Original paper

Comparison of pain perception between computer-controlled local anesthetic

delivery and the conventional syringe for inferior alveolar nerve block in children
Shilpa Shetty1,B,D–F, Shagufta Dalvi1,A,B,D, Farhin Katge1,A,E,F, Devendra Patil1,C, Vamsi Krishna Chimata1,D,F, Ashveeta Shetty2,C
1
Department of Pediatric and Preventive Dentistry, Terna Dental College, Navi Mumbai, India
2
Department of Pediatric and Preventive Dentistry, D.Y. Patil University School Of Dentistry, Navi Mumbai, India

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of the article

Dental and Medical Problems, ISSN 1644-387X (print), ISSN 2300-9020 (online) Dent Med Probl. 2022;59(4):523–529

Address for correspondence

Farhin Katge
Abstract
E-mail: pedotdc@gmail.com Background. Local anesthesia (LA) is commonly used for pain control in clinical dental practice. However,
it is often perceived as the most painful part of the treatment and the factor leading to the avoidance
Funding sources
None declared
of dental care. Hence, research on better means of pain management is being conducted.
Objectives. The aim of the study was to evaluate and compare pain perception using the No Pain III™
Conflict of interest computer-controlled local anesthesia delivery (CCLAD) system and the conventional syringe, for inferior
None declared
alveolar nerve block (IANB) in children.
Acknowledgements Material and methods. Thirty children aged 6–12 years were included in the study. Children were ran-
None declared
domly allocated into 2 groups by the flip of a coin. Group A received LA by conventional syringe and group
B received LA by No Pain III™, on the contralateral side. Physiological parameters including blood pres-
Received on February 7, 2021
Reviewed on April 11, 2021
sure (BP), heart rate (HR) and respiratory rate (RR) were assessed at baseline, during the deposition and
Accepted on April 19, 2021 after the deposition of LA. A subjective evaluation of pain perception was assessed using the Wong–Baker
FACES Pain Rating Scale (WBS). The measured values were subjected to statistical analysis.
Published online on December 8, 2022 Results. A statistically significant difference was observed between group A and group B for pain percep-
tion using the WBS, systolic BP and RR.
Conclusions. The use of the No Pain III™ CCLAD system resulted in reduced pain perception and better
acceptance when compared to the use of the conventional syringe, for IANB in children.
Keywords: children, pain perception, inferior alveolar nerve block, computer-controlled local anesthetic
delivery system, Wong–Baker FACES Pain Rating Scale

Cite as
Shetty S, Dalvi S, Katge F, Patil D, Chimata VK, Shetty A. Comparison
of pain perception between computer-controlled local anesthetic
delivery and the conventional syringe for inferior alveolar
nerve block in children. Dent Med Probl. 2022;59(4):523–529.
doi:10.17219/dmp/135897

DOI
10.17219/dmp/135897

Copyright
Copyright by Author(s)
This is an article distributed under the terms of the
Creative Commons Attribution 3.0 Unported License (CC BY 3.0)
(https://creativecommons.org/licenses/by/3.0/).
524 S. Shetty et al. Pain perception with CCLAD for IANB

Introduction Material and methods

The use of local anesthesia (LA) in dentistry has greatly The present study was carried out in the Department
reduced the pain and discomfort associated with vari- of Pediatric and Preventive Dentistry of Terna Dental
ous dental procedures in children. Local anesthesia is College, Navi Mumbai, India. Ethical clearance was ob-
considered one of the best methods to perform intraoral tained from the institutional Review Board of Ethics
operative and surgical procedures in children. However, at Terna Dental College, Navi Mumbai, India (approval
delivery of LA and needle puncturing of the mucosa are No. TDC/IRB-EC/95/2014).
uncomfortable. Local anesthesia is often perceived by
children as the most painful part of treatment, and in Inclusion and exclusion criteria
some instances as the only painful part, which can lead
to the avoidance of dental care.1 Pain can result from the The inclusion criteria for the study were children aged
mechanical trauma of needle introduction into the site 6–12 years requiring LA by IANB on both sides of the
of injection, or from the sudden distension of the tissues mandibular arch for various dental procedures. Other cri-
due to the rapid discharge of syringe contents. Pain can teria for inclusion in the study were a score of I according
also be caused by the stimulation with the first few drops to the American Society of Anesthesiologists (ASA) Physi-
of the LA solution.2 cal Status Classification System, no previous exposure to
Conventional syringes are commonly used in dentistry, dental anesthesia and a Frankl behavior rating between 3
as their utilization is cost-efficient and less technique- and 4. Exclusion criteria were children requiring unilateral
sensitive. However, while using a conventional syringe, the IANB, patients with a Frankl behavior rating between 1 and
dentist must simultaneously control the movement of the 2, and those who were medically or mentally compromised.
penetrating needle and drug infusion variables. If they are
unable to precisely control both activities, the injection Sample size calculation
technique will be compromised and this can lead to pain-
ful insertion or inadequate deposition.3 Several methods The calculation of sample size was carried out using
have been suggested to overcome conventional techniques G*Power 3 analysis (v. 3.1.92; Heinrich Heine University
of LA administration and to reduce pain caused by the Düsseldorf, Germany). The effect size was 0.5, the α error
administration of LA agents. Computer-controlled local probability was 0.05 and power (1-β error probability) was
anesthesia delivery (CCLAD) systems are one such meth- 0.80. The calculated sample size included 30 children.
od that has been introduced to reduce pain and anxiety A total of 30 children aged 6–12 years who attended the
of dental patients during LA delivery.1 The unit uses a mi- outpatient department were selected for the study. Par-
croprocessor and an electronically controlled motor to ents or guardians accompanying children were briefed
deliver the anesthetic solution. Additionally, it uses a ster- about the procedure in the local language and written in-
ile disposable handpiece that does not look like a syringe, formed consent was obtained.
which greatly reduces fear and anxiety. Furthermore, this
new system eliminates the manual pressure required by Study design
the operator to administer injections by generating a pre-
cisely controlled anesthetic flow rate. The combination The study had a crossover design. The treatment un-
of reduced distension of tissues and controlled flow rate der LA was carried out in 2 subsequent visits with a gap
results in a virtually imperceptible injection.4 of 7 days. The sequence and LA administration method
To assess pain perception during dental anesthesia, vari- were randomly assigned to each child. The randomization
ous objective and subjective parameters have been used.5 was achieved by the flip of a coin to allocate the mode
Objective assessment can be performed by recording phys- of the first local anesthetic delivery system (No Pain III™
iological parameters such as blood pressure (BP), heart rate CCLAD system or conventional syringe) to each subject.
(HR) and respiratory rate (RR) during the administration The children received LA by a single trained operator and
of LA. Subjective pain assessment can be done with the aid on their subsequent visit they received the second local
of non-verbal reporting, which has been used principally in anesthetic delivery system (No Pain III™ CCLAD system
clinical research to measure pain intensity.6 or conventional syringe) on the contralateral side of the
The present study was undertaken to evaluate and same arch (a crossover design).
compare pain perception using the No Pain III™ CCLAD The selected samples were divided into 2 groups.
system and the conventional syringe, for inferior alveolar Group A underwent LA administration by conventional
nerve block (IANB), a technique that is commonly car- syringe and group B had LA administered using the No
ried out during treatment procedures in clinical pediatric Pain III™ CCLAD system. Pre-anesthetic baseline moni-
dentistry. The null hypothesis was that there is no differ- toring of BP, HR and RR was performed using a Contec™
ence in pain perception between the No Pain III™ CCLAD CMS6000 Patient Monitor (Contec Medical Systems Co.
system and the conventional syringe for IANB in children. Ltd., Qinhuangdao, China).
Dent Med Probl. 2022;59(4):523–529 525

All procedures were performed by a single trained

operator. Topical anesthetic gel Precaine® B (Pascal
International, Bellevue, USA) was applied using a cot-
ton pellet at the site of injection. After waiting for 1 min,
IANB was performed. In group A, the conventional sy-
ringe (aspirating syringes; Septodont Healthcare Pvt.
Ltd., Panvel, India)7,8 was used with the LA solution in the
form of cartridge (Lignospan Special consisting of 2% li-
docaine with 1:80,000 epinephrine; Septodont Healthcare
Pvt. Ltd.) and with a 27-gauge needle (0.27 mm × 35 mm,
Septoject™; Septodont Healthcare Pvt. Ltd.) (Fig. 1).
In group B, the No Pain III™ CCLAD system (KMG,
Busan, Korea) was used for LA administration, which
comprised of a disposable component, a handpiece Fig. 3. Topical anesthetic gel Precaine® B, a handpiece component with
component and a computer-controlled unit. The hand- a pen-like handle and plastic microtubing, a Lignospan cartridge, and
piece was an ultra-light pen-like handle that was linked a 27-gauge needle (Septoject™) (from left to right)
to an anesthetic cartridge with plastic microtubing. The
procedure was followed as per the manufacturer’s in- Blood pressure, HR and RR were recorded at baseline,
structions (Fig. 2,3). The delivery of a 1.8-mL single-use during the deposition of LA and after the deposition.
Lignospan anesthetic cartridge was done at slow speed, A subjective evaluation (self-report) of pain perception
regulated by a pedal. during the LA injection was assessed using the Wong–
Baker FACES Pain Rating Scale (WBS). The scale consists
of 6 different facial expressions numbered from 0 to 5 (no
pain to intense pain). Patients were asked to select only
1 face to indicate the degree of pain they felt after the LA
injection.

Statistical analysis
Obtained data was entered into a Microsoft Excel
spreadsheet and subjected to statistical analysis using
SPSS v. 17.0 software (SPSS Inc., Chicago, USA). A paired
t-test was used to evaluate WBS scores between the 2 dif-
ferent groups, after the deposition of LA. Repeated mea-
sures analysis of variance (ANOVA) was used to compare
vital parameters (BP, HR, RR) at baseline, during the de-
Fig. 1. Topical anesthetic gel Precaine® B, a conventional syringe (aspirating position of LA and after the deposition, in both groups.
syringe), a Lignospan cartridge, and a 27-gauge needle (Septoject™) (from
left to right)

Results
The study population consisted of 30 children, 14 boys
and 16 girls. Children were aged between 6 and 12 years,
with a mean age of 9 ±1.8003 years. Because of the cross-
over study design, all 30 children were subjected to IANB
using both the conventional syringe and the No Pain III™
CCLAD system.

Subjective evaluation of pain perception

using the Wong–Baker FACES Pain Rating
Scale
In the evaluation of children’s pain perception using the
WBS Scale, group B showed lower pain scores compared
Fig. 2. Computer-controlled local anesthesia delivery (CCLAD) system to group A. The difference was statistically significant
– No Pain III™ (p < 0.05) (Table 1).
526 S. Shetty et al. Pain perception with CCLAD for IANB

Table 1. Evaluation of pain using the Wong–Baker FACES Pain Rating Scale Heart rate
(WBS)

After deposition of LA Comparison of the mean HR values between group

Groups A and group B is shown in Table 3. No significant differ-
M SD
ences in HR were observed between both groups at vari-
Group A 2.866 1.502
ous time intervals.
Group B 0.467 0.681
p-value 0.002* Respiratory rate
*statistically significant (p ≤ 0.05); LA – local anesthesia; M – mean;
SD – standard deviation. Comparison of RR between both groups indicated that
RR increased during and after the deposition of LA in
group A when compared to group B. The difference was
Assessment of physiological parameters statistically significant (p ≤ 0.05) (Table 4).

Tables 2–4 show intergroup comparisons of physiologi-

cal parameters, including BP, HR and RR at baseline, dur- Discussion
ing the deposition of LA and after the deposition.
Pain is an unpleasant sensation that is often associ-
Blood pressure ated with actual or potential trauma or tissue injury.9
Kaufman et al.10 reported that the injection of the area in
Comparison of BP values indicated that group A had the oral cavity was directly related to pain and perceived
increased systolic BP during the deposition of LA when discomfort. Palatal and IANB injections are more painful
compared to group B. The difference was statistically sig- than local infiltration, mental nerve block or periodon-
nificant (p < 0.05) (Table 2). However, the difference in tal ligament injection.8 However, IANB is the most fre-
diastolic BP was not statistically significant. quently used injection technique for achieving LA during

Table 2. Evaluation of pain using a physiological parameter – blood pressure (BP)

Physiological
Interval Technique n M SD t-test p-value S/NS
parameter

systolic conventional 30 113.900 8.113

0.587 0.560 NS
(baseline) computer-controlled 30 112.530 9.846

diastolic conventional 30 72.667 6.707

0.390 0.690 NS
(baseline) computer-controlled 30 73.433 8.439

systolic conventional 30 129.070 8.586

2.823 0.007* S
(during deposition of LA) computer-controlled 30 122.030 10.600
Blood
pressure conventional 30 86.033 7.876
diastolic
0.843 0.400 NS
(during deposition of LA) computer-controlled 30 84.067 10.070

systolic conventional 30 123.570 7.789

2.331 0.230 NS
(after deposition of LA) computer-controlled 30 118.530 8.896

diastolic conventional 30 79.567 9.518

0.919 0.360 NS
(after deposition of LA) computer-controlled 30 77.433 8.435

*statistically significant (p < 0.05); S/NS – significant/non-significant.

Table 3. Evaluation of pain using a physiological parameter – heart rate (HR)

Physiological parameter Technique M SD p-value S/NS

conventional 104.800 12.707
baseline 0.600 NS
computer-controlled 103.033 13.389
conventional 122.333 17.161
Heart rate during deposition of LA 0.060 NS
computer-controlled 114.200 16.058
conventional 114.900 15.775
after deposition of LA 0.060 NS
computer-controlled 108.066 12.673
Dent Med Probl. 2022;59(4):523–529 527

Table 4. Evaluation of pain using a physiological parameter – respiratory rate (RR)

Physiological parameter Technique M SD p-value S/NS

conventional 27.866 3.559
baseline 0.870 NS
computer-controlled 28.033 4.657
conventional 35.533 4.091
Respiratory rate during deposition of LA 0.000* S
computer-controlled 30.400 3.873
conventional 31.600 3.616
after deposition of LA 0.050* S
computer-controlled 28.551 4.306

*statistically significant (p < 0.05).

mandibular restoration and surgical procedures. There- In addition, pain may cause BP to rise due to the release
fore, the IANB technique was used to compare pain per- of endogenous catecholamine.23
ception between the No Pain III™ CCLAD system and the
conventional syringe. Heart rate
No attempt was made to match the CCLAD and con-
ventional groups by gender, since previous studies in chil- Changes in HR are expected to reflect patient respon-
dren comparing CCLAD and conventional syringes have siveness to procedures, especially during stressful experi-
shown no difference in pain sensation between males and ences. According to Dowling,24 HR increases in response
females.11 to the application of pain. It has been suggested that mean
In the studies by Tahmassebi et al.11 and Gibson et al.12 HR increase during the deposition of LA is due to the fact
each child was assigned to either the CCLAD or the con- that an alarm reaction is initiated by the hypothalamus.
ventional syringe group. The authors reported that the use This results in vasodilatation and causes an increase in
of the CCLAD system resulted in significantly less disrup- the release of endogenous epinephrine and norepineph-
tive behavior when compared to the conventional syringe. rine that subsequently increases HR and cardiac output.25
In the current study, the children served as their own The above findings were in accordance with the study
control, wherein at the first appointment one LA admin- conducted by West et al.26
istration method was used, and the other method was The results of the present study indicate that mean HR
performed on the subsequent visit. This study is in agree- was higher during the deposition of LA by both conven-
ment with those of San Martin-Lopez et al.13 and Langth- tional syringe and No Pain III™. In contrast to our find-
asa et al.14 ings, studies conducted by San Martin-Lopez et al.13 and
Pain perception was evaluated after the deposition Bansal et al.2 showed lower HR using a computer-con-
of LA using the WBS.15 When the 2 methods were com- trolled delivery system compared to conventional meth-
pared using this scale, statistically significant differences ods. These differences may be due to the pen-like design
were observed between group A and group B, indicating of the studies, which was virtually pain-free, more pre-
better patient acceptability towards CCLAD (No Pain dictable and less threatening to the patients.
III™). Since there was a difference in the mean values
between both groups, the null hypothesis was rejected. Respiratory rate
These results are in accordance with studies conducted
by Langthasa et al.14 and Goyal et al.16 In contrast, studies In agreement with the results of the present study, Nich-
conducted by Asarch et al.17 and Koyutürk et al.18 found olson et al.27 and Langthasa et al.14 concluded that the
no difference in the pain rating between the CCLAD and CCLAD system was more acceptable and less anxiety-in-
the conventional syringe. ducing compared to the conventional method. According
to Pashley et al.,28 painful sensation during any needle in-
Assessment of physiological parameters jection comes from administering an anesthetic solution
too rapidly or with too much force. They also stated that
Blood pressure with a conventional syringe, the volume flow and pressure
parameters cannot be precisely controlled, which results in
Akinmoladun et al.19 and Meyer20 hypothesized that difficult, erratic and uncomfortable injections. According
increased HR and alterations in BP during dental proce- to Nusstein et al.,29 CCLAD maintains a constant positive
dures are due to endogenous catecholamine release re- pressure on the flow of anesthetic solution, thereby yield-
sulting from emotional stress, and are not a pharmacolog- ing a virtually pain-free needle insertion. Furthermore, the
ical effect. Meanwhile, Tolas et al.21 and Meechan et al.22 improved tactile feedback, visibility and automated aspi-
considered cardiovascular responses to dental treatment ration achieved with CCLAD allow for concentration on
under LA to be influenced more by the anesthetics. needle positioning and patient interaction.2
528 S. Shetty et al. Pain perception with CCLAD for IANB

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