J Oral Maxillofac Surg

69:1036-1045, 2011

Musical Intervention Reduces Patients

Anxiety in Surgical Extraction of an
Impacted Mandibular Third Molar
Yu-Kyoung Kim, PhD, Soung-Min Kim, PhD, DDS, and
Hoon Myoung, PhD, DDS
Purpose: Patients undergoing impacted mandibular third molar (IMTM) extraction often have severe

perioperative anxiety, which may lead to increased perceptions of pain and vital sign instability throughout
surgery. Intraoperational musical interventions have been used during operations to decrease patient anxiety
levels. We investigated the anxiolytic effects of musical intervention during surgical extraction of an IMTM.
We tested the hypothesis that musical intervention would have positive effects on patients vital signs, anxiety
levels, and perceptions of pain.
Patients and Methods: We recruited 219 patients with IMTM surgery to participate in this study.
Participants were randomly assigned to a music-treated group (106 subjects) or a control group (113 subjects).
In a preoperative meeting, patient demographic data were collected, and the patients favorite songs were
selected. For the music-treated group, their selected music was played from the time of arrival to the operating
room until the end of the operation. Perioperative anxiety and perceptions of pain were assessed using the
Dental Anxiety Scale and the Visual Analog Scale, respectively. Patients vital signs (blood pressure, heart rate,
and respiratory rate) were monitored throughout the surgery. One-way analysis of covariance using perioperative anxiety as a covariant was performed to compare intraoperative anxiety levels and perioperative
perceptions of pain between the 2 groups. Repeated measures analysis of variance was used to compare
changes in vital signs across surgical stages between the 2 groups.
Results: Vital signs changed significantly throughout surgery according to the stage of the procedure. For
both groups, vital signs increased from baseline and reached peak values at the time of the initial incision and
then decreased quickly and plateaued within normal limits. There were no significant differences between
groups in blood pressure; however, the music-treated group showed a significantly smaller change in heart
rate than the control group. The music-treated group reported significantly less intraoperative anxiety than
the nonmusic-treated control group when controlling for preoperative anxiety levels (F 4.226, P .05).
Conclusion: These results support the hypothesis that the use of patient-chosen music during surgical
extraction of an IMTM significantly lowers patient intraoperative anxiety levels.
2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:1036-1045, 2011
Impacted mandibular third molar (IMTM) surgery is
one of the most common oral and maxillofacial surgical procedures.1 From the viewpoints of oral and
maxillofacial surgeons, IMTM surgery is a relatively
minor operation with few risks. However, IMTM surgery is generally perceived by patients and general
dentists as an intensely frightening procedure and
remains a challenging operation associated with nu-

merous intra- and postoperative complications that

may be more serious than originally expected by the
patient.2,3 Moreover, there are many emotional and
psychological factors to consider in this surgery that
endanger not only surgical outcomes but also the
relationships between clinicians and their patients.1,2
Patients who undergo IMTM surgery often have severely negative expectations and resultant anxiety,

Received from the Department of Oral and Maxillofacial Surgery and

Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea.
*Primary Researcher.
Associate Professor.
Associate Professor.
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea funded by

the Ministry of Education, Science and Technology (2009-0075293)

Address correspondence and reprint requests to Dr Myoung:
Department of Oral and Maxillofacial Surgery, School of Dentistry,
Seoul National University, 28-2, Yun-Gun dong, Chong-No gu,
Seoul, Korea; e-mail: myoungh@snu.ac.kr
2011 American Association of Oral and Maxillofacial Surgeons

0278-2391/11/6904-0021$36.00/0
doi:10.1016/j.joms.2010.02.045

1036

1037

KIM ET AL

which directly affects their physiologic states and may

result in serious treatment complications.4 A previous
report has shown that nearly half of all patients undergoing third molar extraction fear pain.5 Increased
levels of preoperative anxiety are known to be associated with an increased need for intraoperative anesthetics, higher perioperative perceptions of pain,
and an increased need for analgesics after surgery.6-9
In addition, this psychoemotional instability can induce even hemodynamic changes, resulting in undesirable cardiovascular effects during surgery.10,11
To decrease perioperative emotional distress and
anxiety, several kinds of sedative drugs are often used;
however, these drugs frequently result in side effects,
such as respiratory depression, hypothermia, decreased blood pressure (BP), and even unconsciousness.12 Psychological interventions to control perioperative anxiety have been studied as an alternative to
drug therapy. Among these types of interventions,
music therapy during surgery has been reported to be
a noninvasive, inexpensive, and effective means of
controlling perioperative anxiety levels in patients.
Brunges and Avigne13 showed that preoperative
musical intervention significantly shortened hospitalization periods in local anesthetized patients and
lowered epinephrine levels in urine after surgery.
Steelman14 reported that musical intervention was
associated with decreased BP in patients undergoing local anesthesia. Lepage et al15 found that musical
intervention was effective in decreasing surgical
stress, and that sedatives were needed less often in
patients who were treated with music during surgery.
Marwick16 also reported that music therapy can induce relaxation, decrease BP, and normalize arrhythmias during an operation with local anesthesia. Musical interventions affect not only physiologic domains
of patient functioning, such as BP, heart rate (HR),
and respiratory rate (RR), but also emotional domains,
such as perioperative anxiety levels and pain thresholds.17 Because patients are continuously exposed to
auditory stimuli during IMTM surgery under local anesthesia, including the alarming sound of monitoring
systems, the metallic sound of surgical instruments,
and the professional conversations of surgical staff
members, musical interventions have the additional
benefit of decreasing exposure to fearsome noises in
the operation room.18,19 In musical interventions to
decrease anxiety levels in patients undergoing IMTM
surgery, the type of music, volume of the music, and
in particular patients musical preferences to music
should be considered.18 As such, it is mandatory to
gain information about musical preferences during
preoperative meetings.19
The main aim of this study was to evaluate the
efficacy and validity of musical intervention to decrease anxiety and the change of vital signs during

surgical extraction of an IMTM. We evaluated the

influence of music on changes in systolic BP (SBP),
diastolic BP (DBP), HR, and RR during the surgical
extraction of lower third molars. In addition, we
sought to identify the effects of musical intervention
on perioperative anxiety levels and patient perceptions of pain. We tested the following 2 hypotheses:
musical intervention will induce smaller changes in
patients vital signs during surgical extraction of an
IMTM, and musical intervention will decrease perioperative anxiety levels and perceptions of pain in patients undergoing IMTM surgery.

Patients and Methods

STUDY PARTICIPANTS AND STUDY
ELIGIBILITY CRITERIA

Institutional review board approval for the present

study was acquired at Seoul National University Dental Hospital and all study procedures were performed
under ethical approval. We recruited participants
from all patients with IMTM treated at the Seoul
National University Dental Hospital from October
2008 to June 2009. As the first step, patients meeting
the following criteria were excluded from the study
based on preoperative examination: a history of mental health concerns; an inability to afford IMTM surgery under local anesthesia; a score of 9 or higher on
the scale of Pell and Gregory,20 measuring difficulty of
third molar extraction; a history of blood disorders,
hypertension, diabetes mellitus, immunosuppression,
or other medically compromised states; a history of a
medical/dental lawsuit; or if the patient was currently
taking medications known to interact with drugs contained in the anesthetic solutions used in IMTM surgery. Then, a study consent form was provided to all
candidates with full information of the present study
in compliance with the institutional review board.
The opportunity of enrollment was given to the patient who agreed on participation and voluntarily
signed the consent form.
Two oral and maxillofacial surgeons and 3 trained
interviewers (dental hygienists and nurses) conducted this study. Participation was voluntary, and
232 patients were initially enrolled; however, because
of missing questionnaire data, 13 participants were
excluded. Therefore, the data from 219 participants
were analyzed. Participants were randomly distributed into 2 groups: a music-treated group (106 subjects) and a control group (113 subjects).
PERIOPERATIVE EXAMINATION

The head surgeon and an interviewer obtained participant consent and conducted the initial survey for
each patient. Patients were given information on the

1038

MUSICAL INTERVENTION DECREASES PATIENT ANXIETY

Table 1. DIFFICULTY OF IMPACTED MANDIBULAR THIRD MOLAR EXTRACTION BASED ON THE CLASSIFICATIONS
OF PELL AND GREGORY20 AND WINTER ET AL17

Factor
Spatial relation
Mesioangular
Horizontal/transverse
Vertical
Distoangular
Depth
Level A
Level B
Level C
Available space
Class I

Score

Remark

1
2
3
4

Position of the third molar with respect to the major axis of the second molar

Highest point of the impacted tooth lies above or at the same level as the
occlusal surface of the second molar
Highest point is below the occlusal line but above the cervical line of the
second molar
Highest point lies at or below the level of the cervical line of the second molar

2
3
1

Class II

Class III

Space between the ascending ramus of the mandible and the distal part of the
second molar suffices to accommodate the entire mesiodistal diameter of the
crown of the third molar
Space between the ascending ramus of the mandible and the distal part of the
second molar is less than the mesiodistal diameter of the crown of the third
molar
All or almost all the third molar lies within the ascending ramus of the mandible

Level of difficulty: 3 to 4, minimal; 5 to 6, moderate; 7 to 10, very difficult.

Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral Maxillofac Surg 2011.

time needed to complete the study, and patients were

reassured that their participation in the study would
have no direct impact on the treatment procedures.
Participating patients were notified that they could
discontinue participation in the study at any time and
were not subjected to any form of persuasion or
efforts to retain them in the study. The perioperative
surveys were completed in a waiting room and in a
postoperative care unit. Preoperative and basic demographic data were collected including gender (male
or female), age (40 or 40 years), academic background (high school/college/university), previous experience of IMTM surgery (yes or no), motivation for
surgery (dentist-referred or self-referred), employment status (yes or no), and the reason for extraction
(preventive or curative). In addition, other preoperative information was collected, including anticipated
difficulty level of the IMTM surgery (very difficult/
minimal/moderate) and level of music preference (little/much/medium). The difficulty level of the surgery
was determined using the classification method described by Pell and Gregory20 and Winter et al17
(Table 1). Before the surgery, routine preoperative
information was given to patients with respect to
duration of the general surgical procedure, possible
intraoperative complications, and the method of communication that would be used during surgery.
SURGICAL PROCEDURES

To control for variation in surgical skill among the

surgeons, the surgical procedure was standardized

and the number of participating surgeons was limited

to 2 experienced oral and maxillofacial surgeons who
were familiar with the aim of this study and standardized surgical procedures. Perioperative procedures
and surgeries were performed uniformly in the standard manner dictated by the surgical department.
After surgical draping, a topical anesthetic was applied at the injection site with an impregnated cotton
roll and numbness of the mucosa was confirmed. The
surgical field was anesthetized by mucosal infiltration,
using 2 to 3 ampules of 2% lidocaine and epinephrine
(1:100,000), and by blocking the inferior alveolar
nerve. The first check for mucosal numbness was
performed 5 minutes after injection with periodontal
curette and additional infiltrative injection of anesthesia was performed if necessary. After checking the
anesthetic state of the mucosa, the surgeon made a
crevicular incision and flap extending to the mesial
side of the second molar and retromolar pad. Ostectomy and odontotomy were performed under massive
irrigation with saline and vigorous curettage was performed after removal of the impacted tooth. Participating surgeons were educated before the study not
to implement procedures such as specific psychosomatic pain control or sedation. If the patient complained
of intermittent pain or discomfort during the procedure,
a limited volume of additional anesthetic solution was
administered, and the procedure was delayed until patient discomfort subsided. After surgery, routine postoperative instructions, such as timetable of wound care
and hemostasis and use of prescribed medications,

1039

KIM ET AL

were provided to the patient. To reduce postoperative swelling, ice packs were provided for all patients.

Table 2. EVALUATION OF POSTOPERATIVE PAIN

Score

Visual Analog Scale to Evaluate Pain

0
1

No pain; the patient feels well

Slight pain; if the patient is distracted, he or she
does not feel pain
Mild pain; the patient feels pain even if
concentrating on some activity
Severe pain; the patient is very disturbed but
nevertheless can continue with normal
activities
Very severe pain; the patient is forced to
abandon normal activities
Extremely severe pain; the patient must abandon
every type of activity and feels the need to lie
down

MUSICAL INTERVENTION

In a preoperative meeting with a patient, a list of

favorite songs was selected by the patient from a
prepared music list, including classical music, pop
songs, folk songs, hymns, and Korean-style country
songs. Patients were asked to choose at least 10 songs
to listen to during the operation. If patients chose
fewer than 5 songs from the list, they were asked to
suggest their own favorites. All selected music and
songs were downloaded from a Korean Internet music Web site (www.bugs.co.kr) and saved in the MP3
file format. An appropriate volume level was chosen
by the patient, and headset positions were simulated
and recorded. Upon the patients arrival at the operating room, the selected songs were played continuously and randomly throughout the operation. During
the operation, the patient was able to control the
volume of the music using a remote control. If the
surgeon needed to communicate with the patient
regarding the procedure or to request cooperation,
the music was temporarily paused and then restarted
by the patient after the communication.
MONITORING VITAL SIGNS AND EVALUATING
PERIOPERATIVE ANXIETY AND PAIN

Patient vital signs were measured upon arrival at

the operating room and after the draping procedure
(baseline). Then, vital sign variables were recorded at
3 surgical steps, which has 2 time points: after local
anesthetic injection and at the beginning of incision
(beginning of the operation), at the time of tooth
sectioning and at completion of tooth removal (middle of the operation), and during the hemostasis procedure and completion of suturing (end of the operation). Values of BPs and RR were determined by the
average of measured values at 2 time points, and HR,
which was monitored on a continuous basis, was
represented as the average of multiple values.
Patient anxiety was assessed preoperatively using
Corahs Dental Anxiety Scale.21 Twenty minutes after
the completion of surgery, intraoperative anxiety was
assessed in the recovery room, using the Dental Anxiety Scale. To evaluate perioperative pain, the Visual
Analog Scale (0 to 5) was used as described by Pasqualini et al22 (Table 2). Intraoperative pain was also
rated by patients in the recovery room after surgery.
Postoperative pain was also recorded in an outpatient
clinic the day after the surgery.
STATISTICAL ANALYSIS

Statistical analyses were completed using SPSS computer software (SPSS, Inc, Chicago, IL). The frequency
distribution of demographic descriptive variables

2
3
4
5

Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral

Maxillofac Surg 2011.

was used to identify the participants demographic

profiles. Dental anxiety is a complex phenomenon
affected by various demographic factors23,24; thus,
demographic factors were controlled for by randomization of participant grouping and by confirming the homogeneity of participants across groups. A
2 test was used to detect differences in basic demographic characteristics between the 2 groups. A repeated measures analysis of variance was used to
detect differences in vital sign changes between the
music-treatment group and the control group. A regression analysis was performed to examine the relation between perioperative anxiety and perioperative
perceptions of pain. Analysis of covariance was used
to examine differences between groups with respect
to levels of anxiety and perceptions of pain, while
controlling for preoperative anxiety, which had been
confirmed in the regression analysis as a covariant.
P less then .05 was considered statistically significant.

Results
DEMOGRAPHIC ANALYSIS AND HOMOGENEITY
ANALYSIS

The mean duration of the surgical procedure from

the time of perioral sanitization to the time of drape
removal was 22.8 5.71 minutes. In no case was
surgery stopped because of an unexpected situation,
such as fainting, unstable vital signs, or failure of
extraction under local anesthesia. As presented in
Table 3, there were 59 male (55.7%) and 47 female
(44.3%) patients in the music-treatment group and 63
male (55.8%) and 50 female (44.2%) patients in the
control group. Using a 2 homogeneity test, no significant differences based on gender distribution
were found between groups (2 0.001, P .989).
In addition, there were 53 participants (44.5%) whose

1040

MUSICAL INTERVENTION DECREASES PATIENT ANXIETY

Table 3. HOMOGENEITY TEST AND t TEST OF GENERAL CHARACTERISTICS (N 219)

Category

Music Treatment

Nonmusic Treatment

P Value

Male
Female
40
40
High school
College
University
Yes
No
Self-referred
Dentist referred
Preventive
Curative
Employed
Unemployed
Minimal
Moderate
Very difficult
Much
Medium
Little

59 (55.7)
47 (44.3)
53 (44.5)
66 (55.5)
11 (10.4)
30 (28.3)
65 (61.3)
61 (47.3)
68 (52.7)
62 (49.2)
64 (50.8)
55 (51.9)
51 (48.1)
55 (51.9)
51 (48.1)
35 (33.0)
38 (35.8)
33 (31.1)
43 (40.6)
50 (47.2)
13 (12.3)

63 (55.8)
50 (44.2)
53 (53.0)
47 (48.0)
9 (8.0)
31 (27.4)
73 (64.6)
45 (50.0)
45 (50.0)
44 (47.3)
49 (52.7)
67 (59.3)
46 (40.7)
51 (45.1)
62 (54.9)
38 (33.6)
28 (24.8)
47 (41.6)
42 (36.8)
56 (49.1)
16 (14.0)

0.000

.989

1.558

.212

0.457

.796

0.156

.693

0.077

.782

1.216

.270

0.999

.318

3.869

.145

0.371

.831

Characteristics
Gender
Age (yr)
Academic background
Previous experience of ITM
Motivation for surgery
Reason for ITM surgery
Employment status
Difficulty level of ITM surgery
Level of music preference

Abbreviation: ITM, impacted third molar.

2 data shown are frequencies (percentages).
Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral Maxillofac Surg 2011.

ages were younger than 40 years in the music-treated

group and 53 (53.0%) in the control group. The 2
groups were homogenous with respect to age distribution (2 1.558, P .212), academic background
(2 0.457, P .796), experience of previous IMTM
surgery (2 0.156, P .693), motivation for surgery
(2 0.077, P .782), reason for extraction (2
1.216, P .270), and employment status (2
0.999, P .318). The distribution of IMTM surgery
difficulty included 35 cases (33.1%) of minimal difficulty, 38 (35.8%) of moderate difficulty, and 33
(31.1%) of high difficulty in the music-treatment
group and 38 cases (33.6%) of minimal difficulty, 28

(24.8%) of moderate difficulty, and 47 (41.6%) of high

difficultly in the control group. There were no differences with respect to group distribution in difficulty
level of IMTM surgery (2 3.869, P .145). The
music preferences of patients did not differ significantly between the control and music-treatment
groups (2 0.371, P .831).
VITAL SIGNS ACROSS SURGICAL STAGES

As listed in Table 4, the mean SBP, DBP, HR, and RR

values were not significantly different between the
music-treated group and the control group upon arrival at the operation room (P .05). The mean value

Table 4. CHANGES IN VITAL SIGNS

Category
SBP (mm Hg)
DBP (mm Hg)
HR (beat/min)
RR (rate/min)

Group (P Value*)
Music
Nonmusic
Music
Nonmusic
Music
Nonmusic
Music
Nonmusic

(.174)
(.850)
(.071)
(.997)

Arrival at OR

Beginning of OP

Middle of OP

End of OP

120.49 14.49
123.26 15.55
78.62 7.64
78.39 9.85
88.30 9.20
90.69 10.24
16.88 2.70
16.87 2.38

135.00 14.29
137.13 20.33
91.06 8.97
89.88 14.12
101.79 14.74
105.64 20.98
17.82 2.92
17.00 2.64

116.66 16.40
115.39 11.03
72.75 6.71
73.03 6.41
76.62 8.66
79.15 8.35
17.52 2.43
16.75 2.68

118.61 12.36
117.92 10.45
74.63 5.46
77.38 11.20
72.54 6.37
76.04 13.83
16.96 1.76
16.30 1.81

Abbreviations: DBP, diastolic blood pressure; HR, heart rate; OP, operation; OR, operation room; RR, respiratory rate; SBP,
systolic blood pressure.
All data are presented as mean SD.
*P value in t test of baseline value between groups.
Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral Maxillofac Surg 2011.

1041

KIM ET AL

Table 5. REPEATED MEASURES ANALYSIS OF VARIANCE OF MUSIC AND NONMUSIC GROUPS VITAL SIGNS

Category

2/P Value in
Mauchlys Sphericity Test

SBP

120.815/0.000

DBP
HR
RR

50.666/000
127.191/0.000
18.489/0.002

Effect
Time
Time
Group
Time
Time
Group
Time
Time
Group
Time
Time
Group

group
group
group
group

Sum of
Squares

Degrees of
Freedom

Mean
Square

P Value

53,194.161
662.256
118.448
38,776.699
463.223
36.125
115,618.254
83.870
2,063.463
74.747
23.661
69.261

2.154
2.154
1
2.565
2.565
1
2.218
2.218
1
2.827
2.827
1

24,700.505
370.561
118.448
15,116.548
180.581
36.125
52,923.291
38.391
2,063.463
26.445
8.371
69.261

199.041
2.478
0.199
220.094
2.629
0.217
281.257
0.204
9.951
5.639
1.785
6.432

.000
.081
.656
.000
.059
.642
.000
.834
.002*
.000
.152
.012*

Abbreviations: DBP, diastolic blood pressure; HR, heart rate; RR, respiratory rate; SBP, systolic blood pressure.
*P .05.
Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral Maxillofac Surg 2011.

of SBP increased gradually after arrival and reached a

peak value at the time of the local anesthetic injection
and the beginning of the incision. SBP quickly decreased after reaching a peak value at the time of the
incision, until the middle of the operation, when it
plateaued until the time of suturing. Overall variations
in SBP showed a similar pattern of change across
stages of the procedure for both groups. As presented
in Table 5, a multivariate approach was used to compare means between groups because the sphericity
assumption was violated in Mauchlys sphericity test
(2 120.815, P .001). The SBP varied significantly
across surgical stages in both groups (F 199.041,
P .001). However, there were no significant interactions between stage of surgery and music treatment
group status (F 2.478, P .081) or between SBP
and music treatment group status (F 0.119, P
.656).
Baseline DBP showed no significant differences between groups. The mean DBPs were 78.62 7.64 in
the music-treated group and 78.39 9.85 in the
control group. Mirroring SBP variation, DBP showed
the highest value at the beginning of the incision,
with a sharp decrease after the incision, which plateaued and stayed within normal limits for both
groups. Again, sphericity assumptions were violated
(2 50.666, P .000), and DBP varied significantly
with surgical stage for both groups (F 220.094, P
.001). However, there were no significant interactions between surgical stage and music treatment
group status (F 2.629, P .059), and there were no
significant differences in DBP between the musictreatment group and the control group (F 0.217,
P .642).
The highest HR and RR were also recorded at the
time of the initial incision, and these variables fol-

lowed the same pattern as BP variation in both

groups. In addition, HR and RR varied significantly
with surgical stage (F 281.257, P .001, for HR;
F 5.639, P .001, for RR). A significant interaction
between surgical stage and music treatment group
status was not observed for HR or RR (F 0.204, P
.834, in HR; F 1.785, P .152, in RR). However,
the music-treatment and control groups did differ
significantly with respect to HR and RR changes from
baseline (F 9.951, P .002, for HR; F 6.432, P
.012, for RR). As presented in Table 4, in the musictreatment group, a smaller change from baseline in
HR was observed throughout the operation, whereas
a larger change from baseline in RR was seen in the
music-treatment group than in the control group.
However, changes from baseline for vital signs were
within normal limits for both groups.
ANXIETY AND PAIN SENSATION

As presented in Table 6, mean anxiety levels before

the IMTM surgical procedure were 13.15 2.87 in
the control group and 13.42 3.09 in the musictreatment group. According to the Dental Anxiety
Scale, a score above 13 is categorized as high anxiety;
thus, both groups fell into that range. However, the
degree of pain perceived during and after the surgical
procedure was generally low for both groups. The
mean intraoperative pain scale scores were 1.63
1.08 for the music-treatment group and 1.83 0.99
for the control group, and the mean postoperative
perception of pain scores were 2.15 1.25 and
2.16 1.19 in the music-treated and control groups,
respectively. With the Student t test, no significance
in differences were found in perioperative perceptions of pain between the 2 groups (t 0.027, P

1042

MUSICAL INTERVENTION DECREASES PATIENT ANXIETY

Table 6. DIFFERENCE OF ANXIETY AND PAIN SENSATION ACCORDING TO MUSIC TREATMENT

Preoperative anxiety
Intraoperative anxiety
Intraoperative pain
Postoperative pain

Music Treatment

Nonmusic Treatment

t/P Value*

F/P Value

13.42 3.09
13.12 3.24
1.63 1.08
2.15 1.25

13.15 2.87
13.51 3.11
1.83 0.99
2.16 1.19

0.676/.498
0.910/.364
0.027/.979
0.104/.104

NA
4.226/.041
0.008/.928
NA

Abbreviation: NA, not available.

*Independent t test.
Analysis of covariance controlling preoperative anxiety as a covariance.
P .05.
Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral Maxillofac Surg 2011.

.979, for intraoperative pain perception; t 104, P

.104, for postoperative pain perception).
The mean preoperative anxiety level of the musictreated group was 13.42 3.09 before the surgery
and decreased to 13.12 3.24 during the operation,
whereas the mean anxiety level score of the control
group was 13.15 2.87 and increased to 13.51
3.11 during the operation. The Student t test also
showed that postoperative anxiety was not different
between the 2 groups (t 0.676, P .498). As
shown in Figure 1, regression analysis revealed that
preoperative anxiety levels significantly affected intraoperative anxiety levels (F 248.223, P .001) and
intraoperative perceptions of pain (F 6.521, P
.011). Accordingly, subsequent analysis of covariant
with preoperative anxiety as a covariant revealed that
musical intervention significantly lowered intraoperative anxiety in patients undergoing IMTM surgery (F
4.226, P .041).

Discussion
To achieve the best clinico-emotional results for
patients and to improve clinicianpatient relation-

FIGURE 1. Relations between perioperative anxiety and perception of pain. Regression analysis reveals that preoperative anxiety
has a direct effect on intraoperative anxiety and intraoperative
pain perception (P .05).
Kim et al. Musical Intervention Decreases Patient Anxiety. J Oral
Maxillofac Surg 2011.

ships and the quality of treatment, dental clinicians

should remain conscious of nonsurgical aspects of
treatment, such as patient anxiety levels, perceptions
of pain, and variation in vital signs, rather than focusing solely on successful surgical outcomes. In the
present study, we tested whether perioperative anxiety levels, perceptions of pain, and vital signs of
patients undergoing IMTM surgery are affected by
musical intervention, and whether this musical intervention could be identified as a viable anxiolytic
method in IMTM surgery. The main goal of this study
was to determine whether musical intervention could
control perioperative psychosomatic states of patients undergoing IMTM surgery, and subsequently,
whether vital signs, perioperative anxiety, and pain
perceptions could be controlled favorably during surgical extraction of an IMTM. Significantly smaller
changes of HR were found in the music intervention
group than in the control group. However, SBP and
DBP were not significantly affected by the music
intervention. Moreover, RR change was greater in the
music-treated group than in the control group. Accordingly, the first hypothesis, musical intervention
will induce smaller changes of the patients vital signs
during IMTM surgery, was partly supported. Nevertheless, there are some limitations in the ability to
support this hypothesis, which should be addressed.
First, several studies have found no effect of musical
interventions on vital signs during surgery involving
local anesthesia.17,25,26 Second, changes in vital signs
may be nonspecific physical responses, which could
be caused by local anesthetics, resulting in bradycardia, or sedation by blocking sympathetic functions. In
these conditions, the effects of music treatment on
vital signs, if any, might be negligible. In the present
study, although HR and RR were found to be significantly different between the 2 groups, changes in
vital signs across the surgical stages were within normal limits for both groups; it is difficult to extend
these findings to groups with clinically significant
changes in physiologic functioning.

KIM ET AL

Nevertheless, along with several other studies, this

study showed that patients vital signs change in accordance with the specific stage of the surgical procedure. Nichols27 reported that BP measurements
were generally higher at the start of a surgical procedure than at the end of the procedure, which was also
found in the present study. With respect to third
molar extraction, specific surgical step-dependent
variations of vital signs are reportedly caused by surgical step-specific pain or noise, such as in ostectomy
or tooth sectioning.28-30 This study also showed that
vital signs change significantly according to surgical
step. However, interestingly in this study, all vital
signs showed the highest value at the beginning of the
operation, that is, during the injection of the anesthetic solution and the first incision, and then decreased suddenly afterward. Clinically, these results
suggest that clinicians concerns and care should begin even before main surgical procedures, such as
ostectomy or odontotomy. There are some possible
causative factors to explain these phenomena. The
first possibility is that increases in BPs, HR, and RR
might be directly caused by the anesthetic solution,
which contains a vasoconstrictor, although some
studies examining the hemodynamic effects of local
anesthetics with epinephrine have reported no significant changes in HR or BP across the stages of surgery.31-33 In addition, the changes in vital signs across
surgical stages might be explained by endogenous
adrenalin release caused by a pain reflex to injection.
Although topical anesthetic solution was applied to
minimize the effect of injection pain, it was surely
possible that a patient might feel sharp pain not only
by the injection but by a decreased pain threshold
associated with stress and fear. Specifically, a patients
preoperative anxiety must be maximized by recognizing the start of an injection and induce significant
variations in vital signs at this surgical stage. Lastly,
changes in vital signs might be caused by certain
demographic factors, such as age, gender, and previous dental experience,34 but this possibility could
have been minimized by the homogeneity test in this
study. Anxiety related to dental procedures is a worldwide problem and presents a significant barrier to
dental care for people of all ages.21,35 In addition,
surgical treatments for diseases of the facial and oral
regions are linked to specific and intense fears for
many individuals.11,36,37 Unlike other fields of dentistry, IMTM surgery is perceived by patients as a
particularly aggressive treatment with a high possibility of anesthesia, bleeding, postoperative complications, and long postoperative recovery periods. Numerous studies have demonstrated that there is a
significant relation between perioperative anxiety levels and perioperative perceptions of pain in surgical
patients. Increased levels of preoperative anxiety are

1043
associated with increased intraoperative anesthetic
requirements,6 and there is a correlation between
high preoperative anxiety levels and high postoperative perceptions of pain.7-9 This study also showed
that preoperative anxiety levels were a significant
predictor of intraoperative anxiety levels and intraoperative perceptions of pain, emphasizing the importance of alleviating preoperative anxiety in patients
undergoing IMTM surgery. Subsequent analyses of
covariance controlling for preoperative anxiety levels
as the covariance partly confirmed the second hypothesis of this study, musical intervention will decrease perioperative anxiety levels and perceptions of
pain in patients undergoing IMTM surgery. The music-treated group definitely showed a significant decrease in intraoperative anxiety levels, whereas the
untreated control group showed an increase in anxiety levels during the operation. This result is compatible with previous study findings reporting that music
interventions decrease intraoperative anxiety levels in
locally anesthetized patients during surgery.17,38
However, the results of this study also suggest that
musical intervention had no effect on perioperative
perceptions of pain. Considering low levels of pain
perceptions throughout the IMTM surgery in both
groups, the pain threshold of a patient undergoing
IMTM surgery might not seriously, but minimally, be
affected by perioperative anxiety. Appreciation of
specific factors that may increase patients anxiety
levels may help clinicians to take the necessary precautions to provide optimal care for their patients.
Although typical anxiolytic strategies involve the administration of sedative drugs, there is little agreement on whether sedation is the optimum strategy,
because there are reports indicating that sedation
does not always decrease patients anxiety about the
operation.39,40 Moreover, according to Johren et al,41
patients who are sedated do not have the opportunity
to develop positive coping strategies for the stress to
come. Based on the findings of this study, it is
important to examine anxiety management in patients undergoing IMTM surgery by assessment of
perioperative anxiety levels, and alternative anxiolytic methods, such as musical interventions.
Although this study showed that music therapy is a
straightforward, noninvasive, and effective anxiolytic
strategy, some considerations for the use of music
therapy in IMTM surgery should be examined. Specifically, the direct effect of music therapy on patients
vital signs, intraoperative anxiety levels, and perioperative perceptions of pain was somewhat less than
expected. One possible explanation for this may be
that the abnormally high preoperative anxiety levels
in patients undergoing IMTM surgery did not allow
for the full intraoperative anxiolytic effects of the
music intervention. The average Dental Anxiety Scale

1044

MUSICAL INTERVENTION DECREASES PATIENT ANXIETY

score in general dental patients has been reported to

range from 7.3 to 8.7,42-44 whereas the perioperative
anxiety levels of patients undergoing IMTM surgery
tends to be significantly higher, as shown in this
study. Patients undergoing IMTM surgery generally
have severe emotional distress before surgery, which
may be related to the decreased efficiency of music
therapy during the IMTM procedure compared with
other surgical or dental procedures. In the present
study, the musical intervention began from the moment of the patients arrival at the operating room.
Accordingly, it is recommended that other music
interventions also begin before the main surgical
treatment to decrease emotional stress and lessen
preoperative anxiety. Numerous researchers have
recommended that clinicians consider patients music preferences and familiarity with selected music
to maximize the anxiolytic effects of music interventions.14,18,38 In the present study, patients musical preferences were easily surveyed using a list of
musical genres during a preoperative meeting. Snyder and Lindquist19 also recommended that it is
necessary for patients to select the appropriate
music volume to prevent discomfort and fatigue
during the intervention. In this study, a headset
with an auxiliary volume control button was used,
and patients could control the volume by themselves. Volume-controllable headsets are recommended over external speakers to avoid distracting
surgical staff members concentration during surgery. As a future study, a larger-scale study is recommended to discover the clinical usefulness of
music therapy. Specifically, it is necessary to evaluate the effect of music therapy on vital signs and
perioperative anxiety according to the trait anxiety
of a patient undergoing IMTM surgery.

9. Katz J, Poleshuck EL, Andrus CH, et al: Risk factors for acute
pain and its persistence following breast cancer surgery. Pain
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14. Steelman VM: Intraoperative music therapy: Effect on anxiety,
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15. Lepage C, Drolet P, Girard M et al: Music decreases sedative
requirement during spinal anesthesia. Anesth Analg 93:912,
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16. Marwick C: Leaving concert hall for clinic, therapists now test
musics charm. JAMA 275:257, 1996
17. Winter MJ, Paskin S, Baker T: Music reduces stress and anxiety
of patient in the surgical holding area. J Post Anesth Nurs
9:340, 1994
18. Stevens K: Patients perception of music during surgery. J Adv
Nurs 15:1045, 1990
19. Snyder M, Lindquist R: Complementary/Alterative Therapies in
Nursing (ed 5). New York, NY, Springer, 2006
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