Effectiveness of a Three-Stage Combined Protocol of Progressive Muscle Relaxation, Cranial Electrotherapy Stimulation, and Virtual Reality–Guided Mindfulness on Preoperative Anxiety in Dental Surgery Patients

Behnood  Khorsand Nobahar; Pegah Farokhzad; Mina Mojtabaee

Authors

Behnood Khorsand Nobahar Department of psychology, Ro.c.,Isclamic Azad University, Rudehen, iran Author https://orcid.org/0009-0005-0050-5660
Pegah Farokhzad Department of psychology, Ro.c.,Isclamic Azad University, Rudehen, iran https://orcid.org/0000-0001-7921-0876
Mina Mojtabaee Department of psychology, Ro.c.,Isclamic Azad University, Rudehen, iran Author https://orcid.org/0000-0002-4131-0676

Keywords:

Progressive muscle relaxation, cranial electrotherapy stimulation, virtual reality, mindfulness, state anxiety, dental anxiety, dental surgery

Abstract

Purpose: This study aimed to determine the effectiveness of a three-stage combined protocol comprising progressive muscle relaxation, cranial electrotherapy stimulation, and virtual reality–guided mindfulness in reducing state anxiety and dental anxiety among patients undergoing dental surgery.

Methods and Materials: This quasi-experimental study employed a pretest–posttest design with an intervention group and a control group. The study population consisted of adult patients undergoing dental surgery at the Implant House Dental Clinic in District 3 of Tehran during 2025–2026. Forty eligible patients were selected through convenience sampling and allocated nonrandomly to an intervention group and a control group, with 20 participants in each group. The intervention group received an initial 45-minute instructional session, four 20-minute sessions combining progressive muscle relaxation with cranial electrotherapy stimulation, and virtual reality–guided mindfulness on the day of surgery. The control group received routine clinical care without any psychological, neuromodulatory, or virtual reality intervention. State anxiety was measured using the state subscale of the State–Trait Anxiety Inventory, and dental anxiety was assessed using the Dental Anxiety Inventory. Data were analyzed using descriptive statistics and analysis of covariance in SPSS version 26, with pretest scores entered as covariates and the significance level set at .05.

Findings: After controlling for baseline scores, analysis of covariance revealed a statistically significant difference between the intervention and control groups in posttest state anxiety, F(1, 37) = 34.11, p < .001, partial η² = .47. A statistically significant between-group difference was also found in posttest dental anxiety, F(1, 37) = 35.61, p < .001, partial η² = .49. Both effect sizes were large, indicating that the combined intervention produced substantial reductions in state anxiety and dental anxiety compared with routine clinical care.

Conclusion: The three-stage combined protocol of progressive muscle relaxation, cranial electrotherapy stimulation, and virtual reality–guided mindfulness was effective in reducing state anxiety and dental anxiety in patients undergoing dental surgery and may represent a practical nonpharmacological intervention for managing preoperative anxiety in dental settings.

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