Application of Virtual Reality on Non-drug Behavioral Management of Short-term Dental Procedure in Children

Application of Virtual Reality on Non-drug Behavioral Management of Short-term Dental Procedure in Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Application of Virtual Reality on Non-drug Behavioral Management of Short-term Dental Procedure in Children Longkuan Ran, Nan Zhao, Lin Fan, Pinping Zhou, Chao Zhang, Cong Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-46868/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Backgroud: The inherent characteristics of immersion, imagination, and interactivity in Virtual Reality,it may be suitable for non-drug behavior management of children in dental clinics.The purpose of this trial was to measure the role of virtual reality distraction on the behavior management of short-term dental procedure in Children. Methods: A randomized clinical trial design carried out on 120 children aged between 4 and 8 years to make clear the comparative efficacy of virtual reality and Tell-Show-Do in improve behavioral management of dental procedure.The levels of operative anxiety and pain were assessed using, respectively, Children’s Fear Survey Schedule-Dental Subscale, Visual Analogue Score. Frankl Behavior Rating Scale was tested before and during dental procedure.The length of dental procedure was compared between the two groups after treatment. Results: The average anxiety and behavioral score of virtual reality group were significant reduced than that of control. The decrease score of anxiety score of virtual reality group and control group were IQR 8(7,11) and 5(5,7), p <0.05. The compliance scores of control group in the treatment time were 3(2,3),the same in virtual reality intervention were 3(3,4), p =0.02. We observed a significant reduction in pain by using Virtual Reality distraction( p <0.05). Comparing the length of dental procedure, we found that VR group(19.02±5.32) had shorter treatment time than the control group(27.80±10.40) Conclusion: The use of virtual reality could significantly reduce the anxiety and pain of children , length of dental procedure and improve the compliance of children undergoing short-term dental procedure without adverse reaction. Trial registration: Chinese Clinical Trial Registry :ChiCTR2000029802. Registered on 14th Feb, 2020. Translational Medicine Internal Medicine Integrative & Complementary Medicine Virtual Reality Dental anxiety Pain Short-term dental procedure Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Behavioral management success may be related to the following two variables: dental anxiety is a psychological state can be modified and controlled with psychological techniques, pain is an unpleasant sensory and emotional experience [1].For the children's cognition levels of dental procedure, it is necessary to conduct behavioral management ,so that the children can cooperate with pediadontist to complete the treatment. In Southwest China , a substantial proportion of children are unable to collaborate well with doctors and nurses because of dental anxiety.The augment of pain,tense and fear-related behaviors during dental procedures was defined as Dental Anxiety（DA), it can be expressed as rapid heart rate, muscle tension and even syncope[2].Dental anxiety refers to a universal level of stress that is characteristic of an individual, that is, may has a constant level during the life span.The emotion interferes significantly with the personal daily life,career development or relationships. Various studies have found the incidence of dental anxiety to be 20%–43% depending on the age of the child.In recent survey, dental anxiety have produced a majority of clinical trouble in pediatric dental treatment[3]. With regard to the treatment of dental anxiety, drug systematic was generally used in the Department of Anesthesiology of Stomatological Hospital affiliated to Chongqing Medical University,such as Nitrous oxide(N 2 O) induced conscious sedation and sevoflurane inhalation anesthesia. The N 2 O sedation can only be applied in children got 3 or 4 Frankl Behavior Rating (FBR)Scale. Because the children are awake and have no other way to distract their attention, many children do not cooperate with pedodontists in the course of dental procedure. In sevoflurane inhalation anesthesia, because the children and their families need to carry out general anesthesia-related preoperative preparation: appointment waiting, fasting and drinking, risk of apnea,recovery after anesthesia, etc. The child's parents may think twice about possible damage from general anesthesia on their children. As a result of the above various problems, some children did not receive timely treatment , result in lifelong poor oral health , even bring long psychological trauma[4]. Hence, timely and effective management of dental anxiety is central to improving the mental and physical health of children with oral diseases. The virtual reality technology(VR) creates a highly realistic virtual ,three-dimensional (3D) environment that provides various sense stimulate ( sense of vision, sense of hearing, touch even includes sense of smell) for the user who escape the real world [5,6].By stimulating visual, auditory and proprioceptive sensations, virtual reality acts as a distraction to interfere the user's handling of noxious stimuli[6].In the last decades VR has applied in different health care. In particular, VR has reported in many clinical trials,such as trauma rehabilitation[7,8],burn care[9,10],cancer treatment[11] ,operation training[12] and weight- related disorders[13].Sato K and Sarig-Bahat have performed VR on the Complex regional pain syndromes[14] and chronic neck pain [15]. The analgesic effects of VR-distraction reduce negative emotions (e.g. anxiety) and lead to positive emotions[16].A part of studies supports VR distraction has been used to relieves both pain and anxiety [5,6，17-22].Similarly, virtual reality as a distraction intervention to relieve pain during perioperative period in dental surgery[17,21].The application of VR technology in behavioral management of children's dental procedure is not deeply studied. There have also been recent reports that could reduce pain and anxiety in the dental setting and procedures [23,24],but the type of dental procedure is single and the Suitable duration of treatment remains to be explored. In this study, we measured the role of virtual reality in non-drug behavior management in children with short-term and simple dental procedure. Methods Setting and patients This single crossover clinical trial recruited 120 preschoolers aged 4-8years who came to the Stomatological Hospital of Chongqing Medical University for dental treatment .This study followed the Declaration of Helsinki on medical protocol and ethics and the regional Ethical Review Board of the Stomatological Hospital of Chongqing Medical University approved the trial. Inclusion Criteria Consenting children(aged 4-8 years)with the Children’s Fear Survey Schedule-Dental Subscale(CFSS-DS)questionnaire greater than to 19[25].Time of dental procedure(Caries treatment,Extraction of deciduous teeth,Incision of abscess,Root canal therapy) is expected within half an hour. Exclusion Criteria The exclude criteria cases were children or their families can't agree, and their families were concerned that VR will have an impact on the eyes of the child, as well as for other reasons to interfere with the cause of the wearing of the VR glasses, such as those with glasses already in myopia. Since VR may cause motion sickness in some users, we exclude children with a history of motor diseases, motor nausea or vomiting. The child with a history of epileptic or epileptic seizures were also excluded, as there were reports that VR had a theoretical risk of inducing seizures. Unpleasant treatment experience can increase anxiety and pain during the next dental sessions, resulting, in turn, to perceive more pain.Therefore, in the study subjects were excluded if they had previous serious dental experience[26]. If the child has serious fear or severe movement during the intervention, the trial will be terminated immediately.Fig. 1 shows the CONSORT flow chart for the trial. Technical Specifications The HTC 's VIVE VR helmet which was commercial, widely used, short delay time for video scenes, and was not prone to head vertigo. The VIVE comprises 32sensors for 360 degrees motion tracking, two 2160 by 1200 combined resolution AMOLED screen, and a 90 Hz refresh rate. The helmet is connected to ASUS Game notebook with an Intel Core i7-8820K processor ,16 gigabyte RAM and a NVIDIA GeForce GTX 1070 graphics card.The virtual environment allows the user to navigate naturally,which is created through a 110 degrees field of view for immersion. Procedure Patients will be randomly allocated to two conditions by using the randomization software (STATA software version 15.1).Eligible children and their families have been informed about the trial by anesthetists,and signature of informed consent statement on preoperative .Once, they agreed to participate in the study,personal medical data were collected by researchers and baseline anxiety were assessed by CFSS-DS (T0：time after signing the consent) .Next, the anesthetist nurse randomly allocated children to the VR intervention, or to the control group(children only received Tell-Show-Do as usual). Block randomization was performed by type of dental procedure:caries treatment,extraction of deciduous teeth,incision of abscess and root canal therapy.After randomization, the VR intervention have took place in a separate room under the guidance of the nurse anesthetist,children in the TSD group were admitted to the other room.Both groups were treated by experienced pediatric dentists. Fig.2 shows an example of dental procedure using HTC 's VIVE helmet. The assessment per time point was performed. Frankl Behavior Rating Scale was scored before intervention(T1：5 minutes before dental procedure) and re-measured at the moment of local anesthetic injection(T2). CFSS-DS and Patient Satisfaction (PS) scores were performed 5 minutes after the end of treatment(T3). Visual Analogue Score (VAS) was evaluated at both T2 and T3 points, and its score ranged from 0 to 10 (0, no pain; 10, extreme pain). Because VR intervention has the potential to cause adverse events, Dizziness, nausea, vomiting, and epilepsy which have been follow up throughout the course of treatment. We also measured changes in heart rate and peripheral capillary oxygen saturation between the two groups before, during and after the dental treatment. Virtual reality intervention Before the dental procedure, we show the patient the corresponding scenes, specific inducers and background music that joint development with psychologists, which can attract his attention to relax him. The child need lie down on the dental chair and not shake his head left and right, causing the treatment to be interrupted.The nurse anesthetist put the helmet and earphone on child,who enter a virtual world he can follow our set route and watch different information expressed in the scene. The story begins in the world of the seabed which is about to be devastated. Only when the undersea creatures share their most precious things to nourish a rare pearl can save the undersea world. At first,"I" am in a shell, and the little elf introduces the creatures of the sea and their precious spirit. Secondly, sea anemone protect the clown fish while the clown fish reduce the surface precipitation of the anemone, and they share this precious friendship of helping each other (Fig. 3a).Next, for children to introduce the ancient precious and tenacious vitality of animals: turtles (Fig. 3b). And then, introduce the parrot fish solidarity (Fig. 3c) and dolphin helpful spirit (Fig. 3d). Scene switching for children to introduce beautiful and dangerous jellyfish, it shares his valuable storm prediction ability (Fig.3e). Finally, the pearl was born from the precious spiritual nourishment of thousands of marine creatures,, and the undersea world restores its former peace and tranquillity.(Fig. 3f). Meanwhile, The virtual environment was also displayed on the ASUS notebook, so the accompanying families could see what the child was viewing. Statistical Analyses Data were performed using SPSS software version 22 ((IBM, Chicago, USA). The statistical significance difference was set at p < 0.05. Chi-square Test was used to assess gender difference, ASA physical status ,type of dental procedure and local anesthetic between the two groups. All quantitative variables were presented as mean± SD (standard deviation), and the analysis of variance or nonparametric test was performed for comparisons in accordance with the data distribution. Mann-Whitney U tests were used to compare the downtrend level of anxiety scale and Frankl Behavior Rating scale. Results The trial comprised 25 girls and 35 boys in VR group and 32 girls and 28 boys in TSD group, respectively. The mean ages of the trails in group VR and TSD were 5.59±0.92 and 5.66±0.99 years, p =0.69. Similarly,with no significant differences between the two groups in the means of regarding gender ,ASA physical status, type of dental procedure and local and type of dental procedure(Pearson chi-square test, p >0.05; Table 1). The mean anxiety scores were decreased significantly after VR distraction. In VR group: the Children’s Fear Survey Schedule-Dental Subscale was 34.17±5.81 before intervention, which decreased to 24.77±6.98 after VR distraction. Meanwhile, in TSD group: the anxiety scores were 34.08±8.42 and 27.98±7.41, respectively(n=60). The anxiety score between VR-intervention and TSD were statistically difference after dental procedure (Table 2). Table 2 also shows the downtrend of anxiety score variations between the two groups and the differences were statistically significant. The Mann-Whitney U tests of Frankl Behavior Rating scores of VR group in the time of Pre-intervention were 2(2,3). Same in the time T2 of VR distraction treatment were 3(3,4),which represented that VR distraction have improved the patient compliance. In control group, the FBR scores before intervention and the time of the maximum procedure pain were 2(2,3) and 3(2,3), respectively. Those indicate that virtual reality could Increase the compliance ( P =0.02; Table 2). A total of 5 children (8.33%) in VR group had severe intraoperative anxiety and stopped treatment in fear, compared with 11 cases(18.33%) in TSD group ( p <0.05).The CFSS-DS score of the children after the exclusion of the above person were found VR interference relative to the control group can still significant alleviate the anxiety of the children, p <0.05. The FBR score of both groups at T2 has no statistical difference. During the operation, we observed that the pain score of the VR group (1.58±1.08) was lower than that of the control group (2.86±0.96). Meanwhile, the results showed that the VR intervention at the end of treatment, relating to the control of operation pain, worked best (p<.001) in patients. Comparing the length of dental procedure, we found that VR group(19.02±5.32) had shorter treatment time than the control group(27.80±10.40). The results of this trial also have indicated the decrease of treatment time was particularly significant in caries treatment and root canal therapy and was statistically significant (p<.001) .Table 2 also shows the overall patient satisfaction of dental procedure of VR intervention (88.33±7.15) was significantly higher than group TSD (76.78±8.49). After monitoring Physiological signs, we found that VR group decreased heart rate while the control group did the opposite ( p< 0.05; Fig.4). There was no significant difference in the SPO 2 , which was detected before- and after-intervention between the two groups. Discussion Our group has been engaged in oral-related sedation and analgesia for a long time, so we consider whether we can use new methods to relieve dental anxiety in this group of children [27-29]. Thus, the trial has focused on the effectiveness of compliance changes in the VR distraction in 4-8-year-old children during short invasive dental treatment [4].This results of the trial support that virtual reality would be associated with a greater decrease in behavioral avoidance compared to who received Tell-Show-Do-intervention. The anxiety score of the two groups before and after the intervention, the VR group have decreased more than the control group, but the compliance score of the children increased. Asl Aminabadi N et al. reported that virtual reality eyeglasses can successfully decrease pain perception and state anxiety during dental treatment in 4-6 years old children [30]. similarly,Shetty V observed that Virtual Reality distraction can be used as a successful behavior modification method in 5 to 8 Year Old children undergoing short invasive dental treatments[31].Therefore, the trial further strengthens that immersing a virtual environment can help control dental anxiety during pediatric dental treatment on children.Researchers have showed that the effect of VR technique on pain perception is beyond simple distraction[32]. In addition, By diverting attention from an unpleasant environment setting to a pleasant and absorbing virtual world,VR also obviously diminish a patient’s physical pain experience[8,33,34 ].By relieving anxiety and reducing pain , children can markedly cooperate with treatment which have be like with Caries treatment, Root canal therapy. Meanwhile,we observed that the treatment time of VR group had significantly shorter than the control group.In our previous clinical treatment, general anesthesia with inhaling sevoflurane have be an invasive medical method which has been used to most children,whom have difficult to adapt to Tell-Show-Do behavioral induction. A part of children maybe had delayed treatment because of family concerns about general anesthesia or their lack of cooperation with behavioral induction, resulting in poor prognosis and long-term teeth problems. This trial suggests that the customized VR content as applied in the present study produces children to be treated as quickly as possible ,maybe reduce the frequency of patients to seek medical treatment, reduce the number of outpatients. In China, the ratio of health workers to people is significantly lower than the global average, especially pediatricians[35].This is beneficial for both doctors and patients. The present trial has several limitations that should be noticed.Firstly, we could not assess the different clinicometric tools and self-assessment.The corresponding scores of anxiety and pain in children were relatively single .Secondly,we did not think deeply about other factors that affect children's behavior.Some researchers reported that several factors,such as age, sex, type of dental treatment,parental anxiety and socioeconomic status were associated with anxiety will be assessed because these may influence the efficacy of VR[36] .Despite evidence reported that older children considered VR technique as a very simple game, have lower level of distraction [32]. This study shows five children who were uncomfortable with VR distraction and terminated the trial, considering that some of them were possible terminated for these reasons.but, An average age analysis of the five children found that was not statistically significant. In addition, their anxiety score were higher than 35 before and after treatment.Thirdly,we could not blind the pedodontists or the patients to the interventions due to the apparent difference between the two group.During the next experiment, the deficiency was overcome by watching different VR animation in different groups.Fourthly,the VR in this trial have only one animation content ,it may be considered a limitation because the stimuli that trigger dental anxiety may differ for each individual .Based on the current data of using virtual reality, anxiety score, and using mobile Internet APP to collect family members' awareness and anxiety about dental diseases, to replace fewer generic intervention scenarios, the next step is hierarchical customization of VR content.We hope that virtual reality will be improved in the process of being widely used in children's department of Stomatology, and finally form a set of intelligent bio-feedback mechanism to achieve closed-loop control of anxiety and pain in children, so that children can get rapid, timely and comfortable oral treatment. The trial has focused on the effectiveness of compliance changes in the VR distraction in 4-8-year-old children during short-term invasive dental procedure. The VR-distraction is purely non-intrusive methods, therefore,the children receive less invasive treatment than general anesthesia. Even with dental treatment time after time, parents and children are much more receptive than other methods. Declarations Acknowledgments The authors would like to thank the pedodontists of the Children's stomatology of the Stomatological Hospital of the Chongqing Medical University for their great help. Author Contribution * LR and NZ make a common contribution. LR: collection of data; drafting of the manuscript; final approval of submitted manuscript.NZ: analysis and interpretation of data; drafting of the manuscript; final approval of submitted manuscript. LF: collection of data; final approval of submitted manuscript.PZ: collection of data; final approval of submitted manuscript.CZ: interpretation of data; final approval of submitted manuscript.CY: conception and design; drafting and revision of the manuscript; final approval of submitted manuscript. Funding This trial was supported by the Research Project of Chongqing Municipal Public Health Bureau,China(2017ZDXM017). To approve that the author give smaller drug interventions to dental procedure in children are the role of the funding body in the study. Availability of data and materials The ethical approval does not permit the sharing of the entire data that we have Acquired, but the information required is already provided in the main manuscript. Conflicts of interest The authors declare no conflict of interest. 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A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent.2007;25(4):177-82. Tables Table1.Patient and dental procedure s. VR a （ n=60,% ） TSD b （ n=60,% ） p Age (year) 5.59±0.92 5.66±0.99 .69 Sex .20 Male 35(58.33) 28(46.67) Female 25(41.67) 32(53.33) ASA c physical status .53 I 43(71.67) 46(76.67) II 17(28.33) 14(23.33) D ental procedure .63 Caries treatment 27(45.00) 20(33.33) Extraction of deciduous teeth 12(20.00) 15(25.00) Incision of abscess 11(18.33) 13(21.67) Root canal therapy 10(16.67) 12(20.00) Local anesthetic .39 Primacaine 48(80.00) 46(76.67 ) Not used 12(20.00) 14(23.33) a VR：Virtual Reality group; b TSD:Tell-Show-Do group. c ASA:American Society of Anesthesiologists. p value<0.05 statistically significant Table2 . Anxiety , pain, p atient Satisfaction and time of dental procedure in both groups VR a （ n=60 ） TSD b （ n=60 ） p VR( n=55 ) TSD (n=49) p Anxiety CFSS-DS c Pre-intervention(T0) 34.17±5.81 34.08±8.42 .95 33.15±4.82 31.45±5.97 .11 Post-intervention(T3) 24.77±6.98 27.98±7.41 .02* 23.34±5.23 25.43±5.20 <0.05* Downtrend（T0-T3） 8（7,11） 5（5,7） < .001* 8（7,12） 5（5,7） <.001* FBR d T1 2（2,3） 2（2,3） .26 2（2,3） 2（2,3） .12 T2 3（3,4） 3（2,3） .02* 3（3,4） 3（3,3） .11 Pain VAS e T2(observed) 1.58±1.08 2.86±0.96 <.001* T3((self-reported) 1.62±1.13 3.59±1.19 <.001* PS f (T3,score 0-100 ) 88.33±7.15 76.78±8.49 <.001* Length of dental procedure (min) T1 to T3 19.02±5.32 27.80±10.40 <.001* Caries treatment 19(16,22) 30(25,30) <.001* Extraction of deciduous teeth 14.75±2.77 19.93±9.01 .07 Incision of abscess 22.40±3.89 26.09±6.80 0.15 Root canal therapy 23.57±4.39 42.43±8.40 <.001* a VR:Virtual Reality group. b TSD:Tell-Show-Do group. c CFSS-DS:Children’s Fear Survey Schedule-Dental Subscale. d FBR: Frankl Behavior Rating Scale. e VAS: Visual Analogue Scale. f PS:Patient Satisfaction. T0: signature of informed consent statement.T1: before intervention.T2: the moment of local anesthetic injection. T3: the end of treatment. * p value<0.05 statistically significant. Supplementary Files CONSORT2010Checklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 29 Jun, 2021 Reviewer # 5 agreed at journal 27 Jun, 2021 Reviews received at journal 14 Jun, 2021 Reviewer # 4 agreed at journal 14 Jun, 2021 Reviewer # 3 agreed at journal 25 Mar, 2021 Reviewer # 2 agreed at journal 23 Mar, 2021 Review # 2 received at journal 23 Mar, 2021 Review # 1 received at journal 23 Mar, 2021 Reviewer # 1 agreed at journal 21 Mar, 2021 Reviewers invited by journal 19 Feb, 2021 Editor assigned by journal 18 Feb, 2021 Submission checks completed at journal 18 Feb, 2021 First submitted to journal 07 Sep, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-46868","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":14440669,"identity":"83169285-4a24-4308-868c-650fbed7628b","order_by":0,"name":"Longkuan Ran","email":"","orcid":"","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":false,"prefix":"","firstName":"Longkuan","middleName":"","lastName":"Ran","suffix":""},{"id":14440670,"identity":"5b032f99-152c-43f1-b7fa-0cd38396f79f","order_by":1,"name":"Nan Zhao","email":"","orcid":"","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Zhao","suffix":""},{"id":14440671,"identity":"8fb5cd29-a086-4ed9-aba0-a834acb24b89","order_by":2,"name":"Lin Fan","email":"","orcid":"","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Fan","suffix":""},{"id":14440672,"identity":"aa5cc374-9575-416a-84d2-b5b40981500f","order_by":3,"name":"Pinping Zhou","email":"","orcid":"","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":false,"prefix":"","firstName":"Pinping","middleName":"","lastName":"Zhou","suffix":""},{"id":14440673,"identity":"61f5a79b-7b3c-4791-8621-024fc6926cbf","order_by":4,"name":"Chao Zhang","email":"","orcid":"","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Zhang","suffix":""},{"id":14440674,"identity":"4cf45675-6956-4c18-8521-59316fe0a33c","order_by":5,"name":"Cong Yu","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-1957-574X","institution":"Chongqing Medical University Stomatology College","correspondingAuthor":true,"prefix":"","firstName":"Cong","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2020-07-21 11:14:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-46868/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-46868/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":6854867,"identity":"e70e1296-da6b-4bbb-ab5b-1ddf760dfb87","added_by":"auto","created_at":"2021-03-11 19:58:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236434,"visible":true,"origin":"","legend":"CONSORT flowchart for the randomized trial.\nCFSS-DS :Children’s Fear Survey Schedule-Dental Subscale . TSD:Tell-Show-Do. VR:Virtual Reality.TSD:Tell-Show-Do. FBR:Frankl Behavior Rating scale.VAS:Visual Analogue Score.HR:Heart Rate.PS: Patient Satisfaction.\n","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/00b5a13e06fea8e63694cff1.jpg"},{"id":6855034,"identity":"808c9845-6e7d-4224-b0e0-79312efe35dc","added_by":"auto","created_at":"2021-03-11 20:01:35","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2169043,"visible":true,"origin":"","legend":"A scene in which HTC 's VIVE VR helmet is being used in dental procedure.","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/e1b6c21a0e3918660e76c006.jpg"},{"id":6854767,"identity":"7b45a98e-02d4-4428-9ce2-a3000a376d30","added_by":"auto","created_at":"2021-03-11 19:55:35","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3149021,"visible":true,"origin":"","legend":"Screenshot of custom scenario.","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/0adc473edfa2a62dcdc2db52.jpg"},{"id":6854866,"identity":"2f035d69-e4ce-4a39-ae58-f711bd700971","added_by":"auto","created_at":"2021-03-11 19:58:35","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":124360,"visible":true,"origin":"","legend":"Changes in heart rate before and during the dental treatment between the 2 groups.\nVR:Virtual Reality group.TSD:Tell-Show-Do group.T1: before intervention.T2: the moment of local anesthetic injection.a,b p \u003c0.05\n","description":"","filename":"Fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/37ff013ca732633cd0b7ca03.jpg"},{"id":13677419,"identity":"06980594-c0ba-48c4-b7fd-57fdc5fbd6f7","added_by":"auto","created_at":"2021-09-17 11:35:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":887423,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/b026c850-816e-401b-a0d3-1fe613dba793.pdf"},{"id":6854763,"identity":"44f6e1c7-ea23-42ec-ba16-652d604cf07a","added_by":"auto","created_at":"2021-03-11 19:55:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32776,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2010Checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-46868/v1/2a718c1803dab222572bc060.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eApplication of Virtual Reality on Non-drug Behavioral Management of\u0026nbsp;Short-term Dental Procedure in Children\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBehavioral management success may be related to the following two variables: dental anxiety is a psychological state can be modified and controlled with psychological techniques, pain is an unpleasant sensory and emotional experience [1].For the children's cognition levels of dental procedure, it is necessary to conduct behavioral management ,so that the children can cooperate with pediadontist to complete the treatment.\u003c/p\u003e\n\u003cp\u003eIn Southwest China , a substantial proportion of children are unable to collaborate well with doctors and nurses because of dental anxiety.The augment of pain,tense and fear-related behaviors during dental procedures was defined as Dental Anxiety（DA), it can be expressed as rapid heart rate, muscle tension and even syncope[2].Dental anxiety refers to a universal level of stress that is characteristic of an individual, that is, may has a constant level during the life span.The emotion interferes significantly with the personal daily life,career development or relationships. Various studies have found the incidence of dental anxiety to be 20%\u0026ndash;43% depending on the age of the child.In recent survey, dental anxiety have produced a majority of clinical trouble in pediatric dental treatment[3].\u003c/p\u003e\n\u003cp\u003eWith regard to the treatment of dental anxiety, drug systematic was generally used in the Department of Anesthesiology of Stomatological Hospital affiliated to Chongqing Medical University,such as Nitrous oxide(N\u003csub\u003e2\u003c/sub\u003eO) induced conscious sedation and sevoflurane inhalation anesthesia. The N\u003csub\u003e2\u003c/sub\u003eO sedation can only be applied in children got 3 or 4 Frankl Behavior Rating (FBR)Scale. Because the children are awake and have no other way to distract their attention, many children do not cooperate with pedodontists in the course of dental procedure. In sevoflurane inhalation anesthesia, because the children and their families need to carry out general anesthesia-related preoperative preparation: appointment waiting, fasting and drinking, risk of apnea,recovery after anesthesia, etc. The child's parents may think twice about possible damage from general anesthesia on their children. As a result of the above various problems, some children did not receive timely treatment , result in lifelong poor oral health , even bring long psychological trauma[4]. Hence, timely and effective management of dental anxiety is central to improving the mental and physical health of children with oral diseases.\u003c/p\u003e\n\u003cp\u003eThe virtual reality technology(VR) creates a highly realistic virtual ,three-dimensional (3D) environment that provides various sense stimulate ( sense of vision, sense of hearing, touch even includes sense of smell) for the user who escape the real world [5,6].By stimulating visual, auditory and proprioceptive sensations, virtual reality acts as a distraction to interfere the user's handling of noxious stimuli[6].In the last decades VR has applied in different health care. In particular, VR has reported in many clinical trials,such as trauma rehabilitation[7,8],burn care[9,10],cancer treatment[11] ,operation training[12] and weight- related disorders[13].Sato K and Sarig-Bahat have performed VR on the Complex regional pain syndromes[14] and chronic neck pain [15].\u003c/p\u003e\n\u003cp\u003eThe analgesic effects of VR-distraction reduce negative emotions (e.g. anxiety) and lead to positive emotions[16].A part of studies supports VR distraction has been used to relieves both pain and anxiety [5,6，17-22].Similarly, virtual reality as a distraction intervention to relieve pain during perioperative period in dental surgery[17,21].The application of VR technology in behavioral management of children's dental procedure is not deeply studied. There have also been recent reports that could reduce pain and anxiety in the dental setting and procedures [23,24],but the type of dental procedure is single and the Suitable duration of treatment remains to be explored. In this study, we measured the role of virtual reality in non-drug behavior management in children with short-term and simple dental procedure.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSetting and patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis single crossover clinical trial recruited 120 preschoolers aged 4-8years who came to the Stomatological Hospital of Chongqing Medical University for dental treatment .This study followed the Declaration of Helsinki on medical protocol and ethics and the regional Ethical Review Board of the Stomatological Hospital of Chongqing Medical University approved the trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsenting children(aged 4-8 years)with the Children\u0026rsquo;s Fear Survey Schedule-Dental Subscale(CFSS-DS)questionnaire greater than to 19[25].Time of dental procedure(Caries treatment,Extraction of deciduous teeth,Incision of abscess,Root canal therapy) is expected within half an hour.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe exclude criteria cases were children or their families can't agree, and their families were concerned that VR will have an impact on the eyes of the child, as well as for other reasons to interfere with the cause of the wearing of the VR glasses, such as those with glasses already in myopia. Since VR may cause motion sickness in some users, we exclude children with a history of motor diseases, motor nausea or vomiting. The child with a history of epileptic or epileptic seizures were also excluded, as there were reports that VR had a theoretical risk of inducing seizures. Unpleasant treatment experience can increase anxiety and pain during the next dental sessions, resulting, in turn, to perceive more pain.Therefore, in the study subjects were excluded if they had previous serious dental experience[26].\u003c/p\u003e\n\u003cp\u003eIf the child has serious fear or severe movement during the intervention, the trial will be terminated immediately.Fig. 1 shows the CONSORT flow chart for the trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnical Specifications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HTC 's VIVE VR helmet which was commercial, widely used, short delay time for video scenes, and was not prone to head vertigo. The VIVE comprises 32sensors for 360 degrees motion tracking, two 2160 by 1200 combined resolution AMOLED screen, and a 90 Hz refresh rate. The helmet is connected to ASUS Game notebook with an Intel Core i7-8820K processor ,16 gigabyte RAM and a NVIDIA GeForce GTX 1070 graphics card.The virtual environment allows the user to navigate naturally,which is created through a 110 degrees field of view for immersion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients will be randomly allocated to two conditions by using the randomization software (STATA software version 15.1).Eligible children and their families have been informed about the trial by anesthetists,and signature of informed consent statement on preoperative .Once, they agreed to participate in the study,personal medical data were collected by researchers and baseline anxiety were assessed by CFSS-DS (T0：time after signing the consent) .Next, the anesthetist nurse randomly allocated children to the VR intervention, or to the control group(children only received Tell-Show-Do as usual). Block randomization was performed by type of dental procedure:caries treatment,extraction of deciduous teeth,incision of abscess and root canal therapy.After randomization, the VR intervention have took place in a separate room under the guidance of the nurse anesthetist,children in the TSD group were admitted to the other room.Both groups were treated by experienced pediatric dentists. Fig.2 shows an example of dental procedure using HTC 's VIVE helmet.\u003c/p\u003e\n\u003cp\u003eThe assessment per time point was performed. Frankl Behavior Rating Scale was scored before intervention(T1：5 minutes before dental procedure) and re-measured at the moment of local anesthetic injection(T2). CFSS-DS and Patient Satisfaction (PS) scores were performed 5 minutes after the end of treatment(T3). Visual Analogue Score (VAS) was evaluated at both T2 and T3 points, and its score ranged from 0 to 10 (0, no pain; 10, extreme pain). Because VR intervention has the potential to cause adverse events, Dizziness, nausea, vomiting, and epilepsy which have been follow up throughout the course of treatment. We also measured changes in heart rate and peripheral capillary oxygen saturation between the two groups before, during and after the dental treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVirtual reality intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the dental procedure, we show the patient the corresponding scenes, specific inducers and background music that joint development with psychologists, which can attract his attention to relax him. The child need lie down on the dental chair and not shake his head left and right, causing the treatment to be interrupted.The nurse anesthetist put the helmet and earphone on child,who enter a virtual world he can follow our set route and watch different information expressed in the scene. The story begins in the world of the seabed which is about to be devastated. Only when the undersea creatures share their most precious things to nourish a rare pearl can save the undersea world. At first,\"I\" am in a shell, and the little elf introduces the creatures of the sea and their precious spirit. Secondly, sea anemone protect the clown fish while the clown fish reduce the surface precipitation of the anemone, and they share this precious friendship of helping each other (Fig. 3a).Next, for children to introduce the ancient precious and tenacious vitality of animals: turtles (Fig. 3b). And then, introduce the parrot fish solidarity (Fig. 3c) and dolphin helpful spirit (Fig. 3d). Scene switching for children to introduce beautiful and dangerous jellyfish, it shares his valuable storm prediction ability (Fig.3e). Finally, the pearl was born from the precious spiritual nourishment of thousands of marine creatures,, and the undersea world restores its former peace and tranquillity.(Fig. 3f). Meanwhile, The virtual environment was also displayed on the ASUS notebook, so the accompanying families could see what the child was viewing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were performed using SPSS software version 22 ((IBM, Chicago, USA). The statistical significance difference was set at\u003cem\u003e p\u003c/em\u003e\u0026lt; 0.05. Chi-square Test was used to assess gender difference, ASA physical status ,type of dental procedure and local anesthetic between the two groups. All quantitative variables were presented as mean\u0026plusmn; SD (standard deviation), and the analysis of variance or nonparametric test was performed for comparisons in accordance with the data distribution. Mann-Whitney \u003cem\u003eU \u003c/em\u003etests were used to compare the downtrend level of anxiety scale and Frankl Behavior Rating scale.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe trial comprised 25 girls and 35 boys in VR group and 32 girls and 28 boys in TSD group, respectively. The mean ages of the trails in group VR and TSD were 5.59\u0026plusmn;0.92 and 5.66\u0026plusmn;0.99 years,\u003cem\u003ep\u003c/em\u003e=0.69. Similarly,with no significant differences between the two groups in the means of regarding gender ,ASA physical status, type of dental procedure and local and type of dental procedure(Pearson chi-square test, \u003cem\u003ep\u003c/em\u003e\u0026gt;0.05; Table 1).\u003c/p\u003e\n\u003cp\u003eThe mean anxiety scores were decreased significantly after VR distraction. In VR group: the Children\u0026rsquo;s Fear Survey Schedule-Dental Subscale was 34.17\u0026plusmn;5.81 before intervention, which decreased to 24.77\u0026plusmn;6.98 after VR distraction. Meanwhile, in TSD group: the anxiety scores were 34.08\u0026plusmn;8.42 and 27.98\u0026plusmn;7.41, respectively(n=60). The anxiety score between VR-intervention and TSD were statistically difference after dental procedure (Table 2). Table 2 also shows the downtrend of anxiety score variations between the two groups and the differences were statistically significant.\u003c/p\u003e\n\u003cp\u003eThe Mann-Whitney U tests of Frankl Behavior Rating scores of VR group in the time of Pre-intervention were 2(2,3). Same in the time T2 of VR distraction treatment were 3(3,4),which represented that VR distraction have improved the patient compliance. In control group, the FBR scores before intervention and the time of the maximum procedure pain were 2(2,3) and 3(2,3), respectively. Those indicate that virtual reality could Increase the compliance (\u003cem\u003eP\u003c/em\u003e =0.02; Table 2).\u003c/p\u003e\n\u003cp\u003eA total of 5 children (8.33%) in VR group had severe intraoperative anxiety and stopped treatment in fear, compared with 11 cases(18.33%) in TSD group (\u003cem\u003ep \u003c/em\u003e\u0026lt;0.05).The CFSS-DS score of the children after the exclusion of the above person were found VR interference relative to the control group can still significant alleviate the anxiety of the children, \u003cem\u003ep \u003c/em\u003e\u0026lt;0.05. The FBR score of both groups at T2 has no statistical difference.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;During the operation, we observed that the pain score of the VR group (1.58\u0026plusmn;1.08) was lower than that of the control group (2.86\u0026plusmn;0.96). Meanwhile, the results showed that the VR intervention at the end of treatment, relating to the control of operation pain, worked best (p\u0026lt;.001) in patients. Comparing the length of dental procedure, we found that VR group(19.02\u0026plusmn;5.32) had shorter treatment time than the control group(27.80\u0026plusmn;10.40). The results of this trial also have indicated the decrease of treatment time was particularly significant in caries treatment and root canal therapy and was statistically significant (p\u0026lt;.001) .Table 2 also shows the overall patient satisfaction of dental procedure of VR intervention (88.33\u0026plusmn;7.15) was significantly higher than group TSD (76.78\u0026plusmn;8.49).\u003c/p\u003e\n\u003cp\u003eAfter monitoring Physiological signs, we found that VR group decreased heart rate while the control group did the opposite (\u003cem\u003ep\u0026lt;\u003c/em\u003e0.05; Fig.4). There was no significant difference in the SPO\u003csub\u003e2\u003c/sub\u003e, which was detected before- and after-intervention between the two groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur group has been engaged in oral-related sedation and analgesia for a long time, so we consider whether we can use new methods to relieve dental anxiety in this group of children [27-29]. Thus, the trial has focused on the effectiveness of compliance changes in the VR distraction in 4-8-year-old children during short invasive dental treatment [4].This results of the trial support that virtual reality would be associated with a greater decrease in behavioral avoidance compared to who received Tell-Show-Do-intervention. The anxiety score of the two groups before and after the intervention, the VR group have decreased more than the control group, but the compliance score of the children increased. Asl Aminabadi N et al. reported that virtual reality eyeglasses can successfully decrease pain perception and state anxiety during dental treatment in 4-6 years old children [30]. similarly,Shetty V observed that Virtual Reality distraction can be used as a successful behavior modification method in 5 to 8 Year Old children undergoing short invasive dental treatments[31].Therefore, the trial further strengthens that immersing a virtual environment can help control dental anxiety during pediatric dental treatment on children.Researchers have showed that the effect of VR technique on pain perception is beyond simple distraction[32]. In addition, By diverting attention from an unpleasant environment setting to a pleasant and absorbing virtual world,VR also obviously diminish a patient\u0026rsquo;s physical pain experience[8,33,34 ].By relieving anxiety and reducing pain , children can markedly cooperate with treatment which have be like with Caries treatment, Root canal therapy.\u003c/p\u003e\n\u003cp\u003eMeanwhile,we observed that the treatment time of VR group had significantly shorter than the control group.In our previous clinical treatment, general anesthesia with inhaling sevoflurane have be an invasive medical method which has been used to most children,whom have difficult to adapt to Tell-Show-Do behavioral induction. A part of children maybe had delayed treatment because of family concerns about general anesthesia or their lack of cooperation with behavioral induction, resulting in poor prognosis and long-term teeth problems. This trial suggests that the customized VR content as applied in the present study produces children to be treated as quickly as possible ,maybe reduce the frequency of patients to seek medical treatment, reduce the number of outpatients. In China, the ratio of health workers to people is significantly lower than the global average, especially pediatricians[35].This is beneficial for both doctors and patients.\u003c/p\u003e\n\u003cp\u003eThe present trial has several limitations that should be noticed.Firstly, we could not assess the different clinicometric tools and self-assessment.The corresponding scores of anxiety and pain in children were relatively single .Secondly,we did not think deeply about other factors that affect children's behavior.Some researchers reported that several factors,such as age, sex, type of dental treatment,parental anxiety and socioeconomic status were associated with anxiety will be assessed because these may influence the efficacy of VR[36] .Despite evidence reported that older children considered VR technique as a very simple game, have lower level of distraction [32]. This study shows five children who were uncomfortable with VR distraction and terminated the trial, considering that some of them were possible terminated for these reasons.but, An average age analysis of the five children found that was not statistically significant. In addition, their anxiety score were higher than 35 before and after treatment.Thirdly,we could not blind the pedodontists or the patients to the interventions due to the apparent difference between the two group.During the next experiment, the deficiency was overcome by watching different VR animation in different groups.Fourthly,the VR in this trial have only one animation content ,it may be considered a limitation because the stimuli that trigger dental anxiety may differ for each individual .Based on the current data of using virtual reality, anxiety score, and using mobile Internet APP to collect family members' awareness and anxiety about dental diseases, to replace fewer generic intervention scenarios, the next step is hierarchical customization of VR content.We hope that virtual reality will be improved in the process of being widely used in children's department of Stomatology, and finally form a set of intelligent bio-feedback mechanism to achieve closed-loop control of anxiety and pain in children, so that children can get rapid, timely and comfortable oral treatment.\u003c/p\u003e\n\u003cp\u003eThe trial has focused on the effectiveness of compliance changes in the VR distraction in 4-8-year-old children during short-term invasive dental procedure. The VR-distraction is purely non-intrusive methods, therefore,the children receive less invasive treatment than general anesthesia. Even with dental treatment time after time, parents and children are much more receptive than other methods.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the pedodontists of the Children's stomatology of the Stomatological Hospital of the Chongqing Medical University for their great help.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e* LR and NZ make a common contribution.\u003c/p\u003e\n\u003cp\u003eLR: collection of data; drafting of the manuscript; final approval of submitted manuscript.NZ: analysis and interpretation of data; drafting of the manuscript; final approval of submitted manuscript. LF: collection of data; final approval of submitted manuscript.PZ: collection of data; final approval of submitted manuscript.CZ: interpretation of data; final approval of submitted manuscript.CY: conception and design; drafting and revision of the manuscript; final approval of submitted manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis trial was supported by the Research Project of Chongqing Municipal Public Health Bureau,China(2017ZDXM017). To approve that the author give smaller drug interventions to dental procedure in children are the role of the funding body in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical approval does not permit the sharing of the entire data that we have\u003c/p\u003e\n\u003cp\u003eAcquired, but the information required is already provided in the main manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe trial followed the Declaration of Helsinki on medical protocol and ethics and the Ethical Review Board of the Stomatological Hospital of Chongqing Medical University approved the trail. Written and verbal consent was obtained from all participants before the start of VR distraction.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVagnoli L, Bettini A, Amore E, De Masi S, Messeri A.Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study. Eur JPediatr .2019;178(6):913-921.\u003c/li\u003e\n\u003cli\u003eVoepel-Lewis T, Malviya S, Tait AR.A prospective cohort study of emergence agitation in the pediatric post anesthesia care unit. Anesth Analg. 2003;96(6):1625-1630.\u003c/li\u003e\n\u003cli\u003eCianetti S, Lombardo G, Lupatelli E, Pagano S, Abraha I, Montedori A, Caruso S, Gatto R, De Giorgio S, Salvato R. Dental fear/anxiety among children and adolescents. A systematic review.Eur J Paediatr Dent.2017;18(2):121-130.\u003c/li\u003e\n\u003cli\u003eZhang C, Huang GJ, Yu C.The effect of general anesthesia for ambulatory dental treatment on children in Chongqing, Southwest China.Paediatr Anaesth. 2017;27(1):98-105..\u003c/li\u003e\n\u003cli\u003eMalloy K, Milling LS.The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin PsycholRev.2010;30(8):1011-1018.\u003c/li\u003e\n\u003cli\u003eLi A, Monta\u0026ntilde;o Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag.2011; 1(2):147-157.\u003c/li\u003e\n\u003cli\u003eShin H，Kim K. Virtual reality for cognitive rehabilitation after brain injury：A systematic review. 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Cyberpsychol Behav.2006;9(2):207-212.\u003c/li\u003e\n\u003cli\u003eHoffman HG, Doctor JN, Patterson DR, Carrougher GJ, Furness TA.Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain.2000; 85(1-2):305-309.\u003c/li\u003e\n\u003cli\u003eGujjar KR, van Wijk A, Kumar R, de Jongh A.Efficacy of virtual reality exposure therapy for the treatment of dental phobia in adults: A randomized controlled trial. J Anxiety Disord.2019; 62:100-108.\u003c/li\u003e\n\u003cli\u003eMorris LD, Louw QA, Crous LC. Feasibility and potential effect of a low-cost virtual reality system on reducing pain and anxiety in adult burn injury patients during physiotherapy in a developing country. Burns.2010;36(5):659-64.\u003c/li\u003e\n\u003cli\u003eNuvvula S, Alahari S, Kamatham R, Challa RR .Effect of audiovisual distraction with 3D video glasses on dental anxiety of children experiencing administration of local analgesia: a randomised clinical trial.Eur Arch Paediatr Dent.2015; 16(1):43-50.\u003c/li\u003e\n\u003cli\u003eNiharika P, Reddy NV, Srujana P, Srikanth K, Daneswari V, Geetha KS . Effects of distraction using virtual reality technology on pain perception and anxiety levels in children during pulp therapy of primary molars.J Indian Soc Pedod Prev Dent.2018; 36(4):364-369.\u003c/li\u003e\n\u003cli\u003eLu JX, Yu DS, Luo W, Xiao XF, Zhao W . Development of Chinese version of children's fear survey schedule-dental subscale.Zhonghua Kou Qiang Yi Xue Za Zhi .2011;46(4):218-21.\u003c/li\u003e\n\u003cli\u003eNichols S, Patel H . Health and safety implications of virtual reality: a review of empirical evidence. Appl Ergon. 33(3):251-271.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Zhao%20N%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=24820727\"\u003eZhao N\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Deng%20F%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=24820727\"\u003eDeng F\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Yu%20C%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=24820727\"\u003eYu C\u003c/a\u003e.Anesthesia for Pediatric Day-Case Dental Surgery: A Study Comparing the Classic Laryngeal Mask Airway With Nasal Trachea Intubation..J Craniofac Surg.2014;25(3):e245-8.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Xi%20MY%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eXi MY\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Li%20SS%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eLi SS\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Zhang%20C%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eZhang C\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Zhang%20L%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eZhang L\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Wang%20T%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eWang T\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Yu%20C%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=31785250\"\u003eYu C\u003c/a\u003e\u003cu\u003e.\u003c/u\u003eNalbuphine for Analgesia After Orthognathic Surgery and Its Effect on Postoperative Inflammatory and Oxidative Stress: A Randomized Double-Blind Controlled Trial.J Oral Maxillofac Surg.2020;78(4):528-537.\u003c/li\u003e\n\u003cli\u003eZhao N, Wu YJ, Yu C.Effect of intravenous nalbuphine on emergence agitation in children undergoing dental surgery under sevoflurane anesthesia.Int J Exp Med.2018;11(9):10215-10222.\u003c/li\u003e\n\u003cli\u003eAsl Aminabadi N, Erfanparast L, Sohrabi A, Ghertasi Oskouei S, Naghili A(2012)The Impact of Virtual Reality Distraction on Pain and Anxiety during Dental Treatment in 4-6 Year-Old Children: a Randomized Controlled Clinical Trial.J Dent Res Dent Clin Dent Prospects.2015;6(4):117-24.\u003c/li\u003e\n\u003cli\u003eShetty V, Suresh LR, Hegde AM. Effect of Virtual Reality Distraction on Pain and Anxiety During Dental Treatment in 5 to 8 Year Old Children. J Clin Pediatr Dent. 2019;43(2):97-102.\u003c/li\u003e\n\u003cli\u003eDas DA, Grimmer KA, Sparon AL, Mc Rae SE, Thomas BH . The efficacy of playing a virtual reality game in modu-lating pain for children with acute burn injuries: a randomized controlled trail. BMC Pediatr .2005;5(1):1.\u003c/li\u003e\n\u003cli\u003eHoffman HG, Richards TL, Coda B, Bills AR, Blough D, Richards AL, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Sharar%20SR%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=15167542\"\u003eSharar SR\u003c/a\u003e.Modulation of thermal pain related brain activity with virtual reality: evidence from FMRI. Neuroreport.2004; 15(8):1245-8.\u003c/li\u003e\n\u003cli\u003eNilson S, Finnstrom B, Kokinsky E, Enskar K. The use of virtual reality for needle related procedural pain and distress in children and adolescents in a pediatric oncology unit.Eur J Oncol Nurs ,2009;13(2):102-9.\u003c/li\u003e\n\u003cli\u003eHu KJ, Sun ZZ, Rui YJ, Mi JY, Ren MX.Shortage of paediatricians in China. 383(9921):954.\u003c/li\u003e\n\u003cli\u003ePrabhaker AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent.2007;25(4):177-82.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable1.Patient and \u003c/strong\u003e\u003cstrong\u003edental \u003c/strong\u003e\u003cstrong\u003eprocedure\u003c/strong\u003e\u003cstrong\u003es.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"width: 482px;\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 39px;\"\u003e\n\u003ctd style=\"width: 158px; height: 39px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 39px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eVR\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=60,%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 39px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eTSD\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=60,%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 39px;\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (year) \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e5.59\u0026plusmn;0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e5.66\u0026plusmn;0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e.69\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e.20\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e35(58.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e28(46.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e25(41.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e32(53.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 38px;\"\u003e\n\u003ctd style=\"width: 158px; height: 38px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e \u003cstrong\u003ephysical status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 38px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 38px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 38px;\"\u003e\n\u003cp\u003e.53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e43(71.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e46(76.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eII\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e17(28.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e14(23.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003cstrong\u003eental procedure\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eCaries treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e27(45.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e20(33.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 48px;\"\u003e\n\u003ctd style=\"width: 158px; height: 48px;\"\u003e\n\u003cp\u003eExtraction of deciduous teeth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 48px;\"\u003e\n\u003cp\u003e12(20.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 48px;\"\u003e\n\u003cp\u003e15(25.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 48px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eIncision of abscess\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e11(18.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e13(21.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eRoot canal therapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e10(16.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e12(20.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocal anesthetic\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003ePrimacaine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e48(80.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e46(76.67 )\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003eNot used\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e12(20.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e14(23.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"width: 158px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 98px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 109px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 89px; height: 35px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eVR：Virtual Reality group;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eTSD:Tell-Show-Do group.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003eASA:American Society of Anesthesiologists.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ep \u003c/em\u003evalue\u0026lt;0.05 statistically significant\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable2\u003c/strong\u003e\u003cstrong\u003e. \u003c/strong\u003e\u003cstrong\u003eAnxiety\u003c/strong\u003e\u003cstrong\u003e, pain, \u003c/strong\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003cstrong\u003eatient Satisfaction\u003c/strong\u003e\u003cstrong\u003e and \u003c/strong\u003e\u003cstrong\u003etime of \u003c/strong\u003e\u003cstrong\u003edental procedure\u003c/strong\u003e\u003cstrong\u003e in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u003cstrong\u003eVR\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=60\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u003cstrong\u003eTSD\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=60\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u003cstrong\u003eVR(\u003c/strong\u003e\u003cstrong\u003en=55\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u003cstrong\u003eTSD\u003c/strong\u003e\u003cstrong\u003e(n=49)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003eAnxiety\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eCFSS-DS\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003ePre-intervention(T0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e34.17\u0026plusmn;5.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e34.08\u0026plusmn;8.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e33.15\u0026plusmn;4.82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e31.45\u0026plusmn;5.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e.11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003ePost-intervention(T3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e24.77\u0026plusmn;6.98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e27.98\u0026plusmn;7.41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.02*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e23.34\u0026plusmn;5.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e25.43\u0026plusmn;5.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;0.05*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u0026nbsp;Downtrend（T0-T3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e8（7,11）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e5（5,7）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026lt; .001*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e8（7,12）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e5（5,7）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eFBR\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eT1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e2（2,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e2（2,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e2（2,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e2（2,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e.12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eT2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e3（3,4）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e3（2,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e.02*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e3（3,4）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3（3,3）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e.11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eVAS\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eT2(observed)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e1.58\u0026plusmn;1.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e2.86\u0026plusmn;0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eT3((self-reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e1.62\u0026plusmn;1.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3.59\u0026plusmn;1.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003ePS\u003csup\u003e f\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e (T3,score 0-100\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e88.33\u0026plusmn;7.15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e76.78\u0026plusmn;8.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003eLength of dental \u003c/strong\u003e\u003cstrong\u003eprocedure\u003c/strong\u003e\u003cstrong\u003e(min)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e\u0026nbsp;T1 to T3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19.02\u0026plusmn;5.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e27.80\u0026plusmn;10.40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eCaries treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19(16,22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e30(25,30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eExtraction of deciduous teeth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e14.75\u0026plusmn;2.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e19.93\u0026plusmn;9.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e.07\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eIncision of abscess\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e22.40\u0026plusmn;3.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e26.09\u0026plusmn;6.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eRoot canal therapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e23.57\u0026plusmn;4.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e42.43\u0026plusmn;8.40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"54\"\u003e\n\u003cp\u003e\u0026lt;.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eVR:Virtual Reality group.\u003csup\u003eb\u003c/sup\u003eTSD:Tell-Show-Do group.\u003csup\u003ec\u003c/sup\u003eCFSS-DS:Children\u0026rsquo;s Fear Survey Schedule-Dental Subscale.\u003csup\u003ed\u003c/sup\u003eFBR: Frankl Behavior Rating Scale.\u003csup\u003ee\u003c/sup\u003eVAS: Visual Analogue Scale. \u003csup\u003ef\u003c/sup\u003ePS:Patient Satisfaction. T0: signature of informed consent statement.T1: before intervention.T2: the moment of local anesthetic injection. T3: the end of treatment. *\u003cem\u003ep \u003c/em\u003evalue\u0026lt;0.05 statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual Reality, Dental anxiety, Pain, Short-term dental procedure","lastPublishedDoi":"10.21203/rs.3.rs-46868/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-46868/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroud: \u003c/strong\u003eThe inherent characteristics of immersion, imagination, and interactivity in Virtual Reality,it may be suitable for non-drug behavior management of children in dental clinics.The purpose of this trial was to measure the role of virtual reality distraction on the behavior management of short-term dental procedure in Children.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA randomized clinical trial design carried out on 120 children aged between 4 and 8 years to make clear the comparative efficacy of virtual reality and Tell-Show-Do in improve behavioral management of dental procedure.The levels of operative anxiety and pain were assessed using, respectively, Children’s Fear Survey Schedule-Dental Subscale, Visual Analogue Score. Frankl Behavior Rating Scale was tested before and during dental procedure.The length of dental procedure was compared between the two groups after treatment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe average anxiety and behavioral score of virtual reality group were significant reduced than that of control. The decrease score of anxiety score of virtual reality group and control group were IQR 8(7,11) and 5(5,7),\u003cem\u003ep \u003c/em\u003e\u0026lt;0.05. The compliance scores of control group in the treatment time were 3(2,3),the same in virtual reality intervention were 3(3,4), \u003cem\u003ep\u003c/em\u003e =0.02. We observed a significant reduction in pain by using Virtual Reality distraction(\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). Comparing the length of dental procedure, we found that VR group(19.02±5.32) had shorter treatment time than the control group(27.80±10.40)\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe use of virtual reality could significantly reduce the anxiety and pain of children , length of dental procedure and improve the compliance of children undergoing short-term dental procedure without adverse reaction.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eChinese Clinical Trial Registry :ChiCTR2000029802. Registered on 14th Feb, 2020.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Application of Virtual Reality on Non-drug Behavioral Management of\u0026nbsp;Short-term Dental Procedure in Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-11 19:55:33","doi":"10.21203/rs.3.rs-46868/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-06-30T00:56:41+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-06-28T00:00:00+00:00","index":5,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-06-15T00:00:00+00:00","index":0,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-06-15T00:00:00+00:00","index":4,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-26T00:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-24T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-03-24T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major Revision\nForm responses:\n---\n\nComments to Author:\n---\nDear Authors,\nThis is a very interesting paper describing an innovative application of virtual reality in a novel population and setting. I have some concerns about the methods, as reported, and the paper would benefit from extensive revision for grammar and syntax, both of which detract from its clarity and flow at present. I believe it could be much improved with careful attention to these, and consideration of the following queries:\nPage 4\nLine 1: This starts a bit unclearly. Perhaps you might consider rephrasing the first sentence to say the behavioral management of... pain? Dental anxiety, etc? That would make the beginning more clear.\nLine 19: Would this be children seeking dental care, or all medical care?\nLine 44: I'm afraid I don't understand what it meant by drug systematic. This would benefit from re-wording.\nLine 52: Suggest \"in children who score 3 or 4,\" rather than \"children got...\"\nPage 5\nLine 6: These two sentences would flow better if combined (lines 1-6)\nLine 32: in different healthcare settings?\nPage 6:\nWas the trial protocol registered, or is it available?\nLine 23: There seems to be uncertainty about the study design. Here, it is a single cross over clinical trial, but in the abstract it is a randomized trial. This needs to be decided upon and consistent. It would seem that this is a randomized controlled trial of the effectiveness of VR, compared to TSD, for reducing anxiety or pain or increasing compliance with a dental procedure.A PICO may help to determine this. If your main outcomes are the reduction in pain or anxiety, or the increase in compliance, then the intervention and comparator are the VR and TSD, not the dental procedure, which would seem like an RCT of VR vs TSD.\nLine 44: This would seem rather rapid for root canals, for example. Does this mean that treatments had to be those that could be performed in under half an hour as part of the inclusion criteria? If so, why is this the case? Also, were children's parents or caregivers giving consent? Can a 4 year-old give informed consent for a dental procedure, for example?\nThe exclusion criteria are well explained. The inclusion criteria would benefit from explanation as well. For example, why 4-8 year-olds, as opposed to other age groups? Why 30-minute procedures as an inclusion criterion? The exclusion criteria did not say procedures longer than 30 minutes, making this unclear. Additionally, were there any medical or health related exclusion criteria not related to the influence of VR? If there were none, it would be helpful to clarify. Might there have been any conditions which might increase the pain or anxiety a child would experience during routine dental procedures, beyond what would typically be expected, which might confound the results?\nLine 33: Was not prone to cause vertigo? How was this established? Please cite if so.\nLine 55: This is in future tense, perhaps from the protocol, but surely this had already taken place? The paper needs considerable editing for grammar and syntax, which would greatly improve the clarity and flow. When the nurse performed the allocation/randmomisation, was it blinded? Was there allocation concealment for the assessors administering the Frankl before the dental procedures, or of outcome assessors after the procedures (administering patient satisfaction evaluations, etc.) and if so, how was this blinding maintained or preserved?\nPage 7\nLine 51: I am uncertain about the procedure. You describe the CR or TSD, but what happens after? The children go on to have the dental procedure, but is there more description that can be added about what happens next in a general sense? The nature and events taking place after may have as much influence on the outcomes as your interventions.\nPage 8\nLine 26: Why is the Frankl Behavioral test being used? What was it being used to show, or to capture? This needs explanation (and citation).\nPage 9\nLine 15: This sounds as if it could be stressful on its own: an undersea world about to be devasted. Could this not have created stress or anxiety in some children, confounding or biasing the results? Why was this particular scenario chosen? Was any of this tested before this trial, for feasibility? What training or supervision did the nurse anesthetists receive in administering the VR interventions? Additionally, was there any fidelity monitoring to ensure the intervention (VR) was being delivered as intended?\nLine 55: Will there be per-protocol or intention to treat analysis?\nPage 10\nLine 28: Was there a sample size/power calculation, performed a priori, to determine the sample size needed? If not, was this a sample of convenience, etc? How or why was this sample size arrived at? Did any children consent but then drop out or refuse the VR or control treatment? A flow chart would be very helpful.\nPage 11\nLine 24: Does this mean that after the 5 children who stopped treatment's data was removed, the FBR scores of both groups at T2 were equal? Also, see my comment about page 9 line 55.\nLines 30-52: This may not have been possible, given the small sample size, but was there any interaction between the kind of dental procedure being performed, the intervention (VR or control) and pain or behavioral outcomes? Did you do any analyses to see if the effects also varied by the kind or dental procedure- not just in terms of time the procedure took, but specifically in terms of whether the VR or control interventions produced effects on pain, anxiety, behaviour differently in different kinds of dental procedures? Some of the procedures may be more anxiety provoking or painful than others- for example root canal treatments more so than other, less intensive treatments. This could influence the observed effectiveness of the VR intervention as well. Was this investigated? Also, were any outcome assessors blinded?\nPage 12\nLine 1-6: How was HR monitored, and by whom? Same with SPO2.\nLine 55: How is it more of different than simple distraction? The next line goes on to say it provides distraction. I am not disputing that there are other potential mechanisms at work, but rather, pointing out that you haven't described them (and should).\nPage 14\nThese are important limitations, and they were well considered. There are other important limitations. One may relate to intervention fidelity: If not monitored, it is impossible to know if subtle variations in the way the VR or control were administered or even described by the administrators may have biased the results by introducing unexpected variability. Even differences in how the interventions were described or directions given could produce a nocebo effect, heightening pain or anxiety beyond what would have occurred with the dental procedure. Importantly, there is no description of any calibration of the devices, checks to make sure they were operating as expected, or checks to make sure they were administered as expected.\nAnother potential influence would be the skill or technique of the dentist or dental surgeon. Could variations in their bedside manner, skill, preferred technique or other factors also influenced participants' pain, anxiety or behaviours, outside of the VR or control intervention?\nAn important consideration not described here is cost of the VR equipment-Is cost an factor in terms of cost-benefit? Why was this particular VR device used? Was it previously used by the authors, or the centre?\nWhat effect might the authors expect if children have never seen a VR device before, and use one for the first time? Might this wearing of the device, it's sound volume, immersion or shear novelty cause anxiety for some children? Was this monitored?\n\nAbstract: Similar to the body of the paper, it would benefit from editing for grammar and syntax. Please also see my comments about page 6 and the study design for this paper, as it comes to play in the abstract as well.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. 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Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article whose findings are important to those with closely related research interests**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Quality of figures: **- Acceptable**\n* Statistical review: **- No, the manuscript does not need to be seen by a statistician**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n* Were you mentored through this peer review?: **No**\n"},{"type":"editorInvitedReview","content":"","date":"2021-03-24T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major Revision\nForm responses:\n---\n\nComments to Author:\n---\nThank you for this manuscript.\n\nThe subject is important, and the results are interesting.\n\nHowever, I have some comments/questions.\nThe introduction explain the problem with anxiety in dental care, and the use of Virtual Reality. However, I would like more information about the use of Virtual Reality in children. Is it safe for a 4 year-old to use Virtual Reality, and does there exist any challenges due to the child´s development?\nIn the method section, I lack a power calculation that confirm that 120 participants were a sufficient number of participants.\nPlease, clarify which instrument that is the primary outcome, and which instruments are the secondary outcomes.\nPlease, clarify if VAS is used as a self-report tool or as a by proxy assessment tool. VAS as a self-report tool is often described as valid in children 7 years old and above. Please, argue for the choice of VAS in children aged 4-8 years old.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Quality of figures: **- Acceptable**\n* Statistical review: **- No, the manuscript does not need to be seen by a statistician**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n* Were you mentored through this peer review?: **No**\n"},{"type":"reviewerAgreed","content":"","date":"2021-03-22T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-20T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-02-19T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-02-18T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-09-08T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18b84ec7-bed4-426c-8554-d436d34c4edb","owner":[],"postedDate":"March 11th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2847731,"name":"Translational Medicine"},{"id":2847732,"name":"Internal Medicine"},{"id":2847733,"name":"Integrative \u0026 Complementary Medicine"}],"tags":[],"updatedAt":"2021-08-13T02:16:17+00:00","versionOfRecord":[],"versionCreatedAt":"2021-03-11 19:55:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-46868","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-46868","identity":"rs-46868","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}