Comparative Assessment of Perceived Pain in Children During Palatal Anesthesia Using Two Injection Techniques: An In Vivo Study.

Background: Computer-controlled local anesthetic delivery (CCLAD) is an approach that uses a constant and slow flow of delivering the anesthetic solution into the tissues, which is capable of alleviating pain and discomfort in children. Aim: Assessment of perceived pain in children during palatal anesthesia using Wand technique and conventional technique. Materials and
Methods: A total of 30 children requiring bilateral palatal anesthesia were included in the study in a split-half design. The children were asked to indicate their intensity of pain response on a visual analog scale (VAS) after administration of anesthesia by the Wand technique and the conventional technique. Statistical Analysis: The data were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0. Mann-Whitney U test compared the mean VAS scores between the two groups. Statistical significance was defined as a P value of less than 0.05.
Results: The mean VAS scores using the Wand technique and the conventional technique were 3.87 ± 1.99 and 4.20 ± 1.44, respectively (P = 0.332). Females had lesser VAS scores compared to males (P = 0.008).
Conclusion: Females readily accepted the Wand technique compared to males, although there was no substantial difference between the two injection procedures. Copyright:

INTRODUCTION

One of the main factors for successful dental treatment in pediatric patients is adequate local anesthesia to reduce pain during painful dental treatment procedures. The use of a local anesthetic (LA) may trigger fear and anxiety, which can lead to enhanced pain perception.[1] This can cause disruptive behaviors, noncompliance, and resistance, leading to the emergence of negative attitude toward dental treatments and the loss of valuable time for the clinician as well. Therefore, it is imperative to explore newer approaches that are capable of alleviating pain and discomfort in children. Some of the newer advances in the field of LA are computer-controlled LA delivery (CCLAD), vibrotactile systems,[2] intraosseous anesthesia, jet injectors, topical LA patches, Eutectic mixture of local anesthetics (EMLA) creams, intranasal sprays, and so on.[3] In order to reduce the pressure exerted by the LA solution on the dental tissues, the CCLAD uses a slow constant flow of solution into the tissues. Such control in the volume, pressure, and flow of anesthetic solution is difficult to achieve with the conventional technique.[1]

Numerous studies have been conducted comparing the CCLAD technique with the conventional technique, recommending its use[4567891011] or revealing no difference between the two techniques.[121314151617] Khatri et al.[18] suggested that both visual analog scale (VAS) and Wong–Baker faces pain rating scale (WBFPS) were suitable tools for gauging pain among children aged 3–14 years in the Indian population. However, few studies have been done in India using the Wand technique in pediatric age group.[7911151920] Further research is needed regarding the sensation of pain during palatal injection and periodontal ligament (PDL) injection.[12] Hence, this study was planned to assess the perceived pain in children during palatal anesthesia using two injection techniques.

MATERIALS AND METHODS

This study was conducted among children aged 6–9 years old attending the pediatric outpatient department of M. G. V.'s K. B. H. Dental College and Hospital, Nashik. The Institutional Ethical Committee provided ethical approval (MGV/KBHDC/pedo/187/2o14-15). A total of 30 healthy children requiring bilateral palatal anesthesia for pulpectomy or extraction treatment, with no previous dental treatment history were included in the study. Children who were medically compromised and uncooperative were not included in the study. Prior to the procedure, informed consent was obtained from the children's parents.

It was decided to employ a split-mouth design, in which both types of injections were given to all the participants. As a result, each child functioned as his or her own control, undergoing two types of anesthesia: conventional and CCLAD performed with the Wand technique, at 1-week interval. All the children were subdivided into two groups randomly. One group received the Wand technique of LA on the first appointment and the conventional technique on the second appointment. The other group received the conventional technique on the first appointment and the Wand technique on the second appointment. The children were blinded to the technique used. Following the administration of LA, pain ratings were measured on a 10-point VAS as shown in Figure 1. A single operator was trained and calibrated to perform the treatment procedures to reduce intraexaminer variability (Kappa statistic = 0.82). No topical LA was used.

Figure 1

Visual analog scale showing the scores ranging from 0 to 10 VAS = visual analog scale

In the conventional technique, a metal syringe (Septoject-Solif 3; Rue Jean-Jacques Rousseau BP 282-81207, Mazamet Cedex, France) with cartridge was used for buccal and palatal infiltration. Wand™ (Milestone Scientific, Inc., Livingston, NJ, USA) is a computer-controlled device that consists of a disposable pen-like handpiece. The procedure was carried out according to the manufacturer's instructions. All injections were made using a 30-gauge, 25-mm needle and 1.8 ml of single-use anesthetic cartridge (Lignospan; Septodont, France) containing 2% lignocaine hydrochloride solution with a 1:80,000 dilution of adrenaline. About 0.9 and 0.4 ml of the solution was used for buccal and palatal infiltration, respectively. The operator explained VAS to the children and immediately after administration of the LA, the children were asked to make a mark on a 10-cm-long horizontal line that corresponded to the intensity of pain he/she had experienced, with the scores ranging from “no pain” to “worst possible pain” from left to right on a 10-point scale. After completion of VAS scoring, the appropriate dental procedures were performed under rubber dam isolation of the selected tooth and the parents and their children were asked to report after 1 week. Losses to follow-up were not present. Mean difference of VAS scores between the two techniques was tested using the Mann–Whitney U test. Statistical Package for the Social Sciences (SPSS) 16.0 was used for statistical analysis, with a significance level of 0.05.

RESULTS

The study consisted of 30 children of the age group 6–9 years, among whom 16 (53.3%) were boys and 14 (46.7%) were girls. The mean age of the participants was 7.47 ± 1.16 years. The mean VAS score was 3.87 ± 1.99 in the Wand group and 4.2 ± 1.44 in the conventional group and it was not statistically significant (P = 0.332). Females had lower VAS scores with the Wand technique than when the conventional technique was used, and the difference was statistically significant (P = 0.008). Between the two approaches, there was no statistically significant difference in males (P = 0.163) [Table 1].

Table 1

Mean VAS scores using the Wand and conventional techniques among males and females

Wand technique		Conventional technique		P
Mean	SD	Mean	SD
Male	5.12	1.75	4.25	1.12	0.163
Female	2.43	1.09	4.14	1.8	0.008*
Overall mean score	3.87	1.99	4.20	1.44	0.332

SD=standard deviation, VAS=visual analog scale. *Significant difference

In the Wand technique, females showed lower VAS scores compared to males (P < 0.05). But no such difference was found in the conventional technique between males and females (P = 0.86). Older age groups showed lower VAS scores compared to younger children in both the treatment groups [Table 2].

Table 2

Mean VAS scores based on age using the Wand and conventional techniques

Age in years	Mean (SD)		P
	Wand technique	Conventional technique
6	5.50 (1.19)	5.50 (1.19)	0.05
7	3.0 (0.75)	4.5 (1.60)	0.026*
8	4.67 (3.14)	4.67 (1.03)	0.743
9	2.5 (0.92)	3.50 (1.77)	0.223
P	0.007*	0.388

SD=Standard deviation, VAS=Visual analog scale. *Significant difference

DISCUSSION

A successful dental treatment in children depends on not just the quality of care provided, but also the creation of a positive attitude toward dentistry. CCLAD is one such method for reducing pain endured during administration of the LA. In the present study and in a study by Chavhan et al.,[15] no significant difference was noted among males (P = 0.163), but females showed statistically significant difference (P = 0.008) between the two techniques. Females found the Wand technique to be less painful compared to the conventional technique. This is in contrast to a study done by Tahmassebi et al.[14] and Ram and Peretz,[12] who found no difference between males and females in the two groups. Similarly, no difference was reported between girls and boys in the modified behavioral pain scale ratings.[8] The difference seen in the present study might be because female patients tend to be more sensitive toward pain. Among the children aged 6–9 years, there was no difference in mean VAS scores. However, there was a significant difference among 12-year-old children.[15] This may be because older children tend to differentiate better between pain and pressure sensations. Younger children may have mistaken the pressure sensation as that of pain sensation. Allen et al.[5] found that using the Wand technique led to fewer disruptive behaviors (25%) in preschool children, when compared to a traditional buccal (75%) and palatal (80%) injection regimen. Mittal et al.[7] reported that patients experienced significantly lesser pain of injection with the Wand method during palatal infiltration, whereas there was no difference during buccal infiltration. This implicates that palatal injections, which are often painful, can be administered using the Wand technique to gain cooperation from children during treatment.

As per Ram and Kassirer,[8] children showed better behavior with the Wand technique compared to conventional buccal infiltration. Other studies reported no difference in perceived pain or anxiety between the Wand and conventional injection techniques.[1213141516] Over the first and second treatment sessions, Versloot et al.[17] found no difference between the two methods, although highly anxious children reported more pain, displayed more pain-related behavior, and showed more distress than the less-anxious children during the first treatment session.

In the control group, the onset of LA took 6.3 min, but in the Wand group, it took 7.25 min. According to Kandiah and Tahmassebi[16] and Palm et al.,[21] there was no measurable difference in the time of onset of LA and pain experience between the two groups. Queiroz et al.[22] measured salivary cortisol levels before and after each injection and anxiety was evaluated using an anxiety questionnaire. They found that both the techniques produced similar levels of stress/anxiety in pediatric patients (P > 0.05). In a study by Ksucu and Akyuz,[23] when dental injectors (Wand, Citoject, metal injector [MI], and plastic injector [PI]) were placed on a tray and shown to the kids, they preferred the Wand (56%), followed by the PI (29%), Citoject (12%), and the MI (3%). This may be due to the universal appearance of the Wand. There seems to be varying results with regard to the usage of Wand technique. In the present study, children were not evenly distributed among all age groups and confounding factors such as presence/absence of parent during treatment were not considered, so the outcome of the results may vary. Further studies are required with a larger sample.

CONCLUSION

In pediatric patients, the Wand computerized delivery method showed no difference in pain perception from the traditional LA technique. However, females showed lower pain perception with the Wand technique compared to males. More research on a broader scale is needed to support and emphasize these findings in order to incorporate the Wand system into ordinary dental practice, which could be beneficial in the care of patients who are difficult to treat.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.