Original Research Article

The International Journal of

Psychiatry in Medicine
Associations Between the 2023, Vol. 0(0) 1–16
© The Author(s) 2023
Perception of Dental Pain and Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/00912174231180855
Pain Anxiety, Mental Pain, and journals.sagepub.com/home/ijp

Dental Anxiety in Iranian

Sample

Amir Abbas Taheri1 , Ali Akbar Parvizifard2 , Sajjad Reisi3 ,

Mahsa Jafari4, Yokhabe Mohammadian5,
Khatereh Heshmati6 , Aliakbar Foroughi7, Masoome Eivazi8,
and Mohammad Ghasemi9

Abstract
Objective: This study examined the perception of dental pain and its relationship to
pain anxiety, dental anxiety, and mental pain.
Methods: This cross-sectional study was conducted on 328 patients referred to dental
clinics in Kermanshah (Iran) from 2020 to 2021. The instruments used in this study
included questionnaires about Pain Anxiety, Dental Anxiety, Mental Pain, and Pain
Perception.

1
Department of Rehabilitation Counseling, University of Social Welfare and Rehabilitation Science, Tehran,
Iran
2
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
3
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
4
Department of Psychology, University of Mohaghegh Ardebili, Ardebil, Iran
5
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
6
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
7
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran
8
Department of periodontics, school of dentistry, Kermanshah University of Medical Sciences, Kermanshah,
Iran
9
Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran

Corresponding Author:
Ali Akbar Parvizifard, Department of Clinical Psychology, Kermanshah University of Medical Sciences,
Kermanshah 6715847141, Iran.
Email: parvizia@yahoo.com
2 The International Journal of Psychiatry in Medicine 0(0)

Results: There was a significant positive relationship(p = .001) between pain per-
ception with dental anxiety (r = .38), pain anxiety (r = .45), and mental pain (r = .25).
Conclusion: Psychological factors are associated with the perception of dental pain.
Given the importance of dental care to overall health, psychological interventions may
help to reduce the perception of dental pain and the fear of seeing the dentist in Iran.

Keywords
dental pain, dental anxiety, mental pain, pain anxiety, pain perception

Introduction
The International Association for the Study of Pain (IASP) defines pain as an un-
pleasant emotional experience related to actual or potential risk. Pain is a symptom of
many diseases and appears in different ways.1 Many factors contribute to the formation
and exacerbation of pain. Biomedical factors and nerve stimulation are the most critical
factors in forming pain. Researchers have recently shown that psychological factors
affect the continuity and worsening of pain.2,3
A person’s experience of pain and how to interpret it plays an essential role in the
perception of it. The part of this experience is only related to physical factors.4
However, considering the multidimensional role of pain, psychological factors also
affect pain perception. Research in medicine focuses on investigating biomedical
factors and their relationship with the body.4,5
Patients with a homogeneous level of damage to body organs present different levels
of pain intensity. This can indicate different perceptions and interpretations of pain.6 It
is possible that a person endures the most severe injuries and fractures and complains of
less pain than expected, and another person reports a lot of pain in the case of minor
damage to the body.7,8 Such an experience is harrowing and is one of the main reasons
for visiting a dentist.
Medical researchers have investigated the role of psychological factors in pain.9,10,11
Research has shown that psychological distress affects aggravating diseases such as
chronic pain, cancer, and rheumatism.10,12,13 Turk et al.’s study (2002) pointed out the
importance of psychological factors to deal with and improve the quality of life in
patients with chronic pain. The evaluation of symptoms, their ability to self-manage
pain, and their pain fear are also crucial in the patient’s perception of pain.14
Dentistry is one of the pain-related fields. People usually go to the dentist to treat
pain.15 Dental pain is one of the reasons for patients avoid receiving dental services.
Therefore, a comprehensive examination of pain in dentistry is necessary. The common
cause of dental pain is damage to the tooth’s nerves.16 People usually benefit from
repair and denervation services for pain relief. In some patients, the intensity of the pain
report is more than the amount of damage, and when receiving services, patients
exaggerate their perception of pain.17 Other patients still complain of pain after
Taheri et al. 3

specialized interventions and express pain without organic damage.18,19 This can be
due to psychological factors such as anxiety and depression and their effect on causing
sensitivity to pain.
Pathological anxiety gradually causes these patients to show anxiety about their
pain. As a result, pain anxiety is created.20 Greenberg and Byrne (2003) classified pain
anxiety as a specific type of fear.21 Avoiding being in painful areas and predicting the
recurrence of pain can be mentioned as the main symptoms of pain anxiety.20 Patients
with dental pain predict the occurrence of severe pain by mentally imaging the dental
setting and equipment and reviewing their previous experiences and others’
reports.22,23 The result of these images and extreme thinking about pain is mental
rumination, worry, and obsessive thoughts about the experience of pain.22,24,25,26,27 If
this process continues, pain anxiety about dental services will develop. Pain anxiety can
lead to hypervigilance about pain stimuli, making patients anxious and worried about
past and future painful symptoms.17 Finally, this unpleasant experience causes patients
to avoid receiving medical services and, as a result, become more disabled.
Studies have shown that pain anxiety plays a vital role in pain perception, and paying
more attention to it in dentistry is necessary. In their research, Strahl et al. examined the
role of pain anxiety, coping, and self-efficacy in the functioning of rheumatoid arthritis
patients. The results showed that the predictor variables explained between 9 and
38 percent of the variance of the criterion variable.28 Studies have shown that pain
anxiety plays a fundamental role in pain perception, and paying more attention to it in
dentistry is necessary.
Based on previous studies, Dental pain is not only caused by nerve damage; part of it
includes the psychological suffering experienced by the patient.29,30,31 Mental pain is
one factor that plays a role in the perception and exacerbation of pain.32,33 In the
research literature, mental, emotional, psychological, and psychological pain are used
interchangeably and refer to a typical structure. The central theme of mental pain is
suffering and despair.34 According to Cassel’s (1999) view, mental pain is a type of
psychological experience of suffering, and it does not only belong to the physical and
physical condition.35 The report of specialists indicates that such incidents are seen in
patients who refer to dental clinics, and it seems necessary to investigate the extent of its
impact on the perception of pain. In a study, Raiisi et al. investigated the relationship
between pain anxiety, mental pain, and pain perception in musculoskeletal patients. The
results showed that mental pain is a mediating variable to pain anxiety and perception.36
Studies have shown that mental pain plays an essential role in pain perception, and
paying more attention to it in dentistry is necessary.
Another psychological variable that most research focuses on is dental anxiety.
Dental anxiety includes fear or stress about the dental intervention.37,38 Things like
needles, drills, or the dental setting, can trigger dental anxiety. Some of the symptoms of
dental anxiety to conceal pressure comprise sweating, suffering from tachycardia,
having the symptoms of crying or panic, retreating, and using aggressiveness.39,40
The etiology of dental anxiety is not well-known because dental anxiety is a multiple
and complex phenomenon.41,42 Some factors that cause and develop this kind of
4 The International Journal of Psychiatry in Medicine 0(0)

anxiety include personality characteristics, pain fear, pain sensitivity, fear of injury and
blood, and coping styles.43,44 Moreover, the painful and damaging experience of
dentistry, especially conditional experiences during childhood in the dental settings,
and observational learning via observing fear of pain by family members are the other
factors causing this anxiety.45 Various studies have investigated the relationship be-
tween dental anxiety and pain perception.46,47 In a study, Sanikop et al. (2011) in-
vestigated the relationship between dental anxiety and pain perception during scaling.
The results showed a significant association between dental anxiety and pain per-
ception.46 As studies have shown, dental anxiety plays an essential role in pain
perception, and paying more attention to it in dentistry is necessary.
Also, anxiety can manifest itself in various forms, including pain anxiety and mental
pain, and such experiences may manifest themselves in dental settings. The space and
place where dental interventions are performed can also intensify the patient’s anxiety
and suffering. Therefore, examining the association between dental anxiety and pain
anxiety, mental pain, and pain perception seems necessary. Finally, the present study
analyzed the relationship between the perception of dental pain and pain anxiety,
mental pain, and dental anxiety in the Iranian sample.

Materials and Methods

The method of the present study was a cross-sectional study. The statistical
population included all people referred to dental clinics in Kermanshah (Iran) city
in the last six months of 2020 and the first quarter of 2021. Two researchers
participate in collecting questionnaires. Krejcie and Morgan’s table was used to
determine the sample size and the convenience sampling method. Considering the
average number of patients in the Kermanshah (Iran) dental clinics, at least
300 people were needed for the statistical analysis. Finally, 449 patients met the
study inclusion criteria. The inclusion and exclusion criteria in the current study
are as follows:
Inclusion criteria: (1) receiving dental services, (2) being able to read and write, (3)
having informed consent to complete the questionnaires, and (4) not using analgesics
and palliatives for a long time.
Exclusion criteria: (1) random response and bias in answering the questionnaires,
and (2) incomplete completion questionnaire.
According to the inclusion criteria, 350 participants filled out the questionnaires
used in this study. Afterward, the information of the participants was evaluated by
exclusion criteria, and the data of 22 of them were excluded from the research process.
Finally, the information from 328 participants was analyzed. The sampling process was
carried out by two master’s students in clinical psychology in person at dental clinics.
Figure 1 shows the flowchart of the research sampling process.
Taheri et al. 5

Figure 1. The flowchart of the research sampling process.

Procedure
After receiving an introduction letter from the Vice-Chancellor for Research and
Technology of Kermanshah University of Medical Sciences, the researchers were
referred to the dental clinics in Kermanshah. Moreover, after coordination with the
clinics, the patients were asked to complete the questionnaires according to the in-
clusion criteria.

Measures
Revised McGill Pain Questionnaire (SF-MPQ-2). 2009 Dworkin et al. revised the McGill
Pain Questionnaire. They added neuropathic and non-neuropathic pain symptoms to
22 items by modifying the response framework to this questionnaire. All subscales in
the Likert scale ranged from not feeling pain = 0 to severe pain = 10. In this ques-
tionnaire, the range of scores ranges from 0–220. Cronbach’s alpha coefficient for
subscales of continuous pain (0.87), varied pain 0.87, neuropathic pain 0.83, and
emotional pain 0.86 was reported.48 Besides, Tanhaee et al. (2012) said Cronbach’s
alpha coefficients for the whole questionnaire 0.92, the subscales of sensory pain 0.87,
emotional pain 0.87, and neuropathic pain 0.78.49

Dental Anxiety Inventory. The questionnaire was developed by Stouthard, Mellenbergh,

and Hoogstraten (1993), including 36 items to assess frightening statements about
dental conditions. All items in the Likert scale ranged from completely false = 1 to
completely true = 5. In this questionnaire, the range of scores varies between 36–180.
These researchers reported Cronbach’s alpha coefficients of this questionnaire between
6 The International Journal of Psychiatry in Medicine 0(0)

0.96 and 0.98 and its reliability between 0.84 and 0.87.50 Furthermore, Yousefi and Piri
(2017) said Cronbach’s alpha coefficient of 0.94.51

Orbach & Mikulincer Mental Pain Scale. This scale was created by Orbach et al. (2003),
including 44 items in 9 subscales. The subscales had irreversibility, loss of control,
narcissistic wounds, emotional flooding, freezing, self-estrangement, confusion, social
distancing, and emptiness. All items in this questionnaire were graded on a Likert scale,
ranging from strongly disagree = 1 to strongly agree = 5. In this scale, the range of
scores varies between 44–220. They reported the test coefficients of the retest of this
questionnaire between 0.79 and 0.94 after three weeks. In addition, Cronbach’s alpha
coefficient reported the subscales of this questionnaire between 0.75 and 0.95.33,52
They said a Cronbach’s alpha coefficient of 0.97 for the whole questionnaire and
between 0.62 and 0.95 for the subscales. In a study by Karami et al. (2018), the 6-factor
model (emptiness, emotional flooding, loss of control, irreversibility, social distancing,
and self-estrangement) was confirmed.51

Pain Anxiety Symptoms Scale (PASS-20). This scale was developed by McCracken et al.
(2002) that includes 20 items and four subscales (cognitive anxiety, avoidance behavior,
fear of pain, and the physiological symptoms of anxiety). All items in the Likert scale are
scored from never = 0 to always = 5. In this scale, the range of scores varies between 1–
100.20 In a study by Kreddig et al. (2015), Cronbach’s alpha was reported as 0.90 for the
whole scale and between 0.66 and 0.84 for the subscales.53 Paknejad et al. (2014)
reported the reliability coefficient of the quarterly subscale retest, ranging from 0.48 to
0.57, and the internal consistency coefficients of the subscales between 0.81 and 0.91.54

Statistical Analysis
SPSS-24 was used to analyze the research results. The descriptive results were
evaluated using the mean, standard deviation, frequency, and percentage indicators.
Kurtosis and skewness indices were run to assess the normality of the data. Further, the
Pearson correlation coefficient and Multiple Linear Regression analysis were used to
evaluate the study’s main findings.

Results
In the present study, 328 patients referred to dental clinics in Kermanshah were se-
lected. One hundred 43 patients (43.6%) were male, and 185 (56.4%) were female. The
mean and standard deviation of the age were 32.41 ± 8.46 for males, 32.17 ± 7.99 for
females, and 32.27 ± 8.19 for all participants. Besides, 111 (33.8%) participants were
single, and 217 (66.2%) were married. In addition, 152 (46.3%) had postgraduate and
lower education, and 176 (53.7%) had a bachelor’s degree or higher. The normality of
pain perception, dental anxiety, pain anxiety, and mental pain variables was confirmed
Taheri et al. 7

Table 1. The Mean and Standard Deviation for Pain Perception, Dental Anxiety, Pain Anxiety,
and Mental Pain Generally Based on Sex (n = 328).

Men (n = 143) Women (n = 185) Total (n = 328)

Standard Standard Standard

Variables Mean deviation Mean deviation Mean deviation

Pain 152.47 13.34 154.55 12.49 153.64 12.89

perception
Dental anxiety 143.79 13.87 145.56 13.48 144.79 13.66
Pain anxiety 57.69 10.77 58.19 11.28 57.97 11.05
Mental pain 172.07 13.42 174.05 12.31 173.19 12.82

Table 2. The Correlation Coefficient Matrix for Pain Perception, Dental Anxiety, Pain Anxiety,
and Mental Pain (n = 328).

Variables 1 2 3 4

1. Pain perception 1
2. Dental anxiety 0.38** 1
3. Pain anxiety 0.45** 0.25** 1
4. Mental pain 0.25** 0.18** 0.19** 1
**p ≤ 0.001.

using skewness and kurtosis indices. Table 1 shows the mean and standard deviation for
pain perception, dental fear, pain anxiety, and mental pain, generally based on sex.
Table 2 presents the correlation coefficient matrix for pain perception, dental
anxiety, pain anxiety, and mental pain.
As shown in Table 2, and based on the results of the Pearson correlation coefficient,
there was a positive and significant relationship (P < .001) between pain perception and
dental anxiety (r = 0.38) and between pain anxiety (r = 0.45) and mental pain (r = 0.25).
Table 3 shows the Results of Multiple Regression Analysis (Enter) to Predict Pain
Perception Based on Predictor Variables (Dental Anxiety, Pain Anxiety, Mental Pain,
Age, sex, Marital Status, and Education Level).
As shown in Table 3, the Predictor variables of the study predict 30% of the variance
of pain perception among patients referred to dental clinics.

Discussion
This study analyzed the relationship between the perception of dental pain and pain
anxiety, mental pain, and dental anxiety in the Iranian sample. The statistical analysis
revealed psychological factors correlated with pain perception, including pain anxiety,
mental pain, and dental anxiety. In this study, pain anxiety showed the highest cor-
relation with pain perception.
8 The International Journal of Psychiatry in Medicine 0(0)

Table 3. Presents the Results of Multiple Regression Analysis (Enter) to Predict Pain Perception
Based on Predictor Variables (Dental Anxiety, Pain Anxiety, Mental Pain, Age, sex, Marital Status,
and Education Level) (n = 328).

Dependent variable: Pain perception

model 1 B (SE)

Independent Variables
Characteristics
Demographics:
Age (years) 0.04 (0.09)
Sex (male & female) 1.22 (1.22)
Marital Status (single & married) -0.45 (1.50)
Education Level (postgraduate and lower education, & -0.56 (1.24)
bachelor’s degree or higher)
Psychological:
Dental Anxiety 0.24 (0.05) **
Pain Anxiety 0.42 (0.06) **
Mental Pain 0.14 (0.05) *
Model R2 (n) 0.30 (328) **
B = unstandardized beta, SE = standard error.
*p < 0.005, **p < 0.001.
Model 1 = final multivariate model.

Various researchers have reported a relationship between psychological factors and

dental pain.55,56,57 Similarly, Lamarca (2018) investigated stress, anxiety in perception,
and expecting dental pain among children. The results were provided before receiving
the intervention, immediately after receiving the intervention, and six months after that.
These results stated that stress and anxiety do not directly affect pain perception while
receiving the intervention. However, patients’ anticipation of attending dental settings
influences their pain perception. This result was repeated among older people as well.58
Thus, it can be concluded that mental moods and people’s attitudes toward dental
intervention affect pain perception.
This research shows a relationship between pain anxiety and pain perception. In
explaining the findings of this research, we can refer to a study by Carlton et al. (2009).
This study examined the relationship between pain fear and anxiety sensitivity. The
results showed anxiety disorders, including general and social anxiety, specific phobia
disorder, panic disorder, and depressive disorder in people with chronic musculo-
skeletal pain.59 It can also be considered anxiety sensitivity, fear of negative evaluation,
and disease sensitivity as common elements between pain fear and other fears.59
Predicting pain is also another important factor in anxiety and perception.
When predicting pain, a person imagines himself in a fearful situation through
thoughts and mental images and makes it catastrophic.60,61 The patient becomes
anxious about his pain and its aggravation in the future. This ‫ ﻩ‬can be due to pain fear
and overestimating the consequences of pain. Maladaptive interpretation of pain
Taheri et al. 9

internalizes it intolerably in the patient’s mind.62 In such a situation, the patient finds a
fusion with his pain. Therefore, prediction can be called an essential factor in pain
anxiety.63
Positive and negative emotions play a vital role in the experience of anxiety and
depression. Studies show that people with positive emotions are less vulnerable to pain
perception in anxiety-provoking situations. Therefore, it can be concluded that emotion
regulation is one of the factors to adjust with pain anxiety.64
Also, the role of mood and mental pain confirms the findings of this research. Our
study showed a relationship between mental pain and pain perception, as we can refer to
a study by e Raiisi et al. (2022). According to the results, mental pain plays a mediator
role between pain anxiety and perception.36 Other studies have revealed that people
who suffer from depression have more complaints about pain. Regarding the vital role
of emotion and mood in the perception of dental pain, the significant role of psy-
chological factors should be considered. The part of maladaptive thoughts and in-
terpretations can be mentioned in explaining the research findings.65,66 Patients with
high mental pain and intensive anxiety see everything through the lens of pain and find
themselves suffering much pain. In other words, all aspects of their life will be
influenced by pain, regardless of their different personality traits.67,68 Also, patients
become identified with their suffering and cannot imagine themselves without pain. In
this situation, psychological interventions such as Acceptance and Commitment
Therapy help people differentiate between their whole selves and their pain and do not
consider the pain their entire existence.69,70
The present study’s results showed a relationship between pain anxiety and pain
perception of this research. We can refer to a study by Eli et al. (2004) which examined
the psychological model of patients who suffered from dental anxiety.71 The results
showed that the negative and painful experiences in a dental setting during childhood
and the existence of pathological personality traits in terms of attachment styles are
effective in perceiving pain. Those who reported unpleasant experiences in dental
settings in childhood complained of having more anxiety in adulthood. In this study, the
kind of child-parent attachment style was an essential predictor of a patient’s pain in
dental environments.71 The patients with a safe attachment style reported less anxiety
concerning their parents having a safer relationship with the dentist.71,72
On the other hand, the people with insecure attachment styles and feelings of
ambivalence had an uneasy relationship with their dentist and suffered from more
anxiety.71 In the same conditions, the people with a safe schema in a child-parent
relationship reported less anxiety than those with an insecure schema. In line with the
findings of this study, it can be concluded that formed personality factors of the patient
during the growing period can cause pain anxiety as a psychological pattern.71,72
Other psychological concepts related to pain perception and psychological traits,
such as catastrophic pain, pain sensitivity, and low resiliency, can be mentioned.64,73
Also, the patient’s interpretation of pain influences the type of pain perception. People
who exaggerate the slightest pain in their teeth, and are sensitive to pain symptoms,
overestimate the pain and overbear it.17 Another critical factor in managing pain is
10 The International Journal of Psychiatry in Medicine 0(0)

resiliency. People with low resilience have low toleration and identify the pain as
insufferable.64,74,75
According to the theoretical background of pain and psychological characteristics, it
can be concluded that dental pain and pain perception do not occur only through neural
pathways. Still, the psychological interpretation is effective in the intensity of pain
experienced.73,76
This research helps to consider the psychological factors of the patients who avoid
going to dental clinics due to pain fear, reducing patients’ anxiety in dental clinics and
finally perceiving less pain among them. Also, based on this research, complementary
psychological interventions can be designed before and after dental services.72
Ultimately, the results indicated the associations between the perception of dental
pain and pain anxiety, mental pain, and dental anxiety. Considering the role of anxiety
in dentistry, it is suggested to investigate whether dental anxiety manifests as health
anxiety or refers to a specific phobia. Designing and evaluating psychoeducational
packages to deal with anxiety and pain was also recommended.
The most important limitation of the current study was the lack of assessment of
participants after receiving dental treatment. The researchers could not compare pa-
tients’ perceptions and pain intensity before and after dental treatment. Finally, further
research is proposed to study the patients’ attitudes toward receiving services and their
perception of the pain after dental services.

Conclusion
Psychological factors are influential in the perception of dental pain. Therefore,
psychological education about dental pain and awareness of the consequences of
avoiding visiting the dentist is a priority. Further, there is a need to seriously identify
people with a fear of dentistry and intervene in their psychological symptoms.

Acknowledgments
The authors of this article sincerely thank the Vice-Chancellor for Research and Technology of
Kermanshah University of Medical Sciences and all those who participated in this research.

Author Contributions
All authors participated in the drafting of the present manuscript and its final approval. AAT:
Ideation of the research subject and writing an article, AAP: corresponding authors and English
edit, SR: data analyses and draft design, MJ: collecting data, YM: draft design and editing, KH:
collecting data, AAF: Edit the discussion, ME, & MG: Edit the introduction.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Taheri et al. 11

Funding
The Vice-Chancellor for Research and Technology of Kermanshah University of Medical
Sciences has financially supported this research. This article is from the approved plan with code
"980,630" in Kermanshah University of Medical Sciences.

Ethical Approval
All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Helsinki Dec-
laration of 1975, as revised in 2000. This investigation has been approved by the ethics committee
of Kermanshah University of Medical Sciences (IR.KUMS.REC.1398.385).

Informed Consent
All participants completed a written informed consent form to enter the study.

Data Availability
It is possible to access the data after coordination with the corresponding author by email.

ORCID iDs
Amir Abbas Taheri  https://orcid.org/0000-0002-2446-0859
Ali Akbar Parvizifard  https://orcid.org/0000-0001-6020-0205
Sajjad Reisi  https://orcid.org/0000-0002-2385-8283
Khatereh Heshmati  https://orcid.org/0000-0002-6318-6960

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