Dental anxiety remains a common and clinically significant problem affecting both children and adults undergoing dental treatment. It is considered a multifactorial condition associated with fear, stress, avoidance of dental care, and poorer oral health outcomes [1–5]. High levels of dental anxiety may negatively influence patient cooperation, increase treatment difficulty, prolong clinical procedures, and contribute to delayed or irregular dental attendance [1, 5, 6]. In pediatric patients, negative early dental experiences may additionally influence future attitudes toward oral healthcare and treatment acceptance [7, 8]. The etiology of dental anxiety is complex and may involve previous traumatic experiences, fear of pain, environmental stimuli, loss of control, and individual psychological characteristics [1–3]. Fear associated with local anesthesia and invasive dental procedures remains one of the most commonly reported triggers of anxiety in dental settings [9, 10]. Several contemporary anxiety-management approaches are based on behavioral conditioning and neurophysiological mechanisms, including the gate control theory of pain and related concepts of pain modulation [11, 12]. These concepts have contributed to the development of interventions aimed at modifying pain perception, emotional response, and patient attention during dental treatment. Traditionally, management of dental anxiety has relied on communication techniques, behavioral management strategies, conscious sedation, and pharmacological interventions [9, 13]. However, growing interest has recently focused on non-pharmacological and minimally invasive methods that may improve patient comfort while reducing the need for pharmacological sedation in selected patients [1, 14]. Technological advances have introduced computer-controlled local anesthetic delivery systems, needle-free anesthesia, laser-assisted procedures, virtual reality distraction, mobile applications, and sensory-adapted environments as potential adjunctive tools in anxiety management [15–32]. A growing number of studies have also investigated complementary and sensory-based interventions such as aromatherapy, breathing exercises, hypnosis, audiovisual distraction, transcutaneous electrical nerve stimulation (TENS), and animal-assisted therapy [32–50], [51–75]. Several of these approaches demonstrated beneficial effects in reducing anxiety, pain perception, and behavioral distress during dental treatment, particularly among pediatric and special care patients [27, 37, 38, 53, 66, 68, 76]. Environmental and interpersonal factors may additionally influence patient cooperation and emotional responses during dental treatment [77–81]. Studies evaluating sensory-adapted dental environments and waiting room modifications have suggested that relatively simple environmental interventions may improve patient comfort and reduce stress associated with dental visits [82–88]. Despite the increasing number of available interventions, the current evidence remains heterogeneous with respect to study design, intervention protocols, outcome assessment methods, and methodological quality. Previous reviews have evaluated selected anxiety-reduction strategies in medical and dental settings. However, comprehensive synthesis of non-pharmacological and technology-assisted interventions used specifically in contemporary dental practice remains limited [4, 45, 63, 89, 90]. In addition, newer technologies and patient-centered approaches introduced in recent years were not fully represented in earlier reviews. Therefore, the aim of this systematic review was to evaluate the effectiveness of contemporary non-pharmacological and technology-assisted interventions used to reduce dental anxiety in children and adults undergoing dental treatment. The review also aimed to assess the certainty of evidence using the GRADE approach and discuss the potential clinical and educational implications of these interventions in modern dental practice.

Dental anxiety remains a major challenge in contemporary dental practice and may negatively influence treatment acceptance, cooperation, appointment attendance, and oral health outcomes [1–6, 90]. The present systematic review evaluated a broad spectrum of non-pharmacological and technology-assisted interventions aimed at reducing anxiety in dental settings. Overall, the included studies demonstrated that many behavioral, sensory, technological, and environmental approaches may contribute to improved patient comfort and reduced procedural stress, although the certainty of evidence varied substantially across intervention categories. Computer-controlled local anesthetic delivery systems (CCLAD) were among the most consistently investigated technological approaches. Several studies demonstrated lower pain perception and reduced anxiety during local anesthesia administration compared with conventional syringes, particularly in pediatric patients. These findings may be associated with slower and more controlled anesthetic delivery, which reduces tissue pressure and injection discomfort [19–22, 91, 96–117]. Additional studies evaluating needle-free anesthesia systems and modified injection techniques also reported encouraging results [98, 102, 118, 119]. Reducing visual exposure to injection devices and minimizing injection discomfort may improve patient acceptance and cooperation during treatment. However, not all studies demonstrated uniformly positive psychological outcomes. Rizzo-Lorenzo et al. [91] reported that detailed information concerning computerized anesthesia systems did not reduce anxiety and, in some patients, increased anticipatory stress. Similar observations suggested that procedural information may either alleviate or intensify anxiety depending on communication style, content framing, and individual coping characteristics. Earlier studies also indicated that psychological stress-reduction strategies may significantly influence emotional responses during dental procedures [88, 120]. TENS and vibratory stimulation techniques were evaluated as adjunctive methods for reducing discomfort associated with local anesthesia administration [23, 24, 32]. Reductions in anxiety and fear were observed among children receiving transcutaneous electrical nerve stimulation, while vibratory stimulation techniques were associated with lower pain perception during local anesthesia administration [32, 34, 35]. These findings are consistent with the gate control theory and related concepts of pain modulation [11, 12]. Electrical stimulation may additionally influence endogenous neuropeptide release associated with pain control mechanisms [121]. Acupressure-based interventions were also investigated in several studies. Reduced need for dental injections during prosthodontic procedures and decreased anxiety levels in pediatric dental patients were reported following acupressure interventions [122, 123]. Although these approaches appear promising, the available evidence remains limited by small sample sizes and methodological heterogeneity. Laser-assisted dentistry represented another important technological category evaluated in the included studies [23, 97, 103–107]. Lower stress and anxiety levels during restorative procedures performed using Er:YAG laser systems compared with conventional rotary instrumentation were reported in several studies [23, 94]. Reduced vibration, noise, and tactile discomfort associated with laser-assisted procedures may contribute to improved patient comfort, particularly in pediatric populations. Nevertheless, despite favorable findings, widespread implementation of laser technologies may still be limited by equipment costs, availability, and the need for specialized operator training [103, 105, 107]. Behavioral and distraction-based interventions were among the most extensively studied approaches identified in this review. Audiovisual distraction, virtual reality systems, mobile applications, and robotic interaction generally demonstrated beneficial effects in reducing anxiety and improving cooperation during dental treatment, especially in children [67, 92, 93, 124–131]. Improved behavior and lower anxiety scores were reported in pediatric patients exposed to audiovisual or interactive distraction techniques [26, 36, 74, 124]. Lower anxiety levels were also observed when dental operating microscope video output was used during restorative treatment [16, 93]. Positive behavioral responses associated with robotic interaction during pediatric dental procedures were also reported. The theoretical basis for distraction techniques involves attentional diversion as an important mechanism in pain coping and anxiety reduction [92, 132]. Earlier reviews also emphasized the beneficial role of distraction techniques in pediatric procedural anxiety management [111, 112]. Mobile applications and digital preparation tools have also gained increasing attention in recent years [15]. Digital preparation applications may improve familiarity with medical and dental procedures before treatment [24, 25]. A mobile application designed for pediatric dental preparation was reported to reduce anxiety more effectively than the tell-show-do technique [26]. Virtual reality and smartphone-based interventions may therefore represent useful adjunctive strategies in pediatric dental anxiety management, although additional high-quality trials remain necessary [15].

Breathing exercises, relaxation techniques, hypnosis, and behavioral desensitization strategies were also investigated in multiple studies [40, 54, 125, 133]. Reductions in anxiety and pain perception following diaphragmatic breathing and bubble-blowing exercises during dental procedures were reported in both pediatric and adult patients [37, 42, 43]. Evidence regarding hypnosis was somewhat more heterogeneous, although several studies demonstrated reductions in procedural anxiety associated with hypnotic interventions and relaxation techniques [39, 40, 96]. Beneficial effects of behavioral rehearsal and video-based desensitization in patients with dental fear were also described [130]. Considerable variability in individual responsiveness to hypnosis may partly explain differences observed between studies [116].

Aromatherapy represented one of the most frequently investigated complementary approaches included in this review [59–63, 126]. Reductions in anxiety levels associated with lavender or orange essential oil exposure were reported in both pediatric and adult dental patients [32, 51, 63, 134, 135]. Systematic reviews further suggested that aromatherapy may provide beneficial anxiolytic effects in dental settings, although the certainty of evidence remains moderate because of heterogeneity in essential oil concentration, duration of exposure, and outcome assessment methods [44, 62]. Lavender and rosemary aromas may additionally influence mood and cognitive processing through neurophysiological mechanisms [51]. Despite generally favorable findings, aromatherapy protocols remain insufficiently standardized across studies. Environmental and interpersonal factors also appeared to influence patients’ emotional responses during dental treatment [29–31, 75–86, 120, 136]. Dentist attire, communication style, and clinic atmosphere may affect children’s cooperation and anxiety perception [76, 77, 79, 84]. Earlier observations additionally indicated that waiting room conditions and waiting times may contribute to elevated anxiety levels before treatment [134]. Sensory-adapted environments were associated with lower stress levels, particularly among children and patients with developmental disorders or sensory sensitivities [30, 31, 78, 86]. Simple modifications involving communication style, clinic atmosphere, and sensory adaptation may therefore be feasible even in routine dental practice and could contribute to improved patient comfort and cooperation. Animal-assisted interventions remain relatively underexplored in dentistry, although preliminary findings appear encouraging [67–74]. Reduced anxiety levels in children treated in the presence of therapy dogs and positive behavioral effects associated with facility dogs in dental care settings have been reported [67, 72]. Animal-assisted activities may additionally improve emotional comfort in pediatric healthcare environments [74]. At the same time, the importance of infection control, allergy prevention, and patient safety when implementing animal-assisted interventions in clinical practice has also been emphasized [73]. Several emerging or less frequently investigated interventions were also identified in the included studies. Reductions in stress and anxiety during peripheral intravenous cannulation associated with green color exposure, as well as possible antinociceptive effects of green light exposure, have been reported in preliminary investigations [135–137]. Although these findings remain preliminary, they may indicate potential directions for future research involving multisensory anxiety-reduction approaches in dentistry. From a clinical perspective, many of the evaluated interventions are relatively inexpensive, easy to implement, and may reduce the need for pharmacological sedation in selected patients. However, substantial heterogeneity between studies, differences in anxiety assessment methods, and variability in intervention protocols limit direct comparison of results. In addition, several included studies involved relatively small sample sizes or short follow-up periods, reducing the overall certainty of evidence. Primary empirical studies were included in the qualitative synthesis, while selected reviews and theoretical publications were used as background references in the Introduction and Discussion. Future research should focus on standardized outcome measures, larger multicenter randomized controlled trials, and long-term evaluation of intervention effectiveness in diverse patient populations. Further investigation is also needed to determine which combinations of behavioral, sensory, and technological interventions provide the greatest benefit in routine clinical dental practice.

Dental anxiety remains a significant challenge that may negatively affect treatment acceptance, patient cooperation, and oral health outcomes. This systematic review suggests that several non-pharmacological and physical interventions may help reduce anxiety and improve the dental experience in both pediatric and adult patients.

The strongest evidence supported computer-controlled local anesthetic delivery systems, while moderate-certainty evidence was identified for aromatherapy, audiovisual distraction, breathing exercises, and selected laser-assisted procedures. Many interventions were relatively simple, non-invasive, and feasible for implementation in routine dental practice, particularly those involving communication strategies, sensory adaptation, and behavioral support.

The findings also emphasize the importance of patient-centered communication and individualized anxiety management in contemporary dental care and education. Future studies should focus on standardized methodologies, validated anxiety assessment tools, and high-quality randomized controlled trials to strengthen the evidence base for non-pharmacological dental anxiety management.