Re: Effects of Preoperative Immersive and Non‐Immersive Virtual Reality Exposure on Dental Anxiety in Children: A Randomised Controlled Trial

We read with interest the randomised controlled trial by Selvaraj and colleagues examining the effectiveness of immersive and non-immersive virtual reality exposure in reducing dental anxiety in children [1]. The finding that both immersive and non-immersive VR modalities significantly reduced dental anxiety compared to control groups, with no significant difference between these two approaches, suggests that resource-limited settings can achieve similar anxiolytic benefits without investing in high-cost interactive technology. In this respect, the more accessible non-immersive format may represent a particularly practical option for routine paediatric care. The absence of reported cybersickness and high acceptability further supports feasibility for integration into clinical practice. Interpretation should nonetheless remain cautious, because the reduction in self-reported anxiety was not matched by a clear physiological effect: the between-group difference in pulse rate did not reach significance (p = 0.052; Cohen's d = 0.09), and the postoperative correlation between self-reported anxiety and pulse rate remained weak (r = 0.285, p = 0.022) [1]. Recent literature suggests this dissociation may be more common than previously recognised; Main and colleagues found that salivary cortisol and alpha-amylase levels were not consistently correlated with psychological measures in children undergoing dental procedures [2]. This pattern suggests that preoperative VR may act primarily through cognitive reappraisal rather than autonomic nervous system regulation. Future studies examining salivary cortisol alongside self-report measures could clarify whether this represents an incomplete therapeutic response or a distinct beneficial pathway. Generalisability is similarly limited. The study's restriction to children aged 9–12 years and an ethnically homogeneous sample (93.8% Malay) limits generalisability [1]. The findings may not extend to younger children, adolescents or more culturally diverse populations, in whom attention, cognitive processing and parental acceptance of behaviour guidance may differ [3]. Moreover, because the trial captured only the immediate preoperative effect, it remains unclear whether VR-facilitated anxiety reduction persists across multiple dental visits. Broader and longer term evaluation, across the full paediatric age range, diverse clinical settings and successive appointments, would strengthen the evidence base and clarify VR's role in establishing positive dental experiences. Selvaraj and colleagues have advanced our understanding of VR's potential in paediatric dentistry, and their findings support the more accessible non-immersive format as a practical adjunct for behaviour guidance. Confirming whether this subjective benefit translates into consistent physiological change, and testing the approach across broader populations and repeated visits, will be essential to define VR's role in paediatric dentistry.