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Evaluation of New Injection and Cavity

Preparation Model in Local Anesthesia
Teaching

Article in Journal of dental education · January 2013

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Evaluation of New Injection and Cavity
Preparation Model in Local Anesthesia
Teaching
Sareh Said Yekta, Ph.D., D.D.S.; Friedrich Lampert, Ph.D., D.D.S.;
Saeid Kazemi, D.D.S.; Reza Kazemi, M.Sc.; Henk S. Brand, Ph.D.;
Jacques A. Baart, D.D.S.; Mina Mazandarani, D.D.S.
Abstract: The aim of this study was to evaluate a recently developed preclinical injection and cavity preparation model in local
anesthesia. Thirty-three dental students administered an inferior alveolar nerve block injection in the model, followed by prepara-
tion on a tooth. The injection was evaluated by three observers, and the feedback from the model was registered. After comple-
tion of the practical session, the opinion of the dental students was explored with a ten-item questionnaire. Thirty dental students
(91 percent) performed the injection correctly according to the feedback of the model, and twenty-eight students (85 percent) did
so according to the expert opinion. The agreement between feedback from the training model and the expert opinion was high.
The students were very satisfied with the opportunity to practice with the training model, as indicated by the high scores on each
item of the questionnaire. These results suggest that use of this preclinical training model in anesthesia teaching may have benefi-
cial effects on the administration of local anesthetics by dental students.
Dr. Said Yekta is in the Department of Conservative Dentistry, Periodontology, and Preventive Dentistry, Aachen University, Ger-
many; Dr. Lampert is in the Department of Conservative Dentistry, Periodontology, and Preventive Dentistry, Aachen University,
Germany; Dr. Kazemi is Lecturer in Computer Science, School of Health and Society, Kristianstad University and DRSK Devel-
opment AB, Sweden; Reza Kazemi is Lecturer in Mechanical Engineering, School of Health and Society, Kristianstad University,
Sweden; Dr. Brand is Assistant Professor, Department of Oral and Maxillofacial Surgery and Department of Periodontology and
Oral Biochemistry, VU University Medical Centre and Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands;
Dr. Baart is in the Department of Oral and Maxillofacial Surgery, VU University Medical Centre and Academic Centre for Den-
tistry Amsterdam, Amsterdam, The Netherlands; and Dr. Mazandarani is Professor, Department of Conservative Dentistry, Peri-
odontology, and Preventive Dentistry, Aachen University, Germany. Direct correspondence and requests for reprints to Dr. Sareh
Said Yekta, Department of Conservative Dentistry, Periodontology, and Preventive Dentistry, Aachen University, Pauwelsstrasse
30, 52074 Aachen, Germany; [email protected].
Keywords: dental education, local anesthesia, educational methodology
Submitted for publication 8/1/11; accepted 3/12/12

L
ocal anesthesia is frequently used during distress.5 Didactic courses may decrease the anxiety
dental treatment. It facilitates more comfort- of dental students in relation to administration of a
able treatment, so that the patient’s comfort is local anesthetic injection.6
mazimized during the treatment and the dentist is able Simple electronic training models that indicate
to work calmly with concentration and precision.1 the accurate site of injection have been available for
However, learning the techniques for the administra- three decades.7,8 Currently, only a minority of dental
tion of local anesthetics is a complex process, and schools use these models before the initial injection
the transition to the first injection of a patient is often on humans, but several other schools have expressed
difficult for dental students.2 plans to introduce them into their curricula.9 Students
Many dental students feel insufficiently pre- who have used a preclinical training model have con-
pared for their first injection in a human. Knowledge sidered it a useful preparation for their first injection
of anatomy and complications of anesthetics have in a human, and many students have supported its
been frequently mentioned as areas in which students introduction into the dental curriculum.3
feel insufficiently prepared.3 This feeling may still be As far as we know, only one study has evalu-
present after graduation as a dentist. Recently gradu- ated the effects of a preclinical training model on
ated dentists indicate that local anesthesia courses subsequent clinical teaching.10 That study found
do not provide adequate preparation for the initial that use of a preclinical training model did not affect
demands of a general practice.4 Nineteen percent the self-reported confidence level of dental students
of dentists in the United States have reported that about injections in a human. However, the recipients
administration of local anesthesia has caused them of the injections rated students who had practiced

January 2013  ■  Journal of Dental Education 51

 on the training model as more confident and calm. the pulp layer can separately generate pseudo-pain
This small improvement was observed despite major signals and consequently different sounds. The jaw
anatomical limitations of the training model used. is equipped with sensors for simulating an anesthetic
Recently, a new injection and preparation injection. By injecting air toward the correct ana-
model has been developed. This model consists tomical space, with the needle positioned near the
of a maxilla, mandible, teeth, and associated soft mandibular foramen, the pseudo-pain signal will be
tissues. Both jaws and teeth are equipped with sen- blocked. When the needle reaches close enough to
sors connected to an embedded computer unit. The the mandibular foramen, pseudo-pain signals from
model simulates pain, and the trainee can practice dentin in the same injected side would be blocked.
the administration of anesthesia near a foramen. The Furthermore, when the injection needle reaches even
purpose of our study was to determine a group of closer to the mandibular foramen, signals from both
dental students’ opinions about the preclinical use of pulp and dentin are blocked.
this injection and preparation model used at Aachen The model displays a light signal represent-
University, Germany. ing the locations of the tip of the injection needle
during the injection. No light means the tip of the
needle is too far from the target site. A yellow light
Methods indicates that the needle is near the correct location.
If the trainee injects air toward this location, after a
The preclinical injection and cavity preparation short waiting time the signals from dentin layer of
model was made available by DRSK Development the tooth model are blocked. The green light turns
AB (Norra Stationsgatan, Hassleholm, Sweden). The on when the tip of the needle is close enough to the
model consists of a maxilla, mandible, teeth, and as- mandibular foramen of the jaw model. An injection
sociated soft tissues (Figure 1). Both jaws and teeth in this area blocks the signals from both the dentin
are equipped with sensors connected to an embed- and pulp layer of the tooth model. After five minutes,
ded computer unit. In the tooth, the dentin layer and this blockade is over, and a new injection is possible.

Figure 1. Preclinical injection and preparation model used in the study

52 Journal of Dental Education  ■  Volume 77, Number 1

 Thirty-three preclinical dental students of the the light indicator, the sounds during preparation, and
dental school of RWTH Aachen University, Ger- the expert opinion was assessed with Cohen’s Kappa
many, participated in this study. All students were in statistics. Levels of significance were set at p<0.05.
the second semester of their third year of study. They
had practiced cavity preparation in the preclinic, but
they had not administered a local anesthetic injection Results
before. During the study, four staff members who
teach injection and cavity preparation were present During the inferior alveolar nerve block injec-
as observers. One staff member recorded the status tion, thirty of the thirty-three dental students (91
of the light indicator. The three other observers percent) succeeded in getting a green signal from the
evaluated the quality of the injection, unaware of training model. The other three students (9 percent)
the light indicator. succeeded in getting a yellow light signal. Accord-
After receiving the regular theoretical instruc- ing to the observers, twenty-eight of the thirty-three
tions regarding the inferior alveolar nerve block injec- participants (85 percent) performed the inferior al-
tion,11 every student had twenty minutes to practice veolar nerve block injection correctly. The agreement
with the model. Each student started with cavity between the status of the light indicator and the expert
preparation. The tooth generated two different sounds opinion was high (K=0.72, p<0.0005). During cavity
depending on whether the dentin or pulp was prepared. preparation, a sound saying “pulp” was registered in
Preparation of enamel did not generate any sound. three cases (9 percent). In all other cases, no sound
The first playing sound was “dentin” when the dentin was recorded. The agreement between the expert
layer was exposed and while the bur was touching or opinion and the sound during cavity preparation was
removing the dentin layer. The second playing sound high (K=0.72, p<0.0005).
was “pulp” when the pulp layer was exposed and while The mean scores of the students on the ten
the bur was touching or removing the pulp tissue. items with regard to the helpfulness of the injection
Subsequently, the student administered an in- and cavity preparation model are shown in Table 2.
ferior alveolar nerve block injection in the model ac- The students were very satisfied with the opportunity
cording to the previous theoretical instructions.1 The to practice with the cavity preparation and injection
injection performed by each student was evaluated model, as indicated by the high scores for each item.
by the three observers. They agreed on one overall Each item of the questionnaire was rated with a score
opinion and qualified the injection as “correct,” of at least 5 (very helpful) or 6 (very much helpful)
“sufficient for superficial preparation,” or “incor- by the majority of the students, except items 4 and
rect.” The status of the light signal of the training 8. These items were scored as 4 (helpful) or higher
model during the injection was registered. After the by the majority of the students. The mean score of
injection, the student had to wait for a short period, item 3, which referred to the use of the model in
depending on the success level of the injection in teaching cavity preparation skills, was considerably
range of one to two minutes, to let the pseudo-pain higher than the mean score of item 4, which referred
signals become blocked. The waiting period was to the potential use of the model in grading prepara-
dependent on how close the tip of the needle was to tion skills during examinations. A similar difference
the mandibular foramen. After the waiting period, was observed with regard to mandibular nerve block
the student prepared a cavity on the same tooth, and skills (items 7 and 8).
the sounds heard during preparation were registered.
After completion of the practical session, the
dental students were asked to indicate their level of Discussion
agreement on ten items (Table 1). Each item was Administration of a mandibular nerve block
quantified with a seven-point scale (from 0=not help- will achieve adequate anesthesia in approximately 85
ful at all to 6=very much helpful). An option of “I percent of the cases.12 Important points for a correct
have no idea” was also included for all items. Data injection are recognition of anatomical landmarks,
were entered into an Excel spreadsheet, and for each like the deepest point of the anterior aspect of the
item the means and standard deviation were calculat- ascending ramus, the plane of occlusion, and the
ed. Data were analyzed using the statistical software distance between the anterior and posterior aspect
package PASW version 15.0 Statistics 18.0.2 (IBM, of the ascending ramus.1 In observational studies,
Somers, USA). The agreement among the status of painful sensations during insertion of the needle for

January 2013  ■  Journal of Dental Education 53

 Table 1. Opinions of dental students on helpfulness of a new injection and cavity preparation model, by number and
percentage of total respondents to each question (n=26 to 33)
Not Helpful Very Much
at All Helpful

Question 0 1 2 3 4 5 6

1. Cavity preparation on a tooth generates signals 0 0 0 0 5 (15%) 14 (42%) 14 (42%)

representing a sensitive layer of the tooth. How
helpful might this function be for students?
2. Cavity preparation on a tooth in dentin or pulp 0 0 0 2 (6%) 4 (12%) 17 (52%) 10 (30%)
generates two different signals representing
dentin or pulp layer. How helpful might this be
for students?
3. How do you evaluate the model as a training 0 0 0 1 (3%) 6 (19%) 12 (38%) 13 (41%)
aid for teaching cavity preparation skills?
4. How do you evaluate the model as a training 0 0 1 (3%) 6 (19%) 12 (38%) 7
(22%) 6 (19%)
aid for grading cavity preparation skills of
students in exams?
5. How does the model represent the superficial 0 0 1 (3%) 3 (10%) 6 (19%) 13 (42%) 8 (26%)
anatomy and landmarks with regard to mandibular
block?
6. How does the model represent the internal 0 0 1 (3%) 2 (7%) 7 (24%) 15 (52%) 4 (14%)
anatomy with regard to mandibular block?
7. How do you evaluate the model as a training 0 0 0 1 (3%) 8 (24%) 15 (46%) 9 (27%)
aid for teaching mandibular block?
8. How do you evaluate the model as a training 0 0 0 7 (22%) 9 (28%) 10 (31%) 6 (19%)
aid for grading the mandibular block skills of
students in exams?
9. In the model, when the injection needle gets 0 0 0 0 5 (16%) 12 (38%) 15 (47%)
close enough to the mandibular foramen,
signals from dentin are blocked. Furthermore,
when the injection needle gets even closer to
the mandibular foramen, signals from dentin
and pulp are blocked. How helpful might this
function be for students?
10. How do you grade the model when it is 0 0 0 0 3 (12%) 6 (23%) 17 (65%)
compared with the traditionally used models
in terms of being helpful for students to increase
their injection skill?
Note: Each item was measured on a six-point scale, ranging from 0=not helpful at all to 6=very much helpful. Percentages may not total
100% because of rounding.

mandibular block anesthesia were reported by 0.9 to It is expected that in the near future virtual
6.3 percent of the patients.13-16 These reactions may reality may play a role in the teaching of landmarks
occur when the needle touches the periosteal layer of and insertion points,17,18 but as far as we know, such
the ascending ramus, a nerve, or the artery wall.1,16 models are not available yet. However, simple train-
A previous study suggested the preclinical ing models that indicate the site of injection have
use of human cadavers as a teaching method for the been available for three decades.7,8 Dental students
injection of mandibular block injection techniques.2 who used a preclinical training model in one study
This would give dental students the opportunity to considered it a useful preparation for their first injec-
practice the insertion of the needle using anatomi- tion in a human.3 Another study, which evaluated the
cal landmarks before their first administration of effects of a preclinical training model on subsequent
mandibular anesthesia in a living individual, usually clinical teaching, found that students who practiced
a patient or fellow student.3,9 However, in a recent on the model were considered more confident and
survey among dental schools in Europe, no school calm by the recipients of their first injection.10 A
reported the use of human cadavers for local anes- near-significant decrease in pain during the insertion
thesia education,9 which may be related to ethical of the needle was also reported in that study. These
and logistical problems. positive effects of a preclinical training model in

54 Journal of Dental Education  ■  Volume 77, Number 1

Table 2. Mean scores and standard deviation for dental students’ opinions regarding helpfulness of a new injection and
cavity preparation model
Mean±Standard
Question Deviation

1. Cavity preparation on a tooth generates signals representing a sensitive layer of the tooth. How 5.27±0.72 (n=33)
helpful might this function be for students?
2. Cavity preparation on a tooth in dentin or pulp generates two different signals representing dentin 5.06±0.83 (n=33)
or pulp layer. How helpful might this be for students?
3. How do you evaluate the model as a training aid for teaching cavity preparation skills? 5.16±0.85 (n=32)
4. How do you evaluate the model as a training aid for grading cavity preparation skills of the students 4.34±1.10 (n=32)
in exams?
5. How does the model represent the superficial anatomy and landmarks with regard to mandibular 4.77±1.06 (n=31)
block?
6. How does the model represent the internal anatomy with regard to mandibular block? 4.66±0.94 (n=29)
7. How do you evaluate the model as a training aid for teaching mandibular block? 4.97±0.81 (n=31)
8. How do you evaluate the model as a training aid for grading the mandibular block skills of students 4.47±1.05 (n=32)
in exams?
9. In the model, when the injection needle gets close enough to the mandibular foramen, signals from 5.31±0.74 (n=32)
dentin are blocked. Furthermore, when the injection needle gets even closer to the mandibular
foramen, signals from dentin and pulp are blocked. How helpful might this function be for students?
10. How do you grade the model when it is compared with the traditionally used models in terms of 5.54±0.71 (n=26)
being helpful for students to increase their injection skill?
Note: Each item was measured on a six-point scale from 0=not helpful at all to 6=very much helpful.

local anesthesia education were observed despite training in the dental curriculum.3 Recently, some
anatomical limitations of the models, such as the dental schools have reported that they intend to in-
poor representation of the oral mucosa in the area troduce such models in their regular local anesthesia
of the ascending ramus of the mandible. Therefore, teaching program.9 Our experiences with the model
during the development of our new training model, described here seem to support these recommenda-
special attention was given to a realistic represen- tions to introduce preclinical training models into the
tation of landmarks, which are important for the dental curriculum. It may offer students a possibility
correct administration of mandibular block anes- to rehearse their skills, even without supervision by
thesia. Therefore, the mandibular bone of the model a staff member, before they perform a real injection.
includes the bilateral ramus, mandibular foramen, This may have positive effects on the administration
coronoid process, mandibular notch, coronoid notch, of local anesthetics by dental students and may help
and sigmoid notch (Figure 2). The soft tissue of the to prepare them for the demands of general practice.
model includes the bilateral mucobuccal fold, ptery-
gomandibular raphe, pterygomandibular depression, Acknowledgments
and mandibular sulcus (Figure 1). Furthermore, the The authors thank the Faculty of Odotology,
bilateral coronoid notch and the posterior border of Malmö University in Sweden; Cecilia Christersson,
the ramus are palpable under the soft tissue similar Head of the Department of Dental Technology and
to a real mouth (Figures 2 and 3). Material Science, for her professional and expertise
In our study using this improved training contribution; and Lars Eriksson, Head of the Depart-
model, the dental students were very positive about ment of Oral Surgery and Oral Medicine, for his kind
the anatomy and landmarks of the training model and critical supervision regarding the anatomical
for mandibular block anesthesia (Tables 1 and 2). improvement of the model. The authors also thank
Using these landmarks, 85 percent of the students Maziar Mir, Department of Conservative Dentistry,
performed the injection correctly, according to the Periodontology, and Preventive Dentistry, Aachen
opinion of the observers. This suggests that practice University, Germany for his critical role in the start-
with this model may be a useful preparation for the up of the study, and Afsaneh Shahrokhi Rad, Dental
first injection of a dental student in a human. Research Center, Tehran University of Medical Sci-
Many dental students have suggested the in- ences, Iran for her professional contributions.
troduction of preclinical models for local anesthesia

January 2013  ■  Journal of Dental Education 55

 Figure 2. Lateral aspect of ascending ramus of the mandible

Note: The entrance of the mandibular canal (at the inner site of the ramus) is situated in a horizontal line behind the deepest point of the
anterior aspect of the ramus, exactly halfway the anterior-posterior distance.

Figure 3. Example of administration of mandibular block anesthesia in the model with approach from the contralateral
premolar region

Note: The non-dominant hand is used to retract the buccal soft tissue (thumb in coronoid notch of the mandible; depth of injection
25mm).

56 Journal of Dental Education  ■  Volume 77, Number 1

 10. Brand HS, Baart JA, Maas NE, Bachet I. Effect of a
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January 2013  ■  Journal of Dental Education 57

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