Effectiveness of Audio and Audio-Visual Distraction Aids for Management of Pain and Anxiety in Children and Adults Undergoing Dental Treatment- A Systematic Review And Meta-Analysis

INTRODUCTION

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described regarding such damage, according to the International Association for the Study of Pain [1]. Dental anxiety is a multi-dimensional model that contains social, perceptive, and physiological components. Anxiety and fear of dental procedures develop in early childhood [1]. It is a feeling of apprehension, worry, uneasiness, or dread, the source of which may be unknown. Corah et al [1] stated that dental anxiety is the patient’s response to anxiety which is very much related to the dental appointments

During dental treatment children are usually very much anxious and it’s very normal for the children to be anxious of new and potentially threatening conditions. There is a strong relationship between a child’s dental anxiety and successful dental treatment, and also between anxiety and pain [2]. Fear of pain influences a child during the procedure, which may result in nervousness, sensitization, and uncooperative behavior during the present and future dental appointments [1].

Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure [3]. Mc Caul and Mallet developed the theory of distraction by giving importance to the fact that the capacity of humans to pay attention is limited. They demonstrated that an individual should concentrate on the painful stimulus so as to perceive pain; therefore, perception of pain decreases when a person’s attention is distracted away from the stimulus [3].

In children, dentists have a wide variety of techniques available to them such as tell-show-do, relaxation, distraction, systematic desensitization, modeling, audio analgesia, hypnosis, and behavior rehearsal [4].

Pharmacological management of patients with dental anxiety, though is used commonly in previous days not far from today, but disadvantages are felt by both the patients and the doctor. Among all variety of pharmacological techniques (nitrous oxide usually is matched with oral drugs), general anesthesia, and other agents (chloral hydrate and hydroxyzine), papoose board and hand over mouth technique can be successful, but the attitude of parents and dental professional towards these techniques is changing and now non-aversive techniques like distraction are becoming more popular [4]. Hence, the non-pharmacological interventions have gained the fame especially in dentists. In distraction technique, distracters can be either in active or passive form. Audiovisual distraction is a method of passively distracting two types of sensations—hearing and seeing [3]. Audiovisual virtual reality is an altered three-dimensional (3D) world generated by a computer [5].

Although there are several studies about the effect of the Audio [6, 7, 8, 9, 10], and audiovisual [1, 2, 3, 4, 5, 11, 12, 13, 14, 15, 16, 17, 18, 19] techniques on anxiety during dental treatments. With reference to the vast amount of literature available on this topic, some systematic reviews were conducted by Liu et al [20] and Prado I et al [21] with adequate methodology and concrete findings. However, they did attempt for qualitatively to assess the individual studies nonetheless, there was a missing quantitative (meta-analysis) conclusion to arrive at a holistic conclusion. Neither did we find any literature which tried to compare audio and audio-visual distraction technique, to show an inclination towards one or the other.

Thus, with reference to this paucity that there is no concrete research as systematic review and meta-analysis which explains and is indicative of the most effective distraction technique, we conducted a systematic review and meta-analysis to summarize and evaluate effectiveness of audio and audio-visual distraction aids for management of pain and anxiety in children undergoing dental treatment.

METHOD

RESULTS

We followed the PRISMA guidelines for the methodology. The study selection process is given in Figure 1 (PRISMA flow Chart-Supplementary file). All the titles and abstracts were screened based on the stringent selection criteria. Subsequently the full texts the assessed independently by the two reviewers. A total of 14 studies over the past fifteen years met the inclusion criteria for full text reading and all 05 were included for further analysis.

Figure 1. Prisma flow diagram showing the studies exclusion and final inclusion with reasons.

Risk of bias

Risk of bias was assessed by the two independent reviews for RCTs included in the review and discrepancies were resolved by discussion and appropriate consultation with a third reviewer. The domains for risk assessment were arranged as high, uncertain or low risk, based on selection bias (random sequence generation and allocation concealment), performance bias (blinding), detection bias (assessor blinding), attrition bias (incomplete outcome data), and reporting bias (selective reporting). Thus, the overall risk for individual studies were assessed as low, moderate or high risk based on the domains and criteria. Most of the studies showed detection and performance bias. Studies conducted by Al Habib et al and Nunna et al could be considered with acceptable methodology for future studies reference (Figure 2 and Figure 3).

Figure 2- Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.

Figure 3- Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

The studies were then selected for quantitative synthesis based on the outcome measures of the parameters. The outcome measures were extracted as post intervention scores/values in mean and standard deviation format. A total 05 studies were eligible for meta-analysis. The analysis was performed with RevMan software version 5.3 and appropriate effect size and effect model after the assessment of heterogeneity.

Quatitative Analysis

Audio distraction techniques vs Control

The meta-analysis was done for the studies which assess pulse rate as primary outcome, in reducing anxiety and pain, which included 4 studies. The fixed effect model was applied as heterogeneity was I²=0%, the cumulative mean difference was -2.42(CI: -3.56, -1.29) this indicating that pulse rate was higher in control group than the intervention group (audio distraction) (Figure 4)

Figure 4. Forest plot for Pulse rate in children

The meta-analysis done for analysing the oxygen saturation level, in 3 studies showed that the cumulative mean difference was 0.02(CI: -0.22,0.26) with I²=0%, on application of fixed effect model. This showed that intervention and control did not show any difference in oxygen levels after the treatment. (Figure 5)

Figure 5. Forest plot for O2 saturation levels in children

The Venham’s Picture test was analysed on quantitative basis, with fixed effect model (I²=0%) showed that cumulative mean difference was -0.03(CI: -0.21,0.14). The mean value indicated that there was not much difference in the anxiety levels between the control and audio distraction group when measured through Venham’s picture test. (Figure 6)

Figure 6. Forest plot for Venham’s Picture Test in children

The meta-analysis was conducted for anxiety when measured through Venham’s clinical test with fixed effect model showed that cumulative mean difference was 0.04(CI: -0.09,0.18). This was interpreted that there was not much difference in Venham’s clinical test scores between the two groups. (Figure 7)

Figure 7. Forest plot for Venham’s Picture Test in children

Audio-visual distraction techniques vs Control

The meta-analysis conducted for audio-visual distraction aids for pulse rate change, on application of fixed effect model, showed that the cumulative mean difference was -6.01(CI: -8.50, -3.52) thus indicating that the pulse rate was higher in control group than the intervention group (AV distraction techniques) (Figure 8)

Figure 8. Forest plot for pulse rate in children

The oxygen saturation level was assessed for audio-visual distraction aids, with fixed effect model, the cumulative mean difference was 0.08(CI: -0.10,0.26). (p≤0.05) Thus it indicated that there was no difference in oxygen saturation levels in both the group as similar to audio distraction findings. (Figure 9)

Figure 9. Forest plot for O2 saturation levels in children

The quantitative analysis done for Venham’s picture test gave a cumulative mean difference as -1.37(CI: -2.57, -0.18) with random effect due the significant heterogeneity I²=93%. This indicated that audio-visual distraction group had less score for Venham’s Picture test as compared to the control group. (Figure 10)

Figure 10. Forest plot for Venham’s Picture Test in children

Audio vs Audio-visual distraction techniques

The meta-analysis was conducted to compare between the two main intervention in reducing anxiety with pulse rate as the outcome. With I²=0%, heterogeneity, we applied fixed effect model and found that cumulative mean difference was 3.70(CI: 1.87,5.53) thus conclusively suggesting that post intervention audio-visual aids the pulse rate is still lower than audio group patients. (Figure 11)

Figure 11. Forest plot for pulse rate in children

The quantitative synthesis was done for comparing the oxygen saturation levels between the two interventions. The fixed effect model was applied due to less heterogeneity on 0%. The cumulative mean difference was -0.04(CI: -0.21, 0.12) (p≤0.05) thus indicating that oxygen saturation levels were almost equal in both audio-visual distraction and audio group patients. (Figure 12)

Figure 12. Forest plot for O2 saturation levels in children

The meta-analysis was conducted for both the groups as Venham’s picture test measurement tool. Fixed effect model application gave a cumulative mean difference as 0.38 (CI: 0.08,0.68) thus indicating audio visual group had lower picture test scores as compared to audio group. (Figure 13)

Figure 13. Forest plot for Venham’s Picture Test in children

DISCUSSION

Dental anxiety and pain are psychological state considered non-specific lack of ease, apprehension, or negative thoughts regarding what may occur during a dental treatment, frequently related with past traumatic experiences in the dental setting [5]. Audiovisual aids can alleviate dental anxiety and pain by distracting two types of sensations; hearing and seeing [11].

The superior results with the audiovisual aids can be explained on the fact that while listening to stories, songs, watching cartoons, children become more engrossed and concentrate deflecting their attention from the anxiety causing dental stimulus. Since they often close their eyes to concentrate, the sights and sounds of the dental treatment are screened out, leading to further reduction of anxiety [10].

Till our knowledge there is scarcity of literature in reviews based on our topic of interest. We aimed to conduct this systematic review and meta-analysis to consolidate and summarize the findings for comparisons between the audio and audio-visual distraction aids, as to which is a concretely better choice for managing pediatric patients. We performed exclusive search on the electronic database with stringent inclusion and exclusion criteria to reduce overall variation in the studies. Fourteen studies were included in this review. We found that majority of the studies had used audio distraction aids as compared to audio-visual distraction techniques in children. Most of the studies included in this review were carried out in India and with almost a balanced gender distribution. The types of distraction aids were of a variety including newer technology like VR box or eyeglasses and traditional ones like songs, cartoons or rhymes. Risk of bias was moderate for all the studies. The studies were further screened and selected for meta-analysis. The heterogeneity was least in almost all the comparisons. Wherever the heterogeneity was high we applied the random effect model and interpreted the cumulative mean difference for a conclusion [22, 23]. The quantitative analysis concluded that both interventions (audio and audio-visual) are better than control (no distraction) in reducing pain/anxiety. But still when both interventions were compared against one another, audio-visual were dramatically better than just audio aids as distraction technique.

This finding was supported by, studies done by Agrawal N et al [2] and Kaur [12] indicated a definite positive effectiveness of AV distraction technique in managing dental anxiety in children. The better results acquired with the Audiovisual aids can be due to the fact that Audiovisual distraction allowed the children to use two of their senses, becoming more engrossed and thereby distracting their attention from the anxiety resulting from the local anesthesia administration [2]. Kaur R et al [12] in his study, observed that children were most relaxed in audiovisual followed by audio group and were least relaxed in control group during three dental visits. Similar results were found in the study by Prabhakar et al 2007 [4]. Owing to the reason that the child while watching the cartoon movie or other audiovisual distraction aids, there is multi-sensory engagement and concentration on the screen, thereby screening out the sight of dental treatment.

In contrast, Saumya Navit et al [10] concluded that audio stories distraction was most effective in reducing anxiety for children undergoing dental treatment. The superior results can be explained on the fact that while listening to stories, children becomes more engrossed and concentrate on the audio story presentations, thus diverting their attention from the anxiety causing dental stimuli. This was in consensus with Prabhakar et al , 2007 [4] study. This might be because of the fact that the child listening to music tends to close his or her eyes thereby removing the sight. Moreover, music helped to cut down the discomforting noise of hand pieces or other anxiety inducing stimuli and these two advantages combined with the effect of choice based music provided relaxation might be due to playing familiar songs helped child gain control over the discomforting stimulus and gave them a feeling of being in the familiar environment. This was also in accordance with the study conducted by Marwah et al, 2005 [7] in which the choice of music was left to the child dental patient [12].

However, in the study performed by Rojas-Alcayaga1 et al [6], the results showed that musical distraction had no effect on the experience of dental anxiety among children who entered the oral health program.

Audio visual distraction using tablet device, which was fixed to the dental chair, was superior in child behavioral management and pain control during IAN block compared to using AV eyeglasses “VR Box” and control group [11].

But Albagieh et al concluded that audio and/or visual distraction using VRD effectively lowered the anxiety levels of adult patients, particularly when noise cancellation was additionally used, this combination was the most effective in reducing anxiety levels [13]. These results were similar to the study by Allani S et al [3].

Virtual reality is the Gen Z invention and innovation. This technology has now seeped into dentistry providing professionals with better techniques to manage anxious children for dental treatment [11, 13].

In a study by Mohammed et al [11], a total of 101 children (60 boys and 41 girls) in all groups, pain and behavioral scales scores (Heart pulse rate, W-B faces, FLACC) were recorded. However, it was found that AV eyeglasses “VR Box” had no added advantage in child behavioral management which was similar to the findings in the control group. This could be due to the use of AV eyeglasses “VR Box” can remove the real world’s vision, thus increasing the child anxiety from the new and more threatening surrounding environment. This result was close to the child anxiety which was faced by the children in the control group from the vision of the dental instruments. The outcomes obtained from the study Garrocho-Rangel et al [5] also did not show that Video Eyeglasses/Earphones System (VEES), employed as distracting devices, exerted any effect on the reduction of children’s anxiety or pain perception during the dental treatment, compared with traditional non-aversive behavioral management [5].

Virtual reality immersion has been shown to be somewhat more effective than audio visual distraction because it augments detachment from viewing and hearing what is happening in the environment. A systematic review conducted by Eijlers et al concluded through their findings that though VR is an effective intervention but still paucity is present in the research to comment firmly [24].

Liu Y et al [20] conducted a systematic review and evaluated audiovisual distraction techniques on the management of dental anxiety of children. The study findings showed that distraction techniques were effective in relieving dental anxiety. But they had low-quality evidence hence our study could contribute a higher evidence with concrete conclusions intended by the meta-analysis. Prado et al [21] also conducted systematic review of randomized controlled trials with the similar aim of ours. The conclusions showed that various distraction techniques ranging from audio to camouflage were effective in reducing fear and anxiety. These findings were in consensus with our study, going further we, inclusively undertook the quantitative analysis and found the results through sub-group analysis with various outcomes. Zhang et al [25] in their meta-analysis, concluded that oxygen saturation levels during the dental treatment in audiovisual distraction group was higher than control. This is in consensus with our findings, and we also assessed many other parameters to confirm the same with Venham’s picture test or pulse rate.

Those patients with dental problems not only doubt about visiting a dentist but also their fear and anxiety in the office makes any action impossible for the dentist [26] .Those patients with dental problems not only doubt about visiting a dentist but also their fear and anxiety in the office makes any action impossible for the dentist. Thus the traditional or conventional distraction aids instead of virtual reality eye wear are more effective as they are easily available, cost effective, portable, popular and well known among kids of all age ranges [26].

We also recommend that future studies may compare the specific audio and AV aids to point out to the exclusive one which can be used pediatric dentist in managing patients. Also we assessed a variety of tools for assessing the outcome. This might have created a bit of heterogeneity and variation in our findings. Hence, we implore future researchers to conduct individual trials with stringent protocol or methodology to contribute for homogenous literature that could build a still stronger meta-analysis evidence. The studies were limited when assessing for pain outcome according to our search. Limited studies were acquired in adult population which may be accounted to less studies conducted using AV aids in the same. There is also a need to conduct studies which compare the traditional audio-visual aids with VR, the technology of current era.

Although it has been hypothesized that active strategies are more effective than the passive ones, all these studies (all articles with positive response) suggested that passive distraction may be as effective or even better, since, the active forms are too demanding for children [3].

We hope that these findings suggest that alteration of the patient’s environment in order to create a more pleasant treatment experience is largely beneficial for both the patient and dentist [13].

Since anxiety should be assessed as a critical step not only in anxiety management for high-DA patients, but also in pain control for all dental patients [27]. When compared to both the types of distraction aids, AV aids were better in reducing anxiety/pain but all the same audio distraction was most commonly used. We assume that it’s because audio aids are more accessible, affordable and comfortable to the child, where he/she is aware of surroundings and less anxious about not able to comprehend the settings in which the child is treated. This creates a bond of trust and faith on the operator eventually for a positive reinforcement now and in the future.

CONCLUSION

This systematic review and meta-analysis indicate that audio-visual distraction aids are always a better tool but when considering the availability and accessibility and comfort, audio distraction aids are still a choice of intervention to reduce pain and anxiety in children. Due to a variety of distraction aids used we could not zero down on a particular one. But using audio distraction aids when audio-visual aids are not available could be acceptable way for distracting and treating children. Newer AV aids are now available which give better results, which should be used in clinics for claiming its effectiveness.

The authors report no conflicts of interest and are alone responsible for the content and writing of the paper.

ABBREVIATION

CI: Confidence Interval

DOAJ: Directory of Open Access Journal

IAN BLOCK: Inferior Alveolar Nerve Block

MCDAS: Modified Corah Dental Anxiety Scale

SD: Standard Deviation

VAS: Visual Analog Scale

VEES: Video Eyeglasses/Earphones System

W-B FACES: Wong Baker’s Faces