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Comparison of anxiety and pain perceived with conventional and computerized local anesthesia delivery systems for different stages of anesthesia delivery in maxillary and mandibular nerve blocks

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Background Fear of local anesthesia (LA) is a significant impediment to dental care as many patients delay or avoid treatment to avert pain. Computer-controlled local anesthetic delivery system (CCLAD), with constant and controlled rate of flow, present a painless alternative. The present study aimed to compare anxiety and pain perceived with conventional and computerized systems, for different stages of anesthesia delivery when administering various nerve blocks. Methods One hundred patients requiring bilateral LA participated in the study. One side was anesthetized using one system and the contralateral side was anesthetized using the other, in two separate appointments. Patients assigned anxiety scores on a 5-point scale and used the visual analogue scale (VAS) for pain determination at needle insertion, during delivery of anesthetic solution, immediately after injection, and at the end of the periodontal procedure. Each patient's preference for the delivery system of future injections was also recorded. Results Patients reported significantly lower anxiety levels with CCLAD compared to the syringe. Significantly lower mean VAS scores for anesthesia deposition, pain immediately after, and at the end of the periodontal procedure were also noted. However, pain at needle insertion was comparable between the two systems, with no statistical significance. Overall, 64.4% patients preferred CCLAD for future anesthesia. Conclusion Lower pain perceived with CCLAD and higher preference for the system suggest that CCLAD should replace conventional syringes to allow pain-free dental treatment.
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Original Article pISSN 2383-9309eISSN 2383-9317
J Dent Anesth Pain Med 2018;18(6):367-373https://doi.org/10.17245/jdapm.2018.18.6.367
Comparison of anxiety and pain perceived with
conventional and computerized local anesthesia
delivery systems for different stages of anesthesia
delivery in maxillary and mandibular nerve blocks
Kamal Aggarwal, Arundeep Kaur Lamba, Farrukh Faraz, Shruti Tandon, Kanika Makker
Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, Delhi, India
Background: Fear of local anesthesia (LA) is a significant impediment to dental care as many patients delay
or avoid treatment to avert pain. Computer-controlled local anesthetic delivery system (CCLAD), with constant
and controlled rate of flow, present a painless alternative. The present study aimed to compare anxiety and
pain perceived with conventional and computerized systems, for different stages of anesthesia delivery when
administering various nerve blocks.
Methods: One hundred patients requiring bilateral LA participated in the study. One side was anesthetized
using one system and the contralateral side was anesthetized using the other, in two separate appointments.
Patients assigned anxiety scores on a 5-point scale and used the visual analogue scale (VAS) for pain determination
at needle insertion, during delivery of anesthetic solution, immediately after injection, and at the end of the
periodontal procedure. Each patient’s preference for the delivery system of future injections was also recorded.
Results: Patients reported significantly lower anxiety levels with CCLAD compared to the syringe. Significantly
lower mean VAS scores for anesthesia deposition, pain immediately after, and at the end of the periodontal
procedure were also noted. However, pain at needle insertion was comparable between the two systems, with
no statistical significance. Overall, 64.4% patients preferred CCLAD for future anesthesia.
Conclusion: Lower pain perceived with CCLAD and higher preference for the system suggest that CCLAD
should replace conventional syringes to allow pain-free dental treatment.
Keywords: Computer-controlled Local Anesthetic Delivery System ; Local Anesthesia; Pain; Pain Perception;
Visual Analogue Scale.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecomm ons.org/licenses/by-nc/4.0/) which p ermits unrestricted non-com mercial use, distrib ution, and reproduc tion in
any medium, provided the original work is properly cited.
Received: October 9, 2018Revised: November 5, 2018Accepted: November 26, 2018
Corresponding Author: Kamal Aggarwal, Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, Delhi, 110002, India
Tel: +91-9999685798 E-mail: kamal208maids@gmail.com
Copyright 2018 Journal of Dental Anesthesia and Pain Medicine
INTRODUCTION
The fear of local anesthesia (LA) is a significant
impediment to dental care, as many patients delay or
avoid treatment to avert pain. Nearly 20-23% of
population is highly anxious about their dental treatment
[1]. Pain can result from the mechanical trauma of needle
insertion, or from the sudden distension of the tissues
caused by rapid deposition of LA from the syringe [2].
Using a conventional hypodermic syringe, the dentist
must simultaneously control the movement of the
penetrating needle and drug infusion variables. The
inability to precisely control both activities can com-
promise the injection technique, leading to painful
insertion or inadequate deposition. Moreover, the
conventional syringe is held with a palm-thumb grasp,
which is not ergonomic.
The first computer-controlled local anesthetic delivery
system (CCLAD) was introduced in 1997 as the Wand
Kamal Aggarwal, et al
368 J Dent Anesth Pain Med 2018 December; 18(6): 367-373
Fig. 1.
The visual analogue scale (VAS) used for evaluating the perceived
pain among patients.
Fig. 2.
The computer controlled local anesthetic delivery system.
(Milestone Scientific Inc., Livingston, USA) to improve
the ergonomics and precision of dental syringe. Its
lightweight handpiece can be held with a pen-like grasp,
which provides better tactile sensation. The operator can
accurately manipulate needle placement with fingertip
accuracy and deliver the solution with a foot-activated
control. The flow rate is computer-controlled and remains
constant. Continuous positive pressure delivers an
anesthetic drip that precedes the needle and provides a
painless path for needle insertion [3]. The disadvantages
associated with the system include high cost, complexity,
space needed to store equipment, and increased time for
LA administration [4,5].
Research on CCLAD is largely limited to pediatric
patients. There is paucity of literature on its use in other
fields of dentistry. The present study was undertaken to
evaluate pain and anxiety associated with conventional
syringe and CCLAD for nerve block LA, administered
for periodontal procedures. In particular, this study
compared pain associated with the two techniques during
different phases of local anesthetic delivery (at needle
insertion, during deposition of anesthesia, immediately
after deposition, and at the end of the periodontal
procedure).
METHODS
This is a prospective randomized split-mouth study.
Patients aged 18-65 years with periodontal disease,
requiring bilateral LA in the same arch, were recruited
for the study. Patients who are allergic to LA or any of
its components, medically compromised, smoking,
pregnant, lactating, or taking corticosteroids or non-
steroidal anti-inflammatory drugs were not included.
Written informed consent was obtained from participants,
in accordance with the Committee on Human Research
Guidelines, University of Delhi. The Institutional Review
Board number for the study was Maids/Perio/01/2011.
Anesthetic Injection Procedure: On the first appoint-
ment for periodontal therapy, the patient underwent a
sensitivity test for LA and was familiarized with the
scales used for evaluating anxiety and pain. Anxiety was
determined immediately prior to LA administration on a
5-point scale as follows: 0-no anxiety, 1-mild anxiety, 2-
moderate anxiety, 3- severe anxiety and 4- extreme
anxiety or panic [6]. The visual analogue scale (VAS)
was used for the evaluation of pain [7]. VAS was scored
on a 100-mm horizontal line with the left end marked
“no pain” and the right end “severe intolerable pain” (Fig.
1).
In each case of CCLAD, 2% lidocaine anesthetic
solution with 1:80,000 adrenaline (Lignospan SpecialTM,
Septodont, India) was used with a 30-gauge 1.25-inch
needle (Fig. 2). A disposable 30-gauge 1.25-inch needle
(Septoject, Septodont, France) was used for conventional
LA delivery via a dental syringe.
Types of injections used for the mandibular arch were
the inferior alveolar (IAN), long buccal (LB), and mental
(MN) nerve blocks. Types of injections used for the
Pain and anxiety with CCLAD
http://www.jdapm.org 369
Fig. 3.
Comparison of mean anxiety scores between the computer
controlled local anesthesia delivery system and conventional syringe.
Table 1.
Types and numbers of injections administered
Type of injection Number
Infraorbital nerve block 24
Posterior superior alveolar 28
Inferior Alveolar Nerve block 24
Greater palatine nerve block 20
Anterior Middle Superior Alveolar block 13
Mental nerve block 16
Long buccal nerve block 10
Total 135
Table 2.
Types of periodontal procedures performed after administration
of local anesthesia
Type of Periodontal therapy Number
Curettage 44
Flap surgery 26
Subgingival scaling 24
Gingivectomy 03
Implant surgery 01
Depigmentation 01
Abscess Drainage 01
Total 100
maxillary arch were the posterior superior alveolar (PSA),
infraorbital (IO), greater palatine (GP), and anterior
middle superior alveolar (AMSA) nerve blocks. The
volume of anesthetic solution injected was in accordance
with the procedure recommended by Malamed [8].
At the first appointment, anxiety was determined prior
to the injection. CCLAD or conventional syringe was
randomly selected and used to deliver LA to one side
of the arch. The patient was asked to rate the associated
pain on VAS at the following stages: during needle
insertion, during delivery of anesthetic solution, and
immediately after the injection. Pain was also assessed
at the completion of the periodontal procedure. Similarly,
at the second appointment, the contralateral side of the
arch was anesthetized for treatment using the other
anesthetic delivery system. Anxiety and pain were
recorded as above. The delivery system preferred by the
patient for future injection delivery was noted.
The data were analyzed using SPSS software version
17.0. Mann-Whitney U tests were used to compare the
anxiety and VAS scores obtained from the patients. The
significance level was set as 5%.
RESULTS
One hundred adults (44 males and 56 females) with
a mean age of 34.15 ± 18.92 years were selected from
the Outpatient Department of Periodontology, Maulana
Azad Institute of Dental Sciences according to the
inclusion and exclusion criteria and enrolled in the study.
In total, 270 injections (135 on each side) were
administered. Table 1 provides data on the numbers of
each type of injection. Periodontal procedures undertaken
included subgingival scaling, curettage, gingivectomy and
flap surgeries (Table 2).
The mean anxiety scores with conventional syringe and
CCLAD were 1.01 ± 1.02 and 0.78 ± 0.91, respectively,
indicating a significantly lower anxiety level in the
CCLAD group (P = 0.043) (Fig. 3).
For pain during needle insertion, the score for
conventional syringe was 16.67 ± 15.24. The mean pain
score for CCLAD was 13.53 ± 13.05, but the difference
was not statistically significant. However, a significantly
lower score for CCLAD was obtained, during drug
deposition. The VAS scores were 14.51 ± 15.40 and
11.24 ± 14.25 for conventional and CCLAD techniques,
respectively. The pain scores for immediately after the
injection were similar, with a significantly lower mean
pain score for CCLAD (3.86 ± 8.86) than conventional
syringe (6.23 ± 9.40). Lastly, pain reported at the
Kamal Aggarwal, et al
370 J Dent Anesth Pain Med 2018 December; 18(6): 367-373
Table 3.
Descriptive data of mean visual analogue scale scores
Stage of administration Conventional syringe CCLAD*
(WAND) Difference P value
Pain during needle insertion 16.67 ± 15.24 13.53 ± 13.05 3.14 0.076
Pain during drug deposition 14.51 ± 15.40 11.24 ± 14.25 3.27 0.053
Pain immediately after injection 6.23 ± 9.40 3.86 ± 8.86 2.37 0.000
Pain at completion of periodontal procedure 1.78 ± 4.51 0.96 ± 4.71 0.82 0.011
*: CCLAD: Computer Controlled Local Anesthetic Delivery System
completion of periodontal procedures was also lower in
CCLAD, and this difference was statistically significant
(1.78 ± 4.51 with conventional syringe; 0.96 ± 4.71 with
CCLAD; P = 0.011) (Table 3).
In total, 64.4% of patients preferred CCLAD and opted
for the same for any future injections; while 32.5%
preferred conventional syringes. Additionally, 2.9%
patients did not find any difference in the two delivery
systems.
DISCUSSION
Local anesthesia is the backbone of pain control in
dentistry. Its proper administration is the dentist’s greatest
aid in treating patients comfortably and in achieving
cooperation. However, administration of LA injection
produces anxiety and pain in patients. Therefore, research
has continued to develop new and better ways of
delivering adequate LA to improve patient comfort.
CCLAD was developed with this same aim. The
manufacturers hoped to minimize pain by delivering a
controlled volume of solution at constant pressure
irrespective of tissue resistance with a pre-puncture
technique and use of careful axial needle rotation [3]. The
present study aimed to evaluate anxiety and pain
perceived with CCLAD, and to compare it with the
conventional method of LA administration.
Anxiety level was significantly less when local
anesthetics was administered using CCLAD compared to
conventional syringes. The lower anxiety levels can be
attributed to the less frightening appearance of the device.
The loading of cartridge in CCLAD does not provoke
fear in patients as it does in the conventional syringes.
Technological advances have led to great dependency and
trust on machines. It could be that patients were less
anxious and more accepting knowing an advanced,
computerized machine was being used to achieve
anesthesia. Krochak and Friedman [6] reported a similar
observation in their patients who were successfully
desensitized against dental injections anxiety, using the
Wand. In contrast, Goodell et al. [9] observed less anxiety
with the syringe than CCLAD. The authors speculated
that the new and unfamiliar anesthesia device was perhaps
more fear provoking [9]. In another study, Tahmassebi
et al. [10] reported no statistical difference in anxiety
when comparing the two systems. This may be attributed
the study being conducted among children, who cannot
accurately and with absolutely determine anxiety levels.
The mean VAS score for needle insertion was lower
in CCLAD, but the difference was not statistically
significant. In previous studies, Yenisy [11] and Yesilyurt
[12] reported lower pain with CCLAD. Conversely,
Nusstein [13] reported similar pain on needle insertion
in both the systems when administered to anesthetize the
anterior middle superior alveolar nerve. It has been
speculated the computer-assisted injection systems create
a continuous positive pressure that delivers anesthetic
solution preceding the needle path, to eliminate dis-
comfort as the needle penetrates the tissue. This
pre-puncture technique could be the reason for lower pain
perceived with CCLAD. However, in the present study,
a significant difference was not obtained. It may be
speculated that the lack of difference may be associated
with same-sized needles being used in both systems.
Pain on LA deposition was significantly lower with
Pain and anxiety with CCLAD
http://www.jdapm.org 371
Fig. 4.
Pen-grasp used in the computer controlled local anesthesia delivery
system.
CCLAD. This is consistent with the findings of the
studies by Yenisy [11] and Nusstein [13]. Lower pain
may be attributed to the delivery of anesthetic solution
at constant pressure, which is rapidly absorbed by
surrounding tissues. A steady flow of 1 drop of anesthetic
every two seconds is maintained by the stepper motor
in the driver unit of CCLAD irrespective of the density
of tissues. In contrast, in the conventional syringe, manual
control does not allow consistent flow. The resistance
encountered when injecting into dense connective tissue
causes the operator to increase force on the syringe
plunger, thus increasing the anesthetic volume that
distends the tissues, thereby resulting in pain.
VAS scores for pain at the end of the periodontal
procedure also showed significantly lower pain with
CCLAD. This is in agreement with the findings of studies
by Asarch et al. [14], Gibson et al. [15], Allen et al. [16],
Fukayama et al. [17] and Palm et al. [18]. Reduced pain
may be attributed to a more accurate technique and
greater precision in the delivery of local anesthesia using
CCLAD [19]. It allows a pen-grasp that is easier to
manipulate and has a small headpiece for increased
visibility of the target site, which enables precise delivery
of the LA solution (Fig. 4). Additionally, CCLAD allows
easier aspiration during injection without a change in the
needle position; a problem frequently encountered with
conventional syringes.
A higher patient preference for the less painful CCLAD
was obtained in the present study. Nicholson et al. [20]
also reported high acceptance of CCLAD amongst both
dentists and patients.
Most of the studies on CCLAD have been conducted
among children. CCLA has been shown to decrease
disruptive behavior. However, in order to obtain more
reliable results and more accurate evaluation, the present
study selected adults as participants. In particular, this
study assessed pain at different stages of anesthetic
administration, whereas most studies in the literature
evaluated the experience overall and generally assessed
pain at the end of a procedure [16,17,20,21].
VAS was used to determine the perceived pain at
different stages of LA administration. Numerous metho-
dologies exist to assess pain. It is well recognized that
it is extremely difficult to quantify pain owing to its
subjective nature. VAS provides the advantage of un-
limited number of possible responses along with a simple
continuum [22].
One limitation of this study was the inability to
implement a double -blinded research design. Blinding
is not possible, because the operator would always be
aware of the significant difference between the two
injection systems during LA administration. In addition,
the patient would be able to hear the built-in beeping
sound of the CCLAD, even if their vision was restricted.
In conclusion, the results of the present study
demonstrated the advantages of CCLAD over the
conventional syringe for delivering LA, as evidenced by
the significantly lower anxiety and perceived pain among
patients, as well as higher preference for CCLAD.
Further studies using objective physiological markers of
pain, such as changes in heart rate and blood pressure,
may be useful for confirming the findings of this study.
AUTHOR ORCIDs
Kamal Aggarwal: https://orcid.org/0000-0002-0424-3312
Arundeep Kaur Lamba: https://orcid.org/0000-0001-5782-0614
Farrukh Faraz: https://orcid.org/0000-0003-1651-8077
Shruti Tandon: https://orcid.org/0000-0002-0524-099X
Kanika Makker: https://orcid.org/0000-0002-3954-6743
Kamal Aggarwal, et al
372 J Dent Anesth Pain Med 2018 December; 18(6): 367-373
FUNDING: This research did not receive any grant from
funding agencies in the public, commercial, or non-profit
sectors.
DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST:
The authors declare that they have no conflicts of interest.
ETHICAL APPROVAL: This article does not include any
animal studies. All procedures performed on human
participants were in accordance with the ethical standards
of the institutional research committee and the Helsinki
declaration.
INFORMED CONSENT: Written informed consent was
obtained from all participants.
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... The other part of the studies showed that mean perceived pain was significantly lower for CCLAD in comparison with the conventional technique (Aggarwal et al., 2018;Berrendero et al., 2021;Ghaderi and Ahmadbeigi, 2018;O'Neal et al., 2022 0,53). 92,5% of the patients preferred computerised anaesthesia, while the rest didn't have any preferences. ...
... The purpose of this paper is to review the data on pain associated with anaesthesia with computerised systems compared to conventional injection. Seven of the considered studies showed significantly lower pain levels during drug administration (Aggarwal et al., 2018;Berrendero et al., 2021;Flisfisch et al., 2021;Garret-Bernardin et al., 2017;Ghaderi and Ahmadbeigi, 2018;Mittal et al., 2019Mittal et al., , 2015, as well as connected with the treatment (Aggarwal et al., 2018;Mittal et al., 2019) for the computerised anaesthesia, compared with the conventional technique. Perugia et al. reported a higher percentage of complete anaesthetic effect with the computerised technique. ...
... The purpose of this paper is to review the data on pain associated with anaesthesia with computerised systems compared to conventional injection. Seven of the considered studies showed significantly lower pain levels during drug administration (Aggarwal et al., 2018;Berrendero et al., 2021;Flisfisch et al., 2021;Garret-Bernardin et al., 2017;Ghaderi and Ahmadbeigi, 2018;Mittal et al., 2019Mittal et al., , 2015, as well as connected with the treatment (Aggarwal et al., 2018;Mittal et al., 2019) for the computerised anaesthesia, compared with the conventional technique. Perugia et al. reported a higher percentage of complete anaesthetic effect with the computerised technique. ...
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Minimising pain with effective local anaesthesia is an essential step towards improving the level of dentally anxious patients’ comfort during dental treatment. It can be provided by many different techniques. One of them is using the Computer-Controlled Local Anaesthesia Delivery systems (CCLADs). This study was conducted to compare the efficacy of computerised anaesthesia with the conventional technique in terms of perceived pain. A database literature search was performed on PubMed, Cochrane Library and Google Scholar, covering up the period between 2015 and 2023. Only the studies comparing computerised anaesthesia technique with the use of conventional carpule were included. An overview of 20 relevant studies (n = 1347 subjects) was provided including pediatric patients, as well as the adults. The evaluated parameters were: pain, child’s behaviour, heart rate, blood pressure, level of satisfaction, anxiety, further anaesthesia method preference, need for additional anaesthetic, as well as the duration of anaesthesia, measured by different scales, devices and questionnaires. The present literature review led the authors to the conclusion, that the use of CCLADs is significantly less painful than the traditional anaesthesia and it is a promising technique for helping patients deal with pain perception. However, it is advisable to conduct further research on the use of CCLAD.
... Several studies have shown that the application of CCLAD systems results in a better patient experience during local anesthesia. For instance, Aggarwal et al. (2018) compared the pain score and anxiety of patients in conventional anesthetic injection with the conventional dental syringe and CCLAD. They reported significantly lower levels of pain and anxiety in the CCLAD group. ...
... Additionally, they reported that 64.4% of patients preferred CCLAD over conventional syringes. Their findings are in line with those of the present study, indicating less discomfort in patients while injecting using CCLAD (Aggarwal et al. 2018). In another study, Flisfisch, Woelber, and Walther (2021) reported that pain and anxiety levels during the conventional anesthetic injection technique were three times the rate in the use of CCLAD. ...
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... A 10 cm line represents the scale with marks at 0.01 cm intervals; 0 denotes no pain, 1 3 mild pain, 4-7 moderate pain, and 710 severe pain. The VAS is considered a valid and reliable tool for measuring pain across various studies and populations [10][11][12]. Tape measurement is a costeffective and straightforward method used in rehabilitation for objective measurement, tracking patient progress, and assessing range of motion (ROM). It is a standard tool for measuring joint circumference, limb lengths, and other quantitative data. ...
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... One of the main factors contributing to this preference is that CCLAD eliminates visual stimuli from dental syringes and reduces injection pain. However, the cost of purchasing replacement syringes and disposable attachments, injection duration, requirement to alter work schedules, and additional space required for the device continue to be obstacles to its widespread adoption in clinical practice [35]. A larger sample size would have been better to observe changes in pain perception. ...
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Computer-controlled local anesthesia delivery (CCLAD) is an innovative electronic injection device that represents a cutting-edge approach to dental anesthesia. This system is promising for painless anesthesia using controlled anesthetic injections. This review aimed to compare the discomfort experienced by patients during local anesthesia using a traditional syringe and the CCLAD system and evaluate the potential of the CCLAD system as a painless dental anesthesia solution. The inclusion criteria for this study were based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The study population, including children and adults, underwent dental anesthesia using the CCLAD system, ensuring a comprehensive and representative sample that instills confidence in the validity of the results. Fourteen clinical trials were included in the analysis after they fulfilled the eligibility criteria. We found that using computer-assisted anesthetic equipment not only led to a significantly lower pain perception score, but also had a profound positive impact on patient behavior. Patients using the CCLAD device exhibited more cooperative and helpful conduct, indicating the system's effectiveness in improving patient comfort and experience and reassuring the audience about its positive impact. In conclusion, using a computer-assisted anesthetic device such as the CCLAD system significantly reduced pain perception scores and improved patient behavior, making them more cooperative and helpful. These findings offer hope for pediatric dentistry and apprehensive adult patients, suggesting a more comfortable and less daunting dental experience with the CCLAD system.
... It is well recognized that it is extremely difficult to quantify pain due to its subjective nature. The VAS has the advantage of simple usage and an unlimited number of possible responses [33]. The VAS mental score in our study was a significant predictor of anesthesia effectiveness in the retromolar triangle. ...
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Unlabelled: Anesthetic techniques play an important role in the outcome of the therapeutic procedures in dentistry. Although inferior alveolar nerve block (IANB) anesthesia is currently the most often used, there are situations that imply the need of an alternative anesthesia technique to overcome the potential risks and complications. The aim of the study was to evaluate the efficacy of the retromolar triangle anesthesia technique in achieving the desired nerve block, while evaluating the duration of the anesthesia for the included cases. Methods: The present prospective study included 50 subjects that had indication of inferior molar extraction. The performed anesthesia technique for these cases was the retromolar triangle approach, and the analyzed parameters for evaluating the efficacy of this anesthesia technique were the positive nerve block of the branches involved in the area (inferior alveolar, buccal, and lingual nerves) and the duration of the anesthesia. Results: The efficiency of the retromolar triangle anesthesia technique was positive in 64% of the cases for the inferior alveolar nerve, 46% of the cases for the lingual nerve, and 22% of the cases for the buccal nerve. The duration of the anesthesia revealed a mean value of 72.4 min, suggesting that the duration is an essential factor in its effectiveness. Conclusions: Retromolar triangle anesthesia can be a viable option for clinicians, offering a simple and easy approach for the management of clinical cases.
... 2,3 Moreover, it is reported that anesthesia injection increases patients' anxiety and fear, particularly in younger patients. 4 According to research, the effectiveness of anesthesia is not deep enough; therefore, obtaining adequate anesthesia in the inferior alveolar nerve block is occasionally necessary for mandibular teeth with symptomatic irreversible pulpitis. Since nerve block anesthesia has the advantage of using less anesthetic overall and producing less discomfort for the patient. ...
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Aim: To determine whether photobiomodulation (PBM) therapy could increase the depth of analgesia during endodontic therapy of teeth affected with symptomatic irreversible pulpitis. Materials and methods: Forty-nine patients with symptomatic irreversible pulpitis were randomized into two groups. In the laser group, before administering anesthesia, the lower molars' crowns were continuously treated with a diode laser (980 nm) for 20 s with a low-level laser tip in the buccal aspect close to the gingival margin. While the teeth of the second group who was blinded to the type of treatment received placebo treatment wherein the laser device was switched off. The visual analogue scale (VAS) was used to assess pain in both groups before the endodontic procedure, during dentin cutting, and at dropping pulp, wherein, the success was defined as no or mild pain. The Chi-square and independent sample t-tests were used to assess the data. Results: During dentin cutting and pulp dropping, the group receiving the laser therapy presented with less mean pain score than the placebo group which was statistically significant. Additionally, it was observed that the need for supplementary injection was less frequent in the laser-treated group than in the placebo group (p = 0.01). Conclusion: The irradiation by diode laser (980 nm) prior to administration of local anesthesia appears to be useful in minimizing discomfort and additional injection during root canal therapy (RCT). Clinical significance: Pain management is essential for providing the best possible treatment to patients before, during, and after endodontic therapy. Adequate pain control during treatment also aids in reducing postoperative discomfort. This implies the need for additional methods to reduce discomfort during endodontic treatment; hence, adjuncts are crucial to achieving this goal. Photobiomodulation may be used as an adjuvant to reduce discomfort and supplementary injections during RCT.
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Introduction Local anaesthesia (LA) is the cornerstone for pain management of invasive dental procedures, but the process of delivering it may itself induce anxiety, especially in paediatric patients that can affect the pain perception. Advances such as the computer-controlled LA delivery system have expanded the horizons of LA and can serve as an alternative for painless injections. To examine the pain perception and anxiety reduction along with patient preference between computer-controlled Starpen device and conventional aspirating cartridge in LA administration for inferior alveolar nerve block. Materials and Methods The patients were randomly allotted into two groups: Starpen and Septodont syringe where the LA injections were given using both the methods in the 1 st week. After a washout period of 1 week, the crossover was performed and the other mode of LA administration was performed in the 2 nd week. Pain scores were objectively recorded by the observer using the Face, Legs, Activity, Cry and Consolability (FLACC) scale during LA administration and extraction. Patients were asked to record the pain scores using the Visual Analogue Scale at three phases: (a) mucosa perforation, (b) needle insertion and (c) solution injection. The effect of pain perception on the vital parameters and the preference between the two techniques were assessed. Statistical Package for the Social Sciences (SPSS) version 23.0, Armonk, NY, USA: IBM Corp was used for statistical analysis, and Mann–Whitney U -test and unpaired t -test were utilised to compare the mean difference of two groups at significance level of 0.05. Results Intergroup differences among the Starpen and Septodont syringe groups were found to be statistically significant ( P < 0.001) during both LA and extraction when pain was objectively assessed using FLACC. Conclusion Computerised devices such as Starpen offer controlled release of local anaesthetics, effectively decreasing pain perception in paediatric patients and can form a mainstay for the behaviour management of young patients.
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Aim: To assess and summarize effect of computerized anesthesia techniques in reducing pain as compared to conventional technique in adult patients undergoing dental treatment. We conducted a comprehensive Methods: literature search on four electronic databases, PubMed, net of information, google scholar, and Cochrane library for this systematic review after registering with Prospero. The inclusion and exclusion was stringent to conduct the filtering and select the Randomised Control Trial/ Clinical Trial which were eligible for qualitative and subsequent quantitative analysis. The heterogeneity was analyzed with the I2 values and risk of bias was conducted with appropriate tool form Cochrane. Review Manager 5.3 was used for meta-analysis. Out of 24 studies, 08 studies were further Results: included for quantitative analysis and the meta-analysis was interpreted with the forest plot. The outcome which we assessed was the pain outcome after anaesthesia. The mean cumulative difference was -1.73 (CI: -3.01to -0.45). The heterogeneity was I2=91%, hence we applied the random effects model for analysis. The CCLAD seems to be a promising Conclusion: device, offering a less painful method of anaesthesia administration; which showed that the pain was higher in conventional group when compared to other interventional techniques.
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Actuality. Currently, the problem of treatment of acute forms of periodontitis, especially in children, is related to the use of anesthetic care against the background of increased stress factors and lability of the nervous system. The works of many authors have proven that after conducting incisor guide anesthesia, anesthesia occurs not only of the soft tissues of the anterior third of the palate, but also of the pulp of the incisors, which is especially important when extirpating the pulp and exposing the pulp chamber. Today, many authors recommend using incisive conductor anesthesia as a monomethod of pain relief for incisors, but this technique has not been widely used in practical health care. Some authors prove the effectiveness of the additional use of incisive conduction anesthesia when infiltration is insufficient. It should be noted that the data analysis has a contradictory character without the presence of a single dominant opinion regarding the combined method of using conductive and infiltration anesthesia, especially in adolescents with an odontogenic inflammatory process. The purpose of the study: to investigate the anesthetic effect with the combined use of infiltration and incisive conductor anesthesia in the treatment of acute periodontitis of the frontal group of teeth on the upper jaw in children of the adolescent period. Materials and methods. The archival data of cone-beam computed tomography of 25 patients on a Planmeca tomograph were studied. Outpatient treatment of 65 patients diagnosed with acute serous and acute purulent periodontitis was carried out. To anesthetize the central or lateral incisor from the side of the causative tooth, infiltration anesthesia with "Ultracain" (4% solution) was performed in the canine area of the maxilla, creating a depot of anesthetic 2-5 mm from the focus of inflammation and blocking the anterior upper alveolar nerves. The VAS (Visual Analog Scale) and the Numerical Rating Scale (NRS) were used to assess pain intensity. The results. According to the tomography results, we have found the following features: the incisive canal begins with two separate nasopalatine openings, which open in the front part of the bottom of the nasal cavity on both sides of the nasal septum, with the merging of the two canals into one incisive canal, which looks like a slingshot on the tomogram. The incisor foramen is located behind the central incisors of the upper jaw by 7-8 mm in girls and 8-9 mm in boys, immediately under the incisor papilla. Based on the results of X-ray studies, we established several forms of the channel. In 75-80% of cases, the incisive canal has the shape of an "eight", less often it is found in the form of a funnel and, in two cases, a cylinder. The length from the top of the incisive papilla to the narrowing of the incisive canal is 9.0-10.5 mm in girls and 10.0-11.7 mm in boys. In 58% of cases, on the tomogram, we have found the relationship between the alveolar canals and the incisive canal. At the level of the bottom of the nose, the microcanals of the anterior superior alveolar nerves connected with the incisor canal, in 22% of cases opening in the anterior third of the palate through independent openings. According to the obtained data, the combination of analgesia used allows the intervention to be completely painless in 82-87% of cases. In 4% of cases, patients complained of painful sensations, there was no need for additional analgesia. In 3% of cases (75% of cases in girls), endodontic treatment was painless, but at the same time, during the opening and drainage of the infiltrate in 5% of cases, additional infiltration anesthesia was performed. Immediately after incisive conduction anesthesia in 75% of cases, patients felt numbness of the nasal cavity, especially its lower third. When re-examining in 40% of cases, patients noted discomfort in the area of the incisor papilla. Conclusions. The use of a combination of infiltration anesthesia and incisive conductor anesthesia allows achieving full analgesia of the pulp and periodontal tissues in the treatment of acute periodontitis of the frontal group of teeth.
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Aim: This prospective, randomised, parallel, controlled study was conducted firstly to compare the onset of local anaesthesia (LA) when using the conventional technique versus the Wand computer-controlled LA and secondly to assess the pain experience in children. Method: Thirty children were randomly allocated to the treatment group (Wand) or the control group (conventional). Lidocaine 2% with adrenaline (1:80,000) was given as a buccal infiltration. The onset of pulpal anaesthesia was tested using an analytic electric pulp tester (EPT). The pain experience during the LA was recorded using a modified visual analogue score (VAS). Results: Median time for the onset of LA was 6.30 minutes for the control and 7.25 minutes for the Wand group. Mean pain experience score for the control group was 9.78% as opposed to 8.46% in the Wand group. Statistical analysis showed that there was no statistically significant difference in the onset of LA (p = 0.486) and the pain experience (p = 0.713) between the two groups. Conclusion: When placing a buccal infiltration on upper first permanent molars, the onset of LA and the pain experience was no different using the Wand and the conventional technique.
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Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables.77 Pain processes do not begin with the stimulation of receptors. Rather, injury or disease produces neural signals that enter an active nervous system that (in adults) is the substrate of past experience, culture, anxiety, and depression. These brain processes actively participate in the selection, abstraction, and synthesis of information from the total sensory input. Pain, then, is not simply the end product of a linear sensory transmission system; rather, it is a dynamic process that involves continuous interactions among complex ascending and descending systems.
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The objective of this study was to compare the pain levels on opposite sides of the maxilla at needle insertion during delivery of local anesthetic solution and tooth preparation for both conventional and anterior middle superior alveolar (AMSA) technique with the Wand computer-controlled local anesthesia application. Pain scores of 16 patients were evaluated with a 5-point verbal rating scale (VRS) and data were analyzed nonparametrically. Pain differences at needle insertion, during delivery of local anesthetic, and at tooth preparation, for conventional versus the Wand technique, were analyzed using the Mann-Whitney U test (p=0.01). The Wand technique had a lower pain level compared to conventional injection for needle insertion (p<0.01). In the anesthetic delivery phase, pain level for the Wand technique was lower (p<0.01). However, there was no difference between the Wand and conventional technique for pain level during tooth preparation (p>0.05). The AMSA technique using the Wand is recommended for prosthodontic treatment because it reduces pain during needle insertion and during delivery of local anaesthetic. However, these two techniques have the same pain levels for tooth preparation.
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This was to compare the sensation of pain when injections were given using the Wand computer controlled local analgesia (LA) system and a conventional technique in children of pre-school and school age. 38 children were randomly assigned to either a treatment or control group. The treatment (Wand) group consisted of 20 children, while the control group (conventional LA technique) consisted of 18 children. The children were aged between 39.0 and 120.0 months with a mean age of 81.9 months (SD- 23.2). One operator carried out all local analgesia administrations. Pain sensation was rated using the VAS scale by the operator, each child and their parent. Anxiety was rated using the Venham scale. No statistical difference in pain sensation and anxiety was found when the Wand was used, compared with the conventional technique (P=0.710, P=0.976). The results also showed no significant difference in anxiety change between males and females in the two groups (P=0.714). There was no difference in the pain or anxiety experienced by the children in the conventional and Wand group.
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This study compared a computerised device (the Wand) with a conventional syringe in terms of the pain of needle insertion and injection during inferior alveolar nerve (IAN) block injection. The subjects were 40 patients between the ages of 18 and 30 years requiring local anaesthesia for dental restoration in the mandible. Before anaesthetic administration, the patients' anxiety levels were determined. Contralateral IAN injections were administrated at two separate appointments with random use of either the Wand or a conventional syringe. Following the injection, the patients used both the pain rating score (PRS) and a visual analogue scale (VAS) to assess the intensity of pain. When pain was measured after the injection, the Wand was found to be less painful than the syringe for the pain of both needle insertion and injection (p <0.05). The Wand technique resulted in significantly lower pain scores during the IAN block injections. Most of the patients preferred the IAN injection with the Wand for future dental injections.
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This article describes a new computerized local anesthetic injection system for pain control. The core technology of this system is the microprocessor-controlled delivery of anesthetic solution at a constant pressure and controlled volume, regardless of encountered variations in tissue resistance. This fine-tuned, high suffusion flow rate of anesthetic provides a rapid onset of anesthesia for most patients. Traditional block injections and infiltrations as well as palatal injections and periodontal ligament injections are administered with precision, ease, and patient comfort.
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Numerical rating scales and mechanical visual analogue scales (M-VAS) were compared for their capacity to provide ratio scale measures of experimental pain. Separate estimates of experimental pain sensation intensity and pain unpleasantness were obtained by each method, as were estimates of clinical pain. Orofacial pain patients made numerical scale and VAS ratings in response to noxious thermal stimuli (45-51 degrees C) applied for 5 sec to the forearm by a contact thermode. The derived stimulus-response function was well fit as a power function only in the case of sensory M-VAS. The power function derived from sensory M-VAS ratings predicted temperatures chosen as twice as intense as standard temperatures of 47 degrees C and 48 degrees C, thereby providing evidence for ratio scale characteristics of M-VAS. The stimulus-response function derived from sensory numerical ratings differed from that obtained with M-VAS and did not provide accurate predictions of temperatures perceived as twice intense at 47 degrees C or 48 degrees C. Both M-VAS and numerical rating scales produced reliably different stimulus response functions for pain sensation intensity as compared to pain unpleasantness and both provided consistent measures of experimental and clinical pain intensity. Finally, both mechanical and pencil-and-paper VAS produced very similar stimulus-response functions. The ratio scale properties of M-VAS combined with its ease of administration and scoring in clinical settings offer the possibility of a simple yet powerful pain measurement technology in both research and health care settings.
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Studies of the prevalence of dental anxiety in general population samples have produced estimates which range from a low of 2.6% to a high of 20.4%. It is not clear whether these reflect real differences among populations or whether they are the result of the use of different measures and different cut-off points. We undertook a large scale mail survey of dental anxiety in a random sample of the adult population living in Metropolitan Toronto designed to assess the performance of and agreement between three measures. These were Corah's DAS, the single item used by Milgrom and colleagues in Seattle and the ten-point fear scale used by Gatchel. These measures and their published cut-off points produced prevalence estimates of 10.9%, 23.4% and 8.2% respectively. While there was a significant association between scores on pairs of measures the agreement between them was far from perfect. Kappa values ranged from 0.37 to 0.56, indicating only fair to moderate agreement beyond chance. There was evidence to indicate that the dentally anxious subjects identified by each measure differed according to certain behavioural and other characteristics. The results of the study suggest the need to revisit the issue of measurement in studies of dental anxiety.
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A study was designed to determine if there are changes in the perception of pain when the flow rate and pressure of an injected anesthetic are precisely controlled. Fifty dentists were given contralateral palatal injections. One side was injected with the Wand injector, a new delivery system that uses a microprocessor and an electric motor to precisely regulate flow rate during administration. The control side was injected using a standard manual syringe, in which flow rate and pressure are operator-dependent and cannot be controlled accurately. The subjects used two subjective scales to describe their perceived pain experience. When their responses were analyzed the Wand injector was found to be two- to three-times less painful than the manual injection. The results were statistically significant (p < .001). The authors conclude that there is an optimal flow rate of anesthetic solution at which the perception of pain during an injection is minimized.