Dental fear and anxiety (DFA) is a significant challenge in pediatric dentistry, affecting 10-24% of children. Anxious children avoid necessary dental treatment, impacting oral health and quality of life. Treating anxious children is more difficult for dentists, requiring more time and effort due to reduced cooperation and behavioral issues. Sensory triggers in dental settings (needle, drill, smells) contribute to anxiety. Aromatherapy and music are non-pharmacological techniques explored for anxiety reduction. Aromatherapy uses essential oils, such as Lavender and Neroli, known for their anxiolytic and analgesic properties. Lavender oil, from *Lavandula angustifolia*, contains linalool and linalyl acetate, contributing to its sedative effects. Neroli oil, from *Citrus aurantium*, contains monoterpenes like linalool and limonene, also impacting the nervous system. Music is another effective non-invasive method, inducing anxiolytic effects and improving mental skills by stimulating relaxation brain waves and increasing functional brain connectivity. While some studies have explored aromatherapy and music combined for non-invasive dental procedures, research is lacking on their efficacy during invasive procedures like anesthesia injections. This study investigated the combined effect of Lavender-Neroli aromatherapy and self-selected music on dental anxiety and pain during IANB in children.

Several studies support the effectiveness of aromatherapy via inhalation for anxiety reduction in medical and dental settings. The aroma of essential oils affects the limbic system, the brain area involved in emotion, memory, and hormone secretion. Lavender and citrus essential oils are commonly used, with evidence suggesting their anxiolytic and analgesic benefits. Similarly, numerous studies indicate music therapy's effectiveness in reducing dental anxiety. Music can stimulate relaxation brain waves, enhancing mental well-being. However, the combined use of aromatherapy and music in pediatric dentistry, especially during invasive procedures, remains under-researched, prompting this study to address this gap.

This single-blind, randomized controlled trial (RCT) with a two-arm parallel superiority design (1:1 allocation) included 56 children (6–10 years old) requiring IANB. Children were randomly assigned to either an aromatherapy with music group (n=28) or a control group (n=28). The sample size was calculated using G*Power, based on a previous study's effect size on pulse rate. Inclusion criteria included healthy children aged 6-10, no previous dental history, Frankl behavior scale score of 2, needing IANB, and sufficient cognitive skills. Exclusion criteria included parental refusal, mental/physical disabilities, respiratory issues, acoustic problems, allergies to the essential oils, or NSAID/analgesic use within 8 hours of treatment. A Lavender-Neroli oil blend (2.3 ml Lavender, 0.9 ml Neroli, diluted in 20 ml grape seed oil) was prepared. In the intervention group, children inhaled the blend via a modified nitrous oxide nasal mask with a 3D-printed box containing cotton balls soaked in the oil blend, while listening to self-selected music. The control group received a placebo (empty nasal mask). IANB was administered using 2% lidocaine with epinephrine by the same researcher. Dental anxiety was assessed using the FIS (five faces ranging from happy to sad), and pain was assessed using the Arabic version of the FLACC scale, evaluated from video recordings by three blind raters. Vital signs (heart rate, SpO2, blood pressure) were measured before and after IANB using a pulse oximeter and blood pressure monitor. Data were analyzed using SPSS 21.0 with Mann-Whitney U, Wilcoxon signed-rank, paired t-test, and independent t-tests (α = 0.05).

Fifty-six children participated (mean age 8.0 ± 1.3 years). There were no significant differences in baseline FIS scores between groups (p=0.916). After anesthesia, the aromatherapy group showed significantly lower FIS scores (p=0.000) compared to the control group. Within-group analysis revealed a significant increase in anxiety after anesthesia in the control group (p=0.000), but no significant change in the aromatherapy group (p=1.000). Diastolic and systolic blood pressure were significantly lower, and SpO2 was significantly higher in the aromatherapy group after anesthesia (p=0.000, p=0.000, p=0.03, respectively). Heart rate showed a non-significant difference (p=0.083). In the control group, all vital signs except SpO2 increased significantly after anesthesia (p<0.05). Pairwise comparisons showed significantly lower diastolic and systolic blood pressure and heart rate in the aromatherapy group compared to the control group (p=0.000, p=0.000, p=0.000, respectively), with no significant difference in SpO2 (p=0.271). There was no significant difference in pain perception between groups (p=0.176).

This study demonstrates the effectiveness of Lavender-Neroli aromatherapy combined with self-selected music in reducing pediatric dental anxiety during IANB. The choice of essential oils was based on their known anxiolytic properties and the importance of scent acceptance for relaxation. Self-selected music was used to enhance engagement and minimize negative associations. The use of background music in the treatment room allowed for continued communication between the dentist and child, unlike headphone use which can hinder this interaction. The study used both psychological (FIS) and physiological measures (vital signs) of anxiety, providing a more comprehensive assessment. The results support the impact of aromatherapy and music on the amygdala, a key brain region in emotion processing. The essential oil components, particularly linalool, likely contributed to the anxiolytic effect through their action on the central nervous system. However, no significant difference in pain perception was observed between groups. This may be due to the short duration of the procedure and the distracting effect of the nasal mask, though the mask could affect SpO2. The findings align with previous research showing the efficacy of combined aromatherapy and music for reducing dental anxiety during non-invasive procedures, while contrasting with studies showing a less consistent effect in adults undergoing different procedures. The study's strength lies in the combined anxiety assessment and use of gas chromatography to identify essential oil components. Limitations include the lack of a control odor and the focus on anesthesia rather than longer procedures.

This study concludes that aromatherapy combined with music is an effective, low-cost, simple, and safe method for managing dental anxiety in children during IANB. Future research should explore the effects of different essential oils, music genres, and application methods during various dental procedures to further validate these findings and understand potential long-term benefits and effects. The potential for expanding this approach to longer, more complex procedures warrants investigation.

This study's limitations include the lack of a control odor to isolate the effect of aromatherapy from the change in clinic scent. The procedures were limited to anesthesia, not evaluating the effects on longer procedures. The long study period required careful maintenance of the essential oil blend to maintain its efficacy, and only self-reported anxiety was taken into account, and the sample size may have been too small to fully demonstrate effect.