Transcutaneous electric nerve stimulation (TENS) in dentistry- A review

Comparative assessment between chewing gum, bite wafers, and ibuprofen in pain control following separators placement among orthodontic patients

Objective

This study aimed to evaluate the efficiency of chewing gum and using bite wafers in reducing pain after the placement of separators in orthodontic patients and to compare that efficiency with ibuprofen use. Additionally, this study evaluated the effect of non-pharmacological pain control methods on the frequency of separators falling out.

Methods

The study sample comprised 105 female patients between 15 and 35 years of age. The patients were randomly selected and classified into three groups (35 each). Each group was given either ibuprofen, viscoelastic bite wafers, or chewing gum immediately after the placement of separators and every 8 h for 1 week, as needed. The patients were asked to record their pain perception using a visual analog scale following separator placement at 2 h, 6 h, bedtime, 24 h, and at 2, 3, and 7 days. Analysis of variance testing was used for the data analysis.

Results

Among the three studied groups, there were no significant differences in pain perception at any time point. The patients experienced significantly higher pain scores at bedtime and 24 h after separator placement. In addition, there were statistically significant findings in pain perception at different time points within each pain relief method (p = 0.000, p < 0.05).

Conclusion

The use of chewing gum and bite wafers in alleviating orthodontic pain was beneficial and comparable to ibuprofen use following the placement of separators before orthodontic treatment among orthodontic patients.

Novel dental anesthetic and associated devices: a scoping review

The efficient management of pain and discomfort is essential for successful dental treatment and patient compliance. Dental professionals are commonly evaluated for their ability to perform treatment with minimal patient discomfort. Despite advancements in traditional local dental anesthesia techniques, the pain and discomfort associated with injections remain a concern. This scoping review aims to provide a comprehensive overview of the literature on novel dental anesthetics and associated devices designed to alleviate pain and discomfort during dental procedures. The Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used to prepare the review. Six databases and two sources of gray literature were searched. This review analyzed 107 sources from 1994 to 2023. Local anesthesia devices were grouped into computer-controlled local anesthetic delivery (CCLAD) systems, intraosseous anesthesia (IOA), vibratory stimulation devices, and electronic dental anesthesia (EDA). CCLAD systems, particularly the Wand and Single-Tooth Anesthesia, have been the most researched, with mixed results regarding their effectiveness in reducing pain during needle insertion compared to traditional syringes. However, CCLAD systems often demonstrated efficacy in reducing pain during anesthetic deposition, especially during palatal injections. Limited studies on IOA devices have reported effective pain alleviation. Vibrating devices have shown inconsistent results in terms of pain reduction, with some studies suggesting their primary benefit is during needle insertion rather than during the administration phase. EDA devices are effective in reducing discomfort but have found limited applicability. These findings suggest that the CCLAD systems reduce injection pain and discomfort. However, the evidence for other devices is limited and inconsistent. The development and research of innovative technologies for reducing dental pain and anxiety provides opportunities for interdisciplinary collaboration and improved patient care in dental practice.

Unraveling the Potential of Electroanalgesia: A Literature Review of Current Therapeutics

Neuropathic pain (NP), arising from dysfunction in the neurological system, poses a significant challenge in pain management due to its intricate origin and unpredictable response to conventional treatments. Electroanalgesia, a collection of techniques such as transcutaneous electric nerve stimulation (TENS), peripheral electrical nerve stimulation (PENS), spinal cord stimulation (SCS), deep brain stimulation (DBS), and electroacupuncture (EA), presents a potential alternative or complementary approach. This review brings together evidence from 56 studies to evaluate the effectiveness and safety of electroanalgesia in chronic NP. It discusses the mechanisms underlying NP, the indications for electroanalgesia, and the techniques utilized, emphasizing the diverse applications and potential benefits. However, despite its potential uses, electroanalgesia has its limitations, including variable effectiveness and potential adverse effects. Furthermore, the review recognizes the limitations of the methodology and the need for further research to refine treatment protocols and enhance the understanding of electroanalgesia's role in comprehensive pain management strategies.

Evaluation of Pain Perception During Orthodontic Debonding of Metallic Brackets with Simultaneous Application of TENS Therapy

Objective

The objective of the present study was to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) therapy on pain during the debonding procedure.

Methods

A placebo-controlled, randomized split - mouth study was conducted on 30 orthodontic patients. The right and left anterior teeth in the maxilla and mandible were randomly allocated to the control and experimental groups (EG) and were stimulated. TENS application was made through a modified electrode probe that was used from an ammeter. The control group (CG) received the mechanical application of the device with no current, whereas the EG received progressively increasing current from 0.1 mA to the point where the patient experienced a mild tingling sensation for 60 s for each tooth. This was followed by a debonding procedure using an orthodontic debonding plier. Pain perception was recorded on a numerical rating scale after debonding each tooth.

Results

The mean pain score was higher in the CG than in the EG, and the difference between the two groups was significant (p=0.001). The pain score was higher in the mandibular teeth than in the maxillary teeth, and the difference between the two groups was also significant (p=0.021). Pain score was higher in female subjects than in male subjects, and the difference between the two groups was significant (p=0.015).

Conclusion

The application of TENS therapy results in pain reduction during the debonding procedure. The female subjects experienced more pain. Higher pain scores were recorded for the mandibular anterior teeth than for the maxillary teeth.

Effect of transcutaneous electrical nerve stimulation on pain, edema, and trismus after surgical removal of impacted third molars: a split-mouth randomized clinical trial

BACKGROUND

The transcutaneous electrical nerve stimulation (TENS) stimulus inhibits the activity of nociceptive neurons of the central nervous system. Pain relief is achieved by increasing the pulse amplitude of TENS to induce a non-painful paranesthesia beneath the electrodes. This study aimed to assess the effect of TENS on acute pain, edema, and trismus after surgical removal of impacted third molars.

MATERIAL AND METHODS

This randomized, double blind, split-mouth clinical trial was conducted on 37 patients with bilaterally impacted mandibular third molars. The angle and body of mandible at the site of surgery in one randomly selected quadrant underwent TENS immediately after surgery (50 Hz, 100-µs short pulse, 15 minutes for 6 days). The TENS stimulator device was used in off mode for the placebo quadrant. The pain score (primary outcome) was measured for 7 days postoperatively, and edema and trismus (secondary outcomes) were assessed at 2, 4 and 7 days, postoperatively. The results were analyzed by repeated measures ANOVA using R software (alpha=0.05).

RESULTS

The overall mean pain score was significantly lower in the TENS than the placebo group (P<0.05). The number of taken analgesics in the first 3 days was significantly lower in the TENS group (P<0.001). Postoperative edema in the TENS group was lower than the placebo group but only the difference was not statistically significant (P>.05). The inter-incisal distance, as an index to assess trismus, was not significantly different between the two group at day 2, but it was significantly higher in the TENS group after the second day (P<0.001).

CONCLUSIONS

TENS effectively decreased pain and trismus following impacted third molar surgery, and may be recommended as a non-pharmaceutical method to relieve postoperative symptoms.

Intercomparison of Efficacy of Transcutaneous Electrical Nerve Stimulation and Precooling Vibration Device on Pain and Anxiety Management during Administration of Local Anesthesia Injection in 6-12-year-olds

Aim

To compare and evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) and a vibrational precooling system in reducing pain and anxiety during the administration of local anesthesia in children aged 6-12 years old.

Materials and methods

A total of 60 children aged 6-12 years old participated in this randomized controlled trial and were randomly allocated to three groups: the conventional method group, the vibrational precooling system group, and the TENS group. The Modified Dental Anxiety Scale (MDAS), pulse rate, and oxygen saturation were recorded to assess the preoperative anxiety of the participating children. Sound, motor, and eyes (SEM) and face, legs, activity, cry, and consolability (FLACC) scores were recorded during the procedure, along with pulse rate and oxygen saturation, to measure pain during the procedure. This was followed by a self-administered visual analog scale (VAS) to assess the discomfort felt by the child.

Results

A statistically significant reduction in pain was observed with the usage of the vibration system and TENS, as measured by the FLACC scale, compared to the conventional method group. Similarly, statistically significant differences in SEM scores were noted between the vibrational precooling system group and the conventional method group, as well as between the TENS group and the conventional method group, with the highest scores observed in the conventional method group. The children reported the highest comfort levels with the usage of the vibration system, as indicated by the self-administered VAS. However, no statistically significant difference was observed within any group.

Conclusion

The new vibrational precooling system as well as TENS can be effectively used to alleviate the pain experienced during the administration of local anesthesia.

How to cite this article

Singh K, Jhingan P, Mathur S, et al. Intercomparison of Efficacy of Transcutaneous Electrical Nerve Stimulation and Precooling Vibration Device on Pain and Anxiety Management during Administration of Local Anesthesia Injection in 6-12-year-olds. Int J Clin Pediatr Dent 2024;17(3):297-302.

Comparative Evaluation of Effect of TENS on Controlling Pain Associated with Orthodontic Separator Placement-A Clinical Study

Aim

To assess and contrast the efficacy of transcutaneous electrical nerve stimulation (TENS) therapy and topical anesthetic gel in reducing the level of pain associated with the placement of orthodontic separators.

Materials and Methods

A cohort of 40 individuals, aged between 16 and 20 years, who were in need of fixed orthodontic treatment, was chosen for the study. Elastomeric separators were positioned bilaterally adjacent to the first molars in all participants, who were subsequently separated into two distinct cohorts. Those in group I received topical anesthetic gel, while those in group II underwent TENS therapy. After the placement of separators, the assessment of pain was conducted using the Visual Analog Scale (VAS) at specific intervals: Immediately after placement, 6, 12, 24, and 48 hours.

Result

TENS group showed a significantly lower VAS score compared to the local anesthetic gel group at immediate, 6 hours, and 12 hours.

Conclusion

Following the placement of elastomeric separators, it was found that TENS was more successful at reducing pain.

Bioelectricity in dental medicine: a narrative review

BACKGROUND

Bioelectric signals, whether exogenous or endogenous, play crucial roles in the life processes of organisms. Recently, the significance of bioelectricity in the field of dentistry is steadily gaining greater attention.

OBJECTIVE

This narrative review aims to comprehensively outline the theory, physiological effects, and practical applications of bioelectricity in dental medicine and to offer insights into its potential future direction. It attempts to provide dental clinicians and researchers with an electrophysiological perspective to enhance their clinical practice or fundamental research endeavors.

METHODS

An online computer search for relevant literature was performed in PubMed, Web of Science and Cochrane Library, with the keywords "bioelectricity, endogenous electric signal, electric stimulation, dental medicine."

RESULTS

Eventually, 288 documents were included for review. The variance in ion concentration between the interior and exterior of the cell membrane, referred to as transmembrane potential, forms the fundamental basis of bioelectricity. Transmembrane potential has been established as an essential regulator of intercellular communication, mechanotransduction, migration, proliferation, and immune responses. Thus, exogenous electric stimulation can significantly alter cellular action by affecting transmembrane potential. In the field of dental medicine, electric stimulation has proven useful for assessing pulp condition, locating root apices, improving the properties of dental biomaterials, expediting orthodontic tooth movement, facilitating implant osteointegration, addressing maxillofacial malignancies, and managing neuromuscular dysfunction. Furthermore, the reprogramming of bioelectric signals holds promise as a means to guide organism development and intervene in disease processes. Besides, the development of high-throughput electrophysiological tools will be imperative for identifying ion channel targets and precisely modulating bioelectricity in the future.

CONCLUSIONS

Bioelectricity has found application in various concepts of dental medicine but large-scale, standardized, randomized controlled clinical trials are still necessary in the future. In addition, the precise, repeatable and predictable measurement and modulation methods of bioelectric signal patterns are essential research direction.

Does transcutaneous electrical nerve stimulation reduce the laparoscopic related shoulder pain?

OBJECTIVE

Although laparoscopic surgery is a good substitute for laparotomy in reducing postsurgical pain, many patients complain of shoulder pain after laparoscopic surgery and require pain-relief. Post-operative pain management leads to increased patient satisfaction. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological, noninvasive modality that reduces pain by activating the descending inhibitory systems in the central nervous system. Given the importance of decreasing shoulder pain after gynecological laparoscopy, the current study aimed to investigate the management of shoulder pain in these patients using TENS.

METHODS

This was a retrospective case-control study. A total of 112 women aged 18-45 years who experienced shoulder pain due to gynecologic laparoscopic surgery were included in the study. Patients were divided into TENS and control groups. In the TENS group, TENS was used twice for 20 minutes each, but in the control group, the patients received regular treatment. Patients were evaluated at intervals of 2, 4, 8, 24, 48, and 72 hours after laparoscopy for shoulder pain score.

RESULTS

The results showed a significant decrease in visual analog scale scores at 2, 4, and 8-hour in the TENS group compared with the control group. At 24 hours evaluation, although the pain was reduced, the difference was not significant. At 48- and 72-hour assessment, all patients in each group reported zero score for severity of pain.

CONCLUSION

The findings suggest that TENS significantly reduces postoperative shoulder pain.

Comparative effectiveness of low-level laser therapy and transcutaneous electrical nerve stimulation in symptomatic Temporomandibular Disorders: A Randomised Control Trial

BACKGROUND

Myofascial pain is one of the most common facial region pains, presenting itself with various signs and symptoms like tenderness of masticatory muscles and difficulty in mouth opening. Considering its multifactorial aetiology various treatment modalities are present.

OBJECTIVE

The aim of this study is to compare the effectiveness of transcutaneous electrical nerve stimulation (TENS)and low-level laser therapy (LLLT) for the patients of temporomandibular disorders (TMDS).

METHODS

The study was conducted with 20 patients diagnosed with TMDS. Group A received LLLT at 660 nm, 6 J/point, two sessions/week for 4 weeks and group B received TENS at 2-250 Hz, two sessions/week for 4 weeks.

RESULTS

Pain Score decreased and mouth opening increased in both groups with time, however, the difference between the two groups was not statistically significant. Right and left lateral excursions showed improvement at different intervals in both groups. However, the LLLT group showed significant improvement.

CONCLUSION

Clinical trial showed improvement in visual analogue scale (VAS), maximum mouth opening (MMO) and lateral excursion in the different time intervals in both the groups with LLLT showed more improvement with lateral excursions movements.

Comparative Evaluation of Electronic Acupuncture Pen and 2% Lignocaine Gel as an Intraoral Topical Anesthetic Agent in Children

Background The most exasperating aspect for pediatric patients in a dental setup is the fear and anxiety caused by injections, called "blenophobia". There are numerous local anesthetic agents available to reduce the needle prick pain. Taking into consideration the paradigm shift, there is always a possibility for alternate treatment options. This study aimed to evaluate and compare the effectiveness of transcutaneous electrical nerve stimulation (TENS) application through an electronic acupuncture pen (Meridian Energy Acupuncture Pen W-912 GENERIC) and 2% lignocaine gel as an intraoral topical anesthetic agent in children. Method Patients aged 6 to 12 years were eligible for inclusion. The topical anesthetic agents were administered to the patients in a bilateral split-mouth technique. In Group A, 2% topical anesthetic gel was administered on the first visit on one side of the mandible and topical anesthesia through the electronic acupuncture pen was administered on the next visit, on the opposite side of the mandible. The electronic acupuncture pen was applied on one side of the mandible on the first visit, and on the next appointment, 2% topical anesthetic gel on the other side was administered in Group B. Sound, eye, motor scale (SEM) and faces pain scale-Revised (FPS) were used as tools of evaluation after local anesthesia was administered.  Results  The comparison between electronic acupuncture pen and 2% lignocaine gel using the SEM scale shows a statistically insignificant difference (p-value = 0.082). Similarly, a comparison of FPS values between both groups indicates no significant difference (p-value = 0.582). However, results show a reduced pain perception in both groups. Conclusion Topical anesthetic agents are commonly used to reduce needle prick pain in children. TENS through the electronic acupuncture pen, a revisited aid in scientific research, has proved its efficacy as a topical pain reduction measure during dental treatment. This device overcomes the shortcomings of the anesthetic gels and also nullifies the chances of overdosage, hypersensitivity, and disagreeable taste. Thus, this tool can be used in dental practice for the management of pain in children.

Glimpse of TENS in Dentistry: A Literature Review

Transcutaneous electrical nerve stimulation (TENS) therapy has been accepted to treat a wide range of illnesses, including phantom limb pain, joint pain, low back pain, and cervical discomfort. TENS is not frequently used in dentistry, despite its potential advantages. 3, 4 Therefore, the rationale of present review is to discuss its dental applications in order to spread awareness of them among the dental profession.

Salivary stimulatory effect of novel low level transcutaneous electro neurostimulator in geriatric patients with xerostomia

BACKGROUND

Xerostomia (dryness of the mouth) is one of the most common long-term consequences of ageing, and it causes a tremendous impact on the function and morphology of the salivary ductal system. As a consequence, it leads to a decrease in the amount of salivary output and also affects the overall quality of life. The purpose of this study was to determine whether electrostimulation using a custom designed transcutaneous electrical nerve stimulation (TENS) device will help to improve the quality of secreted saliva following electrostimulation.

METHODS

One hundred thirty-five participants underwent the intervention for three months, twice daily (80 Hz). Pre-intervention and post-intervention unstimulated saliva were collected. Parameters such as salivary pH, cortisol level, salivary antioxidants, total protein, the viscosity of saliva, and microbial carriage were analysed.

RESULTS

Salivary pH, cortisol, microbial cultures, viscosity, and antioxidants showed a significant difference at the end of the 3rd month (p < 0.05). Irrespective of the patient's age, gender, and common underlying systemic illnesses (diabetes and hypertension), a significant change in the quality of the salivary analytes was observed.

CONCLUSION

The study emphasises the use of a custom designed TENS device in improving the quality of secreted saliva among old patients with oral dryness.

The effect of transcutaneous electrical nerve stimulation on pain and electrical stimulation muscle thickness in patients with non-specific chronic low back pain-based ultrasonographic evaluation

Aim: The existing mechanisms of transcutaneous electrical nerve stimulation (TENS) focuses more on the effect of neural tissue. This study investigated the effect of TENS on the thickness of the erector spinae muscles and reducing pain. Patients & methods: 56 individuals with low back pain participated in this single-blind, pre/post-test study. For 2 weeks, participants underwent ten sessions of TENS. The ultrasound evaluations examined the thickness of the erector spinae muscle, and the visual analog scale measured the severity of low back pain. Results: There was a decrease in pain score and muscle thickness after the interventions (p ≤ 0.004). There was also a strong correlation between reducing pain and decreasing muscle thickness (R = 0.709; p = 0.000). Conclusion: Following TENS in the lumbar, in addition to reducing pain, the thickness of the erector spinae muscles also decreased. Clinical Trial Registration: IRCT20200423047173N1 (ClinicalTrials.gov).

Accurate Diagnosis and Treatment of Painful Temporomandibular Disorders: A Literature Review Supplemented by Own Clinical Experience

Introduction

Temporomandibular disorders (TMD) is a multifactorial group of musculoskeletal disorders often with combined etiologies that demand different treatment plans. While pain is the most common reason why patients decide to seek help, TMD is not always painful. Pain is often described by patients as a headache, prompting patients to seek the help of neurologists, surgeons, and ultimately dentists. Due to the unique characteristics of this anatomical area, appropriate diagnostic tools are needed, as well as therapeutic regimens to alleviate and/or eliminate the pain experienced by patients. Aim of the Study. The aim of this study is to collect and organize information on the diagnosis and treatment of pain in TMD, through a review of the literature supplemented by our own clinical experience. Material and Methods. The study was conducted by searching scientific databases PubMed, Scopus, and Google Scholar for documents published from 2002-2022. The following keywords were used to build the full list of references: TMD, pain, temporomandibular joint (TMJ), TMJ disorders, occlusal splint, relaxing splints, physiotherapy TMD, pharmacology TMD, natural therapy TMD, diagnostic criteria for TMD, and DC/TMD. The literature review included 168 selected manuscripts, the content of which was important for pain diagnosis and clinical treatment of TMD.

Results

An accurate diagnosis of TMD is the foundation of appropriate treatment. The most commonly described treatments include physiotherapy, occlusal splints therapy, and pharmacological treatment tailored to the type of TMD.

Conclusions

Based on the literature review and their own experience, the authors concluded that there is no single ideal form of pain therapy for TMD. Treatment of TMD should be based on a thorough diagnostic process, including the DC/TMD examination protocol, psychological evaluation, and cone beam computer tomography (CBCT) imaging. Following the diagnostic process, once a diagnosis is established, a treatment plan can be constructed to address the patient's complaints.

Comparative assessment of chewing sugar-free gum and conventional analgesic drugs in alleviating self-reported pain associated with fixed orthodontic appliances: A systematic review and meta-analysis

OBJECTIVE

To compare the effect of chewing sugar-free gum towards alleviating self-reported orthodontic treatment (OT) pain compared with conventional analgesic drugs (CADs).

SEARCH SOURCES

An unrestricted search of indexed databases and manual searching was performed up to September 2021.

DATA SELECTION

Randomised controlled trials (RCTs) comparing the impact of chewing gum and CADs on relieving self-reported orthodontic pain were included.

DATA EXTRACTION

Data screening, extraction and risk of bias (RoB) assessment were performed by two authors. Meta-analyses were performed using a random-effects model. The quality of available evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

Nine RCTs were included. Eight RCTs used the Visual Analogue Scale for self-reported pain assessment, while one RCT used the Numeric Rating Scale. Five RCTs had a high RoB and four RCTs had a moderate RoB. Power analysis for sample size estimation was performed in six RCTs. Separate meta-analyses were performed by pooling quantitative data from five RCTs that compared self-reported orthodontic pain between chewing gum and ibuprofen groups for the following timepoints: baseline; immediately; 2 hours; 6 hours; bedtime; 24 hours; 2 days; 3 days; 5 days; and 7 days after the placement of orthodontic appliances. None of the timepoints individually indicated a difference in self-reported pain scores between chewing sugar-free gum and ibuprofen groups. The overall level of evidence was very low.

CONCLUSION

Chewing sugar-free gum is a potentially useful alternative to CADs towards pain alleviation during fixed OT.

A novel form of transcutaneous electrical nerve stimulation for the reduction of dysesthesias caused by spinal nerve dysfunction: A case series

Background

Current therapeutic interventions for dysesthesias caused by spinal cord dysfunctions are ineffective. We propose a novel intervention using transcutaneous electrical nerve stimulation (TENS) for dysesthesias, and we present an in-depth case series.

Patients and methods

Conventional high-frequency TENS and the novel dysesthesia-matched TENS (DM-TENS) were applied to 16 hands of nine patients with spinal cord dysfunction. The dysesthesia-matched TENS’ stimulus intensity and frequency matched the intensity and somatosensory profile of the patients’ dysesthesias. The Short-Form McGill Pain Questionnaire version-2 (SF-MPQ2) and quantitative sensory testing (QST) were applied during electrical stimulation/no stimulation. We determined intraclass correlation coefficients (ICCs) to evaluate the reliability of the setting and the effects on the dysesthesias and the change in subjective dysesthesia between each patient’s baseline without TENS and DM-TENS.

Results

We were able to apply electrical stimulation matching the patients’ subjective dysesthesia for 14 hands (eight patients). TENS could not be applied for the remaining patient due to severe sensory deficits. Compared to the patients’ baseline and high-frequency TENS, the DM-TENS provided significant decreases in tingling/pins-and-needles and numbness on the SF-MPQ2, and it significantly improved the dynamic and static mechanical detection on QST. Regarding the reliability of the dysesthesia-matched TENS settings, the ICCs (1,5) were intensity, 0.95; frequency, 1.00; and effect on dysesthesia, 0.98.

Conclusion

DM-TENS improved the dysesthesias and mechanical hypoesthesia caused by spinal cord dysfunction. The effectiveness of DM-TENS particularly for tingling and numbness was clearly higher and was reliable within the patients. These results may suggest an effective treatment of dysesthesias in patients with spinal cord dysfunction.

Clinical trial registration

[https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000045332], identifier [UMIN000045332].

Comparative Evaluation of the Effectiveness of Different Pain-alleviating Methods before Local Anesthetic Administration in Children of 6 to 12 Years of Age: A Clinical Study

Background and aim of the study

Pediatric patients are apprehensive regarding having dental treatment mainly because of painful local anesthetic (LA) injections. Various techniques like transcutaneous electrical nerve stimulation (TENS), topical anesthetic agents, and vibrator device are introduced to reduce discomfort before LA administration. Therefore, the present study aimed to compare and evaluate the effectiveness of TENS, 2% lignocaine gel, eutectic mixture of lignocaine and prilocaine (EMLA), and vibrating device before LA injections in alleviating pain in pediatric patients.

Materials and methods

Sixty healthy children aged 6 to 12 years who required LA injections for dental procedures were selected and divided into four groups with 15 patients in each group. Wong–Baker's facial pain rating scale (WBFPRS) and face, legs, activity, cry, and consolability scale (FLACC) are used for pain perception which are tabulated, and statistically analyzed.

Results

The test results demonstrated that the TENS group has shown the least mean WBFPRS and FLACC score, followed by vibrator devices, EMLA gel, and lignocaine gel.

Conclusion

The newly introduced TENS apparatus showed encouraging results, hence can be used as a safe and reliable technique to be used in pediatric dentistry.

How to cite this article

Patil SB, Popali DD, Bondarde PA, et al. Comparative Evaluation of the Effectiveness of Different Pain-alleviating Methods before Local Anesthetic Administration in Children of 6 to 12 Years of Age: A Clinical Study. Int J Clin Pediatr Dent 2021;14(4):447–453.

Transcutaneous Electrical Nerve Stimulation: A Review of Dental Applications

Transcutaneous electrical nerve stimulation or TENS is a nonpharmacologic method that is used to alleviate pain from various acute and chronic conditions. TENS works through activation of descending inhibitory neurons of the central nervous system. In dentistry, TENS has applications for pain reduction in temporomandibular disorders and postherpetic neuralgia. It has also been studied for its role in increasing salivary secretion in subjects with xerostomia and as a local anesthetic agent in pediatric dentistry. Its wide applications in the orofacial region make it an important treatment modality. The purpose of the present review was to describe the general principles and its applications in dentistry along with its indications, advantages, and disadvantages. A web-based search was conducted using the keywords “transcutaneous electrical nerve stimulation,” “temporomandibular joint,” “TENS,” “TMJ,” “orofacial pain,” and “Management.” The manuscripts thus obtained were evaluated and used for compiling the present narrative review. The present review focuses on the mechanism of action, applications, and effectiveness of TENS in the management of diseases of the maxillofacial region.

Auxiliary Aids to Alleviate Pain and Anxiety during Local Anesthesia Administration: A Comparative Study

Introduction

In dentistry, pain and anxiety have been the most challenging aspect in the management of a pediatric patient. When every effort to perform local anesthesia (LA) is not successful, the result would be more stressful for both the dentist and the patient. The so-called clichéd paradigm that “pain and dentistry are inseparable” can be resolved by updating the knowledge and skills of the practitioner by using the more advanced techniques in controlling and managing the pain. An array of techniques for administering the LA to improve the comfort level of our patients has been the area of interest.

Aim and objective

To evaluate and compare the efficacy of various adjunctive aids of LA in reducing pain and anxiety in pediatric patients of the 6–8 years age-group. A total of 90 child dental patients were selected and randomly divided into six groups, i.e., control, topical gel, audio, audiovisual, transcutaneous electric nerve stimulation (TENS), and Vibraject group. Physiological parameters, psychological parameters, and pain assessment were recorded.

Results

As reflected by the results, the minimum pulse rate “during” and “after” LA administration is seen in A/V (D) and TENS (E) “during” LA administration. Children were less anxious and more relaxed in the audiovisual group and TENS group. Transcutaneous electric nerve stimulation and Vibraject groups showed maximum reduction in pain.

Conclusion

A/V (D) and TENS (E) groups exhibited the least anxiety. Also, the minimum pain was felt using TENS (E) and Vibraject (F) and hence, may be considered as adjunctive aids in pain reduction during LA administration.

How to cite this article

Midha V, Midha V, Dua R, et al. Auxiliary Aids to Alleviate Pain and Anxiety during Local Anesthesia Administration: A Comparative Study. Int J Clin Pediatr Dent 2021;14(1):104–108.

Parameterization of physical properties of layered body structure into equivalent circuit model

Background

This study presents a novel technique to develop an equivalent circuit model (ECM) for analyzing the responses of the layered body structure to transcutaneous electrical nerve stimulation (TENS) by parameterizing electrical and geometrical properties.Many classical ECMs are non-parametric because of the difficulty in projecting intrapersonal variability in the physical properties into ECM. However, not considering the intrapersonal variability hampers patient-specifically analyzing the body response to TENS and personal optimization of TENS parameter design. To overcome this limitation, we propose a tissue property-based (TPB) approach for the direct parameterization of the physical properties in the layered body structure and thus enable to quantify the effects of intrapersonal variability.

Results

The proposed method was first validated through in vitro phantom studies and then was applied in-vivo to analyze the TENS on the forearm. The TPB-ECM calculated the impedance network in the forearm and corresponding responses to TENS. In addition, the modelled impedance was in good agreement with well-known impedance properties that have been achieved empirically.

Conclusions

The TPB approach uses the parameterized circuit components compared to non-parametric conventional ECMs, thus overcoming the intrapersonal variability problem of the conventional ECMs. Therefore, the TPB-ECM has a potential for widely-applicable TENS analysis and could provide impactful guidance in the TENS parameter design.

Supplementary Information

The online version contains supplementary material available at (10.1186/s42490-021-00054-8).

Neuro-Muscular Dentistry: the "diamond" concept of electro-stimulation potential for stomato-gnathic and oro-dental conditions

Oro-Pharyngeal Dysphagia - or simply dysphagia - is the difficulty (persistent) in swallowing/passing food and/or liquid from the mouth to the pharynx into the esophagus and finally the stomach; a deglutition disorder (a symptom, by definition, often due to neuro-degenerative/−muscular, drug-induced or localized structural pathologies such as head and neck tumors, lesions and associated surgical and/or radiation injuries) linked to severe consequences on Quality of Life (QoL), including malnutrition, dehydration, and even sudden death. Likewise, Temporo-Mandibular Jaw and Joint disorder(s) – or simply TMD – is a multifactorial etiological condition, regularly encountered in the dental office. Whether due to malocclusion, bruxism, stress and/or trauma, TMD destabilizes the whole cranio-mandibular system structurally and functionally, via affecting mastication, teeth, supporting structures, comfort and aesthetics, and thus, QoL, again. While several treatment regimens do exist for such conditions, some of which have been standardized for use over the years, most continue to lack proper evidence-based literature support. Hence, (1) caution is to be exercised; and (2) the need for alternative therapeutic strategies is amplified, subsequently, the door for innovation is wide open. Indeed, neuromuscular electrical stimulation or “NMES”, is perhaps a fine example. Herein, we present the interested oro-dental health care provider with an up-dated revision of this therapeutic modality, its potential benefits, risks and concerns, to best handle the dysphagic patient: an intra-disciplinary approach or strategy bridging contemporary dentistry with speech and language therapy; a rather obscure and un-discovered yet critical allied health profession. A pre-clinical and clinical prospectus on employing inventive NMES-based regimens and devices to manage TMD is also highlighted.

The Effect of Transcutaneous Electric Nerve Stimulation (TENS) on Anxiety and Fear in Children Aged 9-14 Years

Introduction

Dental fear or dental phobia is caused by previous unpleasant dental experiences and pain. It can result in delaying or avoiding dental visits. Most often it leads to individuals avoiding visiting the dentist until physical pain completely impairs the quality of life.

Objectives

Transcutaneous electrical nerve stimulation (TENS) is a method of pain relief involving the use of a mild electrical current. The main aim of this study was to examine whether the TENS device affects the reduction of anxiety and fear during dental procedures.

Material and Methods

The study was conducted on a sample of 125 respondents, aged 9-14 years. Statistical significance of differences between pre- and post-treatment results on all applied measuring instruments was verified by the t-test for dependent samples. The calculation was performed for all respondents and individually for the three observed groups. The Children`s Fear Survey Schedule – Dental Subscale test was used to assess anxiety and fear.

Results

The results on the CFSS-DS scale in all subjects did not differ statistically significantly before and after treatment (p > 0.05). The results on the CFSS-DS scale in subjects who received TENS were statistically significantly different before and after treatment (p < 0.01). The results on the CFSS-DS scale in subjects who received local anesthesia were statistically significantly different before and after treatment (p < 0.05).

Conclusion

The TENS device had an anxiolytic effect after the first visit.

Bio Electro Magnetic Energy Regulation (BEMER) therapy in myofascial pain dysfunction syndrome: A preliminary study

Background

Myofacial pain dysfunction syndrome (MPDS) is of the commonest form of orofacial pain encountered in the clinics. Though, many therapies have been suggested in the recent past, still the management of this condition remains a therapeutic problem. The search for newer, relatively safe and effective long term approach lead to the use of magnetic stimulation in pain modulation. Bio Electro Magnetic Energy Regulation is one such modality that has been studied in the musculoskeletal disorders. However, no studies in this regard have been explored in orofacial region.

Objectives

The objective of the present study was to evaluate the efficacy of BEMER therapy as an adjuvant to relieve pain in myofascial pain dysfunction syndrome.

Materials and methods

The present randomized comparative study was on 40 patients who were diagnosed with Myofacial pain dysfunction syndrome(MPDS). They were grouped into two groups of 20 each. Group 1 patients were administered analgesic + muscle relaxants & Group 2 was receiving both analgesic + muscle relaxants with BEMER therapy. All the patients were evaluated for pain relief on visual analog scale (VAS) and the mouth opening (MO)was measured using digital vernier callipers.

Results

The group 2 showed a significant improvement in the symptoms even after 2 months follow up. In group 2 the mean mouth opening was 45.60 ± 3.648(P < 0.05) and 45.50 ± 3.663(P < 0.05); the Mean VAS Score was 3.10 ± 0.912 and 2.90 ± 0.968(P < 0.05) after one month and after two months respectively. The independent t-test, was used for inferential statistics.

Conclusion

It can be concluded from this study that Combined therapy proved to be more effective in providing long term symptomatic relief compared to conventional pharmacological therapy. BEMER as an adjuvant therapeutic modality proved to be beneficial in the management of MPDS.

Emerging medical applications based on non-ionizing electromagnetic fields from 0 Hz to 10 THz

The potential for using non-ionizing electromagnetic fields (EMF; at frequencies from 0 Hz up to the THz range) for medical purposes has been of interest since many decades. A number of established and familiar methods are in use all over the world. This review, however, provides an overview of applications that already play some clinical role or are in earlier stages of development. The covered methods include modalities used for bone healing, cancer treatment, neurological conditions, and diathermy. In addition, certain other potential clinical areas are touched upon. Most of the reviewed technologies deal with therapy, whereas just a few diagnostic approaches are mentioned. None of the discussed methods are having such a strong impact in their field of use that they would be expected to replace conventional methods. Partly this is due to a knowledge base that lacks mechanistic explanations for EMF effects at low-intensity levels, which often are used in the applications. Thus, the possible optimal use of EMF approaches is restricted. Other reasons for the limited impact include a scarcity of well-performed randomized clinical trials that convincingly show the efficacy of the methods and that standardized user protocols are mostly lacking. Presently, it seems that some EMF-based methods can have a niche role in treatment and diagnostics of certain conditions, mostly as a complement to or in combination with other, more established, methods. Further development and a stronger impact of these technologies need a better understanding of the interaction mechanisms between EMF and biological systems at lower intensity levels. The importance of the different physical parameters of the EMF exposure needs also further investigations.

New method for postoperative pain relief using a combination of noxious and non-noxious stimuli after impacted wisdom tooth extraction

Although in clinical dentistry the major method used for pain relief is oral administration of analgesics, alternative methods are available, such as transcutaneous electrical nerve stimulation (TENS), acupuncture, vibration and conditioned pain modulation (CPM), formerly termed diffuse noxious inhibitory control. The aim of the present study was to investigate the combined effects of non-noxious (TENS) and noxious (CPM) stimuli on postoperative pain after extraction of an impacted wisdom tooth. The study involved 44 patients who were scheduled to undergo impacted wisdom tooth extraction. The patients were randomly allocated into four groups: noxious stimuli, non-noxious stimuli, combined noxious and non-noxious stimuli, and a sham group. On the day after tooth extraction, stimulation procedures for pain relief were performed and changes in the level of perceived pain were scored using a visual analog scale (VAS). The combination of non-noxious and noxious stimuli decreased the VAS scores by 63.7%, indicating a more potent analgesic effect than that in the non-noxious, noxious, and sham groups. This method of analgesia using a combination of non-noxious and noxious stimuli can be applied to patients who are unable to tolerate analgesics, such as those with allergy, hypersensitivity or digestive disorders, and those who are pregnant.

Alternative practices of achieving anaesthesia for dental procedures: a review

Managing pain and anxiety in patients has always been an essential part of dentistry. To prevent pain, dentists administer local anaesthesia (LA) via a needle injection. Unfortunately, anxiety and fear that arise prior to and/or during injection remains a barrier for many children and adults from receiving dental treatment. There is a constant search for techniques to alleviate the invasive and painful nature of the needle injection. In recent years, researchers have developed alternative methods which enable dental anaesthesia to be less invasive and more patient-friendly. The aim of this review is to highlight the procedures and devices available which may replace the conventional needle-administered local anaesthesia. The most known alternative methods in providing anaesthesia in dentistry are: topical anaesthesia, electronic dental anaesthesia, jet-injectors, iontophoresis, and computerized control local anaesthesia delivery systems. Even though these procedures are well accepted by patients to date, it is the authors' opinion that the effectiveness practicality of such techniques in general dentistry is not without limitations.

Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain and Photophobia

INTRODUCTION

"Dry eye" or "keratoconjunctivitis sicca" is a multifactorial disease estimated to have a worldwide prevalence of 5-33%. Conventional therapies targeting the ocular surface with artificial tears, anti-inflammatories, punctal closure, eyelid hygiene, and antibiotics do not provide relief in all patients, especially those with neuropathic-like ocular complaints (wind hyperalgesia and photophobia). We anticipated that ocular transcutaneous electrical nerve stimulation (TENS) would alleviate symptoms of ocular pain, photophobia, and dryness in these latter individuals.

METHODS

All individuals who received electrical stimulation between May 10, 2016 and April 6, 2017 for the treatment of chronic ocular pain at the oculofacial pain clinic of the Miami Veterans Administration Hospital were included in this retrospective review. All patients had symptoms of dryness along with other neuropathic-like symptoms (e.g., photophobia) and minimal signs of tear dysfunction. Ocular pain intensity, symptoms of dryness, and light sensitivity were compared pre-treatment and five min post-treatment via a two-tailed paired Student's t-test.

RESULTS

The use of TENS significantly reduced the mean pain intensity in both the right and left eyes five min after treatment compared to prior to treatment (p < 0.05, paired t-test). The use of TENS significantly decreased light sensitivity in both eyes (p < 0.05). The findings for symptoms of dryness, however, were equivocal with a significant decrease in the left eye but not the right (p < 0.05, paired t-test).

DISCUSSION

Our data indicate that TENS may similarly provide analgesia in patients with dry eye symptoms as it does for many other chronic pain conditions. Furthermore, the noted effect on symptoms of photophobia and dryness suggest that all may be linked by similar trigeminal-thalamic-cortical pathways. Prospective studies with electrical stimulation of dry eye are needed to further elucidate its benefit and mechanism of action.

Treatment of hemifacial spasm in patient with hemifacial atrophy using combination therapy (ultrasound therapy and TENS): a case report

A 19-year-old male patient presented with facial hemi-atrophy with unilateral spasms of the masseter and temporalis muscles. Ultrasound therapy and Transcutaneous Electric Nerve Stimulation therapy, known as combination therapy, were given on alternate days for 2 weeks. At the end of 2 weeks of combination therapy the patient reported a drastic reduction in the number of episodes of muscle spasm. The visual analog scale score for tenderness of the masseter and temporalis was also markedly reduced. No one has previously used combination therapy for the treatment of facial hemi-atrophy with hemi-facial spasms. The encouraging results of the combination therapy has prompted us to document this study.

Unraveling the mechanistic effects of electric field stimulation towards directing stem cell fate and function: A tissue engineering perspective

Electric field (EF) stimulation can play a vital role in eliciting appropriate stem cell response. Such an approach is recently being established to guide stem cell differentiation through osteogenesis/neurogenesis/cardiomyogenesis. Despite significant recent efforts, the biophysical mechanisms by which stem cells sense, interpret and transform electrical cues into biochemical and biological signals still remain unclear. The present review critically analyses the variety of EF stimulation approaches that can be employed to evoke appropriate stem cell response and also makes an attempt to summarize the underlying concepts of this notion, placing special emphasis on stem cell based tissue engineering and regenerative medicine. This review also discusses the major signaling pathways and cellular responses that are elicited by electric stimulation, including the participation of reactive oxygen species and heat shock proteins, modulation of intracellular calcium ion concentration, ATP production and numerous other events involving the clustering or reassembling of cell surface receptors, cytoskeletal remodeling and so on. The specific advantages of using external electric stimulation in different modalities to regulate stem cell fate processes are highlighted with explicit examples, in vitro and in vivo.

The endocannabinoid system, a novel and key participant in acupuncture's multiple beneficial effects

Acupuncture and its modified forms have been used to treat multiple medical conditions, but whether the diverse effects of acupuncture are intrinsically linked at the cellular and molecular level and how they might be connected have yet to be determined. Recently, an emerging role for the endocannabinoid system (ECS) in the regulation of a variety of physiological/pathological conditions has been identified. Overlap between the biological and therapeutic effects induced by ECS activation and acupuncture has facilitated investigations into the participation of ECS in the acupuncture-induced beneficial effects, which have shed light on the idea that the ECS may be a primary mediator and regulatory factor of acupuncture's beneficial effects. This review seeks to provide a comprehensive summary of the existing literature concerning the role of endocannabinoid signaling in the various effects of acupuncture, and suggests a novel notion that acupuncture may restore homeostasis under different pathological conditions by regulating similar networks of signaling pathways, resulting in the activation of different reaction cascades in specific tissues in response to pathological insults.

Electrical nerve stimulation for xerostomia: A meta-analysis of randomised controlled trials

BACKGROUND

Xerostomia leads to caries, infection and overall psychological discomfort. Salivary substitutes and pharmacological agents have been tried only with temporary relief. The use of transcutaneous electrical nerve stimulation (TENS) has been contemplated on by various researchers for treatment of xerostomia. We carried out the present review as a systematic compilation and quantitative synthesis of the existing evidence related to the utility of TENS in patients with xerostomia.

METHODOLOGY

Six randomized controlled trials were identified from databases for inclusion and analysed using non-Cochrane mode in RevMan 5.0 software. The heterogeneity between the studies were assessed using Forest plot, I² statistics wherein more than 50% was considered to have moderate to severe heterogeneity and Chi-square test with a statistical P-value of less than 0.10 to indicate statistical significance.

RESULTS

Results show that the effect of TENS on salivary flow rate in 369 participants with SMD [95% CI] was 0.63 [-0.03, 1.29] and was not statistically significant.

CONCLUSION

To conclude, the current evidence does not support the use of TENS in patients with xerostomia and may be considered as a salivary substitute for symptomatic improvement. However the type, frequency and amplitude of current used needs to be studied in detail. High quality randomized controlled trials with adequate power are required, either to support or refute the use of TENS in xerostomia.

Does noninvasive electrical stimulation of acupuncture points reduce heelstick pain in neonates?

AIM

Noninvasive electrical stimulation at acupuncture points (NESAP) for analgesia is used in children, but has not been widely studied in neonates. The purpose of this study was to determine whether NESAP alone or in combination with sucrose relieved heelstick pain in neonates.

METHODS

Term neonates (n = 162) receiving routine heelsticks for newborn screening were enrolled following parental consent. All infants received facilitated tucking and non-nutritive sucking. Neonates were randomised to standard care, sucrose, NESAP or sucrose plus NESAP. NESAP (3.5 mA, 10 Hz) or sham was administered over four acupuncture points. The Premature Infant Pain Profile (PIPP), heart rate variability (HRV) and salivary cortisol were used to measure heelstick pain.

RESULTS

PIPP scores among all four treatment groups increased during heelstick, F (9,119) = 1.95, p = 0.05 and NESAP therapy had no significant effect on PIPP scores. However, PIPP scores from baseline to heelstick increased the most in the two groups not receiving sucrose (p < 0.01). Mean PIPP scores remained below five during the heelstick in all four groups, indicating minimal or no pain. Differences in HRV and salivary cortisol among groups were insignificant.

CONCLUSION

NESAP at 3.5 mA, 10 Hz is not effective in relieving pain during heelsticks in neonates.

Preemptive Analgesic Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on Postoperative Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological analgesic method used to control different types of pain.

Objectives

The aim of this study was to evaluate the effects of preoperative TENS on post inguinal hernia repair pain.

Patients and Methods

This randomized, double-blind, placebo-controlled clinical trial was performed on 66 male patients with unilateral inguinal hernias who were admitted to the Shahid Beheshti hospital in Kashan, Iran, from April to October 2014. Participants were selected using a convenience sampling method and were assigned to intervention (n = 33) and control (n = 33) groups using permuted-block randomization. Patients in the intervention group were treated with TENS 1 hour before surgery, while the placebo was administered to patients in the control group. All of the patients underwent inguinal hernia repair by the Lichtenstein method, and pain intensity was evaluated at 2, 4, 6, and 12 hours after surgery using a visual analogue scale. Additionally, the amounts of analgesic administered by pump were calculated and compared between the two groups.

Results

The mean estimated postoperative pain intensity was 6.21 ± 1.63 in the intervention group and 5.45 ± 1.82 in the control group (P = 0.08). In the intervention group pain intensity at 2 and 4 hours after surgery were 3.54 ± 1.48 and 5.12 ± 1.41 (P < 0.001), respectively. In the control group these values were 4.0±1.5 and 4.76 ± 1.39 (P = 0.04), respectively. No significant differences were observed in mean pain intensities at 6 and 12 hours.

Conclusions

TENS can reduce postoperative pain in the early hours after inguinal hernia repair surgery.