ORIGINAL RESEARCH

Comparative Evaluation of the Effectiveness of Innovative

Periorbital Eye Massager and Virtual Reality Eyeglasses
for Reducing Dental Anxiety during Dental Restorative
Procedures in Children
Urvi P Gala1 , Ritesh Kalaskar2

A b s t r ac t
Background: Many behavior management techniques are employed to reduce the anxiety associated with dental procedures in children. One
of the most commonly used methods comprises audiovisual distraction using virtual reality (VR) eyeglasses. In this study, an innovative device,
a periorbital eye massager (PEM), is compared with VR to evaluate dental anxiety in children.
Materials and methods: in this study, 22 children were divided into two groups, that is, group I consisting of PEM and group II consisting of VR.
The participants were instructed to wear the device and then subjected to dental restorative procedures. After completion of the procedure,
anxiety was measured using a validated questionnaire by the children and by using the modified behavior pain scale by the second investigator.
Also, physiological parameters like heart rate and oxygen saturation were evaluated before and after a dental procedure.
Results: The results were statistically insignificant for group I and group II when a validated questionnaire and modified behavior pain scale
were used to measure the dental anxiety of children. Also, the data also shows no significant difference in heart rate and oxygen saturation
between the two groups.
Conclusion: The innovative PEM can also be used as an effective behavior management tool in managing dental anxiety in children, as there
was no statistically significant difference between PEM and VR.
Clinical significance: As a pediatric dentist, the methods for administering a patient present a novel challenge because behavior management
varies from patient to patient. As a result, the prospects for augmenting various techniques of behavior therapy for pediatric patients are limitless.
Keywords: Behavior management, Periorbital eye massager, Randomized controlled clinical trial, Virtual reality eyeglasses.
International Journal of Clinical Pediatric Dentistry (2024): 10.5005/jp-journals-10005-2730

Introduction 1,2
Department of Pediatric & Preventive Dentistry, Government Dental
Dental anxiety is a multifaceted condition with physical, emotional, College & Hospital, Nagpur, Maharashtra, India
and social components. Patients with high levels of dental anxiety Corresponding Author: Urvi P Gala, Department of Pediatric
may endure stress and refuse or postpone treatment. Drug-free & Preventive Dentistry, Government Dental College & Hospital,
techniques are being increasingly employed to reduce stress, Nagpur, Maharashtra, India, Phone: +91 8655131908, e-mail:
lessen dental anxiety during treatment, and develop a positive urvigala195@gmail.com
dental attitude.1,2 To develop a long-term interest between the child How to cite this article: Gala UP, Kalaskar R. Comparative Evaluation
patient and oral health care provider, it is necessary to establish of the Effectiveness of Innovative Periorbital Eye Massager and
relationships based on trust with the child. Although a number of Virtual Reality Eyeglasses for Reducing Dental Anxiety during
nonpharmacological behavior modification techniques are put Dental Restorative Procedures in Children. Int J Clin Pediatr Dent
to use for curtailing apprehensiveness in children, the choice of 2024;17(1):48–53.
technique must be tailored to the needs of the individual patient Source of support: Nil
and the skills of the oral health provider. Conflict of interest: Dr Ritesh Kalaskar is associated as the National
In recent years, digital technology has posed an upper hand in Editorial Board member of this journal and this manuscript was
reducing dental anxiety in pediatric patients.3 Virtual reality (VR) subjected to this journal’s standard review procedures, with this peer
glasses are simple, plastic goggles that hold your mobile phone review handled independently of this editorial board member and his
up to your eyes at the proper distance to display a VR app in the research group.
most immersive way possible. It consists of goggles, a screen, and
processing equipment to deliver another level of display capability. vibration, compression, massage, and music via Bluetooth mode.
Studies have shown that VR is more effective in reducing child A study conducted by Dadkhah et al.7 stated that music plus
anxiety during dental treatment as compared to other behavior periorbital massage reduces nausea and vomiting in patients
management techniques.3–5 undergoing chemotherapy and can be considered a complementary
The periorbital eye massager (PEM) has been regularly used medicine method in conjunction with other medicinal therapies to
as an eye massager not only to reduce stress but also to promote relieve symptoms of cancer patients. Similarly, PEM also helps in
a relaxed state of mind.6 PEM is based on the principles of heat, the relaxation of the muscles of the periorbital region, which may

© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 Comparative Evaluation of PEM and VR Eyeglasses

be tensed due to anxiety of unknown origin. Considering this fact, devices. The cavity preparation was prepared using a high-speed
the use of a PEM in reducing dental anxiety is logical. However, handpiece under water spray and restored using glass ionomer
there is a lack of literature regarding the novel use of this device cement restoration (GC high-strength posterior restorative cement).
in dentistry. Thus, the current study was planned with an aim to Baseline and after-dental treatment anxiety levels of the
evaluate the effectiveness of PEM and VR in reducing the dental children were evaluated using a validated questionnaire provided
anxiety of children during dental restorative procedures. to the children in their vernacular language. The validated
questionnaire provided to the child is as follows:
M at e r ia l s and Methods How did you feel while sighting the device?
After obtaining institutional ethical clearance, the randomized • Not worried.
clinical trial was conducted on children aged 7–12 years and • Mildly worried.
reported to the Department of Pediatric & Preventive Dentistry. • Moderately worried.
Considering a 10% loss of sample, 24 children (Frankl’s behavior • Severely worried.
rating scale 3 and 4) meeting the inclusion and exclusion were
Were you worried when the device was used on you? If yes, how
enrolled in the study. Children with noncontributory medical history
was it?
having classes I, II, and V cavities on primary maxillary or mandibular
molars and canines with at least a minimum of two to three cavities • Not worried.
on each side of the jaw were included. A signed written consent • Mildly worried.
was obtained after explaining the procedure to the children and • Moderately worried.
parents. Children were randomly assigned to two groups using • Severely worried.
opaque sealed envelopes. In group I, children were exposed to How did you feel after the completion of the dental treatment
PEM (Renpho Wellness IN), whereas in group II, VR (Procus ONE X using the device?
VR Headset, 40MM lenses with inbuilt headphones) was used, as
shown in Figure 1. As per allocation concealment in the first visit, • Not worried.
12 children were first exposed to PEM (first visit), whereas the other • Mildly worried.
12 children were exposed to VR (first visit), as shown in Figure 1. In • Moderately worried.
the second visit, the devices were interchanged; the 12 children • Severely worried.
who were exposed to VR devices in their first visit were exposed How would you feel if the dentist wanted to reuse the same device
to PEM (second visit), whereas 12 children who were exposed to on you during your next dental appointment?
PEM in their first visit were exposed to VR devices (second visit).
Before the start and after the dental treatment, baseline anxiety, • Not worried.
cooperative behavior, heart rate, and oxygen saturation were • Mildly worried.
evaluated using a validated questionnaire, modified behavior pain • Moderately worried.
scale, and pulse oximeter (Omron CMS50N Contec pulse oximeter), • Severely worried.
respectively. In the subsequent visits (first and second) restorative How would you feel if you watched the dentist using the same
procedure was performed under rubber dam isolation using both device on another child?
• Not worried.
• Mildly worried.
• Moderately worried.
• Severely worried.
The individual items were read in front of the children. The children
were shown four pictorial images showing facial expressions
and were asked to select any one of the images they felt could
best correspond to their response. Figure 2 shows facial images
depicting levels of anxiety as follows:
• The total score of each child was a maximum of 20, and the
minimum score was 4. Based on the score obtained of the
anxiety, each child was further categorized as follows:
• 5 = No anxiety.
• 6–10 = Mild anxiety.
• 11–15 = Moderate anxiety.
• 16–20 = Severe anxiety.

Fig. 1: The figure shows the VR eyeglasses device and PEM device; it
also shows the patient wearing these devices Fig. 2: Facial images depicting levels of anxiety

International Journal of Clinical Pediatric Dentistry, Volume 17 Issue 1 (January 2024) 49

 Comparative Evaluation of PEM and VR Eyeglasses

The cooperation of the child was also assessed by a second The second investigator observed the behavior of the child in
investigator who was observing the dental treatment. Baseline terms of facial expression, crying, and movements during both visits
cooperative behavior and during treatment behavior (visits) and then evaluated it using the above-mentioned scale from scores
were assessed using the modified behavior pain scale, which is 0 to 10. The patients who exhibited negative behavior during the
as follows8: treatment were given higher scores compared to those who were
relaxed during the procedure. The subsequent visit was scheduled
1 week later than the previous visit. During the next visit, the
Behavior observed Score devices of the group were interchanged. Hence, the participants
present in group I who were subjected to PEM in their first visit
Facial expression were now exposed to VR devices during their second visit. Similarly,
Definite positive expression (i.e., smiling) 0 participants in group II were given PEM on the next visit as they
Neutral expression 1 were previously treated wearing a VR device. During the second
visit, a similar procedure was performed, and the anxiety levels
Slightly negative expression (i.e., grimace) 2 of the participants were evaluated in the same manner as done in
Definite negative expression (i.e., furrowed brows, 3 the first visit. The anxiety of the children was classified based on
eyes closed tightly) the score obtained.
Cry • 2 = No anxiety.
Laughing or giggling 0 • 4 = Mild anxiety.
• 7 = Moderate anxiety.
Not crying 1
• 10 = Severe anxiety.
Moaning, quiet vocalizing, gentle, or whimpering cry 2
Heart rate and oxygen saturation were evaluated before and after
Full-lunged cry or sobbing 3 treatment (first and second visits of both devices).
Full-lunged cry, clearly more than the baseline 4
Statistical Analysis
Movements
The sample size was calculated using G*Power software 3.1 from
Usual movements and activity, resting and relaxed 0 the data obtained from a previous study conducted by Padminee
Partial movement or attempt to avoid pain by 2 et al.9 The test of significance applied to calculate the dental
withdrawing limb when the procedure is done anxiety of children using a validated questionnaire between groups
after dental treatment was completed was Mann–Whitney U test
Agitation with complex movements involving the 3
head, torso or other limbs, or rigidity
(Table 1). Using a validated questionnaire, the Wilcoxon sign rank
test was used to measure the dental anxiety of children subjected
Total 10 to PEM and VR devices after the dental treatment of the first and
Test of significance, Mann–Whitney U test second visit (Table 2). The dental anxiety of children was evaluated

Table 1: Posttreatment dental anxiety of the children between the two groups using a validated questionnaire
Group I Group II
Anxiety Baseline anxiety N (%) N (%) p-value
No anxiety 13 (59.09%) 11 (50%) 10 (31.82%) 0.782
Mild anxiety 9 (40.90%) 11 (50%) 12 (54.55%)
Moderate anxiety 0 (0.0%) 0 (0.0%) 0 (0.0%)
Severe anxiety 0 (0.0%) 0 (0.0%) 0 (0.0%)
Total children 22 (100%)
Test of significance, Mann–Whitney U test

Table 2: Posttreatment dental anxiety of the children in the first and second visit of the respective groups using a validated questionnaire
Anxiety PEM (first visit) PEM* (second visit) p-value VR (first visit) VR** (second visit) p-value
No anxiety 2 (18.20%) 9 (81.80%) 0.157 6 (54.55%) 1 (9.1%) 0.257
Mild anxiety 9 (81.80%) 2 (18.20%) 5 (45.45%) 7 (63.6%)
Moderate anxiety 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (27.3%)
Severe anxiety 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
Total children 22 (100%) 22 (100%)
*The children in group I were initially subjected to VR eyeglasses on their first visit, and they were exposed to PEM during their second visit; **the children
in group II were initially subjected to PEM on their first visit, and they were exposed to VR during their second visit; PEM, periorbital eye massager; VR,
virtual reality; test of significance, Wilcoxon sign rank test; *p < 0.05 is considered statistically significant

50 International Journal of Clinical Pediatric Dentistry, Volume 17 Issue 1 (January 2024)

 Comparative Evaluation of PEM and VR Eyeglasses

by the second investigator within the groups during their first and The dental anxiety of the children during treatment was
second visits with the help of a paired sample t-test (Table 3). The evaluated by a second investigator in both groups during their
mean heart rate, blood pressure, and oxygen saturation of children first and second visits. The baseline anxiety of the children before
in group I and group II were also evaluated before and after the the start of the treatment was 1.76 (±0.54). In group I, there
treatment during the first and second visits (Table 4). was an increase in the mean anxiety of children in the second
visit (9.0) as compared to the first visit (7.09); the difference was
R e s u lts not statistically significant. However, when compared with the
baseline anxiety, there was a significant increase in anxiety
Before the start of the dental treatment, approximately 59.09% of
after dental treatment. In group II, there was a slight increase
the children who were involved in the study and divided into two
in anxiety in the second visit (5.63) against that of the first
groups had no anxiety, whereas 40.90% of the children had mild
visit (5.18), but the difference was not statistically significant.
anxiety. After dental treatment, 31.82% of the children who were
Similarly, children exposed to VR (group II) did not show any
exposed to VR were anxiety-free as compared to 50% of children
significant increase in anxiety when compared with the baseline
with PEM. The children with mild anxiety increased in VR (54.55%)
anxiety (Table 3).
against that of PEM (50%). The VR device was more effective in
The mean baseline heart rate of children was 106.54. In the
reducing the anxiety of children as compared to PEM; however, the
PEM group the mean heart rate of the children does not show any
difference was not statistically significant (Table 1).
significant increase in the first and second visit of dental treatment.
During dental treatment children were equally divided into two
Similarly, in the VR group also no significant increase in heart rate
halves of 11 each for their first and second visit. On the first visit,
was observed between the visits.
half of the children were exposed to group I, whereas the other half
Before the start of the treatment, the mean oxygen saturation
of the children were exposed to group II. So, during their second
reported in children was 96.72. There was no decrease in the oxygen
visit the children would have been already exposed to either of the
saturation of the children in both groups on their first and second
groups. The result demonstrated that in the PEM group, children
visits (Table 4).
with no anxiety were more in the second visit (81.80%) as compared
to the first visit (18.20%), whereas the children with mild anxiety
were less in the second visit (18.20%) as compared to first visit Discussion
(81.80%). The difference between the visits of treatment in group Anxiety is an emotional state that precedes the actual encounter
I was statistically nonsignificant, irrespective of the use of devices. with the threatening stimuli, which sometimes is not even
In the VR group, approximately 54.55 and 45.45% of the children identifiable.9 It is normally experienced in day-to-day life, such as
had no and mild anxiety, respectively, on the first visit. However, during exams, while making crucial decisions, in the workplace,
during their second visit, there was a marked increase in the and in several other circumstances. Many children often suffer from
percentage of children with mild anxiety (63.60%). The difference dental anxiety due to invasive past dental experiences, which cause
between the visits within the group was statistically insignificant. It them to neglect their oral health. Hence, it is important for the oral
can be inferred that PEM was also preferred by children along with health provider to reframe the past bad dental experience by using
VR eyeglasses (Table 2). various behavior management techniques.

Table 3: Posttreatment dental anxiety of children evaluated by the second investigator within the groups during their first and second visit
PEM (group I) VR eyeglasses (group II)
Groups Baseline anxiety First visit [N (11)] Second visit* [N (11)] First visit [N (11)] Second visit** [N (11)]
Mean 1.76 7.09 9 5.18 5.63
Standard deviation (SD) (±) ±0.54 ±1.814 ±2.049 ±0.404 ±0.809
p-value 0.062 0.176
*The children in group I were initially subjected to VR eyeglasses on their first visit, and they were exposed to PEM during their second visit; **the chil-
dren in group II were initially subjected to PEM on their first visit, and they were exposed to VR during their second visit; PEM, periorbital eye massager;
VR, virtual reality; test of significance, paired sample t-test

Table 4: Mean heart rate and oxygen saturation of children in group I and group II before and after dental treatment
Before treatment PEM (first visit) PEM (second visit) VR (first visit) VR (second visit)
Heart rate
Mean 106.54 115.09 118.18 111.81 116.36
SD 6.578 8.395 6.274 8.772 4.272
p-value – 0.583 0.138
Oxygen saturation
Mean 96.72 96.36 97.72 97.81 97.63
SD 1.272 0.674 1.009 0.981 1.026
p-value – 0.866 0.676

International Journal of Clinical Pediatric Dentistry, Volume 17 Issue 1 (January 2024) 51

 Comparative Evaluation of PEM and VR Eyeglasses

To date, many behavior modification techniques have been result in the child being deeply soothed by the massager and
used; the trending VR, which is based on digital technology, is playfully engrossed in the immersive video.
proven to be an effective behavior management tool in reducing
dental anxiety. Since this device has several health-related and
economic disadvantages, this clinical trial has been incorporated
C o n c lu s i o n
with PEM. It is a device that enables the child to address his own The present study helps to conclude that both, PEM and VR
anxiety through relaxation methods. There are many studies eyeglasses can be useful in controlling the dental anxiety of
in the literature that highlight the importance of massage children. Since behavior management provides a lot of room for
therapy to reduce anxiety and thereby create relaxation in the new innovative devices and techniques, this massager can be
human body.10 Miller et al.11 evaluated the effects of a brief augmented into it. This device seems to be a cost-effective, user-
bedside massage intervention as an adjunct to pharmacologic friendly, and reliable tool for oral health care providers to manage
pain management in orthopedic surgical patients and found anxious children in performing dental treatment more effectively.
that the addition of a 5-minute massage treatment at the time
of analgesic administration significantly increased patient Orcid
satisfaction with pain management. Also, a study performed
Urvi P Gala https://orcid.org/0000-0003-3715-8189
in 2001 in Korea demonstrated that hand massage decreases
Ritesh Kalaskar https://orcid.org/0000-0001-7403-3364
psychological and physiological anxiety levels in patients having
cataract surgery under local anesthesia.12 In a case report by
Kunusoth et al.,13 a significant reduction in dental anxiety was References
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