Stress of root canal treatment in patients and dentists


Psychological stress is recognised a potential barrier to accessing dental care and root canal treatment is common intervention that may be particularly stressful for both patients and dentists. While a number of studies have examined stress in patients receiving different types of interventions the findings have been variable. In relation to dental provider stress the majority of the literature has focussed on dental students.

The aim of this review was to determine whether root canal treatment causes greater stress than other dental treatments, especially extractions, in patients and providers of dental treatment.


A review protocol was registered in the PROSPERO database. Searches were conducted in the Cochrane Library, Embase, Medline/PubMed and Scopus databases between January 1990 to January 2023. Randomised control trials (RCT), non-randomised controlled trials (nRCT), cohort studies, case-controls studies, or cross-sectional studies involving root canal treatment and measures of psychological or physiological stress and published in English were considered. Comparison procedures were broadly classified as, oral surgery, restorative and clean (routine prophylaxis and scaling, excluding subgingival debridement). One reviewer screened and selected studies. Data was abstracted and risk of bias assessed using the Cochrane domains-based tool. Meta-analyses were conducted for studies with similar methodologies and outcomes.


  • 23 studies were included with 8 studies assessing dental providers and 15 patients.
  • Only one study specified the phase or form of the root canal treatment.
  • All but 2 studies included two comparator dental treatments.
  • Restorative treatment was the most common comparator (20 studies) with oral surgery I 17 studies and cleaning in 13 studies.
  • 4 studies measured physiological stress (salivary cortisol, heart rate, oxygen saturation).
  • All other studies used a variety of psychological instruments to measure stress, 8 studies used Corah’s Dental Anxiety Scale (DAS), 5 studies the Modified Corah Dental Anxiety Scale (MDAS) with 6 using self-developed questionnaires.
  • 12 studies were considered to have a high risk of bias and 11 studies an unclear risk.
  • Meta-analysis showed that Root canal treatment produced significantly higher DAS scores than restorative treatment groups and cleaning treatments (see table below).
Comparison No. of studies Mean difference (95%CI)
Root Canal treatment v Oral surgery 3 -0.36 (-1.26 to 0.54)
Root Canal treatment v Restorative 3 1.21 (0.35 to 2.07)
Root Canal treatment v Clean 3 3.34 (2.61 to 4.07)
  • Meta-analysis also showed higher MDAS scores for root canal treatment than restorative and cleaning treatments (see table below).
Comparison No. of studies Mean difference (95%CI)
Root Canal treatment v Oral surgery 2 -0.63 (-1.43 to 0.17)
Root Canal treatment v Restorative 2 1.14 (0.54 to 1.75)
Root Canal treatment v Clean 2 0.71 (0.13 to 1.28)
  • Physiological outcomes were not reported by any of the 8 studies assessing dental providers focusing on psychological outcomes with only 3 reporting on qualified dental practitioners.


The authors concluded: –

…root canal treatment was more psychologically stressful for patients than routine restorative or cleaning procedures. However, the stress of root canal treatment relative to other dental procedures, especially extractions, was inconclusive for both dental patients and providers. Since patients regard root canal treatment as more stress-evoking than other routine dental procedures, providers should endeavour to minimise their own bias toward root canal treatment when providing adequate information for an informed treatment choice.


This review looked at the relative stress induced by root canal treatment in patient and dental provider groups compared with other dental procedures. A protocol was registered for the review and a good range of databases searched although restriction to those published in English may have excluded some relevant studies. While the included studies involve relatively good sample sizes ranging from 40 to 390 participants none of the included studies were at low risk of bias with 12 of the 23 studies (52%) being at high risk of bias.  A good narrative summary of the included studies is provided and while a number of meta-analyses were undertaken the numbers of studies contributing to the subgroup analyses was just 2-3 studies. Consequently, the overall certainty of the evidence is very-low to low.


Primary Paper

Huynh R, Peters CI, Zafar S, Peters OA. Evaluating the stress of root canal treatment in patients and dentists compared to other dental treatments: A systematic review and meta-analysis. Eur J Oral Sci. 2023 Aug;131(4):e12941. doi: 10.1111/eos.12941. Epub 2023 Jun 25. PMID: 37357152.

Review protocol on PROSPERO


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