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 Table of Contents  
ORIGINAL RESEARCH
Year : 2022  |  Volume : 14  |  Issue : 3  |  Page : 298-305

Assessment of pain and intraoperative anxiety by computerized and traditional local anesthetic methods in periodontal therapies: A comparative study


Department of Periodontology, JSS Dental College & Hospital, JSS Academy of Higher Education & Research, Mysore, Karnataka, India

Date of Submission22-Sep-2021
Date of Decision24-Feb-2022
Date of Acceptance28-Feb-2022
Date of Web Publication28-Jun-2022

Correspondence Address:
Dr. Deepika Pawar Chandrashekara Rao
Department of Periodontology, JSS Dental College & Hospital, SS Nagar, Mysore 570015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_259_21

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  Abstract 

Aim: To evaluate and compare the pain perception and intraoperative anxiety of patients who underwent the computer-controlled local anesthetic technique (CCLAD), as well as the conventional technique. Materials and Methods: This study included 100 individuals who required local anesthetic on both sides of the dental arch for various periodontal operations. We randomized the patients into three groups in our study (root planing, curettage, and surgery). The clinical trial was designed as a “randomized, single-center, single-blinded, parallel-arm, comparative study” with a cross-over design. Randomization was done by the computer-allotted method. Patients who received WAND during first visit in selected quadrants subsequently received “traditional anesthetic technique” during the second visit in contralateral quadrants and vice versa. The patient’s pain perception to each of the two injection procedures was assessed 5 min later using the Wong Baker’s Facial Pain Scale (WBFPS). The anxiety was compared intraoperatively by Wong Baker’s Facial Anxiety Scale (WBFAS) while the procedure was going on. Results: Results from Mann–Whitney U test using SPSS software program, version 17.0 revealed a very aim highly significant difference between WAND and traditional injection regarding pain in all the three groups with WAND showing fewer pain scores (P < 0.05). No statistically significant difference was observed when anxiety was compared in the same groups. Conclusion: In comparison to traditional local anesthetic techniques, WAND produced less pain perception.

Keywords: Anxiety, CCLAD (WAND), Pain, Traditional Local Anesthetic Technique, Wong Baker’s Facial Anxiety Scale (WBFAS), Wong Baker’s Facial Pain Scale (WBFPS)


How to cite this article:
Haridas AV, Pawar Chandrashekara Rao D, Ojha M, Madhushree J T. Assessment of pain and intraoperative anxiety by computerized and traditional local anesthetic methods in periodontal therapies: A comparative study. J Int Oral Health 2022;14:298-305

How to cite this URL:
Haridas AV, Pawar Chandrashekara Rao D, Ojha M, Madhushree J T. Assessment of pain and intraoperative anxiety by computerized and traditional local anesthetic methods in periodontal therapies: A comparative study. J Int Oral Health [serial online] 2022 [cited 2022 Dec 2];14:298-305. Available from: https://www.jioh.org/text.asp?2022/14/3/298/348414


  Introduction Top


“For the success of any dental treatment, the depth of anesthesia is crucial for achieving the patient’s confidence.”[1],[2] “Patients often express more anxiety about the injection of local anesthetics than about the actual dental treatment.”[3],[4],[5],[6] The fear and anxiety that accompany dental care can negatively impact the patient’s health globally.[7]

It has been proposed that topical anesthesia, small diameter needles, and lasers can all be used to reduce pain during injections.[8] The anesthesia part of dental procedures is usually one of the most feared despite current advances in materials and technology.[9] Therefore, there is a need to overcome the fear of administering local anesthesia during a dental procedure.

“In order to reduce or eliminate the pain associated with dental injections, a computer-controlled local anesthetic device called the WAND (Milestone Scientific, Livingston, New Jersey) was developed as a potential tool to reduce or virtually eliminate that pain”[10] [Figure 1]. In this a foot-activated control allows dental professionals to deliver local anesthesia with fingertip accuracy. The anesthetic solution is administered at a precise flow rate and at a controlled volume, according to the idea behind WAND. It is thus most compatible with tissue acceptance due to low pressure, which ultimately reduces pain.
Figure 1: Computerized controlled local anesthetic device showing cartridge and WAND handpiece mounted on the device (red arrow = handpiece, yellow arrow = cartridge)

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Most of the studies comparing WAND vs. traditional anesthetic technique have been conducted on pediatric patients.[1],[11],[12] Hence, the aim of this study was to compare the efficacy of WAND vs. traditional injection method in the adult population in various procedures which require local anesthesia in periodontal therapies with a focus on pain perception and anxiety levels.


  Materials and Methods Top


Study design

“The present experimental clinical trial was designed as a randomized, single-center, single-blinded, parallel-arm, prospective, comparative study. The study was registered in CTRI with the reference number: REF/2022/01/050505.” The study protocol was approved and cleared by IEC (Ref no: JSS/ACP/Ethical/2012–2013). This study was conducted in compliance with all ethical standards established by the institutional research committee. In addition, they adhered to the “1975 Helsinki declaration and its later amendments as well as comparable ethical standards.” Informed consent was obtained from all individual participants included in this study.

Sample size estimation

Based on the prevalence of periodontitis as 28% (P), confidence interval of 95% (z) and confidence level of 10% (d), and power of the study as 90%, the sample size (N) was calculated as follows:

N = z2pq/d2,

where q equals 1 – P. The value was 77. Hence, a sample size of 100 was decided.

Sampling criteria

Patients needing periodontal treatment from ages 18 to 55, patients who are not allergic to Lignocaine, who were willing to participate in the study, were all considered for inclusion. In addition to pregnant/nursing woman and patients with uncontrolled systemic diseases unsuitable for periodontal procedures, mentally challenged patients and others on medications were excluded from participation.

Randomization and grouping

Total, 100 patients were selected from outpatients presenting to the Department of Periodontology of our Institution and the duration of the study was 1 year (from June 2013 to June 2014). The null hypothesis was that computer-controlled local anesthetic showed the same effects as compared to the traditional anesthetic techniques in terms of pain and anxiety.

As part of the initial examination for selected patients, demographic and medical information was collected, periodontal conditions were assessed, and radiographs taken as needed. These patients were divided between the root planing (30), curettage (30), and surgical groups (40) [Flowchart 1]. All the 100 patients were subjected to actual procedure either in the maxillary arch or mandibular arch, based on the treatment needs. The subject received one mode of local anesthetic technique during the first visit. Subsequently, they received the other kind of local anesthetic technique in the second visit on the contralateral side of the same arch. All the blocks were given by a single dentist. The injections were given depending upon the nerve blocks required to anesthetize the area. The same injections were repeated on the contralateral quadrant on the next appointment.
Flowchart 1: Showing the selection of study population

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Methodology

First visit

Ultrasonic scaling was performed on the patient, to be followed by periodontal intervention in the following appointment.

Second visit

After a 15-day gap, this visit was scheduled. During this appointment, computer randomization was used to select the anesthesia quadrants. WAND or traditional anesthetic techniques were used to deliver local anesthesia with lignocaine hydrochloride (and adrenaline 1:100.000).

Injection by WAND

WAND was the equipment used for computer-controlled local anesthesia delivery. It comprised of disposable component handpiece component and a computer control unit. The handpiece was an ultra-light pen-like handle, which was linked to an anesthetic cartridge, with plastic microtubing. The procedure was followed as per the manufacturer’s instructions. The delivery of local anesthesia was done under cruise control mode of the equipment at slow speed, regulated, by a pedal. 1.8 mL single-use anesthetic cartridge was used (Lignospan Special, Septodent) [Figure 2].
Figure 2: Demonstration of anesthesia by WAND

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Injection by traditional anesthetic technique

The traditional syringe was used for the conventional technique of local anesthesia delivery. 1.8 mL of solution withdrawn from 30 mL local anesthetic solution vial was used (2% lignocaine) 26-gauge long needle was used for both techniques.

Wong Baker’s Facial Pain Scale (WBFPS) was used to assess the patient’s pain perception to each of the two techniques 5 min after injection [Figure 3]. The WBFPS system enables the patient to correlate the pain experienced by the patient from 0 to 5 with 5 being the highest pain and 0 being the lowest.
Figure 3: Wong Baker’s facial pain/anxiety scale (WBFPS/WBFAS)

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Periodontal treatment phase

  • 1. After confirmation of onset of the local anesthesia effect, some periodontal treatment was done on the selected side of arch.


  • 2. Also during this phase,” evaluation of the patient anxiety was graded on the WBFAS.”


  • 3. The duration of the curettage and root planing group was 30 min, whereas for surgery the duration was 1.5 h.


Third visit

This visit was planned after 24 h (minimum washout period)

A local anesthetic technique was used during this visit to treat the contralateral side of the selected arch instead of the technique used in the first visit.

All the phases and evaluations were the same as that of the first visit. The examiner noted the scores given by the patients [Figure 3]. Patients in the surgical intervention group underwent surgery after phase-1 therapy had been completed, and the anesthesia administered on the day of surgery was included in the study.

Only nerve blocks were administered

Statistical analysis

The collected data were transferred to IBM SPSS statistics for Windows, version 24.0, Released 2016 (IBM, Armonk, New York) and analyzed using Mann–Whitney U test, and Fisher’s t test and the level of significance at 5%. A value of P < 5% was considered statistically significant and >5% was considered not statistically significant. Intergroup analysis is done by one-way analysis of variance (ANOVA) at a 5% level of significances (degree of freedom 99) and post hoc Scheffé test done for an exact significant difference.

The intragroup analysis was performed by t test at a 5% level of significance


  Results Top


It was carried out on 52 males and 48 females with a mean age of 34.44 × 5.50 years who were periodontally compromised. Detailed demographic data are mentioned in [Table 1].
Table 1: Demographic data

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A total of 630 nerve blocks were administered out of which 258 were administered in the maxillary region and 372 in the mandibular region. The details are given in [Graph 1] and [Graph 2].
Graph 1: Distribution of blocks in the maxilla

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Graph 2: Distribution of blocks in the mandible

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The results of this study are described under the following headings:

  • 1. Assessment and comparison of pain perception in both the techniques.


  • 2. Assessment and comparison of anxiety in both the techniques.


Assessment of pain perception by Wong Baker’s Facial Pain Scale (WBFPS) scores

The WBFPS scores between WAND and conventional local anesthetic technique were highly significant in all the three groups with WAND showing fewer pain scores than the conventional technique (P = .000, .000, and .012) [Table 2][Table 3][Table 4].
Table 2: Intraoperative pain and anxiety scores for root planing

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Table 3: Intraoperative pain and anxiety scores for curettage

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Table 4: Intraoperative pain and anxiety scores for surgery

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Assessment of anxiety by Wong Baker’s Facial Anxiety Scale (WBFAS)

The intraoperative anxiety experienced by patients in all procedures in all the three groups was nonsignificant (P = 0.691, 1, and 0.91) [Table 2][Table 3][Table 4].


  Discussion Top


To create patient’s confidence in the operator, a comfortable anesthesia is imperative. The most effective method of reducing pain is to decrease the speed and pressure of injection, however manual control can be quite overwhelming.[13] Different computerized anesthesia systems have been developed in recent years with the aim of improving this aspect.[14]

Our study was a randomized parallel armed comparative trial whose “objective was to evaluate and compare the pain perception and intraoperative anxiety between WAND and traditional local anesthesia techniques.” Results of this study quantify previous research comparing WAND with traditional techniques in several ways and fill in the gaps in the use of advanced anesthetic techniques in dentists’ everyday routines Local anesthetic blocks were administered in standardized amounts and timeframes based on guidelines for volume and time of delivery.[15] A standardized 26 long gauge needle was used.

Topical anesthetic (that increases the subjective anesthetic effect and reduces anticipatory anxiety associated with dental injections) is Often used to relieve dental injection pain.[16] Hence, was not used in our study. The washout period was also planned in our study. Though the washout period was at least 24 h, all the patients underwent treatment after a gap of 3–4 days in the contralateral quadrant.

“Pain perception was a parameter in this study. We used the Wong-Bakers Facial Pain scale which remains the most trusted, tested, and one of the oldest and reliable techniques to measure pain.”[17] It was found that the WAND technique was significantly less painful than the traditional technique in all the groups (P < 0.05). There are several ways to mitigate pain such as removing the cause, preventing painful impulses from entering the brain, raising the threshold, preventing pain reactions by inhibiting the cortex, and using psychosomatic methods.

Amongst the above mentioned, “blocking the pathway of painful impulses” continues to be the most widely used method in dentistry to control pain which is achieved by local anesthesia.

The use of WAND in our study has given two major advantages over the traditional syringe.

  • 1. An anesthetic solution is continuously delivered as continuous positive solution pressure, eliminating pain while the needle penetrates the tissue. These are the basic principles for how WAND instruments work.


  • 2. Also, it eliminates the visual stimulation that dental syringes present, causing psychological relief of pain and anxiety to the patient.


These have been the key elements for low scores given by the patient. The measurement of anxiety in our study was done intraoperative and was recorded by the WBFAS which is a reliable and valuable scale for anxiety assessment.[18] The standard method to check the anxiety is the Corah Anxiety scale. However, the disadvantage of the original Corah version of the Dental Anxiety Scale and modified anxiety scale[19] is that the patient has to answer a series of questions. This could be very troublesome for the patient intraoperative. Taking this point into consideration, the WBFPS has been used to check anxiety under the name WBFAS. The anxiety scores comparison which was nonsignificant can be attributed to the individual anxiety perception of the patient. Also, the patient’s age could have been a factor with young patients giving more scores than elders leading to nonsignificant scores irrespective of the technique used.

In a study performed by Mittal et al.,[20] “in 82 children Intra-ligamentary local anesthesia was delivered using computerized device and a conventional syringe. Comparison of the pain of needle insertion, injection and heart rate were studied during extraction of teeth. Pain was assessed using the Sound, Eye, Motor (SEM) scale and heart rate recording. Faces Pain Scale-Revised (FPS) scores were self-reported by patients. The Mann-Whitney test was used for evaluation of FPS and SEM scores and the Student’s t-test for evaluation of heart rate readings. Heart rate values during injection were found to be higher, but not statistically significantly higher, for conventional injection versus CCLADS; however, heart rate values during the extraction were significantly higher for the conventional method (P ¼ .009).” They concluded that the computer-controlled technique was more satisfactory than the conventional technique

The findings of our study go in accordance with this study. But this experiment needs to be carried out on a broader population as the patients they studied were young adults only. Hence the results cannot be applied to the elder population. This lacuna has been filled by our study as we concentrated on the adult population with ages ranging from 18 to 54 years.

A study by Gibson et al.[21] was performed on “children aged between 5 to 13 years requiring local anesthesia for restorative treatment only in the maxilla. A palatal approach to the anterior and middle superior alveolar nerves with the WAND injections whereas buccal infiltration and palatal Injections were used for the traditional method. The results showed that WAND gave significantly fewer pain scores.” However, in this study, they have focused only on children. But, in our study focus has remained on periodontally compromised adults.

A randomized split-mouth study was done by Chang et al.[22] “where thirty-one patients who underwent open-flap debridement in the maxillary premolar and molar areas during treatment for chronic periodontitis were administered anesthesia by conventional and computer-controlled techniques and were evaluated for Dental anxiety scale (DAS), perceived stress scale (PSS) and Visual analogue scale (VAS). VAS scores were recorded immediately after LA. DAS and PSS scores were recorded before surgery.” The authors concluded that the VAS score was lower for computer-controlled than for conventional whereas DAS and PSS did not correlate to injection pain. Hence our findings go in agreement with this study.

“A randomized, split-mouth, and a simple blinded clinical trial were carried out by Anna et al.[5] involving a sample of 20 healthy volunteers. Each participant received two palatal injections in the same session (0.3 mL of 3% mepivacaine without vasoconstrictor), using The STA Wand on one side and the Dentapen on the contralateral side (both of which are computer-controlled methods to deliver LA). Immediately after each injection, the patients were asked to rate pain intensity on a horizontal 10-cm numeric rating scale (NRS) ranging from 0 (‘painless’) to 10 (‘worst imaginable pain’). They concluded that both systems (The STA Wand and Dentapen) were equally effective in reducing pain perception when palatal injections were needed.”

“A study was done by Rizzo-Lorenzo et al.,[9] where 68 patients who required upper third molar extraction were into two groups- experimental group where WAND was used and a control group. Each group consisted of 34 patients. Local anesthesia with the Wand consisted of a supraperiosteal infiltrative technique injection of 1.6 mL at the buccal and 0.2 mL at the palatal side was given. Distinct questionnaires for assessing dental anxiety and 100-mm visual analog scales to assess pain were delivered. The authors concluded that the patients who received a detailed explanation of The Wand system previous to an upper third molar extraction did not have a significant reduction of the anxiety degree and perceived pain during the anesthetic act compared to patients that received no information.”

In contrast to our study, there was a statistically significant difference between the two techniques with WAND being less painful. Also, in this study, only supraperiosteal infiltration was used whereas in our study various nerve blocks were used.

WAND and armamentarium costs continue to be a source of worry, particularly in India, making it difficult to employ in routine dentistry practice. At the moment, the dental community has been slow to embrace this technology. Nonetheless, because the blocks provided by WAND resulted in significantly reduced pain, this method can be used in cautious patients. Under the conditions of this study, there was a significant difference between WAND and traditional local anesthetic method for pain sensitivity, thereby contradicting our null hypothesis. For dental injections in the future, most patients preferred using the WAND to a conventional syringe. In addition to lowering pain during injections, for people with low dental anxiety, WAND reduces the visual stimulus of dental syringes. However, further longitudinal studies are required to substantiate the results obtained in the current study with a larger sample size and also with a newer index scale for pain and anxiety.

Conclusion

The following conclusions were made from the data obtained:

  • The pain perception with WAND showed significantly less as compared to the traditional technique in all the procedures.


  • The intraoperative anxiety comparison was nonsignificant.


  • Acknowledgement

    We would like to thank Dr. B. Nandlal (HOD) from the Department of Pediatrics and Preventive Dentistry for his support. We would also like to thank M.C. Sharma for the statistical analysis.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Author’s contribution

    Not applicable.

    Ethical approval and institutional review board statement

    All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was approved and cleared by IEC (Ref no: JSS/ACP/Ethical/2012–2013).

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Date availability statement

    The data used in the study are available on request by contacting the corresponding author (Dr. Deepika Pawar Chandrashekara Rao, e-mail: [email protected]).

     
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        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4]



     

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