ABSTRACT This study evaluated the efficacy of an eye massage device that uses acupressure points combined with natural sounds to reduce anxiety and pain in children receiving dental

anesthesia for the first time. A total of 105 children aged between 8 and 10 years whose dental treatment required inferior alveolar nerve block (IANB) injection participated in this

randomized controlled clinical trial. The participants were randomly divided into three groups: Group A: eye massage with natural sounds; Group B: eye massage only; and Group C (control

group): traditional behavior management techniques. Anxiety and pain were assessed before, during, and after anesthesia using the Children’s Fear Scale (CFS), Wong-Baker pain rating scale

(p < 0.05); however, no significant difference was noted between groups A and B regarding the data recorded after anesthesia using the WBS and CFS (p > 0.05). Changes in pulse rate

and anxiety levels (CFS) measured before and after the procedure in each group revealed a significant decrease in fear and pulse rate in group A and no significant change in group B, whereas

group C showed a significant increase in pulse rate and fear at the end of the procedure. Eye massage with natural sounds can effectively alleviate children’s anxiety in the dental setting

and reduce pain related to anesthesia, and the combination of these two interventions has the best relaxation effect on children. SIMILAR CONTENT BEING VIEWED BY OTHERS THE EFFECT OF

AROMATHERAPY WITH LAVENDER-NEROLI OIL AND MUSIC IN MANAGEMENT OF PEDIATRIC DENTAL ANXIETY: A RANDOMIZED CONTROL TRIAL Article Open access 29 January 2024 CHILD’S FRIENDLY DENTAL ATTIRE, A

GAME CHANGER FOR ANXIETY AND PAIN MANAGEMENT IN DENTAL ENVIRONMENT, A RANDOMIZED CLINICAL TRIAL Article Open access 04 December 2024 AUXILLARY AIDS FOR PAIN AND ANXIETY REDUCTION DURING

DENTAL LOCAL ANESTHESIA IN PEDIATRIC PATIENTS: A SYSTEMATIC REVIEW Article 08 January 2025 INTRODUCTION Dental anxiety is one of the primary emotions experienced when a patient enters the

clinic and arises from threatening stimuli that lead the patient to respond in certain ways1; it also continues to be one of the greatest sources of challenges for dentists when providing

dental care to children2. The prevalence of dental anxiety in children ranges between 6 and 42% and is attributed to many factors3. Due to dental anxiety, patients often avoid visiting the

dentist until they feel pain or discomfort, which leads not only to poor oral health and tooth loss but also to feelings of shame and inferiority4,5. Fear of injection and painful inferior

alveolar nerve block (IANB) injection is one of the most common reasons for children to refuse dental treatment and can badly affect their behavior6. Although the visit might proceed

smoothly, the anticipation itself makes the child anxious and stressed, which reduces his endurance threshold, making him more susceptible to experiencing higher levels of pain7. In

accordance, pain related to needle procedures is considered the primary source of distress for children in dental settings and can vary from mild to severe, resulting in high levels of

anxiety8. For dentists, the relationship between dental anxiety and pain are barrier to a positive dental attitude in pediatric patients, which hinders the delivery of quality dental

treatment9. Studies have shown the effectiveness of nonpharmacological interventions in managing dental anxiety10. These interventions have proven to be as effective as pharmacological

interventions while also having the advantage of reducing side effects associated with the medications, such as nausea, respiratory depression, low heart rate, and blood pressure, in

addition to the refusal of some patients to take medications. Moreover, parents are more accepting and in favor of nonpharmacological interventions10. Therefore, the exploration of

alternative, effective interventions to alleviate pain and anxiety is of crucial clinical importance. Acupoint massage, a nonpharmacological alternative treatment based on Chinese medicine,

offers a promising solution. Acupressure involves the application of steady, gentle pressure manually or through specialized noninvasive devices on one or more of the body’s 365 energy

points across 12 meridians11. In the field of dentistry, the acupressure technique has been utilized in the management of pain, stress, and temporomandibular joint (TMJ) disorders and in

controlling the gag reflex during dental procedures in adults12. However, the use of acupressure in pediatric dentistry is still unexplored. Avisa et al. investigated the impact of

acupressure on anxiety reduction in children undertaking scaling and restorative procedures and concluded that acupressure can be a feasible option for reducing children’s dental anxiety13.

On the other hand, there is a growing awareness that natural stimuli are powerful agents for calming the nervous system14,15. Recently, nature-based interventions such as aromatherapy and

nature sounds have been implemented in many medical settings as nonpharmacological interventions that reduce anxiety14,15. Many studies have reported that natural sound interventions are

effective at reducing state anxiety in patients undergoing different medical procedures, such as heart surgery, colonoscopy, and chemotherapy14,15. Since there are no available studies in

the literature that explore the effect of combining natural sound intervention with acupoint massage in reducing dental anxiety in children, this study was undertaken to evaluate the effect

of eye massage combined with natural sounds in relieving anxiety and pain in children receiving dental anesthesia compared with traditional behavioral management techniques. THE NULL

HYPOTHESIS The effects of eye massage alone and combined with nature sounds are equivalent to those of traditional behavioral management techniques in reducing anxiety and pain during dental

anesthesia. MATERIALS AND METHODS STUDY DESIGN AND SAMPLE SIZE DETERMINATION A three-arm randomized controlled clinical trial design was used. The sample size was calculated using the

G-Power 3.1 sample size calculator at an alpha error of 5% and a study power of 95%. The effect size was calculated according to a previous study16. The minimum sample size needed to detect

differences among the three groups was 105 children. CONSORT guidelines were implemented to report this randomized clinical trial17, and a CONSORT flow chart was provided (Fig. 1). The

CONSORT checklist is provided as a supplementary document. PATIENT SELECTION Children were recruited between February 2023 and September 2023 from those visiting the clinics of the

Department of Pediatric Dentistry, Faculty of Dentistry, Damascus University. All children who visit the clinics undergo an initial examination session where they receive a full oral

examination and behavioral assessment, which get documented along with their medical and personal information. A total of 105 children who met the following inclusion criteria were chosen: *

1. Children aged between 8 and 10 years * 2. Children categorized as having positive or definitely positive behavior on the Frankl behavioral scale. * 3. Children whose dental treatment

requires an IANB injection. * 4. Children with no previous experience with dental anesthesia. * 5. Children who do not suffer from any neurological, psychological, or hearing disorders. * 6.

Children whose parents or caregivers gave their consent to participate in the study Exclusion criteria: * 1. Children who refuse to put the device on. * 2. Children suffering from acute

dental pain. RANDOMIZATION AND ALLOCATION A random allocation sequence was generated via the online service www.random.org, in which each participant was assigned a random number. The

participants were subsequently randomly distributed into three groups via the block randomization method designed using the online service www.randomization.com, which randomly distributes

participants into three random permuted blocks, each containing 35 participants with an allocation ratio of 1:1:1. To achieve allocation concealment, randomization, and allocation were

performed before the commencement of the trial by a third party (a research student unaware of the study details). The operator conducting the trial met the participants for the first time

in the operating room after they were enrolled and assigned a group. * 1. Group A: The vibrating eye massage device combined with natural sounds and topical anesthesia (20% benzocaine gel)

was applied before the IANB injection. * 2. Group B: The vibrating eye massage device was used only, and topical anesthesia (20% benzocaine gel) was applied before receiving the IANB

injection. * 3. Group C (the control group): Basic behavioral guidance techniques (tell-show-do, positive reinforcement, verbal distraction) were used in combination with topical anesthesia

(20% benzocaine gel) before receiving the IANB injection. OUTCOME ASSESSMENTS PRIMARY OUTCOME Anxiety was assessed via the self-reported Children’s Fear Scale (CFS)18. This scale was given

to the child by an assistant to choose from twice: the first time before the injection after the child was seated in the dental chair and the second time after the injection. Heart pulse was

also recorded via a pulse oximeter as a physiological scale that indicates stress and anxiety19. The heart pulse was recorded twice—first before the injection and after the child was seated

in the dental chair and then at the moment the needle penetrated the soft tissues. SECONDARY OUTCOMES Pain during injection was assessed via two measures: 1) the self-reported Wong-Baker

Faces Pain Rating Scale20, which was given to the child once after receiving the injection. 2) A behavioral/observational pain scale was used to evaluate the child’s behavior during the

injection by recording a video of the child before, during, and after anesthesia via an iPhone camera (Apple, Inc., USA). All videos were assessed by an external evaluator who was requested

to observe the child’s behavior during the injection. The evaluation was performed via the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale21,22. THE FUNCTION OF THE USED EYE

MASSAGE DEVICE The Comfort Eye Massage Device (Maxcare, China) is a glass-shaped device with an adjustable head strap. The inner surface of the glasses contains 20 acupressure magnetic

points that rest on the forehead, temple, nasal bridge, and bony margins that form the orbit without touching the eyelid. An internal audio system is fixed inside the device that produces

natural sounds, and it includes three sound options: bird sounds, water sounds, or mixed birds and water sounds. The device produces three vibration patterns: continuous, intermittent, and

alternating. According to the device’s manual instructions, continuous and alternating vibration patterns are considered strong and are used for deep meditation, whereas intermittent

vibrations are used for gentle relaxation, which was applied in this study. INTERVENTION After the children were enrolled and assigned a group, each child entered the operating room where

they met the operator for the first time. The operator reassessed their behavior according to Frankel to ensure they met the inclusion criteria. Interventions were performed according to

which group the child belonged to: GROUP A (MASSAGE WITH NATURAL SOUNDS) After the child was seated and made comfortable in the dental chair, the pulse rate at rest was recorded using a

pulse oximeter placed on his or her index finger. The child’s level of fear at rest was also assessed by a qualified assistant using the self-reported Children’s Fear Scale (CFS), which was

given to the child to choose the face that suited his or her psychological state before starting. After this, the child received a simplified explanation of how the eye massage device worked

and was given the device to familiarize himself with and experience its vibration on his hand before having it applied to his eyes. The child was also informed about the natural sounds that

the device produced. The device was subsequently applied to the child’s eyes with both vibration (intermittent pattern) and natural sounds (mixed sounds) turned on. The region of injection

was subsequently topically anesthetized with 20% benzocaine gel for one minute (GINGICaine, Belport County, CA, USA), followed by the administration of the IANB injection of 1.8 ml of 2%

lidocaine along with 1:100,000 adrenaline (Xylocaine, Dentsply, PA, USA). During the procedure, the child was instructed to raise his hand if he wanted to end the intervention. The heart

pulse rate was recorded again once the needle penetrated the soft tissues. When the IANB injection was performed, the device was turned off and lifted from the child’s eyes. The assistant

then reassessed the child’s fear level after the procedure via the CFS. The child was also given the Wong-Baker Faces Pain Scale to assess the level of pain he or she experienced during the

procedure. FOR GROUP B (MASSAGE ONLY) The same protocol of group A was followed in this group; however, when the eye massage device was applied, only vibration (intermittent pattern) was

turned on during the procedure without natural sounds. FOR GROUP C (THE CONTROL GROUP) The control group received the same local anesthesia via the same technique without the use of the eye

massage device; however, traditional methods of behavioral management were applied. The technique (Tell-Show-Do) and verbal distraction were followed when topical anesthesia was applied and

the IANB injection was administered. CFS and Wong-Baker scales were assessed at rest and after the injection by the assistant, and the pulse rate was recorded at rest and at the moment of

injection. IANB injections in all three groups were administered by the same operator. The FLACC behavioral pain scale was assessed by an external evaluator using the videos recorded of the

children throughout the procedure in all three groups. ANALYSIS The data were analyzed using SPSS software (version 22.0; IBM, USA). Descriptive statistics, including age, sex, and

children’s type of behavior according to Frankel, were used to summarize the demographic characteristics of the 105 participants. Kolmogorov–Smirnov test was used to assess the normal

distribution of the data, the results indicated that the data followed a normal distribution. Consequently, one-way ANOVA test followed by the Bonferroni correction test was used to analyze

the mean change in pulse rate among the three groups. The Kruskal‒Wallis test along with the Mann‒Whitney test were used to determine any significant differences among the three groups in

terms of the Wong-Baker pain scores, Children’s Fear Scale scores, and FLACC behavioral scores. In addition, Wilcoxon test was performed to determine the difference in CFS scores measured

before and after injection in each group. Similarly, paired sample t-test was performed to detect the change in pulse rate measured before and during injection in each group. The level of

significance was set at 0.05. The kappa coefficient statistic was applied to measure the interrater reliability of both the observer and the assistant, and the results revealed an agreement

of 93% for the observer and 90% for the assistant. RESULTS A total of 105 children (64 boys and 41 girls, mean age 8.7 ± 0.7 years) participated in this study. One-way ANOVA and the

Kruskal‒Wallis test revealed no significant differences among the three groups in terms of sex (P value = 0.75), age (P value = 0.89), or child behavior on the Frankel behavioral scale (P

value = 0.23). (Table 1). COMPARISON OF THE MEAN CHANGE IN PULSE RATE The mean differences in pulse rate for groups A, B, and C were −11.97 ± 6.5, 1.65 ± 9.8, and 11.94 ± 9, respectively. A

paired sample t-test was applied to compare the changes in pulse rate before and during injection in each group. Children in group A showed a significant decrease in pulse rate during

injection, with an average of 12 bpm (P = 0.000), whereas children in group B showed no statistically significant difference in pulse rate during injection (P = 0.326); however, a

significant increase in pulse rate was observed in group C during injection, with an average of 12 bpm (P = 0.000) (Table 2). One-way ANOVA revealed a significant difference in the mean

change in pulse rate among the three groups (P value = 0.000) (Table 2). The Bonferroni correction test revealed a statistically significant difference between each pair of compared groups.

Compared with those in group B, the mean pulse rate of the children in group A significantly decreased, with an average decrease of 13 bpm (P value = 0.000) and 23 bpm compared with that in

group C (P value = 0.00). Similarly, the mean change in pulse rate also decreased for children in Group B compared with Group C, with an average decrease of 10 bpm for Group B (P value = 

0.000) (Table 3). COMPARISON OF THE WONG-BAKER PAIN RATING SCALE DATA Data from the Wong-Baker Face Pain Scale revealed that 83% of children in Group A experienced “no pain” during

injection, and 17% experienced “a little bit of pain”, whereas 63% of the children in Group B experienced “no pain”, and 37% experienced “a little bit of pain”; however, only 20% of the

children in Group C experienced “no pain”, and 51% experienced “a little bit of pain”, whereas 29% experienced “a little more of pain”. A comparison of the three groups using the

Kruskal‒Wallis test revealed statistical significance (P value = 0.000) (Table 4). The Mann‒Whitney test revealed that children in Group A and Group B experienced lower levels of pain

compared to children in Group C (P value = 0.000); however, the perceptions of pain for children in Group A and Group B were the same, with no significant difference between the two groups

(P value = 0.062) (Table 5). COMPARISON OF CHILDREN’S FEAR SCALE DATA Before injection, the children in all three groups expressed similar levels of fear as did the Children’s Fear Scale (P 

= 0.249) (Table 6); however, the data collected after injection were significantly different among the three groups (P = 0.003) (Table 6). The Mann‒Whitney test revealed that children in

Groups A and B expressed significantly less fear after the intervention than those in the control group did (Group C) (P = 0.004, P = 0.008); however, no significant difference between

Groups A and B was noted, as the children in both groups expressed similar levels of fear (P = 0.932) (Table 5). The change in the fear level before and after injection in each group was

tested via the Wilcoxon test. The change in fear ratings reported by children using the CFS was significantly greater after injection in the control group (Group C) (P value = 0.022),

whereas Group B showed no statistically significant difference in fear ratings before and after injection (P value = 0.507); however, children in Group A showed a significant reduction in

fear ratings after injection (P = 0.001) (Table 6). COMPARISON OF MEAN FLACC SCORES Behavioral pain scale data evaluated by an external evaluator via the FLACC scale revealed that children

in Group A were “relaxed and comfortable” during injection (mean score 0.5 ± 0.4), whereas the children in Group B showed “mild discomfort” (mean score 1.34 ± 1.4), and children in Group C

expressed “moderate pain” during injection (mean score 4.17 ± 2.6); the comparison among the three groups via the Kruskal‒Wallis test was statistically significant (P value = 0.000) (Table

4). The Mann‒Whitney test was applied for intergroup multiple comparisons. The test revealed that children in Group A experienced lower levels of pain than children in Groups B and C did (P

value = 0.001) (P value = 0.000), whereas children in Group C experienced greater levels of pain and discomfort compared to Group B (P value = 0.001) (Table 5). DISCUSSION 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. CONCLUSION Eye massage

combined with natural sounds was found to be an effective intervention to reduce pain and dental anxiety in children receiving IANB injections. They are easy to use, inexpensive, and safe

techniques for managing dental anxiety. However, further studies should be conducted to confirm the effectiveness of these methods through different dental procedures. ETHICAL APPROVAL This

study was registered with the clinical trial registry of the United States National Institutes of Health (NIH) at ClinicalTrials.gov (Date of registration: 24/10/2022, NCT05592587). Ethical

approval for the conduct of this study was obtained (IRB No. UDDS- 2371–18,042,022) from the Institutional Ethical Review Board of the Faculty of Dentistry, Damascus University. The study

was conducted in accordance with the precepts stipulated in the Declaration of Helsinki. Parents/guardians were informed about the study objectives and procedures and authorized their

children’s participation by signing an informed consent form. DATA AVAILABILITY All the data generated or analyzed during this study are included in this published article. REFERENCES *

Kothari, S. & Gurunathan, D. Factors influencing anxiety levels in children undergoing dental treatment in an undergraduate clinic. _J Family Med Prim Care._ 8, 2036–2041.

https://doi.org/10.4103/jfmpc.jfmpc_229_19 (2019). Article  PubMed  PubMed Central  MATH  Google Scholar  * Alshuaibi, A. F. et al. Prevalence of dental fear and anxiety and its triggering

factors in the dental office among school-going children in Al Ahsa. _Int J Clin Pediatr Dent._ 14, 286–292 (2021). Article  PubMed  PubMed Central  Google Scholar  * Prado, I. M. et al. Use

of distraction techniques for the management of anxiety and fear in paediatric dental practice: A systematic review of randomized controlled trials. _Int J Paediatr Dent._ 29, 650–668.

https://doi.org/10.1111/ipd.12499 (2019). Article  PubMed  Google Scholar  * Al-Namankany, A., de Souza, M. & Ashley, P. Evidence-based dentistry: analysis of dental anxiety scales for

children. _Br Dent J._ 212, 219–222. https://doi.org/10.1038/sj.bdj (2012). Article  CAS  PubMed  MATH  Google Scholar  * Gao, X., Hamzah, S. H., Yiu, C. K., McGrath, C. & King, N. M.

Dental fear and anxiety in children and adolescents: qualitative study using YouTube. _J Med Internet Res._ 15(2), e29. https://doi.org/10.2196/jmir.2290 (2013). Article  PubMed  PubMed

Central  Google Scholar  * McDonald, R. E., Avery, D. R., Dean, J. A., & Jones, J. E. Local anesthesia and pain control for the child and adolescent. _In McDonald and Avery Dentistry for

the Child and Adolescent_ p 326–330. (Mosbey, 2011) * Praveen, S., Sharma, S. & Peters, N. J. A Descriptive Study to Assess Level of Stress, Anxiety, and Pain Among Hospitalized

Children Admitted in the Pediatric Surgery Unit of APC, PGIMER, Chandigarh 2020–2022. _Nursing & Midwifery Research Journal._ 19, 65–71. https://doi.org/10.1177/0974150x231164227 (2023).

Article  MATH  Google Scholar  * Suohu, T., Sharma, S., Marwah, N. & Mishra, P. A Comparative Evaluation of Pain Perception and Comfort of a Patient Using Conventional Syringe and Buzzy

System. _Int J Clin Pediatr Dent._ 13, 27–30. https://doi.org/10.5005/jp-journals-10005-1731 (2020). Article  PubMed  PubMed Central  Google Scholar  * Remi, R. V., Anantharaj, A., Praveen,

P., Prathibha, R. S. & Sudhir, R. Advances in pediatric dentistry: new approaches to pain control and anxiety reduction in children-a narrative review. _Journal of Dental Anesthesia and

Pain Medicine_ 23(6), 303 (2023). Article  PubMed  PubMed Central  Google Scholar  * Liu, Y. et al. Effect of audiovisual distraction on the management of dental anxiety in children: A

systematic review. _International journal of pediatric dentistry._ 29, 14–21. https://doi.org/10.1111/ipd.12430 (2019). Article  CAS  MATH  Google Scholar  * Peng, Z. et al. Acupressure: a

possible therapeutic strategy for anxiety related to COVID-19: a meta-analysis of randomized controlled trials. _Frontiers in Medicine_ 11, 1341072 (2024). Article  PubMed  PubMed Central 

Google Scholar  * Sisodia, M. et al. The Effect of Three-point Acupressure Therapy on Anxiety Levels inChildren Undergoing Dental Procedures. _Int J Clin Pediatr Dent_ 17(2), 16–22 (2024).

MATH  Google Scholar  * Avisa, P. et al. Effectiveness of acupressure on dental anxiety in children. _Pediatr Dent._ 40(3), 177–183 (2018). PubMed  Google Scholar  * Weisfeld, C. C. et al.

Dealing with Anxious Patients: A Systematic Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures. _J Altern

Complement Med._ 27, 717–726. https://doi.org/10.1089/acm.2020.0504 (2021). Article  PubMed  MATH  Google Scholar  * Weisfeld, C. C. et al. Dealing with Anxious Patients: An Integrative

Review of the Literature on Nonpharmaceutical Interventions to Reduce Anxiety in Patients Undergoing Medical or Dental Procedures. _J Altern Complement Med._ 27, 727–737.

https://doi.org/10.1089/acm.2020.0505 (2021). Article  PubMed  MATH  Google Scholar  * Alsibai, E., Bshara, N., Alzoubi, H. & Alsabek, L. Assessing an active distracting technique during

primary mandibular molar pulpotomy (randomized controlled trial). _Clinical and experimental dental research_ 9, 283–289. https://doi.org/10.1002/cre2.702 (2023). Article  PubMed  Google

Scholar  * Schulz, K. F., Altman, D. G. & Moher, D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. _Journal of Pharmacology and

pharmacotherapeutics_ 1(2), 100–107 (2010). Article  PubMed  PubMed Central  MATH  Google Scholar  * McMurtry, C.M. Noel, M. Chambers, C.T. McGrath, P.JChildren’s fear during procedural

pain: Preliminary investigation of the Children’s Fear Scale. Health Psychology, _Advanced Access Online_. (2011). * Yon, M. J. Y. et al. An introduction toassessing dental fear and anxiety

in children. _Healthcare._ 8, 86 (2020). Article  PubMed  PubMed Central  MATH  Google Scholar  * Nagarwal, P., Rana, V., Srivastava, N., Kaushik, N. & Pruthi, T. Reliability of three

pain assessment tools in children requiring dental treatment: A comparative clinical study. _Journal of Indian Society of Pedodontics and Preventive Dentistry_ 41(2), 126–132 (2023). Article

  PubMed  Google Scholar  * Crellin, D. J., Harrison, D., Santamaria, N., Huque, H. & Babl, F. E. The psychometric properties of the FLACC scale used to assess procedural pain. _The

Journal of Pain_ 19(8), 862–872 (2018). Article  PubMed  Google Scholar  * Dak Albab, R. & Shakhashero, H. The validity and reliability of the Arabic version of FLACC scale: a clinical

trial. _J Anesth Clin Res._ 7, 656. https://doi.org/10.4172/2155-6148.1000656 (2016). Article  Google Scholar  * Isik, B., Esen, A., Buyukerkmen, B., Kilinc, A. & Menziletoglu, D.

Effectiveness of binaural beats in reducing preoperative dental anxiety. _Br J Oral Maxillofac Surg._ 55, 571–574. https://doi.org/10.1016/j.bjoms.2017.02.014 (2017). Article  CAS  PubMed 

Google Scholar  * Kvesić, A. J. et al. Possible risk factors for dental fear and anxiety in children who suffered traumatic dental injury. _Dentistry Journal._ 11, 190.

https://doi.org/10.3390/dj11080190 (2023). Article  PubMed  PubMed Central  MATH  Google Scholar  * Sharma, A., Suprabha, B. S., Shenoy, R. & Rao, A. Efficacy of lignocaine in gel and

spray form during buccal infiltration anesthesia in children: a randomized clinical trial. _J Contemp Dent Pract._ 15, 750–754. https://doi.org/10.5005/jp-journals-10024-1611 (2014). Article

  PubMed  Google Scholar  * Malik, F. Marwaha, R. Developmental Stages of Social Emotional Development in Children. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL):

StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534819/ * Merskey, H. A. Pain terms: a list with definitions and notes on usage. Recommended by the

IASP Subcommittee on Taxonomy. _Pain_. 6, 249. (1979). PMID: 460932 * Garra, G. Singer, A. J. Domingo, A. Thode, H. C Jr. The Wong-Baker pain FACES scale measures pain, not fear. _Pediatr

Emerg Care_. 29, 17–20. (2013) https://doi.org/10.1097/PEC.0b013e31827b2299. * Ainscough, S. L., Windsor, L. & Tahmassebi, J. F. A review of the effect of music on dental anxiety in

children. _Eur Arch Paediatr Dent._ 20, 23–26. https://doi.org/10.1007/s40368-018-0380-6 (2019). Article  CAS  PubMed  MATH  Google Scholar  * Field, T. M. Massage therapy effects. _Am

Psychol._ 53, 1270–1281 (1998). Article  CAS  PubMed  MATH  Google Scholar  * Soares, M. E. C. et al. Effect of acupressure on dental anxiety in children: a pilot study for a randomized

clinical trial. _J Acupunct Meridian Stud_ 15, 307–313 (2022). Article  PubMed  MATH  Google Scholar  * Moyer, C. A., Rounds, J. & Hannum, J. W. A meta-analysis of massage therapy

research. _Psychol Bull._ 130, 3–18. https://doi.org/10.1037/0033-2909.130.1.3 (2004). Article  PubMed  MATH  Google Scholar  * Chang, M. Y., Wang, S. Y. & Chen, C. H. Effects of massage

on pain and anxiety during labor: a randomized controlled trial in Taiwan. _J Adv Nurs._ 38, 68–73. https://doi.org/10.1046/j.1365-2648.2002.02147.x (2002). Article  PubMed  MATH  Google

Scholar  * Gupta, D. et al. Acupuncture (zhēn jiǔ) - an emerging adjunct in routine oral care. _J Tradit Complement Med._ 4, 218–223. https://doi.org/10.4103/2225-4110.139113 (2014). Article

  PubMed  PubMed Central  MATH  Google Scholar  * .Buxton, R. T. Pearson, A. L. Allou, C. Fristrup, K. Wittemyer, G. A synthesis of health benefits of natural sounds and their distribution

in national parks. _Proceedings of the National Academy of Sciences_. 118, e2013097118. (2021). https://doi.org/10.1073/pnas.2013097118 * Alvarsson, J. J., Wiens, S. & Nilsson, M. E.

Stress recovery during exposure to nature sound and environmental noise. _Int J Environ Res Public Health._ 7, 1036–1046. https://doi.org/10.3390/ijerph7031036 (2010). Article  PubMed 

PubMed Central  MATH  Google Scholar  * Largo-Wight, E., O’Hara, B. K. & Chen, W. W. The Efficacy of a Brief Nature Sound Intervention on Muscle Tension, Pulse Rate, and Self-Reported

Stress: Nature Contact Micro-Break in an Office or Waiting Room. _HERD._ 10, 45–51. https://doi.org/10.1177/1937586715619741 (2016). Article  PubMed  MATH  Google Scholar  * Boring, B. L.,

Walsh, K. T., Nanavaty, N., Ng, B. W. & Mathur, V. A. How and Why Patient Concerns Influence Pain Reporting: A Qualitative Analysis of Personal Accounts and Perceptions of Others’ Use of

Numerical Pain Scales. _Frontiers in psychology_ 12, 663890. https://doi.org/10.3389/fpsyg.2021.663890 (2021). Article  PubMed  PubMed Central  Google Scholar  * Kunz, M. Karos, K.

Vervoort, T. When, How, and Why Do We Express Pain. In _Social and Interpersonal Dynamics in Pain_. Vervoort, T., Karos, K., Trost, Z., Prkachin, K. (eds) Springer, Cham. (2018)

https://doi.org/10.1007/978-3-319-78340-6_6 Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Pediatric Dentistry, Faculty of Dentistry, Damascus University,

Damascus, Syria Dajma Abed, Jamila Bchara, Jina Alfeel & Nada Bshara * Faculty of Dentistry, Damascus University, Damascus, Syria Dani Abed Authors * Dajma Abed View author publications

You can also search for this author inPubMed Google Scholar * Jamila Bchara View author publications You can also search for this author inPubMed Google Scholar * Dani Abed View author

publications You can also search for this author inPubMed Google Scholar * Jina Alfeel View author publications You can also search for this author inPubMed Google Scholar * Nada Bshara View

author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS A.D: conception and design of the research, conducting the clinical process, and article

writing; B.J: collecting data, and article writing; A.J: data analysis and interpretation, and article reviewing; A.D: conception of research, article reviewing; B.N: research supervision,

article revising. All authors reviewed and approved the final manuscript. CORRESPONDING AUTHOR Correspondence to Dajma Abed. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no

competing interests. ADDITIONAL INFORMATION PUBLISHER’S NOTE Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. RIGHTS AND

PERMISSIONS OPEN ACCESS This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing,

distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and

indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third

party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the

article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright

holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Abed, D., Bchara, J., Abed, D.

_et al._ Reducing children’s anxiety and pain in dental environment using an eye massage device combined with natural sounds—a randomized controlled trial. _Sci Rep_ 15, 1678 (2025).

https://doi.org/10.1038/s41598-024-83613-y Download citation * Received: 17 March 2024 * Accepted: 16 December 2024 * Published: 11 January 2025 * DOI:

https://doi.org/10.1038/s41598-024-83613-y SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable link is not

currently available for this article. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative KEYWORDS * Dental anxiety * Acupressure * Massage * Anesthesia *

Complementary therapies * Pediatric dentistry