A New Experience for Child in Pediatric Dental Clinic during Pulp Therapy Procedures with the Google Card board Device

Introduction

Dental practitioners are expected to recognize and effectively treat childhood dental diseases that are within the knowledge and skills acquired during their professional education.¹ Emotions, such as fear and anxiety prevail in children, which may hamper effective dental treatment. A positive relationship has been seen of dental fear and anxiety with past negative dental experience of painful procedures. Thus, need for behavior management is mandatory in pediatric dentistry.²

According to the American Academy of Pediatric Dentistry (AAPD), the main goals of behavior management are to establish communication with the child and parent, alleviate the child’s fear and anxiety, deliver safe and quality dental care, build a trusting relationship between the dentist, child, and parent, as well as promote the child’s positive attitude towards oral healthcare.²

Management strategies have been proposed to reduce distress during dental treatment in children and are mainly divided into two broad categories. The first category consists of behavioral techniques, including the tell-show-do technique, distraction, inspiration, modelling, and hypnotism. The second category consists of pharmacological techniques.⁴

The majority of behavioral procedures are based on general practice of distraction. The tell-show-do is a behavioral-shaping distraction that is one of the most popular and widely used distratcions¹ . Distraction is a non-aversive behavior management technique of diverting patient’s attention about any unpleasant procedure so that it is not perceived as one such. Mccall and Malate⁵ suggested that perception of pain is reduced when child’s attention is distracted away from the stimulus.

In recent years, there has been an increase in behavioral research in virtual reality (VR) and virtual world. One example is Google’s cardboard VR head-mounted display (HMD), which is a cardboard that the consumer folds up into an HMD, like a viewer and includes plastic lenses. Compared to higher-end VR devices, such as Oculus Rift, the cardboard is significantly less expensive by a factor of 10; and therefore, has the potential for mass consumer use. It depends on a user’s smartphone, which the user inserts into the cardboard viewer.³

This study is conducted to evaluate the child’s experience during the pulp therapy procedures with the use of Google cardboard device.

Material and Methods

The proposed study was conducted split mouth as a single-blinded crossover design in the Department of Paedodontics and Preventive Dentistry at Karnavati School of Dentistry, Gandhinagar, Gujarat. Ethical approval for the study was obtained from the Research Ethics Committee of Karnavati School of Dentistry. A prior written consent was obtained from participants’ parents/guardian before the intervention.

Inclusion criteria

• Children aged 5-8 years.
• Children with no previous dental experience.
• Children with presence of at least two contralateral primary molars requiring pulp therapy procedure.
• Children who demonstrated negative behavior according to Frankl’s behavior rating scale.
• Children whose parents gave written consent for the study.
• Healthy child free from any systemic disease.

Exclusion criteria

• Children or parent not willing to participate. 
• Children with past painful dental experience. 
• Any physical, mental, or medically compromised children.
• Children with any emergency treatment needs, such as abscess, cellulitis, or any space-infections.
• Children having history of allergy with local anesthesic (LA) agents. 

The participants were selected from the outpatient department (OPD) of Paedodontics and Preventive dentistry at Karnavati School of Dentistry, Gandhinagar, Gujarat.

Sixty seven (67) participants were screened and examined by the principal investigator and the children who met the requirements after considering all the inclusion and exclusion criteria, a total of 52 patients were selected. The sample size was calculated using the formula:

Sample size, N = CHISQUARE/W2 (W = 0.5, CHISQUARE = 10, DF = 1). Considering the dropout rate of 20% the minimal sample size is 40.

The participants were divided into two groups by systematic random sampling method, which was performed using coin-toss technique. So, 52 participants were equally divided into 26 participants in each group. Both groups had undergone pulp therapy treatment during three consecutive sessions. In 1st session, all the children of both groups underwent preventive procedures, such as oral prophylaxis, topical fluoride application, and radiographs, and it was an exploratory visit to the operating area to familiarize them with dental clinic. They were also explained about the device and how it will be placed in subsequent visit. But 5 participants in group A and 4 participants in group B did not complete their further treatment. Thus, only 21 patients participated in group A and 22 patients participated in group B. The 3rd session was done 1-2 weeks after the 2nd session. In group A, Google cardboard device was used in 2nd session (αA) and not used in 3rd session (βA), while in group B Google cardboard device was used in 3rd session (αB) and not used during 2nd session (βB) (Figure 1)

The Google cardboard device used during the pulp therapy procedures blocked the visual field of the child completely. A smart phone was put into the Google cardboard device and VR supported “Doremon” and “Tom and Jerry” cartoons were played for 45 min during the pulp therapy procedure. Treatment was carried out by the principal investigator and tell-show-do technique of behavior management was carried out before starting the actual procedure. The pulp therapy procedure was carried out under rubber dam application. Before the starting of pulp therapy procedure, 2% Lignocaine spray (Xylonor spray, Septodont, France) was applied and inferior alveolar nerve block was given for mandibular teeth and infiltration was given for maxillary teeth (2% Lignocaine HCL with adrenaline Bitartrate 1:80,000).

All the parameters like disruptive behavior and pulse rate (physiological parameter for anxiety) were measured at five stages (pre-operational, during LA application, during rubber dam placement, first use of high speed hand piece, and end of the procedure), except for anxiety rating scale, which was recorded at the end of the procedure.

The co-investigator recorded the video of children’s disruptive behavior using face, legs, activity, cry, consolability (FLACC) scale (Merkel S et al. 1997)⁷ at above mentioned five stages, which was than assessed by the principal investigator. Video was recorded 2 m away from the operatory area.

At the conclusion of each appointment, the child was shown and explained the faces version of modified child dental anxiety scale [MCDAS(f)] questionnaire and they were asked to show the face, which best depicted their reaction to each situation.

The collected data were analyzed by Chi square test, independent t-test using Statistical Package for the Social Sciences (SPSS) 18.0 software. In this study, all statistic tests were at 95% level of confidence and the significant level was at 0.05.

Results

A total of 43 children participated and 86 teeth were treated in which 18 were boys (41.86%) and 25 were girls (58.14%). Maximum teeth were treated with pulpotomy ie, 32 teeth (37%) (15 teeth of group A and 17 teeth of group B) followed by infection prevention and control (IPC) approach ie, 29 teeth (33%) and the least with pulpectomy cases ie, 25 teeth (30%) (Table 1).

The parameters, such as pulse rate, disruptive behavior, and dental anxiety levels were assessed using pulse oximetry, FLACC scale, and MCDAS (f) scale, respectively. Pulse rate and disruptive behaviour were observed during all five stages ie, pre-operational, during LA application, during rubber-dam application, during first use of high speed hand piece and end of the procedure. Anxiety level was observed only at end of the procedure. In group A, at all these stages, there was statistically non-significant difference in pulse rate having P value of 0.190, 0.391, 0.416, 0.369, and 0.085, respectively (Table 2). There was non-significant difference in pulse rate in group B at first 3 stages showing P value of 0.146, 0.984, and 0.295. But there was statistically significant difference in pulse rate between session 2 (βB) and session 3 (αB) at first use of high speed hand piece and when procedure completed, both had P value of 0.000 (Table 2).

The mean difference of anxiety scores according to MCDAS(f) between session 2 (αA) and session 3 (βA) in group A was -3.05 with significant P value of 0.005 (Table 5), whereas in group B was 3.27 with significant P value of 0.007.

In group A, the mean difference of time between session 2 (αA) and session 3 (βA) in IPC was 1.07, pulpotomy was 3.50, and pulpectomy was 3.91 with corresponding non-significant P value of .065 in IPC, but showed significant P value in pulpotomy and pulpectomy, 0.002 and 0.001, respectively.

In group B, there was significant mean difference of time between session 2 (βB) and session 3 (αB) in IPC of -6.38, (P value 0.39) and in pulpotomy of -4.27 (P value 0.003) but non- significant mean difference of time in pulpectomy procedure of 1.35 (P value 0.636).

Discussion

The foremost evident challenge in pediatric dentistry that makes this branch unique from other health care professions is the problem of dental anxiety and anxiety. It may cause a long-term avoidance of dental treatment, resulting in a deterioration of oral health state, ultimately leading to pain and distress, and negative effects on social life.⁸ Therefore, the need for behavior guidance is of utmost importance in pediatric dentistry.

Behavior guidance is a continuum of interaction involving the dentist and dental team, the patient, and the parent directed towards communications and education. The goal of behavior guidance is to ease fear and anxiety, while promoting and understanding the need for good oral health and process by which that is achieved.⁹

Among newer distraction techniques, VR is unique in that it is immersive and engaging, integrating many sensory experiences; and thus, capturing a greater degree of attention. The distraction by VR is effective in reducing perception of pain by engaging attention of the patient to a different environment and diverting attention from an unpleasant dental setting. In this study, cardboard VR was used as it was inexpensive, comfortable, and fulfilled all the requirements of any VR device. It also eliminated all the anxiety inducing factors of dental equipment by complete blockage of children’s visual fields, thereby leading to successful distraction technique.11

Because each individual has different anxiety level, the present study was designed as a split mouth study, so that each individual would be compared with their own self in two different situations and crossover study was performed using systemic random sampling method by coin-toss technique to determine which side of treatment should be done first and therefore, the differences in anxiety would not lead to bias in reporting the results.¹⁰

Children of ages 5-8 years were selected for the study as dental problems are difficult to treat in this age group, because they exhibit more disruptive behavior and dental anxiety and were the most difficult to manage.¹² The fingertip pulse oximetry was used to assess the physiological measures, because it is non-invasive and easy method for determining pulse rate. The assessment of pain and disruptive behavior was assessed using FLACC scale as it provided excellent validity and reliability from reliable systemic reviews.¹³ Anxiety rates were recorded by MCDAS(f) as children are limited by the level of cognitive functioning require to complete various other numeric rating scales and this proved to be self-reported and easy one for children.¹⁴ MCDAS(f) was also suggested as an appropriate tool for assessment of dental fear and anxiety in age group of 4-11 years by Pagila.¹¹

After session 1, nine participants did not turn up for their further assessment. So, finally treatment was done for 43 patients, which were further divided into 21 patients in group A and 22 patients in group B (Table1).

In group A, the mean pulse rate at all five stages in session 3 (βA) was relatively greater than session 2 (αA); however, the mean difference in their pulse rate was not statistically significant. This might have occurred, because of positive prolonged effect of distraction technique of session 2 (αA) over session 3 (βA) (Table 2). Venham¹² also concluded significant decrease in anxiety level and increase in co-operative behavior during further visits of distraction technique.

In group B also, there was significant difference in mean pulse rate when cardboard VR was introduced in last session especially during first use of hand piece and at the end of procedure (Table 3). Mitrakul¹⁰, also reported that AV glasses successfully reduced heart rate and physical distress specifically during pre-operational and the first use of high speed hand piece.

There was significant decrease in pain and disruptive behavior in both the groups at all five stages of treatment except at pre-operational period in group B (Tables 4 and 5). This indicated the effectiveness of cardboard VR irrespective of the sequence of session in which it was applied. Our results were comparable to those found by Aminabadi² , Nuvvula^13, and Anup.¹⁴

There was significant difference in anxiety levels also recorded at the end of the procedure with distraction technique in both the groups. The interpretations of Mitrakul¹⁰ and Aminabadi² matched with our results.

The reduction in dental pain and anxiety with the help of distraction technique was directly proportional with the time required for the dental procedures. There was statistically significant decrease in time taken with cardboard VR for all the procedures in both the groups except for IPC procedure in group A and pulpectomy procedure in B group.

Our study results were also in accordance with the studies carried out in medical literature, where VR glasses were used as distraction to overcome pain, fear, and anxiety in a number of treatment procedures, such as burn care, chemotherapy, traumatic injuries, injection or blood sampling, and physiotherapy.³

Conclusion

The following conclusions can be drawn from this study: 

1. VR distraction method using Google cardboard device was effective in reducing dental anxiety among children undergoing various pulp therapy procedure assessed by MCDAS(f) scale.
2. Dental anxiety levels assessed using physiological sign – pulse rate via pulse oximetry was also reduced by Google cardboard device of VR distraction method.
3. VR distraction method by Google cardboard device efficiently reduced the pain and disruptive behavior associated with various pulp therapy procedures among children as compared to the conventional method.

Conflict of Interest

None.