Efficacy of animal-assisted therapy for the relief of dental anxiety: quantitative synthesis of clinical randomized controlled trial evidence

The aim of this systematic review was to comprehensively evaluate the efficacy of animal-assisted therapy (AAT) for alleviating dental anxiety based on clinical randomized controlled trials (RCTs), and to explore its potential implications for dental clinical practice. Following the PRISMA guidelines, inclusion criteria were defined according to the PICO framework. Four databases (PubMed, Embase, Web of Science, and The Cochrane Library) were systematically searched. Two reviewers independently completed study screening, data extraction, and risk-of-bias assessment using the revised Cochrane Risk of Bias tool (ROB 2.0). All statistical analyses were performed in Rstudio software. Subgroup meta-analyses, multiple sensitivity analyses (including alternative pre-post correlation assumptions for change-score calculations and Hartung-Knapp adjustment), and post-hoc exploratory meta-regression (limited by small study count and risk of over-fitting) were performed to investigate potential sources of heterogeneity. One crossover RCT was incorporated using only pre-crossover first-period parallel-group data. A total of 10 RCTs involving 524 patients were included. Meta-analysis showed that dog-mediated AAT was associated with reduced dental anxiety relative to control conditions (SMD = −0.95, 95% CI [−1.65; −0.24], p < 0.01), with high heterogeneity observed ( I 2 = 92%). Dog-mediated AAT also exerted beneficial effects on patients’ behavior responses, pain perception, and physiological indicators. Subgroup analyses indicated more pronounced anxiety-relieving effects among children, while limited improvement in objective anxiety indices was observed in adults despite higher patient satisfaction. Intervention timing and baseline anxiety severity could modulate treatment magnitude. We emphasize that Cohen’s SMD thresholds reflect statistical effect size instead of patient-perceivable clinical benefit. No validated minimal clinically important differences (MCID) exist for mainstream dental-anxiety scales, restricting definitive judgments regarding clinical meaningfulness. GRADE assessment yielded very-low-certainty evidence for the primary outcome. Although dog-mediated AAT appears to be a promising complementary option for dental care, especially for children aged 6–12 years without dog phobia or canine allergy, conclusions should be interpreted prudently, given the substantial clinical heterogeneity observed across intervention and comparator protocols. Future well-designed RCTs with larger sample sizes are required to resolve heterogeneity and identify optimal intervention regimens for different patient subgroups. Systematic review registration https://www.crd.york.ac.uk/prospero/view/CRD420261464388 , identifier CRD420261464388.