Role of Virtual Reality in Pain Perception of Patients Following the Administration of Local Anesthesia.

BACKGROUND: Dental anxiety and anxiety-related avoidance of dental care creates significant problems for the patients and dental practitioners. Administration of local anesthesia is one of the procedures which results in increased anxiety level among patients. AIM: The aim of this study was to study the effectiveness of virtual reality (VR) as a distraction tool during the administration of local anesthesia in patients undergoing a dental procedure.
MATERIALS AND METHODS: Fifty patients were randomized into two groups, namely, control group (n = 25) and study group (n = 25). Preoperative, intra-operative, and postoperative pulse rate and oxygen saturation were measured using pulse oximeter for all the patients. Local anesthesia was administered without the use of VR for the control group and with the VR for the study group. STATISTICAL ANALYSIS: The data were evaluated using the Statistical Package for the Social Sciences 20. Student's t-test was used to compare the variables.
RESULTS: Statistically significant results were obtained for preoperative and postoperative oxygen saturation, intraoperative pulse rate, and postoperative visual analog scale pain scale.
CONCLUSION: The findings of the current study indicate that immersive VR is an effective distraction tool to alleviate the anxiety of the patient.

INTRODUCTION

Dental anxiety and anxiety-related avoidance of dental care creates significant problems for the patients and dental practitioners. Patients with dental fear tend to go to the dentist only when they experience pain, thereby increasing the chance that their visit to the dentist will involve pain. This, in turn, results in exacerbation of their anxiety. It was found that dental anxiety was ranked fifth among the most commonly feared situations.[1] Various cross-sectional studies have concluded that the prevalence of dental anxiety reduces with age.[23456] Dentists themselves suffer from heightened discomfort when treating anxious patients. Patient pain and anxiety are undesirable side effects of dental procedures which affect the willingness of the patient to undergo treatment.

Administration of local anesthesia is one of the procedures which results in increased anxiety level among patients. Analgesics have been the main solution for alleviating pain in the past. However, these medications are not always effective in alleviating the pain. Pain perception is a psychological concept which requires conscious attention to feel the same.[7] Hence, distraction interventions and hypnosis techniques are being used to treat pain. These distraction interventions are noninvasive, nonpharmacological alternatives and are desired by the patients. One such distraction tool is the use of virtual reality (VR). VR is an advanced technology which creates virtual environments wherein the patients are immersed in a simulated environment with sounds and motion to enhance the experience of the patient.

The aim of this study was to study the effectiveness of VR as a distraction tool during the administration of local anesthesia in patients undergoing a dental procedure.

MATERIALS AND METHODS

The study was conducted at the Department of Oral and Maxillofacial Surgery in Saveetha Dental College, Chennai. Ethical Committee clearance was obtained. Fifty patients participated in this study, and informed consent was obtained from the patients. Inclusion criteria were patients undergoing their first dental visit who require tooth removal. Exclusion criteria included patients who had psychiatric problems, history of claustrophobia, and history of epilepsy.

The patients were randomized into two groups, namely control group (n = 25) and study group (n = 25). All the patients were asked to fill the preoperative visual analog scale (VAS), dental concern questionnaire and Norman Corah's anxiety assessment form. All patients underwent procedures to extraction their teeth.

The patients in the study group were exposed to VR through the use of head-mounted immersive type of display powered by a smartphone. Relaxation videos developed for the VR format were played to the patients during the procedure.

Preoperative pulse rate and oxygen saturation were measured using pulse oximeter for all the patients. Local anesthesia was administered without the use of VR for the control group and with the VR for the study group. Intraoperative pulse rate and oxygen saturation were measured. After the administration of local anesthesia and extraction of the tooth, immediate postoperative pulse rate and oxygen saturation were measured. Patients were asked to fill a postoperative VAS scale, and the results were subjected to statistical analysis. All analysis were performed using SPSS for Windows, ver. 20.0; SPSS Science, Chicago, IL, USA. Student's t-test was used to compare the variables. A significance level of P < 0.05 for the 95% confidence interval was chosen to define the statistical significance.

RESULTS

The Norman Corah's anxiety questionnaire obtained from all the patients was analyzed, and it was found that about 8% of the patients had severe anxiety, whereas 20% had high and 56% had moderate anxiety. About 16% of the patients said that they were not anxious [Figure 1]. The mean age of the patients was found to be 39.72 ± 15.93.

Figure 1

Anxiety severity among the patients

The dental concerns’ assessment form contained 26 questions pertaining to the probable causes of anxiety, and the patients were asked to grade them on a four-point Likert scale. The data obtained from the concerns’ assessment showed that the patients had anxiety with regard to extraction, administration of anesthesia, root canal treatment, X-rays, probing, rubber dam, numbness, sound of drills, smells in the hospital, requirement of more treatments and cost of treatment [Figures 2-4]. We also found that the administration of local anesthesia and extractions had the highest anxiety level among the patients.

Figure 2

Dental concerns’ assessment in terms of gagging, smell, more treatment, cost of treatment, and number of appointments

Figure 4

Dental concerns’ assessment in terms of cleaning of teeth, X-ray, rubber dam, root canal treatment, and extractions

Dental concerns’ assessment in terms of sound, numbness, disliking the feeling of numbness, injection, and probing

Statistical analysis of the values of the oxygen saturation obtained from the patients’ revealed significant P < 0.05 for preoperative and postoperative readings [Table 1].

Table 1

Values of oxygen saturation obtained

Treatment groups	Preoperative SpO2	Intraoperative SpO2	Postoperative SpO2
Virtual reality group	97.64±1.63	97.20±1.80	97.48±1.48
Control group	98.40±0.76	97.92±0.90	98.16±0.68
P between groups	0.040	0.081	0.044

Data were expressed as mean±SD. SD=Standard deviation

Statistical analysis of the pulse rate of the patients’ using t-test revealed that intraoperative pulse rate in the control group was 85.80 ± 13.30, and in the study group, it was 77.76 ± 10.11 with significant P = 0.020 [Table 2].

Table 2

Values of pulse rate obtained

Treatment groups	Preoperative pulse rate	Intraoperative pulse rate	Postoperative pulse rate
Virtual reality group	82.64±11.52	77.76±10.11	81.20±9.83
Control group	82.80±12.54	85.80±13.30	85.76±14.21
P between groups	0.96	0.020	0.19

Data were expressed as mean±SD. SD=Standard deviation

Statistical analysis of the VAS pain scale of the patients’ was done using the t-test. The postoperative VAS pain scale in the control group was 2.60 ± 1.384, and in the study group, it was 1.28 ± 0.891. P value between the groups was statistically significant with a value <0.01 [Table 3].

Table 3

Values of Visual Analog Scale pain scale obtained

Treatment groups	Preoperative VAS pain scale	Postoperative VAS pain scale
Virtual reality group	4.84±1.972	1.28±0.891
Control group	5.72±1.792	2.60±1.384
P between groups	0.105	<0.01

Data were expressed as mean±SD. SD=Standard deviation; VAS=Visual Analog Scale

DISCUSSION

Dental anxiety can arise due to multiple factors such as previous negative experience, exposure to frightening portrayals of dentists in the media and by relatives and peers, and the reclined position in a dental chair. Anxiety can also be provoked by triggers such as the sight of needles, sound of drilling and screaming, and various smells in the dental clinic. Some common fears giving rise to dental anxiety are fear of pain, blood-injury fears, fear of radiation exposure, fear of choking, or gagging. Roy Byrne et al. identified four different groups of anxious patients based on their origin or source of fear.[8] They were anxious of specific dental stimuli, distrust of the dental personnel, generalized dental anxiety, and anxious of catastrophe. It was found that the more invasive types of stimuli were ranked as highly anxiety provoking, whereas stimuli related to the dental office, the dental team, and their equipment were found to be the least fear provoking. The results of the study reveal that most of the patients are anxious during their first time dental visit. The key concerns are administration of anesthesia, extraction, numbness, and root canal treatment.

Studies have associated anxiety with pain because the anxiety increases sympathetic activity, thus producing endogenous adrenaline, causing increased pain through the awareness of nociceptors.[9] Chaves et al.[10] concluded that there were no significant changes between anxiety and blood pressure (BP) for both genders. Conceição et al.[11] did not find statistically significant differences in BP and heart rate (HR) of anxious and nonanxious patients. It should be noted that the HR and BP are commonly used as dependent variables in behavioral studies and serve as parameters for the evaluation of anxiety level.[12] According to Andrade,[13] the use of anesthetics with vasoconstrictor promotes pain control and avoids the anxiety. On the other hand, Palma et al.[14] when studying the variation of BP using local anesthetics without vasoconstrictor found that it proved to be more superficial and less lasting, generating pain and anxiety in the patients, thus producing a significant increase in BP in normotensive patients. In the present study, patients with high anxiety levels were seen to have increased preoperative pulse rate. In terms of pain in various sites within the oral cavity during administration, it was observed that patients experienced maximum pain during palatal infiltration followed by inferior alveolar nerve block. This was followed by long buccal nerve block and infraorbital nerve block.

Although there have not been experimental studies wherein the patients who underwent administration of anesthesia were given VR as a distraction tool, a number of studies have been conducted using VR for simulation studies and in periodontal and pedodontics treatment procedures. Sato et al.[15] experimented on the usage of VR for the treatment of complex regional pain syndrome in patients and obtained 50% reduction in the pain intensity scores which is in accordance with our study wherein there was a significant decrease in the postoperative pain perception of the patient. Sarig-Bahat et al.[16] used VR to treat 67 patients with chronic neck pain and found that usage of VR for a single session increased the cervical range of motion and decreased the neck pain. Hoffman et al.[17] used VR for physical therapy sessions for burn victims and found that the pain perception of the patients was significantly lower when the patients used VR which is in accordance with our study. In a simulation study done by Tanja-Dijkstra et al.,[18] it was seen that the usage of VR as a distraction has the potential to influence the patient's perception of the anxiety-inducing procedure. Armfield et al.[19] concluded that the usage of VR alleviates anxiety by blocking the development of vivid memories.

The patients in the control group underwent administration of anesthesia without the use of VR and the patients in the study group underwent the same with the use of VR. Statistically significant results were obtained for the study group in intraoperative pulse rate and postoperative pain perception of the patient. Pain perception was recorded by VAS. The degree of pain was recorded on a scale of 1-10, with 0 being no pain to 10 being the worst pain imaginable.

The limitations of this study include small sample size, BP of the patients was not measured, passive VR was not used, and the patients were not in control of their VR environment.

CONCLUSION

Dental anxiety is a common problem which results in the avoidance of dental care. Dental anxiety can be attributed to the personality of the patient, previous traumatic dental experiences, anxiety due to family members, and due to general fear of pain. The findings of the current study indicate that immersive VR is an effective distraction tool to alleviate the anxiety of the patient. It is easy to use, affordable, and avoids the need for the use of pharmacological agents to reduce the anxiety level of the patient. The usage of VR could help the patients to overcome their fear of dental treatments, and this will, in turn, result in improved oral hygiene in the long run.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.