Topikalno korištenje lokalnog anestetika radi umanjivanja neugodnog osjeta pri ubodu iglom

Kuscu, Ozgur Onder; Sandalli, Nuket; Caglar, Esber; Meechan, John G.

doi:10.15644/asc48/3/3

Topikalno korištenje lokalnog anestetika radi umanjivanja neugodnog osjeta pri ubodu iglom

Ozgur Onder Kuscu ; Zavod za pedodonciju, Stomatološkog fakulteta Sveučilišta Yeditepe, Istanbul, Turska; Privatna praksa, Istanbul, Turska
Nuket Sandalli ; Zavod za pedodonciju, Stomatološkog fakulteta Sveučilišta Yeditepe, Istanbul, Turska
Esber Caglar ; Zavod za pedodonciju, Stomatološkog fakulteta Sveučilišta Yeditepe, Istanbul, Turska; Privatna praksa, Istanbul, Turska
John G. Meechan ; Stomatološki fakultet Sveučilišta Newcastle, Newcastle na Tynei, Velika Britanija

Sažetak
Svrha rada: Željelo se odrediti utječe li topikalna uporaba otopine lokalnog anestetika na neugodnu senzaciju pri ubodu igle u nepce. Metode: Provedeno je nasumično, dvostruko slijepo istraživanje uz sudjelovanje placebo-skupine. Odabrano je 25 zdravih dobrovoljaca koji su bili podvrgnuti dvostrukom ubodu igle tijekom jednog posjeta stomatologu. Mjesto uboda nalazilo se centimetar od marginalne gingive prvih maksilarnih premolara sa svake strane usta. Korištene
su 13-milimetarske igle koje su bile pričvršćene na štrcaljke napunjene 2-postotnim lidokainom s 0,125mg/ml epinefrina ili fiziološkom otopinom. Prije svakog uboda stomatolog je istisnuo kap
otopine na vrh igle te je 20 sekundi prislonio na nepce i vrh igle i kap. Neugodna senzacija ocijenjena je na 100 milimetarskoj vizualnoj ljestvici na kojoj su krajnje vrijednosti označene s bez boli
i nepodnošljiva bol. Rezultati: Pri ubodu nije bilo statistički značajne razlike između dviju otopina na razini neugode (prosječna vrijednost = 26 80 ± 19,36 mm za lidokain i 26 20 ± 18,39 mm za fiziološku otopinu), iako su ispitanici naveli da je drugi ubod bio bolniji od prvoga (prosječna vrijednost = 31,00 ± 19,84 mm za lidokain i 22,00 ± 16,65 mm za fiziološku otopinu). Zaključak: Topikalna primjena otopine lokalnog anestetika nije utjecala na razinu boli nakon uboda iglom u nepce.

▼ Article Information

Copyright statement: All rights reserved. Printed in Croatia. Copyright 2014: University of Zagreb School of Dental Medicine; Croatian Dental Society - Croatian Medical Association. The full text of articles published in this journal can be used free of charge for personal and educational purposes while respecting the copyright of the authors and publishers. For commercial purposes no part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information and retrieval system, without the written permission of the publisher.

Date received: 10 March 2013

Date accepted: 13 May 2014

Publication date (print): September 2014

Volume: 48

Issue: 3

Pages: 193-198

Publisher ID: ASC_48(3)_193-198

DOI: 10.15644/asc48/3/3

Article Information (continued)

Categories:

Subject: Research Article

Key words: :

Key words:

Keyword: diffusion

Keyword: pre-injection

Keyword: local anaesthesia

Keyword: pain

Use of Pre-Injection Diffusion of Local Anaesthetic as a Means of Reducing Needle Penetration Discomfort

Ozgur Onder Kuscu[¹][²]

Nuket Sandalli[¹]

Esber Caglar[¹][²]

John G Meechan[³]

[1] Dept.of Paediatric Dentistry, Dental School, Yeditepe University, Istanbul, Turkey

[2] Private practice, Istanbul, Turkey

[3] School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK

Author notes:

Correspondence to: Correspondence: Assist Prof Dr Ozgur Onder Kuscu Department of Pediatric Dentistry, School of Dentistry, Yeditepe University Bagdat cad 238, Goztepe 34728 Istanbul Turkey Phone: + 90 216 3636044/6432 Fax: +90 216 3636211 Self-phone: +90 532 7690065 ookuscu@yahoo.com

Abstract

Aim

To determine if pre-injection diffusion of local anaesthetic solution influences the discomfort of needle penetration in the palate.

Methods

A placebo-controlled, randomised, double-blind split-mouth investigation was conducted. 25 healthy adult volunteers were recruited and each received two needle penetrations in a random order during one visit. The penetration sites were 1 cm from the gingival margin of the first maxillary premolars on each side of the mouth. 30 gauge-13 mm needles which were attached to syringes that contained either 2% lidocaine with 0.125mg/ml epinephrine or physiological saline were used. For each penetration an operator encouraged a drop of solution to appear at the end of the needle and placed this drop with the bevel of the needle flat on the palate for 20 seconds. The discomfort was noted on a 100 mm visual analogue scale with end points marked “No pain” and “Unbearable pain”.

Results

There was no significant difference in penetration discomfort between solutions, (mean VAS = 26.80±19.36mm for lidocaine and 26.20±18.39mm for saline) however the 2nd penetration was significantly more uncomfortable than the first (mean VAS = 31.00±19.84 mm and 22.00±16.65 mm respectively).

Conclusion

Pre-injection diffusion of local anaesthetic solution did not influence the discomfort of needle penetration in the palate.

Introduction

Anxiety is a barrier to dental attendance (1). The most anxiety-provoking procedure for both children and adults is the local anaesthetic (LA) injection (2-7). However, the most common and efficient method of pain-anxiety control in dentistry is the local anaesthetic injection which also offers patients comfort and co-operation, and also better performance by the practitioner (8-11).

In order to provide optimal dental care it is important to deliver an LA that is pain free and does not give rise to patient anxiety. Previous studies have examined variables that might be involved in painful LA injections and tested possible ways of minimizing the discomfort perceived at the time of injection. Variables included tissue distensibility, speed of injection, age, personality, previous experience and patient characteristics (7, 12, 13). A variety of techniques have been used to overcome injection discomfort, including the use of topical anaesthetic gel, patches, electronic anaesthesia prior to injection (14-16), or electronic computerized devices which offer controlled injection speed regardless of tissue density such as the Wand^®(later rebranded as CompuDent^®, Milestone Scientific, Livingston, NJ, USA (6-9, 17-21). Furthermore, some techniques have been suggested and evaluated to ease the discomfort of intra-oral injections, which have required a prolonged injection time, warmed-up anaesthetic solution (22-24), the possible significance of the needle gauge and the sharpness of the bevel (25-30). None of these techniques by themselves have been able to completely manage the pain connected with injections nor do the papers describing them address the question of the most significant variable(s) and technique(s) in pain perception. However, currently it is reported that following a two-minute topical anaesthetic application, slow and low-pressure injections are the key to pain free and comfortable delivery of local anaesthetic and named as “Pain free local anaesthesia technique”. (31)

Thus, the significant, influential factor(s) in pain perception has not yet been clearly addressed. The present study, aims to determine if the pre-injection diffusion of local anaesthetic solution influences the discomfort of needle penetration in the palate.

Material and Methods

The study protocol was in agreement with the guidelines of the Helsinki Declaration as revised in 1975 and approved by the Ethical Committee of Yeditepe University. Written consent was obtained from all participants after explaining the objectives of the present study.

Participants

Twenty five healthy adult volunteers aged 20 (12 F, 13 M) were recruited and each received two needle penetrations in a random order during one visit. Exclusion criteria included: under 18 years of age, pregnancy, inability to provide written informed consent, allergy to amide local anaesthetic solutions, bleeding disorders and neurological disturbances.

Injection Sites and Injection of LA Solution

A placebo-controlled, randomised, double-blind split-mouth investigation was conducted. A pediatric dentist (OOK: Ozgur Onder Kuscu) gave the injections according to the previously defined injection sites formulated randomly by a computer programme (Table 1). The penetration sites were one centimetre from the gingival margin of the maxillary first premolars on each side of the mouth which is standardized to reach the apex of the tooth (Figure 1). 30 gauge-13 mm needles which were attached to traditional plastic injectors (Hayat Tıbbi Aletler^®, Istanbul, Turkey) that contained either 2% lidocaine with 0.125mg/ml epinephrine (Jetokain^®, I.E.Ulugay, Istanbul, Turkey) or physiological saline were used (Figure 2). For each penetration the same operator who was blinded to the solution in the syringe encouraged a drop of solution to appear at the end of the needle and placed this drop with the bevel of the needle flat on the palate for 20 seconds (Figure 3). In the study method, the contact time of the solution (saline or Lidocaine) can be verified, since we cannot be sure if this 20 seconds of contact time would happen in clinical practice. After that, the needle was gently advanced perpendicularly to the tissue until the bone was contacted (Figure 4).

Table 1 Injection site table used for random allocation of the subjects.

Reg.no	1. Penetration Right buccal	2. Penetration Left buccal
1	Lidocaine	Saline
2	Lidocaine	Saline
3	Saline	Lidocaine
4	Lidocaine	Saline
5	Lidocaine	Saline
6	Lidocaine	Saline
7	Saline	Lidocaine
8	Lidocaine	Saline
9	Saline	Lidocaine
10	Lidocaine	Saline
11	Saline	Lidocaine
12	Saline	Lidocaine
13	Lidocaine	Saline
14	Saline	Lidocaine
15	Lidocaine	Saline
16	Saline	Lidocaine
17	Lidocaine	Saline
18	Saline	Lidocaine
19	Saline	Lidocaine
20	Lidocaine	Saline
21	Saline	Lidocaine
22	Lidocaine	Saline
23	Saline	Lidocaine
24	Saline	Lidocaine
25	Saline	Lidocaine

Figure 1 Each volunteer received two needle penetrations using 30 gauge-13 mm needles in a random order during one visit

Figure 2 The needle and the analgesic solution used

Figure 3 A drop of solution, at the bevel of the needle was positioned flat on the palate for 20 seconds

Figure 4 The route of the needle

Assessment of pain and anxiety

The discomfort of each penetration was noted on a 100 mm visual analogue scale (VAS) with end points marked “No pain” and “Unbearable pain” (Figure 5). At the end of the first and second injection, the subjects were asked to point out the VAS pain score.

Figure 5 Visual Analogue Scale (VAS) used for determining the perceived pain.

Statistical Analysis

The data were processed with the GraphPad Prisma V.3 programme using Paired t test. A p-value less than 0.05 was considered statistically significant.

Results

There was no significant difference in penetration discomfort between the test and control solutions (mean VAS = 26.80±19.36mm for lidocaine and 26.20±18.39mm for saline)(p > 0.05). Regarding penetration comfort, however, the second penetration was significantly more uncomfortable than the first (mean VAS = 22.00±16.65 mm and 31.00±19.84 mm respectively, t = 2.89; p = 0.008) (Table 2).

Table 2 Pain perception and related mean VAS (Visual Analog Scale) pain scores ± S.D.

	Lidocaine	Saline	1. penetration	2. penetration
mean VAS pain scores ± S.D median	26.80±19.36mm 20	26.20±18.39mm 20	22.00±16.65 mm* 10	31.00±19.84 mm* 30

Paired t test * p = 0.008

Discussion

An aspect of dental treatment that produces anxiety in patients is local anaesthesia (32). The delivery of LA injections also produces anxiety among dentists. Simon et al. (33) recorded that 19% of dentists in their study reported that the administration of local anaesthesia caused them distress; 6% considered this problem was serious. Only 2% of the respondents in that study reported no negative reaction to the administration of local anaesthesia.

Today, patient comfort and co-operation, a pain free treatment, and better performance of the dental practitioner can be achieved by proper administration of dental injections. Within this perspective, every practitioner should strive to master delivering relatively painless injections (18) and a new generation of dentists should be educated properly (34). A number of factors may influence injection pain during the administration of dental LA. Controlling pre-injection diffusion of LA as a means of reducing needle penetration discomfort might be helpful in eliminating related confounding factors.

The critical part in dental injections is at the beginning when the target tissue is first punctured by the needle and a few drops of solution are injected slowly, without any pressure; then the analgesia spreads in the tissue which permits a relatively faster injection. A recent study showed that topical anaesthetic reduced the pain of needle insertion if left on the palatal mucosa for 2, 5, or 10 minutes, but had no clinical benefit for the actual anaesthetic injection (35). Recently it was concluded that higher gauge needles such as 27 and 30 are sometimes used in the belief that they cause less discomfort of intraoral needle penetrations (1). Studies carried out on the subject all point to the fact that needle gauge did not affect pain upon insertion (26, 27). In the present study, pre-injection diffusion of LA itself did not affect pain. However, the second application of pre-injection was significantly more uncomfortable than the first.

The present study used the VAS, which is the most commonly used pain-measuring tool. The studies by Revill (36) and McCormack (37) found the VAS to be a reproducible method for measuring pain. Seymour (38), in a clinical trial on postoperative dental pain, found the VAS to be more sensitive than other pain scales and one that could discriminate between small changes in pain intensity. Most of the subjects in the study were comfortable in its use after receiving instructions and did not need any further directions.

The present study is the first study to show that there is no benefit in keeping LA while pre-injecting as a topical anaesthetic to reduce the pain of needle insertion. In conclusion, pre-injection diffusion of local anaesthetic solution did not influence the discomfort of needle penetration in the palate.

Acknowledgements

We would like to thank our volunteers for their contribution.

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Acta stomatologica Croatica, Vol. 48 No. 3, 2014.

Article Information (continued)

Key words:

Use of Pre-Injection Diffusion of Local Anaesthetic as a Means of Reducing Needle Penetration Discomfort

Abstract

Aim

Methods

Results

Conclusion

Introduction

Material and Methods

Participants

Injection Sites and Injection of LA Solution

Assessment of pain and anxiety

Statistical Analysis

Results

Discussion

Acknowledgements

References