Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Abstract
In the age of technology, Virtual Reality
(VR) has stormed into many aspects of our lives, the medical field is no
exception. According to Global Industry Analysts, the VR market in medicine is
expected to grow to $2,2 billion by 2027. This technology hold promises in
revolutionizing the healthcare industry. Its applications are ranging from
training medical professionals (with possibilities for students to better
assess medical notions or to treat virtual patients during their pre-clinical
course) to diagnosing and treating various conditions. The user is immerged
into a tri-dimensional multi-sensory ambiance and his focus is solely on the
scenario. It’s an immensely powerful tool for probing the relationship between
emotion and audio/visual perception. As imaginative and inquisitive as children
are, the immersive quality of VR is most likely to amaze them. Their attraction
for new technologies combined with their ease to escape to a specific scenario
through movies or videogames can make the VR experience, and therefore the
medical or dental procedure, more pleasant for them. This article summarizes
the therapeutic potential of VR in pediatric dentistry through its anxiolytic
and analgesic effects.
Keywords: Virtual reality; Analgesia; Anxiolytic;
Distraction; Dental; Children
Introduction
The coronavirus pandemic and its social
restrictions have helped boost our interest in Virtual Reality (VR) when it
comes to entertainment and business, fields for which it was originally
designed for. Its applications also expand to the healthcare field [1],
especially in pediatric dentistry [2].
Use of virtual reality in
pediatric dentistry
VR is a computer technology that creates
an artificial 3-dimensional simulated environment through audio and visual
immersion. It consists of a head mounted display and a pair of goggles that are
connected to either a computer or a cell phone. The headset has sensors that
track user’s head movements, creating the illusion of moving around in the
virtual space [3]. The VR scenario needs to be adapted to the context of dental
treatment, with calm and anxiolytic scenarios, avoiding any agitation,
hyperstimulation, or head movements during the procedures. However, the child
is much more than a simple passive recipient of VR: he becomes an active
collaborator of his treatment through the choice of the virtual reality
environment. While in VR, he can interact with virtual characters controlled by
computer algorithms called embodied agents. The first-person view in VR creates
the illusion of being surrounded by the virtual environment and sharing the
same physical space with the embodied agent [3]. In addition, VR can create
realistic simulations by allowing users to interact with the virtual
environment using naturalistic movement, similar to how they would navigate the
physical world. Research with children has shown that the brain can respond to
VR stimuli as if it were real [3]. Anxiety is often linked to pain and VR was
found effective, not only on anxiety, but also in pain relieve.
When it comes to pediatric dentistry, as
the patient’s attention is focused on the VR scenario, the visual and audio
stimuli that usually trigger anxiety are shunted. The reduction in fear in
pediatric needle procedure is significant while using VR compared with standard
methods of behavioral management or distraction [4]. Two recent meta-analysis,
published in 2019 and 2020, have investigated the physiological response in
children who received virtual reality devices during dental procedures. The
first one concluded that children with VR have a significant lower heart rate
during local dental anesthesia (MD, -3.78; 95% CI, -6.73, -0.83; p=0.01). This
result is based on 352 participants across 6 studies. However, there was no
significant change for the oxygen saturation level [5]. Unlike the first
meta-analysis, the second shows no significant improvement linked to VR use
during the administration of local anesthetic and the placement of the surgical
site. They concluded, however, that VR audiovisual distraction may reduce pain
perception and improve child behavior during decay removal and restoration
placement [6]. VR is also indicated for cognitive and behavioral therapies
based on progressive exposition to different stimuli such as the dental
anesthesia needle. Psychological preparation for a surgical intervention by
virtual visit of the operating room is possible and allows a reduction in
preoperative anxiety scores [7]. The main objective and interest of VR, in
these cases, is the cognitive reprogramming of anxious children. Furthermore,
there is growing interest in nonpharmacological techniques for anxiety and pain
management. Patients who are intolerant to pharmalogical conscious sedations
such as inhalation with nitrous oxide and oxygen or who cannot benefit from an
administration of benzodiazepines (midazolam) may also be treated under virtual
reality. However, given the nature of the procedure, the contraindications to
the use of virtual reality mainly refers to certain psychopathological contexts
(claustrophobia), a history of post-operative nausea and vomiting, growth
retardation or young age leading to an unsuitability of the virtual reality
mask. Another contraindication to the use of virtual reality is susceptibility
to motion sickness.
Medical hypnosis in
pediatric dentistry
One of the main non-pharmacological
distraction therapies used in pediatric dentistry is medical hypnosis [8]. In
children, clinical hypnotherapy techniques including hypoalgesia have relieved
acute pain associated with local anesthesia and therefore help allay fear or
increase patient cooperation [9]. According to the American Psychological
Association, medical hypnosis induces a “state of modified consciousness
involving focused attention and reduced peripheral awareness characterized by
an enhanced capacity for response to suggestion”. Milton Erickson developed a
permissive, accommodating, and indirect approach, often called Covert or
Conversational Hypnosis. This technique is particularly interesting for
children, who have a natural talent for playing and who find it easy to enter
into an imaginary world. Three fundamental conditions remain essential in
hypnosis: patient‘s motivation, patient’s cooperation, and patient’s confidence
in the therapist [10]. One study demonstrated that hypnosis was effective in
reducing preoperative anxiety in the group of children receiving local dental
anesthesia [11]. The mean modified Yale Preoperative Anxiety Score was 50%
lower in the Hypnosis group than in the Non-Hypnosis group at the time of anesthesia
[11]. There were less crying and decreased pulse rate [11]. Hypnosis also
modified the pain tolerance threshold, as shown by the Visual Analogue Scale
(VAS) scores, with 86% of children from the Hypnosis group compared to 40% from
the Non-Hypnosis group having a VAS score under 3 [11]. Another study found
that children under hypnosis exhibited significantly less resistance to
administration of local anesthesia (P<0.05) and there also was a significant
difference in pulse rate, attributable to the hypnotic condition (P=.000), but
not in oxygen saturation level [9].
A recent Cochrane systematic review
attempted to answer the question: What is the effectiveness of hypnosis (with
or without sedation) for behavior management of children who are receiving
dental care in order to allow successful completion of treatment? Although
there are many case reports indicating the benefits of hypnosis in pediatric
dentistry, only 3 met the inclusion criteria and the authors concluded that
further controlled trials were necessary to suggest the beneficial effects of
hypnosis [12]. Given well‐known
developmental and inter-individual variations in suggestibility, researchers
may want to confine studies to limited age ranges or to include sufficient
numbers of children from various age groups to allow analyses of adequate
statistical power within age categories. Besides, the main difficulties for
comparing medical hypnosis between clinical studies correspond mainly to the
inherent heterogeneity of the hypnosis speech. The variability of the hypnosis
speech between practitioners makes it hard to compare them.
Medical hypnosis through
virtual reality
Several recent software offering a
multisensory immersion in sync with a hypnosis suggestion speech allow a more
standardized hypnosis therapy. It combines the benefits of the visual
distraction through VR with synopsis scripts based on cardiac coherence and
suggestion. It often includes musical constructions that have been clinically
proven to affect the patient’s heart rate through relaxation, associating the
ambient sounds with music therapy compositions.Hypnogram© is one that software
that are easy and clinically ready-to-use and don’t require hypnosis skills for
the practitioner. The patient can choose between different VR scenarios, voice
and music atmosphere. It’s a class 1 medical device, proven effective as a
natural anxiolytic. It can be used as replacement of premedication with a
long-lasting non-pharmacological anxiolytic effect. In association with local
or regional anesthetic adjunct, or during the induction for general anesthesia,
it provides analgesia with reduced side effects. Post-operative hypoalgesia can
reduce pain and opioid use with a faster recovery. When it comes to pediatric
dentistry, our pilot clinical study provides preliminary evidence of the
feasibility of using immersive, interactive VR to distract pediatric dental
patients and increase cooperation and of children during dental procedures. 12
patients were included, and the main inclusion criteria corresponded to an age
comprised between 9 and 13 years old, without any neurological or psychiatric
disease, in absence of previous post-operative vomiting or nausea. Our
preliminary results show a better tolerance and global experience of dental
procedure in a large range of procedures from oral surgery to endodontics or
conservative care.
Long clinical sessions (lasting more than 1 hour) were also carried out under
virtual reality, as part of complex rehabilitations of dental developmental
anomalies, such as Amelogenesis Imperfecta or Molar Incisor Hypomineralisation,
with a good level of cooperation from the patient. When used in conjunction
with local anesthesia, VR procedure decreases anxiety and reduces pain and the
need for sedatives and side effects, with perioperative anxiety score 45% lower
and a satisfaction rate of 8/10. The next step in our clinical research is a
prospective controlled clinical study aiming to compare this VR device with the
nitrous oxide pharmacological sedation in the context of anxious children
undergoing conventional dental treatment. Our main experimental objective is to
investigate the effectiveness of VR on anxiety and pain, as well as to compare
it with the standard option of care for anxious children corresponding to inhalation
conscious sedation with nitrous oxide and oxygen. Success and prognosis factors
such as child’s temperament will be discussed as they may influence
suggestibility in children and overall efficacy of VR procedure.
Conclusion
Recent mass production of immersive VR
goggles has increased their availability and affordability, and there is
growing interest in non-pharmacological techniques for pain management, making
VR analgesia a promising direction for future clinical research. Associating
with medical hypnosis scenario, it combines the benefits of both distraction
through VR and hypnosis. Children can discover the dental office in a playful
and fun way.
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