Odontology (2023) 111:20–32

https://doi.org/10.1007/s10266-022-00711-x

ORIGINAL ARTICLE

Management of fear and anxiety in dental treatments: a systematic

review and meta‑analysis of randomized controlled trials
Cheng Lu1 · Yu Yuan Zhang1 · Bilu Xiang1,2 · Si‑min Peng1 · Min Gu1 · Hai Ming Wong1

Received: 21 December 2021 / Accepted: 15 April 2022 / Published online: 10 May 2022
© The Author(s), under exclusive licence to The Society of The Nippon Dental University 2022

Abstract
Objectives This systematic review was to compare the effects of interventions for the management of fear and anxiety for
dental treatments.
Methods This research project was applied to PubMed, CENTRAL, Web of Science, Cochrane library databases. The last
search was run on March 31st, 2021. A list of references of relevant articles and previous reviews were checked. Qualitative
and quantitative analyses were performed.
Results A total of 20 eligible randomized controlled trials were included, and 969 participations in experimental group and
892 participations in the control group were involved. Anxiety levels decreased more in intervention groups than in control
groups (Z = 3.47, P = 0.0005, SMD = – 0.62, 95% CI − 0.98 to − 0.27). For adults, there was statistical difference between
experimental and control groups [Z = 2.14, P = 0.03, 95% CI − 0.54 (− 1.03, − 0.04)], while there was not no such statistical
difference in children and adolescents [Z = 1.62, P = 0.11, 95% CI − 0.60 (− 1.32, 0.13)]. Patients experienced a signifi-
cant decrease in anxiety level using sedation drugs [Z = 2.44, P = 0.01, 95% CI − 0.61 (− 1.10, − 0.12)] and audio–visual
distractions [Z = 3.1, P = 0.002, 95% CI − 0.86 (− 1.40, − 0.32)]. For the informative intervention groups, patients did not
show significant difference than control groups [Z = 1.22, P = 0.22, 95% CI − 0.55 (− 1.43, 0. 33)]. There was no statistical
difference in vital signs [Z = 1.39, P = 0.16, 95% CI − 0.25 (− 0.61, 0.10)] and pain levels [Z = 0.69, P = 0.49; SMD = – 0.06,
95% CI (0.27, 0.11)] between intervention and control groups.
Conclusions Interventions should be used in managing anxiety and fear for dental treatment. It might be effective for anxiety
alleviating for adults, but there was a low certainty of evidence that interventions could reduce anxiety level in children and
adolescents. Sedation drugs and audio–visual distractions might be useful for managing dental fear and anxiety. Pain levels
and vital signs could not be improved form our study. High-quality randomized clinical trials are required for further study.

Keywords Dental anxiety · Systematic review · Anxiety management · Nonpharmacological intervention

Introduction in avoidance of dental treatment, it may be classified as a

Dental anxiety is identified as a negative and unwarranted
emotion for dental treatment. Patients recognized dental
treatment as a dreadful procedure and often could not control
themselves. When dental anxiety is more severe and results
* Hai Ming Wong
wonghmg@hku.hk
1
Paediatric Dentistry and Orthodontics, Faculty of Dentistry,
2/F The Prince Philip Dental Hospital, The University
of Hong Kong, 34 Hospital Road, Sai Ying Pun,
Hong Kong SAR, China
2
School of Dentistry, Shenzhen University Health Science
Center, Shenzhen, China
dental fear. Specific procedures such as drilling and local
anesthesia can be identified to arise dental fear [1]. Dental
fear and anxiety were used in this study when referring to a
reaction to threatening stimuli for dental procedures.
In dentistry, anxiety measurement techniques involved
physiological measures, and the use of behavioral ratings,
psychometric scales, and projective techniques such as facial
image scales and children’s dental fear pictures [2]. Behavio-
ral ratings and psychometric scales were the two broad types
of measurement techniques that were most frequently used
in research [3]. The most widely used behavioral rating was
Frankl’s Behavior Rating Scale (FBRS) [4] which rated the
child’s attitude and cooperation during dental visit. One of
the most widely used psychometric scales was the Modified

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dental anxiety scale (MDAS) [5]. If the final score was at or
above 19, patients were regarded as “very dental anxious”.
Pain level was found a positive correlation with dental
anxiety. Patients with high level of dental anxiety might
perceive stronger pain [6], and pain or fear of pain was also
a source of anxiety [7]. Additionally, contrary to self-per-
ception, vital signs such as heart rate and pulse rate could
reflect anxiety and relief for dental treatments as well [8].
Thus, pain and vital signs could be used to indicate the effect
of anxiety interventions.
The prevalence of dental anxiety varied in different coun-
tries in the world, with estimates ranging from 5 to 20% [5,
9]. In Hong Kong, 4% of kindergarten children felt anxious
for preventive dental procedures [10]. In Mainland China,
the prevalence of dental anxiety was around 12% for children
from 5 to 12 years old [11], while 83.1% of adult patients
with irreversible pulpitis suffered from moderate or high
dental anxiety [12]. Children with dental anxiety could per-
sist and, intensify into adulthood [13], and almost half of
adult patients with dental fear reported childhood onset [14].
Management on dental fear and anxiety needs to be flex-
ible, and requires understanding between patient and dentist.
Common strategies include providing patients with infor-
mation about procedures to enhancing trust and control,
tell–show–do technique, specific alternative visual or audi-
tory stimuli as distraction, progressive muscle relaxation,
and cognitive restructuring [15, 16]. Given the importance
of managing dental fear and anxiety, the objective of this
systematic review and meta-analysis was to investigate the
effects of interventions for the management of fear and anxi-
ety for dental treatments.
Methods
This systematic review was formulated in accordance with
the PRISMA (The Preferred Reporting Items for system-
atic reviews and Meta-analysis) statement and constructed
according to the PICO (population, intervention, compara-
tor, and outcome). The focus of the review was “Were anxi-
ety alleviating interventions, compared with patients treated
as usual, effective in reducing patients’ treatment-related
dental anxiety?”.
Search strategies
A search strategy was conducted among four electronic
databases: PubMed, CENTRAL, Web of Science, Cochrane
library (last search March 31st, 2021). The search strate-
gies were guided by the Cochrane Handbook for Systematic
Reviews of Intervention version. Only parallel randomized
controlled trials were included in this review. The cur-
rent systematic review was registered in the International
21
Prospective Register of Systematic Reviews (PROSPERO)
(registration number: CRD42021229869).
Eligibility criteria
The eligibility criteria were as follows: (1) parallel rand-
omized controlled trial design and publications written in
English; (2) outcome measurements included self-reported
anxiety scales or vital signs; (3) interventions aimed at
relieving fear and anxiety for dental procedures; (4) con-
trol groups were treatment as usual (patients accepted usual
treatments as regular schedule), blank or placebo during the
experiment; and (5) patients under dental treatments with
or without a high level of dental anxiety and without other
mental health problems. There were no sex, country, or age
restrictions in this study.
Data extraction and management
A template was developed for potentially effective papers
and two investigators independently identified eligible stud-
ies by titles and abstracts. Full texts were downloaded and
two reviewers identified effective articles with the inclusion
and exclusion. Kappa statistics were used to evaluate the
inter-reader agreement. Where disagreement between the
two reviewers occurred, a supervising reviewer was con-
sulted. A data extraction sheet was developed by the first
author and the extracted information included as follows:
(1) the first author and year of publication, (2) the treatment
procedure, (3) the number of participants, (4) and the lower
and upper limit of age; (5) self-reported scales of fear and
anxiety, and (6) other psychological or physiological assess-
ments related to anxiety. The data extraction sheet of the
included eligible studies was checked by the second author
to reduce bias and errors.
Quality and risk of bias assessment
Bias assessment of included articles was performed follow-
ing the criteria defined by the “Cochrane Collaboration’s
tool for assessing the risk of bias” [17]. The domains con-
sidered included selection bias (random sequence generation
and allocation concealment), performance bias, detection
bias, attrition bias, and reporting bias. Each domain was
awarded as ‘unclear risk’, ‘low risk’, or ‘high risk’.
Statistical analysis and measurements
Quantitative analysis was performed by way of meta-analy-
sis. Outcomes were reported in the format of standard mean
difference (SMD) and standard error (SE) between test and
control comparisons. In the meta-analysis, if data had been
pooled from only two studies, a fixed-effect model was
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used. If three or more studies were included, random-effects
model was feasible to conduct meta-analysis [18]. Random-
effects model and fixed-effects model for meta-analysis were
employed by Review Manager 5.4. Subgroup analyses were
performed. Publication bias was assessed using Stata 17 MP.
Fail-safe N Calculation was calculated using the Rosenthal
Approach.
Results
Study selection
The initial database search yielded a total of 4820 citations
following our search strategy and 2910 records remained
after deletion of duplicates for full-text assessment. Stud-
ies with sufficient data were further included for qualitative
analysis. Full texts of potentially effective were downloaded
and eventually identified followed inclusion and exclusion
criteria. A third author was consulted where a disagreement
occurred. There were 2648 articles were considered irrel-
evant and excluded by consensus. Twenty articles [19–38]
met with the inclusion criteria which represented original
research studies (Table 1). Agreement between raters was
assessed using Cohen’s Kappa by Spss 26.0 (Cohen’s kappa
for the two reviewers = 0.805). The PRISMA checklist and
flow diagram of the search process was shown in Fig. 1.
Study characteristics
All the included studies were conducted with the interven-
tion for dental anxiety management. Interventions were
delivered by dentists or trained educators. Among the 20
studies, 969 participants in the experimental group and 892
participations in the control group were involved. The num-
ber of participants in each study ranged from 30 to 349. For
the age range, 5 studies [25, 27, 33–35] were performed for
children under 18 years old and 11 studies [20, 22, 24, 26,
29–32, 36–38] were performed for patients over 18 years
old. One study [28] did not express the age range.
The main characteristics of each study were tabulated
in Table 1. The studies were conducted in Spain (n = 1),
Chile (n = 1), Turkey (n = 2), Japan (n = 1), USA (n = 4),
Iran (n = 2), New Zealand (n = 1), India (n = 1), Australia
(n = 1), France (n = 1), Brazil (n = 2), Korea (n = 1), Ger-
many (n = 1), UK (n = 1), and Finland (n = 1). Seven studies
[19, 21, 23, 24, 26, 28, 37] were under tooth extraction and
one study [38] was under oral surgery related to implants,
tooth extraction and excision of cyst. Twelve studies [19,
21–24, 26, 28, 32, 33, 35, 37, 38] were under local anesthe-
sia. Children in one study [25] only received oral exanima-
tion at the school dental clinic without further treatment.
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Odontology (2023) 111:20–32
Interventions
Six studies [19, 20, 23, 28, 30, 33] had used audio–visual
distractions such as musical stimulation or 3D video glasses
for distraction. Patients listened to music or watching a video
before or during the dental procedures. Seven studies [22,
25, 27, 32, 34, 36, 37] had used informative instruction with
positive information about the procedures, teaching relaxa-
tion, and modeling approaches. Two studies [21, 26] used
essential oil in the separate room before treatment. One
study [31] used auricular acupuncture during dental proce-
dures, and one study [35] improved the technique of local
anesthesia. Brief relaxation such as functional relaxation that
patients performed minute movements of small joints dur-
ing relaxed expiration was arranged before treatment in one
study [29]. Two studies [24, 38] used sedation drugs to help
patients deal with anxiety.
Characteristics of outcome measures
For the included studies, the measurements used to evalu-
ate self-reported anxiety level included State–Trait Anxiety
Inventory (STAI), MDAS, Death Anxiety Questionnaire
(DAQ), Visual Analog Scale (VAS), Modified Children
Dental Anxiety Scale (MCDAS), Dental Anxiety Scale
(DAS), modified Yale Preoperative Anxiety Scale (mYPAS),
Venham Picture Test (VPT), Hierarchical Anxiety Ques-
tionnaire (HAQ), and Dental Fear Survey (DFS). One study
[25] used anxiety questions from Survey of Anxiety and
Information for Dentists (SAID). One of the most objec-
tive and simple ways to measure stress and anxiety was
through salivary cortisol [39]. Two trials [19, 24] utilized
salivary cortisol levels to assess anxiety levels. Among the
20 studies, 7 [21, 23, 24, 26, 28, 33, 35, 37, 38] evaluated
vital signs. The measurements used to evaluate vital signs
included blood pressure, heart rate, pulse rate and peripheral
capillary oxygen saturation. One study only recorded pulse
rate [33]. Four studies [26, 28, 32, 35] measured pain level
using VAS, Numeric Rating Scale(NRS) and Wong-Baker
FACES (WBF) Pain Rating Scale.
Quality assessment and risk of bias
For bias evaluation, all studies had at least one section of
bias. The rating of risk of bias in each study was specified
in detail in Fig. 2. Unclear risk of bias was evident across
studies, particularly in relation to detection bias and selec-
tive reporting bias. Approximately, 15% of the studies were
at high risk of performance bias as well as detection bias.
Because of the obvious characteristics of interventions,
blinding of participants was not possible in most of the stud-
ies. Egger’s test did not detect statistically significant pub-
lication bias (P = 0.105) from the included studies (Fig. 3).
 Table 1  Characteristics of studies on interventions for reducing dental anxiety
Author (year, country) Age range Procedure Intervention group N Control N Outcomes

Toledano-Serrabona J (2020, Spain) 18–40 Tooth extraction An INFORMATIVE video about M3M 25 Blank 22 STAI-S, MDAS, vital signs
removal
Aravena PC (2020, Chile) 15–40 Tooth extraction (1) musical stimulation at 432 Hz 15 min 30 Placebo 12 Salivary cortisol, CORAH-MDAS
(2) at 440 Hz,15 min
Karan NB (2019, Turkey) 18–37 Tooth extraction Inhaled 100% pure, high-strength lavender 63 TAU​ 63 DAQ, MDAS, STAI-S; VAS(pain);vital
Odontology (2023) 111:20–32

oil in a separate room for 3 min prior to signs

surgery
Isik BK (2017, Turkey) 15–47 Tooth extraction Binaural beats through stereo earphones 30 Blank 30 VAS(anxiety)
(200 Hz for the left ear and 209.3 Hz for
the right ear)
Watanabe Y (2016, Japan) 18–64 Oral surgery Midazolam (Dormicum®, Astellas 19 Placebo 19 Vital signs, STAI,VAS(anxiety)
Pharma, Tokyo, Japan) 0.02 mg/kg
intravenously over 30 s
Tellez M (2015,USA) 18–70 High dental anxiety under dental treatment Received C-CBT immediately preceding 74 TAU​ 77 MDAS,ADIS-IV
their scheduled dental appointments
Kebriaee F (2015, Iran) 3–6.5 Mandibular primary molar needing pulp The cognitive behaviour technique 15 TAU​ 15 VCAS(observers), VPT (self-report)
treatment
Jones L (2015, New Zealand) 11–13 Attending the school dental clinic e-SAID 83 Placebo 85 anxiety questions
Nuvvula S (2015, India) 7–10 LA administration in the mandibular arch 3D video glasses; audio (basic techniques 60 TAU​ 30 MCDAS(f), pulse rate
plus music)
Hasheminia D (2014, Iran) 15–44 Tooth extraction orange essential oil 28 Placebo 28 Vital signs, DAS
Heaton LJ (2013, USA) 18–68 Dental injection without reviving an Computer Assisted Relaxation Learning 34 Pamphlet 34 MDAS,DFS,NS
incentive or dental treatment (CARL)
Michalek-Sauberer A (2012, Austrlia) 26–51 Elective dental procedures Auricular acupuncture group 61 Blank 61 STAI,VAS(anxiety)
Ramos-Jorge ML (2011, Brazil) 4–11 Treated at the paediatric clinic Exposed to positive images of dental 35 Placebo 35 modified-VPT
treatment
Morarend QA (2011, USA) 22–69 Inferior alveolar local anesthetic injection A novel biofeedback device (RESPeR- 40 Blank 41 VAS(pain), DISS summary scores
ATE™
Kim YK (2011, Korea) Tooth Extraction Music therapy 106 Blank 113 DAS, VAS(pain),vital signs
Lahmann C (2008, Germany) Over 18 Simple caries treatment Brief relaxation 29 Blank 30 STAI-S,HAQ
Jerjes W (2005, UK) Over 18 Tooth extraction 7.5 mg midazolam 20 Placebo 18 HAD, salivary cortisol, vital signs
Smolarek (2020, Brazil) 5–8 Restorative treatment under local Anaes- 1. vibrational anaesthesia 2.computer con- 70 TAU​ 35 VPTm, VAS(pain),NRS(pain),WBF(pain),
thesia trol local anaesthesia delivery—CCLAD Vital signs
S. Lahti (2020, Finland) > 18 Dental treatment Virtual reality relaxation (VRR) 129 TAU​ 126 MDAS
Arias (2019 ,USA) > 18 Highly dental fearful and phobic adult The treatment condition included 2 weeks 18 TAU​ 18 Dental Fear Survey (DFS)
of self-directed exposure delivered via
a personal smartphone in the patients’
natural environment

VAS Visual Analogue Scale, DAS Dental Anxiety Scale, MDAS Modified Dental Anxiety Scale, DFS Dental Fear Survey, NS Needle Survey, VPT Venham Picture Test, VPTm Venham
Picture Test modified, DISS Dental Injection Sensitivity Survey, STAI-S State–Trait Anxiety Inventory, HAQ Health Assessment Questionnaire, VCAS Venham Clinical Anxiety, CORAH-
MDAS CORAH Modified Dental Anxiety Scale, WBF Wong–Baker Faces Pain Rating Scale, NRS Numerical Rating Scale, HAD Hospital Anxiety and Depression scale, ADIS Anxiety Disor-
ders Interview Schedule

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Fig. 1  Checklist and flow diagram of the study selection process according to preferred reporting items for systematic reviews (PRISMA)
The fail-safe N was 716 with observed significance level
less than 0.0001. The fail-safe N was high, which means
that even a large number of nonsignificant studies may not
influence the statistical significance of meta-analytic results
greatly.
Anxiety level
Qualitative analysis of anxiety level was based on 20
studies. Figure 3 showed the funnel plot test of included
studies. More than half of the studies supported the idea
that patients affected by interventions had significantly
lower anxiety level than the control group. It was feasible
to perform meta-analyses for the 19 studies which used
anxiety scales (Fig. 4). Studies reported that experimen-
tal group was more effective than control group, and the
overall effect size in the random-effects model was 3.47
(P = 0.0005; SMD = – 0.62; 95% CI − 0.98 to − 0.27).
Visual inspection of the forest plots suggested the presence
of two influential studies, i.e., Aravena [19] and Tellez
[36]. Therefore, meta-analysis was performed again with-
out these studies [19, 36] as an influence analysis. There
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Odontology (2023) 111:20–32
was statistical difference between experimental and con-
trol groups [Z = 3.40, P = 0.0007, 95% CI − 0.36 (− 0.57,
− 0.15)].
There were 11 studies [20, 22, 24, 26, 29–32, 36–38]
compared interventions for patients over 18 years old, and
there was statistical difference between experimental and
control groups [Z = 2.14, P = 0.03, 95% CI − 0.54 (− 1.03,
− 0.04)]. Four studies [25, 27, 33–35] compared different
forms of anxiety intervention for children from 3 to 11 years
old. The meta-analysis suggested that children and adoles-
cents under anxiety intervention had no significant differ-
ence when compared with control groups [Z = 1.62, P = 0.11,
95% CI − 0.60 (− 1.32, 0. 13)] (Fig. 5).
For subgroup analysis, a meta-analysis suggested that
for sedation drug and audio–visual, patients experienced a
significant decrease in anxiety level than the control groups
[sedation drug: Z = 2.44, P = 0.01, 95% CI − 0.61 (− 1.10,
− 0.12); audio–visual distractions: Z = 3.1, P = 0.002, 95%
CI − 0.86 (− 1.40, − 0.32)]. For the informative interven-
tion groups, patients did not show significant difference than
control groups [Z = 1.22, P = 0.22, 95% CI − 0.55 (− 1.43,
0.33)] (Fig. 6).
Odontology (2023) 111:20–32
Fig. 2  Risk of bias across overall studies
Twelve studies [19, 21–24, 26, 28, 32, 33, 35, 37, 38]
were under local anesthesia. In the 12 comparisons of
patients under local anesthesia, experimental groups were
deemed more effective than control groups [Z = 2.57,
P = 0.001, 95% CI − 0.43 (− 0.76, − 0.10)] (Fig. 7).
Vital signs
Eight studies compared the efficacy between interven-
tions and placebo using pulse/heart rate. Meta-analyses
were feasible for those studies, but no statistical differ-
ence was detected [Z = 1.39, P = 0.16, 95% CI − 0.25
(− 0.61, 0.10)] (Fig. 8).
25
Pain levels
Meta-analyses of pain level were performed using data
pooled from four comparisons using VAS for self-reported
pain levels for the treatment. There was no statistically
significant difference in pain status [Z = 0.69, P = 0.49;
SMD = – 0.06, 95% CI (0.27, 0.11)] (Fig. 9).
Discussion
Several systematic reviews and meta-analysis analyzing
the effectiveness of different types of interventions on den-
tal anxiety levels have been published [40]. However, no
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Fig. 3  Funnel plot test and Egger’s publication bias plot of included
studies
previous systematic review evaluated the effect of manage-
ment for dental anxiety for all age rage. They were based on
either pediatric or adult population, and could not indicate
which population was more sensitive to anxiety manage-
ment for dental treatments. This study is the first systematic
review aimed to identify effective interventions in improving
anxiety status during dental procedures without age limita-
tion. Twenty studies fulfilled the inclusion criteria and 19 of
them were included in meta-analysis. Meta-regression analy-
sis could be performed to explore the possible factors for
the effect. Unfortunately, insufficient information of gender,
and age in mean (range) or mean (95% CI) are presented in
some of the included papers, thus meta-regression analysis
was not performed in this study. Since there is no significant
difference between genders or among ages, as stated in all
the papers included, gender and age would not influence the
results in our study.
The results of this systematic review indicated that only
weak evidence supported that interventions could decrease
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dental anxiety levels. Non-pharmacological interventions
for reducing dental anxiety might be useful in patients over
18 years old based on the results from 11 studies [20, 22,
24, 26, 29–32, 36–38]. It was assumed that those techniques
might promote a positive attitude in matured patients toward
dental treatment [41]. However, in children and adolescents,
no significant statistical difference was found between exper-
imental and control groups. Anxiety management remained
difficult in children. This may due to their limited ability to
understand instructions [42]. Younger children might have
struggled with the concept of anxiety scale and described
self-rated anxiety level unclearly. Adults might become more
engaged in the interventions and showed significant changes
in anxiety level.
Sedation drugs were evaluated in two studies in the cur-
rent. Midazolam was used in these studies and both the intra-
venous [38] and oral [24] routes showed a positive effect
on anxiety levels during dental treatment. However, only
intravenous midazolam decreased anxiety in another system-
atic review [43], which might be due to different inclusion
criteria. There was weak evidence that interventions could
reduce dental anxiety under local anesthesia. Dental anxi-
ety aroused by specific dental procedures, especially local
anesthesia, was frequently linked with bleeding, pain, and
long post-operative recovery periods, which could increase
the level of anxiety [44].
It was evident in our study that audio–visual distractions
were beneficial in reducing anxiety perception and could be
considered a useful intervention for dental treatments. Our
result for audio–visual distractions was comparable to that in
a previous meta-analysis on the effect of audio–visual man-
agement [45] which found that both physiological measures
and self-reported anxiety levels were significantly lower in
the experimental groups.
Kvale et al. (2004) claimed that dental fear was expected
to reduce significantly due to informative intervention and
this effect seemed to be long-lasting [41]. However, informa-
tive interventions did not show a strong evidence in allevi-
ating dental fear and anxiety in the current review. In the
included studies, cognitive-behavioral interventions and
positive treatment pictures were designed for patients under
18 years old before dental procedures [27, 46]. It appeared
that negative emotion might be aroused in young people
while positive information structures was giving in informa-
tive interventions before dental treatment.
For pain level and vital signs, the goal of included
papers was to determine whether interventions could
control psychosomatic states [21, 23, 24, 26, 28, 32, 33,
35, 37, 38]. Nevertheless, no significant difference was
found between the intervention and control groups in these
studies. One study [40] reported that non-pharmacological
interventions did not show significant difference in respect
to pain, which supported our review. Heart/pulse rate did
Odontology (2023) 111:20–32
Fig. 4  Pooled standard mean difference of overall anxiety level using interventions versus placebo
not show significant changes in our review, which sug-
gested that patients might not be influenced by the inter-
ventions, or the level of effects could not be detected by
heart/pulse rate.
One of limitations in our meta-analysis were that statisti-
cal heterogeneity was high (over 50%). It might be account-
able for different characteristics of studies, such as study
design and diversity in interventions and participants. How-
ever, the individual trials which covered different patient
populations, settings, and concomitant routine care should
be included to increase the generalizability and usefulness
of meta-analysis. This broad meta-analysis increased power
and could facilitate exploratory analyses for generating
hypotheses for future research.
27
The clinical question of whether to use interventions for
dental treatment and which intervention was recommended
could not be answered by the results of our meta-analysis.
First, the quality of included studies was unsatisfactory.
Some studies used small sample sizes, such as [27] and [20]
in each group. Ideally, the operator, assessor and patients
should have been blind to the intervention, which was dif-
ficult in most of the studies because the interventions were
performed during dental treatment. The age range was too
wide in some included studies. For example, one study [23]
included patients from 15 to 47 years old. Adolescents might
react to managements differently compared to adults, and
this could increase the bias of the study. One study [20]
included patients with and without severe dental phobia.
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Fig. 5  Pooled standard mean difference of adult and children’s anxiety level of interventions versus control groups
This was a potential source of bias because patients with
severe dental phobia required more time and effort to be
managed [15]. Second, the information of the long-term
effects of improved anxiety level was limited. The useful-
ness and success of a treatment for fearful dental patients
should be determined by the long-term survey [47], as fear
and anxiety in the childhood can persist into adolescence
and even the adulthood [10]. Finally, it is basically difficult
for anxious patients to follow the instruction of an interven-
tion, and complete the dental procedure that they are afraid
of. It is also the case that what works for one patient may
not work for another. It requires the dentist’s identification
of the patient’s concerns and origins of fear, so that a man-
agement technique can be successfully carried out [15, 48].
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Odontology (2023) 111:20–32
As a result, more well-designed RCTs are required to prove
anxiety preventive efficacy among children and adults.
Conclusion
In conclusion, our review suggested that interventions for
dental fear and anxiety might be effective for dental treat-
ments in adults, but not in children and adolescents. Adult
patients experienced a significant decrease in anxiety level
using sedation drugs and audio–visual distractions. Vital
signs and pain level were not influenced obviously by
interventions. To establish more evidence-based conclu-
sions, further high-quality studies in the clinical setting
adopting a longitudinal design are recommended.
Odontology (2023) 111:20–32 29

Fig. 6  Pooled standard mean difference of anxiety level of different types of interventions versus control groups

Fig. 7  Pooled standard mean difference of experimental versus control groups’ anxiety level under local anesthesia

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Fig. 8  Pooled standard mean difference of pulse heart rate using interventions versus control groups
Fig. 9  Pooled standard mean difference of pain level using interventions versus placebo
Acknowledgements The authors would like to thank staff Ms.
Samantha Li at Clinical Research Centre in the University of Hong
Kong, Hong Kong SAR, China for providing technical help in data
management.
Author contributions LC contributed to data collection, analyses and
manuscript preparation. ZYY contributed to study design, data collec-
tion and analyses. XBL contributed to data analyses and manuscript
preparation. PSM and GM contributed to manuscript preparation.
HMW contributed to data analysis and manuscript preparation, and
acted as the corresponding author. All authors read and approved the
final manuscript.
Funding This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Availability of data and materials The datasets used and/or analyzed
during the current study are available from the corresponding author
on reasonable request.
Code availability Not applicable.
Declarations
Conflict of interest The authors have no conflicts of interest to declare
that are relevant to the content of this article. All authors certify that
they have no affiliations with or involvement in any organization or
entity with any financial interest or non-financial interest in the subject
matter or materials discussed in this manuscript.
Ethical approval No ethical approval was required in this meta-analysis
as we did not access primary patient data.
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Odontology (2023) 111:20–32
Informed consent Informed consent was not required in the systematic
review.
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