Psychological contributors to pain before,during,and after endodontic procedures: A scoping review

Abstract

Background

Despite an increasingly biopsychosocial approach to pain management in healthcare, limited research exists on psychological features in dentistry including endodontic-related pain. This study aimed to identify the scope of evidence on the relationship of psychological variables to pain associated with dentistry specifically endodontics, as a first step towards addressing them for treatment.

Methods

This scoping review was conducted according to the JBI Manual for Evidence Synthesis. Literature searches were performed in MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, Cochrane, and CINAHL, alongside grey literature sources, including ProQuest, ClinicalTrials.gov, and conference materials, reference lists, medRxiv pre-prints, EBSCO theses, and data from clinical trial registers such as ClinicalTrials.gov and Cochrane trials (via Ovid) (from inception to February 2025). Two independent reviewers screened records, and data extraction was cross-verified. The protocol was registered on Open Science Framework (DOI: 10.17605/OSF.IO/FSRJP).

Results

Forty eight studies were included. Twelve broad psychological constructs were evaluated in relation to pre, during, and post-endodontic pain: pain expectancies, positive treatment expectancies, depression, anxiety, positive and negative mood (affect), beliefs about pain, desire for control of dental treatments, perceptions of dentists, somatic focus or awareness, pain coping strategies, personality, and psychiatric diagnoses. Pre-procedural pain was most frequently linked to anxiety. Procedural and post-procedural pain was consistently associated with anxiety, pain expectations, depression, and pain beliefs.

Conclusion

A variety of psychological factors have been investigated in relation to endodontic pain at different time-frames. Whilst associations between endodontic pain and psychological constructs were found, further research is needed to evaluate the strength of these associations, and the scope of evidence for interventions designed to address these psychological contributors to pain in dental practice. Identifying psychological contributors to endodontic pain can enhance pain prediction, patient communication, and clinical care strategies.

Keywords

psychological pain endodontics dentistry dental management

Introduction

Effective pain management is crucial in clinical endodontics,¹ as research consistently links pain during dental procedures, including endodontics, to complications, persisting pain, and flare-ups.^2–4 Current guidelines for dental pain management focus primarily on pharmacological approaches⁵: Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended in combination with paracetamol as first-line treatments,^5–7 and opioids like codeine and oxycodone as second-line treatments.^5–7 Report of 5 to 49% of pain at different stages of endodontic procedures^2,8 suggests that there is a need to improve our approach to pain management in dentistry.⁴

The fear-avoidance and cognitive-affective models of pain provide a conceptual framework for understanding how psychological constructs such as anxiety, depression, expectations, and feelings of helplessness shape the experience of endodontic pain. The fear-avoidance model suggests that these fear-related psychological constructs amplify pain by creating hypervigilance to threat and promoting avoidance behaviours.⁹ Also, the cognitive-affective model of pain suggests that beliefs about pain and anxiety could modulate pain experience because negative appraisals (e.g. expectation of uncontrollability) heighten attention to pain, increase threat perception, and activate emotional distress, which in turn intensify central nociceptive processing.¹⁰ Both these models support biopsychosocial approaches to pain management. Also medical literature provides substantial evidence that psychological factors such as preoperative anxiety, depression, and pain catastrophizing are associated with both greater acute procedural and post-operative pain and longer term chronic postsurgical pain.^11–13

Recognizing pain as a biopsychosocial phenomenon is an important first step towards improving pain management in dentistry.¹⁴ A large body of research demonstrates the modulation of pain by a range of psychological factors.^15–17 However, knowledge of psychological to endodontic pain remains limited.¹⁸ A systematic review found that psychological factors (e.g. Catastrophizing, beliefs, coping, and mood) are strong predictors in the transition from acute to chronic pain across many medical conditions.¹⁹

This paper focuses on the psychological aspects of pain and aims to address this gap in endodontics by using a systematic scoping review methodology to describe available research on psychological variables in endodontic-related pain. Specifically, the objectives of this review were to investigate psychological variables related to periprocedural (pre-procedural, procedural, and post-procedural) endodontic pain.

This initiative seeks to enhance the understanding of the psychological aspects in endodontic pain to guide pain management practices in this specialized field and assess the research body’s sufficiency for a potential systematic review and meta-analysis. Due to concerns about feasibility, the current review excludes an examination of social contributors to pain.

Materials and methods

To uphold rigorous standards, our scoping review adhered to the Joanna Briggs Institute (JBI) Reviewer’s Manual²⁰ and PRISMA Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines.²¹ The research protocol was registered on Open Science Framework (DOI number: 10.17605/OSF.IO/FSRJP). The focus was on exploring the link between psychological factors and pain measures in English-language studies.

Eligibility criteria, population, concepts, and context

The inclusion criteria encompassed studies involving patients undergoing endodontic procedures, including various study designs such as cohort, case-control, cross-sectional, clinical trials (interventional, observational), systematic reviews, and meta-analyses, with an evaluation of at least one psychological factor before, during, or after the endodontic procedure. Pain assessment for pre-procedural, procedural, or post-procedural, and reporting of the association between psychological factors and pain, was also required. Only studies published in English were considered. Exclusion criteria included case reports, case series, animal studies, letters, comments, editorials, and non-systematic reviews.

Search strategy

The relevant keywords were selected by reviewing relevant articles and in consultation with a librarian. We conducted a pilot search on a random sample of 50 records retrieved from PubMed, and achieved 80% agreement in screening.²⁰ The search strategy was then refined based on discrepancies identified during team discussions with experts in the field (Appendix 1).

We performed a search of multiple databases, including MEDLINE (via PubMed), EMBASE (via Ovid), PsycINFO (via Ovid), Web of Science (all databases), Scopus, Cochrane Database of Systematic Reviews (via Ovid), and CINAHL (via EBSCOhost). For the Grey Literature, we searched reference lists of the included studies as well as pre-prints available on medRxiv, theses via ProQuest Dissertations and Theses/EBSCO Open Dissertations, clinical trial registers such as ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials (via Ovid), and conference materials including abstracts and proceedings via the Conference Proceedings Citation Index (via Web of Science) and Scopus (from inception to February 2025). To ensure the final search strategy adhered to the recommended guidelines, we employed the Peer Review of Electronic Search Strategies (PRESS) Checklist.²¹

Study selection

We used EndNote and Covidence Systematic Review software²² for duplicate removal and screening. Literature selection followed predetermined eligibility criteria through a two-pass screening of titles, abstracts, and full texts, resolving disagreements through consensus by two-reviewer or third-reviewer intervention.

Data extraction

There was no methodological quality or bias evaluation of studies included, in line with JBI²⁰ guidelines for scoping reviews. A single reviewer extracted the data, with a second reviewer cross-verifying data in a random sample. Key information was recorded in a charting table for a descriptive summary aligned with the aims and objectives of the review.

Results

The screened search ended with 48 articles for the final data extraction (Figure 1).

Figure 1.

Flow chart of the studies selection process and screening.

Characteristics of the selected studies

The majority of the studies, comprising over two-thirds, are observational studies, predominantly prospective, with four retrospective studies and four cross-sectional studies, supplemented by four clinical trials. Fourteen studies¹⁴ were from North America (the United States and Canada), with 17 conducted in Europe (United Kingdom, Germany, France, Spain, Croatia, The Netherlands, Sweden, and Denmark), 9 conducted in Asia (Australia, China, India, Japan, Korea, Singapore, Taiwan), 4 conducted in the Middle East (Saudi Arabia, Israel, Iran), and 4 across multiple continents.

Study participants

Studies included sample sizes ranging from 30 to 300 patients for observational studies and 1500 to 4800 for national surveys. Participant ages ranged from 6 to 86 years (mostly adults). Samples were 55% female on average, with 80% of patient cohorts coming from university educational dental clinics/hospitals and the remaining 20% from private surgeries.

Pain measurement

Various self-reporting scales measured pain at different stages of the endodontic procedure (pre-procedural, procedural, and post-procedural). Pain intensity, frequently assessed by the Visual Analog Scale,²³ was the most common outcome measured, as shown in Figure 2.

Figure 2.

Details of scales used for pain measurement based on numbers.

Psychological constructs

Data were extracted from 48 studies (Table 1). Among the 48 studies identified, 11 investigated psychological variables associated with pre-procedural pain, 22 investigated psychological variables associated with procedural pain, and 24 focused on psychological variables associated with post-procedural pain (most studies investigated the predictors at one time frame of endodontic treatment, while nine studies investigated pain at two time frames). Psychological variables were organized under 12 higher-level psychological constructs, including ‘anticipated or expected pain’, ‘positive treatment expectation’, ‘depression’, ‘anxiety’ (anxiety encompasses various psychological variables such as state or trait anxiety, dental anxiety, fear, pain-related anxiety [like pain catastrophizing, fear of pain, psychological disability, social disability, and psychological discomfort], oral health–related anxiety, social functioning, and stress, these anxiety variables were grouped together given their strong correlation and frequent co-occurrence, to allow for easier synthesis), ‘beliefs about pain management’ (which encompasses variables such as the belief that stress exacerbates pain, expectations regarding the necessity of opioid medications for endodontic pain, and anticipations regarding pain relief after endodontic treatment), ‘desire for control of dental treatments’, ‘perceptions of dentists’ (this construct includes both perceptions of dentists and empathy of dentist), ‘somatic focus or awareness’, ‘positive and negative affect’ (often described as mood variable in the research), ‘pain coping strategies’, ‘personality’, and ‘psychiatric diagnosis’.

Table 1.

Details of data extraction.

Author, year	Patients	Procedures	Psychological factors and measures	Pain measures	When the pain variable measured	Results
Ahmed et al., 2024	n = 100, F 55%	Endodontic treatment	Anxiety with MDAS and STAI	Pain measured with VAS	Post-procedural	Positive correlation
	n = 100, F 55%	Including RCT
	Mean age 42	Including RCT
Allebring et al., 1995	n = 48, F 90%	RCT; endodontics	Disease conviction measured with IBQ	Pain intensity measured with Likert scale	Post-procedural (time varied, months in most cases)	No correlation
Allebring et al., 1995	Age 30–81 y	RCT; endodontics	Disease conviction measured with IBQ	Pain intensity measured with Likert scale	Post-procedural (time varied, months in most cases)	No correlation
Alroomy et al., 2020	n = 95, F 56%	RCT	Anxiety measured with VAS	Pain intensity measured with ‘VAS-P’	Pre-procedural, before start of treatment in waiting room	Positive correlation
Alroomy et al., 2020	Age 18–>60	RCT	Anxiety measured with VAS	Pain intensity measured with ‘VAS-P’	Pre-procedural, before start of treatment in waiting room	Positive correlation
Applebaum and Maixner, 2009	n = 95, F 43%	RCT	Depression measured with BDI, somatization measured with PILL, anxiety measured with STAI	Pain intensity measured with Likert scale and Gracely box scale	Post-procedural, pain measured for 5 days consequently	Trait anxiety was correlated with post-operative pain
	Mean age 48 y
	Age 30–81 y
Arntz et al., 1990	n = 40, F 50%	Dental treatment including RCT	Dental anxiety with DAS, expected pain with VAS, and fear with VAS	Pain intensity measured with VAS	Procedural, immediately after about during treatment pain	Higher anxiety associated with overpredicted pain
Arntz et al., 1990	Mean age 34 y	Dental treatment including RCT		Pain intensity measured with VAS	Procedural, immediately after about during treatment pain	Higher anxiety associated with overpredicted pain
Attar and Baghdadi, 2015	n = 39, F 49%	Pulpotomy	Dental anxiety with MDAS	Pain measured using Wong-Baker FACES	Procedural, at different stages of RCT	No associations
Attar and Baghdadi, 2015	Mean age 6 y	Pulpotomy	Dental anxiety with MDAS	Pain measured using Wong-Baker FACES	Procedural, at different stages of RCT	No associations
Baron et al., 1993	n = 188, F 60%	RCT	Control over dental treatment with IDCI	Pain intensity measured with VAS	Procedural, immediately after for during treatment pain	Negative correlation between desire for control or felt control with pain
Baron et al., 1993	Mean age 41 y	RCT	Control over dental treatment with IDCI	Pain intensity measured with VAS	Procedural, immediately after for during treatment pain
Brawley, 2019	n = 108, F 56%	Dental treatment including RCT	A self-report survey about drugs	Pain measured using DVPRS	Pre-procedural	Positive correlation
Brawley, 2019	Mean age 39 y	Dental treatment including RCT	A self-report survey about drugs	Pain measured using DVPRS	Pre-procedural	Positive correlation
Chandraweera et al., 2019	n = 69, F 61%	RCT	Expected pain measured with modified VAS	Pain measured with modified VAS	Procedural, after about during treatment pain	No correlation
Chandraweera et al., 2019	Mean age 49 y	RCT	Expected pain measured with modified VAS	Pain measured with modified VAS	Procedural, after about during treatment pain	No correlation
Cho et al., 2017	n = 44, F 64%	Apical surgery	Dental anxiety measured with MDAS	Pain measured with NRS	Procedural, straight after insertion and after injection asked about insertion and injection pain	Positive correlation
Cho et al., 2017	Mean age 39 y	Apical surgery	Dental anxiety measured with MDAS	Pain measured with NRS		Positive correlation
Daline et al., 2020	n = 27, F 46%	RCT	Fear and optimism about the outcome with Likert scale	Pain measured with Likert scale	Post-procedural, after 6 months anytime	Positive correlation between fear and pain
Daline et al., 2020	Mean age 46 y	RCT	Fear and optimism about the outcome with Likert scale	Pain measured with Likert scale	Post-procedural, after 6 months anytime	Positive correlation between fear and pain
De Oliveira et al, 2024	n = 150, F 38 to 52%	RCT	Dental anxiety with MDAS	Pain measured with VAS and efficacy of injection	Pre-procedural and procedural	Positive correlation
Dou et al., 2018	n = 130, F 53%	Endodontics	Dental anxiety with MDAS and CARS	pain intensity measured with VAS	Pre and procedural (immediately after for during RCT pain)	Positive correlation for both
Dou et al., 2018	Mean age 42 y	Endodontics	Dental anxiety with MDAS and CARS	pain intensity measured with VAS	Pre and procedural (immediately after for during RCT pain)	Positive correlation for both
Edwards et al., 2004	n = 46, F 67%	Emergency RCT	Catastrophizing with CSQ	Pain measured with NRS.	Pre-procedural	No correlation
Edwards et al., 2004	Mean age 36 y	Emergency RCT	Catastrophizing with CSQ	Pain measured with NRS.	Pre-procedural	No correlation
Edwards et al., 1999	n = 46, F 67%	Emergency RCT	Anxiety with STAI	Pain measured with NRS	Pre- and post-procedural	No correlation
	n = 46, F 67%		Mood with POMS-Bi and pain coping with CSQ
	Mean age 36 y		Mood with POMS-Bi and pain coping with CSQ
Eli et al., 1997	n = 92, F 38%	Dental treatment	State and trait anxiety with STAI, dental anxiety with DAS	Pain threshold, measured with VAS	Procedural	No correlation
	n = 92, F 38%	Including RCT
	Mean age 28 y	Including RCT
Farias et al., 2024	Four articles	Endodontics including RCT	Dental anxiety with MDAS, CDAS, SDAI, and VAS	Pain measured with VAS	Pre and procedural	Two studies found positive correlation
(Systematic review for pre and procedural pain and dental anxiety, all 4 studies included in this table)	471 total patients	Endodontics including RCT	Dental anxiety with MDAS, CDAS, SDAI, and VAS	Pain measured with VAS	Pre and procedural	Two studies found positive correlation
Gastmann et al., 2024	n = 60, all female (pregnant)	RCT	Dental anxiety with DAS	Pain measured with NRS	Pre- and post-procedural	For anxiety, no correlation
Gastmann et al., 2024	n = 60, all female (pregnant)	RCT	Catastrophizing with PCS	Pain measured with NRS	Pre- and post-procedural	Positive correlation for catastrophizing and post-procedural
Georgelin-Gurgel et al., 2009	n = 60, F 58%	RCT	Anxiety and discomfort and stress with VAS	Pain measured with VAS	Procedural, measured after about during procedural pain	No correlation
Georgelin-Gurgel et al., 2009	Mean age 44 y	RCT	Anxiety and discomfort and stress with VAS	Pain measured with VAS	Procedural, measured after about during procedural pain	No correlation
Gochenour and McNeil, 2003	n = 63, F 56%	RCT	Fear with NRS	Pain measured with NRS	Procedural, at needle insertion, anaesthetic deposition (straight after), and access cavity preparation (not sure when exactly)	No correlation
Gochenour and McNeil, 2003	Mean age 43 y	RCT	Fear with NRS	Pain measured with NRS		No correlation
Khademi et al., 2021	n = 165, F 73%	Endodontics	Depression and anxiety with HADS, personality traits with NEO five-factor IS	Pain measured with VAS	Procedural,	Positive correlation with depression and neuroticism
	n = 165, F 73%				Pain was measured during procedure at needle insertion
	Mean age 35 y				Pain was measured during procedure at needle insertion
Khoo et al., 2020	n = 150, F 45%	RCT or apical surgery	Psychological discomfort, psychological disability with OHIP-14	Pain measured with OHIP-14	Pre-procedural and post-procedural	Positive correlation with pre-procedural pain
Khoo et al., 2020	Mean age 52 y	RCT or apical surgery		Pain measured with OHIP-14	Pre-procedural and post-procedural	Positive correlation with pre-procedural pain
Klages et al., 2004	n = 97, F 57%	Tooth extraction or RCT	Dental anxiety with DAS, and expected pain with NRS	Affective and sensory pain measured with PES	Post-procedural	Positive correlation
Klages et al., 2004	Mean age 39 y	Tooth extraction or RCT	Dental anxiety with DAS, and expected pain with NRS	Affective and sensory pain measured with PES	Post-procedural	Positive correlation
Law et al., 2014	n = 652, F 59%	RCT	Stress measured with Likert scale	Pain intensity measured with Likert scale	Post-procedural, measured 1 week after treatment	Positive correlation
Law et al., 2014	Mean age 48 y	RCT	Stress measured with Likert scale	Pain intensity measured with Likert scale	Post-procedural, measured 1 week after treatment	Positive correlation
Laxmi et al., 2021	n = 46, F 43%	Endodontics	Dental anxiety with DAS	No details	Pre-procedural	Positive correlation
Laxmi et al., 2021	Mean age 46 y	Endodontics	Dental anxiety with DAS	No details	Pre-procedural	Positive correlation
LeClaire et al., 1988	n = 82, F 78%	RCT	Fear with Likert scale	Pain measured with Likert scale	Post-procedural, by a questionnaire	Positive correlation
LeClaire et al., 1988	Mean age NR	RCT	Fear with Likert scale	Pain measured with Likert scale	Post-procedural, by a questionnaire	Positive correlation
Lin et al., 2017	35 articles, F 55%	Dental treatments including RCT	Anxiety, fear, and expected pain measured in various ways across studies	Pain measured with various scales	Pre-, procedural, and post-procedural	Positive correlation of anxiety and pain
Lin et al., 2017	Mean age 31 y	Dental treatments including RCT		Pain measured with various scales	Pre-, procedural, and post-procedural	Positive correlation of anxiety and pain
Maggirias and Locker, 2002	n = 1422, F 58%	Dental treatment including RCT	Dental anxiety with DAS	Pain measured with Likert scale	Pre- and post-procedural, post at day 2, 4 and 7	Positive correlation
Maggirias and Locker, 2002	Mean age 50	Dental treatment including RCT	Dental anxiety with DAS	Pain measured with Likert scale	Pre- and post-procedural, post at day 2, 4 and 7	Positive correlation
Mannan and Greenspan, 2019	n = 39, F 59%	RCT	Anxiety/depression with HADS	Pain intensity measured with VAS	Pre- and post-procedural (immediately after treatment)	No correlation
Mannan and Greenspan, 2019	Mean age 44	RCT	Anxiety/depression with HADS	Pain intensity measured with VAS	Pre- and post-procedural (immediately after treatment)	No correlation
Mijailovic and Kolak, 2024	n = 140, F 42%	RCT	Depression, anxiety, and stress measured with (DASS)-21	Pain measured with VAS	Post-procedural	For anxiety, positive correlation
Mijailovic and Kolak, 2024	Mean age 39 y	RCT	Depression, anxiety, and stress measured with (DASS)-21	Pain measured with VAS	Post-procedural	Stress and depression, no correlation
Miura et al., 2018	n = 383, F 85%	Dental treatment including RCT	Psychiatric diagnoses with ZSRDF	Pain measured with SF-MPQ	Post-procedural,	Positive correlation
	n = 383, F 85%				Post-emergency treatment, not exact time recorded
	Mean age 54				Post-emergency treatment, not exact time recorded
Mohorn et al., 1995	n = 30, F 53%	Emergency endodontics	Anxiety with state-trait STAI and CSQ and POMS	Pain measured with MPI	Pre- and post-procedural	Positive correlation between negative mood and pain
Mohorn et al., 1995	Mean age NR	Emergency endodontics	Anxiety with state-trait STAI and CSQ and POMS	Pain measured with MPI	Pre- and post-procedural	Positive correlation between negative mood and pain
Murillo-Benítez et al., 2020	n = 175, F 51%	RCT	Dental anxiety with S-DAI	Pain measured with VAS	Pre-procedural (immediately after treatment) and procedural	Positive correlation
Murillo-Benítez et al., 2020	Age range, 18 to 68 y	RCT	Dental anxiety with S-DAI	Pain measured with VAS	Pre-procedural (immediately after treatment) and procedural	Positive correlation
Nixdorf et al. (Nixdorf et al., 2016)	n = 651, F 59%	RCT	Fear of appointment with a Likert scale	pain intensity measured using GCPS	Pre- and post-procedural, pain measured at 6 months after treatment	Negative correlation of optimism about the procedure and anxiety
Nixdorf et al. (Nixdorf et al., 2016)	Mean age 48	RCT	Fear of appointment with a Likert scale	pain intensity measured using GCPS
Nogueira et al., 2024	n = 62	RCT	Psychological discomfort (stress, anxiety, and difficulty relaxing) was assessed using the OHIP-14	Pain measured with NRS	Procedural	Positive correlation
Nogueira et al., 2024	Mean 34 y	RCT		Pain measured with NRS	Procedural	Positive correlation
Peretz et al., 1998	n = 98, F 57%	RCT	Dental anxiety with DAS	Pain measured with a Likert scale	Pre-procedural (not exact timing)	No correlation
Peretz et al., 1998	Mean age 45	RCT	Dental anxiety with DAS	Pain measured with a Likert scale	Pre-procedural (not exact timing)	No correlation
Perković et al., 2014	n = 66, F 58%	Endodontics	Anxiety with CDAS, expected pain with Likert scale	Pain measured with VAS	Pre and procedural	No correlation for procedural and positive correlation for pre
Perković et al., 2014	Mean age 34	Endodontics	Anxiety with CDAS, expected pain with Likert scale	Pain measured with VAS	Pre and procedural
Philpott et al., 2019	n = 198, F NR	RCT or RCT retreatment	Pain catastrophizing with PCS	Pain measured using SF-MPQ	Post-procedural, pain measured 5 to 12 months	No correlation
Philpott et al., 2019	Mean age NR	RCT or RCT retreatment	Pain catastrophizing with PCS	Pain measured using SF-MPQ	Post-procedural, pain measured 5 to 12 months	No correlation
Pillai et al., 2020	n = 37, F 65%	Extraction or endodontics	Distress and somatic symptom severity and psychological discomfort with PHQ-4/PHQ-15), and OHIP-49 and PCS and BDI-II and STAI	Pain measured with MPQ) and alsoGCPS	Post-procedural	Positive correlation between the examined psychological predictors and pain
Pillai et al., 2020	Mean age 45	Extraction or endodontics		Pain measured with MPQ) and alsoGCPS	Post-procedural
Rahman et al., 2011	n = 337, F NR	Dental treatments including RCT	Anxiety and depression with HADS	Pain measured with VAS	Post-procedural, pain recorded in 20 days diary	Positive correlation
Rahman et al., 2011	Mean age NR	Dental treatments including RCT	Anxiety and depression with HADS	Pain measured with VAS	Post-procedural, pain recorded in 20 days diary	Positive correlation
Sorrell and McNeil, 2003	n = 104, F 58%	RCT	Fear with NRS, fear of pain with FPQ-III and DFS	Pain measured with NRS	Pre-, procedural, and post-procedural	No correlation
Sorrell and McNeil, 2003	Mean age 44	RCT	Fear with NRS, fear of pain with FPQ-III and DFS	Pain measured with NRS	Pre-, procedural, and post-procedural	No correlation
Silva et al. 2023	n = from 58 to 100	RCT	Anxiety with CDAS	Pain measured with HF-VAS	Procedural	Positive correlation
Silva et al. 2023	n = from 58 to 100	RCT	Anxiety related to injection with MDAS	Pain measured with HF-VAS	Procedural	Positive correlation
Thom et al. (Thom et al., 2000)	n = 50, F 52%	Extraction or endodontics	Dental anxiety with DAS and fear with DFS and STAI	Pain intensity measured with VAS	Post-procedural	No correlation
	n = 50, F 52%				Measured immediately after, 1 week and 1 month after
	Mean age 30				Measured immediately after, 1 week and 1 month after
Vitali et al., 2024	n = 154, F 54.5%	RCT	Dental anxiety with DAS	Pain measured with	Post-procedural	All psychological predictors had positive correlation
	n = 154, F 54.5%		Dental fear with DFS	NRS
	Mean age 33 y		Sense of coherence with SOC-13	NRS
Watkins et al., 2002	n = 333, F 61%	Endodontics	Stress with STAI and IDCI	Pain measured with VAS	Procedural, measured immediately about procedural pain	Positive correlation
Watkins et al., 2002	Mean age 45	Endodontics	Stress with STAI and IDCI	Pain measured with VAS	Procedural, measured immediately about procedural pain	Positive correlation
Weitz et al., 2020	n = 531, F NR	RCT	Fear with Likert scale	Pain measured with Likert scale	Pre-procedural and procedural	Positive correlation
Weitz et al., 2020	Mean age 47	RCT	Fear with Likert scale	Pain measured with Likert scale	Pre-procedural and procedural	Positive correlation
Wu et al., 2022	n = 35, F 57%	Emergent endodontics	Anxiety with NRS	Pain measured with NRS	Pre- and post-procedural	Positive correlation
Wu et al., 2022	Mean age 46	Emergent endodontics	Anxiety with NRS	Pain measured with NRS	Pre- and post-procedural	Positive correlation
Yang et al., 2016	n = 4866, F 56%	Dental treatments including RCT	Depression with Likert scale	Pain measured with VAS	The data is from a national survey; the exact time of measurement is not recorded	Positive correlation
Yang et al., 2016	Mean age 45	Dental treatments including RCT	Depression with Likert scale	Pain measured with VAS		Positive correlation

All scales abbreviations: Illness Behavioural Questionnaire (IBQ), Visual Analog Scale (VAS), Depression with Depression Index (BDI), Somatization with Pennebaker Inventory of Limbic Languidness (PILL), State-Trait Anxiety Inventory (STAI), Modified Dental Anxiety Scale (MDAS), Wong-Baker FACES, Iowa Dental control Index (IDCI), Defense and Veterans Pain Rating Scale (DVPRS), Numerical Rating Scale (NRS), Coping Strategies Questionnaire (CSQ), Thermal pain onset (TPO) and tolerance (TPT), Clinical Anxiety Rating Scale (CARS), the Profile of Mood States-Bipolar (POMS-Bi), Dental Anxiety Scale (DAS), Hospital Anxiety and Depression scale (HADS), the short form of NEO Five-Factor Inventory scale (NEO Five -Factor I), Thermal pain onset (TPO) and tolerance (TPT), Oral Health Impact profile 14 (OHIP-14), the Patient Health Questionnaire 4 and 15 (PHQ-4/PHQ-15, Corah’s Dental Anxiety Scale (CDAS), Pain Experience Scale (PES), Zung’s self-rating depression scale (ZSRDS), Multidimensional Pain Inventory (MPI), Graded Chronic Pain Scale (GCPS), the Oral Health Impact Profile 49 (OHIP-49), Pain Catastrophizing Scale (PCS), the Beck Depression Inventory-II (BDI-II), Fear of Pain Questionnaire-III (FPQ-III), Dental Fear Survey (DFS), Sense of coherence-13 (SOC-13).

Taken together, the evidence suggested that psychological constructs had influence on endodontic pain. Pre-procedural pain appears to have association with two constructs of anxiety and ‘beliefs about pain management’. Procedural pain showed the stronger associations with anticipatory cognitions such as expected pain, alongside anxiety, depression, and some other constructs mentioned. Post-procedural pain demonstrated the most consistent psychological influences, particularly anxiety, coping strategies, and desire for control, highlighting the role of affective and behavioural factors after treatment (Table 2). Appendix 1 shows the search codes used in different databases and Appendix 2 describes the scales used to measure each of the reported psychological variables associated with pre-procedural, procedural, and post-procedural pain.

Table 2.

Summarized comparison of psychological constructs found associated with pre-procedural, procedural, and post-procedural pain.

Pre-procedural pain	Psychological construct	Subtype insights	Number of studies and Number of studies with significant correlation
	Anxiety	Various predictors: State anxiety (2 studies), dental anxiety (7 studies), oral health–related anxiety (1 study). Anxiety linked to fear of pain, procedural concerns, and psychological discomfort	10 studies
			6/10 studies showed correlation
	Beliefs about pain management	Expectations regarding opioid use and its necessity linked with pre-procedural pain anticipation	1 study
			1/1 study showed correlation
Procedural pain	Anxiety	Various predictors: Procedural pain linked to fear, dental phobia, and pre-existing anxiety. Studies used tools such as VAS and anxiety-specific questionnaires	18 studies
			9/18 studies showed correlation
	Depression	Indicators such as emotional states and psychological predispositions (e.g. lack of coping mechanisms) linked to pain intensity	2 studies
			2/2 studies showed correlation
	Expected pain	Predictors included prior experiences and procedural expectations. Tools: PES, NRS, VAS	5 studies
			4/5 studies showed correlation
	Positive treatment expectations	Linked to patient optimism regarding outcomes and reduced procedural distress. Measured via pre-treatment surveys	One study
			1/1 study showed correlation
	Personality	Neuroticism as a predictor. Tools included personality trait surveys	One study
			1/1 study showed correlation
Post-procedural pain	Anxiety	Subtypes: Dental, state, trait, and anticipatory anxiety. Predictors included fear of post-treatment pain and stress	18 studies
			14/18 studies showed correlation
	Depression	Linked to chronic pain and reduced coping ability. Tools: HADS, BDI-II	7 studies
			4/7 studies showed correlation
	Expected pain	Relief expectations often influenced by prior experiences and emergency treatments	One study
			0/1 study showed correlation
	Positive treatment expectations	Optimism about outcomes and reduced long-term pain reported	Two studies
			1/2 studies showed correlation
	Desire for control	Control over treatment linked to reduced anxiety and pain severity. Tools: ICDI	Two studies
			2/2 studies showed correlation
	Perceptions of dentists	Empathy and professionalism linked to lower pain perception	Two studies
			2/2 studies showed correlation
	Somatic focus or awareness	Chronic pain conditions linked to heightened somatic awareness. Mixed findings overall	Three studies
			1/3 studies showed correlation
	Psychiatric disease	Significant psychiatric predictors included melancholy and stress. Tools: National surveys	One study
			1/1 study showed correlation
	Pain coping strategies	Coping inefficacy (e.g. high avoidance) linked to increased pain severity. Tools: CSQ	Two studies
			2/2 studies showed correlation
	Beliefs about pain management	Stress as a pain exacerbator identified as a key predictor	One study
			1/1 study showed correlation
	Positive and negative affect	Mood predictors (positive or negative) showed minimal correlation with outcomes	Two studies
			0/2 studies showed correlation

Psychological constructs associated with pre-procedural pain

Two psychological constructs – anxiety and beliefs about pain – were investigated in association with pre-procedural pain.^24–31

Anxiety

Ten studies investigated various forms of anxiety in relation to pre-procedural pain. State anxiety was measured in two studies,^24,31 while dental anxiety was measured in seven studies,^{27–30,32,33} and one study²⁶ measured oral health–related anxiety. Six of the 10 studies reported a correlation between some form of anxiety and pre-procedural pain of endodontics.^{24,26–28,31}

Beliefs about pain management

One study²⁵ measured patient perceptions of pain relief and expectations of receiving an opioid medication together with pre-procedural pain. The study reported a positive relationship between the expectation of receiving an opioid medication and pre-procedural pain.

Psychological constructs associated with procedural pain

Numerous studies investigated the association between psychological variables and procedural pain, with 20 studies identified in this review.^{18,28,30,34–50} The five psychological constructs investigated for procedural pain were anxiety, depression, expected pain, positive treatment expectations, and personality.

Anxiety

Eighteen studies investigated the association between various forms of anxiety and procedural pain^{18,28,30,34–44,46,48–50} with mixed results. Of these, 9 out of 18 studies reported a significant positive association between anxiety and procedural pain.

Depression

Two studies^42,45 reported a positive correlation between depression and procedural pain.

Expected pain

Expected pain was evaluated in relation to procedural pain of endodontic treatment in five studies.^{36,39,43,46,47} Expected pain was measured using various tools including visual analog scales (VAS), numerical rating scales (NRS), and the Pain Expectation Scale (PES). Four of these studies^36,39,43,47 showed a positive association between pain expectation and procedural pain.

Positive treatment expectations

Weitz et al.⁴⁸ was the only study in this category that measured the expected outcome of root canal therapy for procedural pain, reporting a significant association between higher outcome expectancy and anaesthesia failure or procedural pain.

Personality

Personality was investigated by one study,⁴² which reported a positive correlation between neuroticism scores and pain experience during needle insertion for injection or procedural pain.

Psychological constructs associated with post-procedural pain

The present review included 24 studies that investigated the relationship between 11 psychological variables and post-procedural pain, including anxiety, depression, ‘expected pain’, ‘positive treatment expectations’, ‘positive and negative effect’, ‘pain coping strategy’, ‘desire for control’, ‘perception of the dentist’, ‘somatic focus and awareness’, ‘psychiatric disease’, and ‘beliefs about pain’.^{18,30,31,33,51–64}

Anxiety

Anxiety was investigated in relation to post-procedural pain in 18 studies,^{18,26,30,31,33,43,52,53,56–65} with 14 different anxiety measures used. Overall, 14 out of 18 studies reported a significant association between anxiety and post-procedural pain.

Three studies measured state and trait anxiety, one with a pain diary questionnaire and the other with NRS.^31,59,61 Nine studies measured dental anxiety, using an 11-point NRS, Graded Chronic Pain Scale (GCPS), or another questionnaire (details below).^{18,30,43,52,56,65} Four studies measured pain catastrophizing using either the Pain Catastrophizing Scale (PCS) or the Pain Coping Scale (PCS).^33,53,57,58 Two studies measured oral health–related anxiety, one with the Oral Health Impact Profile Questionnaire (OHIP-14), measuring psychological discomfort, psychological disability, and social disability,²⁶ and the other with PHQ-4, PHQ-15, and OHIP-49, measuring discomfort, somatic symptom, and psychological disability.⁵⁸ One study measured stress through a questionnaire in a national survey.⁶⁰ Both state and trait anxiety were significantly correlated with post-procedural endodontic pain,^31,59 with trait anxiety (HADS) identified as a significant predictor of pain in the first 5 days after endodontic treatment.⁵⁹ Seven out of nine dental anxiety studies showed a positive correlation between post-procedural pain and anxiety, while two (NRS, GCPS) found no relationship.^18,56 One study³⁰ showed a significant correlation between pain and the Dental Fear Survey-Physiological Score (DFS), but had limitations of low sample size. Except for Pillpott et al.,⁵⁷ two out of three studies investigating pain catastrophizing reported a significant correlation with post-procedural endodontic pain.

Depression

Seven studies evaluated the relationship between depression and post-procedural pain. Three studies^57,63,66 showed no significant relationship between depression and post-procedural pain, and four studies^45,58,60 reported a significant association between depression and post-procedural pain. Mannan and Greenspan⁴⁵ and Rahman et al.,⁵⁹ who used the Hospital Anxiety and Depression Scale (HADS) to measure depression, found depression increases post-procedural pain. Pillai et al.⁵⁸ and Yang⁶⁰ reported higher pain in their depressed groups, measures using the Beck Depression Inventory-II and a questionnaire, respectively, after root canal treatment or in patients with Post-Traumatic Trigeminal Neuralgia (PTTN), a chronic pain condition after dental treatment.

Expected pain

Only one study³¹ examined the correlation between expected pain relief and post-procedural pain after emergency endodontic treatment. There was no significant correlations between expected pain and post-procedural pain.³¹

Positive treatment expectations

Two studies examined positive treatment expectations in relation to post-procedural pain.^31,52 Daline et al.⁵² assessed expected outcomes through a questionnaire in patients experiencing chronic pain after root canal therapy and reported no association between long-term persistent pain and patients’ optimism about the treatment outcome measured during the 6 months after treatment. However, Wu et al.³¹ evaluated expected pain relief in patients undergoing emergency endodontic treatment and found a positive correlation between expected pain relief and post-procedural pain reduction.

The desire for control over dental treatment

The desire for control over dental treatment was investigated in relation to post-procedural pain in two studies,^51,65 both of which reported a significant correlation between this psychological construct and post-procedural pain using the Iowa Dental Control Index (ICDI).

Baron et al.⁵¹ assessed patients’ desire for control and felt control in the dental chair 30–40 min before the start of treatment. Participants were asked about the degree to which they wanted to have control over dental treatment and how much they felt they had control. The high desire for control or felt control was reported to be associated with lower pain and higher sensory focus than emotional focus measured with a questionnaire. In addition, Maggirias and Locker⁶⁵ reported that pain was significantly higher in participants with higher scores on the ICDI Felt Control scale than in those who did not report experiencing pain.

Perceptions of dentists

Positive perceptions of the dentist was evaluated in relation to post-procedural pain in two studies^46,65 which both reported negative correlations with pain. Maggirias and Locker⁶⁵ assessed patients’ perceptions of the dentist and how dental care was delivered during endodontic treatments using a baseline question to assess whether patients had ever had a painful, frightening, or embarrassing experience with a dentist. They found a negative correlation between the high reported empathy of dentists and post-procedural pain onea week after treatment.

Somatic focus or awareness

Three studies reported mixed results regarding the relationship between somatic focus or awareness and post-procedural pain.^58,60,61 Pillai et al.⁵⁸ measured somatic symptom severity using the Patient Health Questionnaire 15 (PHQ-15) before various dental treatments, including endodontics, and reported that patients with painful post-traumatic trigeminal neuropathy (PTTN), which is a chronic pain condition, had higher scores for somatic symptoms than healthy controls. Conversely, Applebaum and Maixner⁶¹ measured somatization using the Pennebaker Inventory of Limbic Languidness (PILL) completed after root canal treatment (within 5 days after treatment) and found no significant association between post-treatment somatization and post-procedural pain.

Psychiatric disease

One study⁶⁰ used a national survey to measure melancholy, consultation with a psychiatrist, and suicidal thoughts before various dental procedures, including root canal therapy, and found significant differences in melancholy, suicidal thoughts, or consultation with a psychiatrist between those with and without self-reported dental pain.⁶⁰

Pain coping strategies

Two studies^54,55 used the Coping Strategies Questionnaire (CSQ) to measure pain coping before emergency endodontic treatment and post-procedural pain (1-2 weeks after surgery). Both these studies reported that higher scores on CSQ subscales were significantly associated with higher post-procedural pain.^54,55

Beliefs about pain management

Beliefs about pain were evaluated in only one study.⁶⁷ The study administered a questionnaire to patients before root canal treatment to assess any relationship between the belief that ‘stress makes the pain worse’ and severe post-procedural pain. Patients who reported pain in the previous 7 days were asked if stress made their pain worse (yes or no). The results showed that the belief that pain is made worse by stress was a significant predictor of severe post-procedural pain.⁶⁷

Positive and negative affect

The relationship between ‘positive and negative affect’ and post-procedural pain was examined in two studies.^54,55 Both studies used the Profile of Mood States (POMS) questionnaire prior to emergency endodontic treatment and reported no significant association between mood and post-procedural pain.

Discussion

Although many studies in dentistry and endodontics focus on psychological constructs, particularly anxiety,^68,69 our specific focus was on those studies that evaluated the relationship between psychological factors and endodontic pain. The current review synthesizes the results of 48 studies investigating 12 psychological constructs in relation to pre-procedural, procedural, and post-procedural pain.

Study participants

The majority of studies were conducted in high-income countries, and over 80% of participants were recruited from university educational dental clinics/hospitals and public health centres.

Psychological contributors to pain

Anxiety, with a focus on dental anxiety, emerged as a frequently studied psychological construct, showing a significant association with patients’ pain experiences. Previous research has also indicated a positive correlation between anxiety and pain.^47,70,71 However, it is notable that some studies found no correlation between anxiety and pain.^31,46

This review also underscores the significance of anticipated pain as an important psychological predictor for procedural and post-procedural pain. Perković et al.⁴⁶ investigated the correlation between anxiety and expectations of intraoperative endodontic pain, revealing a positive link between these variables. The relationship between expected and actual pain experiences has also been documented in prior oral surgery studies.^72,73 It is important to recognize that what patients expect before treatment can affect their experience, and this holds for different stages of treatment. Additionally, these expectations can be influenced by factors like thoughts and emotions, such as anxiety and the patient’s memory of past experiences. For instance, anticipating pain has been connected to feeling anxious about the treatment,^72,73 and remembering the pain felt during past procedures is related to both anxiety and what was expected beforehand.^72,74

The majority of presented constructs (11 out of 12) were related to post-procedural pain. Anxiety emerged as the most commonly studied predictor similar to pre-procedural or procedural pain with most studies reporting a positive correlation. This trend aligns with findings from a separate study involving anxiety in other dental procedures, which demonstrated a correlation between state anxiety, anticipated pain, and experienced pain.⁷⁰ Furthermore, similar positive correlations have been observed in the context of post-procedural pain in oral surgery.⁷⁴

Regarding the importance of depression as a psychological construct, it displays a significant relationship with both procedural and post-procedural pain in most studies. This finding is in concordance with a study in the field of oral surgery but contrasts with observations regarding pain following another oral surgery study and implant procedures maybe due to measurement scale difference.^70,75

For the 12 constructs described, the construct of personality received limited attention with only one study⁴² addressing it. Khademi’s study,⁴² investigating the positive correlation of neurotic personality with post-procedural pain, yielded similar results to an oral surgery study.⁷⁰ Consequently, further research in this area is warranted.

For the majority of studies reporting post-operative pain, the exact timing of assessment was either mostly short-term (immediate/within days) with two long-term studies of ∼6 months’ follow-up,^52,56 which show psychological variables (anxiety and positive beliefs about treatment) remain relevant in predicting persistent pain. Our result is consistent with a study that showed some young people develop chronic postsurgical pain (>4 months) with distress and expectations as psychological predictors found.⁷⁶ This supports our aim that psychological factors contribute across pain phases rather than only in acute settings.

Regarding psychological and pain measurement, inconsistencies in defining and measuring scales were evident in the reviewed studies, which may complicate any future meta-analysis; for example, dental anxiety has been measured with different scales (DAS, MDAS, DFS) without proper justification. A 2025 update on the DAS highlights limited longitudinal validity evidence, limiting the use across time.⁷⁷ Another example would be the Mannan and Greenspan study,⁴⁵ who utilized the Hospital Anxiety and Depression Scale (HADS) to measure depression, which increased the study’s feasibility, cost, and potential sample size. Regarding the pain scale, a recent oral-medicine review summarizes practical pros/cons of VAS, NRS, VRS, and face scales in dental settings, which can guide more consistent selection.²³ Most studies used single-dimention pain intensity measures, VAS or NRS, which are valid for pain intensity but do not capture affective factors (like mood), which may influence observed anxiety, pain correlations.^23,78 Another potential avenue for improvement could involve shifting the focus from measuring individual pain experiences to assessing the ‘relief of pain’ as suggested in some studies.^31,74,79 Pain reduction and pain relief represent distinct concepts with different assessment directions. Pain relief is associated with both cortical and descending pain modulation, which supports the notion of an association between pain relief and pain behaviour.⁸⁰ Additionally, thoughtful study design, considering multiple time points for pain measurement and consistent assessment protocols, is vital to enhance the accuracy and comprehensibility of research findings. Many of the studies reviewed assessed procedural pain after treatment, yet the exact timing was often unclear.³¹ For instance, it was unclear whether the effects of local anaesthesia had dissipated at the time of procedural pain measurement.⁴⁸ This practice enhances the comprehensibility of research outcomes and facilitates meaningful comparisons with other investigations.

Our broad inclusion of age groups and treatment types reflects the aim of mapping the scope of available evidence rather than establishing clinical specificity. While this approach may increase heterogeneity, it provides a comprehensive overview and highlights areas where evidence is limited, and future research needed.

Despite the possibility of conducting a systematic review to elucidate the significance of psychological factors, challenges originating from study design heterogeneity and data collection methods must be addressed.

Limitations

Limitations to this study include restricting our search to studies published in English only, and also to psychological and not social factors. We acknowledge that certain constructs, such as perceived empathy, contains social as well as psychological dimensions. We intentionally narrowed the focus to psychological factors in line with our inclusion criteria. This choice does not diminish the importance of social determinants, which need dedicated investigation in future research. The anxiety construct in this review groups together some distinct psychological variables for easier interpretation, which may oversimplify the unique contributions of each individual factor. Also differences in design or treatment protocols may affect associations between psychological factors and pain outcomes. This heterogeneity limits direct comparability; findings therefore should be interpreted with caution.

Future direction

We found some studies working on interventions to address the psychological factors in dental pain, mostly in paediatric patients, with techniques such as distraction employing virtual reality⁸¹ and audio-visual video eyeglasses.⁸² While the literature offers limited insight into interventions for anxiety reduction in adult dental settings, certain strategies, including ‘tell-show-do’,^68,83,84 hypnosis,⁸⁵ auditory distraction through background music,⁸⁶ and cognitive therapy,⁸³ have shown some promise in the field of general dentistry. To advance the development of effective interventions, our next research step should involve a comprehensive review specifically focused on existing interventions relevant to endodontic treatment to reduce anxiety or expected pain as the most common pain contributing factors in research. Understanding the interplay between psychological factors, patient expectations, and technical complexities can contribute significantly to enhancing the patient experience and treatment outcomes in endodontic procedures. Future research should examine other constructs with limited research identified in this review, such as coping strategies, beliefs about pain, personality, and desire for control, to determine whether interventions targeting these factors could complement anxiety-focused approaches.

Clinical Implication

Although this scoping review was not designed to establish causality, it is important to acknowledge the potential bidirectional relationship between anxiety and pain: higher pre-treatment anxiety may heighten pain, while greater pain intensity may in turn reinforce anxiety which needs more investigation in future studies. For endodontic practice, realistic intervention targets include brief chairside strategies such as routine anxiety screening, expectation setting conversations, and offering patients simple control mechanisms (e.g. stop signals) to reduce perceived helplessness.^87,88 Evidence from adult dentistry suggest that short interventions like relaxation guidance, targeted reassurance, or cognitive techniques can be integrated into routine workflows with minimal disruption, though their evaluation in endodontics in limited.^87,89–92 The feasibility of these interventions may depend on factors such as the limited clinical time available in general practice, as well as the level of training and expertise required for dentists to recognize patient anxiety and deliver appropriate support, so a psychology–dentistry collaboration is required for effective results.

Conclusion

Many different psychological factors have been found that relate to pain of pre-procedural, procedural, and post-procedural endodontics. We have classified these predictors into 12 overarching constructs, among which anxiety and expected pain have emerged as the most commonly studied factors. More research is required to understand the main factors with positive correlations to pain and how to manage these psychological factors to help manage pain better in dentistry.

Supplemental Material

Supplemental Material - Psychological contributors to pain before, during, and after endodontic procedures: A scoping review

Supplemental Material for Psychological contributors to pain before, during, and after endodontic procedures: A scoping review by Atieh Sadr, Ali Gholamrezaei, Amy G. McNeilage, Cameron L. Randall, Flavia P. Kapos, Christopher C. Peck, and Claire E. Ashton-James in British Journal of Pain

Footnotes

ORCID iD

Atieh Sadr

Author contributions

AS conceived the presented idea with CAJ, AG, CCP, CLR, and FPK. AS, AG, CLR, FPK, and CAJ prepared the study protocol. Data collection and analysis were done by AS and AGM and subsequently checked and reviewed by AG. AS, AG, and AGM drafted the results. The main draft was written by AS and edited by CAJ, AGM, and AG. All authors read, revised, and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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