|DENTAL SCIENCE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 113-117
Comparative clinical evaluation of transcutaneous electrical nerve stimulator over conventional local anesthesia in children seeking dental procedures: A clinical study
M Varadharaja1, J Udhya2, Ila Srinivasan3, Jambai Sampath Kumar Sivakumar4, Ramasamy Sundararajan Karthik5, M Manivanan6
1 Department of Orthodontics and Dentofacial Orthopedics, C. S. I. College of Dental Sciences and Research, Madurai, Tamil Nadu, India
2 Department of Pedodontics and Preventive Dentistry, C. S. I. College of Dental Sciences and Research, Madurai, Tamil Nadu, India
3 Department of Pedodontics and Preventive Dentistry, M. R. Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India
4 Department of Conservative Dentistry and Endodontics, Vivekanandha Dental College for Women, Tiruchengode, Tamil Nadu, India
5 Department of Oral and Maxillofacial Surgery, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
6 Department of Orthodontics and Dentofacial Orthopedics, SRM Dental College, SRM University, Ramapuram, Chennai, Tamil Nadu, India
|Date of Submission||30-Mar-2014|
|Date of Decision||30-Mar-2014|
|Date of Acceptance||09-Apr-2014|
|Date of Web Publication||25-Jul-2014|
Dr. J Udhya
Department of Pedodontics and Preventive Dentistry, C. S. I. College of Dental Sciences and Research, Madurai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study to evaluate the effectiveness of pain control by employing transcutaneous electrical nerve stimulator (TENS) over conventional injectable local anesthesia for children requiring restorative procedures under rubber dam. Materials and Methods: The study design considered was the split mouth design, in experiment (right) side, dental procedures under rubber dam was performed under TENS and in control (left) side, dental procedures under rubber dam was performed under conventional injectable local anesthetic (LA). The level of comfort and discomfort experienced during TENS and conventional LA was determined using visual analog scale (VAS) and heart rate. Result: Increase in mean heart rate associated with TENS (0.78%) was significantly less compared to increase in heart rate with administration of conventional local anesthesia (11.78%). In VAS, the mean values for pain indicate that minimum pain was felt with TENS, which was closely followed by LA. Conclusion: TENS can offer many safer and psychological advantages and is a valuable alternative to conventional LA for children.
Keywords: Heart rate, local anesthesia, transcutaneous electrical nerve stimulation, visual analog scale
|How to cite this article:|
Varadharaja M, Udhya J, Srinivasan I, Sivakumar JS, Karthik RS, Manivanan M. Comparative clinical evaluation of transcutaneous electrical nerve stimulator over conventional local anesthesia in children seeking dental procedures: A clinical study. J Pharm Bioall Sci 2014;6, Suppl S1:113-7
|How to cite this URL:|
Varadharaja M, Udhya J, Srinivasan I, Sivakumar JS, Karthik RS, Manivanan M. Comparative clinical evaluation of transcutaneous electrical nerve stimulator over conventional local anesthesia in children seeking dental procedures: A clinical study. J Pharm Bioall Sci [serial online] 2014 [cited 2019 Jul 22];6, Suppl S1:113-7. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/113/137407
The most distressing aspect of dentistry for the average dental patient is the fear and anxiety caused by the dental environment, particularly to the dental injection referred to as "needle-phobia" or "blenophobia."  Reducing this fear in children may help to provide overall comfort and well-being during the entire dental experience. Pediatric dentists are constantly searching for tools, which may provide a more comfortable dental procedure.  Electronic dental anesthesia (EDA) is one of the nondrug techniques that is available for the management of pain. Several EDA devices are currently being advertised and used for the control of chronic pain (myofascial pain dysfunction) and acute pain (associated with surgical procedures).  The concept is not new, known also as transcutaneous electronic nerve stimulation (TENS) is the application of electrical stimulation of varying frequency, intensity, and pulse duration to the skin for pain relief. It is noninvasive, safe and a viable mode of pain control during some dental procedures in pediatric dentistry and it appears to be a substantial alternative to the other conventional injectable local anesthetic (LA) technique.  So to provide a feasible alternative in pediatric pain control armamentarium the present study is intended clinically to evaluate the effectiveness of pain control by employing EDA (TENS) over conventional injectable local anesthesia for children requiring restorative procedures under rubber dam.
| Materials and Methods|| |
The apparatus used was TENS [Figure 1]. It has control unit and electrode pad. The control pad consists of two separate galvanic channels. Each channel has individual amplitude control and single frequency control knob. It generates current through 6V battery capable of producing current at amplitude ranging from 1 to 20 mA at the frequency between 2 and 50 Hz and it has a fixed pulse width of 400 μs. The pulse oximeter was used to monitor heart rate of the patient during the experiment.
Prior to starting the treatment under EDA, the procedure was explained to the parents/guardians in local language and an informed written consent was obtained. The ethical clearance for this study was obtained from the Institutional Ethical Clearance Committee before starting the study.
Children aged between 6 and 12 years who were attending the Department of Pedodontics and Preventive Dentistry, M. R. Ambedkar Dental College and Hospital, Bengaluru were considered for the study.
A total 62 subjects (32 males and 30 females) requiring restoration were selected randomly for the study upon fulfilling the following criteria.
- Never exposed to TENS
- Requiring restorative procedures in both lower right and left molars
- Patients who volunteered.
- Immaturity (inability to understand the concept of pain control) such as very young patient, physically and mentally handicapped children
- Medically compromised children such as history of epilepsy, transient ischemic attacks, and status post cerebrovascular accidents.
The study design considered for the study was the split mouth design [Figure 2], in which the same subject served as his/her control.
At the start of the experiment, baseline valves of heart rate were recorded. For standardization, the procedures on the right side was performed under TENS (experimental group) and on the left side was performed under conventional injectable LA technique (control group).
Experimental side (under transcutaneous electrical nerve stimulator)
The site of electrode pad was gently swabbed with surgical spirit to remove any skin oils or substances that may interfere with the flow of current. Electrode gel was applied on the electrode pad before placement. The patient was instructed to open the mouth wide as done during the treatment and then the electrode pad was secured in place using surgical tape to minimize displacement [Figure 3]. The system was switched on, and the investigator controlled the level of electronic anesthesia by gradually raising the amplitude dial until the patient felt a significant sensation. For the patient to acclimatize to the new sensation of electronic anesthesia, this amplitude level was maintained for an initial duration of 20 s. The amplitude is raised to the next level and the cycle was repeated, until the fasciculation was noted on the lower lip in case of mandibular arch. Muscle fasciculation is the sign of reaching the "minimal therapeutic level" at which the procedure can began. The heart rate using a pulse oximeter of the subject was recorded after the stimulation was begun, rubber dam was placed and restorative procedure was carried out. The subject was instructed to indicate the level of comfort or discomfort felt by him/her using a visual analog scale (VAS) [Figure 4].
Control side (under local anesthetic)
On the left side, conventional injectable local anesthesia using 27 gauge needle was administered; heart rate of the subject was recorded. Then, the rubber dam was placed and restorative procedure was carried out [Figure 5]. The subject was instructed to indicate the level of comfort or discomfort on a VAS.
| Result|| |
The values were subjected for the statistical analysis in which Mann-Whitney U test was performed. In VAS, the mean values for pain indicate that minimum pain was felt with TENS, which was closely followed by LA. Though it shows a difference, it is not statistically significant [[Table 1] and Bar diagram 1]. Increase in mean heart rate associated with TENS (0.78%) was significantly less compared to increase in heart rate with administration of conventional local anesthesia (11.78%) [[Table 2] and Bar diagram 2].
|Table 2: Increase in heart rate with respect to TENS and Infiltration (LA)|
Click here to view
| Discussion|| |
The idea of using electricity to reduce pain is not a new concept. The use of electricity in medicine and dentistry has a long and fascinating history, dating back to the year 46 AD when Scribonius Largus claimed to cure headache and arthritis through the application of the electric torpedo fish.  The use of electricity as a means of pain management and as a curative agent flourished well into the nineteenth century in Europe and the United States. Written case reports of pain control through the application of electric current in dentistry exist from the year 1770.  Dentistry has recently seen a rekindling of interest in this area.
Of course, some skepticism about the use, safety, and effectiveness of TENS remains. The currents generated are safe, reliable, and controlled. TENS has passed the scrutiny of the Food and Drug Administration successfully to become a Class II device restricted to use on the prescription of a licensed physician.  Mechanism of action of TENS: It is thought that pain may be alleviated by using peripheral stimulation, such as rubbing, vibration, heat or cold, or as in the case of TENS, electrical stimulation directly over the area of pain. This peripheral stimulation induces electrical activity, which inhibits the brain's perception of pain. The "gate control theory" is based on the principle that there is a gateway in the dorsal horn of the spinal cord, which somehow controls or regulates the flow of pain messages that are then sent to (ascending) and from (descending) higher levels of the brain for central processing, thus reducing the perception of pain. Other postulated mechanisms of the pain relief mediated by TENS include the promotion of endorphin release in the brain and local dilatation of blood vessels in injured tissue. 
The use of TENS as an analgesic in place of LAs during restorative and other dental procedures is supported by several clinical studies. Bishop reported restorative dental procedures were completed at a 93% rate of success in an active TENS group as compared with a 43% rate of success in an inactive TENS (sham) group.  In addition, TENS has been shown to reduce pain during orthodontic movement of teeth. 
The advantages of EDA are:
- Elimination of pain and fear of dental injection, a noninvasive procedure
- Elimination of inconvenience of postoperative anesthesia, unaffected speech
- Elimination of adverse reactions of injectable LAs
- Elimination of the possibility of infection at the injection site and residual analgesic effect for several hours.
In this study, we used a design of split mouth technique. In which the same subject served as his/her own control. This design was used to reduce response variability inherent in studies using separate treatment and control groups. One potential problem with this type of design is the possibility that there was continued analgesia after termination of the stimulation. However, we believe residual analgesia was not a problem in this study because high frequency stimulation administered at low intensity requires over 10 min of stimulation before a long duration analgesic effect is seen.  In this study, electrical stimulation was terminated 8 min after it was began.
Autonomic changes occur in response to painful stimuli; heart rate increases in response to the application of cold - pressor pain.  Increase in mean heart rate associated with TENS was significantly less compared to increase in heart rate with administration of conventional local anesthesia. In the current study, the increase in tooth pain threshold and the decrease in stress - associated tachycardia with respect to TENS suggest that electrical stimulation may be useful as an analgesic during dental procedures (such as placement of rubber dam for restorations).
However, it is inadequate, for oral surgical procedures  the results of VAS are inconsistent with the heart rate result. The inconsistent may reflect the lack of sensitivity to detect changes in comfort produced. Thus, future studies are required to evaluate the reliability, sensitivity, and validity of any VAS used with pediatric patients.
| Conclusion|| |
This study provides valuable information concerning the analgesic properties of peripheral electrical stimulation under highly controlled conditions. This study should help establish a useful baseline for future clinical studies of the efficacy of electrical stimulation during dental procedures.
| References|| |
|1.||Corah NL, O'Shea RM, Ayer WA. Dentists' management of patients' fear and anxiety. J Am Dent Assoc 1985;110:734-6. |
|2.||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. |
|3.||Erickson CJ. Pain measurement in children: Problems and directions. J Dev Behav Pediatr 1990;11:135-7. |
|4.||Croll TP, Simonsen RJ. Dental electronic anesthesia for children: Technique and report of 45 cases. ASDC J Dent Child 1994;61:97-104. |
|5.||Largus S. De compositone medicamentorum liber. Simon Silvius fur chr. Wechel, 1528. |
|6.||Erb W. Handbook of Electrotherapeutics. New York: W. Wood and Co. 1883. |
|7.||Katch EM. Application of transcutaneous electrical nerve stimulation in dentistry. Anesth Prog 1986;33:156-60. |
|8.||Köke AJ, Schouten JS, Lamerichs-Geelen MJ, Lipsch JS, Waltje EM, van Kleef M, et al. Pain reducing effect of three types of transcutaneous electrical nerve stimulation in patients with chronic pain: A randomized crossover trial. Pain 2004;108:36-42. |
|9.||Bishop TS. High frequency neural modulation in dentistry. J Am Dent Assoc 1986;112:176-7. |
|10.||Roth PM, Thrash WJ. Effect of transcutaneous electrical nerve stimulation for controlling pain associated with orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1986;90:132-8. |
|11.||Eriksson MB, Sjölund BH, Nielzén S. Long term results of peripheral conditioning stimulation as an analgesic measure in chronic pain. Pain 1979;6:335-47. |
|12.||Dowling J. Autonomic indices and reactive pain reports on the McGill Pain Questionnaire. Pain 1982;14:387-92. |
|13.||Hansson P, Ekblom A. Afferent stimulation induced pain relief in acute oro-facial pain and its failure to induce sufficient pain reduction in dental and oral surgery. Pain 1984;20:273-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]