Home Pediatric Dentistry Reducing children’s anxiety and pain in dental environment using an eye massage device combined with natural sounds—a randomized controlled trial

Reducing children’s anxiety and pain in dental environment using an eye massage device combined with natural sounds—a randomized controlled trial

by adminjay


Anxiety is an adaptive emotional response to potentially threatening or dangerous situations moderated by the sympathetic nervous system23. Dental anxiety in children compromises oral health due to dental care avoidance and is considered one of the greatest challenges in pediatric dentistry24. The most typical anxiety-inducing stimulus, particularly in children, is the anticipation of needle injury, with inferior alveolar nerve block reported as extremely painful and stressful compared with other infiltration techniques6,25. Hence, managing children’s anxiety and reducing procedural pain are standard practices for pediatric dentists, as they play an essential role in providing children with appropriate dental care and ensuring that they develop a positive perspective on dental treatment.

In this study, an eye massage device that uses acupressure technology combined with natural sounds was tested for its efficacy in reducing dental anxiety and pain related to IANB injection.

In terms of children’s social-emotional development, children at eight years of age can fully understand rules and regulations, show a profound understanding of relationships and responsibilities, and learn more complex coping skills26. This means that children at this age can interact with the dentist, understand his instructions, and build a trusting relationship with him where they can express themselves adequately. Thus, children aged between 8 and 10 years were included in this study.

Comprehensive assessment tools are needed to assess anxiety and achieve a better understanding of patients’ feelings. Self-report anxiety scales are the simplest and most common way to ask children about their feelings19. Similarly, self-report scales are considered the gold standard for pain assessment in children because, compared with clinical judgment, pain is a subjective experience27. In this study, the Wong-Baker pain rating scale was used because of its ease of use, preference for children and parents, and validity in reporting pain.Similarly, the Children’s Fear Scale, which is based on the Faces Anxiety Scale for adults, was used to assess children’s level of anxiety18.

In addition, anxiety is typically accompanied by heightened autonomic nervous system (ANS) activity, which activates the circulation, increasing blood pressure and pulse rate29. In this study, changes in pulse rate were measured using a digital pulse oximeter as a physiological scale.

The results of this study reject the null hypothesis and support the alternative hypothesis that eye massage alone and combined with natural sound are superior to traditional behavioral management techniques in reducing anxiety and pain during dental anesthesia. The results revealed that massage alone and massage combined with natural sounds groups experienced significantly lower levels of anxiety and pain than did the control group in terms of all the implemented measurements. These findings indicate that the children in the two intervention groups were more comfortable and relaxed, less anxious, and felt little to no pain during the IANB injection. To explain the effect of massage on anxiety, one theory suggests that massage works by shifting the ANS from a sympathetic response (which prepares the body to defend against threat) to a parasympathetic response, which decreases stress hormone levels and cardiovascular activity, leading to feelings of calmness and well-being30. Moreover, the eye massage device used in this study targeted the Yin Tang point located at the midpoint between the medial extremities of the two eyebrows, which is considered an anxiolytic acupoint that has been used to induce sedation and provide a balance between the sympathetic and parasympathetic nervous systems, releasing neurotransmitters and mediators that alleviate pain and anxiety31.

A meta-analysis of massage therapy conducted by Moyer et al32.. (2004) described reductions in state anxiety, blood pressure, and heart rate with a single application of massage therapy, which is in accordance with the results of this study, where children who experienced the eye massage device, whether accompanied by natural sounds or not, exhibited a significantly lower pulse rate during injection and expressed less fear after the injection on the CFS scale than did children in the control group whose pulse rate increased and who were more anxious after the injection.

This study also revealed that massage reduced pain levels compared with those in the control group; a theoretical explanation for this could be the gate control theory. Chang et al33,34. (2002) hypothesized that massage may stimulate large-diameter A-fibers, which in turn release enkephalin that inhibits incoming painful sensations, thus closing the gate and minimizing the perception of pain, usually reducing anxiety. This explains why children who experienced massage vibrations in the two intervention groups expressed significantly less pain than did children in the control group, who scored higher levels of pain on the Wong-Baker scale and were more distressed during dental injection according to the FLAAC scale.

On the other hand, when the two intervention groups were compared, the results revealed that children who experienced eye massage combined with natural sounds experienced less anxiety and pain during the procedure, as they were relaxed and comfortable according to the FLACC score and had a significantly lower pulse rate than children who experienced massage alone, who had a higher pulse rate and showed mild discomfort according to FLACC score. This could be attributed to the additional effects that natural sounds have on health and well-being. A systematic review by Buxton et al35.. (2021), on the health benefits of listening to natural sounds, demonstrated that water sounds, such as running water or waterfalls, have the greatest impact on health and positive feelings, whereas bird sounds have the greatest effect on alleviating stress and annoyance. For this reason, a mix of water and bird sounds was chosen for children to listen to during the procedure.

Natural sounds have been found to improve vital signs, decrease sympathetic activity, and increase parasympathetic activity36. Alvarsson et al36. (2010) reported that natural sounds enabled faster physiological recovery in individuals exposed to physiological stress. Moreover, Largo-Wight et al37. (2016) reported that listening to natural sounds resulted in a lower heart rate and blood pressure and decreased muscle tension and stress in healthy volunteers. This study was in accordance with the results of Largo-Wight et al. However, there was no significant difference between the massage group and the massage combined with natural sound group regarding the Wong-Baker pain scale and the Children’s Fear Scale. This could be attributed to the fact that self-report scales can be affected by various biases, including personal interpretation of pain, emotional state, cultural influences, and social desirability38. Children, in particular, might underreport their pain due to the desire to conform to expected behaviors, fear of negative judgment, desire to avoid worrying their parents, or cultural norms that discourage showing weakness39. In this study, children in the massage group reported the same level of pain and fear on the Wong-Baker scale and CFS as did those in the massage and nature sounds group, whereas the FLACC objective behavioral pain scale and pulse rate indicated that the children in the massage group experienced greater levels of pain and discomfort than did those in the massage and nature sounds group. Objective measurements, such as physiological indicators (heart rate) and observational scales, provide quantifiable data that are not influenced by a person’s subjective experience and offer a more reliable and consistent method for assessing pain and anxiety39.

The levels of anxiety recorded via the CFS and pulse rate after the injection for children in the massage with natural sounds group decreased compared with the levels recorded at rest before the intervention. For children in the massage-only group, the CFS score and pulse rate after injection did not change and maintained the same levels recorded before injection. However, the pulse rate and CFS score increased for children in the control group after the intervention. These findings indicate that massage alone stabilized children’s condition throughout the procedure and the injection procedure had a non to marginal effect on their anxiety levels. However, massage combined with nature sounds had a more positive effect on children and resulted in anxiety reduction, making the procedure less stressful and the children more relaxed.

This study is the first to evaluate the effects of natural sounds and massage on children’s anxiety in a dental environment; however, there are several limitations to this study. The procedure was limited to anesthesia, and the effects of the interventions on prolonged procedures, such as restorative treatment, were not studied. Another limitation was the inclusion of only cooperative children, as this group comprises the main group of pediatric patients in dental practice. Moreover, the effects of only natural sounds were also not evaluated, which could be done in further studies.



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