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Evaluation of New Injection and Cavity

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Teaching

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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; ssaidyekta@izkf.rwth-aachen.de.
Keywords: dental education, local anesthesia, educational methodology
Submitted for publication 8/1/11; accepted 3/12/12

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

January 2013  ■  Journal of Dental Education 51

 on the training model as more confident and calm.
This small improvement was observed despite major
anatomical limitations of the training model used.
Recently, a new injection and preparation
model has been developed. This model consists
of a maxilla, mandible, teeth, and associated soft
tissues. Both jaws and teeth are equipped with sen-
sors connected to an embedded computer unit. The
model simulates pain, and the trainee can practice
the administration of anesthesia near a foramen. The
purpose of our study was to determine a group of
dental students’ opinions about the preclinical use of
this injection and preparation model used at Aachen
University, Germany.
Methods
The preclinical injection and cavity preparation
model was made available by DRSK Development
AB (Norra Stationsgatan, Hassleholm, Sweden). The
model consists of a maxilla, mandible, teeth, and as-
sociated soft tissues (Figure 1). Both jaws and teeth
are equipped with sensors connected to an embed-
ded computer unit. In the tooth, the dentin layer and
Figure 1. Preclinical injection and preparation model used in the study
52
the pulp layer can separately generate pseudo-pain
signals and consequently different sounds. The jaw
is equipped with sensors for simulating an anesthetic
injection. By injecting air toward the correct ana-
tomical space, with the needle positioned near the
mandibular foramen, the pseudo-pain signal will be
blocked. When the needle reaches close enough to
the mandibular foramen, pseudo-pain signals from
dentin in the same injected side would be blocked.
Furthermore, when the injection needle reaches even
closer to the mandibular foramen, signals from both
pulp and dentin are blocked.
The model displays a light signal represent-
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
indicates that the needle is near the correct location.
If the trainee injects air toward this location, after a
short waiting time the signals from dentin layer of
the tooth model are blocked. The green light turns
on when the tip of the needle is close enough to the
mandibular foramen of the jaw model. An injection
in this area blocks the signals from both the dentin
and pulp layer of the tooth model. After five minutes,
this blockade is over, and a new injection is possible.
Journal of Dental Education  ■  Volume 77, Number 1
 Thirty-three preclinical dental students of the
dental school of RWTH Aachen University, Ger-
many, participated in this study. All students were in
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
before. During the study, four staff members who
teach injection and cavity preparation were present
as observers. One staff member recorded the status
of the light indicator. The three other observers
evaluated the quality of the injection, unaware of
the light indicator.
After receiving the regular theoretical instruc-
tions regarding the inferior alveolar nerve block injec-
tion,11 every student had twenty minutes to practice
with the model. Each student started with cavity
preparation. The tooth generated two different sounds
depending on whether the dentin or pulp was prepared.
Preparation of enamel did not generate any sound.
The first playing sound was “dentin” when the dentin
layer was exposed and while the bur was touching or
removing the dentin layer. The second playing sound
was “pulp” when the pulp layer was exposed and while
the bur was touching or removing the pulp tissue.
Subsequently, the student administered an in-
ferior alveolar nerve block injection in the model ac-
cording to the previous theoretical instructions.1 The
injection performed by each student was evaluated
by the three observers. They agreed on one overall
opinion and qualified the injection as “correct,”
“sufficient for superficial preparation,” or “incor-
rect.” The status of the light signal of the training
model during the injection was registered. After the
injection, the student had to wait for a short period,
depending on the success level of the injection in
range of one to two minutes, to let the pseudo-pain
signals become blocked. The waiting period was
dependent on how close the tip of the needle was to
the mandibular foramen. After the waiting period,
the student prepared a cavity on the same tooth, and
the sounds heard during preparation were registered.
After completion of the practical session, the
dental students were asked to indicate their level of
agreement on ten items (Table 1). Each item was
quantified with a seven-point scale (from 0=not help-
ful at all to 6=very much helpful). An option of “I
have no idea” was also included for all items. Data
were entered into an Excel spreadsheet, and for each
item the means and standard deviation were calculat-
ed. Data were analyzed using the statistical software
package PASW version 15.0 Statistics 18.0.2 (IBM,
Somers, USA). The agreement among the status of
January 2013  ■  Journal of Dental Education
the light indicator, the sounds during preparation, and
the expert opinion was assessed with Cohen’s Kappa
statistics. Levels of significance were set at p<0.05.
Results
During the inferior alveolar nerve block injec-
tion, thirty of the thirty-three dental students (91
percent) succeeded in getting a green signal from the
training model. The other three students (9 percent)
succeeded in getting a yellow light signal. Accord-
ing to the observers, twenty-eight of the thirty-three
participants (85 percent) performed the inferior al-
veolar nerve block injection correctly. The agreement
between the status of the light indicator and the expert
opinion was high (K=0.72, p<0.0005). During cavity
preparation, a sound saying “pulp” was registered in
three cases (9 percent). In all other cases, no sound
was recorded. The agreement between the expert
opinion and the sound during cavity preparation was
high (K=0.72, p<0.0005).
The mean scores of the students on the ten
items with regard to the helpfulness of the injection
and cavity preparation model are shown in Table 2.
The students were very satisfied with the opportunity
to practice with the cavity preparation and injection
model, as indicated by the high scores for each item.
Each item of the questionnaire was rated with a score
of at least 5 (very helpful) or 6 (very much helpful)
by the majority of the students, except items 4 and
8. These items were scored as 4 (helpful) or higher
by the majority of the students. The mean score of
item 3, which referred to the use of the model in
teaching cavity preparation skills, was considerably
higher than the mean score of item 4, which referred
to the potential use of the model in grading prepara-
tion skills during examinations. A similar difference
was observed with regard to mandibular nerve block
skills (items 7 and 8).
Discussion
Administration of a mandibular nerve block
will achieve adequate anesthesia in approximately 85
percent of the cases.12 Important points for a correct
injection are recognition of anatomical landmarks,
like the deepest point of the anterior aspect of the
ascending ramus, the plane of occlusion, and the
distance between the anterior and posterior aspect
of the ascending ramus.1 In observational studies,
painful sensations during insertion of the needle for
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
6.3 percent of the patients.13-16 These reactions may
occur when the needle touches the periosteal layer of
the ascending ramus, a nerve, or the artery wall.1,16
A previous study suggested the preclinical
use of human cadavers as a teaching method for the
injection of mandibular block injection techniques.2
This would give dental students the opportunity to
practice the insertion of the needle using anatomi-
cal landmarks before their first administration of
mandibular anesthesia in a living individual, usually
a patient or fellow student.3,9 However, in a recent
survey among dental schools in Europe, no school
reported the use of human cadavers for local anes-
thesia education,9 which may be related to ethical
and logistical problems.
It is expected that in the near future virtual
reality may play a role in the teaching of landmarks
and insertion points,17,18 but as far as we know, such
models are not available yet. However, simple train-
ing models that indicate the site of injection have
been available for three decades.7,8 Dental students
who used a preclinical training model in one study
considered it a useful preparation for their first injec-
tion in a human.3 Another study, which evaluated the
effects of a preclinical training model on subsequent
clinical teaching, found that students who practiced
on the model were considered more confident and
calm by the recipients of their first injection.10 A
near-significant decrease in pain during the insertion
of the needle was also reported in that study. These
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
anatomical limitations of the models, such as the
poor representation of the oral mucosa in the area
of the ascending ramus of the mandible. Therefore,
during the development of our new training model,
special attention was given to a realistic represen-
tation of landmarks, which are important for the
correct administration of mandibular block anes-
thesia. Therefore, the mandibular bone of the model
includes the bilateral ramus, mandibular foramen,
coronoid process, mandibular notch, coronoid notch,
and sigmoid notch (Figure 2). The soft tissue of the
model includes the bilateral mucobuccal fold, ptery-
gomandibular raphe, pterygomandibular depression,
and mandibular sulcus (Figure 1). Furthermore, the
bilateral coronoid notch and the posterior border of
the ramus are palpable under the soft tissue similar
to a real mouth (Figures 2 and 3).
In our study using this improved training
model, the dental students were very positive about
the anatomy and landmarks of the training model
for mandibular block anesthesia (Tables 1 and 2).
Using these landmarks, 85 percent of the students
performed the injection correctly, according to the
opinion of the observers. This suggests that practice
with this model may be a useful preparation for the
first injection of a dental student in a human.
Many dental students have suggested the in-
troduction of preclinical models for local anesthesia
training in the dental curriculum.3 Recently, some
dental schools have reported that they intend to in-
troduce such models in their regular local anesthesia
teaching program.9 Our experiences with the model
described here seem to support these recommenda-
tions to introduce preclinical training models into the
dental curriculum. It may offer students a possibility
to rehearse their skills, even without supervision by
a staff member, before they perform a real injection.
This may have positive effects on the administration
of local anesthetics by dental students and may help
to prepare them for the demands of general practice.
Acknowledgments
The authors thank the Faculty of Odotology,
Malmö University in Sweden; Cecilia Christersson,
Head of the Department of Dental Technology and
Material Science, for her professional and expertise
contribution; and Lars Eriksson, Head of the Depart-
ment of Oral Surgery and Oral Medicine, for his kind
and critical supervision regarding the anatomical
improvement of the model. The authors also thank
Maziar Mir, Department of Conservative Dentistry,
Periodontology, and Preventive Dentistry, Aachen
University, Germany for his critical role in the start-
up of the study, and Afsaneh Shahrokhi Rad, Dental
Research Center, Tehran University of Medical Sci-
ences, Iran for her professional contributions.

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


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