Abstract
Dental anxiety is a common problem that may negatively affect patients undergoing tooth extraction procedures. Non-pharmacological interventions have been proposed as supportive strategies to reduce anxiety and improve patient comfort.
The aim of this systematic review was to analyze and summarize non-pharmacological methods used to improve psychoemotional status in adult patients undergoing tooth extraction procedures.
Methods
A systematic literature search was conducted in PubMed (MEDLINE) for studies published between 18 September 2014 and 18 September 2024. A supplementary search was also conducted in ScienceDirect on 18 September 2024, using an adapted keyword strategy and the publication year filter (2014–2024), to reduce the risk of retrieval bias. Randomized controlled trials involving adult patients undergoing dental extraction procedures and evaluating non-pharmacological interventions for anxiety reduction were included. Studies involving pharmacological sedation, non-extraction procedures, or lacking psychoemotional outcomes were excluded.
Results
The PubMed search identified 3692 records. After screening and eligibility assessment according to predefined criteria, 25 randomized controlled trials were included in the qualitative synthesis. The most commonly investigated interventions included music therapy, virtual reality, aromatherapy, guided relaxation techniques, informational interventions, and acupuncture-based methods. Anxiety outcomes were measured using validated scales such as the Modified Dental Anxiety Scale (MDAS), State-Trait Anxiety Inventory (STAI), Visual Analogue Scale (VAS), and Amsterdam Preoperative Anxiety and Information Scale (APAIS), as well as physiological parameters including heart rate, blood pressure, and salivary cortisol. Most studies reported reductions in anxiety indicators following non-pharmacological interventions.
Conclusion
Non-pharmacological interventions may contribute to reducing anxiety in patients undergoing tooth extraction procedures. However, heterogeneity among interventions and outcome measures limits direct comparison across studies. Further well-designed randomized controlled trials are needed to strengthen the evidence base.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-026-08209-6.
Keywords: Dental anxiety, Non-pharmacological interventions, Music therapy, Virtual reality, Aromatherapy, Hypnosis, Systematic review
Introduction
Dental anxiety is a common issue among adults undergoing tooth extraction procedures, often leading to avoidance of dental care, increased stress, and deteriorated oral health. It is considered a significant barrier to accessing dental treatment, negatively affecting both patients’ psychological well-being and clinical outcomes. According to Logan and Marek, “anxiety is both a physical and emotional response to an anticipated experience that the individual perceives as threatening in some way. […] In its most extreme form, anxiety may significantly limit the individual’s ability to function in everyday life.” [1].
Traditionally, pharmacological approaches such as sedation or the use of anxiolytics have been applied to manage dental anxiety. Finn et al. [2] highlight that oral benzodiazepines can be an effective option for managing dental anxiety in patients who experience significant fear before dental procedures.”
However, the widespread use of such interventions is not always recommended, as they are associated with potential side effects, contraindications, and risk of misuse [2]. As a result, growing attention has been directed toward non-pharmacological methods such as music therapy, guided imagery, virtual reality, audiovisual distraction, and patient education, which aim to reduce anxiety without medical sedation.
While numerous studies have investigated these techniques in broader dental settings, a focused synthesis of their effectiveness in the specific context of tooth extraction remains limited as noted by Wong et al., [3] “non-pharmacological interventions appear to reduce fear and anxiety levels in patients undergoing third molar extraction under local anesthesia,” [3] yet the available evidence is scattered and inconsistent. Moreover, Hao et al. emphasize that “no direct comparative RCTs or network meta-analyses (NMAs) exist to contrast the therapeutic effects of these interventions and determine which one is most effective.” [4].
This gap in the literature highlights the need for a systematic review that consolidates current findings and evaluates the effectiveness of non-pharmacological interventions aimed at reducing psychoemotional distress in adult dental extraction patients. Such evidence could help guide clinical decision-making and promote safer, more personalized anxiety management strategies in oral surgery.
The aim of this systematic review is to identify and assess non-pharmacological methods used to improve the psychoemotional status of adult patients undergoing dental extractions, with the goal of providing evidence-based guidance for clinical application and future research.
Materials and methods
Protocol and registration
The methods and inclusion and exclusion criteria were determined in advance and documented in the protocol. This review was registered in PROSPERO, an international prospective register of systematic reviews. The protocol ID CRD420251030729 and it can be accesed by https://www.crd.york.ac.uk/PROSPERO/view/CRD420251030729.
This systematic review adhered to the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [5].
Focused question
The following research question was formulated using the PICO framework (Population, Intervention, Comparison, Outcome):
What non-pharmacological interventions are effective in improving psychoemotional outcomes—such as anxiety, stress, or fear—measured using validated psychological or physiological tools, in adult patients undergoing dental extraction?
Table 1 summarizes the characteristics of the included studies, structured according to the corresponding PICO elements
Table 1.
Pico components
| PICO component | Description |
|---|---|
| P – Population | Adult patients (≥ 18 years old) undergoing tooth extraction procedures |
| I – Intervention | Non-pharmacological psychoemotional interventions used before/during/after dental extraction:- Music therapy (including binaural beats, 432 Hz, etc.)- Virtual Reality / video distraction- Aromatherapy (e.g., lavender oil)- Acupuncture, acupressure, auriculotherapy- Hypnosis or guided relaxation- Psychoeducation / breathing techniques / consent aids |
| C – Comparison | Standard care or no intervention (e.g., routine extraction procedures without psychological aid) |
| O – Outcome | Reduction in dental anxiety, fear, or stress (measured by MDAS, STAI, VAS, HR, BP, cortisol, etc.) |
Types of studies
This review included randomized controlled trials (RCTs) involving adult patients (≥ 18 years) undergoing dental extraction, in which non-pharmacological interventions were applied to reduce anxiety, fear, or psychological distress. Studies were required to report psychoemotional outcomes using validated psychological or physiological measurement tools, such as the Visual Analog Scale (VAS), State-Trait Anxiety Inventory (STAI), Modified Dental Anxiety Scale (MDAS), or comparable instruments. Only full-text, peer-reviewed randomized controlled trials were included. Observational studies, case reports, qualitative studies, review articles, conference abstracts, and studies in which pharmacological or sedation-based methods were the primary intervention were excluded.
Information sources and search strategy
A systematic search was conducted in PubMed (MEDLINE) on 18 September 2024. The publication date filter (“last 10 years”) was applied in the PubMed interface to limit the results to studies published between 18 September 2014 and 18 September 2024. No additional study design, age, or clinical filters were applied at the database level. Eligibility criteria were applied during the title/abstract and full-text screening stages.
The complete search strategy as entered in PubMed, including the applied filters, is provided in Supplementary file 1.
The following search string was used in PubMed:
((((((dental phobia) OR (dental anxiety)) OR (dental fear)) OR (teeth extraction fear)) OR (teeth extraction anxiety)) OR (teeth extraction phobia)) AND (((methods) OR (tools)) OR (strategies)).
In addition to PubMed (MEDLINE), a supplementary search was conducted in ScienceDirect on 18 September 2024 to reduce the risk of retrieval bias. The search strategy was adapted to the ScienceDirect interface using the query: (“dental anxiety” OR “dental fear” OR “dental phobia”) AND (“tooth extraction” OR “teeth extraction”) AND (methods OR tools OR strategies). The publication year filter (2014–2024) was applied. A total of 165 records were identified and screened by title and abstract. A detailed list of screened records and reasons for exclusion from the additional ScienceDirect search is provided in Supplementary Table S2.
To ensure completeness of the search, the reference lists of all included studies and relevant review articles were manually screened to identify additional eligible trials.
Selection of studies
All records were screened independently and in duplicate by two reviewers according to predefined inclusion and exclusion criteria. Discrepancies were resolved through discussion; if consensus could not be reached, a third reviewer was consulted.
Inclusion criteria
Studies were included if they met all of the following criteria:
Randomized controlled trials (RCTs);
Adult participants (≥ 18 years) undergoing dental extraction procedures;
Evaluation of non-pharmacological interventions aimed at reducing anxiety, fear, or stress before or during the procedure;
Conducted in outpatient (ambulatory) clinical settings;
Reported at least one validated psychological or physiological measure of anxiety or stress.
Exclusion criteria
Studies were excluded if they:
Involved pediatric populations or patients with cognitive or psychiatric disabilities;
Included participants with severe systemic conditions that could significantly affect stress response (e.g., epilepsy, Down syndrome, metabolic disorders);
Used pharmacological sedation (e.g., midazolam, diazepam, nitrous oxide) as the primary intervention;
Provided insufficient data or had inaccessible full texts.
The selection process consisted of three stages. First, titles were screened to exclude clearly irrelevant studies, reviews, conference abstracts, and animal research. Second, abstracts were assessed for relevance to the review question. Full-text articles were evaluated for eligibility based on the predefined inclusion and exclusion criteria.
Data extraction
Data extraction was performed independently by two reviewers. In cases of disagreement, consensus was reached through discussion; if necessary, a third reviewer was consulted to make the final decision.
For each included study, the following information was extracted: authors and year of publication, type of non-pharmacological intervention (e.g., music therapy, virtual reality, aromatherapy, auriculotherapy), study design characteristics, sample size, anxiety or stress assessment tools (e.g., MDAS, STAI, VAS, heart rate, blood pressure, salivary cortisol), main outcomes in both control and intervention groups, and reported statistical significance (p-values, where available).
When a study evaluated more than one intervention, each intervention was extracted and reported separately. All extracted data were organized into structured summary tables to enable comparison across studies and facilitate thematic synthesis.
Assessment of methological quality
The methodological quality and risk of bias of the included studies were assessed independently by two reviewers using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool. This tool evaluates five domains: (D1) bias arising from the randomization process; (D2) bias due to deviations from intended interventions; (D3) bias due to missing outcome data; (D4) bias in measurement of the outcome; and (D5) bias in selection of the reported result.
Each domain was judged as “low risk of bias,” “some concerns,” or “high risk of bias,” and an overall risk-of-bias judgment was assigned to each study accordingly.
Certainty of evidence assessment
The certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Because the review used a narrative synthesis and the included studies were heterogeneous in terms of intervention protocols, comparators, and outcome measures, certainty was evaluated by intervention category rather than by pooled effect estimate. Evidence from randomized controlled trials started as high certainty and was downgraded, where appropriate, for risk of bias, inconsistency, indirectness, imprecision, and publication bias. Publication bias was considered qualitatively, as quantitative assessment was not appropriate in the absence of meta-analysis and because fewer than 10 studies were available in most intervention categories.
Synthesis of the results and statistical analysis
Data extracted from the included randomized controlled trials were summarized in tables according to intervention type, outcome measures, and principal findings.
Due to substantial clinical and methodological heterogeneity among the included studies — including differences in intervention protocols, duration and frequency of application, anxiety assessment instruments (e.g., MDAS, STAI, VAS, physiological parameters), timing of outcome measurement, and reporting of effect sizes — a quantitative meta-analysis was not considered appropriate.
Therefore, a narrative synthesis approach was applied. Results were grouped thematically by intervention category (music therapy, virtual reality, aromatherapy, acupuncture/acupressure, guided relaxation techniques, hypnosis, and informational interventions). Findings were analyzed descriptively, with emphasis on statistical significance, direction of effect, magnitude of change (where reported), and consistency across studies.
Results
Study selection
The PubMed (MEDLINE) search with the publication date filter “last 10 years” identified 3692 records. After title and abstract screening, 32 reports were assessed in full text for eligibility. Of these, 7 reports were excluded after full-text evaluation (2 not available in English, 2 inaccessible due to paywall restrictions, and 3 not meeting the randomized controlled trial design criterion). Ultimately, 25 randomized controlled trials were included in the qualitative synthesis. The supplementary search conducted in ScienceDirect identified 165 records, but no additional randomized controlled trials met the inclusion criteria. The selection process is illustrated in Fig. 1. A summary of the main characteristics of the included studies, including intervention types, sample sizes, anxiety measures, and outcomes, is presented in Table 2.
Fig. 1.
Prisma flow chart diagram
Table 2.
Summary of the included studies: interventions applied, anxiety assessment tools, outcome measures, and main findings
| Author | Anxiety reducing methods | Measurement scales | Control group results | Experimental group results | Difference (p) | Effect |
|---|---|---|---|---|---|---|
| Aravena et al. (2020) [6] | Music therapy | CORAH-MDAS, ELISA | MDAS: 17.2 ± 4.60; Cortisol: 1.59 ± 0.70 µg/dL | 432 Hz: MDAS: 8.7 ± 2.67; Cortisol: 0.49 ± 0.37 µg/dL; 440 Hz: MDAS: 8.4 ± 2.84; Cortisol: 1.35 ± 0.69 µg/dL | Significant reduction in anxiety scores (MDAS) and salivary cortisol in 432 Hz group vs. control (p < .001); 440 Hz group also showed significant MDAS reduction vs. control (p < .001); no significant difference between 432 Hz and 440 Hz groups (p = .914). | Positive |
| Gazal et al., (2016) [7] | Visual information (video about tooth extraction procedure) | VAS (Visual Analogue Scale) | Postoperative VAS: Mean = 38.8 (verbal group) | Postoperative VAS: Mean = 9.1 (video group) | p < .001 | Positive |
| Isik et al., (2017) [8] | Binaural beats via headphones (200 Hz left / 209.3 Hz right) for 10 min pre-op | VAS (Visual Analogue Scale) | Pre: 5.52 ± 2.42 → Post: 5.39 ± 2.65 (not significant) | Pre: 5.37 ± 2.12 → Post: 3.59 ± 2.23 (significant) | Within group p < .001; Between groups p = .006 | Positive. Significant reduction in anxiety in the experimental group only |
| Menziletoglu et al., (2021) [9] | Binaural beats | VAS (Visual Analogue Scale) | VAS pre: 4.70 → post: 4.55 (ns) | Pre: 5.03 → Post: 3.54 | p = .003 vs. control | Positive. Significantly reduced anxiety vs. control |
| 432 Hz music | VAS (Visual Analogue Scale) | VAS pre: 4.70 → post: 4.55 (ns) | Pre: 4.71 → Post: 2.94 | p < .001 vs. control; p = 1 vs. BB | Significantly reduced anxiety vs. control; no difference vs. binaural | |
| Sancak & Akal (2019) [10] | Verbal information only | MDAS, VAS, STAI-S, DFS | MDAS: 9 → 7.5 (p = .232); VAS: 3.9 → 1.9 (p = .021) | No statistical change in STAI-S or DFS | MDAS p = .232; VAS p = .021 | No significant reduction in anxiety |
| Written information | MDAS, VAS | MDAS: 11.5 → 10.5 (p = .014); VAS: 5.8 → 3.2 (p < .001) | Compared with verbal group – greater decrease | MDAS p = .014; VAS p < .001 | Positive. Significant reduction in MDAS and VAS scores | |
| Previous surgical experience | MDAS, VAS, STAI-S, DFS | MDAS: 9.5 → 6.5 (p = .004); VAS: 3.4 → 0.6 (p = .002) | Better scores post-op despite no extra info | MDAS p = .004; VAS p = .002 | Positive and Neutral. Significant reduction in MDAS and VAS; STAI-S and DFS remained unchanged | |
| Hasanoğlu Erbasar & Sancak, (2023) [11] | Silent video with subtitles | STAI-S, DFS, MDAS, VAS | MDAS: 10.0 → 8.0 (p = .002); VAS: 5.6 → 2.6 (p = .003) | Compared pre- and post-op: significant reduction | MDAS p = .002; VAS p = .003 | Positive. Significant reduction in MDAS and VAS scores |
| Video with background audio | STAI-S, DFS, MDAS, VAS | MDAS: 10.0 → 8.0 (p = .063); VAS: 4.4 → 3.0 (p = .038) | No statistically significant reduction after correction | MDAS p = .063; VAS p = .038 (not significant post-correction) | Neutral. No significant reduction in MDAS or VAS; minor effect | |
| Written brochure | STAI-S, DFS, MDAS, VAS | MDAS: 8.5 → 7.0 (p = .007); VAS: 3.4 → 1.4 (p = .009) | Clear and significant reduction in anxiety | MDAS p = .007; VAS p = .009 | Positive. Significant reduction in MDAS and VAS scores | |
| Verbal information (control group) | STAI-S, DFS, MDAS, VAS | MDAS: 11.0 → 9.0 (p = .072); VAS: 4.0 → 2.0 (p = .016) | Small changes; not statistically significant | MDAS p = .072; VAS p = .016 (not significant post-correction) | Neutral. No significant reduction in MDAS or VAS | |
| Toledano-Serrabona et al., (2020) [12] | informative + relaxing video (with audio, nature scenes, calming surgeon speech) | STAI-T, STAI-S, MDAS, HR, SBP, DBP | MDAS: 12.1 → 11.8; STAI-S: 18.8 → 14.7; HR higher during bone removal and tooth sectioning | MDAS: 13.7 → 11.0 (p = .006); STAI-S: 25.8 → 14.5 (p = .031); HR significantly lower during surgery | MDAS p = .006; STAI-S p = .031; HR p = .037 | Positive. Significant reduction in anxiety and heart rate during surgery |
| Gurram et al., (2021) [13] | Heartfulness meditation | STAI-S, STAI-T, MDAS, NRS | STAI-S: 35.3% low anxiety; higher moderate/severe anxiety; NRS similar | STAI-S: 80.8% low anxiety; moderate/severe lower; NRS not different | STAI-S p < .002; MDAS p = .132; NRS p = .143 | Positive and Neutral Significantly reduced situational anxiety(STAI-S); no effect on dental anxiety (MDAS) or pain |
| Karan, (2019) [14] | Lavender oil inhalation | MDAS, STAI-S, DAQ, VAS; vital signs | MDAS: 11.06 → 10.17 (p = .006); STAI-S: 42.22 → 36.71 (p = .001) | MDAS: 11.37 → 9.98 (p = .007); STAI-S: 41.16 → 33.86 (p = .001); RR↓ | RR p < .05 between groups; MDAS p = .007 (within group) | Positive. Significant within-group decrease in MDAS and STAI-S; lower intra-op respiratory rate vs. control; BP effect seen |
| Qazi et al., (2024) [15] | Auditory distraction (patient-chosen music or religious recitation via earbuds for 5–10 min) | MDAS | Pre: 11.28 → Post: 11.12 (NS) | Pre: 10.84 → Post: 8.96 | p = .014 between groups | Positive. Significant reduction in anxiety scores before extraction |
| Salehabadi et al., (2024) [16] | Binaural beat music (200 Hz left, 209.3 Hz right) via headphones for 10 min post-anesthesia | STAI (Y-1, Y-2) – overt/covert | Overt: 41.65; Covert: 47.53 | Overt: 35.74 (p = .001); Covert: 39.25 (p = .000) | Overt: p = .001; Covert: p = .000 | Positive. Significant reduction in overt and covert anxiety compared to control group (no music) |
| Gürses et al., (2024) [17] | Wearing glasses with green lenses | DAS, STAI-S, VAS (pain), HR, BP, O₂ sat | DAS ↑ (anxiety increased): 46.1 → 49.8 (p < .001); HR ↓ 1.95 bpm | DAS ↓: 51.8 → 41.5 (p < .001); HR ↓ 6.17 bpm (p = .017); pain VAS: 29.8 | DAS: p < .001; STAI-S: p < .001; HR: p = .017; Pain: p = .045 | Positive. Significant reduction in anxiety (DAS, STAI-S) and heart rate; intraoperative pain also reduced |
| Yamashita et al., (2019) [18] | Classical music during extraction (Rachmaninoff, 58 bpm, via headphones) | HRV (LF/HF), MDAS, STAI (S + T) | LF/HF ↑ significantly during surgery; STAI-S decreased slightly (non-significant) | LF/HF ↓ during incision, flap reflection, bone removal, crown separation; STAI-S ↓ significantly | LF/HF p < .05; STAI-S p = .047 | Positive. Decreased sympathetic activity (LF/HF ratio) and post-op anxiety (STAI-S) during surgical phases |
| Torul et al., (2023) [19] | Standard consent (verbal + written) | MDAS, salivary cortisol | MDAS: ↓ 3.0 pts; Cortisol: ↓ 39.8 nmol/L | - | MDAS p = .867; Cortisol p = .987 | No significant reduction in anxiety or cortisol |
| Visual/spatial-tailored consent (video + written) | MDAS, salivary cortisol | - | Cortisol ↓ post-op; MDAS ↓ post-op (↑ after consent) | Cortisol p = .014 (within group); MDAS NS | Positive and negative. Cortisol ↓ significantly (p = .014); MDAS ↑ after consent, ↓ after surgery | |
| Verbal/linguistic-tailored consent (expressive verbal + written) | MDAS, salivary cortisol | - | Cortisol ↓; MDAS ↓ (both after surgery) | NS (between groups) | Positive. Both cortisol and MDAS ↓ after surgery; aligned trends | |
| Bodily/kinesthetic-tailored consent (hands-on with model + written) | MDAS, salivary cortisol | - | Cortisol: ↓ after surgery; MDAS: ↓ in all phases | Cortisol p = .021; MDAS p < .05 (within group) | Positive. Cortisol ↓ significantly (P = .021 post-op); MDAS ↓ significantly pre–post & post-op | |
| Kupeli & Gülnahar, (2020) [20] | Classical music (Vivaldi) | CDAS, HR, MAP, SpO₂ | CDAS postop: 6.4 | CDAS postop: 4.65 | p = .024 | Positive. Significantly reduced postoperative anxiety (CDAS) more than other genres |
| Turkish music (Saba or Rast) | CDAS, HR, MAP, SpO₂ | CDAS postop: 6.4 | CDAS postop: 6.05 | Not significant | Positive. Moderate anxiety reduction, not significantly better than control | |
| Soft rock music (Elvis instrumental) | CDAS, HR, MAP, SpO₂ | CDAS postop: 6.4 | CDAS postop: 6.0 | Not significant | Positive. Slight anxiety reduction, least satisfaction among music groups | |
| No music (control group) | CDAS, HR, MAP, SpO₂ | CDAS postop: 6.4 | CDAS postop: 6.4 | Reference group | Positive. Anxiety slightly decreased but not significantly; higher scores than all music groups | |
| Choi et al., (2015) [21] | Audiovisual slideshow (illustrated + audio) | STAI-S, STAI-T, DAS, VAS, recall | Self-reported anxiety (post-op): 2.5; complications recalled: fewer | Self-reported anxiety (post-op): 0.7; more complications remembered | Self-report p < .05; recall p < .05 | Positive. Significantly reduced self-reported anxiety and improved knowledge of complications |
| Yamashita et al., (2020) [22] | Virtual reality (VR) headset showing nature scenes during surgery | VAS (anxiety), HRV (LF/HF) | VAS anxiety ↑ 4.0 ± 22.3 mm | VAS anxiety ↓ 13.3 ± 28.7 mm; LF/HF balance improved | p = .0014 (fear), p = .0001 (anxiety) | Positive. Significant decrease in VAS anxiety and shift from sympathetic to parasympathetic nervous state (HRV) |
| Mladenovic & Djordjevic(2021) [23] | Virtual Reality distraction during third molar surgery | Heart rate monitoring (wearable); Face pain scale (self-report) | Higher pain and HR without VR | Lower pain; lower HR before/during extraction | p < .001 VR vs. control | Positive |
| Packyanathan et al., (2019) [24] | Classical instrumental music (Veena) for 5 min before & during extraction | MDAS, SBP, DBP, HR | SBP ↑ +4.04 mmHg (p = .011); DBP ↑ +1.16 mmHg (NS); HR ↑ +31 bpm (NS); MDAS ↑ | SBP ↓ − 7.84 mmHg; DBP ↓ − 6.56 mmHg; HR ↓ − 5 bpm (all p < .05); MDAS ↓ (p < .05) | BP & HR p < .05; MDAS p < .05 (test group) | Positive. Significant reduction in MDAS scores, systolic/diastolic BP, and HR in music group; increased values in control |
| Maulina et al., (2017) [25] | Classical music (Mozart – Molto Allegro) | M-MDAS, systolic/diastolic BP, NAP | NAP ↓ 0.013 ng/mL; SBP ↓ 1.21 mmHg | NAP ↑ 0.053 ng/mL; SBP ↑ 2.46 mmHg; M-MDAS = 15.2 | NAP: NS vs. control; SBP: NS vs. control | Neutral. No anxiety reduction; slight increase in noradrenaline and BP |
| Religious Islamic music (Raihan vocal group) | M-MDAS, systolic/diastolic BP, NAP | NAP ↓ 0.013 ng/mL; SBP ↓ 1.21 mmHg | NAP ↓ 0.110 ng/mL; SBP ↓ 6.23 mmHg; M-MDAS = 15.4 | NAP p = .041 vs. classical, p = .028 vs. control | Positive. Significant reduction in noradrenaline and systolic BP; improved M-MDAS scores | |
| Sorribes de Ramón et al., (2023) [26] | Music therapy (Ravel, Bach via headphones) | STAI-T, STAI-S, VAS, HR, BP, SAT | STAI total: ↓6.63 pts; pain VAS: 15.03 mm | STAI total: ↓15.12 pts; pain VAS: 10.23 mm; SBP ↓7.84 mmHg; HR ↓7.5 bpm (vs. control); SAT ↑1.41% | All p < .05 | Positive. ↓ Total anxiety (–15.12), ↓ HR, ↓ SBP/DBP, ↓ pain; best results of all groups |
| Virtual reality (360° underwater scenes) | STAI-T, STAI-S, VAS, HR, BP, SAT | STAI total: ↓6.63 pts; pain VAS: 15.03 mm | STAI total: ↓9.80 pts; pain VAS: 13.66 mm; SBP ↓5.56 mmHg; HR ↓6 bpm; SAT ↑1.33% | All p < .05 (except pain p = .88) | Positive. ↓ Anxiety (–9.80), ↓ HR, ↓ SBP/DBP, but no significant pain reduction | |
| Dellovo et al., (2019) [27] | Auriculotherapy with mustard seeds (5 days before surgery, placebo pill before) | HR, BP, SpO₂, self-reported anxiety | HR: higher during extraction and suturing; anxiety ↓ in 83.3% patients | HR: significantly lower in 3 surgical stages; anxiety ↓ in 86.7% patients | HR p = .031–0.003; anxiety descriptive | Positive. Significantly reduced heart rate during key phases of surgery; high rate of reported anxiety relief |
| Armond et al., (2019) [28] | Acupuncture (pre-op + 3× post-op sessions) | STAI-S, VAS (anxiety), VAS (pain), trismus, edema | Anxiety VAS ↓ 3.35 mm; STAI-S ↓ 1.52 (NS); Edema higher at all timepoints | Anxiety VAS ↓ 7.94 mm; STAI-S ↓ 1.94 (NS); Edema significantly reduced | Edema: p = .026–0.040; Anxiety: NS (p = .365–0.859) | Neutral. No significant difference in anxiety; edema significantly reduced at 48 h, 72 h, and 7d vs. placebo |
| Ponni et al., (2024) [29] | Listening to preferred music genres (western, classical, popular) via speaker during extraction | MDAS, BP, HR, SpO₂, Temp, RR | RR ↑ during procedure; no other significant changes in vitals or MDAS | RR ↑ during procedure; vitals not significantly different; music had no clear benefit | RR p = .048 (within group); all others NS | Neutral. No significant difference in anxiety-related vitals; only respiratory rate increased in both groups |
| Omezli et al., (2020) [30] | Watching surgical video from internet (plus verbal + written info) | STAI-S, STAI-T, MDAS, APAIS, VAS | Anxiety increased less post-consent; MDAS = 9.14; APAIS = 13.47 | Higher anxiety post-consent; MDAS = 12.73; APAIS = 18.68 | STAI-T p = .014; MDAS/APAIS p < .001 | Negative. Increased anxiety immediately after consent compared to verbal-only group |
Inter-reviewer agreement was high across all screening stages. Cohen’s kappa coefficient was 1.0 for title and abstract screening and above 0.9 for the full-text review stage, indicating almost perfect agreement between the two independent reviewers.
Exclusion of studies
The reasons for exclusion after full-text assessment were as follows: articles not available in English (n = 2), full-text articles inaccessible due to paywall restrictions (n = 2), and studies that did not meet the randomized controlled trial design criterion (n = 3).
Quality assessment
The methodological quality of the 25 included randomized controlled trials was evaluated using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool. This tool assesses five domains: (D1) bias arising from the randomization process; (D2) bias due to deviations from intended interventions; (D3) bias due to missing outcome data; (D4) bias in measurement of the outcome; and (D5) bias in selection of the reported result.
Each domain was rated as “low risk of bias,” “some concerns,” or “high risk of bias,” in accordance with RoB 2.0 guidance. An overall risk-of-bias judgment was assigned to each study based on domain-level assessments.
Overall, 21 studies were judged to have a low risk of bias across all assessed domains. Four studies were classified as having “some concerns,” primarily due to insufficient reporting of the randomization process or limited detail regarding allocation concealment and outcome measurement procedures. No study was assessed as having a high overall risk of bias.
In general, most trials demonstrated adequate randomization procedures, comparable baseline characteristics between groups, and consistent outcome reporting. Missing outcome data were minimal in the majority of studies, and outcome measures were typically based on validated psychological instruments (e.g., MDAS, STAI, VAS) or objective physiological parameters (e.g., heart rate, blood pressure, salivary cortisol).
A detailed domain-level summary of the risk-of-bias assessment is presented in Table 3.
Table 3.
Risk of bias assessment of included randomized controlled trials using the Cochrane RoB 2.0 tool
| Study | D1 | D2 | D3 | D4 | D5 | Overall |
|---|---|---|---|---|---|---|
| Aravena et al. [6] | ? | + | + | + | ? | Some concerns |
| Gazal et al. [7] | Low risk | |||||
| Isik et al. [8] | Low risk | |||||
| Menziletoglu et al. [9] | Low risk | |||||
| Sancak & Akal [10] | Low risk | |||||
| Hasanoğlu Erbasar & Sancak [11] | + | + | + | + | + | Low risk |
| Toledano-Serrabona et al. [12] | + | + | + | + | + | Low risk |
| Gurram et al. [13] | ? | + | + | + | ? | Some concerns |
| Karan [14] | + | + | + | + | + | Low risk |
| Armond et al. [28] | + | + | + | + | + | Low risk |
| Qazi et al. [15] | ? | + | + | + | ? | Some concerns |
| Salehabadi et al. [16] | + | + | + | + | + | Low risk |
| Gürses et al. [17] | + | + | + | + | + | Low risk |
| Yamashita et al. [18] | + | + | + | + | + | Low risk |
| Torul et al. [19] | + | + | + | + | + | Low risk |
| Kupeli & Gülnahar [20] | + | + | + | + | + | Low risk |
| Omezli et al. [30] | + | + | + | + | + | Low risk |
| Choi et al. [21] | + | + | + | + | + | Low risk |
| Yamashita et al. [22] | + | + | + | + | + | Low risk |
| Mladenovic & Djordjevic [23] | Some concerns | |||||
| Packyanathan et al. [24] | + | + | + | + | + | Low risk |
| Ponni et al. [29] | + | + | + | + | + | Low risk |
| Maulina et al. [25] | + | + | + | + | + | Low risk |
| Sorribes de Ramón et al. [26] | + | + | + | + | + | Low risk |
| Dellovo et al. [27] | + | + | + | + | + | Low risk |
Certainty of evidence
The certainty of evidence for the included interventions was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Because the review used a narrative synthesis and the included studies were heterogeneous in terms of intervention protocols, outcome measures, and statistical reporting, the certainty of evidence was evaluated by intervention category rather than by pooled effect estimates.
Overall, the certainty of evidence ranged from low to moderate across intervention categories. Music-based interventions showed moderate certainty of evidence, whereas virtual reality, informational interventions, aromatherapy, relaxation techniques, and acupuncture-based approaches were supported by low certainty evidence, mainly due to heterogeneity of protocols, variability in outcome measures, and relatively small sample sizes. A summary of the certainty of evidence assessment is presented in Table 4.
Table 4.
GRADE certainty of evidence by intervention category
| Intervention category | Included studies* | Main overall finding | Risk of bias | Inconsistency | Indirectness | Imprecision | Publication bias | Overall certainty of evidence |
|---|---|---|---|---|---|---|---|---|
| Music-based interventions | n = 11 | Most trials reported reduced anxiety scores and/or favorable physiological changes; some findings were mixed or not significant across all outcomes | Not serious | Serious | Not serious | Serious | Undetected / not assessable | Moderate |
| Virtual reality / immersive distraction-based interventions | n = 3 | Generally associated with reduced intraoperative anxiety and improved comfort | Serious | Serious | Not serious | Serious | Undetected / not assessable | Low |
| Informational / audiovisual / consent-based interventions | n = 7 | Mixed effects; some formats reduced anxiety, whereas highly detailed surgical information increased anticipatory anxiety | Not serious | Serious | Not serious | Serious | Undetected / not assessable | Low |
| Relaxation / mindfulness / aromatherapy interventions | n = 2 | Some beneficial effects reported, but evidence based on few heterogeneous trial | Serious | Serious | Not serious | Serious | Undetected / not assessable | Low |
| Acupuncture / auriculotherapy-based interventions | n = 2 | Some physiological and descriptive psychological benefits, but anxiety outcomes were not consistently significant | Not serious | Serious | Not serious | Serious | Undetected / not assessable | Low |
| Other sensory modulation interventions (green lenses) | n = 1 | Single trial reported reduced anxiety and heart rate | Not serious | Serious | Not serious | Serious | Undetected / not assessable | Low |
* Intervention categories were not mutually exclusive; some trials included more than one intervention arm and therefore contributed to multiple categories
Types of studies
Among the 25 studies (6–30) included in this review, all were randomized controlled trials (RCTs) in which participants were assigned to intervention and control groups to evaluate the effectiveness of various non-pharmacological anxiety-reducing methods prior to tooth extraction. Some studies employed parallel-group designs, while others used crossover randomized designs, particularly in trials investigating music therapy and virtual reality interventions.
Measurement scales used
A variety of standardized instruments were used to assess dental anxiety and physiological stress across the included studies. The Modified Dental Anxiety Scale (MDAS), Visual Analogue Scale (VAS), and State-Trait Anxiety Inventory (STAI) were among the most frequently applied psychological assessment tools. Some studies also employed additional validated instruments, such as the Corah Dental Anxiety Scale (CDAS), the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and the Dental Anxiety Questionnaire (DAQ).
In addition to subjective psychological assessments, several trials incorporated physiological parameters to provide a more objective evaluation of anxiety. These included salivary cortisol levels, heart rate (HR), blood pressure (BP), heart rate variability (HRV), oxygen saturation (SpO₂), and, in selected cases, biochemical markers such as noradrenaline levels.
The majority of studies relied on a single primary anxiety assessment instrument, while a subset combined psychological questionnaires with physiological measurements to obtain a more comprehensive evaluation of perioperative anxiety responses.
Positive effect reached
Several non-pharmacological interventions demonstrated beneficial effects in reducing dental anxiety and stress among patients undergoing tooth extraction. The most consistently reported positive outcomes were observed in studies investigating music therapy, virtual reality interventions, aromatherapy, acupuncture or acupressure techniques, guided breathing and relaxation methods, hypnosis-based approaches, and structured psychoeducational strategies.
Music therapy was frequently associated with significant reductions in anxiety scores measured using validated instruments such as MDAS, STAI, and VAS, as well as decreases in physiological stress markers including heart rate and salivary cortisol. Virtual reality interventions were reported to improve patient comfort and reduce intraoperative anxiety levels.
Aromatherapy, particularly the use of essential oils such as lavender, demonstrated calming effects in several trials. Acupuncture and related techniques were associated with improvements in both psychological and physiological parameters. Guided relaxation and breathing techniques showed reductions in subjective anxiety indicators, while psychoeducational and cognitive-behavioral strategies contributed to improved coping and decreased perioperative stress.
In general, improvements were observed in both psychological (MDAS, STAI, VAS, DAQ, APAIS) and physiological (heart rate, blood pressure, salivary cortisol, HRV, SpO₂) outcomes, depending on the intervention type and study design.
Negative effect reached
Although most non-pharmacological interventions demonstrated beneficial effects, some approaches were associated with increased or unchanged anxiety levels. In particular, interventions involving detailed surgical video demonstrations or extensive preoperative informational materials were reported to increase anticipatory anxiety immediately after exposure. These findings suggest that excessive or highly detailed procedural information may heighten stress in certain individuals, especially those with higher baseline anxiety levels.
The timing, format, and personalization of informational interventions appear to be critical factors influencing patient responses.
No effect reached
Some interventions did not demonstrate statistically significant reductions in anxiety when compared with control groups. In several trials, music-based or aromatherapy approaches showed reductions in anxiety scores; however, these changes were not consistently statistically significant across all outcome measures. Differences in intervention duration, delivery method, frequency exposure, and patient characteristics may explain these inconsistencies.
Additionally, certain interventions produced improvements in physiological markers without corresponding statistically significant changes in subjective anxiety scales, highlighting the complexity of measuring psychoemotional outcomes in surgical settings.
Discussion
This systematic review evaluated the effectiveness of non-pharmacological interventions in reducing dental anxiety and stress among adult patients undergoing tooth extraction. Overall, the majority of the 25 included randomized controlled trials reported beneficial effects of various interventions on psychoemotional outcomes, supporting the clinical relevance of non-pharmacological anxiety management strategies in dental practice.
Music therapy was among the most frequently investigated interventions and demonstrated consistent reductions in subjective anxiety scores and, in several cases, physiological stress markers such as heart rate and salivary cortisol. However, the magnitude of effect varied across studies, potentially due to differences in music genre, delivery method (headphones vs. ambient sound), duration of exposure, and patient preference. These findings suggest that personalization of music-based interventions may enhance their effectiveness.
Virtual reality interventions were also associated with reductions in intraoperative anxiety and improved patient comfort. By providing immersive audiovisual distraction, virtual reality appears to reduce patients’ focus on surgical stimuli. Nevertheless, variations in hardware type, content design, and timing of application may influence outcomes. Importantly, the format and amount of preoperative information delivered through audiovisual media require careful consideration, as highly detailed procedural demonstrations may increase anticipatory anxiety in some individuals.
Aromatherapy, most commonly involving lavender essential oil, showed calming effects in several trials, although results were not uniformly statistically significant across all studies. Differences in concentration, delivery mode, and patient sensitivity may account for inconsistent findings. Similarly, acupuncture and acupressure techniques demonstrated measurable physiological and psychological benefits in some trials, though effect sizes varied.
Guided breathing and structured relaxation techniques provided low-cost and easily implementable approaches that reduced anxiety indicators in several studies. Cognitive-behavioral strategies and psychoeducational interventions were particularly beneficial for patients with elevated baseline anxiety, highlighting the importance of psychological preparation and coping enhancement.
Despite the generally positive findings, not all interventions produced statistically significant results. Variability in study design, sample size, intervention protocols, and outcome measurement tools likely contributed to heterogeneity across trials. Some studies reported descriptive reductions in anxiety without statistically significant differences between groups, emphasizing the need for adequately powered trials and standardized outcome reporting.
This review also highlights the importance of individualized care. Patient-specific factors—including baseline anxiety level, prior dental experience, personality traits, and preferred coping style—may influence responsiveness to different non-pharmacological strategies. A multimodal and patient-centered approach may therefore provide the most comprehensive benefit.
Several limitations should be acknowledged. First, only one electronic database (PubMed) was searched, which may limit comprehensiveness. Second, heterogeneity in intervention protocols and outcome measures precluded quantitative meta-analysis. Third, although most studies demonstrated low risk of bias, variations in reporting quality and methodological rigor may influence interpretation of results.
Future research should focus on well-designed, adequately powered randomized controlled trials using standardized anxiety assessment tools and transparent reporting of effect sizes. Comparative studies evaluating combinations of interventions may further clarify optimal strategies for specific patient subgroups.
Overall, the evidence suggests that non-pharmacological interventions can serve as valuable adjuncts in the management of dental anxiety during tooth extraction procedures, particularly when tailored to individual patient characteristics and implemented within structured clinical protocols.
Limitations
Several limitations of this review should be acknowledged. First, the search strategy was limited to a single electronic database (PubMed), which may have reduced the comprehensiveness of the evidence base. Second, substantial heterogeneity in intervention protocols, duration and timing of application, anxiety assessment tools, and outcome reporting limited direct comparison across studies and precluded quantitative meta-analysis.
Many included trials involved relatively small sample sizes, potentially limiting statistical power. Blinding was frequently challenging due to the nature of non-pharmacological interventions, which may introduce performance or detection bias. In addition, long-term follow-up data evaluating the durability of anxiety reduction were rarely reported.
Although most studies were assessed as having low overall risk of bias, variability in reporting transparency and methodological rigor may influence interpretation of the findings. Future well-designed randomized controlled trials using standardized intervention protocols, clearly defined outcome measures, and adequate sample sizes are necessary to strengthen the evidence base.
Although an additional database search (ScienceDirect) was performed to reduce retrieval bias, the primary search was conducted in PubMed, which may still limit the completeness of the identified literature.
Clinical implications
The findings of this review suggest that non-pharmacological interventions can serve as effective and low-risk adjuncts to conventional dental care for managing anxiety during tooth extraction procedures. Approaches such as music therapy, virtual reality–based distraction, aromatherapy, guided relaxation techniques, and structured psychoeducational strategies may enhance patient comfort and improve overall treatment experience.
Importantly, intervention selection should be individualized according to patient characteristics, baseline anxiety levels, prior dental experiences, and personal preferences. While informational and audiovisual tools can be beneficial, excessive or overly detailed procedural information may increase anticipatory anxiety in certain individuals.
Integrating patient-centered, multimodal strategies into routine clinical practice may improve emotional outcomes without relying solely on pharmacological sedation. However, further research is required to determine optimal intervention protocols, identify patient subgroups most likely to benefit, and evaluate long-term clinical effectiveness.
Practical recommendations
Based on the findings of this review, non-pharmacological interventions may be considered as supportive strategies for managing dental anxiety in patients undergoing tooth extraction procedures.
Interventions most consistently associated with reductions in anxiety across the included randomized controlled trials include:
Music therapy
Virtual reality–based distraction
Guided relaxation and breathing techniques
Aromatherapy
Acupuncture or acupressure
Cognitive-behavioral and psychoeducational approaches
However, the effectiveness of these methods appears to depend on individual patient characteristics, baseline anxiety levels, and the manner in which interventions are implemented.
Certain informational approaches, particularly highly detailed surgical video presentations or excessively technical preoperative explanations, may increase anticipatory anxiety in some patients. Therefore, the amount and format of information delivered should be tailored to the patient’s preferences and coping style.
In clinical practice, a patient-centered and stepwise approach may be appropriate. Simpler interventions such as background music or guided breathing exercises may be suitable for many patients, while more immersive or structured strategies (e.g., virtual reality or cognitive-behavioral techniques) may be considered for individuals with higher anxiety levels.
These methods are generally low-risk and relatively easy to implement in routine dental settings. Nevertheless, clinicians should consider individual variability and avoid assuming universal effectiveness.
Further research is needed to clarify optimal intervention combinations, identify patient subgroups most likely to benefit, and establish standardized implementation protocols.
Supplementary Information
Acknowledgements
The authors declare no conflicts of interest. No external funding was received for this study. The authors acknowledge the Lithuanian University of Health Sciences for institutional support during the preparation of this systematic review.
Authors’ contributions
B.M. designed the study, conducted the literature search, screening, data extraction, and data analysis, and drafted the manuscript.I.A.J. contributed to the study design, supervised methodological accuracy, assisted in data interpretation, and critically revised the manuscript.G.J. reviewed the manuscript, provided expert clinical and methodological guidance, and approved the final version.D.R. contributed to proofreading and provided minor revisions.All authors read and approved the final manuscript.
Funding
The authors received no specific funding for this work.
Data availability
All data analyzed in this study were obtained from previously published articles identified through the systematic search. No new datasets were generated.
Declarations
Ethics approval and consent to participate
This study is a systematic review of previously published research and did not involve human participants, interventions, or the collection of identifiable personal data. Therefore, ethical approval was not required.
Consent for publication
Not applicable.
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
Data Availability Statement
All data analyzed in this study were obtained from previously published articles identified through the systematic search. No new datasets were generated.