Award-winning research by Dr Kumar Raghav suggests the future of managing dental anxiety may lie in virtual reality rather than sedation. By Rob Johnson
Over the past three months, we have all turned to technology to manage our lives. From expanded telehealth consultations to Zoom dinner parties, the silver lining on the pandemic cloud has been seeing how useful technology can be in a real-life application. But can the virtual world replace something fundamentally physical—like anaesthetics?
In the case of dental anxiety it can. Clearly not in an emergency situation—but there are many cases of dental anxiety where a virtual intervention will be as effective as a chemical one. In fact, award-winning research by Dr Kumar Raghav of Charles Sturt University suggests that virtual reality may be more so.
“What’s happening with this general anaesthesia and conscious sedation is that we’re using drugs to manage the patient’s anxiety,” he says.
“With these methods of management the patient will never learn to overcome their fear. The next time these patients want to get any dentistry done, they’re again subjected to either general anaesthesia or conscious sedation. With these procedures, there’s a heavy cost that is involved.”
He has developed an alternative technique using virtual reality exposure therapy that has more long-lasting effectiveness, without the costs of chemical interventions. Dr Raghav’s research into this field has this year received the prestigious Giddon Award from the International Association for Dental Research (IADR). The award-winning paper, co-authored by Professor Ad De Jongh and Associate Professor Arjen van Wijk from the University of Amsterdam, and Dr Ratika Kumar from the University of Newcastle, Australia, was titled ‘Efficacy of virtual reality exposure therapy for the treatment of dental phobia in adults: A randomized controlled trial’.
One of the positive aspects of Dr Raghav’s findings is that applying his techniques and ideas aren’t that far away from what many practitioners are already doing.
“People already use technology in terms of using music or some distractions such as playing TV to help their patients manage phobia,” he says. “But they are not using the gold standard psychological technique.”
The roots of fear
Dr Raghav’s own interest in the topic springs from his own experience. “When I was a child, I myself had an episode which was very traumatic, and I had dental anxiety myself,” he explains. “My goal was always to investigate psychological methods of managing dental anxiety and fear.”
Born in a small town (Dharwad) in India, he initially trained in paediatric dentistry before moving to Libya for three years, then Malaysia for another five years. “When I was working in India, I was always having this inspiration to share my knowledge and experience with as many people as possible, and to work with people from different cultures,” he says. “I really enjoy places that have a diverse cultural and religious background. I was working in a dental school in Libya as well as treating patients. Similarly, Malaysia is multicultural. And I was very interested in the Indigenous culture in Australia, which I would see particularly in rural Australia—which was part of the attraction to moving to Orange (in Central Western NSW, where Charles Sturt University is based).
“Working across three continents, I noticed that dental anxiety is a very, very common condition seen across almost all populations. If you look at the prevalence of it here in Australia, around one in six Australian adults have a high level of dental fear. It’s quite a common condition. In paediatric dentistry, you come across kids who are bit anxious, and we do use different psychological methods by which we treat their dental anxiety and fear. It was always my passion to work on this topic with children and adults with dental phobia.”
It was clear to him, as it is to any dentist, that dental anxiety is stressful for everyone involved. “It’s a stressful situation, from a dentist’s point of view, to manage patients with dental anxiety because they take lot of time and it’s very difficult,” he says. “Patients who have dental anxiety, or dental phobia, just avoid seeing the dentist. As a result, these people have very poor oral health. They usually see the dentist only when they have pain. Once the pain is relieved, they again avoid seeing the dentist. Consequently, their quality of life is also compromised.
“So, having this background in treating patients with dental anxiety using psychological techniques, I was thinking, ‘What can I contribute to the fraternity of dentistry in terms of managing patients with dental anxiety and dental phobia?’”
The gold standard
He decided to study the topic in greater depth through a PhD from the Academic Centre for Dentistry Amsterdam (ACTA), looking specifically for technology-based psychological interventions wherein he could use the principles of cognitive behavioural therapy in the form of a technology. “If you go through the literature, the gold standard approach for managing any fear is cognitive behavioural therapy,” he says. “When it comes to dentistry, you hardly find any people who use cognitive behavioural therapy in their practice.”
Instead, when faced with a patient exhibiting a large degree of dental phobia, a dentist will refer them to a specialist, who will in turn encourage the patient towards general anaesthesia or conscious sedation. “When I was going through the literature, I came across how virtual reality is used to treat different phobias in the world,” he says. “In virtual reality exposure therapy, the patient wears the VR goggles, and then they are exposed to their fearful situation in a controlled environment until they get used to their fear. This mode of therapy has been popularly used to treat different kind of phobias in the world, such as fear of heights, fear of flying, claustrophobia, arachnophobia, and people have found good results with this mode of therapy.”
He discussed this with his PhD supervisor, who had been working in this space for many decades, and who agreed it was an exciting idea. Then, he says, “We contacted several software developers, and one of the software developers from Canada was willing to help us. We worked together as a team and we were able to develop a unique software that could be used to treat dental phobia.”
Anyone who has experienced virtual reality knows how immersive it is. However, the primary sensory input in a VR experience is still visual. This is great if you’re on a virtual roller coaster or playing Fortnite, but the triggers for dental phobia aren’t necessarily visual at all; often people fear the sound of a dental drill, or even an unexpected touch when they are lying prone in the chair.
“That’s an interesting question, I should say, because you’re right,” says Dr Raghav. “Patients who have high levels of dental fear and dental phobia, the main concern is that they have something known as loss of control when they are seated in the dentist chair. It’s very important from a dentist’s point of view, to always reassure the patient and make sure to inform the patient that they have total control over their treatment.”
In the virtual reality exposure therapy developed by Dr Raghav, the patient was seated on the chair, wearing the virtual reality goggles. Then they were exposed to a range of fearful situations one generally undergoes during dental treatment. This exposure was repeated quite a number of times until the patient’s fear disappeared. The patients were also given a panic button.
“If they were feeling any loss of control or if it was totally overwhelming for them, they used to just hit the panic button and the entire scenario, like the instrument or the drill coming towards them would go back on to the bracket table, and the virtual dentist would be sitting just beside them.
“Every time when they were exposed to their fearful situation, I used to ask them, ‘How are you coping? How are you feeling?’ If they had any kind of a loss of control, I would stop the procedure and then ask them how they were going. Once they were okay, then we would proceed.
“This is how the patients were trained to gain control over their dental treatment.”
The results of his research? Six months after VRET, 85 per cent of patients had lost their dental phobia diagnosis.
Dr Raghav did use the techniques on patients in Malaysia, but hasn’t had a chance to do so here yet. “Last year, August 2019, I cleared my ADC exam,” he explains. “I started my private practice in the first week of March this year. Unfortunately, because of the COVID-19 situation, I was not able to move further. But I am planning to have a similar kind of set-up for my patients, here in Orange.”
You can read Dr Raghav’s award-winning paper at sciencedirect.com/science/article/abs/pii/S0887618518301610com/science/article/abs/pii/S0887618518301610