Microsoft Word - 449 2023.docx Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Effect of Vocal Anesthesia on Adult Dental Patients during Covid-19 pandemic period Mudher MB. Alsunbuli1, Marwa A. A3yia2, Amer Hassan3, Hasanain Faisal Ghazi4 1BDS, FIBMS, Oral and Maxillofacial Surgery Department, College of Dentistry. Al-Bayan University. Baghdad, Iraq 2BDS, FIBMS, Oral and Maxillofacial Surgery Unit, Al-Yarmouk Teaching Hospital, Baghdad, Iraq 3MBCHB, CABS, College of Dentistry, Al-Bayan University, Baghdad, Iraq 4MBCHB, PhD (public health), College of Nursing, Al-Bayan University, Baghdad, Iraq Abstract BACKGROUND: Pain is as a major concern with dental pa5ents. The den5st-pa5ent interac5on can reveal the presence of anxiety and fear, which may result in rise of pain. This study aimed to assess vocabulary communica5on as support to dental anesthesia on the adult dental pa5ent. MATERIALS AND METHODS: This is a prospec5ve, randomized clinical study, conducted from February 2020 through March 2021. Two hundred individuals (112 males, 88 females) of the age range (16 to 84 years) were separated into two groups for tes5ng the level of pain during dental local anesthesia, with vocal communica5on and without vocal communica5on. RESULTS: While the control group showed no difference between males and females, there was a difference between the sexes in the experimental group with past dental visits, VAS and injec5on type having less anxiety (p=0.0001) while with educa5on/VAS having (p£0.01) as appear in sex to age (p£0.05). There was no difference when data were compared by age, or type of anesthesia (inferior alveolar nerve block or infiltra5on technique). CONCLUSION: Dental anxiety can be alleviated by talking to the pa5ents before the procedure, which could reduce the amount of pain. KEYWORDS: Anesthesia; Local; Dental Anxiety; Vocabulary; Communica5on Cita9on: Alsunbuli, MMB et al. (2023) Effect of Vocal Anesthesia on Adult Dental Pa9ents during Covid-19 pandemic period Den9stry 3000. 1:a001 doi:10.5195/d3000.2023.449 Received: February 18, 2023 Accepted: February 19, 2023 Published: March 31, 2023 Copyright: ©2023 Alsunbuli, MMB et al. This is an open access ar9cle licensed under a Crea9ve Commons AVribu9on Work 4.0 United States License. Email: dr.mudhar@albayan.edu.iq Introduction Most dental procedures require pain control [1]. Pain in its traditional sense can be considered as an indicator or alarm for potential tissue damage. Pain response varies based on psychological state, social stratum, age, and other factors. Hence, one can say that pain loses some efficiency, and no longer is a reliable indicator of tissue damage [2]. The site of the dental needle injection, the thickness of the tissue to be pierced by a dental needle, and the degree of tissue adherent to deeper structures are strongly related to the patient’s pain sensitivity and anxiety [3]. The interaction between the dentist and the patient can reveal the presence of anxiety and fear [4]. It is not uncommon that dental injection is used as intimidation for children [5]. Patients with generalized anxiety disorder exposed to changing in talk used as treatment ended with significantly different levels of response according to the severity of the case [19]. To demonstrate that vocal anesthesia can improve analgesia in dental procedures this study aimed to assess vocabulary Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu communication as support to dental anesthesia on adult dental patients. Material and Methods This is a prospective, single-blinded, randomized observational prognostic controlled clinical study. The study was conducted through the Covid-19 pandemic, from February 2020 through March 2021, at Al-Bayan university, college of dentistry, in Bagdad, Iraq. Approval by the local ethics committee according to the Declaration of Helsinki guidelines was obtained. Two hundred (112 males, 88 females) of the age range (16 to 84 years) participated in the study. All participants had a Covid-19 infection and recovered from the disease. The individuals were separated into two groups for testing the level of pain due to dental local anesthesia. Written consent was obtained from patients, explaining that information asked was only for research purposes. The treatment modality (with vocal communication vs. without vocal communication) was decided by tossing a coin, where 'face' was the experimental side and 'back' for control. The study was performed using the ''single injection method'' to remove acquiescence bias. This is where only one injection of local anesthesia was performed on the patient after a vocabulary communication with the patient to explain the pain pattern before injection (study group, N=94), and direct injection of local anesthetic agent to patient without any verbal communication (control group, N=106). Patients were numbered from 1 to 200. Excluded patients from the study were the ones that had uncontrolled systemic diseases or a clinically significant medical history, or if they regularly used analgesic medications or anti- inflammatory medication in the last 24 hours prior the day of the experiment. We also excluded pregnant women or women breast- feeding. Tobacco smokers using ten or more cigarettes per day were also excluded. All areas that were injected were free from infection, inflammation, and the patient did not seek emergency treatment because of pain. All patients were injected with 2% lidocaine with 1:80000 adrenalin dental local anesthetic solution through dental needle gauge 27. Six different dentists were operating in this study with different days and times through the day and different degrees of experience from general practitioners, orthodontists, prosthodontists, and oral surgeons. IBM SPSS Statistics V.26 statistical analysis software program was used to evaluate the experiment through t test using p-value ≤0.05 as statistically significant for rejection of the null hypothesis. Every patient experience was recorded using a questionnaire. Pain was assessed by a 10 mm visual analog scale (VAS) with the two ends assigned as no pain and worst pain ever. When the pain was present, the patient was asked to select a category from 1 to 10. Then, the score was recorded in the case sheet used in this study (Appendix 1). Appendix 1. Study instrument. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Pain sensitivity differences between sexes was assessed. Patient age was tested for compliance to dental work and dental-injection despite anxiety. Type of injection was recorded. Infiltration of almost all the maxillary teeth and some of the mandibular injections or block anesthesia mainly for the inferior alveolar nerve block were used for treating the study participants. Past dental procedures and patient regular visits to the dentist were recorded as null, little, frequent, and usual. Frequency of dental visits was recorded as first-time the patient seeking a dental office, once in a year, once a month, and if he the patient went to the dentist on a monthly basis or even less. Education level, procedures, and marital status were also recorded. Results Table 1 summarizes the 200 study participants. Table 2 describes the distribution of the sex of the participants by ethnicity. Differences were found when age was compared to the sex of the participants. Samples were tested according to age and VAS score, as well as the distribution of samples according to age and marital status and VAS score, appeared statistically significant (P≤0.05) (Tables 2, 3 and 5). Several differences were detected when looking at the distribution of the sample by sex and VAS score, education and VAS score, past dental office visits and VAS score. Other comparisons included distribution of the sample by injection of anesthesia type and VAS, which appeared to be statistically significant different (Tables 4, 6, 7, 8 and 9). Variable N Chi-square (p-value) Male 112 2.88 (0.09) Female 88 Young Adults 41 51.6 (0.0001) Middle Age 114 Elderly 45 Single 116 5.12 (0.02) Married 84 Low 15 71.06 (0.0001) Mid 111 High 74 Null 4 186.72 (0.0001) Little 130 Frequent 44 Usual 22 IADB 67 21.78 (0.0001) Infiltration 133 Control 106 0.49 (0.48) Experiment 94 No Pain 22 95.4 (0.0001) Mild 61 Moderate 79 Severe 37 Worst Pain 1 Table 1. Distribution of variables in the sample studied. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Age Group 15-25 26-35 36-45 46-55 56-65 66-75 76-85 Totals M (no.) 23 10 17 20 16 12 14 112 F (no.) 18 12 17 10 12 12 7 88 Total 41 22 34 30 28 24 21 200 Chi-Square -χ2 (P- value) 5.29 * (0.05) * (P≤0.05). Age 15-25 26-35 36-45 46-55 56-65 66-75 76-85 Totals VAS E C E C E C E C E C E C E C E C Never 6 0 4 0 4 0 4 0 2 0 1 0 1 0 22 0 Mild 11 0 7 0 7 0 10 1 10 1 8 0 6 0 59 2 Moderate 2 13 2 6 3 12 1 9 1 6 2 9 2 11 13 66 Sever 0 8 0 3 0 8 0 5 0 8 0 4 0 2 0 38 Worst 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Total 20 22 13 9 14 20 15 13 13 15 11 13 8 12 95 106 Percent % 21.1 20. 7 13. 7 8.5 14. 7 18. 9 15. 8 12. 3 13. 7 14. 2 11. 6 12. 3 8. 4 11.3 100% Chi-Square -χ2 (P-value) 6.38* (0.02) --- * (P≤0.05). Sex Male Female Totals VAS E C E C E C Table 2. Distribution of sample according to age and sex. Table 3. Distribution of sample according to age and VAS/E&C. Table 4. Distribution of sample according to sex and VAS/E&C. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Never 4 0 18 0 12 0 Mild 22 2 37 0 59 2 Moderate 1 53 12 13 13 66 Sever 0 30 0 7 0 37 Worst 0 0 0 1 0 1 Total 27 85 67 21 94 106 Percent % Chi-Square -χ2 (P-value) 34.69 ** (0.0001) --- Marital status Single Married Totals VAS E C E C E C Never 8 0 14 0 12 0 Mild 39 0 20 0 59 0 Moderate 6 38 7 22 13 60 Sever 0 24 0 21 0 45 Worst 0 1 0 0 0 1 Total 53 63 41 43 94 106 Percent % 56.38% 59.43% 43.72% 40.57 % 100% Chi-Square -χ2 (P-value) 5.87* (0.0277) --- Table 5. Distribution of sample according to marital status and VAS/E&C. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Education Pre-school Primary- high school university Higher Totals VAS E C E C E C E C E C Never 2 0 13 0 6 0 1 0 22 0 Mild 2 0 30 0 21 2 6 0 59 0 Moderate 1 7 8 38 4 18 0 3 13 66 Sever 0 3 0 21 0 9 0 4 37 0 Worst 0 0 0 1 0 0 0 0 0 1 Total 5 10 51 60 31 29 7 7 94 106 Chi-Square -χ2 (P-value) 35.02 (p=0.0001). --- (P≤0.01). Past Dental. Procedures Null little frequent Usual Totals VAS E C E C E C E C E C Never 0 0 14 7 0 1 0 22 0 Mild 1 34 1 16 1 8 0 59 2 Moderate 0 2 8 46 4 10 1 8 13 66 Sever 0 0 0 27 0 6 0 4 0 37 Worst 0 1 0 0 0 0 0 0 0 1 Total 1 3 56 74 27 17 10 12 94 106 Table 6. Distribution of sample according to Education/VAS/E&C. Table 7. Distribution of sample according to past dental visits. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Percent % 1.06% 2.83% 59.57% 69.81% 28.72% 16.04% 10.64% 11.32% 100% Chi-Square -χ2 (P-value) 39.205 ** (0.0001) --- VAS Group Never Mild Moderate Sever Worst Totals Control 0 2 66 37 1 106 Experiment 22 59 13 0 0 94 Total 22 61 79 37 1 200 Chi-Square -χ2 (P-value) 95.400 ** (0.0001) --- IANB Infiltration Totals (mean) VAS E C E C E C Never 7 0 15 0 22 0 Mild 16 1 44 0 60 1 Moderate 2 24 11 34 13 58 Sever 0 16 0 29 0 45 Worst 0 1 0 0 0 1 Total 25 42 70 63 95 105 Chi-Square -χ2 (P-value) 23.483 ** (0.0001) --- Discussion Age, sex, and the surroundings are just a few of the many factors that might have an impact on how people experience pain [20]. The results of the current study showed that injection with the aid of vocabulary anesthesia caused statistically less pain in comparison with the conventional method in males and females. In comparison to men, women reported more pain and had Table 8. Distribution of sample according to VAS/E&C. Table 9. Distribution of sample according to injection type/VAS/E&C. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu a lower pain threshold. This difference was not seen for the other variables. The mechanism underlying this disparity may be due to that neuro-perception processes of pain and pain inhibition correlates with sex differences (20,23). Although needle phobia is a common phobic condition and over 20% of adults aged 20–40 years old have fear of needles [24,25]. Age differences in pain perception were less consistent in our study and the results were insignificant. Some studies implied that pain sensitivity is higher in older adults, whereas others suggest a decrease in sensitivity with age [26]. Pain is commonly under recognized and undertreated in older adults compared to younger adults [27]. There was a significant difference in the experience of pain between the single and married patients who received vocal anesthesia and the effect of marital status on pain. There is a report describing the relation of marriage and chronic pain (29), which stated that marital status was not associated with immediate pain- related unpleasantness. In contrast to a previous study from the United States [30], which stated that adults with higher levels of education generally report less pain our results were did not show differences. Kaufman et al. [31] reported that the inferior alveolar nerve block was more painful than local infiltration or another dental nerve block. However, differences in our study results were insignificant. Another study [32, 33] also found no difference between injection techniques. Previous dental experience likely prepares patients for pain associated with injections [33]. The majority of patients in this study had previous dental procedures and hence injections. Pain perception during the past dental injection is associated with anxiety for the next injections. This result is consistent with other studies that reported the presence of an association between the amount of pain felt during injection and the progressive level of anxiety for injection within subsequent dental visits [34-36]. Conclusion Dental anxiety and phobia can be alleviated by simply talking to the patients before the procedure. which could reduce the amount of pain felt by the patient. The dentist should take the time needed to communicate with the patient before the dental procedure. even before explaining the procedure needed for treatment, to reduce anxiety before interventions requires the identification of their fears and any social conflict or previous bad experiences. All successful treatment will rest on dentist-patient acceptance, and thus a relaxed patient will result in a less stressful environment for the dental team and lastly treatment outcomes. References 1. Pain, anxiety, and quality of life related to the oral health of patients treated in a dental emergency clinic. Queiroz MF, Verli FD, Marinho SA, Paiva PCP, Santos SMC, Soares JA. Cien Saude Colet. 2019;24(4):1277- 86. 2. Evolution, emotions, and emotional disorders. Am Psychol.Nesse RM, Ellsworth PC. 2009;64(2):129-39. 3. Pain perception and dental anxiety during periodontal probing in patients visiting community oral health programme: a cross sectional study. Singh A, Shrestha A, Bhagat T. BMC Oral Health. 2021;21(1):82. 4. Dental fear in children: the role of previous negative dental experiences. Mendoza-Mendoza A, Perea MB, Yanez-Vico RM, Iglesias-Linares A. Clin Oral Investig. 2015;19(3):745-51. 5. What sensitivities matter in dental anxiety? Investigating sensitivity to anxiety, pain, and disgust. Witcraft SM, Wickenhauser ME, Maack DJ, Dixon LJ. Psychol Health Med. 2021;26(3):313-21. 6. Pain and anxiety management for pediatric dental procedures using various combinations of sedative drugs: A review. Gazal G, Fareed WM, Zafar MS, Al- Samadani KH. Saudi Pharm J. 2016;24(4):379-85. 7. Use of Virtual Reality for the Management of Anxiety and Pain in Dental Treatments: Systematic Review and Meta- Analysis. Lopez-Valverde N, Muriel Fernandez J, Lopez- Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu Valverde A, Valero Juan LF, Ramirez JM, Flores Fraile J, et al. J Clin Med. 2020;9(4). 8. Effects of Pretreatment Exposure to Dental Practice Using a Smartphone Dental Simulation Game on Children's Pain and Anxiety: A Preliminary Double-Blind Randomized Clinical Trial. Meshki R, Basir L, Alidadi F, Behbudi A, Rakhshan V. J Dent (Tehran). 2018;15(4):250-8. 9. Comparative evaluation of virtual reality distraction and counter-stimulation on dental anxiety and pain perception in children. Nunna M, Dasaraju RK, Kamatham R, Mallineni SK, Nuvvula S. J Dent Anesth Pain Med. 2019;19(5):277-88. 10. Association between Anxiety and Pain in Dental Treatment: A Systematic Review and Meta- analysis. Lin CS, Wu SY, Yi CA. J Dent Res. 2017;96(2):153-62. 11. Associations between dental anxiety and postoperative pain following extraction of horizontally impacted wisdom teeth: A prospective observational study Wang TF, Wu YT, Tseng CF, Chou C. Medicine (Baltimore). 2017;96(47):e8665. 12. Does preoperative dental anxiety play a role in postoperative pain perception after third molar surgery?. Onwuka CI, Udeabor SE, Al- Hunaif AM, Al-Shehri WAK, Al- Sahman LA. Ann Afr Med. 2020;19(4):269-73. 13. State anxiety and depression as factors modulating and influencing postoperative pain in dental implant surgery. A prospective clinical survey. Gomez-de Diego R, Cutando- Soriano A, Montero-Martin J, Prados-Frutos JC, Lopez- Valverde A. Med Oral Patol Oral Cir Bucal. 2014;19(6):e592-7. 14. Assessment of the impact of stress and anxiety on pain perception in patients undergoing surgery for placement of their first dental implant. Pani SC, AlGarni B, AlZain LM, AlQahtani NS. Oral Health Dent Manag. 2014;13(2):464-8. 15. Association between dental anxiety and intraoperative pain during root canal treatment: a cross-sectional study. Murillo- Benitez M, Martin-Gonzalez J, Jimenez-Sanchez MC, Cabanillas- Balsera D, Velasco-Ortega E, Segura-Egea JJ. Int Endod J. 2020;53(4):447-54. 16. The prevalence of dental anxiety and its association with pain and other variables among adult patients with irreversible pulpitis. Dou L, Vanschaayk MM, Zhang Y, Fu X, Ji P, Yang D. BMC Oral Health. 2018;18(1):101. 17. Atraumatic restorative treatment in relation to pain, discomfort and dental treatment anxiety. Frencken JE, Flohil KA, de Baat C. . Ned Tijdschr Tandheelkd. 2014;121(7-8):388- 93. 18. Comparative study of minimally invasive technique and traditional decaying method for dental caries and the impact of dental treatment on pain and anxiety during pregnancy. Tang H, Huang Q. Shanghai Kou Qiang Yi Xue. 2019;28(3):297-300. 19. Change talk and sustain talk in treatment of generalized anxiety disorder: A secondary analysis of cognitive behavioral therapy and metacognitive therapy in adult outpatients. Isak Joramo, Stian Solem, Bendik Romundstad, Hans M. Nordahl. Journal of Behavior Therapy and Experimental Psychiatry. 2021:72, 101650. ISSN 0005- 7916, 20. The perception of pain in others: how gender, race, and age influence pain expectations. Wandner LD, Scipio CD, Hirsh AT, Torres CA, Robinson ME. J Pain. 2012;13(3):220-7. 21. Pain management during needle insertion with low level laser. Ghaderi F, Ghaderi R, Davarmanesh M, Bayani M, Arabzade Moghadam S. Eur J Paediatr Dent. 2016;17(2):151-4. 22. Pain and anxiety reduction using a manual stimulation distraction device when administering local analgesia oro-dental injections: a multi-center clinical investigation. Touyz LZ, Lamontagne P, Smith BE. J Clin Dent. 2004;15(3):88-92. 23. Sex differences in pain and analgesia: the role of gonadal hormones. Craft RM, Mogil JS, Aloisi AM. Eur J Pain. 2004;8(5):397-411. 24. The fear of needles: A systematic review and meta- analysis. McLenon J, Rogers MAM. Journal of advanced nursing. 2019;75(1):30-42. 25. Author Correction: Comparison between the analgesic effectiveness and patients' preference for virtual reality vs. topical anesthesia gel during the administration of local anesthesia in adult dental patients: a randomized clinical study. Almugait M, AbuMostafa A. Scientific reports. 2022;12(1):805. 26. Age effects on pain thresholds, temporal summation and spatial summation of heat and pressure pain. Lautenbacher S, Kunz M, Strate P, Nielsen J, Arendt- Nielsen L. Pain. J. 2005;115(3):410-8. Effect of Vocal Anesthesia on Adult Dental Pa5ents during Covid-19 pandemic period Vol 11 No 1 (2023) DOI 10.5195/d3000.2023.449 h#p://den*stry3000.pi#.edu 27. Pain assessment and management in persons with dementia. Horgas AL, Elliott AF. Nurs Clin North Am. 2004;39(3):593-606. 28. An emotional component analysis of chronic pain. Wade JB, Price DD, Hamer RM, Schwartz SM, Hart RP. Pain. J. 1990;40(3):303-10. 29. The Relationship between Marital Status and Psychological Resilience in Chronic Pain Wade JB, Hart RP, Wade JH, Bajaj JS, Price DD.. Pain Res Treat. 2013;2013:928473. 30. The Relationship Between Education and Pain Among Adults Aged 30-49 in the United States. Zajacova A, Rogers RG, Grodsky E, Grol-Prokopczyk H. J Pain. 2020;21(11-12):1270-80. 31. A survey of pain, pressure, and discomfort induced by commonly used oral local anesthesia injections. Kaufman E, Epstein JB, Naveh E, Gorsky M, Gross A, Cohen G. Anesth Prog. 2005;52(4):122-7. 32. Patient's pain perception during mandibular molar extraction with articaine: a comparison study between infiltration and inferior alveolar nerve block. Bataineh AB, Alwarafi MA. Clin Oral Investig. 2016;20(8):2241- 50. 33. Articaine infiltration for anesthesia of mandibular first molars. Corbett IP, Kanaa MD, Whitworth JM, Meechan JG. Journal of endodontics. 2008;34(5):5148. 34. A randomised, double-blind, placebo-controlled, comparative study of topical skin analgesics and the anxiety and discomfort associated with venous cannulation. Speirs AF, Taylor KH, Joanes DN, Girdler NM. Br Dent J. 2001;190(8):444-9. 35. Highly anxious dental patients report more pain during dental injections. van Wijk AJ, Makkes PC. Br Dent J. 2008;205(3):E7; discussion 142-3. 36. Strategies to manage patients with dental anxiety and dental phobia: literature review. Appukuttan DP. Clin Cosmet Investig Dent. 2016;8:35-50.