|Year : 2014 | Volume
| Issue : 1 | Page : 32-37
|Impact of gender on attitude toward student-to-student local anesthesia administration
Navaneetha Cugati1, Ramesh Kumaresan2, Balamanikanda Srinivasan2
1 Departments of Pedodontics and Preventive Dentistry, Lecturer in Pediatric Dentistry, AIMST University, Semeling 08100, Bedong, Kedah Darul Aman, Malaysia
2 Departments of Oral and Maxillo Facial Surgery, Lecturer, Faculty of Dentistry, AIMST University, Semeling 08100, Bedong, Kedah Darul Aman, Malaysia
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|Date of Web Publication||17-Oct-2014|
| Abstract|| |
Introduction: In the undergraduate dental curriculum, student-to-student administration of first local anesthetic injection remains to be a traditional method in most of the dental institutions. This exercise is often foreseen by heterogeneous emotional responses both in student operator and respondent.
Aim: This study evaluated the variations in attitude toward student-to-student LA administration and the associated anxiety levels among the genders.
Materials and Methods: 40 female and 24 male preclinical dental students were provided with a questionnaire, containing statements of agreement. The experience and opinion throughout the procedure of first LA mandibular block administration was scored by the students using five-point Likert's scale and their anxiety levels were measured with 'interval scale of anxiety response' (ISAR) before, during and after administration of LA. The results were tested with Chi-Square test and Mann-Whitney test was used to know the significance of gender variation.
Result: The perception of the operators as well as the recipient on mandibular anesthetic block injection analyzed by chi-square test showed significant values (P < 0.05) for all the statements. However, the gender variation performed by means of Mann-Whitney test demonstrated no significant statistical results. The anxiety evaluation using Mann-Whitney test showed significant variation among the genders both as an operator and respondent, except for the anxiety level of the operator after the injection procedure.
Conclusion: This study illustrated the preparedness of the preclinical students for their first local anesthetic injections on humans and suggests for the required modification in the existing dental curriculum for a better training
Keywords: Administration, anxiety, gender, local anesthesia, student to student
|How to cite this article:|
Cugati N, Kumaresan R, Srinivasan B. Impact of gender on attitude toward student-to-student local anesthesia administration
. J Educ Ethics Dent 2014;4:32-7
|How to cite this URL:|
Cugati N, Kumaresan R, Srinivasan B. Impact of gender on attitude toward student-to-student local anesthesia administration
. J Educ Ethics Dent [serial online] 2014 [cited 2019 Nov 14];4:32-7. Available from: http://www.jeed.in/text.asp?2014/4/1/32/143181
| Introduction|| |
Reducing anxiety and enhancing the patients comfort level enables dentist to deliver précised dental therapy.  This can be facilitated by administration of local anesthesia (LA), one of the common procedures performed during routine dental practice. Administering LA is an apprehensive procedure and mastering this complex maneuver requires not only assured teaching, but also veracious practice of LA administration in the dental curriculum.  Although various methods for LA training exists in an undergraduate dental curriculum such as training models, nonhuman objects, and cadavers, student-to-student administration still remains a traditional method in most of the dental institutions across the globe. , Most of the dental students feel themselves insufficiently prepared to administer or receive LA injections. This exercise is often foreseen by a feel of distress, anxiety, or fear, for which their responses are heterogeneous.  The anxiety response to such a situation is subjective and could be innate or due to the past unpleasant experiences, anticipated injuries, pain due to injection or the injection procedure per se. Managing such an event is a challenging task for the operators and requires diverse proficiency to instill an affirmative attitude in them as well as in the recipients.
The feel of distress during the exercise of LA injection for both the operator and the respondent is a factor that can cause trepidation to a varying degree. Though there are no obvious confining elements to measure these pragmatic responses, there queues up a sequelae of reaction to anxiety which ranges from nervousness to terrified responses. Prediction of distress before the procedure is termed as Situation- specific trait anxiety. Depending on the nature of situational stress anxiety may vary in intensity over time and this is termed as State Anxiety, a transitory emotional condition with subjective feelings of apprehension, nervousness, worry and increased activation of the autonomous nervous system. Whereas trait anxiety describes relatively stable differences in individuals' proneness to anxiety and is associated with anxiety about recovery after the procedure. , Studies have shown that female students were more anxious than males about giving and receiving LA injection.  In this study, we evaluated the variations in attitude toward student-to-student LA administration and the associated anxiety levels among the genders.
| Materials and Methods|| |
In this two-fold study, sixty-four preclinical dental students (40 females, 24 males) of AIMST University during the academic year 2012-2013 were included. Before commencement of the study, all students attended identical didactic lectures that included medical, pharmacological, and practical aspects of delivering local anesthetic injection and was followed by a video demonstration of mandibular block administration. Student with known allergic reactions to the drug were not involved in the study and in case of doubt, a test dose was administered to check for the allergic reaction following universal precautions.
None of the students reported a known allergy to the drug used and hence all were involved in the study. They were categorized into eight groups having eight students in each. Every student switched over their roles as operator and recipient. They were monitored by one of the investigators during administration of local anesthesia in preclinical laboratory. First four students of each group took the role of 'Operators' (whereas the other four students in the group were recipients) and they injected 1.8 ml lignocaine with 1:80,000 epinephrine, using 27 guage long needle and an aspirating syringe. The whole process was repeated in the similar manner with other four students.
After the injection procedure, both operator and recipient groups were provided with a questionnaire, containing statements of agreement. Throughout the procedure, their experience and opinion in relation to the first LA mandibular block was scored by the students using five point Likert's Scale (1 = Totally disagree, 2 = Partially disagree, 3 = Partially agree, 4 = Totally agree, 5 = Neither agree/nor disagree). Their anxiety levels were measured with 'interval scale of anxiety response' (ISAR) before, during and after administration of LA [Table 1]. , The obtained data was entered in a excel spreadsheet and subjected to nonparametric statistical analysis with SPSS Version 13. The results were tested with Chi-Square test and Mann-Whitney test was used to know the significance of gender variation. Values of P < 0.05 was considered statistically significant.
| Results|| |
Of the total 64 students involved in the study 40 were females and 24 were males. The responses of students for each of the item, who performed the operators' role is summarized in [Table 2].
|Table 2: Mean score for the dental students (operators) opinion about the first mandibular blocks injection|
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Half the proportion of the operators could put their patient at ease and could make the patient comfortable for the mandibular nerve block procedure. Fifty percent of males expressed that their hand did not tremble while administering LA injection, whereas 45% of females concurred the same. Though 75% of the males agreed that they could locate and recognize the anatomical landmarks for mandibular block injection, only 8.3% of them could easily determine the insertion point. Likewise in this study though 75% of females could recognize the landmarks 62.5% of them found it difficult to determine the point of insertion of needle. Perhaps 50% of males and 30% of the females were not sure about achieving adequate depth of the needle insertion which is often indicated by the feel of bony resistance in the medial portion of the ramus of the mandible.
However, in this study more than half the proportion of the females expressed the need of supervision for their next block injection administration while more than one third of the males agreed for the same. 58.3% of males and 35% of females perceived that simulators could have been a better option for their first block injection exercise rather than administering LA on their fellow colleagues.
The perception of the operators on mandibular anesthetic block injection analyzed by chi-square test showed significant values (P < 0.05) for all the statements. However, the gender variation performed by means of Mann-Whitney test demonstrated no significant statistical results.
[Table 3] summarizes the respondents' opinion on the questionnaire. Though many students felt that the dentist was confident, reassuring and gentle, larger proportion of the students did not perceive the idea. 37.5% to 41.7% of the males felt that the needle insertion and deposition of the anesthetic solution was painless. 47.5% of the females felt that the needle insertion was painful but deposition of the anesthetic solution was painless in majority of them.
Around 60% of the student could not determine paresthesia in the target area after the injection and almost 50% of the students did not want to be the part of this exercise in the forthcoming sessions. Though nearly half of the male students responded that the first injection in the human model did not help to prepare them for the demands in the general practice, female students showed mixed opinion regarding the same.
|Table 3: Mean score for the dental students (respondent's) opinion about the first mandibular blocks injection|
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The recipient's perception analyzed for the mandibular block anesthesia by chi-square test showed significant values (P < 0.05) for all the statements, while the Mann-Whitney test performed to know the gender variation did not demonstrate any significance.
[Table 4] and [Table 5] illustrates the anxiety level of the male and female students both as operator and recipient, before, during and after the injection procedure, which reflects that before performing the injection 54.2% of the male students were little nervous but were tense and upset during the injection procedure and still remained little nervous after completing the procedure. However, 50% of the female operators were tense and upset before the injection procedure and were afraid during the injection but little nervous after the procedure.
As the recipient, 46% of the males were little nervous before the procedure but the anxiety level increased during the procedure making 50% of them afraid however after receiving the injection major proportion of them were calm and relaxed. Females showed exaggerated response as a recipient with 48% of them being afraid before the procedure. But during the procedure 50% of them were very afraid and after receiving the injection 65% of them still remain little nervous.
The anxiety evaluation done using Mann-Whitney test showed significant variation among the genders both as an operator and respondent for the mandibular block administration procedure except for the anxiety level of the operator after the injection procedure.
| Discussion|| |
This self-reported questionnaire study on third year preclinical dental students reflects the confidence, anxiety level, and preparedness for their first local anesthetic block injection on humans. Performing the first injection on patient or on a fellow dental student shows a remarkable geographical difference. In Dental schools of Italy, Slovenia, Romania and Turkey, students administer their first injection on patients needing dental treatment.  Whereas in Northern European countries dental students performed their first injection on each other that is in line with 97% of dental schools in the United States. 
Administering local anesthetic injection is a skill that requires good knowledge concerning the procedure and the dexterity of the performance. In the preclinical scenario, where the students are not yet exposed to manage the human subjects, injecting LA is a challenging skill to execute. It is an activity, filled with the feel of fear and anxiety in the operator as well as in the recipient. In an exercise with the preacquired information of receiving an LA from an inexperienced individual or administering LA without the prior experience is a horrifying reality. However, this is the procedure practiced in majority of the dental schools even today and so is in our institution. Studies have indicated that didactic lectures prior to this exercise may decrease the anxiety of dental students in relation to administration of a LA injection.  Therefore, preceding the exercise all the candidates were given didactic lectures and video demonstration of anatomical, pharmacological, and behavioral sciences related to the procedure. The most important aspect that needs to be considered here is the preparedness of the subject to undertake this exercise, which in turn would influence the psychological mindset of the individual.
In this study, the operators were instructed to administer inferior alveolar nerve block. Inferior alveolar nerve block is the most frequently used and quite possibly the most important injection technique in dentistry. Unfortunately, it also proves to be the most frustrating technique with highest percentage of clinical failures even when properly administered (15-20%). 
This procedure is technique sensitive as palpating the anatomical landmarks to locate the point of needle insertion and to follow the course of needle orientation to reach the exact site for LA deposition is hard to achieve at the first instance. Despite theoretical knowledge and visual observation, performance of this procedure is independent.
In this study, when the students were 'operators' their confidence in putting their fellow-mates at ease to receive the injection and their potential in handling the instruments were equally appreciable among both male and female students. This indicates the preparedness of the students for the LA procedure. This is further reinforced by the contemplated knowledge they had acquired through didactic and video demonstration session. This behavioral and physiological output is as well confirmed by the low anxiety level in the ISAR scale before the injection procedure among the male student. However, the anxiety level of the female operators was high to some degree before the injection procedure.
It was often observed by the supervisors that the palpability of the anatomical landmarks especially the key point for inserting the needle, that is, to locate the ptergyomandibular plica was often foreseen by the subjects.  In our study, though major fraction of the students could palpate the anatomical landmarks before performing the injection, they felt difficulty in determining the point of needle insertion. However, most of the male operators felt difficulty in gaining the tactile feel of resistance by bone at adequate depth of needle insertion due to failure in maintaining appropriate course of needle orientation. This observation was in contrast with the female operators. Thus, the perception of the operator on their dexterity skill was unsatisfactory and the request for supervision by an expert for the forthcoming LA exercises was anticipated by the students. The analysis for the anxiety level of the operators during the injection procedure showed a significant increase in anxiety level in both the genders. Wherein, females showed higher level of anxiety than their male counterpart during the injection procedure. Despite the considerable declination in the anxiety level after the injection, both genders still remained little nervous.
Majority of the male operators expressed their preference toward simulations with models or cadavers whereas the females expressed heterogeneous responses. This observation infers that there is need of preclinical training on models or cadavers, before injecting on humans. The cognitive skills in recognizing the anatomical landmarks require a highly evolved type of simulator that can be sensitive enough to simulate the human. In such instance, use of human cadavers can be a highly suggested educational help for local anesthesia in dental schools.  Previous studies have reported that among students, formerly trained on models for LA administration, 24-74% insufficiently prepared for their first injection on fellow mates.  On the contrary, those who used the preclinical training model considered it as an useful preparation for their first injection in a human and many proposed their introduction in the dental curriculum. , This is in concurrence with the findings in the other medical literature, which have shown that practical courses in relation to injections increased students confidence and improves skills. ,
In this study, the opinion of the respondent is an important feedback, as they mimic the human patient whom the dental students are going to treat in the near future. Many students felt that the dentist was confident, reassuring and gentle, though larger part of the students did not perceive the idea. Sixty percent of the female respondents perceived that their operators were confident to carry out the exercise of LA administration, wherein only 41.7% of male respondents felt the same. However, female were afraid before the procedure, reflecting the higher rate of anxiety than the male recipients who were little nervous.
During the LA injection procedure, though diverse responses were expressed for pain during needle insertion, negative response was established for the query concerning pain during deposition of the anesthetic solution. The ISAR scale therefore reflected a greater degree of anxiety (very afraid) in females compared to their male counterpart. On completion of the procedure despite a calm and relaxed behavior which was evident in males, the females remained little nervous.
Most of the recipients expressed their difficulty in feeling the parasthesia in the target area. This may be because of lack of their previous experience to LA injection. Major division of students did not want to be the part of this exercise in the future and they also felt that this first injection in the human model did not adequately prepare them for the demands in the general practice therefore, reflecting the need of simulators for the practice exercises.
| Conclusion|| |
This feedback study demonstrates concoctional response among the study, where females display more anxiety level than males during all the steps of the injection procedure both as operator and recipient. Though the samples display significant responses to the statement, there was no gender variation amongst the response. Despite, this report warrants the need of change in the preclinical dental curriculum practice to improve the efficiency of dental student population, such as use of simulations for the first block injection practice. This self-reported study proved to be a valuable component for a quality teaching.
| Acknowledgement|| |
The authors thank Dr. Deivani Subramanian and Dr. K. Marimuthu, Associate Professors, Faculty of Applied Sciences, AIMST University for their help in statistical evaluation.
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Departments of Pedodontics and Preventive Dentistry, Lecturer in Pediatric Dentistry, AIMST University, Semeling 08100, Bedong, Kedah Darul Aman
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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