Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 364--369

Effects of distraction using virtual reality technology on pain perception and anxiety levels in children during pulp therapy of primary molars

Puppala Niharika, N Venugopal Reddy, P Srujana, K Srikanth, V Daneswari, K Sai Geetha 
 Department of Pediatric Dentistry, Mamata Dental College, Khammam, Telangana, India

Correspondence Address:
Dr. Puppala Niharika
Department of Pediatric Dentistry, Mamata Dental College, Khammam - 507 002, Telangana


Objective: The aim of this study was to evaluate the influence of using virtual reality (VR) eyeglasses on severity of pain and anxiety during pulp therapy in pediatric patients considering childhood anxiety-related disorders as an important confounding factor in the dental setting. Materials and Methods: A total of 40 children aged between 4 and 8 years with no previous anxiety disorder were randomly divided into two groups. The study consisted of three consecutive treatment sessions. The two groups received pulp therapy with and without VR eyeglasses in a randomized single-blind-controlled crossover fashion. Then, at the end of each session, the patients' pain severity was assessed using Wong–Baker FACES Pain Rating Scale and state anxiety was measured by Faces version of the Modified Child Dental Anxiety Scale [MCDAS]. Changes in pulse oximeter and heart rate were recorded in every 10 min. The values obtained were tabulated and subjected to statistical analysis. Results: The study shows a significant decrease in pain perception (P < 0.001) and state anxiety scores (P < 0.001) with the use of VR eyeglasses during dental treatment. Conclusion: The results of this study provide an initial encouraging for the use of VR device during dental treatment by pediatric dentists, but additional empirical research is required.

How to cite this article:
Niharika P, Reddy N V, Srujana P, Srikanth K, Daneswari V, Geetha K S. Effects of distraction using virtual reality technology on pain perception and anxiety levels in children during pulp therapy of primary molars.J Indian Soc Pedod Prev Dent 2018;36:364-369

How to cite this URL:
Niharika P, Reddy N V, Srujana P, Srikanth K, Daneswari V, Geetha K S. Effects of distraction using virtual reality technology on pain perception and anxiety levels in children during pulp therapy of primary molars. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2021 Jan 15 ];36:364-369
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Oral health is an important factor of children's health. Since ages fear of pain has been the main reason children avoid seeing the dentist.[1] Various studies have found the incidence of dental fear to be 20%–43% depending on the age of the child.[2],[3] The pediatric patients with his/her first visit to dentist are mostly found anxious and apprehensive because of dental equipment and the newness of the experience. Children and adults with high dental fear, may prove difficult to treat, require more time and present with behavioral problems which can result in a stressful and unpleasant experience for both, the patient as well as treating dental practitioner.[4]

Dentists have numerous techniques available to them to assist in management of child with anxiety such as tell-show-do, positive reinforcement, live modeling, contingent escape, mouth prop, voice control, physical restraints, hand-over-mouth exercise, conscious sedation, and general anesthesia. Voice control and hand-over-mouth exercise are the least accepted techniques as they are invasive, so we must provide a technique which has more acceptance of the parents and children and free from invasion and negative sights.[5]

Pain is a complex and multidimensional construct that involves sensory, emotional, and cognitive processes. These factors can modulate the experience of pain. Psychological techniques such as distraction, cognitive reappraisal, preliminary information, and hypnosis have been used for pain control. Recent dental studies have shown that distraction is a common technique used to reduce the pain reaction during short invasive procedures.[6],[7],[8] Distraction is defined as “a state of mind that draws the attention away from painful or unpleasant stimuli.” Distraction techniques tax the patient's limited attention capacity, resulting in the withdrawal of attention away from the noxious stimulus.[9]

In recent years, there has been an increase in behavioral research in virtual reality (VR) and virtual world. VR technology was solely recognized for its entertainment value; however, in the past 10 years, its application has been expanded to a variety of clinical areas, including pain management and treatment of psychiatric disorders.[10],[11] VR utilizes advanced technologies to create virtual environments (VEs) which immerse in a simulated world. The virtual private theater system (VPTS) is viewed with video glasses that integrate video storage, playing, and display in one digital broadcast, earphones are provided for sound. Literature review reveals sparse investigations regarding studies evaluating the effect of VR distraction on the pain perception and state anxiety in children considering primary childhood anxiety disorders as an important confounding variable. The aim of this study was to assess whether VR distraction is effective in reducing pain and anxiety in pediatric patients during pulp therapy.

 Materials and Methods

This single-blind, crossover clinical trial study was carried out in the Department of Pediatric Dentistry at Mamata dental college, Khammam. The participants consisted of 40 children between 4 and 8 years of age who came for routine dental care. Inclusion criteria were the children who did not have anxiety disorders at the first attendance according to SCARED questionnaire, first attendance and presence of at least two carious mandibular primary molars requiring pulp therapy and falling under the category of Frankl's behavior rating 2, that is, negative for preventing bias between the two groups. An exclusion criterion included patients with any visual or auditory deficits. From the 110 children screened, 40 children who met the inclusion criteria were randomly distributed equally into two groups using the stratified random selection method.

There was a random distribution of 40 (n = 40) patients into one of two groups, of 20 patients each. Both the treatment groups had undergone pulp therapy treatment during the session II and III. Participants assigned in Group A underwent treatment with VR device during the session II, but during the treatment session III, the same group underwent treatment without using VR device. Participants in Group B were not allowed to use VR device during the session II, but during the treatment session III, the same group underwent treatment with VR device.

The treatment was done in three consecutive sessions and the procedures were carried out by one pediatric dentist. Tell-show-do technique of behavior management was carried out before starting the actual procedure. Following that, blood oxygen saturation and pulse rate were monitored and recorded throughout the procedure every 10 min using a pulse oximeter. The VR device (Google VR Box and Anti Tank Virtual Reality 3D Glasses) used during the dental procedures blocked the visual field of the child completely and had headphones to deliver the sound and connected to a player capable of playing MP4 audiovisual files. A single episode of the cartoon series “Doreman” was played for all participants throughout the study.

In the first session, all the children in both groups were explained about the device and how it will be placed during the treatment through tell-show-do technique. In the second session, VR device was introduced to the subjects in Group 1. Once VR device was adopted on the child's eyes, playing the cartoon was started. Then, topical anesthetic agent was placed by a piece of cotton roll on the injection site, and nerve block was administered followed by pulp therapy [Figure 1]. Participants in Group 2 received similar procedures without the use of VR distraction. During session III, which took place 1 week after the 2nd session, children in Group 1 had pulp therapy done on another tooth without VR device, but children in Group 2 had VR device while undergoing pulp therapy. Each therapeutic session lasted about 45 min.{Figure 1}

Faces version of the Modified Child Dental Anxiety Scale (MCDAS[f]) Questionnaire was used for evaluating state anxiety in wide age range in children during dental procedures [Figure 2]. This index is self-reported and consists of 8 questions with 5 pictorial answers for each question. Scores on the MCDAS(f) scale may range from 8 to 40, with scores below 19 indicating absence of state anxiety, scores higher than 19 indicating the presence of state anxiety and scores higher than 31, indicating severe phobic disorder.{Figure 2}

Wong–Baker Faces Pain Rating Scale was used to assess pain perceived during dental procedures [Figure 3]. It consists of number of faces ranging from happy to crying. Once the treatment was completed, the eyeglasses were removed, the anxiety and pain rating scales were explained and shown to the participants immediately after treatment and they were asked to show the face which best depicted the pain level they experienced during treatment.{Figure 3}

Data were analyzed using SPSS version 15.0 software (SPSS Inc., Chicago, USA). Fisher's exact test was used to assess gender difference between the two groups. Mann-Whitney U-test was used to compare age and anxiety disorders (SCARED) scores differences between the two groups. Paired sample and independent sample t-tests were used to assess the significance of changes during each visit. The statistical significance was set to 0.05.


Of the 40 participants enrolled in the present study, there were 22 boys and 18 girls, randomly distributed in treatment group A and B, with 20 participants in each group. The participants comprised 10 boys and 10 girls in Group 1 and 12 boys and 8 girls in Group 2, of which there were 4 dropouts after the first visit, 2 boys in each group, with no statistically significant differences between the two groups regarding gender (Fisher's exact test, P = 0.75) [Table 1].{Table 1}

The mean ages of the participants in Groups 1 and 2 were 7.17 ± 0.316 and 7.28 ± 0.300 years, respectively. No significant difference was seen in the means of ages between the two groups (P = 0.740). The mean SCARED score was 19.61 ± 0.882 in Group 1 and 17.28 ± 0.779 in Group 2. Childhood Anxiety-Related Disorders scores did not differ significantly between the two groups (Mann-Whitney U-test, P = 0.085)

In Group 1, the mean of faces scale pain scores in the second (with VR distraction) and third (without VR distraction) treatment sessions were 2.56 ± 0.390 and 5.22 ± 0.515, respectively. These values represent a statistically significant increase in pain score. In Group 2, the mean of faces scale pain score was 5.44 ± 0.682 in the first treatment session (without VR distraction), which decreased to 2.33 ± 0.370 in the second session (with VR distraction). In both groups, a statistically signifi cant difference was detected between the two treatment sessions (P < 0.001) [Table 2] and [Graph 1].{Table 2}[INLINE:1]

Similarly, in Group 1, the mean MCDAS(f) anxiety scores in the first (with VR distraction) and second (without VR distraction) treatment sessions were 14.72 ± 0.843 and 19.38 ± 0.897, respectively. These values represent a statistically significant increase in anxiety score. In Group 2, the mean MCDAS(f) anxiety scores was 19.56 ± 0.883 in the first treatment session (without VR distraction), which decreased to 14.44 ± 0.805 in the second treatment session (with VR distraction). In both groups, a statistically significant difference was detected between the two treatment sessions (P < 0.001) [Graph 2] and [Graph 3].[INLINE:2][INLINE:3]

In treatment group A, there was a statistically significant difference (P < 0.05) observed in pulse rate between the treatment session I and II. Although for Group B, there observed some positive change, that is, decrease in pulse rate between the session I and II, but when compared, the difference did not reach statistical significance (P = 0.09). Observations from [Table 3] show that there was no statistically significant difference in oxygen saturation levels between the two sessions in either of the two groups.{Table 3}


This study tested the effects of distraction using VR technology on pain perception and anxiety level in children who were primarily screened to eliminate childhood anxiety-related disorders as an important confounding factor in the dental setting. There are two kinds of anxieties; state anxiety and trait anxiety. State anxiety reflects a transitory emotional state or a condition that is characterized by subjective, consciously perceived feelings of tension and apprehension, and heightened autonomic nervous system activity. It may fluctuate and can vary in intensity. In contrast, trait anxiety refers to a general tendency to respond with anxiety to perceived threats in the environment and is a relatively stable characteristic of an individual. An individual with higher trait anxiety feels more threats in many situations than someone with low trait anxiety and does not respond well to distraction techniques.[12] Parent version of SCARED questionnaire was used to exclude the children who had anxiety disorders as a confounding effects of anxious personality on dental anxiety.

Since individuals have different pain thresholds, the present study was designed as a crossover study so that each individual would be compared with themselves in two different situations and hence the differences in pain threshold would not result in bias in presenting the results. Similar study design has been adopted by Aminabadi et al.[13] It has also been demonstrated that distraction techniques are less effective in individuals who have a previous bitter pain experience.[14] Therefore, in the present study, paricipants were excluded if they had previous invasive painful medical or dental history.

4–8 year olds were selected for the study as dental problems are difficult to treat in this age group as they exhibit more disruptive behavior and dental anxiety and are most difficult to manage.[15]

We opted three dental visits because we did not want to give local anesthesia in the first visit, at the same time, keep the number of visits to as minimum as possible to avoid patient discomfort. The three visits were in accordance with Yamini et al., 2011 and Rajwinder et al., 2015.[16],[17]

Anxiety rates were recorded by MCDAS(f). Children are limited by the level of cognitive functioning required to complete the various other numeric rating scales. As this index is self-reported one and easy for children, we have selected this. Aminabadi et al., 2012 and Fakhruddin et al., 2015 have also used this scale for recording anxiety in their studies.[13],[18]

According to McCaul and Malott, human beings have a limited capacity of attention and an individual must attend to a painful stimulus in order for it to be perceived as painful.[19] Therefore, if the individual is attending to another stimulus away from the noxious stimuli, they will perceive the painful stimulus as less intense.

Dental care demands repeated multiple visits for adequate preventive and restorative treatment. VR distraction is a relevant intervention for episodes of care in which people's previous experiences affect their behavior for future events. If a dental patient, for example, has a more positive experience of treatment due to the VR distraction intervention, that patient might have less vivid memories and as a consequence might be less likely to postpone a future dental visit.[20]

Additional benefits of VR are ease of use, greater control of the therapy, safe in majority of the patients, no need for instructing the patients and the therapeutic personnel.[21] Moreover, frequent application of the technique does not decrease its positive effects.[22] Therefore, it can easily be used in children and with some size modifications in adults. This technique of behavior management is equally well accepted by both the parents and kids which is its greatest advantage.

The results of the present study show that use of VR distraction is effective in decreasing pain perception and state anxiety level in children during routine dental treatment. Similar results have been obtained by Wiederhold et al. and Sullivan et al. who showed that VR distraction was effective in reducing pain perception and anxiety.[23],[24] The anxiety-inducing appearance of dental equipment and the child's focusing on all the details of the procedure is one of the most important reasons for stress associated with dental procedures in children.[25] Therefore, the positive effects of VR distraction on pain and anxiety in children in the present study are attributed to the complete blockage of children's visual fields and as a result to successful distraction.

VR consists of indispensable elements including a virtual world, immersion, sensory feedback, and interactivity. VR distraction is unique in that it is immersive and engaging, integrating many sensory experiences and thus capturing a greater degree of attention. Another distinguishing characteristic is that VR gives the illusion that objects which do not exist in the real world exist inside a computer-generated VE.[26]


VR distraction is a clinically viable technique with a high potential to alleviate pain and anxiety associated with various dental procedures. It is a safe and noninvasive technique that does not require any previous education and training and has lasting effects in terms of more positive memories of the treatment leading to greater willingness to return for treatment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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