Music interventions for dental anxiety in paediatric and adult patients.

Dental anxiety has been identified as a significant and common problem in both children and adults and is considered an obstacle in the provision of quality dental care by dental care providers. It is reported that one in six adults suffer from some form of dental anxiety and in children the prevalence ranges between 5.7% and 19.5%. (2) Dental anxiety denotes a state of apprehension that something dreadful is going to happen in relation to dental treatment and it is coupled with a sense of losing control. (2) Patients with dental anxiety tend to neglect dental care which poses a problem for both dentists and patients. A dentist-patient relationship dominated by severe patient anxiety may lead tomisdiagnosis and inappropriate treatment. (2) Treatment of dental anxiety and choosing the right method of managing this disorder is not always easy. Effective treatment options may include; an explanation of the treatment procedure, pharmacological strategies involving the use of benzodiazepines and antidepressants, biofeedback, hypnosis and behavioural interventions. (2) Music offers an alternate treatment option which has been used in different medical fields to meet physiological, psychological, and spiritual needs of patients. The anxiolytic effects of music have been studied in a variety of medical patients, including surgical, cardiac, and oncology patients. (2) People of any age may benefit from a music therapy programme regardless of musical skill or background. Several measures and scales have been developed to classify dentally anxious patients and to assess their level of anxiety for prevalence, aetiology and treatment studies. (2) Music is believed to reduce dental anxiety by either having a relaxing or distracting effect (or both) that in turn reduces the activity of the neuro-endocrine and sympathetic nervous systems. (2) 

Definitions 

For the purposes of this information sheet the following definitions were used (2): 

Dental anxiety is defined as an abnormal fear or dread of visiting the dentist for preventive care or therapy and unwarranted anxiety over dental procedures. 

Active music therapy is the planned and creative use of music by a music therapist to attain and maintain health and wellbeing. 

Passive music listening is the passive listening to pre-recorded music offered by healthcare professionals without the involvement of music therapist. 

Objectives 

The purpose of this Best Practice Information Sheet is to present the best available evidence on the effectiveness of music interventions on dental anxiety in paediatric and adult patients. 

Types of Intervention 

The interventions of interest were active music therapy and passive music listening throughout the dental procedure. The former involves a music therapist and interactive communication; the latter involves listening to music or passive listening to pre-recorded music offered by dental personnel. The type of music may vary (e.g., folk, contemporary, classical, lullaby). Studies including a combination of interventions where the direct effect of the music intervention cannot be determined (for e.g. relaxation therapy combined with music or pharmacological therapy with music) were excluded. Comparators included talking, placebo (headphones without music), relaxation techniques (such as progressive muscular relaxation, paced breathing etc) and pharmacological techniques (such as sedation with nitrous oxide and other anxiolytic drugs like diazepam, midazolam etc). 

Quality of the research 

Seven studies were included in the review, two RCT, four quasi-randomised, and one quasi-experimental study. (2) Four studies that claimed to be randomised failed to report the method of random allocation, hence these studies were considered as quasi-randomised studies. The approaches used by studies reporting method of randomisation were: random number table used for block random assignment and electronic spread sheet of random numbers. Only two studies attempted to determine sample size by using power analysis. 

Results 

Paediatric patients 

Upbeat music distraction vs relaxing music distraction vs no music control 

A quasi experimental study investigated the effects of music distraction on anxiety and behavior in 45 patients 4 to 6 years of age Columbus, Ohio (USA). Patients were divided into three equal groups: upbeat music distraction, relaxing music distraction and no music control. The upbeat music consisted of age-appropriate folk music songs (A Child's Celebration of Folk Music by various artists, 1996). The relaxing music was slow, 

lulling instrumental music (In the Enchanted Garden by Kevin Kern, 1996). Behaviour management techniques of tell-show-do and voice control were used, if necessary, in a conventional manner. There was no significant difference in Corah anxiety scores at either visit 1 or visit 2 among the three groups. Visit 1 was a baseline session with no music distraction or headphones used. Visit 2 was scheduled 1-2 weeks after visit 1. Children in the two music groups wore headphones whilst the control group wore headphone without music played. Measurements showed that there was no significant difference in self-reported anxiety among the three groups at visit 1 or visit 2. In addition, there was no statistically significant difference between pre- and post-operative scores in any of the groups. 

Instrumental music vs nursery rhymes vs control 

A quasi randomised controlled trial investigated the effect of music distraction in managing anxious paediatric patients and in addition compared two different types of music to ascertain the type of music most helpful for reduction of anxiety. Forty children aged between 4 and 8 years with no previous dental experience were included in the study conducted in India. Children were randomly divided into two groups initially: control group (group A) and music group. Music group was further equally divided into two groups: instrumental music group (group B) and nursery rhymes music group (group C). Patients chose their music type and listened to the music through headphones throughout the treatment during all the visits. There was statistically significant difference between the anxiety ratings among instrumental music group and nursery rhyme group, with anxiety being more in the later group. The control group showed higher mean pulse rate compared to both the music groups; however the differences were not statistically significant. There was a statistically significant difference between the mean pulse rate of the instrumental music group and nursery rhyme group, with anxiety being more in the later. 

Adult patients 

Relaxation vs music vs music with volume control vs control 

Eighty college students (40 males) who required a minimum of class II amalgam restorations were recruited for a quasi randomised controlled trial. The setting was a dental emergency school clinic in the USA. All patients were randomly assigned to one of the four groups. The groups included relaxation, music, music with volume control (second music group) and control group (treatment not specified). Relaxation involved presentation of tape-recorded relaxation instructions through ear phones worn by the patient. Music intervention included recorded music through earphones throughout the dental procedure and patient had a choice of eight musical programs ranging from classical to popular. Patients had the option to set the volume in the third group (second music group). There was a significant difference in level of anxiety between the visits for control and relaxation groups when each group was tested individually. The decrease in anxiety was not significant for both the music groups. In the group-by anxiety-by-visit analysis, the results indicated that only the high-anxiety control group and the high-anxiety relaxation group showed statistically significant decreases in rated discomfort to the second visit. A repeated measures analysis of relaxation and distraction measures by groups showed that there were significant differences in the relaxation group and the second music group. 

Music vs nitrous oxide/oxygen 

A quasi randomised controlled trial investigated the effects of music on reducing patient's fear and anxiety. Eighty male and female patients (between 18 and 65 years of age), from Utah (USA) were randomly assigned in one of eight categories. Patients in the music group had a choice of five different types of music (classical, Broadway hits, new age, country and western, and light contemporary hits). A statistically significant reduction in the level of stress in female patients was observed with music listening alone, in contrast to male patients where there was no statistically significant difference. 

Music (favourite songs from a music list) vs control 

A quasi randomised controlled trial evaluated the efficacy of musical intervention to decrease anxiety and change of vital signs in participants who underwent surgical extraction of an impacted mandibular third molar (IMTM) at the Seoul National University Dental Hospital (Korea). Participants were randomly assigned to a music treated group and a control group. Patients in the music group were asked to select at least 10 of their favourite songs from a prepared music list that included classical music, pop songs, folk songs, hymns and Korean style country songs. Throughout the dental procedure, patients in the music group had the option of controlling the volume of the music using a remote control. Patient vital signs were measured upon arrival in the operating room (baseline) and throughout the surgical procedure (beginning from local anesthetic injection to completion and suturing). Baseline vital sign measurements were similar in both the groups. The mean systolic blood pressure and diastolic blood pressure varied significantly with surgical stage for both groups. There were significant differences between music treatment group and control group with respect to heart rate and respiratory rate changes from baseline. The study showed that patients in the music treatment group had significantly lower levels of intra-operative anxiety than patients in the control group. 

Music (soothing piano music) vs control 

One randomised controlled trial investigated the effect of music on anxiety during root canal treatment. Forty four subjects between 20 and 65 years of age were randomised to music and control group. Participants in the music group were exposed to a variety of soothing piano music through headphones with adjusted volume. Participants in the control group underwent the same procedure without the evaluation of music preference and a CD of silence played during the procedure. There was a statistically significant difference in state anxiety scores between the music group and control group, anxiety levels being higher in the later group. 

Brief relaxation vs music distraction vs control 

A randomized controlled trial tested the hypothesis that brief relaxation (BR) was effective and superior to music distraction (MD) for the treatment of dental anxiety. Adult participants from a rural area in Germany were randomised to the BR, MD or control groups. Participants in control group did not receive any treatment for dental anxiety. There was a statistically significant decrease in anxiety after dental treatment in all the three groups, with the greatest decrease in the BR group. There was a relatively small decrease in anxiety after dental treatment in the control group whilst the MD group presented a statistically significant reduction in state anxiety compared to the control group. The reduction in anxiety following BR was greater than that in the control and MD groups. Stratification of anxiety levels revealed that BR was effective in alleviating state anxiety throughout all levels of dental anxiety, demonstrating the largest effect in highly anxious participants. Participants in the MD group showed reduced anxiety in the moderately anxious subgroup.