The third molars are the last teeth to erupt in the oral cavity. The mandibular third molars have the highest rate of impaction among all teeth [1]. Impacted third molars may cause pathologies, such as pericoronitis, periodontal disease, tooth decay, cystic tumor formation, and severe systemic infections [23]. Surgical removal of the third molar for various reasons is a common dentoalveolar procedure in oral and maxillofacial surgery [4].

After extraction of an impacted third molar, the patient may develop various complications, including pain, swelling, trismus, bleeding, nerve damage, and mandible fracture. Third molar surgery affects the quality of life of the patient. Typically, adverse effects of third molar surgery are observed in 4–7 postoperative days [56].

Pain is a difficult symptom to experience and usually requires management. It is defined as unpleasant sensory and emotional experiences associated with actual or potential tissue damage. The pain after mandibular third molar extraction reaches its peak with elimination of the local anesthetic effect. Pain perception can be altered by numerous mechanisms, including drugs, environmental stimuli, cognitive and emotional processes, and social and cultural conditions. The least intensity of a stimulus at which it evokes pain is different for each individual.

Pain catastrophizing is a marker of pain. It is described as an exaggerated negative response to a painful stimulus. The intensity of pain experienced by an individual plays a major role in the formation of catastrophic thinking. Sullivan et al. [7] developed the Pain Catastrophizing Scale (PCS). PCS is the most common measure of pain-related catastrophic thinking. It is associated with the experience of more severe pain [78], severe depression and anxiety [9], increased use of analgesics [10], and tendency for longer hospitalization [11].

The aim of this study was to evaluate the correlations of postoperative analgesic use with pain catastrophizing and anxiety in patients who underwent removal of an impacted mandibular third molar.

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This was a survey performed using an individual identification form to evaluate the demographic characteristics, PCS, State-Trait Anxiety Inventory-trait (STAI-T), and State-Trait Anxiety Inventory-state (STAI-S) scores, and the use of analgesics for post-extraction pain relief. We included 92 patients who were admitted to the Department of Oral and Maxillofacial Surgery at the Faculty of Dentistry of Tokat Gaziosmanpaşa University, Turkey, and underwent the extraction of impacted mandibular third molar. The study was approved by the Tokat Gaziosmanpaşa University Clinical Research Ethics Board (Project no: 18-KAEK-175). Informed consent was obtained from all participants.

In order to determine the demographic characteristics of the participants, questions on their age, gender, occupation, marital status, educational level, health problems, and use of antidepressants, were posed in the individual recognition form. Patients who were pregnant or nursing, had a systemic disease or allergies to prescription drugs, or developed alveolitis after tooth extraction were excluded from the study.

In this study, the Pederson [12] index was used preoperatively to determine the difficulty of surgical extraction of mandibular third molars based on their anatomical position. This scale uses three variables, i.e., the angulation, depth, and ramus relationship on a panoramic radiograph, to determine the difficulty of surgical extraction, and an impacted tooth is assigned a numerical value based on each variable. The sum of the numerical values yields the total difficulty score of the impacted tooth. Impacted teeth with total difficulty scores of 3 and 4, 5 and 6, and 7–10 were determined to be minimally difficult, moderately difficult, and very difficult for surgical extraction, respectively. Since the analgesic use after tooth extraction was expected to be low in the minimally difficult group, the present study was performed only on moderately difficult and very difficult groups. A single practitioner with 4 years of experience in oral surgery performed all operations. Patients were provided with the standard postoperative instructions and prescribed with 500 mg of amoxicillin, an antibiotic containing 125 mg of clavulanic acid (Augmentin BID 625 mg tablet, Glaxo Smith Kline, Istanbul, Turkey), an analgesic containing 100 mg of flurbiprofen (Majezik 100 mg tablet Sanovel, Istanbul Turkey), and a mouthwash containing chlorhexidine gluconate and benzydamine hydrochloride (Kloroben mouthwash, Drogsan Pharmaceuticals, Ankara, Turkey) to be used twice daily for 7 days. Patients were asked to note the number of analgesics they took for 7 postoperative days.

Using PCS [7] patients were asked about their thoughts on the assessment of pain in 13 sentences and to rate their feelings when they had pain. Answers were scored as 0 (not at all), 1 (to a slight degree), 2 (to a moderate degree), 3 (to a great degree), and 4 (all the time). A total score in the range of 0–52 is considered a high score and indicates a high level of pain catastrophizing [13]. In this study, patients were divided into two groups based on the PCS score: low and high PCS score groups.

STAI-T and STAI-S questionnaires developed by Spielberger et al. [14] were used to determine the anxiety level of the patients. Spielberger et al. [14] divided anxiety into state and trait anxieties. State anxiety is the presence of anxiety related to a dangerous, unwanted situation. Trait anxiety is the presence of anxiety without any objective cause or the presence of disproportionately long-term and severe anxiety related to an objective cause. STAI has 20 items each for assessing state and trait anxieties. Each item is rated on a scale of 1 to 4, and the anxiety level is determined by adding the scores for each item. A score in the range of 20–80 is considered a high score and indicates strong anxiety.

The obtained data were examined to evaluate the correlations of pain catastrophizing and anxiety with the postoperative analgesic use.

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We recruited 92 Turkish patients, including 60 women and 32 men, in the study. The age of the patients ranged from 17 to 60 years (mean: 26.27 ± 7.38 years). Based on the Pederson index, 56 impacted teeth were moderately difficult (61%) to extract, and 36 impacted teeth were very difficult (39%) to extract (Table 1). The analgesic use was higher in women than in men but without a significant difference (P = 0.871). The analgesic use was higher in the very difficult group than in the moderately difficult group but without a significant difference (P = 0.397). PCS scores were higher in women than in men but without a significant difference (P = 0.161). STAI-T scores were higher in women than in men but without a significant difference. STAI-S scores were significantly higher in women than in men (P < 0.001) (Table 2).

In the moderately difficult group, the analgesic use was higher in patients with high PCS scores than in those with low PCS scores but without a significant difference (P = 0.793). In the very difficult group, the analgesic use was higher in patients with high PCS scores than in those with low PCS scores but without a significant difference (P = 0.413). In the moderately difficult group, STAI-S scores were significantly higher in patients with high PCS scores than in those with low PCS scores (P < 0.05). In the very difficult group, STAI-T scores were significantly higher in patients with high PCS scores than in those with low PCS scores (P < 0.05) (Table 3).

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Extraction of the third molars is a common surgical procedure in the field of oral and maxillofacial surgery. Surgical removal of impacted third molars involves traumatic manipulation of the associated bones, muscles, and connective tissues. Successful management of postoperative pain, trismus, and swelling improves the patient's postoperative quality of life. Environmental factors, cognitive and sensory processes, and sociocultural conditions are associated with pain perception. Therefore, pain perception is different for each individual. In a previous study, many patients with a history of third molar extraction experienced high levels of anxiety [15]. In another study, most patients with a scheduled third molar extraction experienced high levels of anxiety [12]. Patients' anxiety can adversely affect the surgeon's performance and significantly increase the duration of the procedure, recovery time, and dose of analgesics [1314]. Pain catastrophizing is an extremely negative cognitive and emotional response to expected or actual pain [15]. Studies have found significant correlations of pain catastrophizing with anxiety, depression, and fear [161718]. Preoperative knowledge of the patients' catastrophizing characteristics contributes to appropriate pain management and drug selection. In the present study, the analgesic use was higher in patients who catastrophize pain more than in those who catastrophize pain less.

In pain studies, catastrophizing has been described as an exaggerated negative response to a painful stimulus. People who catastrophize pain experience more severe pain and emotional restlessness compared to others [719]. Excessive focus on the sensation of pain is a mechanism underlying the increase in pain intensity in individuals who catastrophize pain. Several studies reported that dealing with the sense of pain increases the experience of pain [720]. Granot et al. [21] reported that the postoperative pain intensity of the patients undergoing elective abdominal surgery can be predicted effectively using the preoperative anxiety and catastrophizing levels. Taenzer et al. [22] reported that anxiety levels correlated with postoperative pain intensity of patients undergoing elective gallbladder surgery. In a study including 59 women who underwent breast cancer surgery, Jacobsen et al. [10] reported that increased pain catastrophizing and decreased use of cognitive coping strategies increased the analgesic use. Kazancıoğlu et al. [14] reported that among the patients who received dental implants, the analgesic use was higher in patients with high levels of anxiety than in those with low levels of anxiety. Consistent with previous studies, this study suggests that pain catastrophizing and anxiety are associated with postoperative pain and analgesic consumption. In this study, the analgesic use was higher in patients with high PCS, STAI-S, and STAI-T scores than in those with low scores.

All factors, such as gender, age, position of the molar in relation to the occlusal plane, and prediction of surgical difficulty faced by the surgeon affect the postoperative recovery time [23]. Opinions differ on the relationship between gender and pain catastrophizing [2425262728]. Several studies including adults revealed that women had higher PCS scores compared to men [2728]. Suren et al. [29] divided adult patients who underwent venipuncture into four groups and compared their PCS scores. They found correlations between gender and PCS scores. Conversely, some studies reported no gender difference in pain catastrophizing. In a study conducted in Germany including 134 patients, Ruscheweyh et al. [15] detected no correlation between gender and PCS scores. Similarly, in a study including 38 patients who underwent abdominal surgery, Granot et al. [21] observed no significant correlation between gender and PCS scores. In the present study, there was no correlation between gender and PCS scores.

The Pederson index is commonly used to estimate the difficulty of removing the impacted mandibular third molars. Similarly, the Parant scale predicts the difficulty of extraction of the mandibular third molars [30]. Diniz-Freitas et al. [23] reported that the Pederson scale had lower sensitivity than the Parant scale. However, the Parant scale is a postoperative assessment tool. However, the Pederson scale, which allows a preoperative assessment, does not account for relevant factors, such as bone density, buccal flexibility, and buccal gap [31]. Thus, a limitation of this study is that these factors could not be considered in determining the difficulty of extraction. In addition, studies on this subject with a larger sample size can be performed. The study model may be designed to allow analgesics, excluding antibiotics, for only 7 days.

In conclusion, individuals who catastrophize pain have a tendency to exaggerate the sensation of pain and low ability to cope with pain. These characteristics hinder dentists from communicating with the patients and may adversely affect the dental treatment. The postoperative analgesic use in patients who catastrophize pain may be higher compared to others. Knowing the patient's catastrophizing characteristics preoperatively would contribute to successful pain management and the appropriate drug selection.

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