Effectiveness of Binaural Beats in Reducing Dental Pain and Anxiety among Children and Adults: A Systematic Review and Meta-analysis

Abstract

Aim and background

Pain and anxiety during dental procedures can be skillfully tackled using effective and efficient behavior management. The current systematic review aimed to assess how effectively binaural beats (BB) work to reduce dental pain and anxiety in children as well as adults.

Methods

An electronic search of the databases was conducted; authors independently extracted the data from nine studies included in the review. Clinical trials included in the review were the studies that reported the effectiveness of BB used during dental procedures for reducing dental pain and anxiety among children and adults. The Cochrane risk of bias tool was used for evaluating the risk of bias. Meta-analyses were performed using the fixed and random effect models. Heterogeneity was quantified with I² statistics. Reduction in the dental pain and anxiety scores [as measured by visual analog scale (VAS)/Venham's picture test (VPT)] was considered the chief outcome.

Results

A total of 580 studies related to the topic were identified. Studies carried out for procedures other than dental as well as duplicates were eliminated, and following analysis of full-text articles, nine studies were included for systematic review. Overall, the results showed high risk of selection and detection bias. Dental pain and anxiety scores showed significant difference when comparing pre- and postintervention values. When comparing BB with controls, there was significant reduction in dental anxiety (DA) scores, while dental pain reduction showed inconclusive results with control (no intervention) and significant reduction with positive control.

Conclusion and clinical significance

Dental pain and anxiety appear to be alleviated by BB. Clinicians may view BB as a viable nonpharmacological treatment for dental pain and anxiety.

How to cite this article

Shukla AD, Subhadra HN, Unnikrishnan S, et al. Effectiveness of Binaural Beats in Reducing Dental Pain and Anxiety among Children and Adults: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent 2025;18(8):1023–1030.

Introduction

Oral and dental health is an integral element of general health.¹ Pain is an important factor that leads individuals to seek dental treatment. Dental treatment is generally considered uncomfortable and painful, and many patients worry about discomfort after dental treatment.¹ Anticipation of pain during dental procedures further makes patients skeptical to go ahead with dental treatment, thus compromising their dental health. Fear and anxiety accompany the painful perceptions associated with dental treatment. Among various anxieties, dental anxiety (DA) is placed fourth in position.^2,3 Estimates from studies performed across different countries suggest 5–30% of people suffer from DA and phobia.³

Effective and efficient behavior management is important in reducing anxiety and pain while carrying out dental procedures, which in turn will help in fostering a positive, fear-free dental attitude. Over time, a spectrum of pharmacological and nonpharmacological methods has been formulated for alleviating pain and anxiety during dental treatment.⁴ Binaural beats (BB) is one among the nonpharmacological emerging modalities used in alleviating dental pain and anxiety.^5,6 BB is an auditory illusion produced by two pure sinusoidal waves of steady intensity but slightly different frequencies that is between the two carrier tones and amplitudes at a rate equal to the difference between them.^1,3,4,7 This resultant difference in frequency produces a distinct tone, that is, binaural beat.

The medial superior olivary nucleus, a little mass of gray matter in the ventral portion of pons reticular formation, is the source of BB and is responsible for contralateral integration of the auditory system.⁶ Mechanism of action by which BB functions is by stimulation of different brain waves depending upon frequency range of stimulation; these different frequency brainwaves together comprise “brainwave entrainment (BWE).” BB can alter the frequency toward a desired state, favoring either relaxation or alertness, by adjusting its own electric cycles to the same rhythm.^5,8 Evidence from previous studies has suggested that BWE is effective in several cognitive domains and also includes stress and pain reduction, improvement in behavior, and creativity.^5,8–10

Rationale

Previous studies have tested the effectiveness of BB in reducing dental pain and anxiety preoperatively, intra- or postoperatively while performing different dental procedures in varied set of populations using other comparators (i.e., music, monaural beats, and other audio distraction aids), and some of the studies have found significant effect, while some inferred insignificant difference for the same. Thus, the present systematic review aims to assess the available literature in this domain and determine an evidence-based conclusive finding on the effectiveness of BB in reducing dental pain and anxiety among children and adults.

Methods

This systematic review was registered in PROSPERO International Prospective Register of Systematic Reviews (CRD42024499347) in January 2024 (Annexure 1) and reported in accordance with the PRISMA¹¹ (preferred reporting items for systematic reviews and meta-analyses).¹¹

Selection Criteria

Research question: Are BBs effective in reducing dental pain and anxiety among children and adults?

The focused PECOS question was as mentioned below:

• Population: Children and adults (5–48 years of age).

• Exposure: Binaural beat.

• Comparison: Controls (without any intervention), positive controls (monaural beat, 432 Hz music, cognitive behavior management, placebo).

• Outcome: Dental pain and anxiety as assessed by visual analog scale (VAS), Venham's picture test (VPT).

• Study design: It is a systematic review and meta-analysis of included randomized clinical and control trials.

Criteria for Considering Studies for This Review

Inclusion Criteria

Clinical trials which reported the effectiveness of BB in reducing dental pain and anxiety among children and adults; studies in the English language only were included. There was no restriction placed on the year of publication.

Exclusion Criteria

Case reports, case series, in vitro studies and observational studies were excluded.

Studies using BB for any other medical/health-related concerns other than dental were excluded from the review.

Type of Participants

Children and adults undergoing dental treatment using BB were included in this review.

Search Strategy

An extensive search for literature that assessed effectiveness of BB in reducing dental pain and anxiety among children and adults was carried out. A comprehensive search for eligible studies was undertaken from the following databases: PubMed, Cochrane Library, EBSCO Host, Medline, and Google Scholar. All electronic searches were updated up to February 2024. Search terms used were “binaural beats,” “dental pain,” and “dental anxiety.” Additional eligible studies were examined manually through references listed in included articles and textbooks. Gray literature was searched on Shodhganga and OpenGrey. Literature which could not be obtained from above-mentioned electronic databases was hand-searched manually from journals, textbooks, and unpublished literature by the reviewers AS and SU.

The MeSH terms used were: (Binaural[All Fields] AND Beats[All Fields]) AND (“toothache”[MeSH Terms] OR “toothache”[All Fields] OR (“dental”[All Fields] AND “pain”[All Fields]) OR “dental pain”[All Fields]) AND (“dental anxiety”[MeSH Terms] OR (“dental”[All Fields] AND “anxiety”[All Fields]) OR “dental anxiety”[All Fields].

Selection of Studies

Records were stored in EndNote. Reviewers AS and SU independently scanned each title and abstract of the studies to focus on and subsequently read the full articles of those studies that were potentially eligible. In case of disagreement between the two reviewers, it was settled through discussion with a third reviewer (SHN).

Data Extraction and Quality Assessment

Two reviewers (AS and SU) independently extracted data from the included studies using single Excel data extraction. The data sheet contained the following information: age, name of the author, journal name, publication year, study design, number of participants, type of intervention, comparator/control, details about procedure, outcome, and key results. In case of a query or insufficient information related to the study, the concerned authors were contacted. Quality assessment was carried out independently by reviewers AS and SU. Another reviewer (SHN) was consulted to resolve disagreements between the reviewers. Quality for a particular study was graded as the study being of good, fair, or poor quality according to the Cochrane Risk of Bias Tool for randomized clinical trials (RCTs). The risk of bias was evaluated based on the following domains:

• Random sequence generation for selection bias.

• Allocation concealment to assess selection bias.

• Selective reporting to assess reporting bias.

• Blinding of participants and personnel to assess performance bias.

• Blinding of outcome assessment to assess detection bias.

• Incomplete outcome data to assess for attrition bias.

• Other bias to assess any other bias that has not been covered elsewhere.

For each category, the risk of bias was categorized as low, unclear, or high. If the provided data did not influence the outcome in any form, it was marked as low risk. Risk of bias was categorized as unclear when there was insufficient information provided about the particular category, and high risk of bias was inferred when there was source of bias that influenced the outcome and results.

Certainty of Evidence¹²

The certainty in the estimates of effect was determined for the outcome using The Grading of Recommendations Assessment, Development and Evaluation (GRADE)¹² approach. RCTs started as high evidence, and the certainty of the evidence decreased if serious or very serious issues related to risk of bias, inconsistency, indirectness, imprecision, and publication bias were present. The quality of the evidence could be upgraded if the magnitude of effect was large or very large, or if the effect of all plausible confounding factors would reduce the effect or suggest a spurious effect. The overall quality assessment was rated as high, moderate, low, and very low levels of evidence.

Results

Study Selection

A total of 580 articles were found after electronic search. From these, 568 articles, including articles of other languages, duplicates, and articles involving use of binaural beat for procedures other than dental were excluded, leaving 12 articles after title and abstract screening. Subsequently, three articles were excluded as they did not fulfil the eligibility criteria, leaving nine articles for qualitative analysis (systematic review). Of them, three articles were excluded due to variation in outcome measures used (different tools, such as salivary amylase being used as biomarker/scales, such as overt covert anxiety scale), which were not comparable leaving six articles for quantitative synthesis (meta-analysis).

The PRISMA flowchart summarizes the selection process in Figure 1.

Figs 1A and B:

(A) Preferred reporting items for systematic reviews and meta-analyses flowchart of studies; (B) Risk of bias graph

Study Characteristics

The characteristics of the included studies are summarized in Table 1.

Table 1:

Characteristics of included studies

Sr. no.	Author and year of publication	Type of study and location	Comparison and control group	Sample size	Parameter assessed and follow-up	Key result/conclusion
1.	Huang et al.2	RCT China	Brainwave music group Cognitive behavioral therapy (CBT) Control group (no intervention)	N: 36 BWM: 12 CBT: 12 Control: 12	Dental pain using VAS 30-day follow-up	BWM and CBT groups presented significantly lower pain perception than the control group on days 1–4. BWM is effective in controlling orthodontic pain
2.	Isik et al.14	RCT Turkey	Binaural beat group Control group (no intervention)	N: 60 BB: 30 Control: 30	Dental anxiety using VAS	Experimental group showed less anxiety as compared to control. Thus, authors concluded that binaural beats may be useful in reducing preoperative anxiety in dentistry
3.	Wulansari et al.15	RCT Bandung, Indonesia	Binaural beat group Control group (no intervention)	48 patients undergoing surgical odontectomy	Dental anxiety by using salivary alpha amylase enzyme level	There was significant difference in salivary alpha amylase enzyme (p < 0.05) in the relaxation music with binaural beat effect music group compared to control group. In conclusion, this treatment can effectively reduce dental anxiety
4.	Menziletoglu et al.13	RCT Turkey	BB group 432 Hz music group Control group (no music)	N: 90 BB: 30 432 Hz: 30 Control: 30	Dental anxiety using VAS	BB and 432 Hz tuned music are a valid nonpharmacological adjuvant to reduce dental anxiety in impacted third molar surgery. They have a positive effect to reduce the dental anxiety
5.	Aly et al.5	RCT Dubai	BB group Placebo group Control group	N: 60 BB: 20 Placebo: 20 Control: 20	Dental pain using VAS among patients undergoing fixed orthodontic treatment Follow-up: 7 days	There was a significant reduction of pain in the BBM group, compared to the control, toward the end of the first week of treatment. There was no difference in reported pain between the BBM and placebo groups for any of the scores
6.	Bhusari et al.3	RCT Karnataka, India	Control Monaural beat Binaural beat	N: 45 BB: 15 Monaural: 15 Control: 15	Dental anxiety using VPT	BB and monaural beats showed a better reduction in anxiety levels as per VPT BB was found to be the most effective followed by the monaural beat
7.	Padawe et al.4	RCT Maharashtra, India	BB group Control group (white noise) Dental	N: 120 BB: 60 Control: 60	Dental anxiety using VPT	Reduction in anxiety levels was statistically significant in the experimental group as compared to the control group. BB was more effective in the reduction of pre- and intraoperative dental anxiety in pediatric patients
8.	Salehabadi et al.1	RCT Sari, Iran	Control group (no intervention) BB group	N: 80 BB: 40 Control: 40	Dental anxiety using Spielberger State Trait Anxiety Inventory	Use of BB significantly reduced the level of overt and covert anxiety in patients and can be used as an alternative nonpharmacologic method to reduce anxiety
9.	Mani et al.16	RCT Tamil Nadu, India	Alpha BWE group Theta BWE group Delta BWE group Control	N: 40 Alpha: 10 Theta: 10 Delta:10 Control: 10	Vital signs Heart rate and blood pressure	Delta entrainment group exhibited significantly lower HR values both pre- and intraoperatively (p < 0.05). BWE can be considered an effective nonpharmacological aid for management of anxiety in patients requiring dental treatment

Risk of Bias and Certainty of Evidence

Most of the studies showed low risk of bias in random sequence generation (selection bias) domain. One study showed unclear risk of bias,¹³ and one of the studies showed high risk of bias¹⁵ in this domain. But most of the studies did not provide any information regarding allocation concealment (selection bias) domain. Most of the studies showed high risk of bias in this domain except two of the studies^5,13 that had low risk of bias. Blinding of participants and personnel (performance bias) was clearly mentioned only by three studies done by Bhusari et al.,³ Padawe et al.,⁴ and Huang et al.² that had low risk of bias, while two studies conducted by Menziletoglu et al.¹³ and Salehabadi et al.¹ showed unclear risk whereas rest of the studies had high risk of bias in this domain. Concerning the blinding of outcome assessment (detection bias), only one study by Huang et al.² showed low risk of bias, two studies by Menziletoglu et al.¹³ and Salehabadi et al.¹ showed unclear risk, whereas rest of all the studies had high risk of bias in this domain. Attrition and reporting bias were not of concern in any of the studies as all the studies had low risk of bias with regard to these domains.

The level of evidence inferred from this systematic review inferred a low certainty for reduction of dental pain and anxiety using the GRADE approach.

Quantitative Analysis

Narrative Synthesis

A total of nine studies assessing the effectiveness of BB in reducing dental pain and anxiety were identified from the year 2016 to 2024. The studies were conducted across different countries including China (n = 1), Indonesia (n = 1), Turkey (n = 2), India (n = 3), Dubai (n = 1), and Iran (n = 1). The study population for majority of the studies belonged to adult age-group (18–48 years), except two studies conducted exclusively on pediatric patients (5–8 years) by Bhusari et al.³ and Padawe et al.⁴ Procedures considered for administration of intervention ranged from simple restorations³ to impacted mandibular third molar extractions^1,13–15 and root canal treatments.¹⁶ Both invasive and noninvasive procedures were considered in the study by Padawe et al.⁴ Local anesthesia administration was included in most of the studies except in the study by Bhusari et al.³ that included only class I restoration patients. Two studies conducted by Aly et al.⁵ and Huang et al.² involved participants undergoing orthodontic treatment. The outcome measures, that is, dental pain and anxiety, were assessed at different time intervals. Seven studies evaluated DA, while two studies^2,5 evaluated dental pain. Most of the studies assessed pre- and postvalues, that is, before start of procedure, outcome measures was assessed (baseline/before intervention score) followed by LA administration; patients then had a wait period during which the subjects were exposed to intervention BB and then the outcome was reassessed (postintervention scores). One study conducted by Mani et al.¹⁶ evaluated pre- and intraoperative scores as the authors believed that intraoperative fear interferes with the treatment, complicating the outcome. Another study conducted by Padawe et al.⁴ evaluated DA at three different time points having 5-minute interval. Follow-up was not involved in majority of studies, except for studies by Aly et al.⁵ (7-day follow-up) and Huang et al.² (30-day follow-up) that evaluated dental and orofacial pain following initial archwire placement.

Synthesis of Results

Overall effectiveness of BB in reduction of dental pain and anxiety:

A. BB for DA (pre- vs postintervention)

Analysis of two studies by comparing the effectiveness of BB in DA as measured by VAS scores using a fixed effect model revealed a pooled mean difference (MD) of 1.62 with a confidence interval (CI) (0.84, 2.40) and I value of 0%. (Fig. 2A). Significant reduction in VAS scores was seen after intervention with BB.^13,14

Figs 2A to G:

(A) Binaural beats for dental anxiety using VAS (pre- vs postintervention); (B) Binaural beats for DA using VPT (pre- vs postintervention); (C) Binaural beats for dental pain using VAS (pre- vs postintervention); (D) Binaural beats vs control for DA using VAS; (E) Binaural beats vs control for DA using VPT; (F) Binaural beats vs control for dental pain using VAS; (G) Binaural beats vs positive control (CBT, placebo) for dental pain using VAS

Analysis of two studies by comparing the effectiveness of BB in DA as measured by VPT scores using a fixed effect model revealed pooled MD of 1.36 with CI of (0.82, 1.89) and I value of 0% (Fig. 2B).

B. BB for dental pain (pre- vs postintervention)

Dental pain reduction using VAS was measured by Aly et al.⁵ and Huang et al.² following a follow-up period of 7 and 30 days, respectively. Meta-analysis of the two studies using fixed effect model revealed pooled MD of 29.88 with CI (23.03, 36.73) and I value of 0% (Fig. 2C) with statistically significant difference of p < 0.0001 signifying effective reduction in dental pain following BB intervention. Thus, overall use of BB reduced dental pain among individuals as postintervention scores were significantly reduced, and this is evident from the results of meta-analysis as well.

C. BB vs no interventions (control) for DA using VAS

On comparison of the effectiveness of BB with control (no intervention) used in the studies the following inferences were drawn: analysis of two studies comprising of two groups, that is, BB vs control (no intervention) for DA reduction as measured by VAS scores using fixed effect model revealed a pooled MD of −1.50 with CI (−2.34, −0.65) and I value of 0% (Fig. 2D).

D. BB vs no interventions (control) for DA using VPT

Analysis of two studies by comparing two groups, that is, BB vs control for DA reduction as measured by VPT scores using random effect model revealed a pooled MD of −1.37 with CI (−1.98, −0.76) and I value of 41% is suggestive of moderate heterogeneity (Fig. 2E).

E. BB vs no interventions (control) for dental pain

Analysis of two studies by comparing BB with control (no intervention) for dental pain as measured by VAS scores using random effect model revealed a pooled MD of −3.30 with CI (−37.67, 31.06) and I value of 94% indicated considerable heterogeneity (Fig. 2F).

F. BB vs positive control for dental pain

Analysis of two studies by comparing BB with positive controls [placebo and cognitive behavioral therapy (CBT)] for dental pain using random effect model revealed pooled MD of −13.78 with CI (−25.68, −1.88) (Fig. 2G). I² value of 68% indicated substantial heterogeneity.

Thus, BB appears to be effective in reducing dental pain as compared to positive controls, that is, CBT and placebo. Also, considering different interventions BB was most effective followed by positive controls (CBT and placebo). On comparison of BB with no intervention, that is, plain control group no significant effect was observed.

Discussion

The current review encompasses an insight into effectiveness of BB alone in DA and pain reduction, as well as it is effectiveness as compared to other nonpharmacological interventions, such as 432 Hz music, monaural beats, cognitive behavior management, and placebo. BB as nonpharmacological intervention has received attention in the recent past, with authors from different countries conducting studies on the same.^{1–5,13–16}

A total of nine studies in the qualitative analysis and six in the quantitative analysis that were carried across different countries were included in this review, which is likely suggestive of the fact that there is paucity of literature with regard to using BB for dental procedures in order to reduce DA and pain. However, enough literature and evidence in support are available regarding BB reducing stress, anxiety, and pain during various medical procedures, such as cystoscopy, biopsy, and cataract surgeries.^17–23 Thus, indicating the need to explore this novel intervention and its effectivity in the field of dentistry as well.

The meta-analysis results from the present study inferred that BB appears to be effective in reducing dental pain and anxiety, with statistically significant difference observed between the pre- and postintervention scores. However, as among the studies that were included there was high risk of bias for more than two categories, so the quality of evidence might be compromised. Results from a meta-analysis study conducted in 2019 inferred BB as useful and effective in different domains affecting pain perception, stress reduction, and anxiety, but its effectiveness relies on factors, such as exposure time, moment of exposure, and the type of sound used to mask the binaural beat.²⁴

Considering the frequency and method of administration of the intervention, among various studies included, most of the studies used frequencies that were produced by one of the following softwares, such as MynioTech Apps, Chapeco, Santa Catarina, Brazil, and Audacity®.

The moment of exposure for most of the studies was pre- and posttreatment, except for study by Mani et al.,¹⁶ wherein the author has considered intraoperative scores to be more significant, as according to Mani, it is the fear during treatment that is more likely to complicate the outcome. Also, another fact supporting the above statement is evidence from previous studies that showed postoperative anxiety to be minimal compared to preoperative levels.

Different scales were used for assessing the outcomes dental pain and anxiety, while most of the authors have considered VAS and VPT as a validated tool for measuring DA and pain, few of them have considered using other tools such as Corah's DA scale¹ and salivary alpha amylase levels¹⁵ as a biomarker for DA. Also, fluctuations in vital signs, such as heart rate,^4,16 blood pressure,¹⁶ and oxygen saturation⁴ were considered by some of the authors.

Overall Completeness of Review and Applicability of Evidence

Evidence on use of BB in reducing dental pain and anxiety was limited. This review has evaluated the effectiveness of BB in reduction of dental pain and anxiety among different age groups. The review suggests that BB appears to be an effective nonpharmacological intervention in reducing dental pain and anxiety, although other modalities, such as monaural beats followed by 432 Hz music have also provided better results. The effectiveness of BB will largely depend on the exposure time, frequency utilized, and method of administration.

Limitations

Articles published in languages other than English were excluded. Access to unpublished articles was also limited.

Conclusion

This systematic review demonstrates that BB appears to be effective in alleviating dental pain and anxiety. Clinicians may view BB as a viable nonpharmacological treatment for dental pain and anxiety. However, the results should be extrapolated with caution owing to the high risk of bias associated with the included studies. Clinical trials with robust methodology are required to accumulate strong evidence.

Clinical Significance

Clinical practitioners may consider BB as an effective nonpharmacological intervention.

Orcid

Ankita D Shukla https://orcid.org/0009-0002-4966-6498