Perioperative dynamics: beyond a homogeneous response to implantology

Although dental implant rehabilitation shows high success rates, it remains a major source of perioperative anxiety and pain for a large proportion of patients. Currently, research struggles to reach a consensus on the precise correlation between dental anxiety and pain perception, often due to an approach that considers patients as a homogeneous population and the use of cross-sectional measures that ignore dynamic fluctuations in experience.

This prospective observational study, conducted with 204 patients, aims to characterize pain and anxiety trajectories across five perioperative measurement points (pre, intra, and postoperative). The objective is to identify latent response profiles within the population to better understand the heterogeneity of psychophysiological responses to the surgical procedure.

The authors test the hypothesis that patients can be segmented into distinct reactivity subgroups. They evaluate whether specific predictors, such as trait dental anxiety (MDAS score), surgical complexity (bone grafting, number of implants), smoking, and social support (presence of family), influence membership in these profiles. The challenge is to identify high-risk patients early to optimize personalized perioperative management.

Methodology: Analysis of perioperative trajectories

This prospective observational study followed a cohort of 204 patients treated in implant surgery (placement of single or multiple implants). The objective was to model the dynamic evolution of pain and anxiety across five key temporal measurement points during the perioperative phase.

The evaluation protocol utilized three specific measurement tools:

• The MDAS (Modified Dental Anxiety Scale) for assessing initial dental anxiety (trait).
• The visual analogue scale (VAS) to quantify the intensity of perceived pain.
• The VAS-A scale to measure situational anxiety at each stage.

Researchers examined the influence of several predictive variables: the complexity of the surgical procedure (number of implants, use or not of a bone graft), smoking status, and social support (presence of a family companion). The statistical analysis was based on a latent profile analysis (LPA) to identify homogeneous subgroups of patients, complemented by binary logistic regression to isolate the risk factors for hyper-reactivity.

Identification of two distinct response profiles

Latent profile analysis (LPA) conducted on the 204 patients in the study identified two dynamic trajectories of perioperative pain and anxiety. The cohort is divided into two heterogeneous groups:

Temporal dynamics and intensity peaks

The study shows that for the hyper-reactive group, pain and anxiety experiences are not linear. Two pivotal moments were identified by repeated measures (VAS and VAS-A):

• Intraoperative peak: Anxiety and pain reach a first peak during the surgical procedure.
• Postoperative peak: A significant increase in pain is observed 6 hours after the procedure.

Predictive factors for hyper-reactivity

Binary logistic regression identified several variables significantly correlated with membership in the hyper-reactive profile:

• Trait anxiety (MDAS): High scores on the MDAS (Modified Dental Anxiety Scale) are major predictors of perioperative hyper-reactivity.
• Surgical complexity: The use of a bone graft and a high number of implants significantly increase the probability of a hyper-reactive response.
• Social support: The absence of family support during treatment is associated with increased vulnerability.
• Smoking status: Notably, smoking was associated with a lower probability of belonging to the hyper-reactive profile in this cohort.

These results highlight that preoperative anxiety and the complexity of the procedure directly influence subsequent pain perception, validating the importance of risk stratification from the initial consultation.

Analysis of pain and anxiety trajectories

This prospective study conducted on 204 patients disrupts the conventional approach that treats candidates for implantology as a homogeneous population. The results reveal a marked heterogeneity, identifying two distinct profiles: hypo-reactive patients (64.2%) and hyper-reactive patients (35.8%). For the latter, pain and anxiety are not only more intense, they follow a specific kinetics with a critical peak at 6 hours postoperatively. Clinically, this means that one third of your patients require reinforced monitoring long after leaving the chair.

The study identifies clear predictors of hyper-reactivity: a high MDAS score (trait anxiety), surgical complexity (bone grafts, number of implants), and social isolation (absence of an accompanying person). Notably, smokers showed a lower probability of belonging to the hyper-reactive group, an observation that warrants attention given the known influence of tobacco on perception thresholds. These data confirm that preoperative anxiety acts as an amplifier of perceived pain, corroborating certain studies while specifying the exact timing of symptom exacerbation.

The limitations of this study lie in its convenience sampling and its single-center setting, which may restrict the generalizability of the results. Nevertheless, the implication for the practice is immediate: risk stratification from the initial consultation is possible. The use of the MDAS score and the assessment of the procedure's complexity allow for the anticipation of needs for sedative premedication or enhanced analgesic protocols for the 6-hour post-intervention window.

In concrete terms, for the practitioner:

• Identify the patient at risk: Integrate the MDAS questionnaire during the preoperative consultation; a high score indicates a patient whose pain management will be clinically more demanding.
• Anticipating the H6 peak: For complex surgeries (grafts), prescribe systematic analgesic intake before the anesthesia wears off, as the pain peak is observed at 6 hours post-operatively in hyper-reactive patients.
• Prescribe the presence of a relative: Family support is a statistically significant protective factor; encourage anxious patients not to come alone to modulate their emotional response.

Technical lexicon of the study

Modified Dental Anxiety Scale (MDAS): Measurement instrument used to assess dental anxiety as a "trait" (stable psychological predisposition), serving here as a predictor to stratify patient risk before surgery.

Latent Profile Analysis (LPA): A person-centered statistical approach used to identify subgroups of patients (latent profiles) sharing similar trajectories of pain and anxiety over time.

VAS-A (Visual Analog Scale for Anxiety): Visual analog scale measuring "state" anxiety, representing the transient and fluctuating psychological response felt by the patient at specific moments during the perioperative period.

Hyper-reactive profile: Patient category identified (35.8% of the sample) manifesting high preoperative anxiety and more intense postoperative pain peaks, particularly 6 hours after the procedure.

State anxiety: A dimension of anxiety corresponding to a temporary emotional reaction triggered by a specific stressful context, such as an implant surgery procedure.

Surgical complexity: Predictive factor of the study including specific variables such as the number of implants placed and the need for a bone graft.

Hypo-reactive profile: Majority group (64.2% of patients) characterized by emotional stability and significantly lower levels of perceived pain throughout the operative process.

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