|Year : 2012 | Volume
| Issue : 4 | Page : 323-328
Comparison of the pain perception in children using comfort control syringe and a conventional injection technique during pediatric dental procedures
M Langthasa, R Yeluri, AA Jain, AK Munshi
Department of Pedodontics and Preventive Dentistry, K.D. Dental College and Hospital, Mathura, Uttar Pradesh, India
|Date of Web Publication||19-Mar-2013|
Department of Pedodontics and Preventive Dentistry, K.D. Dental College and Hospital, Mathura - New Delhi N.H #2, Mathura - 281 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To evaluate and compare the pain perception by the pediatric patients, while experiencing computerized injection device comfort control syringe (CCS) and the conventional injection technique during dental clinical procedures. Materials and Methods: Fifty children (31 boys and 19 girls) aged 6-14 years requiring local anaesthesia on both sides of the dental arch for various treatment procedures were selected for this study. The patients served as their own control, and on the appointed day CCS was used on one side of the dental arch and on the subsequent appointment, i.e., the very next day conventional injection technique was used. Visual analogue scale (VAS) and faces pain rating scale (FRS) were used to assess the child's pain perception to each of the techniques immediately after the injection. Various physiological parameters were measured before, during and after the two injection procedures and compared for statistical variation. Results : Paired t-test revealed a statistically significant difference in the pain perception by children using VAS and FRS between computerized and conventional technique. No statistically significant difference was observed when physiological parameters (heart rate, blood pressure and temperature) were compared at various intervals between the computerized and the conventional technique. Conclusion: Computerized injection device (CCS) provides less painful injections when compared to the conventional injection technique.
Keywords: Comfort control syringe, injection technique, local anesthesia, pain perception
|How to cite this article:|
Langthasa M, Yeluri R, Jain A A, Munshi A K. Comparison of the pain perception in children using comfort control syringe and a conventional injection technique during pediatric dental procedures. J Indian Soc Pedod Prev Dent 2012;30:323-8
|How to cite this URL:|
Langthasa M, Yeluri R, Jain A A, Munshi A K. Comparison of the pain perception in children using comfort control syringe and a conventional injection technique during pediatric dental procedures. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2020 Nov 24];30:323-8. Available from: https://www.jisppd.com/text.asp?2012/30/4/323/108931
| Introduction|| |
Since the introduction of local anesthetics, the injection technique has produced pain and anxiety in the patients.  There seems to be no excuse for not using local anesthesia. Computer controlled local anesthetic delivery system  allows local anesthetic solution to be administered comfortably to the patient in virtually all areas of the oral cavity using computer technology. Hence, this study was undertaken to evaluate and compare the pain perception using Midwest ® comfort control syringe (CCS)™ and the traditional injection technique during commonly carried out treatment procedures in clinical pediatric dentistry.
| Materials and Methods|| |
The present study was carried out in the Department of Pedodontics and Preventive Dentistry. Ethical committee clearance was obtained before the beginning of this study and a detailed informed written consent form was signed by each patient's parents or guardian, who willingly participated in this study.
Fifty children (31 boys and 19 girls) who visited the clinic of the Department of Pedodontics and Preventive Dentistry were selected randomly on the basis of convenience sampling. 
Children between 6 years and 14 years of age requiring local anaesthesia on both sides of the dental arch for various dental treatment procedures, who were co-operative and mentally capable of communicating and satisfying the criteria of the American Association of Anaesthesiologists.  Group-I classification were included in this study.
- Patients having significant behavioral management problems.
- Children suffering from any systemic disease.
- Children having previous negative dental experience; and
- Medically and mentally compromised children were excluded from the study.
| Methodology|| |
CCS™ (Midwest-Densply-Canada) [Figure 1] is an electronic pre-programmed computerized local anesthetic injection device. The CCS comprises a main control unit, a syringe-and-needle hand-piece, ultra tubing connecting the control unit to the syringe-and-needle hand piece. The CCS has five pre-programmed speeds for different injection techniques and can be used for all types of injections [Figure 2]. The injection speed of the device could be adjusted to two levels: Fast or slow. The hand piece has three buttons (a) start or stop button (b) aspirate button and (c) double button [Figure 3]. With the touch of a button, it can start and stop the injection procedure, control aspiration, and can double the flow rate. The base unit has three digital readouts that provide the feedback during the injection procedure. The display shows the rate of injection, time elapsed during the injection, and the cumulative volume injected. The anesthetic cartridge (Lignospan special - Septodent - France) consisting of 2% Lidocaine with 1:80,000 adrenaline loaded into the cartridge sheath and then the sheath is inserted into the hand piece. A standard dental needle of 30 gauge  (0.30 mm × 25 mm) was selected and screwed into the cartridge [Figure 4].
|Figure 1: Midwest "comfort control syringe" showing the base unit and the anaesthetic cartridge loaded in the handpiece|
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|Figure 2: Diagramatic representation of the control unit of comfort control syringe showing the five pre-programmed speeds for different injection techniques|
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All the children were explained about the technique of the administration of the local anesthesia, visual analogue scale (VAS) and faces rating scale prior to the injection procedure. The "tell show do" technique was used for behavior modification for all the children. The local anesthesia was administered using CCS™ on one side of the dental arch on the appointed day and on the subsequent appointment, i.e., the very next day the traditional syringe was used on the other side of the dental arch. The solution for the conventional injection technique also consisted of 2% Lidocaine with 1:80,000 adrenaline (Lignox 2%-Warren-Navi Mumbai, India). Local anesthesia was administered with 24 gauge needle (0.24 mm × 25 mm) (Rilshot-Ribbel International Lt-India).
Injection by the computerized device
During the first appointment, the local anesthesia was administered using computerized device on one side of the arch. Prior to the procedure the heart rate and blood pressure were measured using pulse oximeter (Planet 50-Larsen and Turbo Limited-Mysore, India) and temperature was recorded using digital thermometer (N and B Medical Product Co-India). For the CCS the procedure was followed as specified by the manufacturer. Pre-programmed injection type was selected on the control unit and during the administration of local anesthesia; the heart rate and blood pressure were also recorded. Immediately after the injection the child's pain perception was assessed by the VAS and faces pain rating scale (FRS). After assessing the pain by self-report measures, the heart rate, blood pressure and the temperature were finally recorded.
Injection by the conventional syringe
On the subsequent appointment, i.e., the very next day, the traditional syringe was used on the opposite side of the dental arch. The heart rate and blood pressure and the temperature were recorded prior to the administration of local anesthesia. Local anesthesia was delivered using conventional syringe and during administration the heart rate and blood pressure of the child were recorded. Immediately after the injection the child's pain perception was assessed by the VAS and FRS. After assessing the pain by self-report measures, the heart rate, blood pressure and the temperature were finally recorded.
The data thus obtained was subjected to statistical analysis using statistical package for social sciences version (SPSS) 16.0 for Windows. Paired t-test was used to compare the variables such as VAS, FRS, heart rate (before, during and after the procedure), blood pressure (before, during and after the procedure) and temperature (before and after the procedure) between computerized and the conventional technique.
| Results|| |
Fifty children, 31 boys and 19 girls (mean age, 10.02 years + 2.55 years), were subjected to both computerized and the conventional injection technique. On comparison, statistically significant difference (P < 0.05) in the pain perception by VAS was found between computerized and conventional injection technique [Table 1]. Likewise, pain perception evaluated by FRS also showed statistically significant difference (P < 0.05) between the computerized and the conventional injection technique [Table 2].
|Table 1: Comparison between the computerized and conventional "visual analogue scale" score in the study subjects|
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|Table 2: Comparison between the computerized and conventional "faces pain rating scale" score in the study subjects|
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[Table 3], [Table 4] and [Table 5] show the comparison of the mean heart rate, blood pressure and temperature between the computerized and the conventional technique respectively. No significant differences in the physiological parameters were observed between the computerized and conventional technique at various time intervals.
|Table 3: Comparison of the mean heart rate before, during and after computerized and conventional techniques|
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|Table 4: Comparison of the mean blood pressure (systolic and diastolic) before, during and after computerized and the conventional techniques|
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|Table 5: Comparison of the mean temperature before and after computerized and the conventional techniques|
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| Discussion|| |
The observations in this study suggest that the computerized system of anesthetic injection resulted in significantly less pain perception when compared with the same children who experienced a traditional injection by the conventional syringe also. Indirect reporting can introduce bias into the studies on pain. Non-verbal reporting such as VAS has been tested in clinical research principally to measure the pain intensity. .. This technique uses the images that represent specific feeling and take the form of faces, numbers, colors, cups containing different volume of liquid, thermometers etc., FRS  /Wong - Baker pain rating scale was in clinical use mainly in pediatrics since 1984. The face rating scale consists of six drawings with different expressions ranging from a child smiling to a child crying. In the present study both the VAS and FRS were used to measure the perception of pain. Some patients recognize that the face of the faces pain scale represents sadness rather than pain. Therefore, it has been recommended by some researchers to select at least two different scales in daily clinical practice. 
While analyzing the overall VAS score and FRS scores, it was observed that the children who were exposed to the traditional method of injection reported significant pain perception. Asarch and Beiraghi  and Koyuturk  found no difference in the pain rating between the Wand and the conventional injection technique. Their studies were carried out on two different groups, one group receiving computerized syringe and another group receiving conventional syringe, while in the present study, all the children served as their own control. In the studies by Gibson et al.,  and Tahmassebi et al.,  each child was assigned to either computerized or conventional technique and they found that Wand produced significantly less disruptive behavior when compared to conventional technique. However, in the present study the child served as their own control as on the first appointed day, computerized syringe was used and on the subsequent appointment, conventional syringe was used. This study is in agreement with Lopez et al.,  where the children also served as their own control and the computerized injection (Wand) device reduced the pain perception as compared to the traditional syringe.
A study by Tahmassebi et al.,  showed no significant difference in the anxiety change between the males and females. While, in the present study no statistical difference was found between the males of computerized and conventional injection techniques, however, there was a marked difference between the females of the computerized and conventional injection techniques (Data not shown). Gender differences in dental fear have been of increasing interest among the clinicians and researchers. In a study by Heft et al.,  the authors assessed the gender differences in reports of global dental fear, global fear of dental pain, and specific fear of dental pain. The study found that women were more likely to report global dental fear, global fear of dental pain, and specific fear of dental pain than men, and both women and men were more likely to report 'dread' of dental pain than 'fear' of the dental pain."
Many studies has been conducted to achieve a painless injection such as the use of topical anesthesia, , warming anesthetic solution to body temperature  or increasing the injection time, , intra-osseous injection systems,  electronic dental anesthesia,  Eutectic mixture of local anesthesia  and Needleless jet injection system  have all been offered for clinical use in pediatric dental practice. The analysis of the various physiological parameters in this study like the heart rate, blood pressure and temperature showed no statistically significant differences between the computerized and conventional injection techniques. The present study is not in agreement with the results of Lopez et al.,  where a difference was noted in the heart rate between the computerized and conventional techniques.
In 2001, the CCS (Dentsply International, York, PA, USA) was marketed as an alternative to the Wand.  The CCS differs from Wand in that there is no foot pedal. The benefit of using "CCS" is that it has five pre-programmed speeds for different injection techniques and can be used for all injections. CCS delivers anesthetic agent at a constant pressure and controlled volume, regardless of the resistance in the tissue. Slow injection can be regulated more precisely by the computerized system than the conventional syringe. The injection is guaranteed to be slow and steady and therefore a comfortable device. Other benefits of CCS is pen like grasp of the hand piece which enables the operator to maintain a more gentle and controlled manipulation of the needle. Thus minimal force is required during the administration. In the computer controlled syringe, slow rate of anesthesia delivery dose appears to reliably reduce the pain related disruptive behavior in young children. The disadvantages of CCS is that it is not economical than the traditional syringe and requires more injection time than the traditional injection; the longer duration may cause impatience and stress among the children and also its bulkier look may cause disruptive behavior among the pediatric patients. However, during the present study no such disruptive behavior was encountered and the children reported being satisfied with the CCS technique. Therefore, the CCS seemed as an effective alternative to the traditional syringe. Grace et al.,  noted that the computer controlled dental anesthetic injections and the traditional anesthetic injections were accepted equally well by both the dentists and the patients. However, to the best of our knowledge no study was carried out on the children with CCS device and using physiological parameters like blood pressure and temperature.
| Conclusions|| |
The conclusions drawn from this study are:
- CCS provides less painful injections when compared to the conventional injection technique in the pediatric patients.
- VAS and FRS were well accepted by children and can be used for assessing pain perception in them.
- Various physiological parameters like heart rate, blood pressure and temperature of the study population were not significantly altered during the computerized anesthetic delivery system as well as the conventional injection technique; and
- Further studies are needed to determine the role of these physiological parameters in the assessment of pain and anxiety in the pediatric patients during the injection procedures.
| References|| |
|1.||Asarch T, Allen K, Petersen B, Beiraghi S. Efficacy of a computerized local anesthesia device in pediatric dentistry. Pediatr Dent 1999;21:421-4. |
|2.||In: Proceedings of the 1 st Annual Computer-Controlled Local Anesthetic Delivery (C-CLAD) System meeting. Introductory remarks. New Orleans, La., Feb; 2008. |
|3.||Kothari CR. Sampling Design. In: Research Methodology: Methods and Techniques. 2 nd Revised ed. New Delhi: New Age International (P) Ltd., Publishers; 2008. p. 55-68. |
|4.||Aronson WL, McAuliffe MS, Miller K. Variability in the American Society of Anesthesiologists Physical Status Classification Scale. Am Assoc Nurse Anesth J 2003;71:265-74. |
|5.||Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: Development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990;41:139-50. |
|6.||Hunter M, McDowell L, Hennessy R, Cassey J. An evaluation of the Faces Pain Scale with young children. J Pain Symptom Manage 2000;20:122-9. |
|7.||Malamed SF, Gagnon S, Leblanc D. A comparison between articaine HCl and lidocaine HCl in pediatric dental patients. Pediatr Dent 2000;22:307-11. |
|8.||Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwarts P. Face Scale. In: Wong's Essentials of Pediatric Nursing. 6 th ed. St. Louis: Mosby; 2001. p. 1301. |
|9.||Benaim C, Froger J, Cazottes C, Gueben D, Porte M, Desnuelle C, et al. Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain 2007;128:52-8. |
|10.||Koyuturk AE, Avsar A, Sumer M. Efficacy of dental practitioners in injection techniques: Computerized device and traditional syringe. Quintessence Int 2009;40:73-7. |
|11.||Gibson RS, Allen K, Hutfless S, Beiraghi S. The Wand vs. traditional injection: A comparison of pain related behaviors. Pediatr Dent 2000;22:458-62. |
|12.||Tahmassebi JF, Nikolaou M, Duggal MS. A comparison of pain and anxiety associated with the administration of maxillary local analgesia with Wand and conventional technique. Eur Arch Paediatr Dent 2009;10:77-82. |
|13.||San Martin-Lopez AL, Garrigos-Esparza LD, Torre-Delgadillo G, Gordillo-Moscoso A, Hernandez-Sierra JF, de Pozos-Guillen AJ. Clinical comparison of pain perception rates between computerized local anesthesia and conventional syringe in pediatric patients. J Clin Pediatr Dent 2005;29:239-43. |
|14.||Heft MW, Meng X, Bradley MM, Lang PJ. Gender differences in reported dental fear and fear of dental pain. Community Dent Oral Epidemiol 2007;35:421-8. |
|15.||Gill CJ, Orr DL. A double-blind crossover comparison of topical anesthetics. J Am Dent Assoc 1979;98:213-4. |
|16.||Kreider KA, Stratmann RG, Milano M, Agostini FG, Munsell M. Reducing children's injection pain: Lidocaine patches versus topical benzocaine gel. Pediatr Dent 2001;23:19-23. |
|17.||Bainbridge LC. Comparison of room temperature and body temperature local anaesthetic solutions. Br J Plast Surg 1991;44:147-8. |
|18.||Maragakis GM, Musselman RJ. The time used to administer local anesthesia to 5 and 6 year olds. J Clin Pediatr Dent 1996;20:321-3. |
|19.||Jones CM, Heidmann J, Gerrish AC. Children's ratings of dental injection and treatment pain, and the influence of the time taken to administer the injection. Int J Paediatr Dent 1995;5:81-5. |
|20.||Sixou JL, Barbosa-Rogier ME. Efficacy of intraosseous injections of anesthetic in children and adolescents. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:173-8. |
|21.||Munshi AK, Hegde AM, Girdhar D. Clinical evaluation of electronic dental anesthesia for various procedures in pediatric dentistry. J Clin Pediatr Dent 2000;24:199-204. |
|22.||Munshi AK, Hegde AM, Latha R. Use of EMLA: Is it an injection free alternative? J Clin Pediatr Dent 2001;25:215-9. |
|23.||Munshi AK, Hegde A, Bashir N. Clinical evaluation of the efficacy of anesthesia and patient preference using the needle-less jet syringe in pediatric dental practice. J Clin Pediatr Dent 2001;25:131-6. |
|24.||Clark TM, Yagiela JA. Advanced techniques and armamentarium for dental local anesthesia. Dent Clin North Am 2010;54:757-68. |
|25.||Grace EG, Barnes DM, Reid BC, Flores M, George DL. Computerized local dental anesthetic systems: Patient and dentist satisfaction. J Dent 2003;31:9-12. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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