The effect of aromatherapy with Lavender-Neroli oil and music in management of pediatric dental anxiety: a randomized control trial

Dental fear and anxiety (DFA) affect roughly 10–23.9% of children and can lead to avoidance of care, poorer oral health, and behavior management challenges in the clinic. Sensory triggers such as needles, drills, and smells can exacerbate anxiety. Non-pharmacologic approaches that reduce sensory stimuli, including aromatherapy and music, may help. Lavender (rich in linalool and linalyl acetate) and citrus-derived Neroli (containing linalool and limonene) are commonly used essential oils with reported anxiolytic properties. While aromatherapy and music have individually shown benefits in dental and medical contexts, only two pediatric dental studies examined their combined use during non-invasive procedures (fissure sealants). No study had evaluated their combined effect during invasive procedures like inferior alveolar nerve block (IANB) injection. The study investigated whether Lavender-Neroli aromatherapy combined with background music reduces pediatric dental anxiety and pain during IANB.

Prior research indicates that aromatherapy via inhalation can reduce anxiety in medical and dental settings with minimal side effects and low cost, potentially via olfactory pathways influencing the limbic system (amygdala) to modulate emotions and hormone secretion. Lavender essential oil (Lavandula angustifolia), rich in linalool and linalyl acetate, has anxiolytic and analgesic effects; Neroli (Citrus aurantium) contains monoterpenes like linalool and limonene with CNS effects. Music therapy can reduce dental anxiety by promoting relaxation-related brain activity and enhancing functional brain connectivity; its effects are often individualized, and self-selected music may enhance engagement and reduce negative associations. Two pediatric studies reported that combining aromatherapy and music reduced dental anxiety during non-invasive procedures, but there was a gap for invasive procedures. Mechanistic literature suggests linalool may act via GABAergic modulation and glutamatergic inhibition, while limonene may influence stress hormone pathways.

Design: Single-blind randomized controlled trial (two-arm parallel superiority design, 1:1 allocation) conducted October 2021–October 2023 at the Department of Pediatric Dentistry, Faculty of Dentistry, Damascus University, Syria. Ethics/registration: Approved by Local Research Ethics Committee (UDDS-502-220420121/SRC-3183); registered at ClinicalTrials.gov (NCT05759286); informed consent obtained from parents/guardians; conducted per Helsinki/CONSORT. Sample size: Calculated via G*Power based on prior pulse rate effect size (f=0.34, α=0.05, power=0.85), yielding total n=56. Participants: 70 assessed; 56 eligible randomized (simple randomization via random.org) to aromatherapy+music (n=28) or control (n=28). Inclusion: healthy children 6–10 years, no previous dental history, Frankl behavior scale grade 2 (positive), requiring mandibular treatment with IANB, sufficient cognition for self-report. Exclusion: parental refusal; mental/physical disabilities; respiratory disease (colds, asthma); acoustic problems; allergy to study oils; NSAIDs/analgesics within 8 h pre-treatment. Interventions: Experimental group inhaled a Lavender-Neroli blend via a modified nitrous oxide nasal mask. Blend preparation: 2.3 ml Lavender oil (100% L. angustifolia) + 0.9 ml Neroli oil (100% C. aurantium), diluted to 20 ml with grape seed carrier oil. Oils sourced from Biocham (Damascus, Syria); gas chromatography reported main constituents: Lavender—linalool 37%, camphor 11.6%, 1,8-cineole 9.9%, linalyl acetate 5.5%; Neroli—linalool 23.4%, linalyl acetate 15.5%, trans-nerolidol 12.3%, limonene 11.9%, β-pinene 7.7%. Delivery: three drops on cotton balls placed in cavities of a 3D-printed box affixed to the nasal mask port; children inhaled aroma and listened to self-chosen background music (from cartoons via Bluetooth speaker) for 5 min before and during anesthesia. Control group wore a similarly modified nasal mask with an empty 3D-printed box (placebo; no aroma); no music intervention specified beyond standard environment. Anesthesia: IANB administered by the same researcher using 2% lidocaine with 1:80,000 epinephrine and a 27-gauge needle; approximately 1 ml injected over 1 min. Outcomes: Primary—dental anxiety (Facial Image Scale, FIS) before and after anesthesia; pain during injection (FLACC objective pain scale; Arabic version; 0–10). Secondary—physiological parameters (heart rate, SpO2, diastolic and systolic blood pressure) measured at baseline and 1 min after injection. FLACC scoring performed from video recordings by three trained, blinded residents; audio removed to blind to music; both groups wore identical masks to maintain blinding. Measurement devices: pulse oximeter (Meditech Equipment, China) for HR and SpO2; digital BP monitor with elbow cuff (02 medical systems, India) for BP. Statistical analysis: SPSS 21.0; Mann–Whitney U, Wilcoxon signed-rank, paired t-test, and independent t-test; α=0.05.

Participants: n=56 (control: mean age 8.2 ± 1.3 years; 57.14% boys; aromatherapy+music: mean age 7.8 ± 1.2; 53.57% boys). Anxiety (FIS): No between-group difference at baseline (p=0.916). After anesthesia, FIS scores were significantly lower in the aromatherapy+music group vs control (p=0.000). Within-group: control anxiety increased after injection (p=0.000); aromatherapy+music showed no significant change (p=1.000). Vital signs (within-group): Aromatherapy+music—DBP decreased (baseline 64.07 ± 17.77 to 52.86 ± 16.15; p=0.000), SBP decreased (107.00 ± 20.86 to 93.54 ± 19.40; p=0.000), HR showed no significant change (95.43 ± 13.35 to 92.57 ± 15.06; p=0.083), SpO2 increased (97.39 ± 1.77 to 98.29 ± 1.12; p=0.03). Control—DBP increased (59.57 ± 11.59 to 66.61 ± 16.31; p=0.024), SBP increased (96.36 ± 9.97 to 102.61 ± 11.33; p=0.004), HR increased (92.79 ± 15.76 to 101.04 ± 19.34; p=0.000), SpO2 no significant change (97.93 ± 1.09 to 98.11 ± 1.13; p=0.485). Between-group changes (after vs baseline): ΔDBP: −11.21 ± 12.20 vs +7.04 ± 15.57 mmHg (p=0.000); ΔSBP: −13.46 ± 10.46 vs +6.25 ± 15.25 mmHg (p=0.000); ΔHR: −2.86 ± 10.17 vs +8.25 ± 8.40 bpm (p=0.000); ΔSpO2: +0.89 ± 2.06 vs +0.18 ± 1.33% (p=0.271). Pain (FLACC during injection): No significant between-group difference (aromatherapy+music 1.83 ± 1.99 vs control 3.11 ± 2.42; p=0.176). Safety: No adverse effects reported.

The combined aromatherapy (Lavender-Neroli) and background music intervention significantly reduced dental anxiety and stabilized physiologic responses (lower BP and HR) during IANB compared with placebo. The findings support the hypothesis that multimodal sensory modulation can attenuate anxiety in pediatric dental settings. Mechanistically, olfactory and auditory inputs influence the limbic system (amygdala), with music potentially suppressing amygdala activity and promoting endorphin/dopamine release, and essential oil constituents (notably linalool, linalyl acetate, and limonene) exerting anxiolytic effects via GABAergic modulation, glutamatergic inhibition, and stress hormone pathways. Self-selected music likely enhanced engagement and familiarity, minimizing negative associations and maintaining dentist–child communication by using ambient playback rather than headphones. Pain outcomes did not differ, possibly due to the brief duration of injection and attentional distraction by the mask in both groups. The results align with prior pediatric studies showing anxiety reduction with combined aromatherapy and music during non-invasive procedures, and contrast with adult lithotripsy findings where non-self-selected music and higher procedural stress may have limited efficacy. The intervention appeared safe and feasible in the dental operatory.

Aromatherapy with Lavender-Neroli oil combined with background music is an effective, low-cost, simple, and safe non-pharmacologic method to manage dental anxiety in children undergoing IANB. Future research should evaluate different essential oils, music genres, and delivery methods across various and longer dental procedures to confirm and extend these findings.

No control odor was used, so effects may partly reflect changes in clinic scent. The study focused on anesthesia injection only and did not assess longer or more complex procedures. The extended study period necessitated ensuring oil blend stability; although fresh blends were prepared biweekly and stored appropriately, variability over time cannot be fully excluded. Wearing a mask in both groups may have influenced physiological measures and pain perception.