|Year : 2014 | Volume
| Issue : 3 | Page : 143-148
Pain perception and procedural tolerance with computer controlled and conventional local anesthetic technique: An in vivo comparative study
Rahul Goyal, B Nandlal, Prashanth
Department of Paedodontics and Preventive Dentistry, Jagadguru Sri Shivarathreeswara Dental College and Hospital, Mysore, Karnataka, India
|Date of Web Publication||11-Aug-2014|
Department of Paedodontics and Preventive Dentistry, Jagadguru Sri Shivarathreeswara Dental College and Hospital, Mysore - 570 015, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to evaluate and compare the Pain Perception and Procedural Tolerance (PPPT) by the pediatric patients, while experiencing 'Computer Controlled Local Anesthetic Technique' (CCLAD, Wand) and 'Conventional local anesthetic technique'. Material and Methods: Fifteen subjects, of age 8-10 years requiring local anesthesia on both sides of the dental arch for the purpose of extraction were selected for this study. In this cross-over design study, randomization was done to allocate the type of local anesthetic technique to be used first, children who received CCLAD (Wand) during 'First Anesthetic Exposure' (FAE) visit subsequently received 'Conventional anesthetic technique' during 'Second Anesthetic Exposure' (SAE) visit and vice versa. Behavior assessment using 'Frankel's Behavior Rating Scale' (FBRS) and anxiety assessment using 'Faces Version of Modified Child's Dental Anxiety Scale' (MCDAS f ) were done prior to the anesthetic exposure. 'Wong Baker's Facial Pain Scale' (WBFPS) was used to assess the child's pain perception to each of the two techniques, immediately after the injection. Various physiological parameters like 'Heart Rate'(HR), 'Respiratory Rate'(RR), and 'Oxygen Saturation' were measured during pre-operative phase, LA-phase, post LA-phase, Extraction phase and post Extraction phase, during FAE and SAE. Results: Paired t-test revealed a very highly significant (P = 0.001) difference between CCLAD (Wand) and conventional during SAE. Non-significant difference was observed when physiological parameters were compared at various intervals between the two anesthetic techniques. Conclusion: CCLAD (Wand) provides lesser pain perception as compared to conventional local anesthetic technique.
Keywords: CCLAD (Wand), Conventional anesthetic technique, FBRS, MCDAS f , WBFPS
|How to cite this article:|
Goyal R, Nandlal B, Prashanth. Pain perception and procedural tolerance with computer controlled and conventional local anesthetic technique: An in vivo comparative study. Indian J Pain 2014;28:143-8
|How to cite this URL:|
Goyal R, Nandlal B, Prashanth. Pain perception and procedural tolerance with computer controlled and conventional local anesthetic technique: An in vivo comparative study. Indian J Pain [serial online] 2014 [cited 2020 May 24];28:143-8. Available from: http://www.indianjpain.org/text.asp?2014/28/3/143/138441
| Introduction|| |
Dental treatment requiring local anesthetic injection has long been associated in the mind of children with pain. Concept of 'Computer Controlled Local Anesthetic Device' (CCLAD, Wand, Milestone Scientific, Inc., Livingston, N.J.) was introduced that delivers anesthetic solution at a precise flow rate and at a controlled volume.  This controlled rate and flow causes more rapid onset of anesthesia, easier administration, decreased pain perception, and decreased child anxiety levels.  The present study aims at establishing a comparison between the CCLAD (Wand) and conventional local anesthetic technique by assessing the self-report pain perception by the child.
| Materials and Methods|| |
The present cross-over design study was carried out in Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Mysore. Based on feasibility criteria, a total of 15 subjects in the age range of 8-10 years, among those coming to out-patient department (OPD) of the department were selected for the study. Written informed consent was obtained from the parents or guardians of the children before the beginning of examination. All the 15 subjects were subjected to actual procedure either in maxillary arch or mandibular arch, based on the treatment needs. The randomization was done by lottery system to allocate the mode of local anesthesia delivery, to be used for 'First Anesthetic Exposure' (FAE), in each subject. All the subject after receiving one mode of local anesthetic technique, during the FAE, subsequently, received the other type of local anesthetic technique, in the 'Second Anesthetic Exposure' (SAE) on contra-lateral side of the same arch (cross-over design), after a wash-out period of 7 days.
Co-operative children with no previous dental treatment history requiring extraction of primary teeth as a part of the treatment plan (alternate serial extraction of only first deciduous molar in D4C pattern in case of developing class-1 molar relation) on either sides of the same arch. Children categorized into Group-1 of American Society of Anesthesiologists (ASA) classification.
Pre-cooperative children having acute infections were categorized into Group-2, Group-3, and Group-4 of the ASA classification.
Each child in this study was examined during the course of four dental visits (first visit, second visit, FAE visit and SAE visit, respectively).
During the first visit, child's behavior assessment was done using Frankel's Behavior Rating Scale (FBRS). Second dental visit was scheduled, the immediate day, after the first visit, during which first the child was assessed for his/her behavior using the FBRS and then radiographic investigations, Orthopantomogram (OPG), Lateral cephalogram, and IOPAR's along with impression of maxillary and mandibular arch were carried out.
Child's FAE visit was scheduled, immediate next day after the second visit. This visit was the actual procedure visit, for performing FAE on one side of the selected arch, based on the treatment needs, by either of the two local anesthetic techniques, as per the randomization done by lottery system.
Total time period of FAE visit was scheduled for 20 minutes and was divided into following phases:
- Pre-operative phase (for 3-5 minutes): During this phase Frankel's Behavior Assessment was done using FBRS, following which pre-procedural child's anxiety was recorded by subjective means using Faces Version of Modified Child's Dental Anxiety Scale (MCDAS f ), and by objective means using Pulse-oximeter (BPL Maxima, Multi-para Monitor).
- LA-phase (during local anesthesia administration-for 1-2 minutes): During this phase, local anesthesia was delivered using CCLAD (Wand) or the conventional anesthetic technique, depending upon the particular group, the selected patient belonged. Prior to the delivery of local anesthesia, topical anesthetic, Lox-2% Lignocaine Hydrochloride gel (Neon Laboratories ltd.) was applied, using cotton tip applicator for 60 seconds, on the dried mucosa, on both buccal and palatal/lingual aspect, at the site of injection. Buccal infiltration followed by lingual or palatal infiltration was performed, for both the types of techniques. 0.9 ml of (2% lignocaine with 1:80,000 epinephrine) anesthetic solution was delivered during buccal infiltration, whereas for palatal or lingual infiltration, 0.4 ml of (2% lignocaine with 1:80,000 epinephrine) anesthetic solution was delivered. 27-gauge long needle was used for both the anesthetic techniques.
- Injection by the CCLAD (Wand): The Wand TM (Milestone Scientific, Inc., Livingston, N.J.) was the equipment used for computer controlled local anesthesia delivery. The equipment comprised of disposable component handpiece component and a computer control unit. Handpiece was an ultra-light pen like handle, which was linked to an anesthetic cartridge, with a plastic microtubing. Procedure was followed as per the manufacturer's instructions. The delivery of local anesthesia was done under cruze control mode of the equipment at slow speed, regulated, by a pedal. 1.8 ml single-use anesthetic cartridge (Lignospam special-Septodent-France, consisting of 2% lidocaine with 1:80,000 epinephrine) was used.
- Injection by Conventional anesthetic technique: Traditional syringe was used for conventional technique of local anesthesia delivery. 30 ml local anesthetic solution bottle (Indodoco remedies ltd., consisting of 2% lidocaine with 1:80,000 epinephrine) was used.
Physiological parameters were recorded throughout, while the local anesthesia was delivered.
- Post LA-phase (for 5 minutes): During this phase, child's physiological parameters were recorded for the purpose of objective evaluation of child's pain perception, regarding the experience of the local anesthetic injection. Subjective evaluation (self-report) of child's pain perception regarding the experience of the local anesthetic injection was also done, using Wong Baker's Facial Pain Scale (WBFPS).
- First extraction phase (during extraction-for 1-2 minutes): During this phase extraction of first primary molar, on one side of the selected arch was done. Physiological parameters were recorded, during the course of extraction.
- Post First extraction phase (after extraction for 5 min): During this phase, child's physiological parameters were recorded along with subjective evaluation (self-report) of child's procedural tolerance, regarding the experience of the extraction done, using Wong Baker's Facial Pain Scale (WBFPS).
Child's SAE visit was scheduled 7 days after the FAE visit. During this visit contra-lateral side extraction of the selected arch was done, by the local anesthetic technique other than the technique used during FAE. Total time period of SAE visit was also scheduled for 20 minutes. All the phases and evaluations were same as that of the FAE visit.
The data thus obtained was subjected to statistical analysis using SPSS version 16.0 for Windows. Paired t-test was used to compare various variables such as WBFPS score, heart rate, oxygen saturation, respiratory rate (during all the phases) between the two anesthetic techniques.
| Results|| |
The statistical analysis showed non-significant difference in the mean FBRS scores between the two techniques during sequential dental visits. Very highly significant difference (P = 0.001) of the overall mean values of MCDAS f scores, was observed, where overall mean value in the SAE was reduced from FAE [Table 1]. On comparing the two anesthetic techniques for WBFPS scores, a very highly significant difference (P = 0.001) was observed, in the mean values of WBFPS scores, between CCLAD (Wand) and Conventional, during SAE [Table 2]. Also, highly significant difference (P = 0.007), was observed in the mean values of WBFPS scores with conventional local anesthetic technique used during FAE and CCLAD (Wand) used during SAE, where mean value of CCLAD (Wand) was lower than the mean value of Conventional anesthetic technique [Table 3].
|Table 1: Overall comparison of 'Faces Version of Modifi ed Child's Dental Anxiety Scale' MCDASf scores, between the (FAE) and (SAE)|
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|Table 2: Comparison of WBFPS scores, during 'Second Anesthetic Exposure' (SAE)|
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[Table 4] shows the comparison of heart rate between the CCLAD (Wand) during FAE and conventional anesthetic technique during SAE. No significant difference was observed in the mean heart rate (HR) scores during all the phases, however mean HR score with CCLAD (Wand) during FAE was lower than the mean HR score with conventional during SAE.
[Table 5] shows the comparison of HR between the conventional anesthetic technique during FAE and CCLAD (Wand) during SAE. No significant difference was observed in the mean HR scores during all the phases, however mean HR score with conventional during FAE was higher than the mean HR score with CCLAD (Wand) during SAE.
| Discussion|| |
The overall observations of this study, as evaluated using statistical paired t-test, suggest that the CCLAD resulted in significantly less pain perception when compared with the same children who experienced a conventional injection. This finding is in accordance with the study conducted by Langthasa  , Octay  and Gibson et al.,  however it is not in accordance with the study conducted by Ram  , who reported no significant difference between the two local anesthetic techniques.
The difference in pain perception by subjective assessment was made by WBFPS score. The assessment was made at FAE visit, SAE visit and between FAE and SAE. 
Highly significant (P = 0.007) difference in the mean pain scores was observed in children who received Conventional anesthesia during the FAE and CCLAD (Wand) technique during SAE, with CCLAD (Wand) exhibiting lower mean WBFPS score of (0.63) than the mean WBFPS score of (1.63) with conventional. This shows the technique sensitivity and better acceptability of CCLAD (Wand) by the children during their SAE. This finding is in accordance with the results of the similar study performed by Langthasa  , but not in accordance with the study by Asarch  and Koyurk  , who reported that there is no significant difference between the two anesthetic techniques. However their study was carried out on two different groups, one group, which received CCLAD (Wand) and the other group that received conventional anesthesia. But this present study was a cross-over design study, where the child himself acted as its own control, which is in accordance with the similar study conducted by Tahmassebi et al. and Lopez et al.
This study also aimed to evaluate any changes in the variation of physiological parameters between the two anesthetic techniques-CCLAD (Wand) and conventional. Surprisingly no statistical significant difference was observed in the mean scores of all the three physiological parameters during FAE, SAE, and from FAE to SAE. The reason for non-significant difference could be due to high standard deviation (S.D.), which occurs when there is wide range of heterogeneity in the data recorded. However, the mean HR score was observed to be lower with CCLAD (Wand) as compared to Conventional, from the baseline readings (pre-operative phase of 5 min), during FAE, during SAE and between FAE and SAE, which shows, CCLAD (Wand) has better pain perception and acceptability by the children as compared to Conventional technique. This finding is in accordance with the study conducted by Langthasa  , but not with the study conducted by Lopez et al.
It was observed that mean HR score showed increase during the 'LA-phase' and 'Extraction phase' in both FAE and SAE, which is due to the fact that an alarm reaction by the hypothalamus is initiated that results in vasodilatation and also causes the increased release of endogenous epinephrine and nor-epinephrine, that subsequently increases the HR and cardiac output (CO). 
The above findings have been studied by West et al., and Poiset et al.,  in their respective studies, and they have found that the moment the LA is administered and the moment the extraction procedure is initiated, there occurs a stressful state, leading to an increased endogenous release of adrenaline. The results of this study, was therefore, found to be in accordance with the study by West et al.,  and Poiset et al. 
No significant difference in the Respiratory Rate (RR) and Oxygen Saturation (O 2 S) was observed during this study and these parameters remained unaltered throughout. Similar findings were reported by the study conducted by Langthasa  , Sanadhya  , West et al.,  and Poiset et al. 
In this study FBRS, was used to assess the child's behavior during their dental initial dental visit and thereafter in subsequent visits. This method of assessment of child's behavior in multiple dental visits is in accordance with the study conducted by Sharma and Tyagi. 
The study by Sharma and Tyagi showed an improvement in the child's behavior in sequential dental visits, when assessed by FBRS.  Similar study was conducted by Howitt and Stricker, and they also concluded that the child's arousal level reduces as he/she gains experience in the dental situation. 
However, in this study, the behavior of all the study subjects remained the same during the sequential visits as per the study methodology. This may be attributed to the fact that the study subjects included for this study had positive behavior prior to their selection for this study and their behavior remained positive throughout subsequent visits, due to efficient Behavior Management Techniques (BMTs) adopted throughout the study period.
Anxiety assessment was another beneficial parameter evaluated in this study. Various authors over the years have studied both the psychological (emotional) and physiological component and their inter-relationship, and the results of their studies have shown how stress produces anxiety and how this leads to a chain reaction that affects blood pressure and HR.  Therefore in this study, both the objective and subjective means for assessing anxiety were used, which is in accordance with the study by Jimeno.  In this study, anxiety was assessed during the pre-operative phase of the FAE visit and the SAE visit.
Subjective assessment of anxiety was done using 'Faces Version of Modified Child's Dental Anxiety Scale' (MCDAS f ), which has proved to be a reliable and valuable scale for assessment of anxiety in children, of age-group 8-10 years as studied by Karen. 
This study also showed that the overall difference in the mean scores of anxiety between FAE visit and SAE visit was statistically very highly significant (P = 0.001), as analyzed by Student's paired t-test, with the overall mean anxiety scores being reduced in SAE. This finding suggests that, as the child gets accustomed to the dental operatory and complex dental treatment procedures, the level of anxiety reduces gradually in subsequent dental visits. This finding is in accordance with the study conducted by Rayen et al.,  and Murray et al. 
However, highly significant decrease in the mean anxiety scores, during the SAE, may also be attributed to proper BMTs, adopted throughout the study period. This can be co-related with a study by Abreu et al.,  who described that effective BMT can reduce the level of anxiety in young children, during the course of sequential dental visits.
The objective measurement was recorded using Pulse-oximeter which measured HR and O 2 S. RR was assessed by visual assessment of chest movements.
It is well documented that Pulse-oximeter, which is an electronic monitoring system, is preferred over conventional monitoring of physiological parameters using stethoscope and manual sphygmomanometer, as studied by Robin et al. 
Studies by Jimeno et al.,  and McCarthy  , have shown that HR and blood pressure (BP) were two reliable and safe indicators of anxiety. Similarly in this study, HR was electronically evaluated during FAE and SAE to assess the changes in the level of anxiety. It was observed that the mean scores of HR showed a decrease during the SAE than FAE, which justifies that anxiety decreases in sequential dental visits, even when evaluated by means of variation in physiological parameters. However the difference obtained was statistically non-significant. Assessment of RR and O 2 S was not a reliable finding in co-relation with anxiety.
Hence, the results of this study are in accordance with the study conducted by Rayen et al.  Jimeno  has however, reported that physiological measures of anxiety require a monitoring team, financial expenditure, extra clinical time and hence, is not a commonly used method for anxiety assessment in clinical practice.
Thus the slow delivery of anesthetic solution at a controlled volume and constant pressure makes CCLAD (Wand) a comfortable device for delivery of local anesthesia in children.
| Conclusion|| |
The conclusions drawn from the study are:
- Behaviorand anxiety improved with sequential dental visits, as the child gets acclimatized to the dental operatory.
- Subjective Pain Perception as measured by (WBFPS) score was significantly lower with CCLAD (Wand) than the conventional anesthetic technique.
- Physiological parameter - 'Heart Rate' (HR), was lower with CCLAD (Wand) than the conventional anesthetic technique. However, 'Respiratory Rate' (RR) and 'Oxygen Saturation' (O 2 S) remained un-altered, irrespective of the technique of local anesthesia.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]