A new experience for child in paediatric 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 like 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 behaviour management is mandatory in Paediatric dentistry.²

According to American Academy of Paediatric Dentistry (AAPD), the main goals of behaviour management are to establish communication with the child and parent, alleviate the child’s fear and anxiety, deliver safe, 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 module consists of behavioural techniques including the tell-show-do technique, distraction, inspiration, modelling and hypnotism. The second categories consist of pharmacological techniques. ⁴

The majority of behavioural procedures are based on general practice of distraction. The tell-show-do is a “behavioural-shaping” distraction that is one of the most popular and widely used1. Distraction is a non-aversive behaviour management technique of diverting patient’s attention any unpleasant procedure so 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 increase in behavioural research in Virtual Reality (VR) and virtual world. One example is “Google’s Cardboard VR HMD”, which is a cardboard that the consumer folds up into an HMD – like viewer and includes plastic lenses. Compared to higher – end VR devices like Oculus Rift, the cardboard is significantly less expensive by a factor of ten, and therefore has the potential for mass consumer use. It depends on a user’s smartphone, which the user inserts into the Cardboard viewer³.

This study is conducted to evaluate the child’s experience during the pulp therapy procedures with the use of “Google Card-Board Device”.

Material and methods

The proposed study was conducted split mouth as a Single Blinded Cross Over 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. Prior written consent was obtained from participants’ parents/guardian before 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 behaviour according to Frankl’sbehaviour 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, any space-infections.

• Children having history of allergy with LA.

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

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

Sample size N= CHISQUARE/W^2 (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 like oral prophylaxis, topical fluoride application, radiographs and it was an exploratory visit to the operating area in order 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, finally only 21 patients participated in group A and 22 patients participated in group B. The 3rd session was done 1 to 2 weeks after the 2nd session. In group A Google card-board device was used in 2nd session (αA) and not used in 3rd session (βA), while in group B Google card-board device was used in 3rd session (αB) and not used during 2nd session (βB) (figure 1).

The Google card board device used during the pulp therapy procedures blocked the visual field of the child completely. A smart phone was put into the Google card board device and VR supported “Doorman” and “Tom and Jerry” cartoons were played for 45 min during the pulp therapy procedure. Treatment was carried out by the principal investigator Tell show do technique of behaviour 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 behaviour and pulse rate (physiological parameter for anxiety) were measured at 5 stages (Preoperational, 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 behaviour using face, legs, activity, cry, Consolability (FLACC) scale (Merkel et al)7 at above mentioned five stages, which was then assessed by the principal investigator. Video was recorded 2 meters away from the operatory area.

At the conclusion of each appointment the child was shown and explains 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 analysed 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 i.e. 32 teeth (37%) [15 of group A and 17 of group B] followed by IPC i.e. 29 teeth (33%) and the least with pulpectomy cases i.e. 25 teeth (30%) [Table 1].

The parameters like pulse rate, disruptive behaviour 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 viz Pre-operational, during LA application, during rubber-dam application, during 1st 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 1st 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 1st use of high speed handpiece and when procedure completed, both had P value of 0.000 [Table 3].

In group A, at all these stages, there was statistically significant difference in FLACC scores having P value of 0.037, 0.049, 0.000, 0.002 and 0.002 respectively [Table 4].

There was non-significant difference in FLACC scores in group B between session 2 (βB) and session 3 (αB) only at pre-operational stage having P value of 0.487. Others stages namely during LA application, during rubber dam application, 1st use of high speed hand-piece and at end of procedure showed significant difference in P value of 0.000 and 0.004 [Table 5].

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 6] 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 paediatric dentistry that makes this branch unique from other health care professions is the problem of dental anxiety and anxiety. It may cause a longterm avoidance of dental treatment, resulting in a deterioration of oral health state, ultimately leading to pain and distress, and negative effects on social life⁸. Therefore, the need for behaviour guidance is of utmost importance in paediatric dentistry.

Behaviour guidance is a continuum of interaction involving the dentist and dental team, the patient, and the parent directed towards communications and educations. The goal of behaviour guidance is to ease fear and anxiety while promoting and understanding the need for good oral health and process by which that is achieved⁹ .

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’s by complete blockage of children’s visual fields, there by leading to successful distraction technique¹¹.

Since 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 cross-over 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 results¹⁰.

5-8 year olds were selected for the study as dental problems are difficult to treat in this age group because they exhibit more disruptive behaviour and dental anxiety and were the most difficult to manage¹². 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 behaviour were assessed using FLACC scale as it provided excellent validity and reliability from reliable systemic reviews¹³. 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 children²⁴. MCDAS (f) was also suggested an appropriate tool for assessment of dental fear and anxiety in age group 4 to 11 years by Pagila 11.

After session 1, nine participants did not turn up for their further. So, finally treatment was done in 43 patients which were further divided into 21 in group A and 22 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 had occurred because of positive prolonged effect of distraction technique of session 2 (αA) over session 3 (βA) [Table 2] Venham 12also concluded significant decrease in anxiety level and increased of cooperative behaviour in further visits of distraction technique.

In group B also there was significant difference in mean pulse rate when card-board VR was introduced in last session especially during 1st use of hand piece and at end of procedure [Table 3]. Mitrakul 10, also reported that AV glasses successfully reduced heart rate and physical distress specifically during pre-operational and the 1st use of high speed hand-piece.

There was significant decrease in pain and disruptive behaviour in both the groups at all five stages of treatment except at pre-operational period in group B [Table 4, 5]. This indicated the effectiveness of card board VR irrespective of the sequence of session in which it was applied. Our results were comparable to those found by Aminabadi² , Nuvvula¹³, 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 Mitrakul 10 and Aminabadi² matched with our results.

The reduction in dental pain and anxiety with the help of distraction technique were directly proportional with the time required for the dental procedures. There was statistically significant decrease in time taken with card board 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 physiotherapy³ .

CONCLUSION

The following conclusions can be drawn from this study:

1. VR distraction method using Google card board 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 card board device of VR distraction method.

3. VR distraction method by Google card board device efficiently reduced pain and disruptive behaviour associated with various pulp therapy procedures among children as compared to conventional method.

Financial support and sponsorship: Nil

Conflicts of interest: Nil