Today, the use of Virtual Reality (VR), aromatherapy and stress reduction techniques are transforming the dental experience. As these technologies become more accessible, their integration not only promises to alleviate patient discomfort, pain and anxiety but also stands to enhance the overall efficiency and satisfaction of dental procedures.
These developments ride on the recent trend of spa dentistry or dental spas, presenting innovative and patient-centric solutions. By infusing spa-like elements into the traditional dental setting, dental spas aim to improve the overall patient experience during dental visits. This approach represents a progressive step in addressing not only the physical aspects of dental care but also the emotional and psychological well-being of patients.
In this post, we explore the scientific literature on VR’s efficacy in managing the levels of pain and anxiety during dental procedures. This approach aligns with the 4 S principle proposed by Walsh (2007) for managing anxiety behaviors and their consequences in dental settings. The 4 S principle emphasizes the need to address four primary triggers of stress to minimize patient anxiety and enhance comfort during dental care:
• Sights (e.g. needles, air turbine drills)
• Sounds (drilling)
• Smells (e.g. eugenol and cut dentine)
• Sensations (high frequency vibrations - the annoyance factor)
Medical procedures frequently result in discomfort, pain, and anxiety among a substantial portion of patients (Redelmeier et al., 2003). These challenges are of particular concern in the field of dentistry, where dental anxiety is a pervasive concern. In the United States, approximately 80% of the population is estimated to experience anxiety during dental procedures, and within this group, 5-14% report experiencing intense dental anxiety (Saatchi et al., 2015). Moreover, it is essential to note that dental anxiety is a universal phenomenon, affecting individuals of all ages across different countries (Shim et al., 2015). As revealed by Hofer et al. (2016) it can impact one-third of dental hygiene recall patients.
Individuals with dental anxiety often attempt to avoid or delay necessary dental care (Chlan et al., 2000) and routinely miss dental appointments, which can lead to more complex treatment needs (Armfield & Heaton, 2013). In this line, research studies have confirmed that anxious patients tend to have higher rates of dental issues, including more decayed, missing and unfilled teeth compared to non-anxious individuals (Esa et al., 2010). This poor oral health status negatively impacts their overall quality of life, influencing personal, social, and occupational aspects (Crofts-Barnes et al., 2010). As noticed by Doerr et al. (1998) the anticipation of a painful experience is the major obstacle for seeking dental treatment (Doerr et al., 1998).
Dental anxiety and fear also present significant challenges for dental care providers. Patients with high levels of anxiety are often more difficult to manage during dental procedures, requiring additional time and effort, and they express lower satisfaction with the service (Brahm et al., 2012; Quetish Taani, 2002). Consequently, dentists report that patients with dental anxiety are significant sources of work-related stress and burnout (Goetz et al., 2019).
Despite recent advances in dental technologies and treatments, patients continue to report dental treatments as painful (Tickle et al, 2012). Furthermore, dental anxiety is frequently linked to the experience of pain and unpleasantness during dental procedures, as observed in the study by McNeil et al. (2011). Reducing anxiety and pain during dental procedures has been suggested as a means to create less unpleasant memories of the experience. This, in turn, may enhance the likelihood of future oral health care attendance (Wilson et al., 2014).
Recognizing the impact of dental anxiety on both patient experience and dental care providers, the American Dental Association (ADA) advocates for the implementation of stress reduction techniques in dental offices (Shetty et al., 2018). These techniques may include mindfulness and breathing techniques or the creation of a calm environment using multimedia devices, such as audio or calming images.
In response to these challenges, dental spas have emerged as innovative and patient-centric solutions (Shah et al., 2018), becoming an established part of the dentistry market. These specialized facilities integrate traditional dental care with stress-reducing amenities, aiming to alleviate patient anxiety, pain and other negative emotions. By incorporating spa-like elements such as a calming environment, relaxation and massage techniques and aromatherapy, dental spas seek to enhance the overall patient experience and foster a positive association with dental visits, creating more pleasant memories for patients.
Pain perception during medical procedures is significantly influenced by psychological factors, with conscious attention playing a crucial role in shaping the experience. Distraction and relaxation techniques have been demonstrated as effective methods for diverting a patient's attention away from pain (Krainbuhl et al., 2022). Importantly, the degree of attention directed towards the source of pain not only impacts the reported pain intensity but also influences distress levels. Encouraging patients to shift their attention to other thoughts serves as a potent non-pharmacological analgesic, reducing the attention available for perceiving pain.
The use of immersive and interactive technologies like Virtual Reality (VR) offers an opportunity to capture a significant portion of a patient's limited controlled attentional resources (Hoffmann et al., 2011). This diversion of attention leaves fewer cognitive resources available to process incoming pain signals. Consequently, redirecting patients' attention to a relaxing virtual world has been proven to be an effective and safe method for alleviating acute pain and anxiety levels in patients undergoing painful or unpleasant procedures (Georgescu et al., 2020; Trost & Parsons, 2014).
In the specific case of dental procedures, the existing scientific literature has shown that the use of VR technology is more effective in reducing pain and anxiety compared to more traditional methods such as:
It is also interesting to mention that the use of VR during a dental procedure reduces both subjective and physiological measures of acute pain and anxiety:
Furthermore, the use of VR enhances patient behavior during dental procedures, resulting in faster, more efficient, and more pleasant treatments (Al-Khotani et al., 2016; Nuvvula et al., 2015).
A growing body of literature, including studies by Andrews (2021), Appukuttan (2016), and Tellez et al. (2015), emphasizes the potential efficacy of meditation-based techniques in managing dental anxiety and pain. These practices are commonly associated with inducing high levels of relaxation, characterized by increased parasympathetic tone and decreased sympathetic activity during dental procedures (Lutz et al., 2007).
Meditation-based techniques have proven to be reliable sedative tools in various dental procedures, such as dental implant operations (Turer et al., 2023), dental root canal therapy (Morse, 1977; Thiruvalluvan et al., 2021), or the treatment of periodontal disease in adults (Sudhanshu et al., 2017). Additionally, promising studies suggest the efficacy of meditation-based coping skills training in treating dental phobia among school-aged children (Del Gaudio, 1987). Meditation techniques have also demonstrated a negative correlation with both state and trait dental anxiety (Yao et al., 2023).
Beyond meditation, relaxation techniques like brief relaxation therapy or breathing relaxation have proven useful in reducing anxiety and/or pain before dental procedures in adults (Ali Alhazmi et al., 2022; Ebrahimi & Bamadi, 2018; Lamb & Strand, 1980; Litt, 1999; Rossy, 2004) and children (Nocella & Kaplan, 1982). Positive results have been also found in various pediatric dental procedures, including bilateral pulp therapy of mandibular molars (Bahrololoomi et al., 2022), maxillary buccal infiltration anesthesia (Sridhar et al., 2019), primary molar extractions (Sabherwal et al., 2021), and non-invasive dental examinations (Silverman, 2014).
Recent studies have also demonstrated the efficacy of meditation and relaxation techniques in improving various physical and psychological disorders affecting dental professionals. Notably, these techniques have been particularly effective in preventing musculoskeletal disorders (Gandolfi et al., 2023; Gupta et al., 2014) and in reducing stress levels among dental practitioners and students (Alire et al., 2020; Lane et al., 2021).
The evolving landscape of dental care is witnessing a harmonious integration of meditation and relaxation techniques to alleviate anxiety, stress and pain. Embracing the holistic benefits of these practices not only transforms dental care but also offers a pathway to fostering overall well-being for individuals of all ages.
Binaural beats technology involves the simultaneous delivery of two auditory stimuli, each possessing a constant intensity but differing frequencies, to the left and right ears of an individual. The brain perceives a single tone or beat whose frequency lies midway between the two original tones. The therapeutic properties of binaural beat technology are based on an effect called frequency-following, which induces a brain activity that corresponds to the perceived beat. The applications of binaural beats span a wide spectrum, ranging from cognitive enhancement to anxiety management and pain reduction (see this post for a review of the benefits of binaural beats for mental health).
Recent findings are suggesting that Binaural Beats can be used as a non-pharmacological adjuvant to reduce the levels of anxiety and pain during dental procedures in adults and children. Menziletoglu et al. (2021) and Isik et al. (2017) found that the use of binaural beats effectively reduces preoperative dental anxiety in impacted third molar surgery; while EL Aly et al. (2022) observed that the use of Binaural Beats Music reduced the levels of post-operative pain in adults undergoing maxillary fixed orthodontic appliance. In a similar way, Padawe et al. (2023) found that the use of binaural beats can reduce the levels of preoperative and intraoperative anxiety in pediatric patients requiring a dental treatment.
The collective evidence from these initial studies indicates the promising role of binaural beats as a non-pharmacological intervention for anxiety and pain reduction in dental procedures.
Virtual reality, known for offering immersive experiences, extends beyond visual and auditory stimuli. The sense of smell, for example, is intricately connected to the user's emotions and memories, which enrich the sensory dimensions of VR. Precisely, in current VR experiences the sense of smell can be stimulated through aromatherapy.
Scientific literature underscores the significant role of olfactory stimuli in triggering dental anxiety. Various odors encountered in dental settings, including eugenol, bonding agents, medicaments, the scent of cut dentine, and the odor of the drill, have been identified as key contributors to patient dental anxiety (Blumer et al., 2018; Hmud & Walsh, 2007; Moslemi et al., 2021; Oosterink et al., 2008; Walsh, 2007). These dental odors often evoke memories of past unpleasant experiences, particularly those associated with painful procedures like restorative dentistry on vital teeth, exacerbating patient anxiety (Robin et al., 1998; Robin et al., 1999).
Given this context, strategies aimed at removing or masking olfactory triggers have promise for mitigating anxiety in dental patients. Strategies aimed at mitigating dental anxiety by addressing olfactory triggers show promise. Introducing pleasant ambient odors, such as natural essential oils, into the dental environment can help mask unpleasant smells and potentially alleviate anxiety through the anxiolytic effects of aromatherapy
In contemporary scientific literature, evidence supports the efficacy of aromatherapy in alleviating acute pain and anxiety across various contexts (Lamadah & Nomani, 2016; Mirzai et al., 2009; Tafazoli et al., 2011).
Within dentistry, recent research by Weisfeld et al. (2021) and Jimson et al. (2016) suggests that aromatherapy can effectively reduce the negative emotions of patients undergoing dental procedures. Introducing the orange aroma in dental offices has been found effective to reduce anxiety and enhance mood in patients (Lehrner et al. 2000). Moreover, essential oils such as lavender or rose oil have shown potential in decreasing anxiety levels in orthodontic patients (Premkumar et al., 2019) and anxiety levels preceding oral surgery (Karan, 2019). Studies also indicate the efficacy of aromatherapy in reducing dental pain (Alkanan et al., 2023).
Interestingly, research also highlights the effectiveness of aromatherapy in reducing anxiety and pain in anxious pediatric dental patients (Arslan et al., 2020; James et al., 2021; Janthasila & Keeratisiroj, 2023; Nirmala & Kamatham, 2021; Pradopo et al., 2017).
These findings illustrate the potential benefits for dental spas in incorporating aromatherapy to enhance the emotional experience of their clients.
The integration of VR technology in the field of dentistry offers a promising avenue for enhancing patient experience, reducing anxiety and pain perception, and improving the overall efficiency of dental procedures. The body of scientific literature demonstrates that VR can effectively divert patients' attention away from the sources of discomfort and pain, resulting in more pleasant treatment experiences.
Building upon previous research and reflecting the principles of the 4 S framework, Relax VR integrates exposure to virtual natural scenes, guided meditations, binaural beats, and the use of organic essential oils. This holistic approach aims to elevate user’s positive emotions and alleviate distressing thoughts and emotions, providing a comprehensive and immersive solution to promote well-being during dental experiences.
As the cost of VR equipment continues to decrease and more user-friendly platforms become available, the barriers to its adoption in dental practices are diminishing. Its potential to revolutionize the dental experience should not be underestimated, offering a win-win solution for both patients and practitioners with a relatively minimal investment.
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