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Use of video eyewear to manage distress in children during restorative dental

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PEDIATRIC DENTISTRY V 34 / NO 5 SEP / OCT 12

Scientific Article RANDOMIZED CONTROLLED TRIAL

Use of Video Eyewear to Manage Distress in Children During Restorative Dental Treatment
Mikala A. Hoge, DDS1 • Monica R. Howard, MA2 • Dustin P. Wallace, PhD3 • Keith D. Allen, PhD4

Abstract: Purpose: The purpose of this study was to evaluate the effectiveness of video eyewear in reducing disruptive behavior in a typical pediatric
dental population during restorative treatment appointments. Methods: One hundred twenty-eight 4- to 16-year-olds were recruited from a continuous
sample of patients seen in an urban dental clinic. Direct observations of distress, self-reported measures of pain, and patient satisfaction were obtained
in a randomized clinical trial comparing 2 different types of glasses: (1) wraparound video eyewear; and (2) sunglasses (typical treatment in this dental
clinic). Results: Analyses of covariance, using treatment condition (control vs experimental) as the primary independent variable and controlling for the
effects of age, found that children wearing video eyewear glasses demonstrated significantly less disruptive behavior than those in the control group
and that they liked their eyewear significantly better than those wearing the regular sunglasses. Conclusions: Wraparound video eyewear can be an
effective approach to managing distress in children undergoing restorative dental treatment. (Pediatr Dent 2012;34:378-82) Received February 11, 2011 |
Last Revision November 10, 2011 | Accepted November 10, 2011

KEYWORDS: CHILD, ADOLESCENT, DENTAL CARE, PAIN, BEHAVIOR, RANDOMIZED CONTROLLED TRIAL

Reviews of dental literature consistently show that children who
present with dental anxiety or dental behavior management
problems are a relatively common occurrence in dentistry.1,2
Further, the prevalence of dental anxiety and behavior man-
agement challenges is often reported to be higher in younger
children.3,4 The presence of disruptive behavior, whether the
result of anxiety, temperament, or simple noncompliance, is of
particular concern, given that it can limit children’s access to
quality oral health care5-7 as well as increase risk of injury, in-
crease the number of staff required to complete procedures, and
affect other patients’ experiences. Therefore, managing a child’s
distress during a dental appointment may increase access to
care and also contribute to successful treatment for both the
child and the pediatric dentist.
Much of the distress exhibited by children during dental
treatment is created by the unusual and sometimes unpleasant
sights, sounds, and sensations of the dental operatory.8 Distress
is an expected reaction for young children (2-5 years old), for
whom the fear of strangers, strange situations, separation from
caregivers, noises, masks, and novel stimuli are developmen-
tally appropriate reactions.9 Older children, however, may also
experience anxiety about a potentially unpleasant situation,
particularly in light of children’s tendency to overpredict the
discomfort they may experience during treatment. 10
Distraction has been examined in a variety of medical and
dental settings as a relatively easy, inexpensive, and simple ap-
proach to reducing distress and disruptive behavior in children.11
1 Dr. Hoge is a postdoctoral fellow in pediatric dentistry, Department of Pediatric Den-
tistry; 2Dr. Howard is a doctoral candidate in Applied Behavior Analysis, Department
of Psychology; and 4Dr. Allen is a professor of Psychology, Department of Psychology, all
at the Munroe-Meyer Institute, University of Nebraska Medical Center, Omaha, Neb.
3
Dr. Wallace is an assistant professor of Pediatrics, Department of Pediatrics, School of
Medicine, University of Missouri-Kansas City, Kansas City, Mo., USA.
Correspond with Dr. Allen at kdallen@unmc.edu
Distraction works by engaging the child in salient attention-
occupying visual or auditory activities (eg, watching TV), which
then limit the child’s attention to sights, sounds, and sensation
in the dental operatory.12 Investigations of visual and auditory
distraction in the dental clinic, however, have not reliably found
reductions in pain, anxiety, or disruptive behavior.13-15
One possible explanation for these differing results is that
many of the most common distracting stimuli (eg, TV, music)
may lack adequate salience to compete for attention. In other
words, common distracters may not be loud enough, close
enough, or interesting enough to hold a child’s attention and
distract him or her from the dental environment. Thus, one
way to improve the effectiveness of distraction may be to in-
crease the salience of the distractors.
To enhance the salience of an auditory distractor in the
dental clinic, one group of investigators added a choice compo-
nent.16 Children were provided a variety of music, soundtracks,
or audio stories to listen to and could change selections during
dental appointments. Even when enhanced with a choice com-
ponent, however, auditory distraction by itself did not signi-
ficantly reduce overall distress. Thus, choice alone did not
sufficiently enhance the salience of distraction.
One approach that may enhance the salience of distraction
is through the use of video eyewear—which refers to a light-
weight, goggle-like, portable set of glasses that connects to a
variety of media (eg, TV, videogame consoles, and DVD players)
and provides private media viewing. Clinically, the use of video
eyewear provides a method of distraction that combines visual
and auditory distraction, eliminates visual interference, and
reduces auditory interference, all in close proximity. Thus, video
eyewear has the potential to reduce attention to external distur-
bances by providing highly salient access to a familiar leisurely
activity. In addition, video eyewear appears to offer minimal
interference with dental treatment and negligible effort for the
dentist or staff.

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 PEDIATRIC DENTISTRY V 34 / NO 5 SEP / OC T 12

Table 1. PARTICIPANT CHARACTERISTICS, DESCRIBED BY on a 15-second partial-interval recording system. In this type of
EXPERIMENTAL CONDITION observation system, observers recorded the occurrence of any
physically or vocally disruptive behavior during a 15- second
Characteristics Experimental Control
(n=75) (n=53) interval. Observers then counted the number and overall per-
centage of intervals in which any disruptive behavior (physical
Mean age (S.D.) 8.9 (2.8) 9.9 (2.7) or vocal) occurred during the appointment. This particular
Gender (%) Females (45) Females (45)
approach has been used in numerous previous investigations
and found to have good validity in the dental clinical set-
Ethnicity (%) Hispanic (56) Hispanic (53) ting.16,19,20 Coding began when the dentist first looked at and
African American (36) African American (26) touched the patient’s face and was suspended when the dentist
Caucasian (7) Caucasian (21) and/or assistant refrained from looking and touching the pa-
Number of prior 10.9 (8.8) 8.0 (7.1)
tient for 5 continuous seconds. Coding stopped when the
visits (S.D.) overhead light was turned off by the dentist or assistant.
Child pain rating. At the conclusion of the appointment,
Appointment length 15.9 (7) 17.1 (7)
in min (S.D.) each patient was prompted to indicate the amount of discomfort
experienced during treatment using the Faces Pain Scale—
Revised (FPS-R), a 6-point scale ranging from 0 (no pain) to
10 (extreme discomfort).21 The FPS-R has extensive support as
Video eyewear devices are increasingly popular, and there a valid indicator of a child’s pain experience.22
is some empirical evidence that they can provide effective Treatment satisfaction. Treatment satisfaction was also
distraction in a number of different environments. For example, assessed at the conclusion of the appointment. Each patient
wraparound video eyewear is associated with reduced distress was asked to indicate how he or she felt about the sunglasses or
during medical examinations. 17 In addition, when used with video eyewear worn during treatment (ie, “How did you feel
adults undergoing dental procedures, video eyewear was asso- about the glasses that you wore?”) using a 5-point faces rating
ciated with a reduction in anxiety and discomfort and decreased scale ranging from 1 (happy face) to 9 (sad face), with 1 indi-
treatment time; these adults also stated a preference for the use cating extreme like and 9 indicating extreme dislike.
of video eyewear.18 As yet, however, video eyewear has not been Pain behavior reliability. A graduate research assistant cod-
evaluated for reducing distress during pediatric dental treatment. ed child behavior. A second observer independently conducted
The purpose of this investigation was to evaluate the effec-
tiveness of video eyewear in reducing disruptive behavior in a
typical pediatric dental population during restorative treatment
appointments. Specifically, patients wearing video eyewear were
hypothesized to demonstrate less disruptive behavior, report less
discomfort, and state greater satisfaction with treatment com-
pared with patients wearing standard eyewear.

Methods
Participants and settings. One hundred twenty-eight 4- to
16-year-old children were recruited from a continuous sample of
patients seen at the pediatric dental clinic at the Munroe-Meyer
Institute in Omaha, Neb., and were selected based on their
need for restorative dentistry. Restorative dentistry included
amalgams, composites, stainless steel crowns, pulpotomies, and
extractions. Each type of procedure was assigned a categorical
number, and a chi-square test showed that the 2 groups—control
and treatment—were similar regarding the type of restorative
work that was performed during this investigation (chi-square
(5)=4.7; P>.05). There were no restrictions based on gender,
race, or ethnic origin; however, patients with easily discernable
mental status limitations were excluded. In addition, to evaluate
the independent effects of the eyewear, patients who required
nitrous oxide or general anesthesia were also excluded. The group
demographics are presented in Table 1, and there are no statisti-
cally significant differences between the control and experimental
groups in: age (t (126)=1.92; P>.05); gender (chi-square(1)=0;
P>.05); ethnicity (chi-square(3)=6.59; P>.05); length of the
current restorative visits (t [126]=0.96; P>.05); or number of
prior visits (all types) to the dentist (t [125]=1.79; P>.05).
Child pain behavior measures. The occurrence of pain-
related disruptive behaviors, specifically body movements and
vocalizations, were recorded for the duration of the appointment Figure 1. Video eyewear.

VIDEO EYEWE AR 379

PEDIATRIC DENTISTRY V 34 / NO 5 SEP / OCT 12

Table 2. AVERAGE DISRUPTIVE BEHAVIOR (% OF APPOINTMENT), PAIN each participant chose a DVD, the pediatric dentist de-
RATING (0-10 SCALE), AND TREATMENT SATISFACTION (1-9 SCALE), monstrated the use of video eyewear using the tell-show-
DESCRIBED BY EXPERIMENTAL CONDITION do technique. Each participant in the experimental condition
watched the DVD for the duration of the appointment.
Dependent variable* Control Experimental Analyses of covariance
Mean±(SD) Mean±(SD) Patients assigned to the control condition were pre-
F (1, 125)† P-value E.S.‡ sented with a pair of generic sunglasses, which were placed
Disruptive behavior 22.0±22.0 14.9±15.1 7.74 .006 .059 over their eyes for the duration of the appointment. Two
different sizes were available for use to accommodate dif-
Median/range 15/0-89 13/0-67
ferent size faces.
Self-reported pain 2.83±2.64 3.25±3.17 .09 >.76 .001 Video eyewear or sunglasses were removed from the
Median/range 2/0-10 2/0-10 patient’s face at the conclusion of the appointment. Pa-
Treatment satisfaction 2.58±1.81 1.56±1.45 10.47 .002 .077 tients were then asked to rate the pain they experienced
Median/range 3/1-9 1/1-9 during the appointment with the FPS-R and their satis-
faction with either the sunglasses or video eyewear using
* For each dependent measure, lower values represent more desirable outcomes (ie, less disruptive the treatment satisfaction faces scale.
behavior, less self-reported pain, more treatment satisfaction).
† For disruptive behavior, error df is only 123, due to 2 missing cases. Results
‡ Effect size is reported as partial-eta squared. Cohen (1977) provides a rule of thumb for eval-
uating this multivariate effect size by characterizing .01 as small, .06 as medium, and .14 as large.
Experimental effect of video eyewear. To evaluate
effectiveness of video eyewear, analyses of covariance
(ANCOVAs) were conducted using 3 different dependent
reliability observations on 10% of all appointments. Mean inter- variables: (1) percentage occurrence of any type of disruptive
observer agreement was 96%. behavior during the appointment; (2) self-report of pain in-
Research design and data analyses. Participants were tensity; and(3) self-reported satisfaction with the eyewear. Each
randomly assigned to either an experimental (wearing video analysis used treatment condition (control vs experimental) as
eyewear) or control (wearing sunglasses) condition through the the primary independent variable and controlled for the effects
use of a coin toss procedure. Sunglasses were used in the control of age. The results of these analyses for each dependent variable
condition, in part because this constituted “treatment as usual” are presented in Table 2.
in this particular dental clinic and because it controlled for Results show that children wearing video eyewear glasses
any effect of simply wearing glasses. Data were analyzed using demonstrated significantly less disruptive behavior than those in
PASW Statistics 18.0 software (SPSS Inc, Chicago, Ill., USA). the control group (F [1,123]=7.74; P=.006). Those in the con-
Procedure. All procedures were reviewed and approved by trol group were disruptive, on average, approximately 22% of
the Institutional Review Board at the University of Nebraska the time, while those in the experimental group were disruptive
Medical Center, Omaha, Neb. Parental/guardian informed con- only approximately 14% of the time. Interestingly, video eye-
sents and patient assents were obtained in the dental clinic prior wear resulted in these significant improvements in behavior,
to beginning the dental appointment. The parent(s) waited in despite having no effect on self-reported pain. Children in both
the waiting room. groups reported relatively low levels of pain (ie, 2-3 out of 10
Participants assigned to the experimental condition wore on the FPS-R). Finally, children in the experimental group re-
lightweight, wraparound goggles that produced a virtual 50- ported significantly more satisfaction with their eyewear than
inch, full-color LCD screen along with stereo earbuds (see Figure those wearing the regular sunglasses (F [1,123]=10.47; P=.002).
1). They were presented with a choice of 5 DVDs to watch, The use of video eyewear demonstrated moderate effect sizes
including popular G-rated movies and television shows such as for both disruptive behavior and treatment satisfaction.
Hannah Montana, Shrek, and SpongeBob SquarePants. After Differential effect on physical and verbal behavior. Given
that the primary measure of disruptive behavior combined phys-
ical and vocal behavior into a single score, follow-up tests were
conducted to determine whether these 2 types of disruptions
were differentially impacted by the use of video eyewear.
ANCOVAs were conducted using physically disruptive behavior
followed by vocal behaviors as dependent variables. Each anal-
ysis used treatment condition as the primary independent
variable and controlled for the effects of age on the depen-
dent variable of interest. Figure 2 presents the results of these
analyses, which indicate that the use of video eyewear was as-
sociated with significantly reduced physical disruptive behavior
(F [1,123]=9.07; P=.003), but had no effect on vocal behaviors
(F [1,123]=0.45; P>.50) after controlling for the effects of
age. Again, the impact of video eyewear on physical disruptive
behavior was associated with a moderate effect size (partial-eta
squared=.069).
Age differences in observed effects. To assure that the
observed treatment effects were not simply due to video eye-
Figure 2. Effect of video eyewear on disruptive behavior—overall and by type. wear’s effect on a certain age group, we split the sample into

380 VIDEO EYEWE AR

 PEDIATRIC DENTISTRY V 34 / NO 5 SEP / OC T 12

younger (<8 years old; n=61) and older (>8 years Table 3. AVERAGE PERCENTAGE OF DISRUPTIVE BEHAVIOR PER APPOINTMENT,
old; n=67) groups of children. A series of standard DESCRIBED BY TYPE OF DISRUPTIVE BEHAVIOR, AGE, AND EXPERIMENTAL
analyses of variance were conducted using: age CONDITION
group, condition, and their interaction as indepen-
Dependent variable Control Experimental Analysis of variance F (3, 122)
dent variables; and percentage of overall disrup- Mean±SD Mean±SD Condition Age group Interaction
tive behavior per appointment, percentage of
physical disruptive behavior per appointment and Overall disruptive behavior 8.51† 8.37† 1.82
percentage of vocally disruptive behavior per ap- Younger (n=61) 31.3±26.9 17.1±14.8
pointment as dependent variables (see Table 3). Older (n=67) 17.2±17.6 11.9±15.1
Note that interval recording combines phys-
Physically disruptive behavior 9.05† 3.27 0.30
ically and vocally disruptive behaviors into a single
Younger 22.4±23.2 11.9±14.2
overall score, so the average physical score and the
Older 15.4±16.8 8.1±11.4
average vocal score do not necessarily equal the
overall mean disruptive behavior. This is because Vocally disruptive behavior 0.92 12.30‡ 2.29
interval recording systems calculate the mean by Younger 14.2±21.3 8.9±9.6
counting the number of intervals in which any Older 3.4±7.8 4.6±8.9
disruptive behavior occurred, not the frequency
of individual behaviors. The “age group” test *P<.05. † P<.01. ‡ P<.001.
showed that age was significantly associated with
overall disruptive behavior and vocally disrup-
tive behavior and that younger children were more disruptive Interestingly, pain ratings were not affected by wearing
than older children. This was the expected reason why the video eyewear. These results are somewhat surprising, given that
prior analyses on overall treatment effects were conducted participants were significantly less distressed and disruptive. Per-
using ANCOVAs, which controlled for this age effect. haps video eyewear is more effective at distracting children from
Results again indicate, however, that video eyewear had a external stimuli (eg, the sights and sounds of the operatory)
significant effect on both overall disruptive behavior and physi- than from internal stimuli (eg, sensations associated with dental
cally disruptive behavior. Finally, no interactions were statis- treatment). It is also possible that the lack of significant differ-
tically significant, indicating that video eyewear did not have a ences is simply a function of the fact that the pain ratings were
differential effect on younger and older children. Stated differ- quite low in both groups. Overall, the participants did not
ently, both younger and older children showed similar benefits report experiencing very much pain, perhaps reflecting the fact
with the use of video eyewear. that, for the most part, dentists manage pain quite well.
Although younger participants were, in general, more dis-
Discussion ruptive than older participants, video eyewear was equally effec-
The results of this investigation provide evidence that video eye- tive regardless of age. Video eyewear was associated with
wear can provide an effective approach to managing distress in significant reductions in disruptiveness irrespective of age, and
typical children undergoing restorative dental treatment. Chil- these reductions were focused primarily on reductions of phys-
dren who wore video eyewear had significantly less disruptive ically disruptive behavior rather than vocal disruptions. This is
behavior during their dental appointments. In addition, subse- noteworthy, because younger children are often more difficult
quent analyses of direct observation data showed that the differ- to manage and can require management approaches that are
ences in distress reflected changes almost exclusively in physical tailored to their unique developmental needs. Finding a man-
disruptions rather than verbal disruptions. agement approach that can address the needs of children across
These results represent an important extension of the litera- a wide range of ages has the potential to be more cost-effective.
ture for a number of reasons. First, previous research has ge- While video eyewear appears to have some benefits, the
nerally found that simple distractions do not significantly results must be viewed with caution. First, the participants in
impact distress. Yet here, a relatively simple although highly both groups showed relatively low rates of disruptive behavior,
salient distraction was effective. Second, the marked reductions so it is difficult to know how video eyewear might function with
in physically disruptive behavior may mean increased access to individuals selected specifically because of high anxiety, pro-
quality oral health care and reduced risk of injury. Finally, be- blematic disruptive behavior, or developmental disability. This
cause video eyewear is widely available and relatively inexpen- study’s participants do, however, represent a large, typical popu-
sive, it presents a potentially cost-effective approach to patient lation of patients seen in an urban pediatric dental clinic, so the
management, allowing the dentist to accomplish restorative results would be expected to apply to similar populations.
work without additional time or effort. The absence of additional information on patient charac-
The children who wore video eyewear during their ap- teristics or patient history also limits the extent to which mode-
pointments also showed higher ratings of treatment satisfaction. rator variables can be identified. For example, there was no
These results are consistent with previous studies of common information on the specific types of previous dental treatment
distraction methods. This suggests that, generally speaking, chil- the participants had experienced or on psychological variables
dren like having distractions available and rate dentists who use such as child temperament or child anxiety. Nevertheless, the
them more favorably. It is unclear whether it was the video eye- expectation of randomization of a large number of participants
wear itself, the fact that the participants had a choice of what is that the effects of variables such as these will be controlled
to watch, or some combination that added to the overall satis- and evenly distributed across the groups.
faction. This may warrant additional investigation.

VIDEO EYEWE AR 381

PEDIATRIC DENTISTRY V 34 / NO 5 SEP / OCT 12
Finally, it was not possible to tell from this investigation
how video eyewear produced the benefits that were observed.
For example, it is possible that video eyewear provided a more
salient distraction, in part through the close proximity of the
video display but also by blocking the view of other stimuli.
This study, however, was not designed to answer that question.
Instead, its purpose was to evaluate the effectiveness of the eye-
wear in reducing distress in a population of typical children, and
that purpose was achieved.
While there have been considerable advances in dental
technology, materials, and training for dentists, there continues
to be a need for advancements in cost-efficient behavior manage-
ment technology. Video eyewear appears to offer at least one
effective means of accomplishing this task. Perhaps equally im-
portant is the fact that video eyewear is relatively inexpensive,
requires almost no effort to employ, and is well liked by children.
Thus, video eyewear could be considered one important com-
ponent of the general behavior management armamentarium.
Conclusions
Based on this study’s results, the following conclusions can be
made:
1. Wraparound video eyewear can be an effective ap-
proach to managing distress in children undergoing
restorative dental treatment.
2. Additional research is needed to determine if video
eyewear is effective with children with special needs.
Acknowledgments
The authors wish to thank the Maternal and Child Health
Bureau, Rockville, Md (project no. 8188) and the Administra-
tion on Developmental Disabilities, Department of Health and
Human Services, Washington, DC (grant no. 90DD0533) for
their support.
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