Pain behaviour and distress in children during two sequential dental visits: comparing a computerised anaesthesia delivery system and a traditional syringe

IN BRIEF • No clear difference was found for the RESEARCH Pain behaviour and distress in children during two sequential dental visits: comparing a com puterised anaesthesia delivery system and a traditional syringe self-reported pain and distress reaction of children between an injection with the Wand® or the traditional technique. • It is of great importance to the dentist to know the level of dental anxiety of the patient since this seems to be of greater influence on children’s reaction than the injection technique. • The Wand technique does not seem to benefit dentally highly anxious children. J. Versloot,1 J. S. J. Veerkamp2 and J. Hoogstraten3 Objective To compare the pain and distress response of children receiving a local anesthesia injection using a computerised device (Wand®) or a traditional syringe over two consecutive treatment sessions and to study whether the response to the two injection techniques was different for high or low dentally anxious children. Design Randomised controlled trial. Setting Secondary dental care practice specialised in treating children. Subjects and Methods Children were selected and randomly allocated to the Wand® or traditional injection condition. Parents completed the Dental Subscale of the Children’s Fear Survey Schedule (CFSS-ds). Based on video recordings of the injections, for each 15 seconds, the occurrence of five pain related behaviours was registered and a score was given on the Venham distress scale. Children rated their pain after each injection. Intervention Over two consecutive treatment sessions one group received two local anaesthesia injections with the tradi tional syringe and the other group received two injections with the Wand®. Outcome measures The mean number of pain related behaviours, the mean distress scores and the self-reported pain scores were compared. Based on the CFSS-ds subjects were split into highly and low dentally anxious children. Results One hundred and forty-seven subjects participated in the study: aged 4-11 years, 71 girls. Based on the behaviour displayed during the local anaesthesia injection and the self-reported pain after the injection, no difference could be found between an injection with the traditional syringe or the Wand® over the first or second treatment session. However, on the first treatment session, highly anxious children reported more pain (p = 0.001), displayed more pain related behaviour (p = 0.002) and more distress (p <0.001) than low anxious children in reac tion to the local anaesthesia injection. Conclusion No clear difference in the response of referred children could be found between an injection with the Wand® or the traditional syringe. Level of dental anxiety was found to be an important factor in the response of children to a local anaesthesia injection. INTRODUCTION Dental caries is a common problem in young children. Often, more than one tooth is affected and several treatment sessions are needed. Although use of anaesthetics can lead to a relatively painless dental procedure, the delivery of local anaesthetic solutions and the needle puncturing the mucosa is known 1* University of British Columbia, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, Canada; 2,3Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit, the Netherlands and 3 University of Amsterdam, Department of Psychological Methods, the Netherlands *Correspondence to: Dr Judith Versloot Email: Online article number E2 Refereed Paper - Accepted 14 November 2007 DOI: 10.1038/sj.bdj.2008.414 © British Dental Journal 2008; 205: E2 to be uncomfortable. Besides pain and discomfort, the prospect of an injection can also provoke anxiety, particularly in children. Research shows that about 14% of Dutch children between 4-11 years are dentally anxious and the strongest fears are associated with injections.1,2 One of the systems developed to minimise pain and discomfort during local anaesthe sia injection is the Wand® system. The Wand® device is a computer-automated injection system that provides a pre cise injection flow-rate, regardless of tissue resistance.4 In previous studies with children, divergent results are found with the Wand®. Some showed lower pain ratings for injections with the Wand® in compar ison with injections with the traditional syringe5,6 and another study 7 reported lower pain ratings upon anaesthetic solution depositing using the Wand® system but similar pain ratings for nee dle insertion. In addition, there are also studies reporting no difference between the two injection methods, the Wand® system and the traditional syringe.8 In our earlier study we found that low anxious children showed less pain related behaviour when injected with the Wand® compared with the tradi tional syringe.10 No research has been done so far to study the effect of the Wand® on the pain behaviour of chil dren over sequential treatment sessions. Therefore, to study if the positive effect of the Wand® on low anxious children persists over treatment sessions, the aim of the present study is to compare the pain and distress response of children receiving a local anaesthesia injection using a computerised device (Wand® ) BRITISH DENTAL JOURNAL 1 © 2008 Macmillan Publishers Limited. All rights reserved. RESEARCH with the response of children receiving an injection using a traditional syringe over two sequential treatment sessions. Furthermore, it was studied whether the response to the two injection tech niques was related to the child’s dental anxiety level. MATERIAL AND METHODS Subjects A total of 152 children were asked to par ticipate, however, three children could not be included in the study because their parents did not give permission to videotape the treatment session and two children because the parents did not have sufficient knowledge of the Dutch language to fill out the question naire. Therefore, this study was con ducted among 147 children. Children were selected as a convenience sam ple ie all children that came for treat ment during the study period and who met the selection criteria were selected. Selection criteria included: need for two subsequent treatment sessions requir ing local anaesthesia, age between 4-11 years and no suspected or known devel opmental delay. All patients were treated by two paediatric dentists in a special ised dental care clinic. For 20 children only their first treatment session could be included due to rescheduling of the second appointment (Fig. 1). Ethical approval was obtained from the University Ethics Committee and the Interuniversity Dentistry Research School (IOT) at the Academic Centre of Dentistry Amsterdam. Written parental consent was obtained by the researchers before every individual treatment. The authors have no connection with the manufacturers of the Wand®. Methods Each child was randomly assigned to either the Wand® (n = 71) or the tradi tional injecti (...truncated)