
4.6), expected anxiety (M = 56.0, SD = 5.2 vs. M = 28.9, SD =
5.1), and recalled anxiety (M = 65.0, SD = 5.7 vs. M = 34.9,
SD = 5.6). Although patients in the high-dental-fear group also
reported more anxiety during the extraction (M = 52.1, SD = 5.9 vs.
M = 35.9, SD = 5.8), the difference was not statistically significant.
Simple comparisons of anxiety at different rating times for
both DFS groups further revealed that participants low in dental
anxiety reported less state anxiety prior to extraction compared
with expected, reported, and recalled anxiety. Participants with
a higher level of dental anxiety, however, recalled significantly
High DFS
75
Low DFS a, B
65
a, A
a, A a, A
55
b, D
a, D
25 b, D
15 b, C
5
state expected reported recalled
Rating Time
Figure 2.  Mean rating of anxiety across rating times for participants in
both DFS groups. Means that do not share lower-case subscripts differ
significantly between groups, and means that do share upper-case
subscripts differ significantly within groups across rating times. Each cell of
data for the low-dental-anxiety group represents 40 participants, and each
cell of data for the high-dental-anxiety group represents 39 participants.
Error bars represent the standard error of the mean.**p < 0.001.
greater anxiety during tooth extraction than they reported imme-
diately after the procedure.
Relation of Anxiety and Pain
The DFS and SF-FPQ correlated significantly (r = 0.51, p <
0.001), consistent with McNeil and Berryman (1989). Pain and
anxiety related significantly at the p < 0.05 level at all time-
points, and the correlation increased over time (Appendix B).
Further, correlation between recalled state anxiety and dental
pain (r = 0.56) was higher than the correlation prior to the proce-
dure (r = 0.24, z = 2.39, p < 0.05) or the correlation of expected
anxiety and pain (r = 0.30, z = 1.99, p < 0.05). Correlation
between anxiety and pain reported about the extraction (r = 0.44)
did not significantly differ from other correlations.
Further, two significant predictors of recalled pain emerged
from a hierarchical regression equation: pain reported following
extraction, and recalled anxiety (Table 1). The three strongest
predictors of recalled anxiety were trait dental anxiety, anxiety
during the extraction, and recalled pain (Table 2). Additional
analyses are in Appendix C.
Discussion
Regarding the first hypothesis, trait dental anxiety had a signifi-
cant effect on state pain prior to extraction. Results also partially
replicated those from Kent (1985), in that recall of pain for all
participants was exaggerated even after 2 wks. Perhaps differ-
ences in recall of pain between high- and low-dental-anxiety
patients take longer to manifest, as in Kent (1985), in which dif-
ferences were shown at 3 mos.
The second hypothesis also was supported, since the high-
dental-anxiety group had greater ratings of anxiety than the
low-dental-anxiety group at all times except immediately after
tooth extraction. Additionally, patients high in dental anxiety
recalled more anxiety weeks later than immediately after sur-
gery; patients low in dental anxiety reported less state anxiety
J Dent Res 90(2) 2011 Memory of Pain and Anxiety   223

Table 1. Hierarchical Regression Analysis Summary for Patient Variables Predicting Recalled Pain

Variable B SE B b R2 ΔR2

Step 1 0.03 0.03

  Gender 5.08 7.79 0.07  
  Age –0.44 0.32 –0.16  
Step 2 0.04 0.01
  DFS total score 0.17 0.23 0.10  
  SF-FPQ total score 0.05 0.61 0.01  
Step 3 0.09 0.05
  NRS rating of state pain –0.19 0.11 –0.20  
  NRS rating of state anxiety –0.15 0.17 –0.16  
Step 4 0.12 0.03
  NRS rating of expected pain –0.19 0.13 –0.18  
  NRS rating of expected anxiety 0.11 0.17 0.12  
Step 5 0.45** 0.33**
  NRS rating of pain during extraction 0.63 0.12 0.60**  
  NRS rating of anxiety during extraction 0.03 0.11 0.03  
Step 6 0.62** 0.17**
  NRS rating of recalled anxiety 0.64 0.12 0.71**  

Notes. DFS = Dental Fear Survey, SF-FPQ = Short Form-Fear of Pain Questionnaire, NRS = Numerical Rating Scale. Each regression equation is
based on 79 participants. Gender was coded as male = 0 and female = 1, so being female was (non-significantly) associated with higher
recalled pain. Also, age was entered in years; being younger was (non-significantly) associated with more recalled pain.
**p < 0.001.

Table 2. Hierarchical Regression Analysis Summary for Patient Variables Predicting Recalled Anxiety

Variable B SE B β R2 ΔR2

Step 1 0.17* 0.17*

  Gender 22.58 8.03 0.30*  
  Age –0.81 0.34 –0.25*  
Step 2 0.43** 0.25**
  DFS total score 0.90 0.20 0.46**  
  SF-FPQ total score 0.49 0.53 0.10  
Step 3 0.45** 0.02
  NRS rating of state pain –0.07 0.10 –0.07  
  NRS rating of state anxiety 0.22 0.15 0.21  
Step 4 0.45** 0.01
  NRS rating of expected pain –0.12 0.12 –0.10  
  NRS rating of expected anxiety 0.05 0.15 0.05  
Step 5 0.67** 0.21**
  NRS rating of pain during extraction 0.15 0.10 0.12  
  NRS rating of anxiety during extraction 0.48 0.10 0.46**  
Step 6 0.77** 0.10**
  NRS rating of recalled pain 0.48 0.09 0.43**  

Notes. DFS = Dental Fear Survey, SF-FPQ = Short Form-Fear of Pain Questionnaire, NRS = Numerical Rating Scale. Each regression equation is
based on 79 participants. Gender was coded as male = 0 and female = 1, so being female was associated with higher recalled pain (or
anxiety). Also, age was entered in years; being older was associated with less recalled anxiety.
*p < 0.05, **p < 0.001.

immediately before surgery. Several processes may help explain
this pattern. First, differences in state anxiety before tooth
extraction might have influenced later recall of the procedure, as
it did with recall of pain and unpleasantness in Gedney et al.
(2003). Second, patients high in dental anxiety might have
experienced more anxiety in recalling a dental event and,
subsequently, recalled more anxiety-provoking aspects of the
procedure. Third, perhaps patients high in dental anxiety under-
reported their procedural anxiety immediately after the extrac-
tion, with a sense of relief from being “finished”, and their
recall of anxiety was closer to their actual experience during
extraction.
Strong support was provided for the third and fourth hypoth-
eses. Dental anxiety and fear of pain were significantly related,
224  McNeil et al. J Dent Res 90(2) 2011
and the correlation between anxiety and pain ratings converged
with time. Finally, in terms of the fifth hypothesis, recalled
anxiety was one of only two significant predictors of recalled
dental pain; perhaps state anxiety was less of a predictor than in
other studies (Eli et al., 2003; Gedney et al., 2003) because of
the shorter duration before recall. Similarly, recalled pain was a
significant predictor of recalled anxiety, as was trait dental
anxiety. Although neither trait dental anxiety nor anxiety during
extraction significantly predicted recalled pain, these variables
could have indirectly influenced recalled pain through their
effects on recalled anxiety. Thus, the aversive states of fear and
pain became assimilated in memory over time, a finding congru-
ent with both Gedney et al. (2003) and laboratory research by
Rainville et al. (2004) suggesting that memory of pain quickly
becomes less precise and more categorical.
A limitation is that oral surgery is a variable experience; the
tooth extraction experience varied across participants. Also, this
sample received emergency oral surgery at a dental school, and so
may be somewhat unique. NRS data were collected by different
formats (i.e., interview vs. questionnaire) depending on the time-
point in the study. Differences likely are minimal, however, since
the questionnaire version was handed immediately to the researcher.
Overall, findings lend support to the idea that memory of
dental pain becomes exaggerated with time, and memory of
anxiety becomes exaggerated for high-dental-anxiety patients.
Furthermore, the relation between anxiety and pain increases
with time. Results highlight the important role both trait dental
anxiety and state anxiety play in exaggerating recall and subse-
quent prediction of dental pain, especially for highly dentally
anxious patients. Additionally, analysis of these data emphasizes
the importance of reducing both trait dental anxiety and state
anxiety, potentially through behavioral and/or pharmacological
methods, to reduce the potential aversiveness of the dental expe-
rience (Heaton et al., 2010).
Acknowledgments
Thanks to the participating patients as well as the WVU Anxiety,
Psychophysiology, and Pain Research Laboratory, and staff of
the WVU Oral Surgery Clinic. Funding was provided by the
WVU Department of Psychology, Eberly College of Arts and
Sciences, School of Dentistry, and McNair Scholars Program, as
well as Psi Chi, the International Honor Society in Psychology.
A preliminary report was presented at the 84th General Session
of the International Association for Dental Research, July, 2006,
in Brisbane, Queensland, Australia.
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