In dentistry, local anaesthesia enhances the comfort of both the patient and the dentist, allowing for the planned treatment to be completed with minimal discomfort. By definition, local anaesthesia is the loss of sensation in a circumscribed area of the body, caused by the depression of excitation in nerve endings or by the inhibition of the conduction process of peripheral nerves (Stanley Malamed, 1980) [1]. A locally acting substance is applied or injected to achieve this effect. There are various local anaesthetics and anaesthesia procedures available, each with specific benefits and drawbacks [2]. The administration of local anaesthesia has historically been a source of fear for patients, acting as a barrier that prevents many adults and children from seeking dental care. Patients who experience poorly controlled pain often exhibit negative reactions, which can hinder the clinician’s ability to provide a positive patient experience. For the purposes of intraoperative pain control, diagnostics, and therapeutic goals, local anaesthesia is a crucial component of clinical practice in dental procedures. Its administration is essential for reducing discomfort and anxiety during dental treatments, fostering respect for the dentist as the patient remains pain-free and cooperative, and thus facilitating the best possible care [3].
When selecting a local anaesthetic agent and technique for a specific procedure, dentists must consider several factors, including the site of delivery, the injection technique, the dosage, and any potential allergic reactions. All of these factors influence the effectiveness of local anaesthesia. Over the years, local anaesthesia has evolved; in the 21st century, advancements such as computer-controlled delivery systems and ultra-safe syringes have made its administration safer and more effortless. As a result of these advancements, patients now seek painless and hassle-free dental procedures. However, despite the mastery of keeping patients safe, one often do not make an effort to explain the techniques to the general public. As their awareness has increased, patients have become more anxious about the surgical aspects of their treatment [4].
Materials and Methods
The cross-sectional study was conducted among patients visiting Karpaga Vinayaga Institute of Dental Sciences in the Chengalpattu district, Tamil Nadu, India. The study took place over a period of three months, from August to October 2022. Ethical clearance was obtained from the Institutional Ethics Committee (IEC) of Karpaga Vinayaga Institute of Dental Sciences (IEC NO: KIDS/IEC/2023/III/010). The planning for the study was based on the guidelines of STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Written informed consent was obtained from all participants.
Inclusion criteria: The study involved individuals over 18 years of age. Patients receiving local infiltration, maxillary nerve blocks (including incisive nerve block, anterior superior alveolar nerve block, middle superior alveolar nerve block, and posterior superior alveolar nerve block), and mandibular nerve blocks (including mental nerve block and inferior alveolar nerve block) were included in this study.
Exclusion criteria: Patients with mental disabilities and those who could not communicate verbally were excluded from the study.
Sample size calculation: The sample size was calculated using G*Power software based on a previous study [5], with inputs including an effect size of 0.20, an α error of 0.05, and a power of 0.80. The critical t-value was 1.97, and the total estimated sample size was 398.
Questionnaire: The questionnaire was self-designed and modified based on similar research regarding awareness of local anaesthesia [5]. Participants were provided with a pretested questionnaire, and their responses were recorded after validation, item development, and pilot testing. Content validation of the items was conducted by distributing the questions among subject-matter experts. Interexaminer reliability was assessed using kappa statistics and was found to be good (kappa value=0.78). A pilot study was conducted to scrutinise internal consistency and reliability among 15 patients. The values (Cronbach’s alpha=0.81) indicated strong consistency and reliability.
An English-language self-administered survey was created and then uniformly translated into Tamil, the local dialect. The survey consisted of 15 items, including perceptions and attitudes about local anaesthesia. The questionnaire was divided into three domains: the first domain contained seven questions asked prior to the injection of local anaesthesia; the second domain included three questions during the administration of local anaesthesia; and the third domain comprised five questions asked following the administration of the injection.
Data were gathered by a single, qualified investigator. The study’s purpose and methods were briefly explained to all the participants, who were free to choose whether or not to participate. The respondents filled out the unique questionnaire that served as the study’s research tool. Participants’ confidentiality and anonymity were guaranteed, and relevant data were collected to determine demographic information regarding their age and gender.
Statistical Analysis
The responses were initially entered into Microsoft Excel, and statistical analysis was performed using SPSS 22.0 software. Descriptive statistics were conducted, and the Chi-square test was used for inferential analysis. A p-value <0.05 was considered statistically significant.
Results
Among the 398 study participants, 218 (54.8%) were males and 180 (45.2%) were females. Additionally, 126 participants (40.20%) were between 46-60 years of age [Table/Fig-1].
Age and gender cross tabulation.
| Age (years) | Male n (%) | Female n (%) | Total |
|---|
| 18-30 | 19 (8.72) | 26 (14.44) | 45 (11.56) |
| 31-45 | 79 (36.24) | 60 (33.33) | 139 (28.64) |
| 46-60 | 67 (30.73) | 59 (32.78) | 126 (40.20) |
| 60 above | 53 (24.31) | 35 (19.44) | 88 (19.6) |
| Total | 218 (54.77) | 180 (45.23) | 398 (100) |
In the first domain, the percentage of patients who visited the dental hospital was quite high, with 178 (44.72%) attending for a second visit. Furthermore, 338 (84.92%) of the patients reported having no relevant history of extractions in the past. A significant 304 (76.38%) of the patients were not aware of the preinjection topical anaesthetic, as they had not been informed about it even during their second visit. The majority of participants 280 (70.35%) experienced anxiety, particularly as they were undergoing treatment for the first time. Multiple reasons contributed to this anxiety, including previous bad experiences, but the fear of injections was predominant, affecting 264 (66.33%) of the participants [Table/Fig-2].
First domain-questions that included before the administration of local anaesthesia.
| S. No. | Question | Options | Total n (%) | p-value |
|---|
| 1. | Number of visits to the dentist so far | a. First visit | 118 (29.65) | 0.2 |
| b. Second visit | 178 (44.72) |
| c. More than two | 102 (25.63) |
| 2. | Have you underwent extraction in the past? | a. Yes | 60 (15.08) | 0.8 |
| b. No | 338 (84.92) |
| 3. | Are you aware of preinjection topical anaesthesia? | a. Yes | 94 (23.62) | 0.2 |
| b. No | 304 (76.38) |
| 4. | State of mind before administration of local anaesthesia | a. Calm and relaxed | 42 (10.55) | <0.01 |
| b. Anxious | 280 (70.35) |
| c. Neutral | 76 (19.1) |
| 5. | How would you grade your anxiety? | a. Mild | 62 (15.58) | 0.04 |
| b. Moderate | 236 (59.30) |
| c. Severe | 100 (25.12) |
| 6. | Reason for the anxiety | a. Unknown | 170 (42.71) | 0.28 |
| b. Bad previous experience | 88 (22.11) |
| c. Information from others | 36 (9.05) |
| d. Fear of pain | 104 (26.13) |
| 7. | Feeling of fear due to? | a. Fear of extraction | 92 (23.12) | 0.69 |
| b. Fear of injection (local anaesthesia) | 264 (66.33) |
| c. Fear of blood | 42 (10.55) |
Chi-square test (p≤0.05), statistically significant
In the second domain, about 174 (43.72%) of patients experienced anxiety during the injection. Additionally, 284 (71.36%) of the patients reported muscle tension during the administration of local anaesthesia. Moderate pain was experienced by 300 (75.38%) of the patients, as trained residents with adequate knowledge of anatomical landmarks administered the local anaesthesia [Table/Fig-3].
Second domain- that included questions during the administration of local anaesthesia.
| S. No. | Question | Options | Total n (%) | p-value |
|---|
| 1. | How you feel while injecting with syringe | a. Anxious | 174 (43.72) | 0.03 |
| b. Pain | 124 (31.16) |
| c. Fear | 100 (25.12) |
| 2. | Muscle tension during administration of injection (such as griping the arms of the chair) | a. Normal | 46 (11.56) | 0.02 |
| b. Increased | 284 (71.36) |
| c. No change | 68 (17.08) |
| 3. | Assessment of pain during administration of local anaesthesia | a. No pain | 14 (3.52) | 0.009 |
| b. Moderate pain | 300 (75.38) |
| c. Increased | 84 (21.10) |
Chi-square test (p≤0.05), statistically significant
The third domain included five questions regarding the postadministration effects of local anaesthesia. It revealed that 252 (63.32%) of the patients experienced anxiety after administration. Furthermore, 194 (48.74%) of the patients displayed a groaning vocal response following the administration of local anaesthesia. Intraoral swelling was observed in 222 (55.78%) of the patients within five minutes after administration, and 264 (66.33%) experienced slurred speech. Physical manifestations of fear, such as palpitations, lightheadedness, sweating, and tremors, were also reported by the patients [Table/Fig-4].
Third domain- questions after the administration of local anaesthesia.
| S. No. | Question | Options | Total n (%) | p-value |
|---|
| 1. | Mental state after administration of local anaesthesia | a. Nervous | 86 (21.61) | 0.001 |
| b. Anxious | 252 (63.32) |
| c. Excited | 60 (15.07) |
| 2. | Vocal response after administration of local anaesthesia | a. Neutral response | 44 (11.06) | 0.025 |
| b. Groaning | 194 (48.74) |
| c. Sighing | 158 (39.70) |
| d. Wordless | 2 (0.50) |
| 3. | Intraoral changes that occurred five minutes after administration of local anaesthesia | a. Numbness | 136 (34.17) | <0.01 |
| b. Swelling | 222 (55.78) |
| c. Pain | 40 (10.05) |
| 4. | Any physical manifestations of fear | a. Sweating | 92 (23.12) | <0.01 |
| b. Light headedness | 102 (25.63) |
| c. Palpitation | 190 (47.74) |
| d. Tremors | 14 (3.51) |
| 5. | Vocal change during speech after administration of local anaesthesia | a. No change | 34 (8.54) | 0.07 |
| b. Slurred speech | 264 (66.33) |
| c. Anxious speech | 100 (25.13) |
Chi-square test (p≤0.05), statistically significant
Discussion
In this study, patients were questioned about the mental status and physical changes they experienced before and after the administration of local anaesthesia. A total of 70.35% of patients reported experiencing anxiety prior to the administration of local anaesthesia. This anxiety may be attributed to the extensive dental setup and the college environment, which typically features unfamiliar equipment and numerous dentists. Perspectives among the general population regarding local anaesthesia vary depending on their prior dental history, level of education, and curiosity about the procedure itself [7,8]. According to Saheer A et al., 56% of patients experienced anxiety before the administration of local anaesthesia [9]. Similarly, Gadve VR et al., reported a moderate average dental anxiety level before the administration of local anaesthesia, with a mean score of 10.3±2.95 [10].
According to Milgrom P et al., 61.0% of patients experienced a sevenfold increase in dental anxiety due to past dental experiences [11]. This finding aligns with the present study, which found that 22.11% of patients reported anxiety related to previous negative dental experiences. In the current study, 66.33% of patients expressed a fear of injections before receiving local anaesthesia, which was greater compared to their fear of extractions or blood. This observation was consistent with findings from Milgrom P et al., who reported that 26.5% of patients experienced significant fear of injections [12]. Rankin JA and Harris MB, concluded that anxiety plays a major role in determining how much pain a person feels during dental procedures [13]. They stated that anxiety has been linked to personal traumatic dental experiences, as well as negative family and peer attitudes towards dentistry [13], which was in consonance with the current study. It is evident that patients were anxious before and during the administration of local anaesthesia, and this anxiety was due to multiple factors such as advice from neighbours, previous negative experiences, and fear of pain.
Among the dental events that caused the most fear in 160 dental phobic patients, Berggren U and Meynert G discovered that extractions ranked fourth [14]. In this study, the fear of injections was greater compared to the fear of extractions. Anderson LD and Reagan SE, studied local anaesthesia with vasoconstrictors and concluded that the majority of patients experienced moderate pain during the administration of local anaesthesia [15]. Similarly, in the present study, most patients reported experiencing moderate pain during the administration of local anaesthesia. According to Curley RK et al., patients administered with lidocaine experienced increased muscle tension during the procedure [16]. In agreement, the present study found that muscle tension increased in the majority of patients during the administration of local anaesthesia. Curley RK et al., also noted that patients experienced intense pain, unilateral facial swelling, swelling of the eye, shortness of breath, urticaria, as well as sensations of itching, flushing, and anxiety after the administration of dental local anaesthesia [16]. Similarly, in this study, patients presented with physical manifestations of fear such as sweating, lightheadedness, and palpitations after the administration of local anaesthesia.
Webber B et al., reported a case where a patient experienced dizziness and lightheadedness shortly after the administration of local anaesthesia [17]. In the present study, it was evident that patients experienced palpitations, dizziness, and lightheadedness. According to Newton JT and Buck DJ, through their 10-year evaluation study, they found that patients often anticipate more pain compared to their past experiences, and their perception of pain plays a crucial role in this anticipation [18]. Similarly, in the present study, the majority of patients exhibited an anxious state of mind, which likely elevated their fear before the administration of local anaesthesia in 66.33% of cases. Nuttall NM et al., indicated that individuals with high anxiety scores, accounting for 43% of the patients, were prone to overstate their pain levels and feelings of fear [19]. In the present study, 43.72% of patients experienced an anxious mental state during the administration of local anaesthesia.
Limitation(s)
The study was limited by the use of a questionnaire featuring only close-ended questions, which constrained participants’ ability to provide detailed insights into their experiences with local anaesthesia. This format may not fully reflect the diversity of their perspectives. The study provides insights only into the current perceptions and attitudes regarding local anaesthesia among the patients, indicating the need for further research in this area. Nevertheless, despite these drawbacks, the survey offered valuable baseline data that will guide future questionnaire research in the field.
Conclusion(s)
The majority of patients who filled out the questionnaire experienced anxiety prior to the administration of local anaesthesia. A greater number of patients were fearful of the injection rather than the extraction. The outcome of anaesthesia may be significantly influenced by educating patients about dental treatment processes, scheduling regular check-ups with the dentist, and employing psychotherapy methods to lessen dental anxiety before anaesthesia. Therefore, the role of topical anaesthesia should be considered when performing procedures in the oral cavity.
Chi-square test (p≤0.05), statistically significant
Chi-square test (p≤0.05), statistically significant
Chi-square test (p≤0.05), statistically significant