Effect of Virtual Reality and Musical Earplug Temporal Tap Technique in Reduction of Gag Reflex in Pediatric Patients

DISCUSSION

Dental anxiety and fear are frequently encountered problems while treating pediatric patients. They evoke physical, cognitive, emotional, and behavioral responses in an individual, which may exaggerate any stimulus perceived by them.¹ Anxiety is an emotional state that precedes the actual encounter with the threatening stimuli, which sometimes is not even identifiable. According to Cohen et al., dental anxiety has both physiological and cognitive effects, with the physiological effects including signs and symptoms of the fright reaction and feelings of weariness following a dental appointment. The behavioral impacts include not only avoidance but also other behaviors related to eating, oral hygiene, self-medication, crying, and aggression.⁵

The prevalence of the gag reflex ranges from 15 to 34% in pediatric patients according to studies by Katsouda et al.⁶ and Gucyetmez Topal et al.⁷ Local, iatrogenic, psychological, medical, and prosthetic factors are involved in the etiology of gagging.⁸ The neurophysiology of gagging explains that receptors send impulses from the sensory neurons to the gag center in the medulla oblongata through afferent neurons. Motor neurons then transmit these impulses via efferent fibers to the throat muscles, inducing gagging.⁹ Methods involved in the management of gagging work on these sensory receptors to either mask the transmission of the gag impulse or nullify it completely.¹

Researchers have tried to classify gagging based on its etiology, risk factors, and severity. The GSI is used to classify gagging in the present study, as the index separates gagging problems into five grades of increasing severity and can be used to compare the treatment a patient requires, allowing for the assessment of the level and type of gagging management techniques needed.¹ The GPI is used to assess the amount of gag reflex mitigated, as it records the effectiveness of the management methods employed to control the gag reflex and links it to the complexity of the dental treatment.¹

Several pharmacological and nonpharmacological approaches for the management of dental anxiety have been proposed.¹⁰

These procedures, while successful, have limitations during impression making since each patient’s reaction to the procedure is instinctual. The two noninvasive treatments used in the present study were distraction¹¹ and acupuncture.¹² Therefore, the current study included a comparison of the effects of a VR device and METTT on the management of the gag reflex during impression making.

Virtual reality (VR) is a human-computer interface using three-dimensional (3D) head-mounted displays with a wide field of view.¹³ The VR device works on the principle of sensory shielding explained by McCaffery and Pasero,¹⁴ wherein the child is protected from the painful stimulus by increased sensory input from VR distractors.

The METTT is an amalgamation of distraction, sensory depression, and acupuncture. Current research suggests that oropharyngeal and ear skin sensations merge with those in the cortex and brainstem.¹⁵ The trigeminal nerve and its spinal nucleus frequently transmit oral pain to the ear (otalgia), which may be a result of the ear’s distinct representation in the somatosensory cortex. This connects the ear to the oropharyngeal regions. Additionally, it is hypothesized that activating the auricular acupuncture site can reduce muscle activation in gag reflex (GR). The external auditory canal (EAC) skin, which is innervated by the auricular branch of the vagus nerve, and the skin next to the auricle correspond to this location on the ear, which is the antigagging point 5 (innervated by the auriculotemporal branch of the mandibular division of the trigeminal nerve). In light of this, it is possible to postulate that stimulation of the EAC caused by an earplug may affect or inhibit gag reflex sensory pathways in the somatosensory cortex, brainstem, or as antidromic stimulation of the neuronal pathways of mouth-referred pain (otalgia) over the EAC skin. George Goodheart invented the temporal tap method. It is carried out by tapping (with the palm surface of the fingertips) along the temporal-sphenoidal diagnostic line,¹⁶ beginning in front of the ear and progressing forward, up, and then along the line. After each mild stroke, tapping is done forcefully enough to penetrate the hair and spring away from the head. Sensory input is provided prior to, during, and shortly following temporal tapping. It assists the patient in better understanding the supplied instructions and provides the power required to achieve the desired impact. It is especially effective in suppressing involuntary processes like gagging.¹⁵ Music was used to facilitate this distraction tool. The use of music helps reduce anxiety in pediatric patients according to studies done by Navit et al.,¹⁷ Alkahtani et al.,¹⁸ and Tshiswaka and Pinheiro.¹⁹

This research focused on children aged 6–12 years. This age range was chosen because children have established the cognitive ability to interpret instructions and distinguish emotions by the age of 6. Children older than 12 were omitted because they are generally more cooperative. This approach aligns with the study conducted by Samaleti and Jawdekar.²⁰

The Faces Version of the MCDAS was used as a subjective self-reporting tool in the present study after impression making. Self-report scales are the simplest way to determine whether a child is scared or anxious. One benefit of self-report assessments is their simplicity of administration, which requires only a short amount of time to complete. Additionally, they can gauge how patients are responding to different aspects of the dental experience. The facial version of the MCDAS scale was employed to minimize any bias that could have resulted from impaired cognitive function and comprehension under potentially anxiety-inducing situations.²¹

In the present study, the intragroup comparison of VR-facilitated maxillary impression making and standard mandibular impression making showed no discernible impact on the reduction in gag reflex (GPI scores). This might be because when a child uses VR, the bulky size of the gadget blocks their full field of vision, causing fear of the unknown. The technology blinds the child, preventing them from seeing or anticipating what is coming, even if the dentist has properly explained it. Statistically insignificant changes were observed in heart rate, oxygen saturation, and self-reported dental anxiety scale. This could be explained by the fact that the mandibular impression was made by a skilled and experienced operator who guided the children well and made them comfortable, using the standard method of impression making (leg-lift).⁴ Hence, VR could not show significant anxiety reduction or improve patient comfort during impression making. Since no other studies have been conducted using VR for the reduction of gag reflexes, we cannot substantiate the results of our study.

The intragroup comparison of METTT-facilitated maxillary impression making and standard mandibular impression making showed a significant reduction in heart rate. This indicates that METTT can be used to reduce anxiety during impression making. However, no significant changes were observed in GPI scores (gag reduction), oxygen saturation, or the self-reported dental anxiety scale. Partial effectiveness of METTT on anxiety was observed in our study.

Intergroup comparison for all four parameters showed no significant differences. Hence, no technique proved better than the other. Samaleti and Jawdekar.²⁰ compared the earplug and temporal tap technique with the standard distraction method for gag reflex related to maxillary impression making and concluded that the ETTT did not mitigate the gag reflex but led to a better patient experience. This was consistent with the results of the present study. To alleviate anxiety and ameliorate the gag reflex in pediatric patients, studies have been conducted using intellectual colored games,² stress balls,²² and low-level laser therapy.²³ In contrast to the current study, the authors found that these distraction tactics resulted in a significant reduction in gag reflex and anxiety.

Much research has not been conducted to assess the presence and treatment of the gag reflex in pediatric patients. As a result, this randomized clinical trial provided the information needed to prompt further investigation into evidence-based management of the gag reflex.

However, the present study’s shortcomings included not being a crossover study, having a wide age range, and the impossibility of triple blinding, which led to operator-generated biases.