Effectiveness of Electronic Dental Anesthesia for Restorative Care In

Home , Dental anesthesia

Effectivenessof electronic dental anesthesia for restorativecare in children Shiu-yinCho, BDS, FRACDS Bernadette K. Drummond, BDS,MS, PhD, FRACDS MichaelH. Anderson,BSc, MBChB, DipObs, Dip AV Med, Dip IH, MRNZCGPSheila Williams BSc(Hons)

Abstract mission. The gate control theory states that activity Theeffectiveness of electronic dental anesthesia(EDA) generated by myelinated primary afferent fibers (the A fibers) inhibits the transmission of activity in the for pain control duringrestorative procedureswas compared with local anestheticinjection (LA) in 32 children aged small unmyelinatedprimary afferent fibers (the C fibers),6 acting via inhibitory circuits in the dorsal horn. to 12years. Eachchild selected had two antimereprimary In addition to activating local inhibitory circuits, one or permanentmolars requiring similar-sized Class I or Class II restorations.The pain levels duringrestorative treatment possible explanation for the effectiveness of TENSis that the electrical stimulationcauses release of pituitary wereassessed using a visual analoguescale. Heartrates and and hypothalamic opioid peptides into the systemic behaviorwere also recorded.A crossoverdesign was used with circulation or into the cerebrospinal fluid. 7 Another eachchild actingas his/her owncontrol. Theresults showed theory is that serotonin, dopamine,and nor-adrenalin, that overall, EDAwas less effective thanLA for cavity prepa- which may have roles in the effects of electrically ration. Thereported pain scores for EDAwere higher in per- produced analgesia, are produced.8 Drugs affecting manentteeth for the deepercavities, and with one of the these neurotransmitters have been shown to alter operators.The pre- or post-treatmentanxiety scores were not analgesia produced by stimulation or opioids. The foundto differ significantly betweenthe two restorativeap- exact mechanismof TENSremains unknownand may pointments.However, children with the highestpretreatment be a combinationof one or moreof the theories. Woolf scoreswere more likely to reporthigherpain scores with EDA. and Thompson6 believe that the most likely mecha- Despite this, 63%of the children preferred EDAto LA. nismis the activation of segmentalinhibitory circuits Dentalanxiety, cavity depth, the tooth beingtreated, and in the spinal cord supplementedby descendinginhibi- operatorattitude mayalso be importantfactors in determin- tory pathways. ing the success of EDA.(Pediatr Dent20:2 105-111, 1998) Effectivenessofelectronic anesthesia indentistry ain control is an important part of pediatric TENSdevices have been used to control the pain dentistry. Althoughmost children can cope with of trigeminal neuralgia or atypical facial pain, and to p local anesthetic injections, a few children are relieve* musclespasms in myofascialpain dysfunction. Resultsof clinical studies are limited and extremelyvar- needle-phobic, and giving them an injection presents x’ a challenge to the dentist. For other children, the ied. 2 In the mid-1980s,several devices weredeveloped paresthesia which may linger for hours after the for dentistry. These were TENSunits modified for 9 completion of the dental procedure is more intraoral use. Malamedet al. used the term electronic objectionable than the injection. In the past decade, dental anesthesia (EDA)when referring to the appli- there has been renewedinterest in the applications of cation of TENSto dentistry. In their study, they electronic pain control in dentistry and several elec- reported a success rate of morethan 80%for shallow tronic dental anesthesia machinesare currently being and moderatelydeep restorations. The success rate for advertised and used. deep restorations was 60%. The EDAdevice is a modified TENSunit which uses lower currents and Mechanismofaction of transcutaneous higher frequencies. electricalnerve stimulation Onereported indication for EDAis for needle-pho- In 1967, Shealy4’ 5 first introducedthe use of trans- bic children even thoughonly a few studies have tested cutaneous electrical nerve stimulation (TENS)to help its effectiveness in children. In a double-blindstudy of control chronic pain. The explanation of the mecha- the effect of EDAin 30 children using electric pulp testing and rubber dam clamp application as the nism by which TENSproduces anesthesia is based on 1° several theories describing mechanismsof pain trans- stimuli, Abdulhameedet al. found a significant rise

Pediatric Dentistry-20.’2, 1998 AmericanAcademy of Pediatric Dentistry 105 in the pain threshold when EDAwas used. The sub- Dunedin, NewZealand. After obtaining approval from jective pain scores of the children and the assessment the Southern Regional Health Authority Ethics Com- of the children’s pain levels by the investigator werenot mittee, 32 healthy children aged 6-12 years who had significantly different from measurements when an two primary or permanentantimere molars with simi- inactive machinewas used. Harveyand Elliot ~ evalu- larly sized carious lesions wereselected. Theteeth had ated pain perception in 20 children during Class I no recorded history of trauma or pulpitis. Informed amalgampreparations on permanent mandibular first written consent wasgiven by the parents and the chil- molars. They reported a significant decrease in pain dren were invited to take part and give their assent. perception with EDAcompared with a placebo inac- Dental treatment was provided by three dental thera- tive machine. Reported pain with EDAincreased when pists (school dental nurses) trained by the principal deeper cavity excavation was necessary. investigator to use the 3MDental Electronic Anesthe- teDuits et al. 12 comparedthe effectiveness of EDA sia System8670. with conventional local anesthesia for restorative pro- A crossover study design was used. The antimere cedures in 27 6- to 12-year-old children. Theyfound teeth were restored in two separate visits with random no significant differences betweenthe effectiveness of selection of use of EDAor LA. The principal investi- EDAand local anesthesia. The dental procedures were gator was present at each appointment to ensure the rubber damapplication and preventive resin restora- set procedures were followed and to record the obser- tions, which maybe painless without anesthesia. In vations and measurements. For the control visits, another study, Jedrychowskiand Duperon~3 tested the anesthesia wasgiven by infiltration for the maxillary effectiveness of EDAin restorative procedures on 40 teeth and inferior nerve block for the mandibularteeth. children. Only two children reported moderate dis- Throughoutthe study, local anesthesia was referred to comfort requiring injection of local anesthesia to as sleepy juice ("shot" is not a term knownby these completetreatment. These two children still reported children). Cavity preparation beganafter 5 min. Injec- discomfortafter local anesthesia. tions wererepeated if the anesthesia wasnot effective. Recently, the 3M company introduced an EDA EDAwas referred to as using the "funny stickers" device whichuses extraoral electrodes (3MDental Elec- throughout the study. Whenusing EDAfor mandibu- tronic Anesthesia System 8670). The extraoral lar primary teeth, the electrodes wereplaced over each electrodes eliminate the inconveniences of intraoral mental foramen and for mandibular permanent mo- electrodes such as difficulty in application, obstructed lars, they were placed over the apices of the last molar field of operation, and easy detachment. Croll and and over the mental foramenipsilaterally, with at least Simonsen~4 reported use of the system in 45 children 0.5 in in between. For maxillary primary molars, the aged 3 to 13 years. Thirty-seven children having pro- electrodes were placed over the apices of the primary cedures including extraction of primary teeth with molars just below each zygoma and for permanent resorbing roots or Class II restorations were success- maxillary molars the electrodes were placed over the fully treated with EDAalone. No control group was apices of the last molar and just belowthe ipsilateral used. Morerecently, Segura et al. 15 investigated the zygoma,with at least 0.5 in in between. effectiveness of EDAfor "moderate" procedures (14 The EDAmachine was set to the maximumfre- Class II restorations and one stainless-steel crown)in quency (140 Hz) and pulse width (2501~s) primary molars of 15 children aged 7 to 12 years. The recommendedby the manufacturer. A pilot study car- children’s past experiences with restorative procedures ried out prior to the main study established that under local anesthesia were used as the control. Mini- acceptance was greatly improved when the children mal pain was reported in most procedures and 14 of were allowed to control their owncurrent output. The the 15 children said they preferred EDAto local anes- children were asked to increase the output from the thesia. Sasa and Donly~6 comparedthe effectiveness of EDAuntil they felt significant tingling. The amplitude EDAto local anesthesia in 17 children aged 6 to 14 was reduced slightly for 20 s with the principal years. Theprocedures included Class II restorations or investigator’s guidance and then gradually increased stainless-steel crowns with and without pulpotomies. again until there were signs of involur~tary muscle Sixty percent, of the patients stated that they preferred movementsnear the electrodes. The amplitude was LAto EDA,which was only abandonedin four cases. kept at this level if the child reported they were com- Of the children who preferred LA, 70%received re- fortable. Cavity preparation began immediatelyand the storative procedures in the mandible, including children weretold to increase the amplitudeif they felt stainless-steel crownsand pulpotomies. pain during the procedure. Analgesic effectiveness was measuredusing a visual Methods analogue scale (VAS)where one end represented "no The present study was carried out in the clinics of pain" and the other represented "worst pain". The the Healthcare Otago School Dental Service in children positioned a sliding bar to indicate their lev-

106 AmericanAcademy of Pediatric Dentistry Pediatric Dentistry- 20.’2, 1998 els of pain. The degrees of pain were recorded as the Pulse rates wererecorded using a pulse oximeter(Pulse distance from zero when the tooth was probed by an Oximeter 503, Criticare System Inc) to evaluate explorer. The procedure washalted to allow the chil- changesin physiological arousal (Table 1). dren to score after the cavity preparation wascomplete The depths of the cavities were measured with a and after the restoration had been placed and com- graduated periodontal probe and the cavities in perma- pleted. The children were encouraged during the nent teeth were classified accordingto the criteria by procedures to concentrate on adjusting the EDAma- Malamedet al.9 as shallow, medium,or deep (< 0.5 chine to obtain the best comfort. Children’s anxiety mm,0.5-2 mm,or > 2 mminto dentin, respectively). levels were recorded at the beginning and end of each Theclassifications for primaryteeth wereslightly modi- visit using the VenhamPicture test. 17 Information fied to shallow, medium,and deep (< 0.5 mm,0.5-1.5 about their previous dental experiences were also re- mm,or > 1.5 mminto dentin, respectively). corded. This was obtained from the clinic records and After both visits were completed, the children were from the therapist if she had met the child previously. asked about their preferred methodof anesthesia and The children were asked if they had had local anaes- the reasons. Theywere asked if they preferred the funny thesia or TENS/EDApreviously for dental or medical stickers (EDA)or the sleepy juice (LA). As previously treatment. The TENS/EDAwas shown and described mentioned, children in New Zealand do not use to help the children’s memories.Behavior was assessed the term "shot" for an injection. At the completion throughout18 the procedure using the Frankl Scale. of study, each dental therapist’s reactions to the use of EDA were evaluated. Their responses were cor- related with the Before Probe High Slow Hand Cavity Matrix End Out acceptance of EDA Speed Speed Finish Band of Chair by the children. The data were Anxiety Score analysed as a cross- (O-8)" X X over trial using Pain ANOVAand adjust- (o-lt oo) X X X ing for a period effect using SAS HR X X X X X X X X System (SAS Insti- tute Inc.). Changes Behavior ¢ in heart rate wereex- (1-4) X X X X X X X X amined by including Cavity~ Depth X pretreatment heart rate as a covariatein the model. The ef- ¯ Venhamanxiety test,~7 t Visualanalogue scale, * Frank] scale of behavior,18~ Measuredby graduated fects of age, anxiety, periodontal probe. operator, cavity

Gender N Age Range Teeth Treatment (Years) (Cavity Classoqcation) 3/14 19/30 18/31 A/J B/I L/S K/T Female 14 6-12 4 4 4 8 8 2 (4 cl II) (4 cl I) (2 cl I) (8 cl II) (8 cl II) (2 d II)

Male 18 6-12 10 6 - 6 4 46 (6 cl (4 d (2 cl II (4 cl II) (2 cl II (2 cl 4 cl II) 2 d II) 4 cl II) 2 cl II) 4 cl II)

cl I : class I amalgam,cl II : class II amalgam.

PediatricDentistry -20:2, 1998 AmericanAcademy of Pediatric Dentistry 107 depth, tooth type, and tooth position on the differences lars (26 maxillary, 12 mandibular) and 26 permanent in the pain scores between EDAand LAduring cavity molars (14 maxillary, 12 mandibular) were treated. preparation were compared.The results are presented Twocavities were measuredas shallow, 36 as medium, as differences between the methodsof anesthesia and and 26 as deep. Details of the restorative procedures their 95%confidence intervals. Before the study was are shownin Table 2. carried out, it was estimated from results of previous Only three children exhibited negative behaviors studies that using a 5%level of significance, 33 sub- (Frankl category 2) throughout the study. Onechild jects would provide an 80%chance of showing a exhibited negative behavior during cavity preparation difference in reported pain scores of half a standard with EDA.Two children exhibited negative behavior deviation between EDAand LA. during both visits. The measurementsand observations of pain and anxiety are summarizedin Table 3. Because Results the distribution of the pain scores with probing and A total of 32 children (14 females, 18 males) aged the pre- and post-treatment anxiety scores were skewed to 12 years (mean8.8 + 2.0 years), each having paired toward the lower end, natural logarithms were used to restorations, completedthe study. Twenty-fivehad pre- normalize data. A significantly higher meanreported vious experiences of dental treatment under local pain score was found during cavity preparation with anesthesia. Noneof the children had ever experienced EDAthan in cavity preparation with LA(P < 0.01). EDAor TENSfor any previous dental or medical treat- There were no significant differences betweenthe pain ment. The restorative procedures included 40 Class II scores at the two visits at the beginningor at comple- and 24 Class I restorations. Thirty-eight primary mo- tion of each restoration. The pre- or post- treatment Venham anxiety scores werenot foundto differ significantly betweenthe two EDA LA Differences 95%Confutence t visits. Twenty-twochil- Meaurements Mean + SD Mean+ SD (EDA- LA) Intervals Significance dren scored 3 or less Anxiety 1.7 -+ 2.2 1.7 + 2.2 1.0’ 0.7-1.5’ NS at each measurement (pre-op) time in both visits. Twenty-eight children Anxiety 1.1 -+2.3 1.3 -+2.1 0.9* 0.6-1.2’ NS had similar pretreat- (postop) ment scores between visits and 29 had Pain 4.9 -+ 10.5 1.5’ 0.7-3.1’ NS 9.3 +- 17.0 similar post-treatment (probe) scores. No significant Pain 47.8 -+35.5 25.1 -+25.9 22.9 6.9-38.9 P< 0.01 differences were found (cavityfinished) in absolute heart rates or in changes in heart Pain 14.3-+15.2 13.2-+20.0 1.0 -8.9-10.9 NS rate between the two (completion) visits. All children showed the highest Heartrate 92.8-+ 11.3 92.8-+ 10.1 - 0.1 - 5.6-5.4 NS heart rates during (pre-op) high-speedcavity prep- Heartrate 102.0-+ 10.7 104.5-+ 12.7 - 2.5 - 8.5-3.6 NS aration and the lowest (high speed) heart rates at the completion of treat- Heartrate 94.8 -+ 10.7 98.4-+ 12.5 - 3.7 - 10.2-2.7 NS ment. All children (slowspeed) except for two showed pretreatment heart Heartrate 90.3-+11.1 91.7-+11.2 -2.0 NS -7.9-3.9 rates within the normal (cavityfinished) resting heart rates for Heartrate 87.1-+ 10.7 88.7-+10.9 - 1.7 -7.1-3.8 NS their ages.19 (completion) Six treatment procedures using EDAwere interrupted because of ¯ Differences adjusted for period effect between EDAand LA visits. * Differences expressed in terms of insufficient pain con- ratios of ~:l-Wt.~ after using log transformation. * NSStatistically not significant (/3 > 0.05).

108 AmericanAcademy of Pediatric Dentistry Pediatric Dentistry - 20:2, 1998 trol and treatment was completedusing local anesthe- numberswere too small to makestatistical conclusions. sia. Four of those children showedhigh pre-treatment The operators’ support for EDAvaried. Onewas very anxiety scores. Of the six restorations, two were in positive and planned to continue to offer EDA.The maxillary second primarymolars, two in maxillary first other two were moresceptical and felt they wouldonly permanent molars, and two in mandibular permanent offer EDAfor small cavities in primaryteeth or to chil- first molars. Cavity depths were deep in four and me- dren who were needle-phobic. dium in two teeth. Twochildren reported "worst pain" for the cavity preparations even after LAwas adminis- Discussion tered and one reported the same"worst pain" for cavity The criteria to determine success of EDAhave dif- preparation of the antimere molar when LAwas used. fered between studies. In Hochman’sstudy, 2° success Table 4 summarizesthe pain scores for EDAand LA. wasa self-report of at least 90%pain relief. Otherstud- Reported pain scores during cavity preparation with ies using self-report pain scales have allowedsome pain EDAwere found to be significantly higher than those in the lowerpart of the scales.9’ 15, 2~ In moststudies, with LAfor permanentteeth (P < 0.01), deep cavities success has been determined by whether the procedure (P < 0.01,) and with one of the operators (P < 0.01). was completedwith EDAalone. =’ 23 In our study, 81% Whenthe pretreatment anxiety was included as a of procedures were completed with EDAalone, which covariate in the model of ANOVA,the reported pain is similar to the 82%success in the clinical report of score during cavity preparation wasfound to be signifi- Croll and Simonsen~4 but lower than the 100%re- cantly related to pretreatment anxiety (P < 0.05). ported by Harvey and Elliot ’~ and the 95% by statistically significant relationships werefound between Jedrychowskiand Duperon.~3Differences in study de- the effectiveness of EDAor LAin controlling pain and sign and restorative procedures prevent exact the location of teeth (maxillary or mandibular), se- comparison,but it should be noted that in Harveyand quenceof treatment, age of children or previous dental Elliot’s study, only two of 10 children reported "no experience with LA. pain" after the procedure, whichsuggests that profound Whenasked whether they would prefer EDA(funny analgesia maynot be necessary for EDAsuccess. Simi- stickers) or LA(sleepy juice), 20 children (63%) larly, Quarnstrom defined the success with EDAas they preferred EDAto LA. Eleven of them preferred "either the absence of pain, or an acceptable level of EDAbecause there was no need for injection, three pain that the patient tolerates to avoid receiving local liked to control the anesthesia, four liked the feeling anesthesia".3 with EDA,and one preferred EDAbecause there was Theresults of the present study showeda relation- no paresthesia after treatment. Twelvechildren pre- ship of reported pain scores during cavity preparation ferred LAbecause they found LAmore effective for pain with pretreatment dental anxiety, which has also been control. Therewere differences in the children’s accep- reported by Quarnstrom and Milgrom 23 and tance of EDAbetween the three operators. The Hochman2° in adults. The VenhamPicture Test, a

EDA LA Differences 95%Confidence Subgroups N Mean ± SD Mean ± SD (EDA- LA) Intervals Significance Tooth primary 19 36.8 ± 32.8 20.3 ± 23.8 16.8 - 3.0-36.6 NS permanent 13 63.9 - 34.3 30.4 ± 25.9 37.5 11.2-63.8 P < 0.01 Cavity Depth medium/shallow 20 36.0 __ 30.0 23.2--- 20.5 13.8 - 3.3-30.8 NS deep 12 67.5 ±36.4 26.4±31.5 41.1 9.9-72.3 P< 0.01 Operator A 13 38.8 + 27.5 24.0 + 23.2 15.2 - 7.3-37.6 NS B 9 78.9 -+ 27.7 29.1 ± 31.4 53.0 17.4-88.6 P < 0.01 C 10 31.4 _+ 35.6 20.6 ± 21.9 8.7 - 25.5-42.8 NS

¯ Differences adjusted for period effect between EDAand LAvisits. * NSStatistically not significant (P > 0.05).

Pediatric Dentistry-20.’2, 1998 AmericanAcademy of Pediatric Dentistry 109 projective measurementof the children’s self-report ration,26 wassimilar to that reported by Myerset al. anxiety which was used in our study, has been shown Decreasein heart rate during cavity preparation with to be a valid and reliable measurementof situational either EDAor LAmay reflect relaxation whenthe pa- anxiety in children. ~7, 2a Noother studies have looked tient realizes that anesthesia is adequateand the cavity at the influence of children’s dental anxiety on the ef- preparation is not painful. There was no relationship fectiveness of EDA,and the results suggest that between heart-rate changes and reported pain in measuring pretreatment anxiety may be useful in Abdulhameedand coworkers’ study.~° They queried the screening children to determine their possible accep- sensitivity and validity of using a visual analoguescale tance of EDA. in children. However,in a series of studies examining The present study employeda crossover design in children’s ability to use visual analoguescales to mea- whichchildren served as their owncontrols. This design sure dimensions of their pain, McGrath27 found that reducedthe responsevariability inherent in studies us- children older than 5 years of age were able to use vi- ing separate treatment and control groups. In the study sual analogue scales in a reliable and valid mannerto of teDuits et al.~2 placing PRRrestorations, there were describe their perceptions, independentof their sex, no significant differences reported between EDAand age, or health status. LA. Howeverin Sasa and Donly’s stainless-steel crown Oneproblem commonto all visual analogue scales and Class II restoration study,~6 the reported pain scores is the limitation imposedby extremes.Ifa patient rates with EDAwere significantly higher. With restorative pain at the worst end of the scale and then it gets worse, procedures involving the dentin, we found the success the measurementstays the same. This was not a major rate of EDAto be betweenthe two previous studies. For problemin the present study as only one child reported both pain and anxiety measurementsthere were large maximumpain in both visits. As each child evaluated standarddeviations whichwere explained by the fact that treatment under both EDAand LA, the differences in the distribution of both scores waspositively skewed.For the pain scores between the two visits were more im- the pain scores there wasone extremeoutlier and for the portant than the actual scores. Additionally, the anxiety scores there wereonly three children whoscored children were reminded of what they had scored pre- very differently to the others. Becauseof the positively viously so that they could attempt to makea deliberate skeweddistributions, the analysesinvolved log transfor- comparisonof the pain. In somestudies, subjects do mation of the scores which were then analyzed and not see previous scores. This mayintroduce errors, es- presentedin terms of ratios. pecially whenthere is delay betweenthe two treatment Thepatient’s pain-control preference has also been times in a paired study and patients mayoverestimate usedas one of the criteria of success.15’ 2~. 25 Twentychil- pain severity. 28 The high standard deviations of pain dren (63%) in this study preferred EDAto LA for scores reported during cavity preparation maybe due further treatment. This is lower than the 78%in the to variations in pain perception or threshold in differ- study by teDuits et al.12 but higher than the 40%in ent children. Sasa and Donly’s study.16 The variation in preference Both Quarnstrom5 and Croll and Simonsen~4 sug- maybe due to the severity of the different procedures. gested children younger than 9 years should not be Theresults of the present study suggest that the effec- allowed to control their ownEDA amplitude, as younger tiveness of EDAmay be lower in deeper cavities, which children mayincrease the amplitude rapidly out of cu- agrees25 with Malamedet al? Both Donaldsonet al. riosity. In the present study, the children wereasked to and Malamedet al. 9 have reported that the effective- control their ownEDA current output after it wasfound ness of EDAmay be tooth-dependent in adults. Our that this gave the best acceptancein the pilot study. results suggest that EDAis effective in primaryteeth, There were no problems with even the youngerchildren but we found no differences between maxillary and having this control. Onepossible explanation was that mandibular molars, which was also reported by the children in this study controlled the EDAunits un- Abdulhameedet al) ° and teDuits et al.12 der close supervision and very careful instructions and No radiographs were exposed for the diagnosis of explanations weregiven at the start of the procedure. caries in this study as they are not routinely usedin this The success of EDAwas somewhat dependent on school dental service. In further studies, radiographs the operator acceptance of the method, although num- may allow cavity depths to be matchedmore closely. bers were too small to draw definitive conclusions. EDAand LAcould be comparedwith a nonanesthesia Hochman2° suggested that the attitude of operators is group, although this does not allow antimere teeth to an important factor as one of the mechanismsof EDA be used and it may not be possible to recruit enough maybe a placeboeffect. Observationthat not all of the children prepared to have restorative treatment with- operators wouldcontinue to use EDAsuggests that in out pain control. future studies the operator’s experience or belief in The pattern of heart rate changes we found, where EDA,their behavior-management techniques, their heart rate increased at the beginning of cavity prepa- method of introducing the EDA,and their treatment

110 AmericanAcademy of Pediatric Dentistry Pediatric Dentistry - 20.’2, 1998 techniques should be more closely evaluated, as these 9. Malamed SF, Quinn CL, Torgersen RT, Thompson W: factors may play an important role in how well patients Electronic dental anesthesia for restorative dentistry. Anesth Prog 36:195-98, 1989. accept EDA. Various methods of introducing the EDA 10. Abdulhameed SM, Feigal RJ, Rudney JD, Kajander KC: should also be evaluated. Effect of peripheral electrical stimulation on measures of Conclusions tooth pain threshold and oral soft tissue comfortin children. Anesth Prog 36:52-57, 1989. 1. Overall, EDAwas less effective than LA in con- 11. HarveyM, Elliott M: Transcutaneouselectrical nerve stimulation (TENS)for pain managementduring cavity preparations trolling pain during cavity preparation in children in pediatric patients. ASDCJ Dent Child 62:49-51, 1995. aged 6 to 12. Sixty-three percent of the children 12. teDuits E, Goepferd S, DonlyK, PinkhamJ, Jakobsen J: the preferred EDAto LA for future dental treatment. effectiveness of electronic dental anaesthesia in children. 2. This study suggests that the effectiveness of EDA Pediatr Dent 15:191-96, 1993. is related to children’s dental anxiety, the depth 13. Jedrychowski JR, DuperonDF: Effectiveness and acceptance of electronic dental anesthesia by pediatric patients. ASDC of the restoration, operator attitudes, and whether J Dent Child 60:186-92, 1993. the teeth are permanent or primary. 14. Croll TP, SimonsenRJ: Dental electronic anesthesia for chil- 3. EDA can be a useful adjunct to providing pain dren: technique and report of 45 cases. ASDCJ Dent Child control during restorative dental care in children. 61:97-104, 1994. 15. Segura A, Kanellis M, Donly KJ: Extraoral electronic dental Weare grateful to 3Mfor their support in supplying the EDAunits anesthesia for moderateprocedures in pediatric patients, J Dent for the study. Wethank Ms. H. Nicolson, Ms. M. Peterson, and Res 74:27 [Abst 123], 1995. MsR. Hammond,dental therapists, for helping with this study 16. Sasa L, DonlyKJ: Extraoral electronic dental anesthesia for in- and Ms. W. Neilson for help in preparing the manuscript. vasive restorative proceduresin children. J DentRes 74:27[Abst 124], 1995. This project was submittedin partial fulfilment of the requirements 17. VenhamLL, Gaulin-KremerE: A self-report measure of situ- for the degree of Master of Dental Surgery in Paediatric Dentistry ational anxiety for youngchildren. Pediatr Dent 1:91-96, 1979. in the University of Otago School of Dentistry, NewZealand. 18. Frankl SN, Shiere FR, Fogds HR: Should the parent remain with the child in the dental operatory? J Dent Child 29:150- Dr. Chowas a graduate student in pediatric dentistry at the time 63, 1962. the study was undertaken, Dr. Drummondis senior lecturer and 19. BernsteinD: Evaluationof the cardiovascularsystem. In Nelson specialist in pediatric dentistry, Departmentof Oral Health, School Textbook of Pediatrics, 15th Ed. Nelson WE,Behrman RE, of Dentistry, and Ms. Williamsis medical statistician, Schoolof KliegmanRM, Arvin AM,Eds. Philadelphia: W.B. Saunders, Medicine, University of Otago, Dunedin, NewZealand. Dr. 1996, pp 1262-82. Andersonis physician in the Pain Relief Clinic at DunedinHos- 20. HochmanR: Neurotransmitter modulator (TENS)for control pital, Healthcare Otago, Dunedin, NewZealand. Ms. Williams of dental operative pain. J AmDent Assoc116:208-212, 1988. is supported by the Health Research Council of NewZealand. 21. Esposito CJ, Shay JS, MorganB: Hectronic dental anesthesia: a pilot study. QuintessenceInt 24:167-70,1993. 22. 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