Key points

  • Provides some studies where virtual reality (VR) has been used within healthcare for anxiety reduction.

  • Highlights patient groups that have greater preference toward the use of VR during dental extractions.

  • Provides the basis for future larger-scale studies on the use of VR during dental extractions.

Introduction

Dental anxiety is known to be the fifth most common cause of anxiety according to Agras et al.1 It is defined as anxiety associated with the thought of visiting the dentist and undergoing dental treatment.1 Patients may experience different levels of severity, ranging from a slight uneasy feeling to a severe dental phobia.

Virtual reality (VR) has been used in clinical settings as a distraction method in order to reduce anxiety. It is a form of human-computer interaction whereby the experience of auditory, tactile and visual stimuli through a headset allows the patient to feel part of a computer-controlled virtual world.

By using VR as a distraction, it takes away attention which is a crucial component in experiencing pain. Many studies have been carried out in the medical field and reports have found a reduction in pain perception when using VR in surgery, physical therapy, burn wound surgery and chemotherapy.2 However, studies in the dental field regarding VR distraction are limited. One study by Aminabadi et al.2 found that VR had positive effects in reducing pain, anxiety, behaviour and also stress levels among children during dental treatment. Another study by Hoffman et al.3 on patients receiving subgingival plaque removal resulted in substantial reduction in anxiety when using VR distraction. This was a comparison between patients who watched a movie during treatment and those who did not have any other distraction methods. Nonetheless, more research into the efficacy of VR distraction within dentistry is required, perhaps in areas away from its use in paediatrics, but more into its use during extractions and pulp therapy among adult patients.2

The aim of this explorative study was to gain patients' perspectives on using VR during dental extractions and whether they find it beneficial in helping to reduce their anxiety levels. This study aims to identify those groups of patients who prefer VR use the most so that future larger scale studies can be targeted at these groups.

Method

Fifty patients consented to take part in this study within the Oral Surgery Department of Birmingham Dental Hospital in July 2017. These included patients who had undergone screening and a consultation previously to ensure an extraction was required, whether this was surgical or non-surgical. All patients that were selected had teeth extracted previously with a conventional method, without the use of VR or any other distraction measures. Approval to gain data was given by the Birmingham Dental Hospital and School of Dentistry Clinical Governance Committee.

Before starting the extraction procedure, the anxiety levels of each patient were assessed using the Modified Dental Anxiety Scale (MDAS) questionnaire. The MDAS is the most frequently used dental anxiety questionnaire in the UK. It includes series of five questions aiming to assess anxiety levels in different dental situations. Each question has 5-point Likert scale responses ranging from 'not anxious' to 'extremely anxious.' Each response is given a score and the sum of all responses is recorded. The total score of this scale ranges from 5-25 with a cut-off score of 19 suggesting severe dental anxiety.1 The reliability and validity of this scale has been established in previously published work by Humphris et. al.4 It is important to note that Humphris and Hull found that using this questionnaire does not increase anxiety.1

Throughout treatment, each patient wore a Virtoba Virtual Reality Headset until the teeth were extracted. All extractions were carried out by experienced clinicians within the Oral Surgery Department of Birmingham Dental Hospital. The VR headset was worn by all patients for at least a minimum of 5 minutes. All patients were involved in an interactive virtual aquarium journey via the 'Aquarium VR' app played on an iPhone 6, which was inserted into the VR headset. Patients could see sea creatures and hear instrumental music in the background. By gazing at each fish, each patient could learn about what type of fish was present within the virtual aquarium.

Following treatment, each patient was given another questionnaire to complete. The questionnaire contained a mixture of Likert scale, multiple-choice and open-ended questions. The Likert scale statement 'I felt the use of the virtual reality system in helping with my anxiety was...' allowed patients to choose from five responses ranging from 'of no benefit' to 'extremely beneficial'.

Patients were asked whether they would like the dentist to use the VR headset again if they were given the option next time. All patients rated their VR experience out of 10, 0 being not good at all and 10 being very good. Patients had the option of leaving any comments in the comments section of the questionnaire.

Patients' basic information including age, gender, the type and duration of treatment was recorded as was the clinician who carried out the treatment. Face validity of the questionnaire was achieved by the Birmingham Dental Hospital and School of Dentistry Clinical Governance Committee and the Oral Surgery Department.

Overview of participants

There were 50 questionnaires distributed; however, ten of those were disregarded as treatment with VR was discontinued. Therefore, of the 40 questionnaires accepted; there were 20 males and 20 female respondents. Looking at the data, respondents were of varied age groups. There were 22 participants between the ages 18-35 years old, 11 participants between 36-55, and 10 participants were over 55 years old.

Results

Figure 1 shows participant responses to the statement: 'I felt the use of the virtual reality system in helping with my anxiety was...'. Responses from the study were varied, with the majority of participants (35%) finding VR to be 'extremely beneficial'. Only 10% of participants found VR to be of 'little benefit'. The number of participants who responded with 'quite beneficial' and 'of some benefit' were similar, with only a 5% difference between the two. There weren't any participants who found the VR to be of 'no benefit'.

Fig. 1
figure 1

Participant responses to the statement: 'I felt the use of the virtual reality system in helping with my anxiety was...'

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Table 1 shows the responses of participants when asked whether they would want the VR to be used again on their next visit to the dentist. 87.5% of participants responded with a yes, 5% of patients refused whereas 7.5% of patients were unsure.

Table 1 Participant response to 'if I was to visit the dentist again, I would want VR to be used'
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Participants were asked to rate their VR experience as part of the post-treatment questionnaire. While comparing male responses to females (Fig. 2), it was found that females displayed less liking towards the VR compared to males. Only females gave ratings below 7/10, with four females giving a rating of 6/10 and one giving a rating of 4/10. Males were more likely to give higher ratings. This was represented by twelve males scoring their VR experience as 10/10, compared to seven females. More males than females also gave the high ratings of 8/10 and 9/10.

Fig. 2
figure 2

How would you rate your VR experience: males vs. females

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Data were split between three groups: young adults (18-35 years), middle-aged adults (36-55) and older adults (55+). The box and whisker plot below (Fig. 3) shows the varied responses by these different age groups to the statement 'I felt the use of the virtual reality system in helping with my anxiety was...'. The key shows the different response codes.

Fig. 3
figure 3

Distribution of responses amongst different adult age groups to the statement: 'I felt the use of the virtual reality system in helping with my anxiety was...'

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As a general trend, young and middle-aged adults found the VR to be much more beneficial in comparison to older adults. This is represented by the median scores. The median scores of young and middle-aged adults were 4 and 5 respectively, whereas the median for older adults was 3. The large range shows there were more middle-aged adults who found the VR to be of little benefit in comparison to younger adults. Younger adults were more consistent in their preference towards the VR as shown by their narrower, but high interquartile range.

Using the MDAS scale sheet responses, each participant was divided into mild anxiety (MDAS scores of 10 and under), moderate anxiety (MDAS scores 11-18) and severe anxiety (MDAS score 19 to 25).5 When participants were asked to comment on the statement 'I felt the use of the virtual reality system in helping with my anxiety was...', the most common responses were noted (Table 2). Patients with mild anxiety presented a modal response of 'quite beneficial'. The modal response from those with moderate anxiety was 'extremely beneficial' and those with severe anxiety was 'of some benefit'.

Table 2 Modal responses to the statement: 'I felt the use of the virtual reality system in helping with my anxiety was...' by participants of mild moderate and severe anxiety levels
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The data can be split into two categories: non-surgical extractions vs. surgical extractions involving drilling of bone. Figure 4 shows that those participants who had surgical treatment found VR to be much more beneficial than those who had non-surgical treatment. This is shown by the increased number of surgical treatment participants who found VR to be 'quite beneficial' and 'extremely beneficial'. In fact, only 10% of participants who had surgical treatment found VR to be 'of some benefit' in comparison to 30% of those who had non-surgical treatment. No participants who had surgical treatment found VR to be 'of little benefit' or 'no benefit'.

Fig. 4
figure 4

Distribution of responses to the statement: 'I felt the use of the virtual reality system in helping with my anxiety was...' amongst those who underwent non-surgical extractions vs. surgical extractions

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Discussion

In general, the views of participants were positive. The majority of participants made comments on how the VR system managed to divert their attention away from the procedure which helped reduce their anxiety levels. One patient compared the VR system to 'magic' and proclaimed they did not need to use the stress ball they had brought with them to the appointment. Out of all participants, there weren't any patients who found the VR to be of 'no benefit' which suggests that VR holds at least some value as a distraction and anxiety-reducing facility within the Oral Surgery Department. However, a small number of participants did find that being unable to see what was going on around them made them feel disconcerted. Surprisingly, some clinicians raised similar concerns, whereby they refused to take part in the study as they preferred being able to see patients' eyes in order to assess how patients are responding to treatment. Some clinicians found the Virtoba VR headset to be bulky, and therefore found some extractions - particularly of maxillary teeth - to be more challenging.

By looking at the data collected we can identify particular trends that can help ascertain areas where VR may be more useful than others.

This study illustrated that females rated their VR experience lower than males. Some females commented that the VR made them feel uncomfortable, claustrophobic and unaware of their surroundings. The reasoning behind this negative response from females is unclear; however, the results correlate closely with a study carried out by Ernst & Young Global Limited. They wrote about the Reality of VR for women.6 Their study stated that women were less likely than men to have tried the VR (14% vs. 20%), and were also less impressed than men by it. They stated that VR was 'underwhelming' and 'futuristic', whereas males found it 'realistic' and 'positive'.6

The study found that younger adults found VR much more beneficial than middle-aged adults and older adults. Older adults found VR least valuable. Perhaps this is because the younger population are more tech-savvy than the older population, hence currently, younger adults may be a better target for VR. However, there are high promises for the use of VR in the future. Despite the ageing population we currently have, the future cohort of older people will have likely been exposed to advanced technology far more than the current older population. This bodes well for the future of VR since there will be a bigger tech-savvy population to benefit from it.

From the study, those with moderate anxiety (MDAS scores 11-18) felt they benefited the most from VR. Although the majority of those with mild anxiety still found VR to be 'quite beneficial', it seems as though it was not of maximum benefit to them. Maybe this is because their anxiety levels were not high enough in the first place to be drastically reduced by the effects of VR. They were relatively at ease to start with, such that the VR was simply a bonus aspect of the procedure. The majority of those with severe anxiety only found VR to be of 'some benefit'. It is interesting to note that although ten participants had completed the MDAS score sheet and were categorised as those with severe anxiety, they could not go ahead with VR during the treatment. They claimed they felt more anxious with the headset on as they weren't aware of what the clinician was doing. Perhaps this is an indication that VR is not suitable for those with severe anxiety.

It is remarkable to see how the results varied between participants involved in surgical treatment and those involved in non-surgical treatment. Those who underwent surgical treatment appreciated the effects of VR much more than those who underwent non-surgical treatment. This was possibly due to higher anxiety levels associated with the term 'surgery' and with the involvement of bone removal, such that VR had a bigger role to play in distracting the patients. In fact, one patient had commented that by wearing the VR headset, they couldn't see the surgical instruments involved and this made them feel much more relaxed throughout the procedure. The median length of time taken for surgical treatment was twenty minutes compared to ten minutes for non-surgical treatment. Having the VR headset on for longer could have also been the reason why those who had surgical treatment preferred the VR much more since they had a greater experience with the world of virtual reality.

Limitations

The aim of this explorative study was to gain participant views on using VR during dental extractions and whether it is helpful in reducing their anxiety levels. Due to the small sample size however, statistical analyses of the data was unfeasible. Hence any conclusive statements on the use of VR cannot be made.

Despite this, this study highlights positive trends in relation to participants' responses to using VR during dental extractions. The study identifies those groups that took a greater liking towards VR so future larger scale studies can focus on these groups to gain conclusive data.

Conclusion

In conclusion, this study found that the majority of participants had positive views on the use of VR in reducing anxiety levels during extraction procedures. Since this is only an explorative study with limited participants, certain trends have been identified that suggest where and for whom VR may be better suited. This study can therefore form the foundation for future investigations in terms of the use of VR within dentistry.