An interesting article titled “Does Viewing a Third Molar Informed Consent Video Decrease Patients’ Anxiety?” appears in the Journal of Oral and Maxillofacial Surgery in 2018 written by Laskin et al. (vol. 76, pp. 2515-2517). The article discusses a study of 100 patients having impacted wisdom teeth removed and if watching a video during the informed consent process makes them more or less anxious.
The authors were interested in such a study because in the past watching a video during the informed consent process of wisdom teeth removal has decreased anxiety in some cases but in other cases has increased anxiety. Further, if patients are more anxious prior to surgery they can be uncooperative which can cause the surgeon stress and lead to longer surgeries.
In the study, 100 patients between 18 and 35 years of age having impacted wisdom teeth removed watched a video during the informed consent process. Prior to watching the video the patients were asked to complete a form asking them to grade their level of anxiety about the surgery as either calm, slightly anxious, moderately anxious, or very anxious. Similarly after the watching the video the patients were asked to again complete a form asking them to grade their level of anxiety about the surgery using the same rating scale as before. The authors then tabulated the results and analyzed the difference between the anxiety level before and after viewing the video for each patient. The video the patients watched was a video regularly used by the American Association of Oral and Maxillofacial Surgeons and produced by PBHS Dental Marketing. The video was 11 minutes long and discussed the diagnosis of impacted wisdom teeth teeth, the potential risks of not having wisdom teeth removed, what happens during treatment, complications that can occur and various anesthetic options. The video is designed to focus more on presenting the risks and complications of the surgery and anesthesia.
Of the 100 patients, a total of 47 indicated they were calm prior to viewing the video, 29 indicated they were slightly anxious prior to viewing the video, 15 indicated they were moderately anxious prior to viewing the video, and 9 indicated they were very anxious prior to viewing the video. After viewing the video, 29 of the 47 calm patients remained calm but 13 became slightly anxious, 3 became moderately anxious, and 2 became very anxious. After viewing the video, 15 of the 29 originally slightly anxious patients remain slightly anxious while 4 became calm, but 9 became moderately anxious and 1 became very anxious. After viewing the video, of the 15 initially moderately anxious patients, 8 remained moderately anxious, while 1 became calm and 3 became slightly anxious but 3 became very anxious. After viewing the video, of the 9 initially very anxious patients, 5 remained very anxious while 1 became slightly anxious and 3 became moderately anxious. This translated to increasing anxiety in 31% of the patients and decreasing anxiety in 12% of patients. In order to preform statistical analysis the authors also scored anxiety with 1 representing calm, 2 representing slightly anxious, 3 representing moderately anxious, and 4 representing very anxious. Based on these scores the authors found the average anxiety level before viewing the video was 1.86 and after viewing the video, the average anxiety score had increased to 2.11 which was a statically significant increase in anxiety.
The authors state that they are not sure what information in the video lead more patients to become more anxious then before viewing the video. One possibility they put forth is the patient’s hearing more details about the surgical procedure. Another possibility is that when a patient hears about complications that can occur such as numb lips and fracture jaws this could lead to more anxiety. The authors say:
” Because a certain amount of negative information needs to be included in an informed consent video and this can increase anxiety, it is important to use other measures to calm the patient. “
In a letter to the editor response to the article by Laskin, an article titled “Third Molar Patient Education Materials,” written by Lee et al. appearing in the Journal of Oral and Maxillofacial Surgery in 2019 (vol. 77, pp. 5-6) looked at patient education materials (PEMs) online. Specifically they identified 54 websites using search terms including ‘‘third molar’’ and ‘‘wisdom teeth.’ They found that 46 of the websites (85.2%) mentioned benefits, while 30 of the websites (55.6%) mentioned postoperative care, 25 of the websites (46.3%) mentioned risks, and 20 of the websites (37.0%) discussed the surgical procedure. The authors state
“In addition, many online PEMs are already highlighting the benefits of treatment whereas information about the risks and surgical procedure itself are less commonly reported.”
The findings of the study by Laskin et al. do not seem particularly surprising. The 100 patients in the study seem to have already decided they were proceeding with having impacted wisdom teeth removed prior to the informed consent consultation and viewing the video. One could argue that that is not how informed consent is really supposed to work, see for example the post Informed Consent in Dentistry: Can Change Impact Personal Injury Cases?. The informed consent process is supposed to be about presenting all the options, in this case 1) retaining impacted wisdom teeth or 2) removing impacted wisdom teeth. Perhaps the video is heavily slanted towards assuming the patient is removing impacted wisdom teeth whereas if it were less biased the patient would receive information from both sides and feel more like they are in control of making the decision. In addition, perhaps when the video discuss complications it is lacking on presenting the incidence or the likely chance of occurrence of such complications as fractured jaws. Even so many of the patients viewing these videos may have no idea about such complications prior to the video informing them so it is not that surprising that such new information could make them more anxious. Perhaps Lee is trying to make this last point that many of these patients don’t have good resources they may have looked at online prior to the consultation appointment. It is also not clear how many days prior to surgery the 100 patients had the consultation appointments but perhaps another round of the anxiety questionnaire a day or two after the consultation but still prior to the surgery would have been informative.