Journal of Dentistry 31 (2003) 912

www.elsevier.com/locate/jdent

Computerized local dental anesthetic systems:

patient and dentist satisfaction
E.G. Gracea,*, D.M. Barnesb, B.C. Reidb, M. Floresb, D.L. Georgeb

a
Brotman Facial Pain Center, Suite Z-A-IS, University of Maryland Dental School, 666 West Baltimore, MD
21201, USA
b
Advanced Education in General Dentistry, Suite G-100, University of Maryland Dental School, 666 West
Baltimore Street, Baltimore, MD 21201, USA

Received 27 August 2002; accepted 29 November 2002

KEYWORDS
Dental; Anesthesia;
Computer controlled;
Anesthetic technique;
Dentist satisfaction;
Patient comfort
Summary A computer controlled dental anesthetic delivery system was studied with
the Objective of evaluating and comparing the unit to the traditional method of
anesthetic delivery. The research design and Method of study involved the use of
trained dentists who used both types of delivery systems on patients seen during their
routine practice of dentistry. After the dental appointment was finished each dentist
completed a survey concerning the injection. Patients completed a survey before the
injection concerning their previous anesthetic experiences and completed another
survey at the end of the dental appointment concerning the injection they had just
received. Statistical analyses yielded Results showing the two methods were rated
very similarly by both patients and dentists. Conclusions resulting from the study are
that computer controlled dental anesthetic injections and traditional anesthetic
injections were accepted equally well by both dentists and patients.
Q 2003 Elsevier Science Ltd. All rights reserved.

Introduction
Dental fear is very prevalent in all age groups,
across gender, and in all countries. Recent sur-
veys1 4, using a variety of different instruments,
have demonstrated that from 5 to 15% of the
population are dental phobics and from 11 to 26%
have high dental fear and anxiety. These preva-
lence rates are very similar to earlier studies5 7,
thus indicating no substantial reduction in dental
fear in the last 25 years. One of the primary
identified fears of both the dental phobic and
*Corresponding author. Tel.: 1-410-706-2404; fax: 1-410-
706-2403.
E-mail address: egg001@dental.umaryland.edu
the high dental fear and anxiety groups is the fear of
dental injections. This concern about dental injec-
tions is usually ranked first or second in a hierarchy
of specific dental fears8 11).
Recently, the use of computer controlled local
dental anesthetic systems has become the subject
of clinical scientific investigations. The theory
behind the use of the computerized local dental
anesthetic systems is that the anesthetic solution is
delivered at a precise flow rate and at a controlled
volume that is most compatible with tissue accep-
tance of the anesthetic solution12. This controlled
rate and flow have been associated with more rapid
onset of anesthesia13, easier administration14,
decreased pain perception 15 , and decreased
patient anxiety levels16. Some studies have shown

0300-5712/03/$ - see front matter Q 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0300-5712(02)00130-6
10
no advantages to using a computerized injection
unit and that traditional methods of anesthetic
delivery, when done well, are superior17. An earlier
study by two of the authors of this present study
found that dentists were very satisfied with the
effectiveness and performance of a prototype of a
computer controlled dental local anesthetic system
(Comfort Control System, Dentsply/Midwest tm)
and patients were satisfied with both the level of
comfort of the anesthetic delivery and the effec-
tiveness of the anesthesia itself12. This present
study was a follow-up to that previous study and
used a similar study design but employed a
comparison group who were given anesthesia with
traditional techniques.
More dentists (26 vs 11) and more patients (260 vs
72) were also involved with this present study. The
CCS tm computer controlled dental anesthetic
delivery system was again used in this investigation.
However, since the previous study several design
changes were made to the CCS device by the
manufacturer in order to make the unit quieter and
easier for the dentist to handle. The system is
marketed as the comfort controlled syringe (CCS)
(Dentsply/Midwest). The purpose of the study was to
clinically evaluate this new computer controlled
dental anesthetic syringe system and to compare it
to traditional methods of dental anesthetic delivery.
Methods and materials
The principal investigator (DMB) was trained with
the original prototype used in the first study12 by
the inventor and was again trained with the
modified device by the sponsor. In addition, all
faculty and residents of the Advanced Education in
General Dentistry Program at the University of
Maryland Dental School were trained in the use of
the device by the Principal Investigator. The
training took 1 h and used the Directions for Use
and a video supplied by the manufacturer, Dentsply
International. During the dentists first use of CCS,
they were observed by a faculty member who had
extensive clinical exposure with the system. All
dentists were rated as proficient in the use of the
device before participating in the study.
Twenty-six dentists were involved in the study
and 260 injections were given to patients. Prior to
entering a patient into the study and initiating an
injection, a complete patient medical history was
taken and a consent form was reviewed and signed
by every patient. When a patient was accepted for
the study, a traditional or CCS injection was
performed by one of the 26 dentists involved in
E.G. Grace et al.
the study. Patients were selected based solely on
the dentists schedule. Each patient completed a
pre- and post-injection survey that questioned
them on the profoundness of the anesthesia and
their comfort with the injection. Every dentist
completed a short survey concerning the ease of
administration and effectiveness of the anesthetic
injection after each injection was performed. After
the injection was given, the practitioner would
complete the necessary dental care.
After the first 26 CCS injections were given to
patients (one per dentist during the observation
period), the dentists were to start with a CCS
injection for the first patient and then give a
traditional injection (TA) and continue to rotate
the type of injection they gave throughout the day in
that same manner. For this traditional injection a
Leur-lock plunger-aspirating syringe was utilized. All
participating dentists were very familiar with the
traditional technique and used it for their routine
injections. Lidocaine (2% with 1/100,000 epineph-
rine) was used for all injections of both types.
Data for analyses were derived from the dentist
and patient surveys described earlier as well as
from patient demographic survey forms. All ana-
lyses, including mean scores and percentages, were
carried out using the SPSS analytic software
(Statistical Program for the Social Sciences 1997
version 7.5). p-Values for group differences were
derived using two-sided t tests with a p-value for
statistical significance of less than or equal to 0.05.
Results
The total number and type of injections are shown
in Table 1. There were more CCS injections than TA
because of the initial observation period and
because each dentist started the daily rotation
with a CCS injection. The gender and age of the
patients in each group can be seen in Table 2.
Table 1 Injections by type and number.
Injections by type: CCS TA Total
Infiltration 70 41 111
Buccal 4 1 5
P-ASA 5 0 5
AMSA 23 15 38
IA 35 37 72
PDL 8 3 11
Mental 5 3 8
Lingual 7 3 10
Total 157 103 260
Computerized local dental anesthetic systems: patient and dentist satisfaction 11

Post-injection survey
Table 2 Age and gender.

CCS (N 157) TA (N 103)

1. How much discomfort did you have today?
rated from 1 to 10 with 1 being the best. CCS
Gender Male 49.7% 44.7%
Female 50.3% 55.3% mean 1.6 and TA mean 1.5 with a p-value of
Age ,20 1 2 3 (01.2%) 0.48. Thus, both groups had low discomfort with
2130 15 7 22 (08.5%) no statistically significant differences.
3140 23 16 39 (15.0%) 2. How was the overall experience today? Rated
4150 38 21 59 (22.7%)
5160 34 27 61 (23.5%)
from 1 to 10 with 1 being the best. The CCS
61 46 30 76 (29.3%) mean 1.9 and the TA mean 1. 4 with a p-
value of 0.09. Thus, both were rated has having
good experiences with the TA rated as better but
the difference was not statistically significant.
Dentist survey 3. What was your level of anxiety today? Rated
from 1 to 10 with 1 being the best. CCS
1. How profound was patients anesthesia? Rated mean 2.0 and TA mean 1.7 and a p-value
from 1 to 10 with 10 the best. CCS mean 9.1; of 0.38. Both were rated as eliciting low anxiety
TA mean 9.20 and p-value of 0.79. Both were and there were no statistical differences.
rated as yielding very profound anesthesia with 4. How was your level of numbness today? Rated
no significant statistical differences. from 1 to 10 with 1 the best. CCS mean 1.3 and
2. How much discomfort did patient experience? TA mean 0.9 with a p-value of 0.04. Statistical
Rated from 1 to 10 with 1 the best. CCS differences were reached in favor of TA. How-
mean 2.3; TA mean 2.3 and p-value of ever, patients receiving CCS injections were
0.98. Both were rated as having very low more likely than patients receiving TA to have
discomfort with no statistical differences. experienced problems achieving numbness in the
3. How well did patient accept the CCS? CCS mean past (pre-injection survey question #3). When
of 8.5 with 10 being the best, thus rated highly. changes between pre-and post-injection survey
4. How well did CCS unit function? with 10 being levels of numbness were assessed, no statisti-
the best. The unit was rated as 9.8 or almost cally significant differences were found. This
perfect. The only negative comment was that indicates that the observed better numbness
one dentist commented It took too long to give level for TA may be due to pre-injection group
the injection. differences in past problems with achieving
numbness.
Patient survey 5. Would you prefer this method of injection in the
future? Ratings were from 1 to 10 with 1 being
Pre-injection survey the best. The CCS mean 1.9 indicating a strong
preference for the CCS in the future. The TA
patients had the same type of injection as they
1. How do you feel about receiving an injection?
had received in previous appointment, so results
CCS and TA mean 3.3 each with a p-value of
were not tabulated, since there was no differ-
0.97. Thus there were no statistically significant
ence in method of delivery.
differences and both groups had slight to
moderate anxiety.
2. How would you describe your previous experi-
ence with injections? Rated 1 10 with 1 no Discussion
past discomfort. CCS mean 2.8 and TA
mean 2.4 with a p-value of 0.17. Both groups Patient acceptance of the CCS unit and injection
had slight to mild discomfort in past and were not technique was good and was comparable to
significantly different. traditional anesthetic delivery systems. Overall
3. Did previous injections make you numb enough? results indicated that both CCS and traditional
Rated from 1 to 10 with 1 indicating sufficient anesthetic techniques are effective and relatively
past numbness. CCS mean 3.1 and TA painless from the patients point of view.
mean 1.4 with a p-value of 0.11. While Interestingly, while the overwhelming majority
statistical significance was not reached, the of the dentists believed that usage of the CCS
CCS group had experienced more problems with yielded anesthetic and comfort levels similar to
achieving numbness in the past. traditional anesthetic techniques, most would not
12
use it or use it for only some injections. Several
dentists reported that the computerized syringe
worked more favorably for certain injections. The
anterior middle superior alveolar injection (AMSA)
was the injection for which most dentists preferred
the CSS because, according to the dentists, it
produced very little discomfort and produced
adequate anesthesia for restorative procedures
from premolar to central incisor better than the
traditional technique. However, there were too few
of these types of injections to analyze statistically.
In post-study discussions, the dentists reasons
for not continuing to use a computer controlled
syringe were: (1) cost and (2) can do as well as
without it. Those who used it the most during the
study expressed the most satisfaction and preferred
it to traditional anesthetic techniques. Dentists felt
that they were giving good, quick injections at
present and did not see the need for the expense of
another gadget that might break down or go
unused but, at the same time they were intrigued
by the possibilities of a computer controlled
syringe. Several dentists felt that as technology
continues to progress, computer assisted syringes
will become more commonplace especially as
cordless technologies are developed.
Summary and conclusions
The CCS unit performed as described in the
Directions for Use and there were no mechanical
failures. Overall, dentists felt that the CCS unit
worked well. No adverse events occurred in patient
care. Dentists rated the CCS and traditional
anesthesia approximately equally as to patient
comfort and profoundness of anesthesia.
Patients accepted the computerized injection
device well and they rated the CCS and traditional
anesthesia very similarly on level of anxiety,
profoundness of anesthesia, overall experience,
and comfort with the injection.
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