Managing Dental Anxiety

Dental anxiety is an emotional or physical reaction to an anticipated threat of an oral health professional or dental visit.¹ Dental fear and dental phobia are often used interchangeably with dental anxiety; however, they are distinct and separate disorders. Dental fear produces a physical or psychological reaction to a perceived threat associated with the dental setting.¹ Dental phobia is an illogical, persistent, severe, and overwhelming fear of dental stimuli.^2-4 Dental phobias can be intense, yet are rarely diagnosed.

Dental anxiety is a very common psychological condition that may lead to avoiding treatment, resulting in deteriorating oral health, low self-esteem, and low oral health-related quality of life.^5,6 Avoiding dental care may lead to oral health problems, which can then lead to shame or embarrassment, increasing the likelihood of further avoidance of dental care.

Prevalence and Etiology

According to the World Health Organization, anxiety disorders are the most common of all mental disorders, affecting more than 300 million people worldwide.⁷ A global meta-analysis determined approximately 15% of the adult population has dental anxiety.⁸ Women report experiencing dental anxiety more than men, and anxiety tends to decrease with age.^1,2,8,10

Research suggests dental anxiety may be more prevalent among those of low socioeconomic status compared to those of higher socioeconomic status^.9,10 Dental anxiety may be triggered by patients thinking about upcoming dental treatment and while sitting in the waiting room. Patients may experience dental anxiety when they feel a loss of control in the dental chair, hear the sounds of dental equipment, undergo scaling and polishing, or anticipate an injection of local anesthesia.⁹

Dental anxiety can arise from past traumatic experiences.^4,11-14 Research indicates children who have history of traumatic dental experiences are more likely to experience dental anxiety as adults.¹² Vicarious conditioning, in which individuals develop anxiety toward dental procedures by observing others experiencing fear or discomfort during dental visits, is another risk factor.^11,12

Another source of dental anxiety is genetics.^12,14,15 Inherited genetic predispositions play a role in individuals who have phobias that make them susceptible to anxiety.^11,12,15  There is no specific gene responsible for dental anxiety; however, people with a family history of dental anxiety are more likely to develop it. Research also shows that the personality trait “neuroticism” is a significant risk factor for developing dental anxiety.¹⁶ Neuroticism or a neurotic personality is behaving in a strange or anxious way with feelings of anxiety and depression. Those who have a neurotic personality are also likely to have dental anxiety.

Pathophysiology

Anxiety-producing stimuli trigger the autonomic nervous system, leading to an increase in blood pressure, heart palpitations, pulse, and respirations. The autonomic or fight-or-flight response is triggered by the hypothalamus-pituitary-adrenal axis, leading to the release of adrenaline into the sympathetic nervous system. This cascade of events induces various physiological and psychological responses observed in the patient’s vital signs and overall physical and psychological symptoms.¹⁷ The most common of these responses are tremors or restlessness, lightheadedness, sweating, headaches, and low pain tolerance.^3,17 Dilated pupils, anxious facial expressions, involuntary leg and arm movements, stiff body position, and avoiding eye contact are also signs of anxiety.¹⁸

Assessments for Identifying Dental Anxiety

Assessments enable oral health professionals to identify patients experiencing dental anxiety and determine the severity of their dental anxiety. Several types of assessment methods are available, including single-item questionnaires and multiple-item questionnaires.¹⁹ A single-item question listed on the dental history form may be “Are you afraid of going to the dentist?” Alternatively, more thorough questionnaires are available to assess dental anxiety.

The most widely accepted questionnaires to assess dental anxiety include the single-item visual analog scale, or VAS (Figure 1), Corah’s dental anxiety scale (CDAS), and modified dental anxiety scale (MDAS).^19,20 The VAS consists of a horizontal line with numbers ranging from 0 to 10, with lower numbers indicating less dental anxiety and higher numbers indicating greater dental anxiety.^19,21 Patients self-report how anxious they feel by giving a number from 0 to 10. The VAS typically takes less than 1 minute to complete.

The CDAS consists of four questions asking how the patient would feel in varying situations. A score of 15 or higher almost always indicates the patient is experiencing a high level of dental anxiety.²² Although the CDAS is a reliable source for measuring dental anxiety, it does not address anxiety toward local anesthesia injections. Therefore, in 1995, it was modified to the MDAS to include a fifth question regarding the level of anxiety surrounding dental injections (Table 1, page 34). If the total score on the MDAS is 19 or above, it may indicate the patient has high dental anxiety.²⁰

Effective communication during a review of the medical and dental history can act as a bridge, allowing rapport and trust to be established between patients and providers, reducing anxiety.²⁴ Additionally, explaining the procedure and what the patient should expect can help alleviate anxiety.¹⁷ When using assessments, oral health professionals need to properly document and include responses in the patient record so levels of dental anxiety can be assessed over time and per appointment. Evaluating vital signs, symptoms, and results of dental anxiety assessments can help gauge the level of anxiety experienced by the patient. If the patient has dental anxiety, the oral health professional should discuss what management technique the patient prefers based on options available in the dental setting.

Nonpharmacological Management

Dental anxiety can be managed by nonpharmacological or pharmacological interventions, or a combination of both.⁴ However, pharmacological interventions, such as oral sedation, may have unwanted side effects including nausea, dizziness, drowsiness, delayed onset and/or prolonged duration of the sedative effect. In addition, inhalation sedation, such as nitrous-oxide oxygen, may be contraindicated in patients with upper respiratory tract infections, severe chronic obstructive pulmonary disease, claustrophobia, nasopharyngeal obstruction, and first trimester pregnancy.²⁵ Alternatively, nonpharmacological interventions may be used to reduce dental anxiety.

Music therapy is noninvasive, cost-effective, and does not cause side effects associated with pharmacological interventions.^26-29 Research has shown that implementing music during dental procedures can decrease blood pressure,^26-28 heart rate,²⁸ and salivary cortisol levels.³⁰

In one study, patients who received music therapy also self-reported a statistically significant reduction in dental anxiety when measured using the MDAS.²⁷ However, other studies found conflicting results.^29,32 Specifically, a meta-analysis included several studies that used varying music therapy techniques with patients who had dental anxiety and concluded the efficacy of music therapy to decrease dental anxiety was inconclusive.³² Another study compared a group of patients exposed to slow rhythm music and a group not exposed. Results found those exposed to music showed lower levels of salivary cortisol, blood pressure, heart rate, and body temperature compared to the control group; however, these findings did not reach statistical significance.²⁹

Some studies indicate patients who listen to music using headphones may have reduced dental anxiety as the music masks the sound of dental equipment.^28,31 However, another study recommended allowing patients to choose whether they want headphones or not, as headphones may make it more difficult to communicate with the clinician. Patients should have control over the volume and music selection, as it enhances their sense of control in what could potentially be an unpleasant situation.³² Additionally, studies consistently show a reduction in dental anxiety when the patient starts listening to music before the start of dental procedures.^27,28,32

Music therapy may reduce dental anxiety in some cases, however, it is important to customize it to each patient. In addition, oral health professionals should consider working in conjunction with a trained music therapist to collaborate on effective strategies to manage the patient’s dental anxiety with music.³²

Aromatherapy uses essential oils that are diffused or applied topically to stimulate the olfactory sense. Olfactory nerves are capable of transmitting signals to the brain’s portion of the limbic center that controls emotions and is shown to decrease anxiety and improve mood.⁴ A systematic review concluded aromatherapy, most commonly lavender and orange aroma, is effective in reducing dental anxiety when compared to no aromatherapy and comparable to the effects of music therapy.³⁴

A study comparing three intervention groups (music therapy, lavender aromatherapy, combined music therapy and lavender aromatherapy) against a control group found the group exposed to a combination of music therapy and aromatherapy experienced a more significant decrease in dental anxiety than groups provided a single treatment or no intervention.²⁶ Therefore, oral health professionals may want to consider implementing multiple management strategies for most effective dental anxiety reduction.

Additional studies using lavender essential oils found a significant reduction in dental anxiety among patients who received aromatherapy compared to those who did not receive aromatherapy.^33,35 Aromatherapy can be an effective way to reduce dental anxiety during dental procedures.

Several studies conducted on aromatherapy in the dental setting have utilized lavender and orange oils for dental anxiety reduction. Lavender essential oils have been shown to soothe the nervous system, alleviate anxiety, lower blood pressure, and decrease pain. Similarly, orange essential oils are also used to alleviate anxiety and promote relaxation of the nervous system. Due to these calming properties, orange and lavender essential oils are ideal choices for aromatherapy for anxious patients in the dental setting.³⁶

Several methods are available for administering essential oils to patients including topical application on the skin or through inhalation.³⁶ An essential oil(s) mixture can be created using a ratio of 10 to 15 drops of oil for every 4 oz of water in a spray bottle, then sprayed around the treatment room prior to patient care.³⁷

Another aromatherapy delivery method involves applying essential oils onto a cotton ball or gauze, which can be given to the patient for inhalation as needed during dental procedures when anxiety arises.³⁷ Alternatively, a diffuser can be used that breaks down essential oils into molecules then disperses them into the air for a calming effect. Running the diffuser for 15 minutes every 2 hours is advised, since the molecules persist in the air for approximately that duration.³⁷

Prior to utilizing essential oils, a patient’s medical history should be reviewed to check for potential allergies or chronic conditions such as asthma. Patients should be educated about the potential benefits of essential oils in managing dental anxiety and asked about their favorite scents so the experience is personalized.³⁶

Several systematic reviews have found virtual reality (VR) can be an effective method for reducing dental anxiety.^17,38-40 VR utilizes a headset to provide a computer-generated simulation and is a distraction technique for reduced pain perception and dental anxiety. Some examples of VR software are interactive games and calming imagery. Oral health professionals should be mindful of side effects related to VR such as nausea, dizziness, or headaches.^21,40 However, reported incidence of these side effects is low, with one study reporting participants showed no symptoms of cybersickness (motion sickness due to immersive reality environments)⁴¹ and another study reported nausea was not a significant finding in participants.²¹ These potential side effects should be discussed with the patient before VR use.

Patients who report they are prone to cybersickness should not utilize VR.²¹ When selecting the software, opting for stationary imagery could prove advantageous in reducing cybersickness, as it allows patients to keep their head still during treatment.⁴⁰ In a study of patients receiving scaling and root planing while exposed to VR via a headset, the dental hygienist providing treatment reported the headset did not impede treatment or clinician positioning.²¹

Conclusion

Dental anxiety is a psychological condition eliciting physiological responses such as elevated blood pressure, heart rate, and respiration. When someone experiences dental anxiety, it can result in avoidance of dental care and a deterioration in oral health. Oral health professionals can use dental anxiety assessments to ascertain the necessity for anxiety management and gauge its severity. Depending on the patient’s dental anxiety level and preferences, pharmacological or nonpharmacological management techniques can be implemented to reduce dental anxiety. Nonpharmacological management options can include music therapy, aromatherapy, and VR. Management methods implemented should be individualized to enhance patient comfort and encourage regular appointments.

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From Dimensions of Dental Hygiene. November/December 2025; 23(6):32-35.