Relaxing Music in the Dental Waiting Room Has Paradoxical Effects on Dental Anxiety in Patients with High Cognitive and Social Anxiety Sensitivity

Abstract

We sought to determine the efficacy of a music intervention in decreasing state anxiety and dental-related anxiety among patients awaiting dental clinic services, particularly those with high AS-physical concerns (i.e., fear of adverse physical consequences of arousal sensations). Forty-six dental patients between the ages of 20 and 78 years (61% female) participated in the intervention. While awaiting dental procedures, patients completed the Anxiety Sensitivity Index-3 and were exposed to music selected by experts to be either relaxing (n = 24) or neutral (n = 22). During the exposure period, participants completed the State-Trait Anxiety Inventory-State Form-6, and the Dental Anxiety Scale-4 as outcome variables. Contrary to predictions, participants exposed to relaxing (vs. neutral) music did not report lower levels of dental or state anxiety. Paradoxically, participants in the relaxing music condition showed a significant positive correlation between AS-cognitive concerns (e.g., fear of losing control) and AS-social concerns (e.g., fear of public embarrassment) with dental anxiety. Dental clinics should be more intentional in their selection of music in the waiting room, as patients with high AS-cognitive and/or high AS-social concerns may experience a paradoxical increase in dental anxiety from music intended to be relaxing.

1. Introduction

Many people fear dental care: the prevalence of clinically significant (i.e., high) dental anxiety is ~15.0–24.3% [1, 2, 3]. About 3.7% of the population meets the diagnostic criteria for the most severe form of dental anxiety, namely dental phobia. Avoidance caused by dental anxiety, including phobic-level fears, can lead to dental erosion and decay, periodontal disease, and tooth loss [4]. Poor oral health has been linked to heart and respiratory diseases, diabetes, and oral-related cancers, as well as to major mental disorders such as anxiety, depression, obsessive-compulsive disorder, and eating disorders [4, 5, 6, 7]. Indeed, high dental anxiety increases the risk for other phobias, depression, mood disorders, and other psychiatric disorders and symptoms [7].

Unlike other Blood-Injection-Injury (BII) phobias, dental phobia is marked by intense anxiety at the sight and sound of dental equipment and the dental treatment setting as opposed to the sight of blood and/or needles [8, 9]. Individuals with high dental anxiety focus attention on perceived dental threats (e.g., dental pain) and feared dental stimuli (e.g., sight of drill or dentist) [9, 10]. Dental anxiety is related to anxiety sensitivity (AS)—the specific fear of arousal-related sensations due to beliefs that anxiety-related sensations signify harmful consequences [11]. Examples of such beliefs include: a racing heart rate portending a heart attack (AS-physical concerns); dizziness signifying loss of control or “going crazy” (AS-cognitive concerns); and/or trembling eliciting social humiliation (AS-social concerns). AS is linked to, but distinct from, both state (i.e., transitory) and trait anxiety (i.e., dispositional anxiety-proneness) [12]. In a sample of military workers (88% male), AS predicted dental fears but not more general BII fears [13]. Although AS-physical (vs. cognitive or social) concerns have been found to uniquely predict pain-related anxiety [14], no studies have examined relations of AS components to dental anxiety and phobic-level fears, specifically.

Good rapport with patients, allowing them to express their fears, and talking them through procedures can reduce low to moderate dental anxiety [15, 16, 17, 18, 19]. High dental anxiety may require more intensive intervention. Cognitive-Behavioral Therapy (CBT) is highly effective [17] but requires specific training and dedicated treatment sessions [18]. More easily administered options, such as music interventions, may be preferable for dental clinics. Focusing on pre-operative music interventions, Thoma et al. [20] found that patients who listened to music (relaxing music) vs. those who did not (i.e., silence) had lower state anxiety prior to dental hygiene treatment. A meta-analysis conducted by van der Weijden et al. [21] examined the effects of playing background music specifically during dental treatment. Results showed that listening to music during dental treatment reduced state anxiety more than treatment-as-usual and that background music provided a small reduction in dental anxiety [19, 21]. Classical music and non-classical relaxing music demonstrated the strongest effects on anxiety. More recently, a study with two meta-analyses of 104 music interventions (coded separately for physiological and psychological stress-related outcomes) revealed significant beneficial effects of music as compared to control groups. Results showed a significant small-to-medium effect of music intervention on physiological outcomes (e.g., blood pressure, heart rate; d = .380) and a medium effect on psychological outcomes (e.g., state anxiety, nervousness, feelings of worry; d = .545) across various settings (e.g., mental health settings, medical settings) [22]. No significant moderating effects of intervention characteristics were found but a trend for music tempo (p = .064) indicated that music with a slow tempo (60–80 bpm) yielded somewhat larger effects than music with a faster or unspecified tempo.

To date, studies have examined the effects of music on state anxiety in the dental context, with few directly examining the effect of music on dental anxiety specifically. Furthermore, AS and its components have not been investigated as individual difference factors that might moderate susceptibility to the anxiolytic (i.e., anxiety-reducing) effects of music. Moreover, studies have been inconsistent in defining type (e.g., relaxing; neutral) and intention (e.g., distraction vs. anxiolysis) of intervention music. Norr [23] found exposure to classical music (control condition) reduced AS-cognitive concerns more than a psychological treatment (i.e., exposure to feared dissociative symptoms; active condition). It was concluded that classical music might be relaxing and, therefore, an effective state anxiety-reducing intervention for those with high AS. Accordingly, the present study explored the efficacy of an in-situ music intervention in reducing general state anxiety and specific dental anxiety among patients awaiting dental procedures. We also explored, for the first time, the potential effects of AS components (physical, cognitive, and social concerns) in moderating the hypothesized anxiety-reducing effects of music. Patients were pseudo-randomly exposed to music intended to be either relaxing or neutral, and completed validated measures of state anxiety and dental anxiety as outcomes, and of AS as a moderator of intervention effects.

Two hypotheses were proffered: (H1) Music condition would impact both state and dental anxiety, such that levels would be lower in participants exposed to relaxing (vs. neutral) music; and (H2) Music condition effects would be moderated by AS-physical concerns, with AS physical concerns positively correlating with state and dental anxiety more strongly in the neutral (vs. relaxing) music condition, due to the dampening effects of the relaxing music on state and dental anxiety, particularly among those with high AS physical concerns.

2. Method

2.1 Participants

Recruitment took place at a dental clinic in northeastern Nova Scotia. Of 57 dental clinic patients invited to participate, eight declined and 49 gave consent (86% recruitment). Three cases were removed due to incomplete answers (>20% missing data) for a final sample of 46 patients [M (SD)_age = 47.44 (15.49), range 20–78 years, 2.2% of unknown age; 89.1% White; 30.4% completed university]. Of the total sample of N = 46: 61.9% reported visiting a dentist about every 6 months; 4.8% visited once a year; 19% visited once every 2 years or less frequently; and 14.3% visited once every 5 years or less frequently. No intellectual, physical, or other mental health conditions were screened for given the scope of the study. Twenty-four (52.2%) were exposed to relaxing music and twenty-two (47.8%) were exposed to neutral music. Table 1 includes descriptive statistics and Pearson Product Moment correlations. Between-group t-tests and chi-square analyses confirmed the two music conditions did not differ significantly in age, sex, visits to dental clinic (every 6 months vs. less frequently), or levels of the three AS components.

	Music condition
	Relaxing (n = 24)		Neutral (n = 22)		Test statistics
	M	SD	M	SD	t	Χ^2	p
Age	46.25	15.46	48.81	15.79	.55	—	.59
Sex	66.7% female		57.1% female		—	.43	.55
AS-P	4.92	3.80	4.32	4.57	.49	—	.63
AS-C	2.38	2.84	3.55	3.94	−1.16	—	.25
AS-S	6.25	4.63	7.00	4.64	−.55	—	.59
DAS	9.13	3.64	9.27	4.32	−.13	—	.90
STAI-S-6	10.81	3.88	12.29	5.43	−1.07	—	.15

Table 1.

Descriptive statistics and between-group test statistics.

Note. AS-P = Anxiety Sensitivity Index-3 (ASI-3) physical concerns; AS-C = ASI-3 cognitive concerns; AS-S = ASI-3 social concerns; DAS = Dental Anxiety Scale; STAI-S-6 = State-Trait Anxiety Inventory (State Scale only). M = Mean; SD = Standard deviation.

2.2 Measures

2.2.1 Demographic information

Data collected included participant age, sex, ethnicity, education, and frequency of dental clinic visits.

2.2.2 Anxiety Sensitivity Index 3 (ASI-3)

The ASI-3 [24] is an 18-item self-report questionnaire that uses a 5-point Likert scale ranging from 0 (‘very little’) to 4 (‘very much’). It has three subscales: AS-physical concerns (i.e., fear that physical sensations portend adverse physical consequences such as heart attack or death), AS-cognitive concerns (i.e., fear that cognitive sensations signal dyscontrol), and AS-social concerns (i.e., fear that observable anxiety sensations will have adverse social consequences). Cronbach’s alphas in the present study ranged from acceptable to good (.77 for AS-physical and AS-social to 0.81 for global AS).

2.2.3 State-Trait Anxiety Inventory-State Form-6 (STAI-S-6)

The STAI-S-6 [25] is a 6-item self-report measure of state anxiety derived from the 20-item Spielberger State-Trait Anxiety Inventory-State subscale (STAI-S) [25, 26]. It is scored on a 4-point Likert scale ranging from 1 (‘not at all’) to 4 (‘very much’). Total scores can range from 6 to 24; higher scores (>12) indicate greater state anxiety [25]. The STAI-6 has demonstrated good internal consistency (Cronbach’s alpha = 0.82 [25]; 0.84 in the current study) and showed concurrent validity with the 20-item full form and 14-item short form of the STAI-S [25].

2.2.4 Dental Anxiety Scale-4 (DAS-4)

The DAS-4 [27] measures anxiety specific to dental health. It is a four-item, self-report questionnaire to which participants respond on a 5-point Likert scale ranging from 1 (‘Relaxed’) to 5 (‘So Anxious’). The sum of the item scores yields a total score that can range from 4 to 20. The DAS-4 has demonstrated good construct and content validity, internal consistency, and test-retest reliability (Cronbach’s alpha = 0.82; 0.89 in the current study) [27].

2.3 Procedure

Data collection occurred across five consecutive workdays (see Figure 1). Assignment to music condition was achieved by playing ‘relaxing’ vs. ‘neutral’ stimuli (detailed in Table 2) in the clinic waiting room on alternating days as patients arrived for their scheduled appointments. To best investigate the effects of the music intervention in the real-world context, few controls were implemented. The order of presentation of the ‘relaxing’ vs. ‘neutral’ stimuli conditions were pre-determined; the assignment of the first day as relaxing or neutral was determined arbitrarily. Participants were pseudo-randomly assigned to one of two conditions depending on when their appointment occurred. To match music condition sample sizes as closely as possible, on day 5 the ‘relaxing’ playlist was administered in the morning and the ‘neutral’ playlist in the afternoon. Patients were exposed to music stimuli upon arrival for approximately 5 minutes, then were checked in and invited to participate in the study. Willing participants provided informed consent and completed the study measures immediately following exposure to the music stimuli. No incentive was provided for participating. Music stimuli were selected based on a previous study of contrasts in structure between music used for arousal reduction vs. arousal induction [28]. In that study, 160 music selections were analyzed by three expert raters (all musical composers with doctorates) to obtain a single Relaxing/Energizing Index (REI) score for each selection. Each REI score was an average of six equally weighted musical property measurements, each comprised of the mean of three expert ratings. Intra-class correlations (ICCs) were used to assess interrater reliability (IRR) for each musical property measurement. IRR was fair for Rhythmic Definition (ICC = 0.551), good for Metric Accentuation (ICC = 0.719) and Textural Complexity (ICC = 0.670), and excellent for Relaxing vs. Energizing (ICC = 0.875), Intensity (ICC = 0.862), and Tempo (ICC = 0.822) [29]. These REI scores were used to rank the 160 music selections from those predicted to be most arousal reducing (i.e., relaxing) to most arousal inducing (i.e., energizing). For the present study, the 31 lowest-ranked selections (i.e., those with the greatest preponderance of anxiolytic musical structures) comprised the ‘relaxing’ music playlist (MRelaxing (SD) = 3.32 (0.58)) and the 27 selections closest to the median ranking comprised the ‘neutral’ music playlist (MNeutral (SD) = 4.94 (0.23); see Table 2). The difference in REI scores between the two conditions was statistically significant (t (40.33) = 14.19, p < .001; Cohen’s d = .46 (medium effect size)). [Levene’s test was significant, F = 17.62, p < .001, so the independent samples t-test was conducted with equal variances not assumed.] Each music condition playlist was loaded onto a Micro SD card and played through a speaker in the dental waiting room. The playlist for each condition was played in a continuous loop and was not restarted prior to each participant. As an awareness check, participants were asked post-treatment whether they had noticed the music; if yes, they were asked to classify the music as relaxing or neutral.

Figure 1.

Music condition design.

Relaxing music stimuli N = 31 songs				Neutral music stimuli N = 27 songs
Song title/artist	REI score	Song title/artist	REI score	Song title/artist	REI score	Song title/artist	REI score
California Stars/Billy Bragg and Wilco	4.11	Adiemus/Karl Jenkins	3.28	Don’t Stop Believin’/Journey	5.22	Something Good/alt-J	4.94
Crazy Girl/Eli Young Band	4.00	Canon in D piano music/Pachelbel	3.28	Dancin’ (Krono Remix)/Aaron Smith	5.22	Lean On (feat. M0 & DJ Snake)/Major Lazer & DJ Snake	4.89
Matilda/Alt J	3.94	Imagine/John Lennon	3.22	Blank Space/Taylor Swift	5.22	Jackie and Wilson/Hozier	4.83
A Rush of Blood to the Head/Coldplay	3.94	Lay Me Down/Sam Smith	3.22	Drops of Jupiter/Train	5.17	Chicken Fried/Zac Brown Band	4.83
The A Team/Ed Sheeran	3.89	When you Believe/Mariah Carey & Whitney Houston	3.11	Every Other Freckle/alt-J	5.17	I’m Comin’ Over/Chris Young	4.78
Basket/Dan Mangan	3.89	Between the Bars/Elliott Smith	3.06	Bleeding Out/Imagine Dragons	5.17	Yer Fall/Hey Rosetta!	4.72
Stairway to Heaven/Led Zeppelin	3.83	Nuvole Bianche/Ludovico Einaudi	3.00	Sound of your Heart/Shawn Hook	5.11	Younger - Kygo Remix/Seinabo Sey	4.67
My Kind of Crazy/Brantley Gilbert	3.83	Moonlight Sonata/Beethoven	2.94	Cheerleader/OMI	5.11	Perfect/Hedley	4.61
Small Things/Ben Howard	3.83	Love Yourself/Justin Bieber	2.94	Fitzpleasure/alt-J	5.11	Dirt Road Diary/Luke Bryan	4.50
Primavera/Ludovico Einaudi	3.72	Flume/Bon Iver	2.83	Comfort Zone/Rebelution	5.11	The Freshman/The Verve Pipe	4.50
Way it is, Way it could be/The Weather Station	3.72	After the Storm/Mumford and Sons	2.61	Welcome to New York/Taylor Swift	5.06	Arrival to Earth/Steve Jablonsky	4.50
The Girl/City and Color	3.67	Landslide/Fleetwood Mac	2.61	Sippin’ on Fire/Florida Georgia Line	5.00
Talk Me Down/Troye Sivan	3.61	Everything/Ben Howard	2.50	What do you mean?/Justin Bieber	5.00
Careless Whisper/George Michael	3.61	Claire de lune/Debussy	2.11	Puritan Heart/Matt Duncan	5.00
Photograph/Ed Sheeran	3.50	You’re The Reason I Come Home/Ron Pope	1.78	Believe/Mumford and Sons	4.94
Midnight/Coldplay	3.39			Crash & Burn/Thomas Rhett	4.94

Table 2.

Music stimuli listed by music condition.

Notes. REI = Relaxing/Energizing Index (REI); scores were a composite of six musical property ratings. Scales and anchors were as follows: Intensity, from 1 (‘Very Gentle/Soft’) to 7 (‘Very Aggressive/Loud’); Metric Accentuation, from 1 (‘Very Light’) to 7 (‘Very Well Marked’); Relaxing vs. Energizing, from 1 (‘Very Relaxing’) to 7 (‘Very Energizing’); Rhythmic Definition, from 1 (‘Very Vague’) to 7 (‘Very Salient/Prominent’); Tempo, from 1 (‘Very Slow’) to 7 (‘Very Fast’); Textural Complexity, from 1 (‘Very Simple’) to 7 (‘Very Complex’).

2.4 Data analytic strategy

We (a) tested between-group (relaxing vs. neutral) differences in demographic variables, global AS, and AS dimensions to ensure equivalence between groups; (b) examined H1 through between-group t-tests on state anxiety and dental anxiety; and (c) examined H2 through one-tailed correlations between AS dimension scores and both dental anxiety and state anxiety in each music condition. Comparisons of correlation magnitude across groups, using z-tests, were planned a priori. Given that directional predictions had been made a priori, H2 was evaluated using one-tailed tests. We also explored participants’ awareness of the presence of the music and of the music condition to which they had been assigned through between-group chi square tests on the proportions who reported being aware of the music and, of those, the proportions who reported having heard “relaxing” vs. “neutral sounding” music.

3. Results

3.1 Hypothesis testing and correlational analyses

Hypothesis 1 was not supported: no significant between-group (relaxing vs. neutral music) differences in state anxiety or dental anxiety were found. Hypothesis 2 also was not supported: AS-physical concerns were unrelated to state anxiety and dental anxiety in both music conditions. By contrast, dental anxiety was unexpectedly significantly positively correlated with both AS-cognitive and AS-social concerns in the relaxing condition but not in the neutral condition (see Table 3). Due to the null results in the neutral condition, the comparisons of correlation magnitudes across music conditions that had been planned a priori were not undertaken.

	Neutral music condition (n = 22; above diagonal)
	Age	AS-P	AS-C	AS-S	DAS	STAI-6
Age	—	−.40*	−.33	−.62**	−.15	−.16
AS-P	.58**	—	.78***	.82***	.11	.11
AS-C	.00	.29	—	.74***	.12	.09
AS-S	−.33	.13	.49*	—	.25	.18
DAS	−.13	−.01	.48**	.43*	—	.78***
STAI-S-6	−.19	−.21	.11	.27	.80***	—
	Relaxing music condition (n = 24; below diagonal)

Table 3.

Pearson Product Moment correlations, split by music condition (relaxing vs. neutral).

^*

p < .05 (one-tailed).

^**

p < .01 (one-tailed).

^***

p < .001 (one-tailed).

Note. AS-P = Anxiety Sensitivity Index-3 (ASI-3) physical concerns; AS-C = ASI-3 cognitive concerns; AS-S = ASI-3 social concerns; DAS = Dental Anxiety Scale; STAI-S-6 = State-Trait Anxiety Inventory (State Scale only).

3.2 Awareness check

Of participants who acknowledged having noticed the music (21/24 [87.5%] and 18/22 [81.8%] in the relaxing and neutral conditions, respectively), the majority classified the music they heard as “relaxing” vs. “neutral sounding” (15/21 [71.4%] and 13/18 [72.2%] in the relaxing and neutral conditions, respectively). Neither of these between-group differences were statistically significant. This null result for a between-group difference did not change when we compared the proportion of those in each condition who reported having heard music that was “relaxing” vs. “neutral sounding/not noticed” (i.e., using the number in each condition as the denominator: 15/24 (62.5%) vs. 13/22 (59.0%) in the relaxing and neutral conditions, respectively).

4. Discussion

It was expected that patients exposed to music intended to be relaxing (vs. neutral) would report lower state and dental anxiety while awaiting dental treatment. Surprisingly, music condition had no effect on state or dental anxiety, in contrast to previous studies [19, 30]. AS is known to amplify dental anxiety [31]; therefore, it had also been predicted that the magnitude of relations between AS-physical concerns and state/dental anxiety, while awaiting a dental procedure, would be largest in the ‘neutral’ music condition and dampened (or decoupled) in the ‘relaxing’ music condition. Instead, AS-cognitive and AS-social concerns were associated with increased dental anxiety in the relaxing rather than in the neutral condition. It appears that for patients with elevated AS-cognitive and AS-social concerns, hearing music judged by experts to be relaxing while awaiting dental treatment may be countertherapeutic.

These unexpected findings may reflect a phenomenon known as “relaxation induced anxiety” in the dental context—a paradoxical effect whereby physiological, behavioral, and cognitive aspects of anxiety are enhanced via relaxation techniques [32]. Our findings suggest that dental anxiety may be exacerbated by listening to ostensibly “relaxing” music while awaiting treatment among patients who fear losing control (high AS-cognitive concerns) or public humiliation (high AS-social concerns) when anxious. The anticipatory nature of fearful thoughts associated with dental anxiety may have contributed to their specific paradoxical increase in dental (vs. general state) anxiety when hearing music intended to be relaxing in the waiting room prior to dental treatment. Furthermore, fears of losing control and being viewed negatively by others may cause increased dental anxiety as these patients begin to relax and “let go” while immersed in relaxing music as they await a feared treatment in a public space. Indeed, high AS has been found to be associated with fear of the loss of vigilance that can occur during states of meditative relaxation [33].

Despite differing arousal-reducing potential between music conditions as previously judged by expert raters [28], most participants in both the ‘neutral’ and ‘relaxing’ conditions classified the stimuli they heard as “relaxing”. This could reflect differing music perception in expert vs. casual music listeners, a failed manipulation underlying the lack of a differential effect of music condition on state and dental anxiety, or an insufficiently sensitive manipulation check. Importantly, however, the differing correlations with AS dimensions between conditions suggests the two types of music stimuli did indeed produce differential effects that were dependent on levels of two specific AS components. One explanation for this paradoxical finding involves differences between emotion perception and emotion induction in response to music. These are known to be distinct processes and are therefore not always congruent [34, 35]. The majority of participants in each music condition may have classified both ‘neutral’ and ‘relaxing’ music stimuli as ‘relaxing’ based on their explicit (or conscious, effortful) perception of musical content, despite differing implicit (or automatic) effects between music conditions on the magnitude of the association between AS-cognitive/AS-social concerns and dental anxiety levels.

Music neutral in the tension–relaxation dimension of affect [36] (upon which the Relaxing/Energizing Index (REI) is based [28]) may be needed to maximally benefit dental anxiety reduction in those with high AS cognitive or social concerns. Norr [23] attributed the reduction in fear in his control condition to relaxation (an oblique reference to tension–relaxation) induced by music. Thus, it may be that Norr’s classical music playlist (comprised of selections previously found to induce mood of neutral affective valence) was also appropriately neutral in the tension-relaxation dimension of affect. This may have produced Norr’s anxiolytic effects, in line with the results of the neutral (vs. relaxing) condition in the current study. One possible explanation of the anxiolytic effects among high AS cognitive/social concern participants in the neutral vs. relaxing music condition could be distraction—which paves the way for anxiolysis. While relaxing music, like neutral music, would have a distracting effect, relaxing music might also have a counter-therapeutic paradoxical anxiety enhancement effect in those prone to relaxation-induced anxiety, making neutral music a better choice for distraction and hence dental anxiety reduction in these patients in the dental waiting room. Thus, our results highlight two potential processes at play: (1) relaxing music may paradoxically increase dental anxiety in those with high AS social or cognitive concerns; and/or (2) neutral music could be sufficient to distract and hence reduce dental anxiety in patients with high AS social or cognitive concerns.

5. Limitations and future research

Several limitations should be acknowledged. First, caution must be taken in interpreting these results as—apart from ensuring that the two music conditions did not differ significantly on several potentially important confounding variables—few controls were exerted in this study, to ensure the findings were generalizable to the naturalistic dental treatment context. Second, as music stimuli were drawn from a previous study [28] conducted with undergraduate students, the current music selections may have been perceived and responded to differently by the somewhat older participants in the current study. The relaxing and neutral music playlists were based on perceived arousal-reducing and/or arousal-increasing properties as rated by experts. However, these stimuli have yet to be experimentally validated [37] as capable of inducing their hypothesized changes in emotional arousal. It is possible that the neutral and relaxing playlists may not have been sufficiently contrasting to have had the anticipated main effects on dental and state anxiety. Playlists focused on a smaller number of the most arousal-reducing/most ‘neutral’ selections might have achieved greater contrast. Moreover, it is possible that the exposure duration of approximately 5 minutes was insufficient to induce the expected effects on dental and state anxiety. Indeed, previous studies have used exposure times lasting 15–30 minutes [36, 38]. Finally, it was not possible to determine whether both or neither music condition(s) led to reductions in dental and/or state anxiety. Feasibility constraints inherent to our real-world dental office setting precluded establishment of a pre-musical induction baseline. Future studies incorporating a no-music control group, pre-and post-assessments of state and dental anxiety, and ruling out other potentially confounding variables (e.g., mood disorders, use of other distraction techniques) are warranted.

6. Implications for group therapy

Being more intentional in selecting background music for therapeutic purposes has implications for various settings, including group therapy. Music intended to promote relaxation could induce anxiety in clients inclined to maintain vigilance (like those with high levels of AS cognitive or social concerns). Let’s imagine that a well-intentioned facilitator chooses “relaxing” (vs. neutral) music with the intention of alleviating the anxiety commonly experienced by members of a newly formed group. In approaching group therapy, it is not unusual for clients to be somewhat guarded -- wary of group therapy processes, feelings of vulnerability, and of oversharing with unfamiliar facilitator(s) and other group members. Selecting “relaxing” music, however, could have the paradoxical effect of increasing these clients’ anxiety and, thereby, impede the development of group cohesiveness. If the group was designed to explore mindfulness, the “relaxing” music could undermine clients’ early efforts to become observers of their thoughts and emotions, to let them come and go, to practice self-compassion, etc. all of which require letting one’s guard down (i.e., reducing vigilance). On the other hand, “relaxing” music might be more appropriate in later group therapy sessions when the therapeutic alliance among group members has been established and clients’ self-perceived need to maintain vigilance has diminished. Early group therapy sessions might be better served by music that is more “neutral” (neither activating nor deactivating) or by no music at all.

7. Conclusion

Many dental clinics use music to relax patients and/or provide distraction from fear-inducing sounds (e.g., dental drills). Results of the present study, however, belie the assumption that the presence of music rated as relaxing by experts will effectively relax patients while awaiting dental treatment. Up to 20% of dental patients are at heightened risk of treatment avoidance due to high AS [22]. The current results suggest that a more intentional (vs. random, i.e., relying on radio or internet playlists) approach to the selection of “neutral” music (i.e., neither extremely arousal-inducing nor arousal-reducing) may best achieve the goals of reduced dental anxiety and preventing future avoidance of dental care among high AS patients.

Acknowledgments

The authors would like to acknowledge the contributions of dental hygienist Michelle Duchovni, clinical staff, and our dental patient participants. Dr. Brad Stark, Dr. Fiona Ryan, and Dr. Colin Pridy completed music analyses [28], with additional assistance from Dr. Christopher Lively. Financial support was provided to the first author by the Nova Scotia Health Research Foundation. The last author is supported through a Tier 1 Canada Research Chair in Addictions and Mental Health.

Conflict of interest

The authors declare no conflict of interest.