The extraction of wisdom teeth stands out as one of the most anxiety-inducing procedures among dental patients [1]. Presurgical anxiety significantly impacts surgical outcomes by adversely affecting constituent factors such as operative time, pain perception, and recovery [2,3]. The primary concern associated with tooth surgery lies in the potential for iatrogenic injury to the inferior alveolar nerve (IAN) as the most significant patient-related outcome [4,5]. Preoperative imaging is taken to evaluate the anatomical relationship between the mandibular third molar and the IAN canal, aiming to predict the risk of IAN injury [6]. Conventionally, two-dimensional imaging techniques such as panoramic radiography, also known as orthopantomography (OPG), are utilised, however, their capability diminishes when a close anatomical relationship between the structures, or superimposition, is observed [7]. More recently, cone-beam computed tomography (CBCT) has been utilised as it provides high-resolution three-dimensional visualisation [8], but at the cost of higher radiation dosage. Additionally, the clinical benefit of a reduction in nerve injury with more advanced imaging has yet to be confirmed [9,10]. Therefore, evidence-based guidelines currently recommend that CBCTs are only indicated after a high-risk relationship has been suggested on conventional preoperative OPG imaging [11,12]. There is no data in the literature on how these recommendations affect the patients psychologically.

In the context of patient anxiety related to preoperative scans, the concept of “scanxiety” has been reported in multiple studies [13,14]. In oncology patients, a rise in anxiety levels occurs when subjected to multiple imaging episodes before operations or follow-up appointments [13]. However, this is a considerably different clinical and emotional context compared to wisdom tooth surgery. Conversely, one previous report on patient knowledge and understanding of preoperative scans identifies a reduction in patients’ anxiety levels with preoperative imaging compared to those without scans [15]. Taken together, this information suggests that the effect of the recommended additional CBCT, after OPG, on patients requiring high-risk wisdom tooth surgery could either be to increase their anxiety about surgery, potentially adversely affecting clinical outcomes. However, if CBCTs improve patients’ understanding of surgical risks, their anxiety may be reduced with consequent improvements in surgical outcomes.

This cross-sectional study seeks to identify the impact of the additional cone-beam computed tomography imaging, as recommended by evidence-based guidelines [11,16], on patients’ presurgical anxiety levels related to high-risk wisdom tooth surgery.

Study design

A cross-sectional study, aligning with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scheme [17]. Participants were recruited between January 13, 2023 and February 24, 2024 at Aberdeen Dental Hospital, United Kingdom. Ethical approval for this study was obtained from the National Health Service (NHS) Grampian, United Kingdom (project ID: 5859). In full accordance with the Declaration of Helsinki, all patients received comprehensive information about the study’s aims, and informed consent was obtained from all participants before their inclusion in the study. Patient data was anonymised with no personally identifiable information recorded. Convenience sampling is employed due to the absence of prior research and available data to calculate the appropriate sample size and estimations for power calculations.

The NHS standard clinical pathway for treating wisdom teeth was not altered, and all participants completed their treatment and proceeded to schedule appointments for their surgical procedures, with none opting out following CBCT. Each participant was managed by their designated NHS surgeon, in line with standard care pathways. All surgeons followed consistent discussion protocols when reviewing CBCT findings with patients, ensuring uniformity in the communication process across the cohort. Patients identified as low risk for IAN injury on OPG proceeded directly to the surgical waiting list. In contrast, those assessed as high risk were referred for an additional CBCT scan, followed by a post-CBCT consultation. Of these, Group A completed a questionnaire when attending for the CBCT before they were aware of the results, while Group B completed the questionnaire after discussion of the CBCT findings with their surgeon.

This study involved two independent patient groups within this existing pathway, as illustrated in Figure 1. Only patients requiring CBCT specifically to assess the IAN and wisdom tooth relationship were included. The selected time points were chosen to capture patient perceptions at each stage of the diagnostic process, thereby allowing evaluation of the direct impact of each imaging modality. Each group completed a short questionnaire developed with input from the University of Aberdeen School of Medicine, Medical Sciences and Nutrition, Patient and Public Involvement (PPI) group.

Questionnaire structure

The study’s primary outcome was the patients’ anxiety levels about wisdom tooth surgery. Secondary outcomes included CBCT perceptions, such as its influence on decision-making and its worth, along with qualitative outcomes of the patients’ reasoning for needing a CBCT. Age categories, gender, and group allocation (A or B) served as key predictors. Potential confounders included prior awareness of CBCT necessity from their referring dentists’ discussions. No diagnostic criteria were applicable as the study focused on exploratory participant perceptions.

Anxiety was measured using a 12 cm visual analogue scale, ranging from “less anxious” to “more anxious”, with “no difference” at the midpoint. Age and gender were collected through demographic questions, while secondary outcomes were assessed through binary questions. Additionally, participants were asked to answer an open-ended question, allowing them to give unbiased responses without restriction on the reasons for undergoing the CBCT. These were employed to minimise leading or suggestive language, ensuring clarity and objectivity.

The full versions of both questionnaires are provided in Appendix 1 (Group A) and Appendix 2 (Group B), respectively. Data cleaning involved manually checking for errors and validating questionnaire responses. Missing data were systematically addressed and excluded to ensure dataset accuracy.

Statistical analysis

Quantitative data analysis was performed using SPSS^® Statistics version 29.0.1.0 (IBM Corp.; Armonk, New York, USA) software using descriptive statistics expressed as mean and standard deviation (M [SD]), Chi-square tests, linear regression, and independent t-tests. The statistical significance level was defined at P = 0.05. Qualitative data were thematically analysed using manual coding in Excel^® for Microsoft 365 version 2409 (Microsoft Corp.; Redmond, Washington, USA).

Participant demographics

There was no missing data for any variable of interest in this study, and no patient drop-out.

The total sample consisted of 119 patients, with 62 participants in Group A and 57 in Group B (Table 1). Group A had a mean age of 29.5 (SD 8.9) years, and Group B had a mean age of 29.7 (SD 8.8) years. Across both groups, female participants were the majority. Group A included 44 females (71%) and 18 males (29%), while Group B included 42 females (74%) and 15 males (26%).

Impact of CBCT on patients’ anxiety

Overall, there was a reduction in patient anxiety associated with having a CBCT before wisdom teeth surgery (Table 1). In Group A, the mean score was -1.42 (SD 2.46), corresponding to a 23.67% reduction in anxiety levels with a range from -6 to +3 and a skewness value of -0.76. In comparison, Group B had a greater decrease with a mean of -1.88 (SD 2.31), suggesting a 31.3% anxiety reduction within a range spanning from -6 to +4. The t-test for equality of means revealed no significant difference in anxiety scores between the two groups (t(117) = 1.044, P = 0.149). Figure 2 shows the visual analogue scale responses of how the additional scan affected patient anxiety levels.

Anxiety was assessed using a single-item scale, with a standard error of measurement (SEM) used for further analysis. Scores were categorised as less anxious, no change, or more anxious, as shown in Table 2. In Group A, participants with scores between -6 and -1.1 cm were classified as “less anxious,” those between -1.1 and +1.1 cm as “no change,” and those above +1.1 cm as “more anxious.” Similarly, Group B used SEM thresholds of -1.03 and +1.03 cm for categorization. In total, 38 out of 62 in Group A reported no change in anxiety, while 21 felt less anxious, and only 3 were “more anxious” about their surgery due to needing a CBCT. Amongst them, 57 participants were already aware that a CBCT would be used before attending Aberdeen Dental Hospital.

In Group B, 33 out of 57 reported reduced anxiety (-3.45 [SD 1.57]), with a 57.5% reduction in the “less anxious” group indicating a tendency for participants to report higher reductions in anxiety within this category than Group A. 22 participants reported no change and only 2 experienced increased anxiety. Most participants found CBCT worthwhile (54 out of 57), with 55 participants agreeing it improved their understanding of surgical risks. Only 9 participants found the additional time or visits involved in having a CBCT problematic.

In Group B, 10 participants reported that CBCT influenced their decision on whether to opt for total removal or partial removal of the wisdom tooth (if this was an option). Chi-square tests carried out (Table 3) revealed a highly significant association between anxiety levels and treatment decisions (P < 0.001), with more anxious participants showing a stronger predisposition to changing their treatment decisions. No significant association was found between anxiety and whether participants found the CBCT worthwhile (P = 0.081), additional time required (P = 0.471), or risk understanding (P = 0.192). However, a marginal trend suggested that most participants, regardless of anxiety levels, found CBCT worthwhile.

The relation between age, gender and anxiety

A linear regression analysis found a weak but significant negative correlation between age and anxiety scores (r = -0.199, P = 0.015), indicating that anxiety decreases with age. An independent samples t-test revealed no significant difference in anxiety levels between females (-1.808 [SD 2.484]) and males (-1.215 [SD 2.111]).

Characteristics of the “less anxious” group

A t-test revealed a 57.5% anxiety reduction in the “less anxious” group, with Group B showing a significantly greater decrease by 17% (t(52) = -2.34, P = 0.023). This group was older on average (31.09 [SD 9.46]) than those with no change/more anxiety (28.19 [SD 7.9]), with a significant difference (t(117) = -1.816, P = 0.036).

Qualitative findings

The thematic analysis of Group A open-ended responses, as shown in Table 4, identified three key reasons why participants believed a CBCT was necessary: assessment of tooth-nerve proximity (n = 59), aiding decision-making (n = 16), and surgeon recommendation (n = 14). These responses suggest a high level of patient understanding of the CBCT’s purpose in their surgical pathway.

This study provides the first reported insights into the patient’s perspective on the impact of additional CBCT imaging for high-risk wisdom tooth surgery as recommended by evidence-based guidelines such as those from the European SEDENTEXCT project and UK National Institute for Health and Care Excellence (NICE) [11,12]. Only 5 patients reported increased anxiety with the additional imaging, suggesting the concept of “scanxiety” previously documented in other healthcare contexts [13,14,18] is a context-dependent effect. Unlike the anxiety induced by imaging in oncology [19], dental CBCTs appear to have a predominantly positive psychological impact.

CBCTs reduce presurgical anxiety associated with wisdom tooth surgery

For most patients, surgical procedures stimulate anxiety, with dental anxiety affecting 12.4 to 15.3% of patients [20], impacting surgical outcomes such as the anaesthetic approach, surgical duration, post-operative pain, as well as the healing process [2,21,22]. Anxiety management primarily relies on non-pharmacologic measures as a first line, such as preoperative education, reducing the need for sedation or general anaesthesia [23], which are often not required for the complexity of the surgical procedure itself.

Our findings suggest that a preoperative CBCT reduced anxiety in 33 out of 57 patients by an average of 31.3%. While the clinical significance of this reduction remains unclear, it may alter their need for pharmacologic management. Further research is needed to quantify these effects, balance them against CBCT-associated radiation risks and explore whether targeting high-anxiety patients could enhance the anxiolytic effect.

Improved preoperative information

The 31% anxiety reduction observed in Group B may be linked to improved preoperative information as reported by Wong et al. [24]. We suggest that the CBCT likely contributed to this effect, with 55 participants reporting a better understanding after reviewing their scans with a surgeon. As Group A showed a 24% reduction in anxiety, without reviewing the CBCT findings, it seems that having a CBCT itself could be a compounding factor. However, this finding, based on a subjective visual analogue scale, is limited by the absence of a control group and should be interpreted with caution. Additionally, there is a delicate balance in delivering information, as when appropriately tailored, it can enhance understanding, but there is a risk of information overload, leading to higher levels of stress [25]. This study explored patient anxiety specifically related to undergoing and discussing CBCT imaging rather than focusing on differences based on CBCT outcomes (high vs. low risk). Despite the high correlation between OPG and CBCT findings suggesting minimal anxiety impact from scan results alone, future studies should investigate anxiety differences related to CBCT outcomes.

CBCTs and treatment decision-making

In the United Kingdom, NICE guidelines [26] recommend patient involvement in treatment decisions, requiring a clear understanding of risks. Surgical extraction and coronectomy were both viable options within our clinical setting. Our study found a significant association between anxiety and treatment decision-making (P < 0.001), strengthening previous findings that CBCTs can influence treatment decisions [27]. Notably, 10 out of 57 participants reported modifying their approach based on CBCT results, supporting its role as a decision-aid [28]. However, this change might partly reflect cases where surgeons withheld a definitive plan based on the OPG alone [29], leading patients to perceive the idea of a shift in treatment after CBCT.

Patient acceptance of additional visits for CBCT

The high acceptance rate (54 out of 57) of CBCT, despite the added time, highlights its strong perceived value. Even though 9 out of 57 found the extra time/visits problematic, patients prioritise comprehensive diagnostic information over time efficiency. Insights from our PPI group further support this preference, with the group favouring advanced imaging despite limited clinical evidence, as long as risks are relatively minimal.

Influence of age and gender on anxiety levels

Our study provides some evidence that older participants undergoing wisdom tooth surgery showed slightly lower anxiety levels (r = -0.199, P = 0.015), aligning with Facco et al. [30]. The broad age range reflects NICE guidelines discouraging routine extraction of asymptomatic wisdom teeth, until they become problematic [12], while the predominance of young adults in our study potentially also supports ongoing debates on prophylactic removal [31]. Gender also had no significant impact on anxiety, though the higher proportion of female participants aligns with known healthcare-seeking behaviour [32].

Patient understanding of the need for CBCT

Our qualitative analysis identified three themes, with the majority of participants acknowledging the importance of nerve-tooth position assessment. This aligns with current guidelines [11], justifying CBCT use and confirming appropriate patient consent for imaging.

Despite the study’s novel insights, it has limitations. The sample size and convenience sampling may limit the generalisability. A single-item anxiety scale could be improved by using validated multi-item measures for greater reliability. The absence of within-cohort comparisons limits longitudinal insights. Future research should adopt larger, more diverse cohorts with within-patient comparisons for improved validity.

We report for the first time that cone-beam computed tomography imaging may reduce presurgical anxiety associated with wisdom tooth surgery. High patient satisfaction and improved risk understanding also support its use in pre-surgical planning and shared decision-making. However, further investigation into the anxiolytic phenomenon is required to determine whether any clinical benefit outweighs the known risks of the radiation dosage associated with cone beam computed tomography. This study lays the groundwork for future investigations, encouraging a more comprehensive understanding of the role of CBCTs in wisdom tooth surgery.