A randomized clinical trial was conducted to investigate the efficacy of periodontal surgery in combination with cognitive behavioral therapy (CBT) compared to standard surgery alone in the treatment of 52 outpatients with periodontal disease. Patients were randomly assigned to one of the following: (1) standard treatment - periodontal surgery, which served as a reference condition in this study (Control); (2) standard treatment plus CBT (Intervention). The psychological outcomes investigated were pain, anxiety and distress. Mechanisms of change (irrational beliefs and expectations) were hypothesized to have mediating effects. Our results indicate that a brief CBT intervention before periodontal surgery significantly reduces general distress and anxiety. CBT also changed irrational beliefs and expectations. Mediation analyses showed that the effect of treatment (CBT intervention plus standard treatment) on the outcome (general distress and anxiety) was mediated by changes in cognitions (irrational beliefs and expectations).
Keywords: cognitive behavioral therapy, periodontal surgery, distress, anxiety, theory/mechanisms of change
Dental anxiety is common among children and adults. It prevents patients from seeking dental care, causing them to cancel, miss, or arrive late for dental appointments. Fear of dental treatment has been repeatedly recognized as a serious public health obstacle (Alvesalo et al., 1993). The most cited reasons for dental anxiety are fear of pain and previous unpleasant experience (Fardal & Hansen, 2007).
Gum diseases are among the most common reasons for dental intervention referrals. The prevalence of gingivitis has ranged from 40% to 60% in various surveys (National Center for Health Statistics, 2005). Gingivitis usually progresses to periodontal diseases with subsequent loss of bony support and eventually loss of teeth. Data on the prevalence of periodontal disease are dependent on how this disease is defined and the age group on which data are collected. Between 5%-20% of the population suffers from severe, generalized periodontitis, although mild to moderate periodontitis affects the majority of adults (National Center for Health Statistics, 2005; Oliver, Brown, & Löe, 1999).
Periodontal surgery has been the treatment of choice for severe destructions caused by various forms of periodontal disease for a number of years (Arlin, 1986; Haffajee, Socransky, Smith, & Dibart, 1991; Lindhe, Haffajee, & Socransky, 1983). First, periodontal surgery addresses the effects of periodontal tissue loss and it generally aims to reconstruct the affected bone. Depending on the severity of the lesions (Miller, 1985) and on the degree of the periodontal involvement (O'Leary, Drake, & Nayor, 1972), patients often need several subsequent surgical interventions. Second, periodontal surgery aims to address mucogingival problems and to cover the exposed roots associated with gingival recessions. In both cases, the final goal is to facilitate periodontal healing in the affected areas.
Dentistry is considered the medical area with the highest correlation between pain and anxiety (Newton & Buck, 2000). Moreover, a series of empirical studies have indicated that both anxiety and a number of cognitive mechanisms (e.g., expectations, irrational beliefs and personality traits such as optimism or pessimism) play an important role in the subjective experience of pain (Feeney, 2004; Gaskin, Robinson, Greene, & Geisser, 1992; Varni et al., 1996) Patients with high levels of anxiety have a much lower threshold for pain than non-anxious patients (Feeney, 2004) and patients with high awfulizing tendencies experience higher levels of pain associated with orthodontic treatments than the non-anxious.
To date, few studies have looked at the influence of psychosocial factors on outcome after periodontal surgery (Axtelius, Söderfeldt, Nilsson, Edwardsson, & Attström, 1998; Vettore, Quintanilha, Monteiro da Silva, Lamarca, & Leão, 2005; Wimmer, Köhldorfer, Mischak, Lorenzoni, & Kallus, 2005). …