Journal of Dental Sciences 18 (2023) 203e210

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Original Article

Music therapy and aromatherapy on dental

anxiety and fear: A randomized controlled
trial
Natthatida Janthasila a,b, Orawan Keeratisiroj c*

a
Master of Public Health Program, Faculty of Public Health, Naresuan University, Phitsanulok,
Thailand
b
Sirindhorn College of Public Health, Phitsanulok, Thailand
c
Faculty of Public Health, Naresuan University, Phitsanulok, Thailand

Received 2 June 2022; Final revision received 16 June 2022

Available online 30 June 2022

KEYWORDS Abstract Background/purpose: Dental anxiety and fear in children are major public health
Aromatherapy; concerns. This study aimed to determine the effectiveness of music therapy combined with
Dental care; aromatherapy, in reducing the children’s dental anxiety and fear.
Dental fear; Materials and methods: A total of 128 school-age children aged 10e12 years were randomly allo-
Dental anxiety; cated into 4 groups: a control group with 32 volunteers, an experimental group that received mu-
Music therapy sic therapy, with 33 volunteers, an aromatherapy experimental group with 31 volunteers, and 32
volunteers in an experimental group with music therapy combined with aromatherapy.
Results: The results found that within-group comparisons before and after the experiment re-
vealed the outcomes with a statistically significant change at the 0.05 level of each group as fol-
lows. The control group had increased heart rate. The music therapy group showed decreased
dental anxiety and fear and systolic blood pressure. The aromatherapy experimental group ex-
hibited increased oxygen saturation. The experimental group receiving music therapy combined
with aromatherapy showed decreased dental anxiety and fear, heart rate, and systolic and dia-
stolic blood pressure as well as increased oxygen saturation values. In addition, it was found that
music therapy combined with aromatherapy had a co-influence on dental anxiety and fear
(F Z 22.22, P < 0.001) and oxygen saturation (F Z 17.40, P < 0.001), and the two main treat-
ments also significantly influenced these outcomes at the 0.05 level.
Conclusion: The results showed that music therapy in combination with aromatherapy reduced
children’s anxiety and fear of dental services better than a single treatment.
ª 2022 Association for Dental Sciences of the Republic of China. Publishing services by Elsevier
B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

* Corresponding author. Faculty of Public Health, Naresuan University, Tambon Tha Pho Amphoe Mueang, Phitsanulok, 65000, Thailand.
E-mail address: orawansa@nu.ac.th (O. Keeratisiroj).

https://doi.org/10.1016/j.jds.2022.06.008
1991-7902/ª 2022 Association for Dental Sciences of the Republic of China. Publishing services by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 N. Janthasila and O. Keeratisiroj

Introduction There are limited studies of these two non-drug ap-

proaches in pediatric dentistry. Only one study by Pradopo
Dental anxiety and fear are recognized in many countries as and colleagues concluded that pandan aromatherapy and
one of the major public health problems, as it deprives soothing music could reduce anxiety levels in pediatric
cooperation and increases dental treatment failures.1 patients undergoing dental treatment.22 However, a study
Studies in many countries around the world have found by James and colleagues looked at the effects of the two
prevalence between 3 and 43%.2e5 In Thailand, the preva- non-drug approaches but did not consider the effects
lence of dental fear among 12-year-olds is 23.6%.6 together. They concluded that these non-invasive tech-
Children’s dental anxiety and fear are caused by several niques, alone or in combination, may be used in ortho-
factors. Previous studies have found that young age and dontics of pediatric dentists for cooperating patient
females are factors that increase dental anxiety and fear.7 molding.23 In addition, the effect of music therapy and
A study by Wu and Gao found that family structure and aromatherapy on anxiety reduction in other groups such as
sibling presence were important factors for children’s nurses24 and nursing students25 was also studied. There-
dental anxiety and fear.8 Additionally, childhood dental fore, it is unclear whether to report the effect of music
anxiety and fear were associated with a higher prevalence therapy combined with aromatherapy in reducing anxiety
of tooth decay, toothache, and extraction. This pain also among dental pediatric patients. This study aimed to
worsens the quality of life in terms of oral health in chil- examine the effect of music therapy combined with
dren.9 Over time, this effect will result in more and more aromatherapy on anxiety and fear of dental services among
serious oral health problems in children, making treatment school-aged children.
more complicated. This is a reinforcement that causes
children to have more anxiety and fear.10 Materials and methods
The goal of reducing children’s anxieties and fears is to
involve them in cooperation with dental personnel, which
Study design
is critical to the success of treatment.11 Methods for
managing anxiety and fear in dentistry are both pharma-
cological and non-pharmacological. Pharmacological This was a randomized controlled trial with a 2  2
methods of suppressing anxiety and fear in dental services factorial design that evaluated the clinical efficacy of a
include inhalation, sedative (nitrous oxide), and intrave- music therapy in combination with aromatherapy for
nous and oral sedatives. This sedative has some unwanted reducing anxiety and fear of dental services among school-
side effects and risks, such as lethargy, rash, dizziness, age children. Participants, dentists and assessors are not
nausea, headache, or confusion.12 It also increases the blind to the allocation mode of organizing a treatment
cost of dental treatment. Therefore, patients appreciate a group. The trials were divided into 4 groups: 1) control
non-drug approach to management. This is because the group, 2) experimental group receiving music therapy, 3)
use of the drug may have unwanted risks.11 There are experimental group receiving aromatherapy, and 4)
many ways to reduce dental anxiety and fear without experimental group receiving music therapy combined
medication, but one that is simple and non-invasive, and with aromatherapy. The study was following the Declara-
suitable for pediatric patients is a distraction and envi- tion of Helsinki guidelines and was conducted according to
ronmental manipulation of the clinic such as music ther- CONSORT recommendations. Ethical approval was ob-
apy and aromatherapy. tained from The Institutional Review Board of Naresuan
Today, music therapy is used in many medical and University, Thailand (COA No.: 509/2021; IRB No.: P3-
therapeutic procedures, such as in patients undergoing bi- 0152/2564) and the clinical trial register (http://www.
opsy for breast cancer screening,13 and in reducing anxiety thaiclinicaltrials.org/show/TCTR20220220001). Informed
while waiting for dental services14 Therefore, music ther- consent was also taken from all patients before starting
apy is recognized as an effective method of reducing anx- treatment.
iety and fear. Having patients choose music according to
their preferences has a beneficial effect on reducing anxi- Participation and recruitment
ety and fear.15 Another therapy is aromatherapy, which is
used as an adjuvant in medical practice.16 A study on This randomized clinical trial was conducted in Sirindhorn
anxiety and fear of dental services found that the smell of College of Public Health, Phitsanulok. One hundred thirty-
the dental lab had a strong effect.17 There are several two school-age children were recruited from three primary
studies conducted a study on the effects of lavender on schools in Wang Thong Sub-district, Wang Thong District,
dental anxiety, which confirmed its effectiveness in Phitsanulok Province of Thailand during February 2022. The
reducing dental anxiety.18e20 One of the most popular inclusion criteria were: 1) school-aged children aged 10e12
essential oils is lavender oil. The active ingredients linalool years studying in grades 4e6; 2) being in good health
and linalyl acetate act as sedatives by affecting the amino without congenital diseases, not allergic; 3) being subject
acid butyric acid receptors in the central nervous system, to coating services a dentition is a tooth with narrow and
calming the brain and reducing anxiety.21 deep pits and grooves, teeth that have not yet decayed or
In summary, music therapy and aromatherapy are prac- have started to appear white and cloudy; 4) having a
tical, effective, cost-effective and appropriate methods of normal body temperature between 36.0 and 37.5  C; and 5)
dental treatment in pediatric patients who may have anx- voluntary and with the consent from the parent. Exclusion
iety and fear. criteria were: 1) having problems with smelling or sinusitis;

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2) having problems with hearing; and 3) having a history of during the sealant procedure and the volunteers were
oil allergy or essential oils. restricted from other activities.
The sample size was calculated using the effect size The experimental procedure was carefully organized to
value from the previous research26 with mean diastolic prevent contact between the subjects during the experi-
blood pressure in the experimental and control groups ment. All study participants were arranged to rest in the
118.8  12.1 and 127.8  9.5, respectively. The sample size lounge. Then take the 1st and 2nd volunteers to the waiting
was calculated using the Bernard (2000) formula.27 The room. To collect information before receiving dental ser-
type I error was defined as 5% and the power of the test was vices from vital signs, including heart rate, blood pressure,
90%. At least 31 samples were used per group. In addition, and oxygen saturation and the researchers inquired about
the sample size for drop out was increased by 5%, so the dental anxiety and fear questionnaire. Then, the first
sample size was 33 per group. Subjects were divided into research participant was taken to the dental service room
four groups with block randomization by the research team. for sealant (3M Clinpro Sealant Refill, St.Paul, MN, USA)
treatment. This takes about 10e15 min when the sealant is
Outcomes and measures finished. The researchers recorded the same data after one
more service and then took the volunteers to rest in
Dental anxiety and fear scores were the primary outcomes another room.
of the trial. Secondary outcomes were vital signs: blood
pressure, heart rate and oxygen saturation. These variables Statistical analysis
were measured only once, with pre-and post-treatment
assessments by the research team. Statistical analyses were performed using the Statistical
Data collection tools include record forms of baseline Package for Social Sciences (SPSS) version 17.0 for Windows
characteristics and outcome variables, standard measure- (SPSS Inc., Chicago, IL, USA). Descriptive statistics were
ment forms, and scientific instrumentation. The Children’s used by number and percentage for categorical data, and
Fear Survey Schedule (CFSS-DS)1 and Facial Image Scale the mean and standard deviation for continuous data. The
(FIS)28 were applied to measure dental anxiety and fear using baseline characteristics of the participants in the four arms
15 questions on CFSS-DS. To ask the question and have the were compared using Chi-square tests for categorical vari-
children choose the answer to each question by selecting five ables and one-way analysis of variance for continuous var-
different facial expressions, in order from the most anxious iables. Differences in outcomes (change in the dental
(a score of 5) to the least anxious (a score of 1), which was anxiety and fear scores, blood pressure, heart rate, and
also assessed for reliability, had Cronbach’s alpha coefficient oxygen saturation before and after treatment) were
of 0.795 for school-age children aged 10e12 years. compared within groups with paired t-tests. In case the
data is non-normally distributed, non-parametric statistics
Interventions are used. Finally, the main effect and the interaction effect
of music therapy and aromatherapy were analysed by 2  2
Each experimental group underwent three different in- factorial analysis of variance. The level of significance was
terventions while receiving the sealant services from the set at 0.05.
institution’s dentist. In the first group of music therapy, the
most popular instrumental Thai pop songs were played, Results
which were surveyed by researchers before the trial began.
By dividing the songs into four sets, then choosing 1 set of the
Baseline characteristics
most desired sets to play music during dental services. This
offers volunteers an option to listen to their favorite music
through an MP3 player by turning the music through a Blue- A total of 132 volunteers were randomly assigned to each
tooth radio transmitter to a speaker that can be adjusted at a group prior to the trial date, 33 participants per group.
certain volume level. The sound does not exceed 60 dB and Overall, data for 128 school-age children were used in the
has a letter plate in front of the service room (It says “Music final analysis; these patients were divided into the control
therapy activities, please do not disturb) to prevent dis- group (n Z 32), an experimental group with music therapy
turbing the patient while listening to music therapy. In the (n Z 33), an experimental group with aromatherapy
second group of aromatherapy, use the aroma diffuser (MUJI (n Z 31), and experimental group with music therapy
Retail, Thailand) to start by adding 300 ml of water at room combined with aromatherapy (n Z 32) as shown in Fig. 1.
temperature to the receptacle of the device. Lavender There was a balance of baseline data between groups for
(Lavandula officinalis var. maillette, France) scent into 3 demographic and clinical characteristics (Table 1). Except
drops, then turn on the device half an hour before the pro- for quantitative data, dental anxiety and fear scores were
cedure. Finally, add water and 3 drops of lavender essential not balanced between groups (P Z 0.013). Therefore, the
oil every 2 h. And the last group of music therapy with pre-and post-treatment difference of the outcome variable
aromatherapy, the subjects received both of the above was used to compare between groups as shown in Table 3.
programs together during dental treatment.
The control group arranged the environment, placement Effects of music therapy and aromatherapy
of the music player, Bluetooth speaker, and procedures, as
in the three experimental groups, using only water-only Within-group comparisons before and after the experiment
essential oil diffusers. Additionally, no music was played revealed that the control group had no change in outcomes

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 N. Janthasila and O. Keeratisiroj

Figure 1 The CONSORT flow diagram.

except increased heart rate values. For the three experi- was found to be effective in managing the anxiety and fear
mental groups, the change in outcome was statistically of dental care in school-aged children as a non-
significant at the 0.05 level as follows: The music therapy pharmacological manipulation in the intervention. Anxiety
group and the aromatherapy group had dental anxiety and is both a physiological and psychological structure. The two
fear, and systolic blood pressure decreased and the oxygen interact with each other, and their effects can be measured
saturation value increases. For the experimental group by central nervous system activity, heart rate and respira-
receiving music therapy combined with aromatherapy, tion, among others.29
there was a positive change in outcomes for all variables, In the present study, the experimental group receiving
including dental anxiety and fear, heart rate, systolic and the music therapy had decreased dental anxiety and fear
diastolic blood pressure decreased, and the oxygen satu- and decreased systolic blood pressure and increased oxygen
ration value increased (Table 2). saturation values. This is consistent with a previous study
by Kaur and colleagues who enrolled 30 children aged 4e8
Main effect and interaction effects of music years, the children were divided into three groups: control
therapy and aromatherapy group, music group and audiovisual group. It was found that
the use of video and audio or music alone reduced stress in
children better than in the control group.30 This is also
Assessment of the between-subject effects revealed a sig-
consistent with the study by Singh and colleagues. It was
nificant interaction effect between music therapy and
found that listening to their favorite music was effective in
aromatherapy on dental anxiety and fear (F Z 22.22,
reducing anxiety among 60 children aged 6e12 years while
P < 0.001) and oxygen saturation (F Z 17.40, P < 0.001).
having their teeth extracted. Therefore, it is important to
The main effects of music therapy and aromatherapy were
consider music preferences when giving music therapy.26
both statistically significant at the 0.05 level for all out-
We also found that the aromatherapy experimental
comes (Table 3).
group had reduced dental anxiety and fear and systolic
blood pressure and increased oxygen saturation supported
Discussion by several studies18,31 Ghaderi and Solhjou found that
saliva cortisol, pulse rate and lavender’s Face Rating Scale
Children’s dental anxiety and fear are major problems in scores could reduce children’s stress and pain perceptions
dental services as anxiety and fear deprive them of coop- during dental treatment.32 A study by Arslan and col-
eration and increase dental treatment failures. The main leagues found the effect of inhaling lavender reduced the
reasons why some children do not visit dental personnel intensity of pain during tooth extraction.33 Because lav-
despite toothache are lack of time and dental anxiety and ender oil, the active substances linalool and linalyl ace-
fear. As a result, children avoid visiting dental personnel, tate, act as a sedative by affecting the aminobutyric acid
resulting in a decrease in their quality of life of the child.1 receptors in the central nervous system, calming the brain
In this study, music therapy combined with aromatherapy and reducing anxiety.21 Lavender essential oil improves

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 Journal of Dental Sciences 18 (2023) 203e210

Table 1 Baseline characteristics of the participants in the four groups.

Parameters CG (n Z 32) EG1 (n Z 33) EG2 (n Z 31) EG3 (n Z 32) P
a
Sex 0.434
male 19 (59.4) 13 (39.4) 16 (51.6) 17 (53.1)
female 13 (40.6) 20 (60.6) 15 (48.4) 15 (46.9)
Age (years) 11.00  0.88 11.00  0.83 10.94  0.89 10.88  0.87 0.955 a
a
Religion 0.424
Buddhism 32(100.0) 33(100.0) 31(100.0) 31(96.9)
Islam 0(0) 0(0) 0(0) 1(3.1)
a
Education 0.989
Grad 4 12(37.5) 13(39.4) 13(41.9) 14(43.8)
Grad 5 8(25.0) 10(30.3) 7(22.6) 8(25.0)
Grad 6 12(37.5) 10(30.3) 11(35.5) 10(31.3)
a
Sibling 0.916
Yes 29(90.6) 28(84.8) 27(87.1) 28(87.5)
No 3(9.4) 5(15.2) 4(12.9) 4(12.5)
Dental history
a
Never 1(3.1) 2(6.1) 2(6.5) 3(9.4) 0.773
Used To 31(96.9) 31(93.9) 29(93.5) 29(90.6)
a
Filling 19(59.4) 19(57.6) 12(38.7) 16(50.0) 0.342
a
Extraction 18(56.3) 20(60.6) 15(48.4) 14(43.8) 0.524
a
Scaling 7(21.9) 13(39.4) 5(16.1) 8(25.0) 0.174
a
Apply fluoride 22(68.8) 28(84.8) 19(61.3) 25(78.1) 0.153
a
sealant 3(9.4) 4(12.1) 3(9.7) 5(15.6) 0.861
SBP 104.7 13.0 104.2  12.9 105.2  10.7 104.0  5.6 0.971 b

DBP 67.7  10.4 68.9  8.7 68.0  6.9 70.2  4.6 0.587 b

HR 85.0  6.2 83.6  10.8 81.9  8.8 84.5  8.9 0.513 b

SpO2 98.3  1.1 98.2  0.9 98.1  1.0 98.4  0.9 0.644 c

FIS, CFSS-DS 35.2  7.4 35.3  5.1 39.4  5.9 38.2  6.0 0.013 b

CG, control group; EG1, music therapy group; EG2, aromatherapy group; EG3, music therapy with aromatherapy group; SBP, systolic
blood pressure; DBP, diastolic blood pressure; HR, Heart rate; SpO2, oxygen saturation; FIS, Facial Image Scale; CFSS-DS, The Children’s
Fear Survey Schedule
The data are presented as the mean  standard deviation (SD) for continuous data; n (%) for categorical data.
a
The P-value was obtained by Chi-square test.
b
The P-value was obtained by one-way ANOVA.
c
The P-value was obtained by Kruskal-Wallis test.

mood, and reduces anxiety because it depresses the between those who listened to the upbeat music group,
parasympathetic nervous system, which is the autonomic relaxing group, and no music group. And likewise, the study
nervous system.34 It is believed that the effect of used the music therapy-only program by Gupta and col-
breathing begins with the absorption of volatile odor leagues. They studied three groups of pediatric patients
molecules. The odor molecules are then converted into aged 3e7 years: upbeat music, relaxing music, and control.
chemical signals in the olfactory bulbs. The amygdala and Studies have shown that music does not reduce pain, anx-
the limbic system stimulate the secretion of certain hor- iety, or disruptive behavior.38
mones such as enkephalins, endorphins and serotonin, Additionally, our study found that music therapy com-
thereby creating a feeling of pleasure.35 bined with aromatherapy had an interactive effect on dental
The results showed that the experimental group who anxiety and fear and oxygen saturation. The benefits of
received music therapy combined with aromatherapy had music therapy are stimulating the brain to produce alpha-
decreased dental anxiety and fear, heart rate, systolic and wave and bringing a relaxing effect on the listeners. Music
diastolic blood pressure and increased oxygen saturation. therapy can help overcome anxiety caused by psychological
Systolic and diastolic pressure were the main factors in effects, such as by lowering blood pressure, pulse rate, and
controlling anxiety levels. But heart rate variability, espe- respiration rate so that the patient becomes more relaxed
cially those that increase during contiguous periods, risks and calmer. And the benefits of aromatherapy affected the
mental health, cardiovascular health, and mortality.36 gamma-aminobutyric acid (GABA) receptors. GABA receptor
By contrast, another study by Aitken and colleagues11 is an important target for hypnotic sedative components in
about the efficacy of music therapy on forty-five children humans that can cause relaxation and decrease anxiety
aged 4e6 years old who were about to undergo dental levels.22 Using a single program is not enough to effectively
treatment showed no significant differences statistically reduce dental anxiety and fear. The findings are supported

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 N. Janthasila and O. Keeratisiroj

Table 2 Functional outcomes (baseline vs post-treatment) for the four groups.

Groups Scale Baseline Post-treatment DChange t/Z P
CG (n Z 32) SBP 104.7 13.0 106.5 11.7 -1.8  1.4 -1.28 0.210a
DBP 67.7  10.4 69.2 9.8 -1.5  1.0 -1.45 0.158a
HR 85.0  6.2 91.5 9.1 -6.5  1.4 -4.74 <0.001*,a
SpO2 98.3  1.1 98.0 1.0 0.3  0.2 0.98 0.409b
FIS, CFSS-DS 35.2  7.4 33.6 10.8 1.6  1.4 1.08 0.288a
EG1 (n Z 33) SBP 104.2  12.9 101.2 11.3 3.0  1.2 2.63 0.013*,a
DBP 68.9  8.7 67.3 7.9 1.6  1.1 1.45 0.156a
HR 83.6  10.8 82.6 9.9 1.0  1.5 0.63 0.535a
SpO2 98.2  0.9 99.4 0.9 -1.2  0.2 -5.29 <0.001*,b
FIS, CFSS-DS 35.3  5.1 22.4 7.3 12.9  1.3 9.65 <0.001*,a
EG2 (n Z 31) SBP 105.2  10.7 101.8 8.4 3.4  1.2 3.00 <0.001*,a
DBP 68.0  6.9 66.7 7.2 1.3  1.1 1.26 0.218a
HR 81.9  8.8 79.6 11.1 2.3  1.8 1.28 0.210a
SpO2 98.1  1.0 99.4 0.8 -1.3  0.2 -5.78 <0.001*,b
FIS, CFSS-DS 39.4  5.9 19.8 6.7 19.6  1.2 16.63 <0.001*,a
EG3 (n Z 32) SBP 104.0  5.6 95.2 6.0 8.8  1.1 8.13 <0.001*,a
DBP 70.2  4.6 65.0 5.3 5.2  0.8 6.73 <0.001*,a
HR 84.5  8.9 80.6 8.5 3.9  1.2 3.17 <0.001*,a
SpO2 98.4  0.9 99.2 1.0 -0.8  0.2 -3.82 <0.001*,b
FIS, CFSS-DS 38.2  6.0 19.6 3.9 18.6  1.3 14.34 <0.001*,a
CG, control group; EG1, music therapy group; EG2, aromatherapy group; EG3, music therapy with aromatherapy group; SBP, systolic
blood pressure; DBP, diastolic blood pressure; HR, heart rate; SpO2, oxygen saturation; FIS, Facial Image Scale; CFSS-DS, The Children’s
Fear Survey Schedule
The data are presented as the mean  SD
DChange in value before vs after treatment.
* Statistically significant at P-value < 0.05
a
The P-value was obtained by the paired samples t-test.
b
The P-value was obtained by the Willcoxon signed-rank test.

Table 3 Assessment of between-participant effects.

f
Outcome Source of SS df Mean Square F P
Variables Variation
DSBP Music 827.42 1 827.42 17.57 <0.001*
Aroma 970.18 1 970.18 20.60 <0.001*
Music and Aroma 1.44 1 1.44 0.031 0.861
DDBP Music 388.67 1 388.67 12.26 0.001*
Aroma 334.27 1 334.27 10.55 0.001*
Music and Aroma 5.38 1 5.38 0.17 0.681
DHR Music 660.21 1 660.21 9.34 0.003*
Aroma 1087.74 1 1087.74 15.38 <0.001*
Music and Aroma 262.33 1 262.33 3.71 0.056
DSpO2 Music 5.94 1 5.94 3.92 0.050*
Aroma 11.52 1 11.52 7.59 0.007*
Music and Aroma 26.42 1 26.42 17.40 <0.001*
DFIS, CFSS-DS Music 878.68 1 878.68 15.89 <0.001*
Aroma 4493.10 1 4493.10 81.26 <0.001*
Music and Aroma 1228.31 1 1228.31 22.22 <0.001*
Music, Music Therapy; Aroma, Aromatherapy; SS, type III sum of squares; f Factorial Between-Subjects;
SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate; SpO2, oxygen saturation; FIS, Facial Image Scale; CFSS-DS,
The Children’s Fear Survey Schedule. DChange in value before vs after treatment.
* Statistically significant at P-value < 0.05

by the research of Toet and colleagues that found that affected by noise sources such as crowds and people.37
neither apple nor orange was effective in reducing expected Pradopo and colleagues,22 they studied four different
anxiety in waiting patients in dental clinics. Results can be treatments: control group, pandan leaves aromatherapy

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