Devan, Hegde K, Bhat, Ballal, Rao H T, and Harshitha K: Effectiveness of virtual reality eyeglasses as a distraction technique in managing anxious paediatric patients undergoing dental treatment- A cross-sectional study


Introduction

Managing paediatric patients in dental clinic is the greatest challenge that a dentist is facing today. Dental anxiety and phobia result in avoidance of dental care. Children reporting to the dental clinic are found to be anxious as they consider the dental clinic to be an undesirable place to visit. False information from the peer groups, social media and even indirectly from the parents have created an objective fear and anxiety within many children.1

Dental anxiety is a state of apprehension that something dreadful is going to happen in relation to dental treatment and it is coupled with a sense of losing control.2 The general perceptionof dental anxiety is that it can lead to avoidance which results in lack of dental care and delay in finding suitable treatment.3, 4

Managing the behaviour and anxiety of a child by rendering additional positive experience is the primary objective of pediatric dentist and to perceive this various behaviour management techniques are used.5 These techniques are divided into two broad categories.

  1. First category consist of behavioural techniques including the tell show do (TSD), inspiration, modelling, distraction and hypnotism.

  2. The second category consists of pharmacological methods such as conscious sedation and general anaesthesia.

Among these, the distraction technique appears to be safe and cost effective.6

Distraction technique is a method of diverting a child’s attention from perceiving an unpleasant procedure. It is the most common technique used to reduce pain in short invasive dental procedures. The principle behind its effectiveness is to hinder the ability to pay attention to unpleasant stimuli during the dental procedures and switching the child’s focus to mesmerizing distracters. Distraction can be of two forms; that is active or passive. Active distraction promotes a child’s participation including various sensory components such as interactive toys, virtual reality eyeglasses, controlled breathing, and relaxation. Passive distraction includes listening to music and watching television.5

Virtual Reality refers to a human-computer interface that allows the user to interlink effectively with the computer generated environment. This technique is superior to previous distraction methods as it offers a better immersive images that shows the images in front of our eyes. It combines the audio, video and kinesthetic sensory modalities. Depending upon how captivating the presenting stimulus are, the person’s concentration will be more or less ‘drained’ from the actual world, thus reducing the attention from the real world procedure, which includes painful stimulus. Immersion is more during virtual reality(VR) because of the use of head mounted, wide field of view, three dimensional displays (HMD’s) that restricts the children from seeing the things happening in the real world and manage the focus on what’s going in the virtual world. So the child’s concentration is deviated from the surrounding world to the virtual world.7 The aim of the study is to evaluate the effect of virtual reality eyeglasses as a distraction technique in managing anxious pediatric patients undergoing dental treatment such as restoration and extraction.

Materials and Methods

A total of 148 subjects with 37 each in four groups, were selected from the OPD in the Department of Pediatric and preventive dentistry, Yenepoya Dental College, in the age ranging between 7-14years. All subjects were healthy individuals free of medical comorbidities, post traumatic stress disorder and anxiety disorders. This study was conducted after obtaining the institutional ethics committee clearance and informed written consent from the subjects or parents of the selected subject.

Parents were given a brief introduction explaining the procedure and purpose of the study.

Children’s dental anxiety was measured using Modified Dental Anxiety Scale and Pulse oximeter. The pulse rate and oxygen saturation (SPO2) was measured.

After assessing the anxiety levels of the children, children who were found to be anxious were taken for the study.

Figure 1

Virtual reality eyeglasses

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Patients were then seated for appropriate dental treatment.

Group A: included children who had to undergo extraction without virtual reality eyeglasses.

Group B: included children who had to undergo restoration without virtual reality eyeglasses.

Group C: included children who had to undergo extraction with virtual reality eye glasses.

Group D: included children who had to undergo restoration with virtual reality eye glasses.

Figure 2

Patient undergoing extraction with virtual reality eyeglasses

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Children’s anxiety was again evaluated using the Modified Dental Anxiety Scale and Pulse oximeter after dental treatment. The results obtained were then compared.

Statistical analysis

The data was collected, tabulated, and statistically analyzed using the paired t-test (IBM SPSS Statistics Version 23, IBM Corporation, New York, USA). Descriptive statistics and paired t-test were used at a significance level of P less than or equal to 0.05.

Result

Table 1

Extraction without virtual reality eyeglasses (Group A)

Mean

N

Std. Deviation

Std. Error Mean

Pulse Rate

Before

87.14

37

5.731

0.942

After

94.97

37

4.592

0.755

SPO2

Before

98.05

37

1.053

0.173

After

98.57

37

1.168

0.192

Modified Dental Anxiety Score

Before

20.30

37

1.824

0.300

After

22.30

37

2.120

0.348

Table 2

Shows the group in which the extraction was being carried out without using virtual eyeglasses

Paired Differences

Mean

Std. Deviation

95% Confidence Interval of the Difference

Sig. (2-tailed)

Lower

Upper

Pulse rate Before-after

-7.838

3.617

-9.044

-6.632

0.000

SPO2 Before - After

-0.514

0.804

-0.781

-0.246

0.000

Modified Dental Anxiety Before-after

-2.000

2.173

-2.725

-1.275

0.000

There were statistically significant changes in pulse rate, oxygen saturation (SPO2) and modified anxiety scale (p<0.05).

Table 3

Restoration without virtual reality eyeglasses (Group B)

Mean

N

Std. Deviation

Std. Error Mean

Pulse Rate

Before

89.78

37

6.281

1.033

After

92.38

37

6.339

1.042

SPO2

before

98.92

37

0.894

0.147

after

98.73

37

1.851

0.304

Modified Dental Anxiety Score

before

19.30

37

1.266

0.208

after

22.54

37

1.726

0.284

Table 4

Shows group in which the restoration was being carried out without using virtual eyeglasses

Paired Differences

Mean

Std. Deviation

95% Confidence Interval of the Difference

Sig. (2-tailed)

Lower

Upper

Pulse Rate Before-After

-2.595

1.624

-3.136

-2.053

0.000

SPO2 Before-After

0.189

1.838

-0.424

0.802

0.535

Modified Dental Anxiety Before-After

-3.243

1.832

-3.854

-2.632

0.000

There were statistically significant changes in pulse rate and modified anxiety scale (p<0.05), but there were no statistically significant changes in the oxygen saturation (SPO2) level (p>0.05).

Table 5

Extraction with virtual reality eyeglasses (Group C)

Mean

N

Std. Deviation

Std. Error Mean

Pulse Rate

Before

90.59

37

5.956

0.979

After

81.92

37

5.030

0.827

SPO2

Before

98.68

37

1.203

0.198

After

98.65

37

1.230

0.202

Modified dental anxiety score

Before

20.54

37

1.909

0.314

After

8.49

37

2.281

0.375

Table 6

Shows group in which the extraction was being carried out using virtual eyeglasses

Paired Differences

Mean

Std. Deviation

95% Confidence Interval of the Difference

Sig. (2-tailed)

Lower

Upper

Pulse rate Before-after

8.676

3.909

7.372

9.979

0.000

SPO2 Before -After

0.027

0.499

-0.139

0.193

0.744

Modified dental anxiety Before -after

12.054

2.483

11.226

12.882

0.000

There were statistically significant changes in pulse rate and modified anxiety scale (p<0.05), but there were no statistically significant changes in the oxygen saturation (SPO2) level(p>0.05).

Table 7

Restoration with virtual reality eyeglasses (Group D)

Mean

N

Std. Deviation

Std. Error Mean

Pulse Rate

Before

89.78

37

6.083

1.000

After

85.32

37

6.896

1.134

SPO2

Before

98.46

37

1.238

0.204

After

98.54

37

1.169

0.192

Modified Dental Anxiety Score

Before

21.73

37

2.009

0.330

After

9.65

37

2.781

0.457

Table 8

Shows group in which the restoration was being carried out using virtual eyeglasses

Paired Differences

Mean

Std. Deviation

95% Confidence Interval of the Difference

Sig. (2-tailed)

Lower

Upper

Pulse rate Before-after

4.459

3.388

3.330

5.589

0.000

SPO2 Before-After

-0.081

0.682

-0.309

0.146

0.474

Modified dental Anxiety Before-after

12.081

3.639

10.868

13.294

0.000

There were statistically significant changes in pulse rate and modified anxiety scale (p<0.05), but there were no statistically significant changes in the oxygen saturation (SPO2) level (p>0.05).

Figure 3

Mean value of pulse rate, oxygen saturation (spo2), modified dental anxiety scale score (MDAS) of group A (extraction without virtual reality eyeglasses)

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Figure 4

Mean value of pulse rate, oxygen saturation (spo2), modified dental anxiety scale score (MDAS) of group B (restoration without virtual reality eye glasses)

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Figure 5

Mean value of pulse rate, oxygen saturation (spo2), modified dental anxiety scale score (MDAS) of group C (extraction with virtual reality eye glasses)

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Figure 6

Mean value of pulse rate, oxygen saturation (spo2), modified dental anxiety scale score (MDAS) of group D (restoration with virtual reality eye glasses) of group D (restoration with virtual reality eye glasses)

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Figure 7

Mean pulse rate, oxygen saturation (spo2), modified dental anxiety scale (MDAS) score in each group before treatment pulse rate, oxygen saturation (spo2), modified dental anxiety scale (MDAS) score in each group before treatment

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Figure 8

Mean pulse rate, oxygen saturation (spo2), modified dental anxiety scale (MDAS) score in each group after treatment

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Discussion

Dental anxiety in children has become as a recognized potential behavioral management problem with a prevalence of 3 to 43% in various population.3, 4 Managing the behaviour and anxiety of an anxious child to become a cooperative patient is critical for the success of dental treatment.7 Diminishing a child’s anxiety about the dental treatment procedure is therefore an important in reducing apprehension that may later continue into adulthood.8 Although traditional techniques may be successful, the attitude of parents and dental professionals towards the technique is changing.7 Virtual Reality (VR) eyeglasses is a promising effective distraction technique for reducing the pain during painful dental procedures.9, 10, 11, 12

The age group of the patients selected in the present study belonged to 7–10 years as children show disruptive or negative behaviour in this age group and are difficult to manage.12 The pulse oximeter works by placing a sensor device on the extremities or a thin part of the patient’s body, usually a finger, toe or earlobe. The device passes two wavelengths of light through the body part to a photodetector.13 The sensor measures the amount of red and infrared light received by the detector and calculates the amount absorbed. The arterial blood is the only light absorbing component due to its pulsating action over time and gives it an advantage over venous blood and other components of the body which includes bone, tissue, skin, muscle and fat.13 Momentary stress or anxiety causes the body to breathe a little more shallowly. A shallow breath lowers oxygen levels in the blood, due to which the brain senses as stress. Breathing then becomes a little faster and shallower. Oxygen levels fall a little more.14

Many scales have been in use to measure dental anxiety, but many researchers have proved that Modified Dental Anxiety Scale (MDAS) is the most reliable and most acceptable scale to determine dental anxiety because of its high sensitivity and positive and negative predictive values.14

The mean pulse rate value in Group A, before extraction without virtual reality eyeglasses was 87.14 + 5.731 and after extraction without virtual reality was 94.97 ± 4.592 which was statistically significant. If the pulse rate value increases after the dental procedure relatively, it gives an idea that the child is anxious. This suggests pulse rate as an important parameter for assessing anxiety in children. The importance of pulse rate as a physiological parameter of anxiety in children was first reported by Mccarthy et al.15 The mean modified dental anxiety scale value in Group A before extraction was 20.30 + 1.824 and after extraction was 22.30+ 2.120 which was statistically significant. The mean oxygen saturation (SPO2) in Group A before extraction was 98.68+ 1.203 and after extraction was 98.65 +1.230 which was statistically significant. This results were similar to the study by Ize-Iyamu IN et al.13 Whereas in Group C the mean pulse rate value before extraction with virtual reality eyeglasses was 90.59+5.956 and after extraction with virtual reality was 81.92±5.030 which was statistically significant. The mean modified dental anxiety scale value in Group C before extraction was 20.54+ 1.909 and after extraction was 8.49+ 2.281 which was statistically significant and this is in contradictory to the study by Koticha P et al.16 The observations from our study indicated that the MDAS gave a statistically significant result. The findings showed that the virtual reality eyeglasses which can be used as audiovisual distraction technique have shown a reduction in anxiety. This was in accordance to the results been obtained by Wiederhold et al.17 and Sullivan et al.18

The mean pulse rate value in Group B, before restoration without virtual reality eyeglasses was 89.78+6.281 and after restoration without virtual reality was 92.38±6.339 which was statistically significant. Similar results were obtained by Khokhar et al.19 The mean modified dental anxiety scale value in Group B before restoration was 19.30+ 1.266 and after extraction was 22.54+1.726 which was statistically significant. The mean oxygen saturation (SPO2) in Group B before restoration was 98.92+ .894 and after restoration was 98.73+1.851 which is statistically insignificant. These results were similar to the study by Rayen et al.20 Whereas in Group D the mean pulse rate value before restoration with virtual reality eyeglasses was 89.78+6.083 and after restoration with virtual reality was 85.32±6.896 was lesser than mean pulse rate value before restoration, which was statistically significant. The mean modified dental anxiety scale value in Group D before restoration was 21.73+ 2.009 and after extraction was 9.65+ 2.781 which was statistically significant.

In the present study, VR eyeglasses showed their effectiveness in respect to pulse rate. These results were in accordance with previous studies conducted by Prabhakar et al. and Hoffman et al. who concluded that the use of audiovisual distraction during dental treatment was more effective in managing anxious children.21, 22 The reason for increased anxiety scores during the cavity preparation and restoration visit maybe due to the sound and sight of the airotor hand piece; a possibility taken into account by Kleinknecht et al.23 Anxiety levels also increased during the stressful extraction visit because patient feel more anxious about tooth removal mainly due to the sight of needles than perceiving a pain or feeling helpless.24, 1 Similar results was also observed by Baldwin et al.25 This result was true in relation to pulse rate; However, no statistically significant difference was seen in relation to oxygen saturation, Clinical signs of anxiety include an increase in the heart rate and hyperventilation.13 In the present study, no patients with hyperventilation were observed and this can be attributed to the no change in oxygen saturation of the patients before and after procedure. This findings were in accordance by Yelderman et al26 and Modified dental anxiety scale which is a reliable tool in measuring dental anxiety concludes virtual reality eyeglasses is an acceptable distraction technique in managing pediatric patient and its similar to the findings observed by Wiederhold et al.17 The distraction of children by making them watch virtual reality frees all clinicians to concentrate on their work without the need to pacify, reward, or verbally encourage

The use of AVD eyeglasses inspires pleasant memories and positive attitudes toward the dental experience.

Limitations

The virtual reality eyeglasses method has got certain limitations. Children who demonstrated uncooperative behaviour and refused treatment immediately rejected the virtual reality eyeglasses. Further, virtual reality eyeglasses are not appropriate for children who are highly vigilant and insist on controlling the situation, and also the need for maintenance and the unavailability of eyeglasses for children with small faces limit the use of virtual reality eyeglasses. Further, virtual reality eyeglasses can present as a technical obstacle that limited their access to the children’s teeth.

Conclusion

For children of all ages and temperament, the impressions of distress left by the first dental visit, as well as the experience associated with each successive dental procedure, build memories that affect conduct on upcoming appointments. From our study within the limitations, we conclude that virtual reality eyeglasses are an effective distraction technique in management of pediatric patients undergoing dental treatment.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest.

References

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Received : 03-07-2021

Accepted : 05-07-2021

Available online : 13-07-2021


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https://doi.org/10.18231/j.ijohd.2021.027


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