Can virtual reality reduce anxiety and pain in dental patients?

The fear of pain and dental anxiety are widely recognised as factors that can negatively impact the quality of care and may result in patients discontinuing treatment¹. This avoidance of dental care contributes to poor oral health, including decay and tooth loss. Dentists often face challenges in effectively managing patients’ fear and anxiety².

Several approaches have been used to manage dental pain and anxiety, including techniques such as guided imagery, hypnotherapy and acupuncture. Additionally, strategies such as enhancing patient control, voice control, behaviour shaping, the ‘tell-show-do’ technique, and distraction have also proven effective in alleviating anxiety and dental pain³.

One known distraction technique, virtual reality (VR), aims to immerse users in a three-dimensional environment, disconnecting them from their immediate surroundings^4,5. Research on the use of VR in dental settings has been inconsistent and primarily focused on children. This quantitative systematic review and meta-analysis examined the impact of VR on reducing dental anxiety and pain across all age groups and dental conditions⁶.

The review was conducted with a strong methodological framework. It reports a clear aim and research question, employs a PICOS-guided search strategy, and presents a detailed PRISMA flow diagram⁷. This enhances the reliability of findings and allows the reader to interpret results with a high degree of confidence. The search encompassed two reputable primary databases, PubMed and the Cochrane Library. However, extending the search to include additional databases and grey literature could have further strengthened the review and reduced the risk of publication bias. Positively, the inclusion criteria included all patient groups, regardless of age, gender, or race, and included randomised controlled trials (RCTs) of various designs, including parallel, crossover, and split-mouth trials. Other study designs, for example cohort studies and case control studies, would not have been suitable to answer the research question and provide low quality evidence. The review was not limited by publication date. VR is likely to have advanced in recent years, and recent studies may not be comparable to older studies. A meta-analysis could have been completed grouping publication date on effect. Only studies published in English were included, and there is a risk that relevant studies published in other languages or using different terminologies were not identified.

Data extraction was performed by two independent researchers. The inclusion of a third reviewer could have helped resolve any disagreements and reduced the risk of subjective bias.

The 27 studies included in the review were conducted across various countries and published in reputable journals. Notably, 70% of the studies focused on the effects of VR on children and there was a ‘predominance of female gender’. This reduces generalisability of the review findings. Positively, the effects of VR were explored across a wide range of dental procedures, including the extraction of primary/permanent teeth, pulp therapy, restorative treatment and Inferior Dental Blocks. This increases external validity of the review.

A strength of this systematic review is the authors application of the GRADE assessment tool⁸, which provides guidance for how much confidence can be placed on findings. Additionally, two independent reviewers assessed bias using the Risk of Bias 2 tool⁹. The review authors are transparent in noting that all included studies had a high risk of bias, citing issues such as inadequate concealment of allocation sequences and deviations from the intended interventions. Notably, none of the studies employed double blinding, and 17 studies lacked pre-registered protocols. The quality of evidence was rated low to moderate. Appropriate statistical methods were used to assess heterogeneity, which was found to be high. Adopting a core-outcome set for dental pain and anxiety could support reduced heterogeneity in future reviews.

The high heterogeneity, low to moderate quality of evidence, and high risk of bias in the included studies limits the validity of results. The authors state that the results should be ‘interpreted with caution’.

This review provides valuable insights into the potential use of VR in dental settings, particularly for reducing dental anxiety and pain. It is important for researchers, especially those conducting RCTs, to minimise bias and control for confounding variables. Well-conducted research is needed to build upon these findings and strengthen the evidence base for VR use in dentistry.