An Interactive Augmented and Virtual Reality System for Managing Dental Anxiety among Young Patients: A Pilot Study

Abstract

Dental anxiety is a common health problem among children. It creates major issues for patients, parents, and dental professionals. Children who cancel or otherwise miss their dental appointments generally do so due to fear of the unknown and lack of understanding of what they can expect from the environment and treatment when they arrive there. Some distraction interventions are already used by dental professionals, such as using clown doctors, watching cartoons, and utilizing the tell–show–do (TSD) technique. Still, the problem is common, and the fail to attend (FTA) rates at clinics are high. Familiarizing children with the dental setting and procedures in advance may help to manage their anxiety. This paper aims to help in managing children’s dental anxiety in a simple, attractive, and age-appropriate way through the use of augmented reality (AR) and virtual reality (VR) technologies. The developed system is named “Dr. Barea”. It targets Arabic-speaking children aged from 7 to 10 years old. It uses model–view–control (MVC) as its architectural design pattern. The proposed solution consists of three main sections: a 360° VR video that simulates a dental clinic environment, an educational description on dental tools using AR technology, and interactive educational stories that educate children about dental hygiene. The system performance was evaluated using unit, integration, performance, and user acceptance testing. The results demonstrate that the proposed solution, which performed reasonably, achieved the usability requirements and was engaging for learning information about dental hygiene. A feasibility study with 16 children was conducted to evaluate the effectiveness of the proposed system. The Child Fear Survey Schedule—Dental Subscale (CFSS-DS) was used to measure children’s dental anxiety level. The T test was used to evaluate the differences between groups, and Fisher’s exact test was used to compare the distributions of gender and age between the groups. The CFSS-DS index in the VR group decreased after dental consultation (35.04 ± 9.14 before consultation and 32.32 ± 8.32 after consultation, p = 0.041). The implications of this study shall be beneficial to patients, parents, and dental professionals.

1. Introduction

Children’s dental anxiety is a common health problem which has a negative impact on the quality of a child’s life and oral health. Moreover, it may cause psychological problems and sleep disorders [1]. Dental anxiety is characterized as a particular fear that predisposes a person to a negative or unpleasant experience during dental procedures.

Dental anxiety can affect people of all ages, with many experiencing it in childhood and adolescence [2]. According to [3], dental phobia and anxiety are widespread among both dentists and the general population in Saudi Arabia. This often leads many individuals to postpone or avoid routine dental care, which can have detrimental effects on their oral health. Furthermore, the study found that dental phobia is more prevalent among females than males in Saudi Arabia.

Another study found a high degree of fear and anxiety among Saudi children towards dental practices, with injections being the most feared practice [4].

Children’s dental anxiety is a significant concern that stops patients from cooperating completely during dental treatment, which may result in a lack of time for the doctor, needless complications during the treatment, and increases dental services [5]. There are some methods used by dentists to distract children during treatment, but these methods have not completely resolved the problem, which is still widespread among children [6].

Virtual reality is quickly emerging as one of the most promising tools for managing stress and anxiety [7,8,9,10]. Moreover, several studies have presented evidence for the effectiveness of VR in rehabilitation [11,12]. By providing an immersive and interactive experience, creating a familiar and comfortable environment, providing educational experiences, and offering relaxation and distraction techniques, these systems can help to make dental visits less intimidating for young patients. A recently published review paper [10] stated that various studies have shown that virtual reality glasses are successful in distracting pediatric dentistry patients; however, to date, few systems have been developed to serve this domain, especially for young dental patients.

Motivated by this, we developed an interactive AR/VR-based system for managing the dental anxiety of young children. Specifically, the work presented here aims to manage children’s dental anxiety by using 360° VR video and AR technology. Additionally, it aims to improve the relationship between children and the dental clinic environment to make any future procedures more comfortable.

1.1. Children’s Dental Anxiety

Dental anxiety is a pervasive concern, and there are various perspectives on its definition. The term “dental anxiety” is used in the field to describe all types of dental fears and phobias. According to a study, anxiety is a non-specific apprehension of a situation that does not require personal experience or is relative to the patient’s response [13].

High dental anxiety is proportional to bad oral hygiene and more dental pathology [14]. Previous studies have also showed that children with high dental anxiety have greater caries than children with low dental anxiety [15] as they avoid dental treatment due to anxiety, which increases problems related to patients’ oral health. The effective control of anxiety and pain is an essential part of dental care. Scientists and dental consultants believe that the main cause of dental anxiety is related to patients’ first childhood experiences [16].

A variety of different mechanisms have been applied to understand the etiology of dental anxiety [17]. However, there is no single explanation of the existence and the development of dental anxiety [18]. In a study of dental anxiety among Saudis [3], it was found that fear of pain (35.86%), dental anesthetic injections (16.66%), and prior negative experiences (13.40%) are of the most common reasons for dental anxiety.

There are varied and multiple causes of dental anxiety in children that can be correlated to their personality traits, general fear, previous painful dental experiences, dental anxiety in their parents, age, and gender [14].

There are many techniques used to manage children’s dental anxiety. One study [19] investigated techniques for managing dental anxiety in children, using tell–show–do (TSD) and audiovisual distraction (AVD) methods. TSD involves telling the child what the dentist will do, showing them the tools, and then performing the procedure. AVD uses audio and visual stimuli to distract the child from the clinical environment. The study found that a combination of TSD and AVD was the most effective method for reducing a child’s anxiety, based on results from 400 children. Moreover, some of the techniques can be considered general strategies, such as having a trusting relationship between the patient and their doctor. Moreover, specific psychological treatment techniques can be implemented using different strategies such as rehearsal, distraction, and guided imagery, etc. [20].

1.2. Virtual Reality

Virtual reality (VR) is a simulation that makes the user feel that they are immersed in a three-dimensional environment via an interactive technology setup that acts as a human-to-computer interface [21]. VR requires resources such as hardware (computer, VR devices, and I/O devices) and software (application and database) [22].

1.3. 360° VR Video

VR videos of 360° have achieved popularity around the world. They use an omnidirectional camera to capture everything around in a sphere. Unlike regular videos, 360° VR videos provide an immersive experience [22]. One of the most important features is that the user does not need a special device in order to view 360° videos as all it takes is tilting the device to explore everything from every angle, and if the user desires an immersive experience, they can use a VR headset.

Videos of 360° and VR are both immersive technologies, but they differ in a few keyways. First, 360° videos are videos that are filmed using a special camera that captures a 360-degree view of the surroundings [22]. VR, on the other hand, is a fully immersive experience that transports users to a computer-generated environment [22]. In summary, 360° videos offer a passive viewing experience that allows users to explore a 360-degree environment from a fixed vantage point, while VR provides a fully immersive experience that allows users to interact with a computer-generated environment in a natural and intuitive way.

1.4. Augmented Reality

Augmented reality (AR) is a technology that has received much attention. It allows the user to see virtual objects by mixing the virtual with the real world to achieve a high level of immersion, as shown in Figure 1. AR technology has been applied in many fields, including education, entertainment, and medicine.

The basic element of augmented reality is that information has a physical space or location in the real world. Figure 2 illustrates a digital vase on a real table, meaning that the vase has a location in the real world. If the person moves away from the table, the vase will stay in the same place [23].

2. Related Work

Some of the recent literature has explored the potential of utilizing virtual reality to reduce dental anxiety. In [24], the authors conducted a review of the last 10 years of research on augmented reality and VR in dentistry, though they were unable to make scientifically proven recommendations. Nonetheless, AR and VR have been found to be advantageous for clinical practice as they can be used to demonstrate to patients the outcomes of dental procedures and help to alleviate dental phobia. Moreover, the authors in [10] investigated the utility of virtual reality glasses as a tool to distract children during dental procedures. Based on their review of the existing literature, they determined that VR glasses are an effective distraction technique in pediatric dentistry.

Furthermore, an investigative study examined the influence of an AR character on the behavior of children aged 5–10 years. One of the experiments found that the presence of an AR character significantly impacted pathway selection [25]. In another study, the use of VR tours of the operating theatre for children prior to surgery and anesthesia was explored to determine if it could reduce anxiety. The results showed that the VR tour effectively reduced and relieved anxiety before surgery and anesthesia [26].

In the present age, numerous intelligent applications have been employed in the arena of dentistry. With respect to diminishing dental anxiety, multiple contemporary applications can be utilized to provide aid. One such example is that of Doctor Teeth [27], an edutainment application that simulates the process of dental treatment to entertain and educate children about the human mouth and teeth and aid in emulating the role of a dentist. Moreover, Dentalk [28] has been found to be an effective tool to help dental professionals effectively communicate different diseases, treatments, and hygiene techniques to their patients. Additionally, its visual components can promote patient satisfaction and reduce dental anxiety. Brush Monster [29] utilizes a mobile camera to enable children to interact with the brushing process in real time, providing them with proper instructions on the correct brushing technique. In addition, My Bright Smile [30] helps young ones to maintain their white smiles through lessons and gameplay, while Going to The Dentist prepares children for their first dental appointment by making use of cartoon characters and voice-over to elucidate the procedure in a gentle manner. Lastly, a storybook application named Hetty’s Hospital [31] has been designed to help reduce anxiety about going to the hospital.

To sum up, many analogous systems have been examined and evaluated. The comparison in

Table 1. Comparison of similar applications to Dr. Barea.

Features	Doctor Teeth	Hetty’s Hospital	My Bright Smile	Going to Dentist	Brush Monster	DenTalk	Dr. Barea
Supports Arabic language	X	X	X	X	X	X	√
Is free of charge	√	√	√	X	√	√	√
Is an educational application	√	√	√	√	√	√	√
Targets children	√	√	√	√	√	X	√
Uses AR	X	X	X	√	√	X	√
Uses gamification	√	√	√	√	√	X	X
Uses storytelling	√	√	√	√	√	X	√
Targets dental anxiety	X	X	X	√	X	√	√
Includes dental tool scanner	X	X	X	X	X	X	√
Includes dental tools education	√	X	X	X	X	√	√
Includes teeth brushing tutorials	√	X	√	√	√	X	X

provides us with a clear understanding of effective applications and which features we should consider when creating a useful system. Furthermore, none of the applications support the Arabic language, and all of them are geared towards children, except for Dentalk, which is for adults. Additionally, we discovered that there is a lack of systems employing AR/VR technologies; only Brush Monster and our own system, Dr. Barea, have features that can only be used within the clinic. Moreover, there are few systems that focus on dental anxiety. Our system, Dr. Barea, supports the Arabic language, and we trust that the system will provide children with an excellent learning experience that will be beneficial in managing their dental anxiety.

3. Materials and Methods

3.1. System Overview

Our proposed system is built on the proven benefits of VR and AR technology in managing stress and anxiety, as demonstrated by various studies [7,8,9,10,11,12,25,26]. By providing an immersive and interactive experience, creating a comfortable and familiar environment, offering educational experiences, and incorporating relaxation and distraction techniques, VR and AR systems can help make dental visits less intimidating for young patients as, after using them, they will better understand the experience they will face [32].

Dr. Barea, our proposed system, is an Arabic mobile application designed specifically for a dental clinic to help children manage their dental anxiety. The primary target users for this project are children aged 7 to 10 years, as studies have shown a high prevalence of dental anxiety in this age group [33].

The system consists of three main sections: a 360° VR video that simulates a dental clinic environment, an educational description of dental tools using AR technology, and educational stories that provide children with information about dental hygiene. The 360° VR section aims to manage anxiety by allowing children to explore and become more familiar with the dental clinic environment, which can help them feel more at ease during their dental appointments. The AR section focuses on identifying dental tools and equipment and illustrating their usage and purpose in a child-friendly way.

While it is recommended to use a VR headset to simulate the 360° VR environment for a more immersive experience, it is not a mandatory requirement for the application to function. The child can still view the 360° videos without a VR headset, but the experience may not be as engaging.

With regard to the AR feature, it can be utilized at home with any toothbrush or dental equipment available to the child. It is important to note, however, that the AR feature is only one component of our proposed system, and the other sections (360° video and stories section) can be used at home without any additional equipment.

3.2. System Architecture

Dr. Barea uses model–view–control (MVC) [34] as the architecture design pattern, as illustrated in Figure 3. This helps us separate the development of the Dr. Barea system based on three components: system logic as the controller, Dr. Barea interface as the view, and, lastly, the data as the model.

3.3. System Analysis and Design

The target audience of Dr. Barea’s system is children aged between 7 and 10 years old who suffer from dental anxiety. The system supports the Arabic language and requires no technical expertise. To ensure that the system design fulfills a need while developing the system, we created two questionnaires: one for dentists and another for parents. These questionnaires were distributed to gain a broad understanding of the problem and to focus on needs and requirements. We also interviewed Dr. Abeer Al-Namankany, a dental professional and expert on dental anxiety, to gain insights into the causes and potential solutions for children’s dental anxiety.

After conducting interviews with experts, monitoring children’s behavior in clinics, and reviewing the related research, we selected the most important eight tools (probe, mirror, dental chair, dental light, air water syringe, toothbrush, explorer, and ultrasonic scaler) for the system. For the toothbrush, we decided to display a video from the Saudi Ministry of Health about the proper technique of teeth brushing [35]. Figure 4 shows a use case diagram that displays the main actions that can be performed by the child within the system. Additionally, Figure 5 illustrates the main functionality of the application, which is to scan the dental tools and their functions.

The following are the descriptions of the three main use cases:

Use case name: Scan dental tools.

Purpose: Allow the child to scan dental tools.

Overview: This use case begins when the child wishes to discover dental tools. The child should select the “discover dental tools” section; then, they should point the camera to scan a specific tool.

Table 2. Typical course of events for “Scan Dental Tools” function.

User Actions	System Responses
1. This use case begins when the child wishes to discover dental tools during his/her visit.
2. The child opens the camera by selecting “discover dental tool” section.	3. The system displays Dr. Barea as a 3D object.
4. The child points the camera to a specific tool.	5. The system detects the tool.
	6. The system displays the tool description.
Alternatives: In step 5, the system should display a message to the child if no dental tool is found.

illustrates the typical course of events for this use case.

Use case name: View dental clinic.

Purpose: Allow the child to view the dental clinic.

Overview: This use case begins when the child wants to view the dental clinic in advance. The child should select the “view dental clinic” section, then the system should take the child on a virtual tour inside the clinic, using 360° VR technology.

Use case name: View an educational story.

Purpose: Allow the child to view an educational story.

Overview: This use case begins when the child wants to watch an educational story and gain access to the questions at the end of each story.

3.4. System Implementation and Integration

3.4.1. Hardware and Software Tools

There is varying hardware and software utilized in the development of the Dr. Barea system, including:

• 3D Virtual Reality Helmet, (VR Shinecon, Mainland China)—used to test and view the 360° VR video.
• Samsung Galaxy A71 (Samsung Electronics, Suwon, Republic of Korea)—an Android smartphone used for running and testing the project.
• insta360 Camera, (Shenzhen, China)—special camera to take 360° video.
• Canva (version 3.0, Windows, Canva, Sydney, Australia) [36]—a platform used to create social media graphics, presentations, posters, documents, and other visual content.
• Procreate (version 5.3.1, iOS, Savage Interactive Pty Ltd., North Hobart, Tasmania, Australia) [37]—a raster graphics editor app for digital painting.
• Scanner (PTC. INC., Boston, MA, USA) [38]—used to scan 3D objects.
• Visual studio (version 17.0, Windows, Microsoft, Redmond, WA, USA) [39] Atom (San Francisco, USA) [40]—used to write the scripts.
• Insta 360° One X (Android, Insta360, Los Angeles, CA, USA) [41]—used to view and edit the shots in 360°.
• Unity hub (San Francisco, CA, USA) [42]—a tool to manage all the projects that have been uploaded by the team in the cloud.
• Unity (San Francisco, CA, USA) [43]—a cross-platform engine used to develop games, VR, and AR applications.
• Vuforia (PTC. INC., Boston, MA, USA) [44]—software version 10.14. for creating augmented reality for mobile devices.

3.4.2. Implementation

The implementation of the Dr. Barea system involved the integration of various components, which were divided into three groups and three levels. The first group contained the general functions of the system, including the user interface, data storage, and system management. The second group contained the video functions, which included the recording, editing, and integration of 360-degree videos into the system. The third group contained the AR functions, which included the identification of dental equipment.

To ensure a systematic and efficient integration process, we first focused on implementing the first level of the system. This involved treating each group of functions independently, ensuring that each group was fully functional and tested before moving on to the next level. Once each group was implemented, we then combined the components that depend on each other, as outlined in

Table 3. The system’s components combined at level 2.

Level 2
Group 1	Group 2	Group 3

. At the final level, we combined all the components together to create a fully functional and integrated system, as shown in

Table 4. The system’s components combined at level 3.

Level 3

. The system was tested extensively to ensure that all the components worked seamlessly together to provide a smooth and engaging user experience.

To develop the Dr. Barea system, we utilized the Unity platform. Unity is a closed-source, cross-platform game engine that allows developers to create applications by manipulating objects in 2D/3D and attaching various components to them. Scripts are written in C# and attached to objects as components, which are stored in the assets folder in Unity. With just a few clicks, the Android application package can be exported with all its components stored without the need for an external database engine.

Furthermore, we used Vuforia, an AR software development kit for mobile devices that enables the creation of augmented reality applications inside Unity, to detect objects as markers. We used the Scanner application provided by Vuforia to scan and store specific points of the dental tools in the Vuforia database. While Vuforia excels at detecting and tracking specific physical objects in the real world, object recognition in Vuforia is not typically considered part of 360-degree recognition.

Our application can detect objects from various positions. However, the detection accuracy depends on the quality of the scan and the similarity between the scanning position and the current position of the object. In other words, the closer the current position of the object is to the position it was scanned in, the better the detection. This implies that there might be certain positions where the detection is more reliable, but the application is not limited to detecting the objects from only those specific positions.

The VR section shooting was performed at Sigal dental clinic in Riyadh, Saudi Arabia, and the 360-degree videos were edited and integrated into the system using Unity.

Overall, the implementation process involved careful planning and execution to ensure that the different components of the system were integrated efficiently and effectively.

3.5. Application Layout and User Interface

The User Interface Design of our application focuses on being child-friendly [45], creative, and simple at the same time. Several factors were considered during the design process. For example, we chose bright colors as they help to attract and engage children, and we used images and icons to help the child understand the content. Furthermore, we incorporated animation into the system since children love it. Last, we ensured that the layout was simple by removing all unnecessary elements, leading to an easy-to-use interface. Figure 6 depicts a snapshot of the system’s user interface.

3.6. Experimental Settings

The feasibility study was carried out in Sigal Dental Clinic, Riyadh, Saudi Arabia. The study was conducted in accordance with ethical principles and standards set forth by the Research Ethical Committee in King Saud University. Prior to conducting the study, written informed consent was obtained from the parents or legal guardians of all child participants, and their confidentiality and privacy were protected throughout the study.

The functionality and acceptability of the proposed system were examined with children who had or had not had prior dental exposure. Children were randomly assigned to one of the two groups: the VR group, which used the proposed systems, and the control group, which used conventional distraction techniques such as the tell–show–do (TSD) technique to assist children in adapting to the dental setting.

A total of 16 children, 6 boys and 10 girls, ranging in age from 7 to 10 with an average age of 8.3 ± 1.0, were randomly allocated to the VR group (n = 8) and the control group (n = 8).

The Statistical Package for Social Science (SPSS) version 25 was used to analyze all data. The significance threshold was set at 5% (p < 0.05). The T test was used to evaluate the differences between the groups. Fisher’s exact test was used to compare the distributions of gender and age between the groups. Due to the possibility of sample bias and varying levels of anxiety, all the children’s clinical consultations were conducted by a single dentist.

Dental anxiety levels in children and adults have been measured for many years through validated questionnaires in the literature [46,47]. The Children’s Fear Survey Schedule—Dental Subscale (CFSS-DS) [46] is the most used questionnaire to assess dental anxiety in children over the age of six years, and it was chosen for use in this research.

4. Evaluation and Results

The purpose of a system test is to evaluate the end-to-end system specifications and to verify that an application performs tasks as designed. In the Dr. Barea system, we ensured the effective performance of the system using unit, integration, performance, and user acceptance testing. In addition, we measured anxiety levels through the CFSS-DS.

4.1. Unit and Integration Testing

The purpose of unit testing, which is considered the first level of testing, is to validate that each unit of the software performs as designed. Integration testing is the process of taking all program units that have already been “unit tested,” combining them with the rest of the software, and testing them as a group [48]. The goal of this level of testing is to ensure there are no faults in the interaction between the integrated units. Our strategy for the integration testing is a bottom-up approach, which begins testing with the smallest and lowest modules in the software and then moving upward [49]. Unit testing was performed for each unit and the functionalities were passed based on the required function, which means they were successful, and integration testing of the Dr. Barea system was performed using the bottom-up approach. The testing of the components integrated the higher modules preceding the lower ones. This approach enabled all Dr. Barea’s functions to be integrated successfully.

4.2. Performance Testing

Performance testing was conducted to determine the overall quality of the designed system, considering that CPU usage was one of the selected metrics for valuing the performance of an application. We conducted performance testing using the Profiler module provided by Unity3D, which records multiple areas of application performance and exhibits that information for analysis. As shown in Figure 7, the CPU usage chart displays the time spent on the application’s main thread. It shows a good response time for displaying UI for 0.03 ms, rendering graphics for 0.59 ms, and running scripts for 0.12 ms, which concludes that the overall response of the application is less than a second, implying that the system is fast.

Figure 8 shows system memory usage and information about how Unity allocates memory. A variety of resources were used, including texture memory, which describes the texture used in the system. The total space used by the system is 476.7 MB.

4.3. User Acceptance Testing

User acceptance testing is a phase of testing in which targeted end users test the software to determine whether it can be accepted or not. We conducted our test with 5 children ranging in age from 7 to 10 years old. We planned for the test session to last under an hour. We gave the participants a VR headset to explore VR videos, and each user was tested one-on-one by a researcher.

Table 5. Results of a user acceptance testing on a child.

Task	Time Needed	User Feedback	Completion Status
Enter name	00:04:89	-	Pass
Choose section	00:01:05	-	Pass
Explore VR video	00:11:00	“بالنظارة احلى” “it is more exciting wearing the VR headset”	Pass
View 3D dental tool description	00:12:78	”كنت احسبها ابرة“ “I have been always thinking that tool is a needle”	Pass
View 3D dental tool	00:04:24	-	Pass
Scan dental tool	00:17:22	-	Pass
View 3D Dr. Barea	00:01:09	“قاعد احركه” “wow, I can move him”	Pass
Rotate 3D Dr. Barea	00:04:50	-	Pass
View educational stories	00:11:02	“ماكنت اعرف وش القواطع” “I just knew what the incisors actually is”	Pass
Pause story	00:02:20	-	Pass
Replay story	00:05:10	-	Pass
Zoom in 3D Dr. Barea	00:03:00	-	Pass
Zoom out 3D	00:02:23	-	Pass
Zoom in 3D dental tool description	00:02:03	-	Pass
Zoom out 3D dental tool description	00:02:00	-	Pass
Rotate 3D dental tool description	00:01:28	-	Pass
Rotate 3D dental tool	00:01:50	-	Pass
Answer quiz	00:14:04	“حليته على طوول” “I solved it immediately”	Pass
Replay story	00:05:10	-	Pass
Zoom in 3D	00:03:00	-	Pass

below illustrates the user acceptance testing results for one of the participants and the given feedback.

We tested our system on children and found that all of them successfully completed the tasks. To assess the children’s satisfaction with the system’s usability and user interface, we conducted a survey in which they rated their satisfaction level as ‘Very satisfied’, ‘Satisfied’, ‘Neutral’, ‘Dissatisfied’, or ‘Very dissatisfied’.

Table 6. User interface survey.

Question	Child 1	Child 2	Child 3	Child 4	Child 5
Interface colors were excellent
Navigating between sections was easy to me
I can hear sounds in the application clearly
Understanding the interface was easy
Overall experience was great

presents the results of the survey on user interface.

In summary, the user acceptance testing showed successful results among different children, indicating that we have achieved our goal of developing the Dr. Barea system. Furthermore, the system encountered no crashes.

4.4. Anxiety Level

After evaluating user acceptance, we conducted a second phase of the study to evaluate the system’s effectiveness. In total, 6 boys and 10 girls, ranging in age from 7 to 10 years with an average age of 8.3 ± 1.0, were randomly allocated to the VR group (n = 8) and the control group (n = 8). Fisher’s exact test reveals that there was no statistically significant difference between the groups in terms of age distribution (p = 0.619) or gender distribution (p = 0.608).

We observed no statistically significant variation in the CFSS-DS index between the VR and control groups prior to consultation (p = 0.674). However, a statistical difference was observed after consultation between groups, with children in the VR group presenting lower levels of dental anxiety compared with the control group. As shown in

Table 7. Dental anxiety levels before and after consultation in different groups.

	CFSS-DS (Before Consultation)	CFSS-DS (After Consultation)	p
VR group	35.04 ± 9.14	32.32 ± 8.32	0.041
Control group	36.76 ± 0.92	35.16 ± 2.79	0.094
p	0.674	0.528

, there is a significant difference in the decrease in the CFSS-DS index in the VR group (p = 0.041) compared to those in the control group (p = 0.094).

5. Discussion

Fear and anxiety are commonly experienced during dental visits, particularly among children. There are several treatments for dental anxiety in children, such as behavior management techniques including distraction and tell–show–do [19]. Moreover, pharmacological management, including nitrous oxide (laughing gas) and oral sedation [50], can be used to help children feel more relaxed and comfortable during dental procedures. In addition, cognitive behavioral therapy (CBT) [51], which is a type of talk therapy, can be used to help children manage anxiety and fear related to dental procedures. Still, fear and anxiety are widespread among children [6].

Fortunately, advances in technology have enabled the development of interactive augmented and virtual reality systems that can help manage anxiety. These systems provide an immersive experience that can reduce fear and anxiety related to dental visits. AR and VR systems can create a virtual dental office, dental chair, and other equipment [52], making the environment more familiar and less intimidating for young patients. Additionally, AR and VR systems can provide relaxation techniques and distraction strategies, such as calming visuals and sounds, to reduce anxiety.

Research has been conducted on the application of AR and VR in various areas of dentistry, but only a few studies have examined the results. Our study introduces a system designed for Arabic-speaking children aged 7 to 10 years to manage dental anxiety using VR and AR technologies. The system’s performance and effectiveness were evaluated using unit, integration, performance, and user acceptance testing. Dental anxiety was measured using the CFSS-DS, a widely adopted international scale to assess children’s anxiety during dental care [53].

The results demonstrate that the proposed solution performed reasonably, met usability requirements, decreased negative emotions in the clinic, and was engaging for learning about dental hygiene. The user acceptance testing showed positive results among different children, indicating that the system achieved its goal. Furthermore, the system encountered no crashes, demonstrating its stability and reliability. Additionally, the results of the second phase of the study suggest that the use of VR/AR technologies has a positive impact on managing anxiety in children, as evidenced by the lower CFSS-DS scores in the VR group compared to the control group.

These findings are consistent with previous studies [54,55] that have shown the potential of VR technology in reducing anxiety in various medical settings, including dentistry. One possible explanation for the effectiveness of VR technology is that it provides a distraction from the dental procedure, which can help to reduce anxiety and pain. By immersing the child in a different environment, VR technology can also help to create a sense of control and safety, which can further reduce anxiety levels. This study also contributes to the Arabic content in the field of AR and VR technologies. Dr. Barea is primarily intended for use in dental clinics; however, the application will also be available on smartphones, providing easy access from any location. Overall, the proposed system proved to be advantageous in the dental environment, alleviating the worries and stress of pediatric patients.

Despite the promising results in terms of anxiety management, the current system and research have certain limitations. First, the feasibility study only included a small number of participants for one session, which limits the generalizability of the findings. Our long-term aim is to conduct a longitudinal study with a larger cohort and multiple trials to further validate the effectiveness of our proposed system.

Second, we intend to measure anxiety levels before and after using the system through the Chotta Bheem–Chutki scale (CBC) [56], which will provide a more comprehensive evaluation of the effectiveness of our proposed system.

Third, physiological indicators of emotional responses, such as heart rate variability, were not evaluated in this research. Future studies should consider including such measurements to provide a more complete understanding of the impact of the proposed system.

Fourth, further research is needed to determine if AR and VR technology can help students considering a career in dentistry practice various treatments on their own. This could be an important application of AR and VR technology in the dental field.

Finally, prior dental experiences are another factor that could affect dental anxiety levels. Several studies have found that prior painful experiences have a direct impact on dental anxiety [57]. It is important to note that dental anxiety in children can be caused by a variety of factors and overcoming this anxiety may require a combination of techniques. In addition to VR and AR techniques, children with dental anxiety may benefit from various other techniques, such as cognitive behavioral therapy, relaxation techniques, and desensitization to the dental environment.

Overall, while VR and AR techniques may be helpful tools in managing dental anxiety in children, they are unlikely to be a complete solution on their own. Future research is needed to combine this emerging technology with other features, such as low noise instruments [58] and computerized anesthesia devices [59], which could lead to more advanced and effective systems that improve the dental experience for children and reduce the burden on dental professionals.

6. Conclusions

This paper presents a VR- and AR-based system designed to manage dental anxiety among children. Our feasibility study with 16 children demonstrated that the proposed solution performed well, met usability requirements, decreased negative emotions in the clinic, and was engaging for learning about dental hygiene. The results suggest that the use of the system to manage dental anxiety is both feasible and effective.