Accepted Manuscript Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar? Dariush Hasheminia, Mahmood Reza Kalantar Motamedi, Fatemeh Karimi Ahmadabadi, Hadi Hashemzehi, Abbas Haghighat PII:
S0278-2391(14)00367-X
DOI:
10.1016/j.joms.2014.03.031
Reference:
YJOMS 56278
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 26 January 2014 Revised Date:
20 March 2014
Accepted Date: 27 March 2014
Please cite this article as: Hasheminia D, Motamedi MRK, Ahmadabadi FK, Hashemzehi H, Haghighat A, Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar?, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/ j.joms.2014.03.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar? Author 1: Dariush Hasheminia, Assistant Professor, Torabinejad Dental Research Center,
Medical Sciences, Isfahan, Iran (Email: [email protected])
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Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of
Author 2: Mahmood Reza Kalantar Motamedi, Dental Students Research Center, School of Dentistry,
Isfahan
University
of
Medical
Sciences,
[email protected])
Isfahan,
Iran
(Email:
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Author 3: Fatemeh Karimi Ahmadabadi, General Dentist, Private Office, Isfahan, Iran (Email: [email protected])
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Author 4: Hadi Hashemzehi, Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Zahedan University of Medical Sciences, Zahedan, Iran (Email: [email protected])
Corresponding author: Abbas Haghighat, Assistant Professor, Torabinejad Dental Research Center, Department of Oral & Maxillofacial Surgery, School of Dentistry, Isfahan University of
Email: [email protected],
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Medical Sciences, Isfahan, Iran.
Address: Hezar-Jarib Ave., School of Dentistry, Isfahan University of Medical Sciences, Isfahan,
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Iran
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Tel & Fax: +98 6266260, Zip code: 81746-73461
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Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar?
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Abstract
Purpose: To investigate if the ambient orange fragrance, when compared with a control
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group, can reduce patient anxiety before and during surgical removal of an impacted mandibular third molar.
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Materials and Methods: In this randomized clinical trial, patients who required extraction of impacted mandibular third molar and fulfilled the predetermined criteria were included. A dental anxiety scale (DAS) questionnaire was used to determine the anxiety level of the patients prior to surgery. Only patients with moderate and high
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anxiety levels (scale of 9 ≤ DAS ≤ 14) were included. The predictor variable was fragrance exposure. The fragrance group was exposed to orange fragrance, whereas no odor was used for the control group. The outcome variable was physiologic measures
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related to anxiety, including mean blood pressure, respiratory rate, and pulse rate. The physiologic vital changes were determined before and during the surgical procedure. Data
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were analyzed using independent t-test, Chi-Square and Mann–Whitney tests (SPSS, Version 16) (α = 0.05).
Results: 56 patients fulfilled the inclusion criteria (fragrance group: 19 males, 9 females; no-fragrance group: 12 males, 16 females). Before entering the waiting room, patients’ vital signs were recorded twice and there was no significant difference between the two groups. Mean blood pressure, pulse rate, and respiratory rate were significantly lower in
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the fragrance group during surgery (from when sitting in the dental chair to the end of surgery) (p < 0.05). Conclusion: Orange fragrance is effective in reducing anxiety relating to surgical
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removal of an impacted mandibular third molar.
Keywords: Dental Anxiety, Aromatherapy, Orange, Mandibular Third Molar
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Introduction
without any particular reason [1].
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Anxiety is defined as an unpleasant state, often accompanied with fear or nervousness
Frequently patients perceive dental treatment as a painful and unpleasant procedure and often complain of experiencing pain during or after treatment [2]. Different factors have been attributed to cause this anxiety such as dental office environment, cognitive
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perceptions, and past unpleasant dental experiences [3, 4]. Four primary triggers of dental anxiety are a) sights (e.g., needles, drills) [5], b) sounds (drilling), c) smells (e.g., eugenol, methyl methacrylate, disinfectants, cut dentine) [4], and d) sensations (high
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frequency vibrations) [6-9]. Removing or masking these four major sensory triggers may alleviate dental anxiety [7, 9]. This is called the 4 S Principle that aims to reduce the 4
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primary triggers of stress in the dental setting. In addition, stressful dental operations, such as complicated extractions, injections, painful procedures [10] and drilling sounds can intensify the effects of other factors [6]. Different techniques have been advocated to control anxiety during dental treatment including pharmacological [11] and non-pharmacological interventions [12] or a combination of these methods [7].
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However, pharmacological interventions, such as sedation, anesthesia, and local analgesia, carry some inherent risk [13]. Non-pharmacological methods have found its niche recently among clinicians. Kim et al.
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investigated the positive effect of music therapy on anxiety during mandibular third molar surgery [14]. In 2012, hypnotism was used to reduce the anxiety and hemorrhage during impacted third molar surgeries, and this method efficiently controlled anxiety and
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hemorrhage [15]. Aromatherapy is a form of non-pharmacological method [16] that uses aromatic compounds for the purpose of altering a person's mind, mood or cognitive
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function [16]. There is a consensus among clinicians that aromatherapy is mostly influential in alleviating pain, controlling anxiety, and healing wounds; however, these effects have not been delicately examined [17]. Aromatherapy can be applied in different modes such as massage or inhalation.
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The exact mechanism of aromatherapy has not been explained; however, one potential mechanism may be that aromas stimulate the limbic system, which excites neuronal cells to release neurotransmitters such as encephalin, norepinephrine, and serotonin [17].
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Another potential mechanism described is that aromas may affect human emotions and behavior [18]. This may rely on emotional learning, conscious perception, beliefs and
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expectations [18].
Orange is a fruit of Citrus auratium species of the family Rutaceae, and is one of the materials employed for aromatherapy. The anti-spastic and sedative effects of orange have been discussed in various studies. The anxiolytic properties of inhalation of orange oil have been described in physiological studies on humans [19], and also in animal
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studies [20, 21]. Orange can be easily absorbed through mucosal membranes and can stimulate the central nervous system after passing the blood-brain barrier [22]. Dental anxiety can lead to a long-term avoidance of dental treatment [23], resulting in a
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negative effect on oral health [7], and quality of life [24]. Thus, managing dental anxiety is considered an important aspect of dental practice [12, 25]. Controlling anxiety also plays an important role in the rehabilitation phase after surgery. No documented study
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has investigated the effect of aromatherapy in reducing anxiety in patients who were candidates for surgical removal of an impacted mandibular third molar.
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The current study aims to address the following question: among patients with impacted third molar, does the use of ambient orange fragrance, when compared with a control group, reduce the anxiety during removal of impacted mandibular third molar? The authors had the hypothesis that the anxiety of patients in the treatment group is lower
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than that in the control group. In this study, we compared the patients’ anxiety between treatment and control groups by measuring physiological signs (i.e., mean blood pressure,
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pulse rate, and respiratory rate).
Materials and Methods
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Study Design
To address the research purpose, the investigators designed a prospective, placebocontrolled, randomized clinical trial study. The study population was composed of all patients presenting to a private dental office for the evaluation and management of impacted mandibular third molars between 2011 and 2013.
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Study Sample Patients compatible with the following criteria were included in the study: patients with a mandibular third molar with B II classification [26] of impacted teeth; ASA class I
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patients, non-smokers, non-pregnant, and non-allergic with a healthy olfactory system. Moreover, a dental anxiety scale (DAS) questionnaire was used to determine the anxiety level of the patients prior to surgery. Only patients with moderate and high anxiety levels
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(scale of 9 ≤ DAS ≤ 14) were included. The questionnaire consists of four questions addressing the feelings of the patient; a) for taking a dental visit referral, b) when waiting
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for treatment, c) when the dentist is getting the instruments ready, and d) when the dentist is about to drill or scale with the corresponding instruments in his/her hand. Each question can be answered on a 5-point Likert scale. This scale ranges from a score of 4 to 20. DAS is the most widely used measure of anxiety [27], and is highly validated and
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reliable [28, 29]. All the patients were included in the study after an informed consent. The patients were excluded if; they did not fulfill one or all of the inclusion criteria; they were reluctant to participate in the study, and those with cardiovascular disease (who are
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not eligible for more than 2 cartridges of anesthetic solution containing 2% lidocaine with 1:100000 epinephrine).
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This study was approved by the Iran Clinical Trial Center (IRCT 201212277949N 3). Moreover, the Institutional Review Board and Ethics Committee of the Isfahan University of Medical Sciences, Iran approved the protocol, according to the Declaration of Helsinki (# 391286).
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Study Variables In this study, the predictor variable was fragrance exposure. The outcome variable was physiologic measures related to anxiety, including mean blood pressure, respiratory rate,
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and pulse rate. DAS, another variable related to the inclusion criteria was evaluated. In addition, demographic factors were collected including age, gender, and education. Data Collection and Practical Procedure
corresponding to fragrance and no-fragrance groups.
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The included patients were randomly divided into two groups each by tossing a coin,
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Patients of the fragrance condition were exposed to 5 drops of orange essential oil (Barij scent, Kashan, Iran). 0.25 mL of the essential oil was poured in 5 L of water and diffused using an electrical dispenser (Macform, China) in both the waiting and operating rooms with an area of 36 m3. Patients in the control condition had the same environment except
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there was no orange fragrance. All the patients (control and experimental) waited about 10 min in the waiting room.
Vital signs (physiologic measures) consisting of mean blood pressure, respiratory rate,
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and pulse rate were recorded five times in both the groups i.e., fragrance condition (patients who were exposed to orange fragrance) and control condition (no-fragrance
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condition). They were recorded twice before patient’s entering the waiting room (to register the baseline vital signs and verify the accuracy of measurements), once before anesthesia injection (third time), once exactly before surgery (fourth time), and finally, for the fifth time at the end of treatment session. The blood pressure was taken in the seated position using the left arm with a digital blood pressure monitoring device (OMRON, Omron Health Care, Kyoto, Japan). Respiratory rate was recorded visually, by
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observation of the patient’s chest movements. Pulse rate was noted by radial artery palpation. No sedation was used before the surgery. At the beginning of the surgery, inferior
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alveolar nerve block and long buccal nerve infiltration injections (two cartridges of 2% lidocaine with 1:100000 epinephrine) were administrated with aspirating syringe over 1 min. After 5 min, a sulcular incision was positioned from the mesial surface of the second
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molar to the third molar tooth and sequentially an oblique releasing incision was performed at the distal aspect of the impacted molar. Bone was removed using a surgical
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hand-piece (NSK, SGS-ES, Japan) with copious irrigation with physiological saline to gain access and visibility. At the end, the surgeon sutured the wound. All surgeries took about 20 to 25 min. A specialist in maxillofacial surgery performed all the surgical procedures and a researcher recorded the vital signs.
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Statistical Analysis
Descriptive statistics were calculated. Data were analyzed using Chi-Square test, independent t-test, and Mann–Whitney (SPSS software, Version 16, SPSS Inc., Chicago,
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significant.
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USA). For all analyses, a probability level of p < 0.05 was considered to be statistically
Results
In total, 56 patients who fulfilled the inclusion criteria participated in this study (fragrance group: 19 males, 9 females; no-fragrance group: 12 males, 16 females) (Table 1). A Chi-Square test did not show significant gender differences between the two groups (p = 0.06). Other demographic data including level of education (Table 1) and age (Table
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2) were collected and analyzed. Mann–Whitney and t-test did not show significant differences between two groups for education (p = 0.85) and age (p = 0.37), respectively.
(vocational education), and aged between 20 and 24 years (33.9%).
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The patients ranged in age from 15 to 44 years. Most patients (42.9%) had a diploma
The self-report level of anxiety was collected using the DAS questionnaire prior to surgery. Conforming to t-test, mean of DAS did not reveal a significant difference (p =
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0.87) between the two groups (Table 2). It meant that the level of patients’ anxiety was approximately equivalent at the beginning of the study for the two groups.
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Before entering the waiting room, patients’ vital signs, including mean blood pressure, pulse and respiration rate, were recorded twice. At this stage, vital signs did not show a significant difference between the two groups (Table 3).
According to t-test, during the third, fourth and fifth time of measurement of vital signs
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(i.e., during surgery), the mean blood pressure, pulse rate, and respiratory rate were significantly lower in the fragrance group than that in the control group (Table 3).
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Discussion:
The current study aims to address the following question: among patients with impacted
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third molar, does the use of ambient orange fragrance, when compared with a control group, reduce the anxiety during removal of impacted mandibular third molar? The authors had the hypothesis that the anxiety of patients in the treatment group is lower than that in the control group. In this study, we compared the patients’ anxiety between treatment and control groups by measuring physiological signs (i.e., mean blood pressure, pulse rate, and respiratory rate).
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The results of this study confirms the hypothesis that orange fragrance reduces patient anxiety during impacted third molar surgery. In fact, the mean blood pressure, pulse rate, and respiratory rate showed significant difference between the two groups during surgery.
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In the present study, for the first time in the literature, the effect of aromatherapy on controlling patient anxiety during surgery of impacted third molar tooth was investigated. Previous studies reported the anxiolytic influence of orange scent on patient anxiety in
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small dental environments [30, 31]. In this study, vital signs measurements showed significant differences between the two groups, which may be due to the sedative effect
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of the orange fragrance during surgery for the impacted third molar. These findings concord with the studies by Lehrner et al. where the efficacy of orange fragrance in reducing anxiety during dental treatment was described [30, 31]. However, in those studies, the level of anxiety was collected only in the waiting room, but not when sitting
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in the dental chair. In addition, the ambient odor was only diffused in the waiting room in those studies. In the current study, the odor was constantly maintained even during the surgical procedure. On the other hand, Toet et al. concluded that orange and apple scents
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are not effective enough in reducing dental anxiety in large dental clinics [32]. These controversies may be attributed to the fact that the study by Toet et al. was conducted in
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three busy public clinics with many stressful conditions, and confounding variables may have affected the results; also the ambient odors may not have been very effective in large dental clinics.
It has been suggested that a patient’s personal beliefs in the waiting room [3], type of anesthesia syringe and injection [4], impacted molar surgery operation [3], and pain during and after the procedure [2] are factors which influence dental anxiety.
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Accordingly, in this study, five different time intervals were considered for vital sign measurements to include the effects of all the factors that may alter anxiety levels. Confounding variables such as age [33-35], gender [33, 36-39], and educational level
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[33] may have had some effects on the anxiety scale in this study. However, there were no significant differences between the two groups for these characteristics.
The investigators tried to control other confounding variables such as surgical trauma,
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length of surgery, amount of anesthetic, and inadvertent IV injection. Using a surgeon for all the surgeries, the same protocol of incision and bone removal, the same level of
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impaction, and administration of the same amounts of anesthetic cartridges with aspirating syringe for all the patients might control the confounding variables. All surgeries took about 20 to 25 min. Moreover, the time that patients spent in the waiting room was limited to about only 10 min in order not to produce further anxiety.
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Different studies have been conducted to investigate the effect of aromatherapy in controlling anxiety. Aromatherapy effects have been studied during surgeries [40], renal dialysis [41], and magnetic resonance imaging (MRI) [42]; and it was determined that it
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significantly reduces the level of anxiety in patients suffering from anxiety disorders. However, aromatherapy has not shown promising results in reducing anxiety during
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cancer therapy [43] or endoscopy [44]. This inconsistency may be explained by the fact that aromatherapy may not be effective in reducing very high levels of anxiety. Hence, in the present study, patients with a high scale of anxiety corresponding to dental phobia were excluded.
As suggested by Lehrner et al. for future studies [30], in addition to the questionnaire (as an inclusion criteria), we also included physiological measurements for assessing anxiety
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levels. Moreover, in previous studies [17, 22, 42], patients underwent different dental procedures that had different baselines of anxiety. However, we only focused on one dental procedure i.e., tooth extraction, which is responsible for the highest level [45] or
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one of the highest levels [46] of anxiety among dental procedures. It is worth mentioning that previous studies did not determine the anxiolytic effect of the odor when the patient was seated in the dental chair [17, 22, 42]. However, we considered this an important
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factor as many stressful situations may occur during dental procedures.
Of the limitations of this study was the method for recording respiratory rate. We
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employed a visual method; however, it would best be recorded with a capnography machine rather than having to measure this by actually counting the reparations manually. Another limitation of this study was the small sample size. In conclusion, the results of the present study suggest that ambient orange fragrance is
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helpful in reducing dental anxiety during surgical removal of an impacted mandibular third molar. Future randomized clinical trials with a larger selection of patients are
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recommended to validate the results of this study.
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References:
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TABLE 1. Summary of gender and education variables for experimental and control groups.
Male Female
Education No Primary Vocational University
% 32.14 67.86
0 2 13 13
0 7.1 46.4 46.4
2 2 11 13
Chi-Square test, **Mann–Whitney test
7.1 7.1 39.4 46.4
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*
N 9 19
No-fragrance group N % 16 57.14 12 42.86
P-value 0.06*
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Gender
Fragrance group
0.85**
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Variable
TABLE 2. Summary of age and DAS results for experimental and control groups. No-fragrance group (mean ± SD) 27.5 ± 5.7
P-value
Age
Fragrance group (mean ± SD) 26.4 ± 5.3
DAS
11.78 ± 2.45
11.89 ± 2.47
0.87
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Variable
0.37
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Note: P-value calculated using independent t-test Abbreviation: SD, standard deviation; DAS, dental anxiety scale
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Fragrance group (mean ± SD) 9.81 ± 1 9.63 ± 1 9.47 ± 0.88 8.75 ± 0.87 9.12 ± 0.98
No-fragrance group (mean ± SD) 9.63 ± 0.76 9.82 ± 0.86 10.26 ± 1.2 10.37 ± 1.7 10.44 ± 1
Stage 1 Stage 2 Stage 3
100.42 ± 9.5 98.82 ± 9.5 96.9 ± 9
100.17 ± 12.7 102.28 ± 13.5 106.25 ± 14.1
0.93 0.27 0.005
Stage 4 Stage 5
98.57 ± 12.4 95.14 ± 10.9
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TABLE 3. Primary predictor versus outcome variable.
0.02 0.003
PR/min
Stage 1 25.57 ± 1.87 27.14 ± 2.2 0.44 Stage 2 27.92 ± 2.27 27.78 ± 2.8 0.83 Stage 3 27 ± 1.9 29.64 ± 2.9 < 0.001 Stage 4 26.14 ± 2.3 30 ± 2.7 < 0.001 Stage 5 27 ± 1.8 29.85 ± 2.4 < 0.001 Not: P-value calculated using independent t-test Abbreviation: SD, standard deviation; MAP, mean arterial pressure; PR, pulse rate; RR, respiratory rate
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RR/min
106.89 ± 13.2 104.71 ± 11.7
0.46 0.46 0.007 < 0.001 < 0.001
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MAP Stage 1 (cm/Hg) Stage 2 Stage 3 Stage 4 Stage 5
P-value
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Variable
S0278-2391(14)00367-X
DOI:
10.1016/j.joms.2014.03.031
Reference:
YJOMS 56278
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 26 January 2014 Revised Date:
20 March 2014
Accepted Date: 27 March 2014
Please cite this article as: Hasheminia D, Motamedi MRK, Ahmadabadi FK, Hashemzehi H, Haghighat A, Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar?, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/ j.joms.2014.03.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar? Author 1: Dariush Hasheminia, Assistant Professor, Torabinejad Dental Research Center,
Medical Sciences, Isfahan, Iran (Email: [email protected])
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Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of
Author 2: Mahmood Reza Kalantar Motamedi, Dental Students Research Center, School of Dentistry,
Isfahan
University
of
Medical
Sciences,
[email protected])
Isfahan,
Iran
(Email:
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Author 3: Fatemeh Karimi Ahmadabadi, General Dentist, Private Office, Isfahan, Iran (Email: [email protected])
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Author 4: Hadi Hashemzehi, Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Zahedan University of Medical Sciences, Zahedan, Iran (Email: [email protected])
Corresponding author: Abbas Haghighat, Assistant Professor, Torabinejad Dental Research Center, Department of Oral & Maxillofacial Surgery, School of Dentistry, Isfahan University of
Email: [email protected],
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Medical Sciences, Isfahan, Iran.
Address: Hezar-Jarib Ave., School of Dentistry, Isfahan University of Medical Sciences, Isfahan,
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Iran
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Tel & Fax: +98 6266260, Zip code: 81746-73461
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Can Ambient Orange Fragrance Reduce Patient Anxiety during Surgical Removal of Impacted Mandibular Third Molar?
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Abstract
Purpose: To investigate if the ambient orange fragrance, when compared with a control
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group, can reduce patient anxiety before and during surgical removal of an impacted mandibular third molar.
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Materials and Methods: In this randomized clinical trial, patients who required extraction of impacted mandibular third molar and fulfilled the predetermined criteria were included. A dental anxiety scale (DAS) questionnaire was used to determine the anxiety level of the patients prior to surgery. Only patients with moderate and high
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anxiety levels (scale of 9 ≤ DAS ≤ 14) were included. The predictor variable was fragrance exposure. The fragrance group was exposed to orange fragrance, whereas no odor was used for the control group. The outcome variable was physiologic measures
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related to anxiety, including mean blood pressure, respiratory rate, and pulse rate. The physiologic vital changes were determined before and during the surgical procedure. Data
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were analyzed using independent t-test, Chi-Square and Mann–Whitney tests (SPSS, Version 16) (α = 0.05).
Results: 56 patients fulfilled the inclusion criteria (fragrance group: 19 males, 9 females; no-fragrance group: 12 males, 16 females). Before entering the waiting room, patients’ vital signs were recorded twice and there was no significant difference between the two groups. Mean blood pressure, pulse rate, and respiratory rate were significantly lower in
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the fragrance group during surgery (from when sitting in the dental chair to the end of surgery) (p < 0.05). Conclusion: Orange fragrance is effective in reducing anxiety relating to surgical
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removal of an impacted mandibular third molar.
Keywords: Dental Anxiety, Aromatherapy, Orange, Mandibular Third Molar
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Introduction
without any particular reason [1].
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Anxiety is defined as an unpleasant state, often accompanied with fear or nervousness
Frequently patients perceive dental treatment as a painful and unpleasant procedure and often complain of experiencing pain during or after treatment [2]. Different factors have been attributed to cause this anxiety such as dental office environment, cognitive
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perceptions, and past unpleasant dental experiences [3, 4]. Four primary triggers of dental anxiety are a) sights (e.g., needles, drills) [5], b) sounds (drilling), c) smells (e.g., eugenol, methyl methacrylate, disinfectants, cut dentine) [4], and d) sensations (high
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frequency vibrations) [6-9]. Removing or masking these four major sensory triggers may alleviate dental anxiety [7, 9]. This is called the 4 S Principle that aims to reduce the 4
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primary triggers of stress in the dental setting. In addition, stressful dental operations, such as complicated extractions, injections, painful procedures [10] and drilling sounds can intensify the effects of other factors [6]. Different techniques have been advocated to control anxiety during dental treatment including pharmacological [11] and non-pharmacological interventions [12] or a combination of these methods [7].
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However, pharmacological interventions, such as sedation, anesthesia, and local analgesia, carry some inherent risk [13]. Non-pharmacological methods have found its niche recently among clinicians. Kim et al.
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investigated the positive effect of music therapy on anxiety during mandibular third molar surgery [14]. In 2012, hypnotism was used to reduce the anxiety and hemorrhage during impacted third molar surgeries, and this method efficiently controlled anxiety and
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hemorrhage [15]. Aromatherapy is a form of non-pharmacological method [16] that uses aromatic compounds for the purpose of altering a person's mind, mood or cognitive
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function [16]. There is a consensus among clinicians that aromatherapy is mostly influential in alleviating pain, controlling anxiety, and healing wounds; however, these effects have not been delicately examined [17]. Aromatherapy can be applied in different modes such as massage or inhalation.
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The exact mechanism of aromatherapy has not been explained; however, one potential mechanism may be that aromas stimulate the limbic system, which excites neuronal cells to release neurotransmitters such as encephalin, norepinephrine, and serotonin [17].
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Another potential mechanism described is that aromas may affect human emotions and behavior [18]. This may rely on emotional learning, conscious perception, beliefs and
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expectations [18].
Orange is a fruit of Citrus auratium species of the family Rutaceae, and is one of the materials employed for aromatherapy. The anti-spastic and sedative effects of orange have been discussed in various studies. The anxiolytic properties of inhalation of orange oil have been described in physiological studies on humans [19], and also in animal
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studies [20, 21]. Orange can be easily absorbed through mucosal membranes and can stimulate the central nervous system after passing the blood-brain barrier [22]. Dental anxiety can lead to a long-term avoidance of dental treatment [23], resulting in a
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negative effect on oral health [7], and quality of life [24]. Thus, managing dental anxiety is considered an important aspect of dental practice [12, 25]. Controlling anxiety also plays an important role in the rehabilitation phase after surgery. No documented study
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has investigated the effect of aromatherapy in reducing anxiety in patients who were candidates for surgical removal of an impacted mandibular third molar.
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The current study aims to address the following question: among patients with impacted third molar, does the use of ambient orange fragrance, when compared with a control group, reduce the anxiety during removal of impacted mandibular third molar? The authors had the hypothesis that the anxiety of patients in the treatment group is lower
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than that in the control group. In this study, we compared the patients’ anxiety between treatment and control groups by measuring physiological signs (i.e., mean blood pressure,
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pulse rate, and respiratory rate).
Materials and Methods
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Study Design
To address the research purpose, the investigators designed a prospective, placebocontrolled, randomized clinical trial study. The study population was composed of all patients presenting to a private dental office for the evaluation and management of impacted mandibular third molars between 2011 and 2013.
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Study Sample Patients compatible with the following criteria were included in the study: patients with a mandibular third molar with B II classification [26] of impacted teeth; ASA class I
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patients, non-smokers, non-pregnant, and non-allergic with a healthy olfactory system. Moreover, a dental anxiety scale (DAS) questionnaire was used to determine the anxiety level of the patients prior to surgery. Only patients with moderate and high anxiety levels
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(scale of 9 ≤ DAS ≤ 14) were included. The questionnaire consists of four questions addressing the feelings of the patient; a) for taking a dental visit referral, b) when waiting
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for treatment, c) when the dentist is getting the instruments ready, and d) when the dentist is about to drill or scale with the corresponding instruments in his/her hand. Each question can be answered on a 5-point Likert scale. This scale ranges from a score of 4 to 20. DAS is the most widely used measure of anxiety [27], and is highly validated and
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reliable [28, 29]. All the patients were included in the study after an informed consent. The patients were excluded if; they did not fulfill one or all of the inclusion criteria; they were reluctant to participate in the study, and those with cardiovascular disease (who are
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not eligible for more than 2 cartridges of anesthetic solution containing 2% lidocaine with 1:100000 epinephrine).
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This study was approved by the Iran Clinical Trial Center (IRCT 201212277949N 3). Moreover, the Institutional Review Board and Ethics Committee of the Isfahan University of Medical Sciences, Iran approved the protocol, according to the Declaration of Helsinki (# 391286).
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Study Variables In this study, the predictor variable was fragrance exposure. The outcome variable was physiologic measures related to anxiety, including mean blood pressure, respiratory rate,
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and pulse rate. DAS, another variable related to the inclusion criteria was evaluated. In addition, demographic factors were collected including age, gender, and education. Data Collection and Practical Procedure
corresponding to fragrance and no-fragrance groups.
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The included patients were randomly divided into two groups each by tossing a coin,
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Patients of the fragrance condition were exposed to 5 drops of orange essential oil (Barij scent, Kashan, Iran). 0.25 mL of the essential oil was poured in 5 L of water and diffused using an electrical dispenser (Macform, China) in both the waiting and operating rooms with an area of 36 m3. Patients in the control condition had the same environment except
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there was no orange fragrance. All the patients (control and experimental) waited about 10 min in the waiting room.
Vital signs (physiologic measures) consisting of mean blood pressure, respiratory rate,
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and pulse rate were recorded five times in both the groups i.e., fragrance condition (patients who were exposed to orange fragrance) and control condition (no-fragrance
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condition). They were recorded twice before patient’s entering the waiting room (to register the baseline vital signs and verify the accuracy of measurements), once before anesthesia injection (third time), once exactly before surgery (fourth time), and finally, for the fifth time at the end of treatment session. The blood pressure was taken in the seated position using the left arm with a digital blood pressure monitoring device (OMRON, Omron Health Care, Kyoto, Japan). Respiratory rate was recorded visually, by
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observation of the patient’s chest movements. Pulse rate was noted by radial artery palpation. No sedation was used before the surgery. At the beginning of the surgery, inferior
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alveolar nerve block and long buccal nerve infiltration injections (two cartridges of 2% lidocaine with 1:100000 epinephrine) were administrated with aspirating syringe over 1 min. After 5 min, a sulcular incision was positioned from the mesial surface of the second
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molar to the third molar tooth and sequentially an oblique releasing incision was performed at the distal aspect of the impacted molar. Bone was removed using a surgical
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hand-piece (NSK, SGS-ES, Japan) with copious irrigation with physiological saline to gain access and visibility. At the end, the surgeon sutured the wound. All surgeries took about 20 to 25 min. A specialist in maxillofacial surgery performed all the surgical procedures and a researcher recorded the vital signs.
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Statistical Analysis
Descriptive statistics were calculated. Data were analyzed using Chi-Square test, independent t-test, and Mann–Whitney (SPSS software, Version 16, SPSS Inc., Chicago,
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significant.
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USA). For all analyses, a probability level of p < 0.05 was considered to be statistically
Results
In total, 56 patients who fulfilled the inclusion criteria participated in this study (fragrance group: 19 males, 9 females; no-fragrance group: 12 males, 16 females) (Table 1). A Chi-Square test did not show significant gender differences between the two groups (p = 0.06). Other demographic data including level of education (Table 1) and age (Table
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2) were collected and analyzed. Mann–Whitney and t-test did not show significant differences between two groups for education (p = 0.85) and age (p = 0.37), respectively.
(vocational education), and aged between 20 and 24 years (33.9%).
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The patients ranged in age from 15 to 44 years. Most patients (42.9%) had a diploma
The self-report level of anxiety was collected using the DAS questionnaire prior to surgery. Conforming to t-test, mean of DAS did not reveal a significant difference (p =
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0.87) between the two groups (Table 2). It meant that the level of patients’ anxiety was approximately equivalent at the beginning of the study for the two groups.
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Before entering the waiting room, patients’ vital signs, including mean blood pressure, pulse and respiration rate, were recorded twice. At this stage, vital signs did not show a significant difference between the two groups (Table 3).
According to t-test, during the third, fourth and fifth time of measurement of vital signs
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(i.e., during surgery), the mean blood pressure, pulse rate, and respiratory rate were significantly lower in the fragrance group than that in the control group (Table 3).
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Discussion:
The current study aims to address the following question: among patients with impacted
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third molar, does the use of ambient orange fragrance, when compared with a control group, reduce the anxiety during removal of impacted mandibular third molar? The authors had the hypothesis that the anxiety of patients in the treatment group is lower than that in the control group. In this study, we compared the patients’ anxiety between treatment and control groups by measuring physiological signs (i.e., mean blood pressure, pulse rate, and respiratory rate).
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The results of this study confirms the hypothesis that orange fragrance reduces patient anxiety during impacted third molar surgery. In fact, the mean blood pressure, pulse rate, and respiratory rate showed significant difference between the two groups during surgery.
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In the present study, for the first time in the literature, the effect of aromatherapy on controlling patient anxiety during surgery of impacted third molar tooth was investigated. Previous studies reported the anxiolytic influence of orange scent on patient anxiety in
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small dental environments [30, 31]. In this study, vital signs measurements showed significant differences between the two groups, which may be due to the sedative effect
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of the orange fragrance during surgery for the impacted third molar. These findings concord with the studies by Lehrner et al. where the efficacy of orange fragrance in reducing anxiety during dental treatment was described [30, 31]. However, in those studies, the level of anxiety was collected only in the waiting room, but not when sitting
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in the dental chair. In addition, the ambient odor was only diffused in the waiting room in those studies. In the current study, the odor was constantly maintained even during the surgical procedure. On the other hand, Toet et al. concluded that orange and apple scents
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are not effective enough in reducing dental anxiety in large dental clinics [32]. These controversies may be attributed to the fact that the study by Toet et al. was conducted in
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three busy public clinics with many stressful conditions, and confounding variables may have affected the results; also the ambient odors may not have been very effective in large dental clinics.
It has been suggested that a patient’s personal beliefs in the waiting room [3], type of anesthesia syringe and injection [4], impacted molar surgery operation [3], and pain during and after the procedure [2] are factors which influence dental anxiety.
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Accordingly, in this study, five different time intervals were considered for vital sign measurements to include the effects of all the factors that may alter anxiety levels. Confounding variables such as age [33-35], gender [33, 36-39], and educational level
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[33] may have had some effects on the anxiety scale in this study. However, there were no significant differences between the two groups for these characteristics.
The investigators tried to control other confounding variables such as surgical trauma,
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length of surgery, amount of anesthetic, and inadvertent IV injection. Using a surgeon for all the surgeries, the same protocol of incision and bone removal, the same level of
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impaction, and administration of the same amounts of anesthetic cartridges with aspirating syringe for all the patients might control the confounding variables. All surgeries took about 20 to 25 min. Moreover, the time that patients spent in the waiting room was limited to about only 10 min in order not to produce further anxiety.
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Different studies have been conducted to investigate the effect of aromatherapy in controlling anxiety. Aromatherapy effects have been studied during surgeries [40], renal dialysis [41], and magnetic resonance imaging (MRI) [42]; and it was determined that it
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significantly reduces the level of anxiety in patients suffering from anxiety disorders. However, aromatherapy has not shown promising results in reducing anxiety during
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cancer therapy [43] or endoscopy [44]. This inconsistency may be explained by the fact that aromatherapy may not be effective in reducing very high levels of anxiety. Hence, in the present study, patients with a high scale of anxiety corresponding to dental phobia were excluded.
As suggested by Lehrner et al. for future studies [30], in addition to the questionnaire (as an inclusion criteria), we also included physiological measurements for assessing anxiety
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levels. Moreover, in previous studies [17, 22, 42], patients underwent different dental procedures that had different baselines of anxiety. However, we only focused on one dental procedure i.e., tooth extraction, which is responsible for the highest level [45] or
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one of the highest levels [46] of anxiety among dental procedures. It is worth mentioning that previous studies did not determine the anxiolytic effect of the odor when the patient was seated in the dental chair [17, 22, 42]. However, we considered this an important
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factor as many stressful situations may occur during dental procedures.
Of the limitations of this study was the method for recording respiratory rate. We
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employed a visual method; however, it would best be recorded with a capnography machine rather than having to measure this by actually counting the reparations manually. Another limitation of this study was the small sample size. In conclusion, the results of the present study suggest that ambient orange fragrance is
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helpful in reducing dental anxiety during surgical removal of an impacted mandibular third molar. Future randomized clinical trials with a larger selection of patients are
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recommended to validate the results of this study.
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TABLE 1. Summary of gender and education variables for experimental and control groups.
Male Female
Education No Primary Vocational University
% 32.14 67.86
0 2 13 13
0 7.1 46.4 46.4
2 2 11 13
Chi-Square test, **Mann–Whitney test
7.1 7.1 39.4 46.4
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*
N 9 19
No-fragrance group N % 16 57.14 12 42.86
P-value 0.06*
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Gender
Fragrance group
0.85**
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Variable
TABLE 2. Summary of age and DAS results for experimental and control groups. No-fragrance group (mean ± SD) 27.5 ± 5.7
P-value
Age
Fragrance group (mean ± SD) 26.4 ± 5.3
DAS
11.78 ± 2.45
11.89 ± 2.47
0.87
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Variable
0.37
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Note: P-value calculated using independent t-test Abbreviation: SD, standard deviation; DAS, dental anxiety scale
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Fragrance group (mean ± SD) 9.81 ± 1 9.63 ± 1 9.47 ± 0.88 8.75 ± 0.87 9.12 ± 0.98
No-fragrance group (mean ± SD) 9.63 ± 0.76 9.82 ± 0.86 10.26 ± 1.2 10.37 ± 1.7 10.44 ± 1
Stage 1 Stage 2 Stage 3
100.42 ± 9.5 98.82 ± 9.5 96.9 ± 9
100.17 ± 12.7 102.28 ± 13.5 106.25 ± 14.1
0.93 0.27 0.005
Stage 4 Stage 5
98.57 ± 12.4 95.14 ± 10.9
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TABLE 3. Primary predictor versus outcome variable.
0.02 0.003
PR/min
Stage 1 25.57 ± 1.87 27.14 ± 2.2 0.44 Stage 2 27.92 ± 2.27 27.78 ± 2.8 0.83 Stage 3 27 ± 1.9 29.64 ± 2.9 < 0.001 Stage 4 26.14 ± 2.3 30 ± 2.7 < 0.001 Stage 5 27 ± 1.8 29.85 ± 2.4 < 0.001 Not: P-value calculated using independent t-test Abbreviation: SD, standard deviation; MAP, mean arterial pressure; PR, pulse rate; RR, respiratory rate
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RR/min
106.89 ± 13.2 104.71 ± 11.7
0.46 0.46 0.007 < 0.001 < 0.001
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MAP Stage 1 (cm/Hg) Stage 2 Stage 3 Stage 4 Stage 5
P-value
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Variable
