Journal of Dr. NTR University of Health Sciences

: 2022  |  Volume : 11  |  Issue : 4  |  Page : 281--287

Effect of music therapy on patients undergoing periodontal flap surgery

PG Punnyamol, Shabeer Ahamed, Greeshma Sudhakaran, M Shilpalakshmi, Hasbeena Ali, Ann Renji 
 Department of Periodontics, Malabar Dental College and Research Centre, Edappal, Malappuram, Kerala, India

Correspondence Address:
Dr. P G Punnyamol
Department of Periodontics, Malabar Dental College and Research Centre, Edappal, Malappuram, Kerala


Introduction: It is very difficult to deliver periodontal treatment to extremely anxious patients. Therefore, there is a need to find measures to reduce the anxiety levels without causing any side-effects. This study was conducted to evaluate the effect of music on the anxiety level of the patients who were undergoing periodontal flap surgery. Objective: The objective of this research was to investigate the effectiveness of music therapy on adult patients undergoing periodontal flap surgery. Methods: Ten patients admitted to the department of periodontics for periodontal surgery were recruited for this study. These patients were provided with a questionnaire including Corah Dental Anxiety Scale, prior to the periodontal surgical procedure. Vital signs (diastolic and systolic blood pressure and pulse) were also recorded before and after the procedure. Patients were asked to fill out a short questionnaire about their experience after the procedure. Results were collected and statistically analyzed. Results: Overall, the evidence points to good results for music and patient satisfaction. Indeed, the overall heart rate and blood pressure decreased over the duration of treatment. When patients were asked whether they felt relaxed as compared to the time they entered the clinic, 90% of the patients said “yes.” When patients were asked about the reduction of pain 70% of them said “yes.” When patients were asked about their experience on music therapy, most of them graded it as “Good.” Conclusion: Music can help people in being more at ease during dental care. It was found to be a non-pharmacological sedative and anxiolytic that was cost-effective, painless, and had no side-effects.

How to cite this article:
Punnyamol P G, Ahamed S, Sudhakaran G, Shilpalakshmi M, Ali H, Renji A. Effect of music therapy on patients undergoing periodontal flap surgery.J NTR Univ Health Sci 2022;11:281-287

How to cite this URL:
Punnyamol P G, Ahamed S, Sudhakaran G, Shilpalakshmi M, Ali H, Renji A. Effect of music therapy on patients undergoing periodontal flap surgery. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Mar 22 ];11:281-287
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The patient can experience fear and anxiety as a result of dental surgical procedures performed under local anesthesia.[1],[2],[3] Dental anxiety is characterized as a state in which a person is elicited and prepared for something else to happen, with a specific sense of apprehension, and is related to abnormal conditions.[4]

Anxiety is a severe condition that affects many people in daily life and in many fields of medicine, and it can lead to a number of complications. Anxiety can be alleviated by the likelihood of a successful procedure and thereby improving the patient's health, as well as by focusing the physician's attention on the treatment in order to achieve success in a limited period of time.[5]

Dental anxiety is a form of anxiety that occurs as a result of dental care. Dentophobia is a psychological bias that involves emotions like not wanting to go to the dentist, anxiety, disgust, or dislike. It is described as the patient's reactions to the specific stresses they face during dental treatment.[6],[7]

Despite recent technological advances in dentistry, anxiety and pain remain an obstacle to dental treatment and surgical procedures. The noise made when using various instruments in the mouth, the need to hold the mouth open, and the fear of needles are all factors that lead to these feelings.[8],[9]

Pressure, bleeding, rotary noise, injections, and the smell of the drugs, as well as other patients in the waiting room making noise or their previous dental experience, are all factors that contribute to anxiety. There are a few clinical options for effectively managing anxiety, including pharmacological approaches including the use of benzodiazepines and antidepressants, hypnosis, biofeedback, and others, all of which have the potential for side-effects.[10]

Regardless of the type of dental anxiety, patients with dental anxiety will exhibit certain medication refusal symptoms. Physiological symptoms, behavioral symptoms, cognitive symptoms, and emotional symptoms may all be categorized as refusal symptoms of anxiety. Physiological symptoms including dyspnea, hyperventilation, tachycardia, hypertension, elevated respiration rate, nausea, and vomiting are the most common ones that can lead to treatment failure.[11] These symptoms are the manifestation of the secretion of stress hormones such as cortisol and cathecolamine (noradrenaline and adrenaline).[12] If cortisol is the stress hormone released in response to long-term anxiety, cathecolamines are the stress hormones released in response to short-term anxiety.[13] The assessment of noradrenaline plasma level can be used as a dental anxiety measure as the anxiety during dental care falls under the category of short-term anxiety.

Dental practitioners have been attempting to apply intervention strategies that are intended to alleviate dental anxiety levels, such as hypnodontic, sedation, and sound therapy, in order to decrease the potential for these symptoms to occur and resulting in failing dental procedures. The effects of sound and music on mood and vital functions have been the subject of numerous studies and analysis.[14] Music therapy has been proposed as a way to calm the autonomic nervous system.[15] Low-pitched, slow-tempo music inhibits the nervous system's ability to control impulses that cause pain and anxiety, thereby affecting the limbic system of the brain, which is the origin of emotion and excitement.[16] While there is some research on the effects of music on patient anxiety during medical surgeries, there are limited data on the effects during peridontal surgery.[17] Music can be used in practice to improve patient experience and as an adjunct to sedation potentially.


To study the effects of music on patient anxiety levels during periodontal flap surgical procedures as a pilot study.


To study the effects of relaxing music during periodontal flap surgical procedures on:

Patients' perceived anxiety and painPhysiological parameters—mainly heart rate measured as beats per minute and systolic and diastolic blood pressure.


This pilot study was conducted on patients visiting the department of periodontology in Malabar dental college, Edappal for their treatment procedures. A total of 10 patients who were admitted to the Department of periodontology and who were in need of periodontal surgery and were randomly included in the study.

Anxiety of the patients was assessed through Pre-treatment questionnaire based on Modified Corah's Dental Anxiety Scale [Table 1], checking the blood pressure (systolic and diastolic blood pressure) and pulse rate of the patient. The pre-treatment questionnaire consisted of six questions [Table 1]. The first five questions were from the Modified Corah's Dental Anxiety scale,[18] the sixth question was self-added in the pre-treatment questionnaire considering the factors that cause anxiety having five most common options.{Table 1}

The Modified Dental Anxiety scale[18] used to assess is a brief, validated questionnaire with a 5-point likert scale responses to each question ranging from “not anxious” to “extremely anxious. The responses were scored from one to five. The score of the scale ranges from a minimum of five to a maximum of 25. Higher score denotes higher anxiety. The final assessment of anxiety levels is given by the sum of points of scale. Less than eight is considered to be no anxiety, 9–12 considered as moderate anxiety, 13–14 as high anxiety, and 15–20 as severe anxiety.[18]

An initial pulse rate and blood pressure was taken before the treatment procedure. Patients were given blutooth earphones connected to a mobile phone and the music selected for this study consisted of five tracks (1: lotus, 2: summer, 3: signs, 4: white flower, and 5: melody) composed by Stefano Crespan Shantam. The music was played on instruments. The track was set to a standardized volume and each patient was exposed to the selected track. Following this, surgical treatment was carried out. At the end of the treatment, pulse rate and blood pressure was taken. Patients were given a post-therapy feedback form [Table 2] to acknowledge their opinion on the music therapy.{Table 2}

Ethical approval for this study (IEC/02/PERI-A/MDC/2019) was provided by the institutional ethical committee of malabar dental collage and research centre, edappal on 27-11-2019.


The pre-therapy questionnaire [Table 1] was used to assess the anxiety levels of the patient and how the patient felt before coming for a dental treatment. The first five questions were from Modified Corah's Dental Anxiety Scale and the answers received were statistically calculated; it was found that 70% of the patients were severely anxious, 10% of the patients were highly anxious, and 20% patients were moderately anxious [Figure 1].{Figure 1}

The sixth question in the pretreatment questionnaire contained five options. This question assessed analysis of factors that cause anxiety before coming to the dentist. It was found that almost all the factors increase the anxiety, but noise of dental instruments was the most alarming factor. [Figure 2]{Figure 2}

Considering the pulse rate and blood pressure of the patients, the pulse and blood pressure show variations. [Figure 3] and [Figure 4].{Figure 3}{Figure 4}

Post-music feedback

The post-therapy feedback form was given to patients who were exposed to music. This feedback form was self-designed having six most relevant questions [Table 2]. The statistical analysis of the fourth question was not done as it consisted of patient's individual personal response.

The results of the statistics of the questions were as follows. When patients were asked whether they felt relaxed as compared to the time they entered the clinic, 90% of the patients said “yes” [Figure 5]a. When they were asked about the reduction of pain, most of them said “yes” [Figure 5]b. Patient's views were asked on having similar music therapy set up in other clinics too for which most of them agreed [Figure 5c]. When patients were asked about their experience on music therapy, most of them graded it as 'Good' [Figure 5]d.{Figure 5}


Dental care is considered as an invasive procedure that causes patients' anxiety. Dental treatment phobia is widespread, affecting more than half of the population. The aim of this research was to see how efficient music therapy was for patients undergoing periodontal flap surgery.

Anxiety is an important issue in the dental care of adults, children, and adolescents and dental anxiety affects 10-20% of adults and 43% of children and adolescents.[1],[2] Surgical applications in dentistry are strongly alarming. High levels of anxiety have been reported for pain before periodontal scaling/surgical treatment in patients on periodontal therapy.[3]

The periodontal surgery process and recovery time is rarely life-threatening, but the physical and psychological impact makes it a stressful condition.

The Corah Dental Anxiety Scale (CDAS) is one of the most commonly used dental anxiety scales in adults for determining dental anxiety levels. CDAS, which aims to determine the dental anxiety level, was introduced by Corah in 1969.[18] A total of four questions, the sum of the responses to the numerical answers of the person gives information about the level of dental anxiety. Corah Dental Anxiety Scale evaluates the relationship between score and dental anxiety. Corah Dental Anxiety Scale is an assessment scale with ease of application and adequate psychometric properties.[5]

In our study, severe anxiety before periodontal surgery was identified in 70% of the patients, 10% of the patients were highly anxious, 20% patients were moderately anxious, and 0% patients were not anxious [Figure 1].

The sixth question in the pretreatment questionnaire assessed analysis of factors that cause anxiety before coming to the dentist. It was found that almost all the factors increase the anxiety, but noise of dental instruments was the most alarming factor.

According to the study conducted by Muglali et al.[19] in 2008, 30% of patients undergoing oral surgery had mild, 40% moderate, 14% high, and 11% very high levels of anxiety, and only 5% of patients with no anxiety were reported.

Pharmacological interventions, non-pharmacological interventions, or a combination of the two are often used to manage dental anxiety. Benzodiazepines, nitrous oxide, general anesthesia, and other agents (chloralhydrate and hydroxyzine) are examples of pharmacological interventions.

Conscious sedation in dentistry has raised the cost of dental care while also introducing a number of negative side-effects and risks. Inhalation includes sedation (nitrogen oxide), conscious intravenous sedation and oral sedation, but their price is high. The cost of quality dental care is important for treatment compliance. As a result, alternative therapies with sedative effects have become more relevant. Non-pharmacological interventions include audiovisual distraction, virtual reality, musical distraction, strengthening, show and tell, and so on.[6],[7]

In recent years, it has been claimed that music and health care systems have a close relationship, and that music is a complementary therapy that is inexpensive, safe, and painless.[20] Music therapy is a non-pharmacological treatment that aims to maintain the well-being of people.[21]

During preoperative dental anxiety in order to combat the stress of the organism, it has been reported that blood pressure increases, heart rate is accelerated and muscles are stretched. In the studies, it is stated that music therapy allows physical and psychological reactions in the body by acting on the limbic system and stimulates the parasympathetic nervous system, and tends to cause changes in physiological findings such as blood pressure and pulse.[14]

According to the study results, systolic and diastolic blood pressure values were compared before and after music therapy. There was found to be a significant decrease in the systolic blood pressure (SBP) and diastolic blood pressure (DBP) scores, which were previously found in high levels. These results demonstrate that music therapy applied before periodontal surgery is effective in reducing systolic blood pressure and diastolic blood pressure.

Loomba et al.[22] stated that in meta-analysis of investigating the effects of music on the patient's life findings, music therapy had beneficial effects on the reduction of systolic blood pressure, diastolic blood pressure and pulse in various clinical settings such as preoperative environment and intensive care unit and these physiological changes may be the result of patient anxiety relief.

Rubalcava et al. reported that music therapy had a positive effect on the control of dental anxiety and significant differences in salivary cortisol concentration, systolic–diastolic pressure, heart rate, body temperature, and stimulated saliva flow.[23]

Wong et al.,[24] in their study, found that patients' exposure to a 30-minute tape recorder music therapy resulted in a decrease in their systolic blood pressure values. Within that, it may be stated that music therapy is an independent intervention that can be implemented to decrease the blood pressure value.

In the study, pulse rate averages were re-measured after music therapy. Korhan et al.,[25] in the study investigating the effects of music therapy on physiological symptoms of anxiety in patients receiving mechanical ventilator support, observed a reduction in the pulse rate values of the participants was reported. Yet, no statistically significant difference was observed in the lower respiratory rates and systolic and diastolic blood pressure of the patients during a comparison of study and the control groups.

Lee et al.,[26] in the study on the effects of music therapy on vital signs in patients on mechanical ventilator support, had the experiment group exposed to music for 30 minutes and their pulse rates were measured five times during the intervention. As a result of the study, it was determined that there was a decrease in the experimental group compared to the control group.

In a study conducted by Almerud et al.[27] on patients in intensive care units who were on mechanical ventilator support, the experiment group received music therapy for 60 minutes, and pulse rate values were taken during the intervention. The pulse rate values of the experimental group were found to be reduced at the end of the study. In our study, similarly, it was found to be effective in decreasing the increased pulse values due to anxiety before periodontal surgery.

A mechanism for why music may contribute to reducing anxiety is: anxiety is an emotional stress response. It is usually influenced by HPA (hypothalamus – pituitary axis) which produces cortisol stress hormone, and the sympathetic nervous system. Music may help to reduce sympathetic behavior. While listening to music can influence several cognitive processes in the brain, it can be claimed that music might reduce stress-induced thoughts and physiological activity. Some positive changes in the stress hormone, cortisol, were reported when listening to music before and during surgical therapy, which was considered stressful.[28]

This pilot study provides sufficient data to suggest further research is required into the effects of music on patient anxiety during periodontal surgical procedures. More standardized conditions are required and also a control group as a means of comparison.


According to the outcome of the research designed to investigate the effect of music therapy on vital signs of the patients before periodontal surgery, it was reported that music therapy had a positive, major influence to the vital signs of the patients. Considering the useful results available in the literature, we claim that music therapy is a cheap, pain-less, and non-adverse non-pharmacological method, which can be used to reduce anxiety prior to surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Suchetha A, Tanwar E, Darshan B, Bhat AS. Post-operative complications after periodontal surgery. Anxiety 2018;15:16.
2Boyar R, Cross M. Temperament and trait anxiety as predictors of child behavior prior to general anesthesia for dental surgery. Pediatr Dent 1997;19:427-31.
3Cohen S, Fiske J, Newton J. Behavioural dentistry: The impact of dental anxiety on daily living. Br Dent J 2000;189:385.
4Klingberg G. Dental anxiety in children and adolescent. Cognitive Behavioral Therapy for Dental Phobia and Anxiety. 2nd ed. New York: Wiley; 2013. p. 79-88.
5Hill KB, Hainsworth JM, Burke FJ, Fairbrother KJ. Evaluation of dentists' perceived needs regarding treatment of the anxious patient. Br Dent J 2008;204:E13; discussion 442-3. doi: 10.1038/sj.bdj. 2008.318.
6Leutgeb V, Übel S, Schienle A. Can you read my pokerface? A study on sex differences in dentophobia. Eur J Oral Sci 2013;121:465-70.
7Dorofeev A. Assessment of pain perception of elderly patients with different levels of dentophobia during surgical dental appointment. Asian J Pharm 2018;12.
8Asl AN, Shokravi M, Jamali Z, Shirazi S. Barriers and drawbacks of the assessment of dental fear, dental anxiety and dental phobia in children: A critical literature review. J Clin Pediatr Dent 2017;41:399-423.
9Fukayama H, Yagiela JA. Monitoring of vital signs during dental care. Int Dent J 2006;56:102-8.
10Thoma MV, Zemp M, Kreienbühl L, Hofer D, Schmidlin PR, Attin T, et al. Effects of music listening on pre-treatment anxiety and stress levels in a dental hygiene recall population. Int J Behav Med 2015;22:498-505.
11Shives LR. Basic Concept of Psychiatric-Mental Health Nursing. 8th ed. Philadelphia, Baltimore, New York, London, Buenos Aire, Hongkong, Sydney, Tokyo: Wolters Kluwer-Lippincott Williams and Wilkins; 1998.
12Indu K. Essentials of Medical Physiology. 3rd ed. E-Book, ISBN 9780080472706. India: Elsevier; 2008.
13Brooker C. Human Structure and Function: Nursing Applications in Clinical Practice. 2nd ed. Elsevier Health Sciences; 1997.
14Hosseini SE, Hosseini SA. Therapeutic effects of music: A review. Rep Health Care 2018;4:1-13.
15Tomaino CM. Music therapy and the brain. Music Therapy Handbook. New York, London: Guilford Press; 2015. p. 40-50.
16Smith FS. Music Therapy: A PACU evidence-based practice project. J Perianesth Nurs 2017;32:e54.
17Corah NL, Gale EN. Comparative study. Relaxation and Musical programming as a means of reducing psychological stress during dental procedures. J Am Dent Assoc 1981;103:232–4.
18Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc 1978;97:816-9.
19Muglali M, Komerik N. Factors related to patients' anxiety before and after oral surgery. J Oral Maxillofac Surg 2008;66:870-7.
20Bradt J, Teague A. Music interventions for dental anxiety. Oral Dis 2018;24:300-6.
21Goettems ML, Zborowski EJ, dos Santos Costa F, Costa VP, Torriani DD. Nonpharmacologic intervention on the prevention of pain and anxiety during pediatric dental care: A systematic review. Acad Pediatr 2017;17:110-9.
22Loomba RS, Arora R, Shah PH, Chandrasekar S, Molnar J. Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: A meta-analysis. Indian Heart J 2012;64:309-13.
23Mejía-Rubalcava C, Alanís-Tavira J, Mendieta-Zerón H, Sánchez-Pérez L. Changes induced by music therapy to physiologic parameters in patients with dental anxiety. Complementary Therapies in Clinical Practice 21;282-6. doi: 10.1016/j.ctcp.2015.10.005.
24Wong H, Lopez-Nahas V, Molassiotis A. Effects of music therapy on anxiety in ventilator-dependent patients. Heart Lung 2001;30:376-87.
25Korhan EA, Khorshid L, Uyar M. The effect of music therapy on physiological signs of anxiety in patients receiving mechanical ventilatory support. Clin J Oncol Nurs 2011;20:1026-34.
26Lee OK, Chung YF, Chan MF, Chan WM. Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: A pilot study. Clin J Oncol Nurs 2005;14:609-20.
27Almerud S, Petersson K. Music therapy—A complementary treatment for mechanically ventilated intensive care patients. Intensive Crit Care Nurs 2003;19:21-30.
28Thoma MV, La Marca R, Brönnimann R, Finkel L, Ehlert U, Nater UM. The effect of music on the human stress response. PLoS One 2013;8:e70156. doi: 10.1371/journal.pone. 0070156.