Journal of Dentistry 69 (2018) 22–31

Contents lists available at ScienceDirect

Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Review article

Non-pharmacological interventions for reducing mental distress in patients T

undergoing dental procedures: Systematic review and meta-analysis
⁎
Sophia Burghardta, Susan Koranyib, Gabriel Magnuckic, Bernhard Straussa, Jenny Rosendahla,
a
Jena University Hospital, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
b
University Hospital Leipzig, Department of Medical Psychology and Medical Sociology, Leipzig, Germany
c
Private dental practice, Bassum, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This meta-analysis investigates the efficacy of non-pharmacological interventions in adults under-
Dental anxiety going dental procedures under regional or general anesthesia compared to standard care alone or an attention
Mental distress control group on the reduction of mental distress, pain, and analgesic use.
Non-pharmacological interventions Data sources: To identify relevant papers a comprehensive literature search was carried out in MEDLINE,
Systematic review
CENTRAL, Web of Science, and PsycINFO (last search August 2017). Additionally, lists of references of relevant
Meta-analysis
articles and previous reviews were checked. ProQuest Dissertations and Theses Full Text Database was screened
Randomized-controlled trials
to identify any unpublished material.
Study selection: A total of 29 eligible randomized controlled trials were included, comprising a total of 2.886
patients. Included trials investigated the effects of hypnosis, enhanced information, relaxation, music, or cog-
nitive-behavioral approaches including distraction.
Results: Random effects meta-analyses revealed significant positive treatment effects on the reduction of mental
distress (g = 0.58, CI 95% [0.39; 0.76]). Effects on pain relief (g = 0.00, CI 95% [−0.28; 0.28]) and the re-
duction of analgesic use (g = 0.26, CI 95% [−0.22; 0.73]) were not significant. Because effects on mental
distress were substantially heterogeneous, subgroup analyses were run yielding significantly larger effects for
studies with low risk of bias compared to studies with high or unclear risk of selection and attrition bias. No
significant differences appeared between various types of non-pharmacological interventions.
Conclusions: In summary, benefits of non-pharmacological interventions on reducing mental distress were de-
monstrated with largest effects being shown for hypnosis. However, further high quality trials are needed to
strengthen the promising evidence.
Clinical significance: This systematic review and meta-analysis indicated that non-pharmacological interventions
may be beneficial for reducing mental distress in patients undergoing dental procedures and could thus be
considered as valuable adjunct to standard care.

1. Introduction diagnosed condition of a specific (dental) phobia (e.g., according to the

Even though dental treatment is largely painless under local or
general anesthesia by now, it is commonly perceived as an un-
comfortable, threatening, and confusing situation. Hence, many pa-
tients experience fear or anxiety not only during invasive procedures.
Sights, sounds, and smells associated with the dental clinic, injections,
dental instruments, perceived lack of control and predictability, and
(anticipated) pain result in patients’ mental distress [1].
While many people experience anxiety and fear of going to a dental
practitioner ranging from very mild to more severe manifestations, only
a relatively small percentage of dental patients will have a clinically
International Statistical Classification of Diseases and Related Health
Problems 10th Revision [ICD-10]). Up to every fourth adult is reporting
dental fears, whereas the point prevalence of clinically relevant dental
phobia is estimated to be about 4% [2]. Contemporary models hy-
pothesize a continuum of situation-specific fear or anxiety experiences
related to dental care, including those being considered as “normal,”
those that contain only infrequent and insignificant fear/anxiety be-
haviors, and those that include more frequent or impairing fear/anxiety
behaviors with complete avoidance of dental care [1]. The most
common way to measure dental anxiety is by using the Dental Anxiety
Scale (DAS) [3]. This questionnaire captures the possible continuum of

⁎
Corresponding author at: Jenny Rosendahl, PhD Jena University Hospital, Friedrich Schiller-University, Institute of Psychosocial Medicine and Psychotherapy, Germany.
E-mail address: jenny.rosendahl@med.uni-jena.de (J. Rosendahl).

https://doi.org/10.1016/j.jdent.2017.11.005
Received 15 June 2017; Received in revised form 7 November 2017; Accepted 13 November 2017
0300-5712/ © 2017 Elsevier Ltd. All rights reserved.
S. Burghardt et al.
dental anxiety also allowing for the identification of highly anxious
patients.
Research suggests that the general dental practitioner is capable of
treating adults with mild or moderate forms of dental anxiety effec-
tively, while treatment of severe dental anxiety or even dental phobia
often requires more specialist interventions, e.g., psychotherapy [4]. In
recent years, numerous non-pharmacological approaches have been
developed to improve the handling of anxious patients during as well as
before dental treatments [4–6]. Primarily, those interventions aim at
reducing mental distress in patients before and during dental proce-
dures. Related indirect effects of reduced mental distress might be the
reduction of pain and the facilitation of recovery after therapy since
mental distress is known to impair post-operative treatment success of
surgical, endodontic, or other dental procedures [7–9].
Hence, non-pharmacological interventions could be considered as
an adjunct to standard care and to “first-line treatment” such as phar-
macological strategies such as pre-medication, sedation, or analgesia.
There are several different approaches that can be used in the dental
clinic or surgery in order to assist anxious patients. Existing techniques
can be categorized into enhanced information, cognitive-behavioral
interventions, hypnosis, relaxation procedures or music interventions
[5,10]. Enhanced information draws on the patient’s cognitive level to
transmit sensory and/or procedural information before, during and
after dental procedure. Cognitive-behavioral strategies focus on the
reduction of dental anxiety through, e.g., distraction, sensory focusing,
positive reinforcement, cognitive restructuring, or systematic desensi-
tization. Relaxation techniques are described as teaching or instructing
patients in, e.g., progressive muscle relaxation, guided imaginary,
breath control, or autogenic training aim to induce relaxation and
comfort [11]. Hypnosis has a longstanding tradition in use during
medical procedures. It is suggested to work mainly through two me-
chanisms: reducing distress and targeting patient expectancies with
suggestions for positive outcomes [12]. Music interventions have been
used in different medical fields to meet patients' psychological, phy-
sical, social and spiritual needs. Inherent elements of music are known
to influence physiological and psycho-emotional responses in patients,
e.g., arousing memory and association, stimulating imagery, evoking
emotions, and promoting relaxation and distraction [13].
Existing meta-analyses included only trials conducted before 2001
[14] or focused exclusively on the efficacy of psychological treatments
(cognitive-behavioral therapy and behavioral therapy) for severe levels
of dental anxiety or dental phobia [15]. Hence, the aim of the present
systematic review and meta-analysis is to give a comprehensive over-
view of non-pharmacological interventions for patients with mild,
moderate and severe levels of anxiety (excluding dental phobia) that
are implementable in general dental practice before or during dental
procedures. Moreover, we aim to quantify the efficacy of these ap-
proaches to reduce mental distress in patients undergoing dental pro-
cedures in comparison to standard care alone or to attention control
groups.
2. Methods
Objectives, inclusion criteria, and methods have been pre-specified
in a review protocol (registered in PROSPERO; June 28, 2016; http://
www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=
CRD42016041661).
2.1. Identification and selection of studies (PICOS)
2.1.1. Patients
Adult patients (18 years and older) undergoing dental procedures
usually provided under general and regional anesthesia. Studies with
children and adolescents were excluded.
23
Journal of Dentistry 69 (2018) 22–31
2.1.2. Interventions
Any non-pharmacological intervention which is implemented be-
fore or during dental procedures in general dental practice.
2.1.3. Comparators
Eligible control groups were “treatment as usual” (defined as the
standard dental care policy of the dental practice) and “attention con-
trol” groups (defined as providing the same amount of time and at-
tention to the patients just as in the intervention group but without
applying a specific therapeutic technique).
2.1.4. Outcomes
The included trials reported on at least one of the following out-
comes measured via self- and/or observer reports: mental distress (i.e.,
anxiety, mood; primary outcome), pain, and medication (i.e., analgesic
use; secondary outcomes).
2.1.5. Study design
We included randomized controlled trials (RCTs) only.
2.2. Search methods
We carried out electronic searches in the databases MEDLINE,
CENTRAL, Web of Science, and PsycINFO (last search August 2017).
The MEDLINE search strategy is shown in Supplementary Table 1. We
adapted the strategy for Web of Science, Central and PsycINFO.
Additionally, we checked lists of references of relevant articles and
previous reviews. We further screened ProQuest Dissertations and
Theses Full Text Database to identify any unpublished material. One
author (SB) screened titles and abstracts of database records and re-
trieved full texts for eligibility assessment.
2.3. Data extraction and management
The following data were extracted from the included studies by
using a pilot-tested data extraction form: characteristics of patients,
intervention, control group, outcomes, bibliographic information, and
effect size related data. Two raters (SB, JR) independently extracted the
data; inter-rater disagreement was resolved through consensus. Study
authors were contacted in case of missing information. If information
on effect sizes was missing and could not be retrieved, data was ap-
proximated using different estimation methods (e.g., we estimated
statistics from graphs without numerical data, set an effect size to zero
if non-significant results were mentioned without reporting statistical
parameters).
2.4. Assessing the risk of bias in included studies
We assessed risk of bias in the included studies by common markers
of internal validity from the Cochrane Risk of Bias Tool [16]. The risk of
selection bias (sequence generation, allocation sequence concealment),
the risk of reporting bias (selective outcome reporting), and the risk of
performance bias (blinding of dentist and medical personnel) were as-
sessed at study level, and the risk of detection bias (blinding of outcome
assessors) as well as attrition bias (handling incomplete outcome data)
at outcome level, respectively. Blinding of outcome assessors was as-
sessed only for observer-reported outcomes, not for self-reported. Risk
of bias assessment was conducted by two independent, previously
trained raters (LH, JR). Disagreements were resolved through consensus
with a third author (SK).
2.5. Summary measures
We calculated bias-corrected standardized mean differences
(Hedges’ g) [17]. An effect size of 0.5 thus indicates that the mean of
the intervention group is half a standard deviation larger than the mean
S. Burghardt et al.
of the control group. The magnitude of Hedges’ g was interpreted
within the same ranges as Cohen’s d, regarding 0.20, 0.50, and 0.80 as
small, medium, and large effect sizes, respectively [18]. For dichot-
omous outcomes, Log Odds Ratios were calculated and converted to
Hedges’ g in order to pool across different effect size formats [19]. If
available, intention-to-treat data were used to calculate effect sizes.
2.6. Data synthesis
Comprehensive Meta-Analysis (CMA; Version 3.0; Biostat Inc.) was
used to perform data analyses. Outcome data were meta-analyzed using
a random-effects approach. The generic inverse variance method was
applied with heterogeneity estimated using the DerSimonian-Laird
method [20]. Statistical heterogeneity between trials was assessed with
χ2 heterogeneity tests (Cochrane’s Q) and I2 statistic [21]. I2 describes
the percentage of the variability in effect estimates that is due to het-
erogeneity rather than chance, with values from 0 to 40% indicating no
important heterogeneity, 30% to 60% moderate, 50% to 90% sub-
stantial, and 75% to 100% considerable heterogeneity, respectively
[22].
For multiple comparisons within a study we computed a combined
effect defined as the mean effect size in that study with a variance
adjusted by a correlation of 0.50 among the comparisons. If compar-
isons within one study were considered for different categories in the
subgroup analyses (e.g., TAU and attention control), results of both
comparisons were included as separate estimates [19]. If multiple
outcomes were reported within one outcome domain (e.g. two mea-
sures of anxiety), effect sizes were aggregated within domains for each
unit of analysis and correlations between outcomes were set at 0.50
[23].
2.7. Risk of bias across studies
We visually inspected funnel plots and run the Egger test [24] to test
for publication bias. Additionally, we used Duval and Tweedie's trim
and fill procedure to obtain an adjusted estimate of the treatment effect
after the publication bias had been taken into account and to indicate
how many missing trials have been imputed to correct for publication
bias [25].
2.8. Additional analyses
We conducted sensitivity analyses in order to test the robustness of
findings, examining if meta-analytic results change when excluding
outliers or approximated effect sizes. We further run exploratory sub-
group analyses to explain statistical heterogeneity [26].
3. Results
3.1. Study selection
We screened a total of 3.424 records and finally included N = 29
RCTs in the meta-analysis. Fig. 1 contains the flow chart of the study
selection process.
3.2. Study characteristics
All included studies were published in English between 1979 and
2017 (Table 1). Among the primary studies, 14 were from USA, three
from China/Taiwan, two each from Germany, Korea, and Turkey, and
one each from Spain, Sweden, United Kingdom, Saudi Arabia, Malaysia,
and the Netherlands, respectively.
While 27 studies were published in scientific journals, we identified
two studies reported in dissertation theses [33,50]. The 29 RCTs in-
cluded provided k = 46 comparisons between an intervention and a
control group, incorporating a total of 2.886 patients. Weighted mean
24
Journal of Dentistry 69 (2018) 22–31
age of patients was 33.3 years. 54% of the patients were female. Two
studies included highly anxious patients only [36,44], defined by va-
lues ≥ 13 in the Dental Anxiety Scale [3] or values ≥ 40 in the State
Trait Anxiety Inventory [53], whereas in all other studies also mild
manifestations of anxiety were included. Dental procedures adminis-
tered in the included studies were restorative treatment, endodontic
treatment, tooth filling, tooth removal, removal of third mandibular
molars, or oral surgery not further specified.
Ten studies evaluated cognitive-behavioral or behavioral ap-
proaches, including distraction. Nine of the primary studies reported on
the effects of enhanced information. Relaxation was examined in seven
studies, music in four studies, and hypnosis in four trials, respectively.
In five studies, interventions were applied using a combination various
approaches. Non-pharmacological interventions were applied before
dental procedures in 20 studies, in two studies during dental treatment,
and in seven studies both, before and during treatment, respectively. In
nine studies the dentist was actively involved in the delivery of the non-
pharmacological interventions, predominantly providing enhanced in-
formation, whereas in 19 trials printed material, videos, audio records,
or virtual reality were used.
In 26 studies the effects of a non-pharmacological intervention were
compared against treatment as usual. Attention control was used as a
comparison group in four primary studies. Primary outcome mental
distress was reported in 26 studies, with 20 studies yielding results for
anxiety and eight for other distress outcomes (e.g., comfort, dis-
comfort), respectively. Pain intensity was measured in 13 trials, effects
on medication were provided in four studies.
3.3. Risk of bias within studies
Risk of bias varied across the included studies (Supplementary
Table 2). A lack of reporting impeded the evaluation of risk of bias
particularly for selection bias and reporting bias where the majority of
the studies did not allow for an informed decision. There was some
evidence that risk of performance bias might be present in the included
studies with only 41% of the studies fulfilling the requirements for low
risk of bias by blinding of medical staff. About half of the studies were
judged as low risk of attrition bias reporting on intention-to-treat
samples or having no attrition.
3.4. Results of individual studies and synthesis of results
Across all reported outcomes, non-pharmacological interventions
showed a significant effect with Hedges’ g = 0.46, 95% CI [0.26; 0.66],
k = 29, p < 0.001. Heterogeneity of effects was considerable with
I2 = 77%, p(Q) < 0.001. When analyzing effects for each outcome
category separately, a significant effect in favor of non-pharmacological
interventions emerged for the primary outcome mental distress,
g = 0.58 [0.39; 0.76], k = 26, p < 0.001. However, effects were non-
significant for secondary outcomes, i.e. pain intensity, g = 0.00 [-0.28;
0.28], k = 13, p = 0.996 and analgesic use, g = 0.26 [−0.22; 0.73],
k = 4, p = 0.294 (Figs. 2 and 3).
Effects of non-pharmacological interventions on mental distress did
not differ (p = 0.907) when compared to TAU (g = 0.54 [0.36; 0.72],
k = 25) or to attention control groups (g = 0.60 [−0.43; 1.63], k = 3),
respectively. Detailed analyses of various primary outcome measures
revealed a medium to large effect for anxiety while the pooled effect
was small for distress outcomes (e.g., comfort). We also considered
different times of measurement of mental distress yielding medium
effects for preoperative distress, small effects for distress measured
during the dental procedure, and medium effects for postoperative
distress (Table 2).
3.5. Risk of bias across studies
There was no indication of a publication bias as shown by a visual
S. Burghardt et al.
inspection of the funnel plots for the primary outcome mental distress;
all trials are distributed symmetrically around the pooled effect size
(Supplementary Fig. 1). Equally, Egger’s test of funnel plot asymmetry
did not indicate a publication bias (p = 0.070), and Duval and
Tweedie’s trim and fill procedure did not result in any trimmed studies.
3.6. Additional analyses
Subgroup analyses were run for the primary outcome mental dis-
tress to explain the heterogeneity of the results. Although at first sight
hypnosis revealed the largest effects compared to other types of inter-
vention, differences were not significant. These pattern of results
emerged when considering only studies using single types of interven-
tions, i.e. excluding combined approaches, p = 0.424. When combined
interventions, e.g., hypnosis + distraction [40] were included in the
analyses, differences between interventions comprising hypnosis and
those that do not provide hypnosis were marginally significant,
p = 0.088 (Table 3). Moreover, type of intervention implementation,
i.e. the dentist was actively involved in the intervention delivery, and
type of anesthesia did not significantly impact treatment effects.
However, we found several indicators of risk of bias to significantly
influence the efficacy of non-pharmacological interventions. Studies
with low risk of selection bias and attrition bias resulted in larger effects
than studies with high or unclear risk of bias, though heterogeneity
remained substantial in the respective subgroups (Table 3).
25
Journal of Dentistry 69 (2018) 22–31
Fig. 1. Flowchart of identification,
screening, and assessing studies for inclu-
sion eligibility.
We identified three outlying studies in the effects on mental distress:
two positive outliers investigating the effects of hypnosis [34] and
music [46], and one negative outlier providing enhanced information
[43]. However, sensitivity analyses revealed the robustness of findings;
results for mental distress remained significant when excluding these
outliers. Likewise, excluding approximated effect sizes did not result in
different conclusions (Supplementary Table 3).
4. Discussion
Our meta-analytic study focused on the efficacy of non-pharmaco-
logical interventions for patients with mild to more severe levels of
anxiety (excluding dental phobia) that were implemented in general
dental practice before or during dental procedures. We found sig-
nificant positive effects for reducing mental distress, in particular an-
xiety. However, pain could not be reduced significantly by the use of
non-pharmacological interventions. Moreover, effects on analgesic use
were not significant.
The robustness of results on mental distress was generally confirmed
by sensitivity analyses and the absence of publication bias. Because
single study effects varied greatly, we conducted subgroup analyses to
identify sources of heterogeneity. Surprisingly, studies with low risk of
selection bias and attrition bias yielded significant larger effects than
studies with high or unclear risk of bias. This result suggests that our
analyses are unlikely to be biased by low quality studies. However, this
 Table 1
Characteristics of the included studies.

Study Patients’ level of Dental procedure Description of non-pharmacological intervention n Description of control group n Outcomes
anxiety#
S. Burghardt et al.

Biggs 2003 [27] DAS M = 7.9 dental procedure (1) relaxation: deep diaphragmatic breathing, 10–30 min* before procedure 88 TAU 90 Mental distress (anxiety)
high: 9.6% (2) cognitive intervention: focused attention on a neutral part of body, 10–30 min 94
before procedure
Choi 2015 [28] DAS M = 10.8 third molar surgery enhanced information: basic information and slideshow presentation including 25 TAU (incl. basic information) 26 Mental distress (anxiety)
simple illustrations, audio and visual cues, before procedure Pain intensity
Colorado-Bonnin 2006 – third molar extraction enhanced information: prior to extraction, instructions from a surgeon about the 45 TAU 46 Pain intensity
[29] postoperative course after extraction with a written text containing postoperative
instructions, before procedure
Corah 1979 [30] – Class II amalgam (1) relaxation: standard relaxation instructions, before and during procedure 20 TAU 20 Mental distress (discomfort self/
restoration dentist)
(2) distraction: playing a video ping pong game, before and during procedure 20
Corah 1981 [31] – Class II amalgam relaxation: standard relaxation instructions, 25 min, before and during procedure 20 (1) TAU 20 Mental distress (discomfort)
restoration (2) AttCG: listening to a story 20
about traveling in Vermont
Croog 1994 [32] – periodontal surgery cognitive intervention: repeated psychological messages, designed for short-term 11 TAU 9 Mental distress (anxiety, distress)
cognitive reshaping, 8 min, before procedure Pain intensity
Medication (analgesics)
DeNitto 2012 [33] DAS M = 5.9 endodontic treatment distraction: relaxation movie via video eyewear, 90 min, during procedure 30 TAU 30 Mental distress (anxiety)
Eitner 2011 [34] – dental-implant surgery hypnosis: audio pillow with hypnosis text and relaxation music, 66 min, during 44 AttCG: audio pillow without 38 Mental distress (anxiety)
procedure hypnosis
Enqvist 1997 [35] – third molar extraction hypnosis: daily listening a hypnosis tape containing a hypnotic relaxation 33 TAU 36 Mental distress (anxiety)
induction, 20 min, 6–8 days before procedure Medication (analgesics)
Gan 2017 [36] DAS M = 12.5 restorative treatment combined psychological intervention: psychoeduaction + relaxation + modeling 15 TAU 15 Mental distress (anxiety)
technique: 45 min, before procedure

26
Gazal 2016 [37] – tooth removal enhanced information: video-tape with information demonstration of ideal 29 TAU 29 Mental distress (anxiety)
painless procedure, before procedure
Getka 1992 [38] DAS M = 15.1 Class 1 or Class 2 (1) behavioral intervention: 50 min, 6 sessions, before procedure 10 TAU 10 Mental distress (anxiety)
high: 100% carious lesion (2) cognitive-behavioral intervention: 50min, 6 sessions, before procedure 11 Pain intensity (pain experienced)
Ghoneim 2000 [39] STAI-S M = 31.9 third molar surgery hypnosis: daily listening a hypnosis-tape, 20 min, 6–8 days before procedure (see 30 TAU 30 Mental distress (anxiety)
Enqvist 1997) Pain intensity
Medication (analgesics, number of
vicodin/ibuprofen tablets)
Johnson 1992 [40] DAS M = 11.5 tooth removal (1) enhanced information: listen to an audio tape recording of general surgical 25 TAU 25 Mental distress (relaxation,
information, 6 min, before procedure anxiety)
(2) relaxation: listen to a relaxation tape, before procedure 25
(3) enhanced information + relaxation: audio tape + relaxation information, 25
before procedure
Katcher 1984 [41] – oral surgery (elective (1) distraction: contemplation of an aquarium/poster, 40 min, before procedure 8 TAU 10 Mental distress (comfort)
extraction) (2) distraction + hypnosis: contemplation of an aquarium/poster + hypnosis, 8
before procedure
Kazancioglu 2015 [42] DAS M = 11.2 third molar extraction (1) enhanced information: basic information given verbally with details of 95 TAU 103 Mental distress (anxiety)
operative procedures and recovery, before procedure Pain intensity
(2) enhanced information: basic information and a movie of a man undergoing 102
third molar surgery, 5 min, before procedure
Kazancioglu 2017 [43] dental implant surgery (1) enhanced information: basic information given verbally with details of 20 TAU 20 Mental distress (anxiety)
operative procedures and recovery, before procedure Pain intensity
(2) enhanced information: basic information and a video including a patient 20
undergoing the dental procedure (2 min), before procedure
Kim 2011 [44] DAS M = 13.3 third molar extraction music: favorite songs selected by the patient presented via headset, 23 min, 106 TAU 113 Mental distress (anxiety)
during procedure Pain intensity
Lahmann 2008 [45] STAI-S M = 41.9 restorative treatment, (1) relaxation: brief (functional) relaxation, during procedure 29 TAU 30 Mental distress (anxiety)
high: 17.2% only filling (2) music: during procedure 28
(continued on next page)
Journal of Dentistry 69 (2018) 22–31
 Table 1 (continued)

Study Patients’ level of Dental procedure Description of non-pharmacological intervention n Description of control group n Outcomes
anxiety#
S. Burghardt et al.

Lai 2008 [46] STAI-S M = 50.2 root canal treatment music: selected sedative (piano) music presented via headphones, 60 min, during 22 AttCG: headphones without 22 Mental distress (anxiety)
high: 100% procedure music
Litt 1993 [47] – third molar extraction (1) relaxation: monitoring the extent of relaxation by means of a galvanic skin 19 TAU 17 Mental distress
response apparatus, 60 min, before procedure
(2) relaxation + self-efficacy enhancement, 60 min, before procedure 19
Litt 1995 [48] – third molar extraction (1) relaxation (see Litt 1993), 20 min, before procedure 46 TAU (incl. oral premed) 46 Mental distress
(2) cognitive-behavioral intervention: relaxation + self-efficacy 45
enhancement + needle desensitization, 20 min, before procedure
Logan 1995 [49] – endodontic treatment (1) cognitive intervention: sensory focusing (instructing to pay attention to the 83 TAU 83 Pain intensity
physical sensations in the mouth), 1 min, before procedure
(2) enhanced information: procedural information (brief explanation and 83
description of endodontic treatment), 2 min, before procedure
(3) cognitive intervention + enhanced information: combination of (1) and (2), 82
3 min, before procedure
Ng 2004 [50] – oral surgery (1) enhanced information: details of the dental procedures, before procedure 48 TAU (incl. basic information) 48 Mental distress (anxiety)
(2) enhanced information: details of the expected recovery, before procedure 48
(3) enhanced information: combination of (1) and (2), before procedure 48
Robertson 1991 [51] DAS M = 10.7 emergency oral surgery, behavioral treatment program: videotape with information about dental fear and 20 TAU 20 Mental distress (anxiety)
extraction behavioral interventions effective in its reduction, 25 min, before procedure Pain intensity
Ross 1981 [52] – third molar extraction hypnosis: hypnosis tape with suggestions for bleeding and edema control, before 9 AttCG: tape with information 9 Medication (analgesics)
procedure about third molars
Tanja-Dijkstra 2017 DAS M = 13.0 tooth filling and/or (1) virtual reality distraction: urban environment to be actively explored by 22 TAU 28 Mental distress
[53] extraction thumbstick controller, during procedure Pain intensity
(2) virtual reality distraction: coastal environment to be actively explored by 20
thumbstick controller, during procedure

27
Van Wijk 2008 [54] – third molar extraction enhanced information: detailed information about third molar removal in a 21 TAU 29 Mental distress (anxiety)
separate consultation with a surgeon, before procedure Pain intensity
Yi-Yueh 2014 [55] – root canal treatment (1) music: Chinese music presented via loudspeaker 60 TAU 30 Mental distress (anxiety)
(2) music: Western classic music (Mozart K.448) presented via loudspeaker 60 Pain intensity

# Measure, mean and/or proportion of highly anxious patients are given; *Length of intervention given as range or mean; AttCG = Attention control group; DAS = Dental Anxiety Scale [3]: values ≥ 13 indicate high anxiety; TAU = treatment as
usual; STAI-S = State trait anxiety inventory − state anxiety [56]: values ≥ 40 indicate high anxiety.
Journal of Dentistry 69 (2018) 22–31
S. Burghardt et al. Journal of Dentistry 69 (2018) 22–31

Fig. 2. Efficacy of non-pharmacological interventions on mental distress.

is contrary to most findings on the effects of risk of bias which com- studies [58].
monly report larger effects for studies with high risk of bias [57,58]. When comparing different types of non-pharmacological interven-
Nevertheless, there is no consensus on a specific direction of the bias tions, we could prove the efficacy of all considered types of interven-
since it depends on the type of assessment and sample of included tions as being significant. The largest effects were found for hypnosis

Fig. 3. Efficacy of non-pharmacological in-

terventions on pain and analgesic use.

28
S. Burghardt et al. Journal of Dentistry 69 (2018) 22–31

Table 2
Effects of non-pharmacological interventions on mental distress with respect to different control groups, types of outcomes, and times of perioperative outcome measurement.

Hedges’ g 95% CI k p Heterogeneity

Q df p I2

Control group#
Standard care 0.54 0.36; 0.72 25 < 0.001 70.25 24 < 0.001 66%
Attention control 0.60 −0.43; 1.63 3 0.252 18.00 2 < 0.001 89%
Outcome
Anxiety 0.65 0.41; 0.89 20 < 0.001 87.87 19 < 0.001 78%
Distress 0.39 0.17; 0.61 8 0.001 7.25 7 0.403 4%
Measurement time
Before 0.55 0.23; 0.88 9 0.001 24.95 8 0.002 68%
During 0.31 0.09; 0.52 7 0.006 8.99 6 0.174 33%
After 0.59 0.30; 0.88 16 < 0.001 68.29 15 < 0.001 78%

#No significant differences appeared between comparisons against standard care or attention control groups (p = 0.907).

though not significantly different from other types of intervention
which might be attributable to insufficient statistical power. Our results
for hypnosis are comparable to effects found in a meta-analysis on the
efficacy of hypnosis in patients undergoing surgery or medical proce-
dures [59], that included three studies also comprised in our analysis
[34,35,52]. It is known that hypnosis shows an increased efficacy in
patients with heightened suggestibility [60]. In clinical situations as-
sociated with high affective participation of the patient – as distressing
and anxiety inducing dental treatment is − suggestibility is naturally
enhanced and suggestions given to the patient are particularly effective
[61]. It has also been discussed that it is advantageous to combine ni-
trous oxide and hypnosis, because the gas has an anxiolytic effect and
increases suggestibility [62]. In clinical practice, the induction of
hypnosis can be realized by the dentist him-/herself or delegated to a
trained member of staff (hypnosis assistant). Live hypnosis and
suggestion by means of audio files do not appear to differ significantly
[59]. All studies included in our review applied hypnosis interventions
by means of pre-recorded audio files. In the light of the large effects
shown for hypnosis, using pre-recorded audio files for hypnosis might
be an economic approach in clinical practice.
We identified one study as being a negative outlier [43] with a small
negative effect being non-significant. This study provided enhanced
information to the patients with details of operative procedures pro-
vided by a video showing a patient undergoing the dental procedure.
The authors themselves conclude that detailed preoperative multimedia
information of the dental procedure is a stressful event for patients and
might increase their anxiety.
Although we found differences in our subgroup analyses, it must be
stated that finally heterogeneity could not be reduced leaving some
uncertainty about the true effect of non-pharmacological interventions.

Table 3
Subgroup analyses for primary outcome mental distress.

Hedgeś g 95% CI k p Heterogeneity pdiffe

Q df p I2

Type of interventiona 0.424

Hypnosis 1.12 0.32; 1.91 3 0.006 14.66 2 0.001 86%
Relaxation 0.60 0.23; 0.97 7 0.001 20.44 6 0.002 71%
Music 0.56 0.02; 1.10 4 0.042 16.15 3 0.001 81%
Enhanced information 0.47 0.16; 0.79 7 0.003 16.45 6 0.012 64%
Cognitive-behavioralb 0.37 0.13; 0.60 9 0.002 11.98 8 0.152 33%
Type of interventionc 0.088
Hypnosis 1.08 0.45; 1.70 4 < 0.001 14.79 3 0.002 80%
No hypnosis 0.52 0.36; 0.68 29 0.001 75.18 28 < 0.001 63%
Type of anesthesia 0.568
Regional 0.60 0.38; 0.81 22 < 0.001 74.65 21 < 0.001 72%
General 0.47 0.10; 0.84 4 0.012 7.64 3 0.054 61%
Implementationd 0.566
Dentist involved 0.52 0.22; 0.83 9 0.001 24.71 8 0.002 68%
Dentist not involved 0.64 0.40; 0.88 19 < 0.001 66.82 18 < 0.001 73%
Random allocation 0.008
Low risk 1.08 0.62; 1.54 6 < 0.001 20.74 5 0.001 76%
High risk or unclear 0.41 0.26; 0.57 20 < 0.001 35.14 19 0.013 46%
Allocation concealment 0.007
Low risk 1.09 0.63; 1.56 6 < 0.001 19.03 5 0.002 74%
High risk or unclear 0.42 0.26; 0.57 20 < 0.001 35.58 19 0.012 47%
Blinding of personnel 0.651
Low risk 0.64 0.34; 0.94 9 < 0.001 21.22 8 0.007 62%
High risk or unclear 0.55 0.30; 0.79 17 < 0.001 61.47 16 < 0.001 74%
Handling missing data 0.004
Low risk 0.81 0.51; 1.12 13 < 0.001 51.25 12 < 0.001 77%
High risk or unclear 0.31 0.17; 0.46 13 < 0.001 13.27 12 0.350 10%

a
Comparisons including a combination of different types of non-pharmacological interventions (e.g., distraction + hypnosis) were excluded from the analyses.
b
Cognitive-behavioral interventions also comprise cognitive interventions, e.g. sensory focusing, behavioral interventions and distraction.
c
Treatments including hypnosis vs. treatments not using hypnosis, combined interventions were included.
d
Dentist actively vs. not actively involved in the delivery of the non-pharmacological intervention.
e
p-value for differences between subgroups.

29
S. Burghardt et al.
Statistical heterogeneity might be accountable for the variability in the
characteristics of the included studies, commonly described as metho-
dological diversity (study design, risk of bias) and clinical diversity
(participants, interventions, outcomes) [22]. In our analyses, we could
prove risk of bias indicators to be a source of statistical heterogeneity
due to (methodological) diversity. We found no significant differences
with respect to variability in intervention type or intervention im-
plementation. Further analyses failed due to a large extent of missing
information in the trial reports or limited variability between the stu-
dies on the characteristics of interest.
Heterogeneous effects might also be a result of different patient
characteristics that should be considered in future studies as influencing
treatment efficacy. For instance, in some of the included studies
[49,51], stratified results for gender or coping preferences have been
reported, indicating a differential efficacy of non-pharmacological in-
terventions. It is also assumable that the amount of patients’ anxiety has
an impact on the effects of non-pharmacological interventions.
There is a long debate about how much diversity should be allowed
for retaining validity. One of the classical problems of meta-analytic
research is that of including “apples and oranges” in the same analysis
leading to too much variability for a homogeneous combined effect
estimate [63]. Studies should therefore be sufficiently similar to be
included in the same analysis, which is described as a “narrow” ap-
proach. On the contrary, it has been argued that “the generalisability
and usefulness of meta-analyses are increased considerably if the in-
dividual trials cover different patient populations, settings, and con-
comitant routine care” (p. 585) [64]. This approach, also named “broad
meta-analysis”, increases power, might reduce the risk of erroneous
conclusions, and can facilitate exploratory analyses for generating hy-
potheses for future research. Since we also aimed at giving an overview
of existing interventions in the field, our broad approach seems to be
justified and appropriate.
Nevertheless, the unexplained heterogeneity with the related un-
certainty about the true effect of non-pharmacological interventions
constitutes a weakness of the present review. Hence, external validity of
the results might be restricted. Moreover, internal validity of the results
might be limited since it cannot be excluded that the included studies
are prone to bias. Only two of the included studies [35,52] qualified for
a low risk of bias judgment in at least four of the five bias indicators.
This was mainly due to the rather low reporting quality, i.e. com-
pleteness and transparency, of the included studies making it difficult to
adequately evaluate potential risks of bias.
Hence, future studies on the efficacy of non-pharmacological in-
terventions in dental patients should aim for reducing risk of bias to
avoid systematic errors and to strengthen the reliability of the study
results [16]. A complete and transparent reporting of study methods
and results should further be an indispensable request to ongoing and
future studies in the field.
5. Conclusion
Based on the results we can conclude that non-pharmacological
interventions may be beneficial for reducing mental distress in patients
undergoing dental procedures and thus, could be considered as valuable
adjunct to standard care. Although results are promising and significant
positive effects on reducing mental distress were found for all types of
non-pharmacological interventions, further high quality studies are
needed to strengthen the evidence.
Acknowledgements
We kindly thank Lars Hoppe (LH) for his support in risk of bias
assessment. Our thanks also go to Karin Tanja-Dijkstra and her collea-
gues and Claas Lahmann for replying to our requests and for providing
further information. The authors declare no potential conflicts of in-
terest with respect to the authorship and/or publication of this article.
30
Journal of Dentistry 69 (2018) 22–31
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.jdent.2017.11.005.
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