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. 2026 May 12;38(5):68. doi: 10.1007/s44445-026-00172-w

Digital patient education and its role in overcoming dental anxiety and barriers to endodontic care

Iuliana Sofian-Pauliuc 1, Antonio Castaño-Séiquer 1, David Ribas-Perez 1,✉, Ignacio Barbero-Navarro 1
PMCID: PMC13168390  PMID: 42118430

Abstract

Dental fear and anxiety (DFA) serve as a significant obstacle to oral healthcare, affecting approximately 15% of the adult population. In endodontics, misconceptions regarding procedural pain and complexity often lead to treatment avoidance or a preference for extraction over tooth-preserving therapy. Currently, there remains a notable information gap regarding the efficacy of modern educational modalities in mitigating these barriers. The purpose of this scoping review is to map the existing research on DFA, socioeconomic barriers to endodontic care, and the relative effectiveness of new educational tools, particularly multimedia and Artifical Intelligence (AI) -driven interventions, in raising patient awareness and lowering DFA. Following the Arksey & O’Malley guidelines and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), a systematic search was carried out for the years 2015–2025 using PubMed/MEDLINE, ScienceDirect, Cochrane, and Wiley. Two reviewers conducted independent data charting and study selection. Joanna Briggs Institute (JBI) critical assessment techniques were used to evaluate methodological quality. Notably, there was no pre-registered review protocol, which is recognised as a methodological limitation. Ten studies met the inclusion criteria, representing diverse geographic cohorts, including Saudi Arabia, India, Pakistan, Brazil, and Turkey. The findings indicate that previous negative dental experiences, fear of pain and limited knowledge regarding root canal treatment are major contributors to DFA. Educational interventions, particularly video-based and animated materials, were associated with improved patient understanding and reduced anxiety levels. Recent studies also suggest that AI-generated educational content may enhance clarity and trust while reducing patient anxiety, although further validation is required. Socioeconomic factors, including treatment cost and access to specialised care, were also identified as important determinants influencing treatment decisions. Emerging digital and AI-driven educational tools show promise in reducing DFA but require further expert validation and ethical oversight before widespread implementation to avoid misinformation and ensure clinical safety. Future research should prioritise longitudinal and multi-centre studies to evaluate the long-term impact of digital education on patient decision-making and treatment outcomes.

Supplementary information

The online version contains supplementary material available at 10.1007/s44445-026-00172-w.

Keywords: Dental anxiety, Root canal treatment, Endodontics, Patient education, Digital education, Artificial intelligence, Health literacy

Introduction

Access to dental care is shaped by multiple factors that can prevent individuals from obtaining necessary treatment, with dental fear or anxiety and financial constraints emerging as the most frequently reported barriers (Alsakr et al. 2023, Åstrøm et al. 2024, Hakeberg and Wide Boman 2017, Lantto et al. 2020, Muneer et al. 2022).

Dental anxiety is a frequent psychological condition marked by intense dread or fear related to dental environments and procedures. It represents a stress reaction that frequently occurs before, during, or after dental treatment and can occur even in the absence of a clear threat (Alsakr et al. 2023, Muneer et al. 2022, Armfield et al. 2006, Haag et al. 2017, España et al. 2022, Hoffmann et al. 2022, Jeddy et al. 2018).

Despite their occasional interchangeability, “dental fear” and “dental anxiety” have different meanings. Dental fear is an instantaneous emotional, behavioural, and physiological response to a genuine, recognisable stimulus, such as drills or needles. On the other hand, dental anxiety develops prior to a circumstance that is dreaded, frequently with an ambiguous or anticipated threat (Armfield et al. 2006, España et al. 2022, Jeddy et al. 2018, Silveira et al. 2021). According to World Health Organization (WHO) estimates, dental phobia (odontophobia), a persistent and overwhelming fear that affects 15–20% of the population, can develop from severe anxiety (Muneer et al. 2022, Aardal et al. 2023, Stefano 2019). Dental fear and anxiety (DFA) will be applied in this investigation.

DFA has effects that go beyond simply causing feelings of discomfort. Dental appointments are more likely to be postponed, rescheduled, or avoided by individuals with high anxiety levels. This creates a vicious cycle where anticipatory worry causes care to be postponed, which exacerbates pathology and calls for more invasive therapies, which in effect reinforce the patient’s initial DFA. This phenomenon is deeply linked to dental disadvantage, where socioeconomic status and fear create a self-perpetuating deficit in systemic health (Alsakr et al. 2023, Muneer et al. 2022, Armfield et al. 2006, Haag et al. 2017, Jeddy et al. 2018, Murad et al. 2020, Silveira et al. 2021). DFA also negatively impacts daily functioning, including sleep, social behaviour, and overall Oral Health-Related Quality of Life (OHRQoL) (Alsakr et al. 2023, Aardal et al. 2023, Manasa et al. 2023).

Factors associated with DFA

DFA have been found to be influenced by several factors:

  • Gender: Women consistently describe a higher degree of DFA, probably due to greater expressiveness regarding pain and cultural norms affecting men’s reporting (Alsakr et al. 2023, Muneer et al. 2022, Armfield et al. 2006, Jeddy et al. 2018, Silveira et al. 2021, Heft et al. 2007, Yilmaz Çirakoğlu and Gökcek 2021).

  • Age: Anxiety typically decreases with age. Children and young adults exhibit the highest fear, middle-aged adults (40–64 years) moderate levels, and adults over 80 years the lowest (Alsakr et al. 2023, Muneer et al. 2022, Armfield et al. 2006, Jeddy et al. 2018, Heft et al. 2007, Álvarez-Muguercia et al. 2024, Haag et al. 2017).

  • Previous experiences: Painful or negative dental encounters in childhood, adolescence, or early adulthood strongly predict later anxiety and avoidance behaviours (Åstrøm et al. 2024, Haag et al. 2017, Jeddy et al. 2018, Murad et al. 2020, Heft et al. 2007, Álvarez-Muguercia et al. 2024).

  • Socioeconomic Status (SES) or Position (SEP): SES is a mixture of education, income and cultural background that dictates a patient’s vulnerability and their capacity to access resources, opportunities or any health treatment. Higher anxiety and worse oral health outcomes are correlated with lower SES, but the impact of education is complicated since more awareness can occasionally make anxiety worse (Hakeberg and Wide Boman 2017, Muneer et al. 2022, Armfield et al. 2006).

  • Psychiatric comorbidities: generalised anxiety disorders increase susceptibility to dental fear and may affect treatment outcomes (Muneer et al. 2022, Chatzopoulos et al. 2018).

  • Financial barriers are a major deterrent to dental care. High treatment costs, especially for adults who pay out-of-pocket, often lead to avoidance, delayed care, or selection of less costly treatments, such as extractions over root canal therapy. Sedation or advanced techniques may further increase costs, limiting access for vulnerable populations (Åstrøm et al. 2024, Hakeberg and Wide Boman 2017, Lantto et al. 2020, Muneer et al. 2022, Hoffmann et al. 2022, Alfaisal et al. 2024, Burns et al. 2024, Ghasemianpour et al. 2019, Schwendicke and Herbst 2023).

  • Lack of knowledge and oral health literacy also contribute to delayed care. Misunderstanding procedures, fees, or benefits of preventive visits can heighten fear and avoidance. Interestingly, higher education can both improve oral health literacy and increase anxiety due to awareness of potential risks. Providing clear verbal and written explanations about procedures, including endodontic treatments, is essential for mitigating fear and supporting informed decisions. Also, patients increasingly rely on mass media and the internet, though many still gain knowledge through unreliable word-of-mouth from friends and relatives (Muneer et al. 2022, Hoffmann et al. 2022, Murad et al. 2020, Manasa et al. 2023, Yilmaz Çirakoğlu and Gökcek 2021, Corovic et al. 2023).

Strategies for anxiety reduction

Effective management of DFA relies on evidence-based strategies, broadly categorised into psychotherapeutic (behavioural) and pharmacological approaches (Hoffmann et al. 2022).

Psychotherapeutic behavioural strategies

These have very few adverse effects, are minimally invasive, and change behaviour through learning. Virtual Reality Exposure Therapy (VRET), music, and aromatherapy are examples of distraction therapies that may redirect attention from distressing stimuli and encourage desensitisation (Hoffmann et al. 2022, Jeddy et al. 2018, Aardal et al. 2023). Mind-body techniques, Cognitive-Behavioural Therapy (CBT) or hypnosis, have demonstrated long-term efficacy in managing dental fear. Gradual exposure and acclimatisation, starting with less invasive treatments, further reduce anticipatory anxiety and foster patient trust (España et al. 2022, Hoffmann et al. 2022).

Pharmacological Strategies

Sedation via nitrous oxide, oral agents, or intravenous routes is effective for moderate to severe anxiety but may increase costs and limit accessibility (Hoffmann et al. 2022, Srinivasan et al. 2024).

  • Local Painless Anaesthesia: as traditional injections are a primary fear inducer, computer-assisted anaesthesia delivery systems, such as the Wand (soft tissue infiltration) or QuickSleeper (intraosseous injection), have been shown to provide significantly lower pain perception scores, reduce discomfort and improve patient cooperation (Alsakr et al. 2023).

Strategies for improving knowledge and communication

Improving patient knowledge and communication is essential for reducing DFA and enhancing treatment acceptance. A major contributor to fear is inadequate understanding of procedures or perceived loss of control during treatment (Srinivasan et al. 2024).

Explaining the procedure before commencing, along with discussions of expectations, safety measures, and possible sensations, reduces uncertainty and improves cooperation. Empathetic, clear, and non-threatening communication, alongside written materials, empowers patients and improves cooperation. Enhancing oral health literacy helps patients make informed choices and engage in preventive care (Hoffmann et al. 2022, Manasa et al. 2023, Heft et al. 2007, Yilmaz Çirakoğlu and Gökcek 2021, Álvarez-Muguercia et al. 2024, Alfaisal et al. 2024, Srinivasan et al. 2024, Glaesmer et al. 2015, Röing and Holmström 2014, Srinivasan et al. 2024, Vahdati et al. 2019).

Innovation in education and technology

Technological and educational innovations are rapidly transforming dentistry, enhancing both clinical precision and patient management. Emerging tools such as Virtual Reality (VR), Immersive Visualisation (IV), and biofeedback systems support anxiety management training for patients and clinicians. VRET represents a promising cognitive-behavioural intervention, offering a safe, cost-effective, and less stigmatising approach to managing DFA during treatment (Hoffmann et al. 2022).

DFA affects approximately 15% of adults, with high levels in 12% (Armfield et al. 2006, Silveira et al. 2021). Anxiety influences oral health behaviours, increases treatment complexity, and imposes financial burdens (Muneer et al. 2022, Hoffmann et al. 2022, Chatzopoulos et al. 2018). Given the multifactorial nature of anxiety and treatment decisions, such as choosing between root canal therapy and extraction, a scoping review is appropriate. It allows thematic synthesis across heterogeneous studies, highlights evidence gaps, and informs clinical strategies to improve patient outcomes, efficiency, and quality of care (Alsakr et al. 2023, Muneer et al. 2022, Jeddy et al. 2018).

With an emphasis on DFA, this scoping review seeks to map the primary barriers influencing patients’ decisions between root canal therapy and tooth extraction and new digital educational techniques, such as artificial intelligence.

Methods

A scoping review was carried out to research the existing literature on DFA, patients’ perceptions of root canal treatment, and emerging patient education strategies in endodontics. The research question was: how do psychological, socioeconomic, and literacy-related barriers influence patient decision-making between tooth-preserving root canal treatment and extraction, and to what extent can emerging digital educational interventions, specifically artificial intelligence and multimedia tools, mitigate DFA and improve informed clinical outcomes?

Search strategy

The Arksey and O’Malley framework and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines were applied to ensure methodological rigour.

A thorough literature search was carried out using PubMed/MEDLINE, ScienceDirect, Cochrane, and Wiley to identify studies published in English between 2015 and 2025, with significant previous publications included as relevant. Keywords included “dental anxiety”, “dental fear”, “root canal treatment”, “endodontic”, “decision-making”, “patient education”, “perception”, “artificial intelligence”, “digital education”, and “economic”. Searches were refined using Boolean operators (AND, OR). To guarantee reproducibility, Supplementary Appendix 1 contains the whole electronic search approach for at least one database.

This PRISMA-ScR flow diagram is shown in Fig. 1. The review protocol was not pre-registered, which is acknowledged as a methodological limitation.

Fig. 1.

Fig. 1

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PRISMA-ScR flow diagram adapted for this scoping review

Study selection

Titles and abstracts were screened using Mendeley by two reviewers (ISP and IBN). Any disputes were resolved by agreement with ACS. Then, using predefined inclusion and exclusion criteria (shown in Table 1), one reviewer (ISP) assessed full-text publications for eligibility; any discrepancies were reviewed with IBN.

Table 1.

Inclusion and exclusion criteria

INCLUSION CRITERIA EXCLUSION CRITERIA
DFA related to endodontic treatment was investigated. Studies not involving endodontic treatment and patient education or DFA.
Patient perceptions or knowledge of root canal treatment were examined. Case reports.
Educational intervention or digital tools evaluated. Editorials or opinion papers.
Published in English (the primary language used in clinical research, feasibility and consistency). Language biases were acknowledged. Non-English publications.
Adult population (above 18 years old because of autonomous decisions). Paediatric population.
Studies issued between 2015 and 2025. Studies not published in the 2015–2025 frame.
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Data extraction

Before full data extraction, a calibration exercise was conducted on two sample studies to ensure inter-rater consistency and refine the data charting form. Predefined data variables, such as author, year, country, study design, population or sample size, type of educational intervention, anxiety measuring methods, and important findings about patient perceptions and anxiety outcomes, were used to create a data extraction table. In order to guarantee uniform classification of works across thematic domains, this was improved during the review process.

One author extracted the data (ISP), and the supervisor (DR) was consulted. The results were summarised and tabulated (please refer to Table 2 in Sect. 3, results).

Table 2.

Characteristics of the articles included

Authors (Year) Country Study Design Sample Size Educational Intervention Key Findings JBI tool
Anatürk & Özkan (2025) Turkey Randomised Controlled Trial 120 (final 60) Video-based information Significant reduction in pre-treatment anxiety compared to verbal info. High
Islam (2025) Pakistan Comparative, cross-sectional 100 AI-generated (ChatGPT) Anxiety scores dropped from 3.50 to 2.63, showing superior trust and clarity. Moderate
Nassar et al. (2024) Saudi Arabia Randomised Controlled Trial 150 (final 76) Educational Animation Animations are superior to leaflets for 1-month knowledge retention. High
Alsakr et al. (2023) Saudi Arabia Prospective 115 Intern-led care Anxiety is higher in females/younger patients and drops significantly post-treatment. Moderate
Manasa et al. (2023) India Observational 300 Awareness Questionnaire 60% concerned about pain; significant knowledge gaps identified. Moderate
Qasim et al. (2022) Pak/Saudi Descriptive 209 Expectations Survey 47% prefer specialists; mass media is cited as the primary information source. Moderate
Aleid (2021) Saudi Arabia Qualitative/Exploratory N/A Structured Information 85% preferred saving teeth via RCT over extraction post-education. Moderate
Bansal & Jain (2020) India Survey. Descriptive 450 Knowledge Questionnaire 51.5% cited fear of pain; 91.5% reported self-medication habits. Moderate
Jeddy et al. (2018) India Cross-sectional 300 (final 299) Trigger Assessment Top triggers: pain (79.7%) and injections; females report higher DFA. Moderate
Melgaço-Costa (2016) Brazil Qualitative 10 Interviews/Diaries Satisfaction is linked more to empathy and humanity than technical skill. Moderate
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Critical appraisal and quality assessment

In order to provide further context for evaluating the data, methodological quality across study designs was assessed using the Joanna Briggs Institute’s (JBI) critical assessment tools. The appraisal’s findings were taken into account throughout the qualitative synthesis to emphasise the advantages and disadvantages of the available data rather than being used to reject research. Only two studies had high methodological quality, while the majority (8 out of 10) showed intermediate quality.

Although critical appraisal is an optional step in scoping reviews according to JBI methodology, it was conducted in this study to provide essential context for interpreting the evidence. The JBI Critical Appraisal Tools were selected because they provide specialised checklists tailored to the heterogeneous research designs—including randomised clinical trials, cross-sectional surveys, and qualitative studies—identified in this review. The appraisal focused on study design, sampling methodology, and the validity of outcome measurements. Importantly, the results of this assessment were used to weight the qualitative synthesis and highlight the strengths and limitations of the current evidence base, rather than as a basis for excluding studies.

Results

The systematic search across PubMed, ScienceDirect, Cochrane, and Wiley identified 2477 records. After identifying duplicates and reviewing titles and abstracts, 52 articles were evaluated for full-text eligibility. In conclusion, ten articles were included in the final review since they met the inclusion criteria. The PRISMA-ScR flow diagram (Fig. 1) provides specifics on the study selection method.

A wide variety of study designs are represented in the included literature, including prospective quantitative studies, cross-sectional surveys, randomised controlled trials (RCTs), and qualitative interviews. These studies provide a global perspective, with data originating from Saudi Arabia, India, Brazil, Pakistan, and Turkey. The findings indicate that fear of pain, limited knowledge regarding root canal treatment and previous negative dental experiences are major contributors to DFA. Educational interventions, particularly video-based and animated materials, were associated with improved patient understanding and reduced anxiety levels. Recent studies also suggest that Artificial Intelligence (AI)-generated educational content may enhance clarity and trust while reducing patient anxiety, although further validation is required. Socioeconomic factors, including treatment cost and access to specialised care, were also identified as important determinants influencing treatment decisions.

Methodological summary of the included studies

Experimental and randomised designs

  • Anatürk et al. (2025): a randomised clinical trial of 60 analysed patients (120 recruited) in Turkey to compare Visual Video Information (VVI), consisting of a 65-second procedure introduction and a 246-second clinical step explanation delivered via iPad, to routine verbal information provided by the clinician. Anxiety was measured using the Modified Dental Anxiety Scale (MDAS) [range 5–25], State-Trait Anxiety Inventory, State and Trait Subscales (STAI-S/T) [range 20–80], and Visual Analog Scale (VAS) [range 0–100 mm], alongside objective stress recorded via Galvanic Skin Response (GSR) devices.

  • Islam (2025): a comparative cross-sectional study in Pakistan involving 100 participants. It compares AI-generated materials (produced by ChatGPT using a prompt for customised endodontic/restorative descriptions, risks, and aftercare) to traditional education (verbal instructions and printed pamphlets provided by clinical staff). Outcomes were measured using a 1–5 Likert scale (potential range = 1–5) for clarity, trust, and usefulness, where higher scores indicated higher quality.

  • Nassar et al. (2024): Conducted a randomised controlled trial in Saudi Arabia to compare educational animation (delivered via WhatsApp) to printed leaflets. Out of 150 volunteers recruited, 76 were considered. Knowledge gain and retention were measured using a 7-item validated questionnaire (scored on a 0–7 accuracy scale) at three intervals: baseline (T1), immediate post-intervention (T2), and a one-month follow-up (T3).

Prospective and cross-sectional surveys

  • Alsakr et al. (2023): Conducted a prospective study in Saudi Arabia on 115 patients treated by intern dental doctors under specialist supervision. Pre- and post-treatment anxiety were evaluated using the MDAS (5-item Likert, range 5–25), using a cut-off score of 19 to define high-level anxiety.

  • Manasa et al. (2023): Performed an observational survey in India on 300 patients using a double-blinded questionnaire available in English, Hindi, and Urdu to assess awareness and perceptions of endodontic advancements. Knowledge was self-evaluated by patients on a 3-point categorical scale (minimum, average, or high).

  • Qasim et al. (2022): descriptive quantitative survey in Pakistan and Saudi Arabia using a multiple-choice questionnaire to characterise knowledge, experiences, and expectations regarding root canal treatment (RCT) in 209 patients.

  • Jeddy et al. (2018): Conducted a cross-sectional survey on 300 outpatients (299 analysed) in India using a custom 10-question questionnaire to identify anxiety triggers and influencing factors.

  • Bansal & Jain (2020): Performed a descriptive survey in India using a 15-question pre-structured survey to evaluate public knowledge and common myths regarding RCT (450 outpatients).

Qualitative and exploratory designs

  • Aleid (2021): Conducted a qualitative exploratory survey in Saudi Arabia to assess patient perceptions and experiences, specifically comparing treatment preferences between RCT and extraction.

  • Melgaço-Costa et al. (2016): Utilised a qualitative methodology in Brazil involving 10 semi-structured interviews and a field diary (direct observation of 30-minute sessions) to explore patient perceptions of endodontic care within public health services.

Prevalence and psychological factors associated with DFA

The review confirms that DFA remains a pervasive barrier to endodontic care. According to demographic research by Jeddy et al. (2018), Alsakr et al. (2023), and Anatürk et al. (2025), women express considerably higher levels of anxiety than men. Furthermore, Alsakr et al. (2023) and Anatürk et al. (2025) identified that anxiety typically decreases with age, with younger patients exhibiting the highest fear levels.

Regarding clinical triggers, Jeddy et al. (2018) and Anatürk et al. (2025) found that the anticipation of pain, local anaesthetic injections, and the noise or vibration of dental drills were the most distressing stimuli. Notably, Aleid (2021), Alsakr et al. (2023), and Anatürk et al. (2025) all observed that anxiety levels drop sharply once the procedure is completed, suggesting that anticipatory stress is often more intense than the clinical reality.

Patient knowledge gaps and misconceptions

Analysis of patient endodontic literacy reveals significant deficits. Bansal & Jain (2020) and Qasim et al. (2022) noted that patients increasingly rely on mass media and the internet, though many still obtain information from unreliable word-of-mouth sources. A widespread misconception identified by Bansal & Jain (2020) is the belief that RCT-treated teeth become brittle or structurally weak, a myth held by nearly 80% of patients.

Furthermore, Bansal & Jain (2020) and Manasa et al. (2023) found that patients often incorrectly believe that antibiotics alone can resolve endodontic infections. Despite these fears, Aleid (2021) determined that when patients receive high-quality information, up to 85% express a preference for RCT to preserve their natural teeth over extraction.

Educational and technological interventions

Multimedia and animation evidence

It suggests that visual educational tools outperform traditional methods. Anatürk et al. (2025) and Nassar et al. (2024) both found that VVI and educational animations are highly effective for delivering information. Specifically, Nassar et al. (2024) reported that animations are significantly more effective for knowledge retention at a one-month follow-up compared to traditional leaflets. Additionally, Anatürk et al. (2025) confirmed that video-based information provided via tablets significantly lowers pre-treatment anxiety and improves emotional preparedness before treatments.

AI and clinical efficiency

Generative AI tools represent a transformative development in patient communication. Islam (2025) assessed AI-generated educational materials created by ChatGPT for endodontic and restorative procedures against conventional patient education (verbal explanations and printed pamphlets). Patients rated clarity and trust using a 1–5 Likert scale, with higher scores indicating greater satisfaction. AI-generated materials demonstrated significantly higher clarity (4.42 vs. 3.25) and trust (4.00 vs. 2.96) and were associated with reduced procedural anxiety (3.50 vs. 2.63), while cutting clinician explanation time by 50% and educational costs by nearly 60%.

Socioeconomic barriers and literacy

Access to endodontic care is deeply influenced by external structural factors. Bansal & Jain (2020) highlight that high treatment costs are a primary deterrent (65% of patients found that RCT was too expensive), often forcing a choice of extraction over tooth preservation. In regions with high economic barriers, Bansal & Jain (2020) noted that the rate of self-medication reaches 91.56%.

Regarding professional expectations, Bansal & Jain (2020) and Qasim et al. (2022) found a marked patient preference (up to 92%) for being treated by a specialist (endodontist) rather than a general practitioner. Finally, Melgaço-Costa (2016) identified that in public health settings, patient satisfaction is linked more closely to a dentist’s interpersonal skills, humanity, and empathy than to their technical competence.

The following table, Table 2, shows the included articles, type of study, findings and the JBI tool applied.

Table 3 shows four included articles that discuss intervention and outcome for further understanding of the findings.

Table 3.

Educational interventions and anxiety outcomes

Study Intervention Study Design Outcome
Anatürk & Özkan (2025) Video-based patient education Randomised clinical trial Significant reduction in DFA before RCT.
Nassar et al. (2024) Educational animation Randomised clinical trial Improved knowledge retention compared with leaflets.
Islam et al. (2024) AI-generated educational material Comparative study Anxiety scores significantly reduced.
Bansal & Jain (2020) Knowledge assessment Cross-sectional Fear of pain was identified as the primary cause of avoidance.
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Discussion

Misconceptions surrounding endodontic treatment remain a major driver of avoidance behaviour and treatment rejection. Many patients overestimate procedural pain and risk, often perceiving extraction as a simpler alternative despite its long-term disadvantages for oral health. The included studies in this review demonstrate a consistent relationship between DFA, patient knowledge, and treatment acceptance in endodontic care. Limited understanding of root canal treatment frequently contributes to patient hesitation and anxiety, particularly when information is derived from informal sources such as social media, anecdotal experiences, or outdated perceptions of dental procedures. Consequently, exaggerated fears may influence patients to avoid treatment or choose extraction rather than tooth preservation (Aleid 2021, Melgaço-Costa et al. 2016, Nassar et al. 2024, Anatürk et al. 2025). These perceptions are further reinforced by structural barriers such as limited access to specialist care, inefficiencies within public dental systems, geographic barriers, and high out-of-pocket costs, which collectively contribute to treatment delays (Åstrøm et al. 2024, Bansal and Jain 2020, Qasim et al. 2022, Melgaço-Costa et al. 2016).

Educational interventions appear to be effective in addressing these challenges. Multimedia educational tools, including animations and video-based explanations, have demonstrated improvements in patient comprehension and reductions in reported anxiety. Visual educational materials may be particularly effective in communicating complex procedures, enabling patients to better understand treatment steps and expected outcomes. Evidence suggests that improved education can influence treatment preferences (Aleid 2021, Melgaço-Costa et al. 2016, Anatürk et al. 2025).

Recent advances in artificial intelligence (AI) suggest additional opportunities to enhance patient education. AI-generated educational materials can provide simplified explanations of complex procedures, potentially improving communication between clinicians and patients with varying levels of health literacy. Preliminary evidence suggests that AI-generated content may improve comprehension and communication efficiency compared with traditional verbal or written explanations (Srinivasan et al. 2024, Bansal and Jain 2020, Qasim et al. 2022, Melgaço-Costa et al. 2016, Islam 2025, Nassar et al. 2024). Some studies also report potential operational benefits, indicating that AI-generated educational materials could reduce education-related costs and decrease clinician explanation time (Islam 2025, Nassar et al. 2024). However, these findings should be interpreted cautiously, as the evidence base remains limited.

Despite these advantages, the integration of AI into patient education raises important ethical considerations. AI systems may generate inaccurate or misleading information if not appropriately supervised, sometimes referred to as “artificial hallucinations” (Islam 2025). To mitigate this risk, AI-generated educational content should undergo expert validation before patient use. Interdisciplinary review panels comprising clinicians, psychologists, and informatics specialists are proposed to ensure accuracy and reliability, with recommended inter-rater reliability thresholds such as a Kappa coefficient ≥ 0.75 to ensure clinical safety and high-quality content (Islam 2025, Anatürk et al. 2025, Bommanavar et al. 2025).

Furthermore, digital equity remains an important concern. Many AI systems rely primarily on English-language datasets, potentially limiting accessibility for linguistically diverse populations. Without careful design, digital educational tools may inadvertently widen existing oral health disparities. Future AI platforms should therefore prioritise multilingual accessibility and optimisation for low-bandwidth environments to ensure equitable access across diverse patient populations (Islam 2025, Nassar et al. 2024, Anatürk et al. 2025, Bommanavar et al. 2025).

Although professional organisations such as the American Association of Endodontists (AAE), the British Endodontic Society (BES) and the European Society of Endodontology (ESE) provide high-quality educational materials, these resources are often fragmented and may contain complex terminology that is difficult for patients with limited health literacy to interpret. The development of centralised multimedia educational platforms incorporating AI technologies could therefore improve accessibility and dissemination of endodontic information.

Emerging technologies may also complement educational strategies aimed at reducing DFA. Techniques such as virtual reality exposure therapy, biofeedback, and immersive visualisation have shown potential in reducing sensory triggers associated with dental procedures. Although these approaches were not widely evaluated in the included studies, future research could explore whether combining AI-generated education with immersive technologies may further enhance anxiety reduction strategies.

Methodological gaps in the current literature

Despite promising developments in digital patient education, several methodological limitations remain within the existing evidence base. One major challenge is the lack of standardisation in anxiety measurement tools across studies. Various instruments have been used to assess DFA, limiting comparability between studies and complicating the synthesis of outcomes (Anatürk et al. 2025). Future research should prioritise validated and widely used scales, such as the MDAS (Humphris et al. 1995), potentially in combination with diagnostic frameworks derived from DSM-5 criteria.

Additionally, studies using physiological stress indicators, such as GSR, have highlighted challenges in achieving consistent environmental control. Variables including temperature, humidity, and ambient noise can influence electrodermal readings, potentially affecting the reliability of objective anxiety measurements (Anatürk et al. 2025).

Study design is another methodological limitation. Many studies use single-institution samples or cross-sectional surveys, which limit external validity and the capacity to determine causal links between educational interventions and reduction in DFA. Future research should therefore incorporate multi-centre designs and more diverse patient populations to enhance generalisability (Islam 2025, Nassar et al. 2024, Anatürk et al. 2025).

Randomised trials evaluating multimedia education may also benefit from improved control conditions. For example, incorporating neutral or “sham” educational videos for control groups could provide a more balanced comparison when evaluating the effectiveness of educational interventions (Anatürk et al. 2025).

Future directions for research

Although interest in educational strategies to reduce DFA is increasing, most available studies remain cross-sectional and descriptive. To assess the long-term efficacy of educational treatments and their influence on patient decision-making, high-quality longitudinal and randomised clinical studies are crucial.

Future investigations should focus on assessing whether AI-enhanced or multimedia educational approaches produce sustained behavioural changes and improved clinical outcomes over time (Islam 2025, Anatürk et al. 2025). One promising research direction involves tracking “treatment reversion”, defined as whether patients who initially select root canal treatment following educational interventions subsequently revert to extraction preferences within a defined period (Bansal and Jain 2020, Islam 2025, Nassar et al. 2024, Anatürk et al. 2025, Bommanavar et al. 2025).

Personalised AI-driven educational interventions may also represent a valuable area for future research. Tailoring educational content based on patients’ baseline anxiety levels could potentially enhance the effectiveness of interventions for individuals experiencing high levels of procedural stress (Islam 2025).

Further studies should also address the ethical implications of digital health technologies by developing multilingual AI educational platforms designed to prevent digital exclusion among non-English-speaking and low-resource populations. Ensuring equitable access to digital education tools will be essential to avoid widening existing oral health disparities (Islam 2025, Anatürk et al. 2025).

Additionally, emerging research may explore the potential for predictive analytics in dentistry, although this is not yet a common practice. AI systems capable of analysing patient behavioural patterns and clinical data may eventually be helpful to clinicians in identifying individuals at higher risk of DFA before treatment, allowing targeted interventions to be implemented earlier in the care pathway (Jeddy et al. 2018, Islam 2025, Bommanavar et al. 2025).

Clinical implications

From a clinical perspective, improving patient understanding of endodontic procedures represents an important strategy for reducing DFA and increasing acceptance of tooth-preserving treatments. The findings of this review suggest that multimedia and AI-assisted educational tools may enhance communication between clinicians and patients by simplifying complex procedural information and addressing common misconceptions surrounding root canal treatment. However, these technologies should be implemented as supportive decision-aid tools rather than replacements for clinician-patient interaction. Combining validated digital education with empathetic communication from dental professionals may offer the most effective approach to addressing both the “literacy gap” in procedural understanding and the “empathy gap” often experienced by anxious dental patients.

Limitations of the present scoping review

A number of restrictions should be considered when interpreting the review’s findings. First, the body of research on digital or AI-based educational techniques in endodontics is still quite small. Many studies also rely on cross-sectional designs and convenience sampling, which restrict generalisability and limit the ability to determine causal relationships (Muneer et al. 2022, Silveira et al. 2021).

Second, most studies evaluate short-term outcomes, and there is limited evidence regarding the long-term impact of educational interventions on treatment acceptance, behavioural change, or clinical outcomes. Longitudinal research is therefore required to determine whether digital educational tools exert sustained influence on treatment decisions and tooth preservation (Islam 2025, Nassar et al. 2024, Anatürk et al. 2025).

Lastly, only English-language publications were included in this review, which could lead to linguistic bias and possibly omit relevant research carried out in non-English-speaking countries. The findings offer valuable insight into the evolving role of patient education in reducing DFA and improving engagement with endodontic care despite the limitations mentioned.

Conclusion

DFA, misinformation, and economic barriers restrict the acceptance of endodontic treatment and contribute to preventable tooth loss. Educational interventions, particularly multimedia approaches such as animation and video-based explanations, demonstrate promising potential for improving patient understanding and reducing treatment-related anxiety. Although early evidence suggests that artificial intelligence may further enhance patient education, further high-quality clinical research is required to evaluate the long-term effectiveness and accessibility of these technologies in dental practice.

Combining empathetic clinician communication with technology-driven educational content represents a multimodal solution capable of breaking the cycle of DFA and improving oral health outcomes.

Supplementary material

Below is the link to the electronic supplementary material.

Supplementary File 1 (DOCX 24.2 KB) (24.3KB, docx)

Author contributions

Conceptualisation, ISP; methodology, ISP, IBN and DRP; validation, IBN; formal analysis, ACS; investigation, ISP; resources, ISP; data curation, ISP and ACS; writing-original draft preparation, ISP; writing-review and editing, ISP and DRP; visualisation, ISP; supervision, IBN, ACS and DRP.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary File 1 (DOCX 24.2 KB) (24.3KB, docx)

Data Availability Statement

No datasets were generated or analysed during the current study.

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