ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10005-2588 |
Effectiveness of Distraction with Virtual Reality Eyewear in Managing 6–11-year-old Children with Hearing Impairment during Dental Treatment: A Randomized Controlled Trial
1–6Department of Pedodontics & Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
Corresponding Author: Kakarla Sri RojaRamya, Department of Pedodontics & Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India, Phone: +91 8985774540, e-mail: rojachowdary28@gmail.com
ABSTRACT
Aim: To assess the effectiveness of distraction with virtual reality (VR) eyewear along with modified tell-show-do (MTSD) on anxiety levels of 6–11-year-old children with hearing impairment (HI) during the noninvasive dental procedure.
Materials and methods: The randomized controlled trial included 40 children with HI aged 6–11 years requiring oral prophylaxis. The children were randomly allocated into two groups. Oral prophylaxis was carried out in both groups, where in group I (VR + MTSD, n = 20), distraction with VR eyewear was performed along with MTSD, and in group II (MTSD, n = 20), MTSD alone was used. Pre and postoperative anxiety levels were assessed using facial image scale (FIS) (subjective) and pulse rate (PR) (objective) measures. Paired t-test and unpaired t-test were used to analyze the obtained data.
Results: Postoperative (post-op) PR readings in the VR + MTSD group were reduced by 6.95, whereas it was increased in the MTSD group by 8.55, and the difference was statistically significant (p = 0.001). Post-op FIS scores were found to be reduced in the VR + MTSD group by 2.15, whereas it was increased in the MTSD group by 0.10, and the difference was statistically significant (p = 0.033).
Conclusion: Distraction using VR eyewear along with MTSD is effective in reducing anxiety levels in 6–11-year-old children with HI during noninvasive dental procedures.
Clinical significance: Hearing-impaired children are usually anxious about the unknown and have unmet oral health needs due to communication barriers. This study provides evidence that the distraction using VR eyewear along with MTSD is effective in reducing anxiety levels in children with HI.
How to cite this article: Varshitha K, Uloopi KS, Vinay C, et al. Effectiveness of Distraction with Virtual Reality Eyewear in Managing 6–11-year-old Children with Hearing Impairment during Dental Treatment: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2023;16(6):820–823.
Source of support: Nil
Conflict of interest: None
Keywords: Anxiety, Children with hearing impairment, Distraction, Facial image scale, Virtual reality
INTRODUCTION
Dental anxiety (DA) is the most challenging emotional aspect in children, which acts as an obstacle affecting the management of children in the dental office. Childhood DA has also been related to poor oral health outcomes and leads to a greater need for expensive specialist dental treatment.1 Children with special healthcare needs are much more vulnerable to DA because of the communication barriers, and the prevalence of DA among them is high (17.2%) compared to normal children (5.7–20.2%).2–4
Hearing impairment (HI) refers to a condition in which an individual has either profound HI or a less severe disability to detect audible frequencies. HI children are usually anxious about the unknown, which could be the major reason for not seeking dental care, which results in unmet oral health needs, leading to deterioration of oral health over a period of time.5 Management of such children in dental offices requires effective strategies and aids.
Distraction is a non-pharmacological behavior management method that is widely used and accepted for the effective reduction of anxiety in children during dental treatment.6 Distraction can be achieved by various means in the dental office. VR is fast catching up in today’s world, which refers to a human-computer interface that allows the user to interact dynamically with the virtual world, which is essentially a computer-generated environment.7 It is learnt that the concept of VR is effectively utilized for distraction in children during dental treatment. Since children with HI can visualize, it was thought that VR eyewear could be an effective tool for distraction in them. Hence, the present study was carried out with an aim to assess the effectiveness of distraction with VR eyewear along with MTSD on anxiety levels of 6–11-year-old children with HI while performing noninvasive dental procedures.
MATERIALS AND METHODS
The study was carried out from March to May 2021. The clinical study design was reviewed and approved by the Institutional Ethical Committee (VDC/IEC/19/PG0/PPD/IVV/35), and the protocol was in accordance with the ethical standards laid down by the Helsinki declaration. The study was registered with the Clinical Trials Registry of India (CTRI/2021/05/033766).
The sample size calculation was done based on the results of a pilot study. G*Power 3.1.9.2 software for power analysis indicated that a total of 40 children were required (corresponding to achieve 90% power with 95% confidence). Cooperative children of age 6–11 years with a profound level of HI and in need of oral prophylaxis were included in the study. Children with any systemic diseases or those participating in any other studies were excluded from the study.
After obtaining permission from school authorities for screening, a total of 93 children with HI were screened. Level of hearing loss data was collected from school authorities. Among 93 children, 40 children who had a profound level of HI (cannot hear sound lower than 91 dB) were chosen based on predetermined inclusion and exclusion criteria. Prior to the start of the study, written informed consent was obtained from the parents and school authorities, and they were explained thoroughly regarding the nature of the study.
Computer generated block randomization technique was adopted for recruiting the participants. Allocation concealment was done with sequentially numbered non-transparent envelopes that were sealed. The participants were allocated into two groups of 20 each. In group I (VR + MTSD, n = 20), distraction with VR eyewear was performed along with MTSD while doing oral prophylaxis, whereas, in group II (MTSD, n = 20), MTSD alone was employed (Fig. 1).
Fig. 1: Consolidated Standards of Reporting Trials flow diagram
Children participating in the study were explained the procedure of oral prophylaxis using nonverbal communication, that is, MTSD (treatment procedure was explained to the children using sign language followed by showing and performing the procedure). MTSD was performed by the investigator with the help of a school teacher who was trained in sign language. The children in group I (test group) were provided with VR eyewear, which was attached to the phone, to view videos. They were given the freedom to choose what they wished to watch. The VR eyewear partially occludes the environment around the child and allows them to involve in videos being played. Oral prophylaxis was performed using hand scalers while they were watching videos. Whereas in group II (control group), MTSD (sign language) alone was used to sensitize the children, and the treatment was performed without any distraction.
In both groups, pre and post-op anxiety levels were recorded subjectively by instructing the children to express their present emotional status with the help of the facial image scale (FIS), which consisted of five different facial expressions rated 1–5, one being very happy with treatment to five being very unhappy with the treatment. Anxiety levels were assessed objectively by measuring PR using a fingertip pulse oximeter before and after the completion of the treatment.
Statistical Analysis
The obtained data were subjected to statistical analysis using parametric tests. Mean pre and post-op treatment anxiety levels were compared within the groups using paired t-test. Whereas the mean difference between pre and post-op treatment anxiety levels was compared between the groups using the unpaired t-test. A probability value of less than or equal to 0.05 and 0.000 was considered for statistical significance and high significance, respectively.
RESULTS
A total of 40 children, 20 in each group, were randomly assigned to VR + MTSD and MTSD alone. All the children received intervention without any losses. The mean age of participants was 8 years (range—6–11 years), with similar numbers of boys and girls.
Intragroup comparison of mean values of pre and post-op PR and FIS scores in the VR + MTSD group revealed that there is a significant reduction in the post-op values. The mean difference of PR was found to be 6.95 ± 10.70 (p = 0.009), and the FIS score was 2.15 ± 0.75 (p = 0.001). Whereas in the control group (MTSD alone), the post-op scores were found to be significantly increased. The mean difference of PR was found to be −8.55 ± 11.11 (p = 0.003), and the FIS score was −0.10 ± 0.97 (p = 0.649) (Table 1).
| Groups | Test parameters | Time of recording | Mean ± standard deviation (SD) | Mean difference ± SD | t- value | p-value |
|---|---|---|---|---|---|---|
| Group I (VR + MTSD) | PR | Preoperative (pre-op) | 90.45 ± 10.83 | 6.95 ± 10.70 | 2.905 | 0.009* |
| Post-op | 83.50 ± 7.21 | |||||
| FIS scores | Pre-op | 3.25 ± 0.79 | 2.15 ± 0.75 | 12.903 | 0.001* | |
| Post-op | 1.10 ± 0.31 | |||||
| Group II (MTSD) |
PR | Pre-op | 82.35 ± 11.92 | −8.55 ± 11.11 | −3.442 | 0.003* |
| Post-op | 90.90 ± 11.27 | |||||
| FIS scores | Pre-op | 2.75 ± 0.64 | −0.10 ± 0.97 | −0.462 | 0.649 | |
| Post-op | 2.85 ± 0.99 |
*Significant; paired t- test
On intergroup comparison of the mean difference of assessed parameters, there was a significant difference between the groups, suggesting VR + MTSD was more effective for distraction compared to MTSD alone (p = 0.001, 0.033) (Table 2).
| Test parameters | Groups | Mean difference ± SD | t-value | p-value |
|---|---|---|---|---|
| PR | Group I (VR + MTSD) | 6.95 ± 10.70 | 4.494 | 0.001* |
| Group II (MTSD) | −8.55 ± 11.11 | |||
| FIS scores | Group I (VR + MTSD) | 2.15 ± 0.75 | 8.238 | 0.033* |
| Group II (MTSD) | −0.10 ± 0.97 |
Unpaired t-test, *significant
DISCUSSION
Distraction is a widely used behavior management approach in pediatric dentistry that diverts a child’s attention away from those which are perceived as unpleasant procedures. Conventional distraction techniques for children include listening to music, storytelling, and watching videos, all of which serve to divert the child’s attention away from anxiety-inducing stimuli.8
In recent years, the use of VR has grown largely in the gaming and animation industry. Because of its immersive and entertaining features, this has been used in children for distraction.9 It compensates for the lack of interaction and kinesthetic stimulation in conventional audiovisual distraction techniques. VR provides more immersive images directly in front of the user’s eyes and blocks out real-world (visual, auditory, or both) stimuli. Immersion is enhanced during VR because of the head-mounted display, which prevents patients from seeing what is happening in the real world and instead directs their attention to the virtual world. It also has the benefits of ease of use, greater control of therapy, and safe in the majority of patients.10
Effective communication in the dental operatory builds a child’s trust, instils a favorable attitude, and leaves a lasting impression. Tell-show-do (TSD) technique is the universally used technique to build rapport with the child. In the present study, as HI children were considered, the TSD technique was modified (MTSD), such that sign language (nonverbal) was used to convey the information.
Cooperative children of age 6–11 years with a profound level of HI were included in the study, as this age group exhibits higher DA due to social fear, fear of injury and exposure to a new environment. At this age, children demonstrate concrete operations and have good centering capacity, and as a result, distraction works better in this age group children. Children who had previous dental histories were excluded from the study since distraction techniques were proven to be less effective in people who have experienced severe pain during their previous dental visits.
In the present study, both subjective and objective measures were assessed for anxiety. As one of the major senses is compromised in HI children, their level of understanding about the situation varies, and they may misinterpret their feelings towards the dental treatment. In order to overcome these, the objective measure was also recorded.
Facial image scale (FIS), a self-reported measure, is considered since it is easier for HI children to express their emotions nonverbally by choosing faces. It consists of five faces ranging from very happy to very unhappy. FIS has a high level of reliability and validity when compared to Venham’s picture test in young children.11,12 In the current study, anxiety was objectively measured by recording the heart rate because the increase in heart rate is the most common physiologic indicator of anxiety. Pulse oximeter was used to record PR since it provides continuous measurements.
In the current study, it was observed that children treated with VR + MTSD demonstrated a significant reduction in post-op anxiety levels. This observation can be attributed to the complete blockage of peripheral vision by VR eyewear which distracted the children away from dental treatment. Children focus more on watching videos rather than on what is being done to them. Children’s response was overwhelming to the videos watched through VR eyewear which might have made them less anxious.
Similarly, various studies have reported that the use of VR distraction was effective in reducing pain during dental treatment.13–16 Nunna et al. reported that pain experienced during local anesthesia (LA) administration was less in children distracted with VR. They stated that children didn’t perceive pain stimuli because of the increased sensory input from VR distractors.17 Whereas, Felemban et al. found that children who intervened with VR eyewear during local LA administration caused a significant increase in heart rate.18 Perhaps the administration of LA is an invasive and fear-provoking procedure. Similarly, Fakhruddin et al. also demonstrated a significant increase in the heart rate in children using video eyewear while performing pulp treatment in hearing-impaired children. They stated that video eyewear blocking the surroundings might frighten the child.5
Children who intervened with MTSD alone exhibited a significant increase in PR readings at the end of treatment. Although TSD itself is one of the behavior management methods, it is found to be not effective when used alone since children get to see the ongoing procedure, and there is no distraction to divert their attention. It is also learned that TSD is not as effective as audiovisual distraction.19,20
The study outcomes revealed that VR distraction is beneficial when treating HI children since it blocks the child’s vision from dental equipment while performing painless treatments. However, further research is recommended to find out its effectiveness as a distraction tool while performing all kinds of dental procedures in anxious children.
CONCLUSION
Distraction using VR eyewear along with MTSD was found to be effective in reducing anxiety levels in 6–11-year-old children with HI while performing noninvasive dental procedures. The MTSD technique alone was found to be less effective.
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