CLINICAL RESEARCH
Brian B. Partido, MSDH, BSDH*
John M. Nusstein, DDS, MS†
Kyerston Miller, BSDH* and
Mary Lally, BSDH*
SIGNIFICANCE
Using the Dentapen for the
administration of local
anesthesia to the maxillary
lateral incisors resulted in no to
mild pain with the ramp-up
mode compared with
moderate to severe pain with
the continuous mode.
From the *Divisions of Dental Hygiene and
†
Endodontics, The Ohio State University
College of Dentistry, Columbus, Ohio
Address requests for reprints to Prof Brian
B. Partido, Dental Programs, Healthcare
and Human Services Division, Seattle
Central College, HEC 330 1200 West 12th
Avenue South, Seattle, WA 98144.
E-mail address: brian.partido@
seattlecolleges.edu
0099-2399/$ - see front matter
Published by Elsevier Inc. on behalf of
American Association of Endodontists.
https://doi.org/10.1016/
j.joen.2020.07.029
1592 Partido et al.
Maxillary Lateral Incisor
Injection Pain Using the
Dentapen Electronic Syringe
ABSTRACT
Introduction: When patients express fear and anxiety about dentistry, 1 main source
involves the administration of local anesthetic. The Dentapen (Septodont, Lancaster, PA) is a
computer-controlled local anesthetic device that regulates the rate of anesthetic deposition to
reduce pain associated with dental injections. The purpose of this study was to evaluate
differences in perceived pain during the administration of local anesthesia of the maxillary
lateral incisors using the ramp-up and continuous injection modes of the Dentapen.
Methods: This study used a randomized, controlled, double-blind, crossover, experimental
design. The investigators randomly assigned the order of the teeth (#7 or #10) and the 2
delivery modes (continuous or ramp-up). Participants completed a Corah dental anxiety scale
at each visit and were injected on 2 separate visits at least 2 weeks apart. After each injection,
participants rated their perceived pain using a Heft-Parker visual analog scale at needle
insertion, needle placement, and solution deposition. Repeated measures analysis of variance
was used to determine differences in perceived pain between the 2 modes. Results: The
data from 116 participants were analyzed. The perceived pain at deposition with the ramp-up
mode (mean 5 51.98, standard deviation 5 30.04) was less than the continuous mode (mean
5 59.98, standard deviation 5 36.28) although not statistically significant (F1230 5 2.569,
P . .05). Clinically, the perceived pain with the ramp-up mode was in the mild range (,54
mm), whereas the mean perceived pain with the continuous mode was in the moderate/
severe range (.54 mm). Conclusions: Further research should evaluate whether the ramp-
up mode could be used to reduce the pain perceived with other dental injections. (J Endod
2020;46:1592–1596.)
KEY WORDS
Dentapen; electronic syringe; injection pain; maxillary lateral incisors
The perception of pain is a conscious experience affected by the interpretation of multiple nociceptive
factors1. Pain and anxiety have been investigated throughout the medical and dental fields for years. One
main concern in dentistry involves the pain and anxiety associated with the administration of local
anesthetic. When patients experience discomfort and anxiety during dental procedures, their negative
experiences may cause avoidance and delays in any type of future dental treatment2. The sources of pain
associated with the administration of local anesthetic include the needle penetration of the soft tissue oral
mucosa, the temperature of the anesthetic solution, the pH of the anesthetic solution, the specific
components of the anesthetic, the increased pressure from the spread of the anesthetic solution, and the
speed of the deposition3. Novel technology has been focused on mitigating the discomfort associated
with the rate of deposition of local anesthetic.
Computer-controlled local anesthetic devices (CCLADs) were designed to decrease perceived
pain by delivering a constant slow rate of anesthetic after the penetration of the oral mucosa and
throughout the deposition of the anesthetic solution4,5. The results of systematic reviews and meta-
analyses have revealed significantly less perceived pain with CCLADs compared with using a
conventional syringe in the administration of local anesthetic6. Although multiple rates of injections can be
administered, the limitations of CCLADs include the design of the syringe, the weight of the syringe, the
location of the cartridge, the ability for aspiration, and infection control management7.
The Dentapen (Septodont, Lancaster, PA) is a type of CCLAD that addresses the limitations of
other CCLADs8. The lightweight (1.4 oz/40 g), cordless design and the shape of the device allow for
JOE  Volume 46, Number 11, November 2020
personal adaptation of the operator for
flexibility with syringe-style or pen-style grips.
Standard needles and anesthetic cartridges
can be used, and the unit is capable of
aspiration. Single-use plastic sheaths for the
motor and autoclavable parts help maintain
infection control standards. The Dentapen
allows for 3 speeds of injections (fast, 1 mL/30
s; medium, 1 mL/60 s; and slow, 1 mL/90 s).
The Dentapen also has an intraligamentary
mode for the slowest speed at maximum force
and a ramp-up mode for gradual to constant
flow of anesthetic. The intention of the ramp-
up mode is to slowly deposit anesthetic to gain
initial anesthesia and gradually increase to a
constant flow within 5 seconds, after the initial
anesthesia has been established, thereby
reducing the pain with the deposition of
anesthetic (Fig. 1).
Currently, limited evidence exists on
whether the different modes of the Dentapen
minimize perceived pain during the delivery of
local anesthetic. Therefore, the purpose of this
study was to evaluate for differences in
perceived pain during the administration of
local anesthesia of the maxillary lateral incisors
using the ramp-up and continuous modes of
the Dentapen. The first aim was to evaluate for
significant differences in perceived pain at
needle insertion, needle placement, and dental
anxiety. The second aim was to evaluate for
significant differences in perceived pain during
the solution deposition between the
continuous and ramp-up modes of the
Dentapen.
MATERIALS AND METHODS
Upon approval from the institutional review
board at the Ohio State University (IRB
#2019H0117), this study used a randomized,
controlled, double-blind, crossover,
Rate of deposition
Time
FIGURE 1 – A comparison of the ramp-up mode (dotted red ) and the continuous mode (solid gray ).
JOE  Volume 46, Number 11, November 2020
experimental design. One hundred ten
participants were recruited from the
Columbus, OH community using no-cost
advertisements on www.studysearch.osu.edu
and paper flyers posted in the dental clinics. All
participants completed a medical history form
to report good general health, no medications
that affected pain or anxiety, and American
Society of Anesthesiologist classification I or II
health status. The exclusion criteria included
the following: younger than age 18 years or
older than 65 years of age, allergies to local
anesthetics, pregnant or nursing, actively
taking medication that could affect perceived
pain or anxiety (ie, nonsteroidal anti-
inflammatory drugs, opioids, antidepressants,
or alcohol), active pathosis at the injection site;
unwillingness to commit to the time
requirements of the study, or inability to
provide informed consent. All data were
collected in the Ohio State University dental
clinics.
Materials
The Dentapen electronic syringe was used to
administer local anesthesia according to the
manufacturer’s protocol8. For the
administration of local anesthesia, 20%
benzocaine gel (Topox; Sultan Healthcare, Inc,
York, PA) was applied topically, and 3%
mepivacaine hydrochloride without
epinephrine (Henry Schein, Melville, NY) was
injected.
Each participant completed a Corah
dental anxiety scale9,10 to report their general
level of dental anxiety and completed a Heft-
Parker visual analog scale (VAS)11 to report
their level of perceived pain. The Heft-Parker
VAS has been validated to qualitatively report
pain using a 170-mm line with various
descriptions11. Before each injection, the
researchers instructed participants to note
their pain at the 3 phases of the injection (ie,
need insertion, needle placement, and solution
deposition) and to record their pain on the VAS
immediately after the injection. To interpret the
data, each VAS was independently measured
to the nearest half millimeter by 2 raters
(intraclass correlation coefficient 5 .999). For
the clinical interpretation, the measurements
were grouped into the following dichotomous
categories: none to mild pain was defined as
measurements from 0 mm 5 no pain to ,54
mm and included the descriptors of no, faint,
weak, and mild pain, and moderate to severe
pain was defined as measurements .55 mm
and included the descriptors of moderate,
strong, intense, and maximum possible pain.
Procedures
Data from each participant were collected in 2
visits over a minimum of 2 weeks. Using the
randomization function in SPSS Version 26
(IBM Corp, Armonk, NY), participants were
randomly assigned by mode (continuous
medium rate [1 mL/60 s] or ramp-up medium
rate [1 mL/60 s]), tooth (#7 or #10), and visit
(first visit or second visit). Only the principal
investigator had access to the random
assignment list, and both the operators and
participants remained blinded to the random
assignment. The principal investigator
assigned the participant numbers in order
according to the random assignment list. All
participants received a standard maxillary
infiltration injection using a 30-G 1.5-inch
needle (Henry Schein) and 0.5 cartridge (0.9
mL) of 3% mepivacaine hydrochloride with no
epinephrine. The third author (K.M.)
administered the first 128 injections, and the
fourth author (M.L.) administered the remaining
108 injections.
After reviewing the medical history and
the instructions, the operator lowered the
participant into a supine position; provided
eyewear for protection; and visually inspected
for the absence of inflammation, infection, or
pathosis at the injection site. The target
injection site was centered over the root apex
of the maxillary lateral incisor at the height of
the mucobuccal fold. After the target area was
dried with a 2 ! 2 inch cotton gauze, a minimal
amount of topical anesthetic (20% benzocaine)
on a cotton-tipped applicator was placed for
60 seconds using a digital timer. No other
distraction techniques were used to minimize
any confounding variables. After the 60
seconds, the target site was wiped with
another 2 ! 2 inch cotton gauze. After
retracting the upper lip with the thumb and
index finger, the needle was inserted at the
height of the mucobuccal fold (needle
Maxillary Lateral Incisor Injection Pain 1593
insertion). While maintaining an orientation
parallel to the long axis of the tooth, the
operator advanced the needle into the tissue
until it was estimated to be over the root apex
(needle placement). After aspiration, the
Dentapen was activated to deposit the solution
at a medium rate (1 mL/60 s) using either the
continuous or ramp-up mode (solution
deposition). After deposition of the 0.5
cartridge (0.9 mL), the operator returned the
participant to an upright seated position in
order to independently record his or her
perceived pain on the VAS.
On the second and final visit, the same
procedures were completed for the
administration of local anesthetic by activating
the Dentapen to deposit the solution at a
medium rate (1 mL/60 s) using the opposite
mode from the initial visit (ie, continuous or
ramp-up mode). After completion of the
injection, the participant independently
recorded his or her perceived pain on the VAS.
Statistical Tests
Descriptive statistics were used to analyze the
demographic characteristics of the
participants. Repeated measures analysis of
variance (ANOVA) was used to determine
whether differences in perceived pain existed
between the continuous and ramp-up modes.
Comparisons were made at needle insertion,
needle placement, and solution deposition.
Repeated measures ANOVA was used to
determine whether differences in dental anxiety
existed between the first and second visits.
Using a nondirectional type 1 alpha error risk of
0.05 and an assumed standard deviation of 38
mm, it was determined that a sample size of
112 participants would be needed to
demonstrate an effect size of 10 mm on the
VAS with a power of 80%.
RESULTS
Of the 117 participants recruited for the study,
99.1% (n 5 116) of the participants completed
both visits of the study. The data from 1
participant were excluded from the data
analysis because the first visit was completed
and not the second. The data from 62
participants were collected from May–July
2019, and the data from 54 participants were
collected from October–December 2019.
Most participants were female (63.8%, n 5 74)
and white (71.6%, n 5 83). The mean age was
29.7 years (standard deviation 5 10.7 years).
The first aim was to evaluate for
significant differences in perceived pain at
needle insertion, needle placement, and dental
anxiety. Before conducting ANOVA, the data
were evaluated to meet the assumptions of
normality and homogeneity of variance. Using
1594 Partido et al.
repeated measures ANOVA, no significant
differences were found in perceived pain
between the continuous and ramp-up modes
at needle insertion (F1,230 5 2.053, P . .05),
needle placement (F1230 5 .891, P . .05), and
dental anxiety (F1230 5 .043, P . .05) (Table 1).
The second aim was to evaluate for
significant differences in perceived pain during
the solution deposition between the
continuous and ramp-up modes of the
Dentapen. Before conducting ANOVA, the
data were evaluated to meet the assumptions
of normality and homogeneity of variance.
Using repeated measures ANOVA, no
significant differences were found with pain at
solution deposition between the continuous
and ramp-up modes (F1230 5 2.569, P . .05)
(Table 1). The perceived pain at deposition with
the ramp-up mode (mean 5 51.98 mm,
standard deviation 5 30.04 mm) was less than
the continuous mode (mean 5 59.98 mm,
standard deviation 5 36.28 mm) although not
statistically significant (P 5 .063). Clinically, the
perceived pain with the ramp-up mode was in
the none to mild range (,54 mm), whereas the
mean perceived pain with the continuous
mode was in the moderate to severe range
(.54 mm).
DISCUSSION
Controlling the rate of deposition of anesthetic
may help alleviate the pain experiences during
the administration of dental local anesthetic.
The purpose of this study was to evaluate for
differences in perceived pain during the
administration of local anesthesia of the
maxillary lateral incisors using the ramp-up and
continuous modes of the Dentapen. The
perceived pain at deposition with the ramp-up
mode was less than the continuous mode
although not statistically significant. Clinically,
the perceived pain with the ramp-up mode
was in the mild range, whereas the mean
perceived pain with the continuous mode was
in the moderate/severe range.
Given the lack of similar studies involving
the ramp-up mode, it was not possible to
compare the results with other studies.
However, multiple studies have found less
perceived pain associated with a continuous
flow using CCLADs. Aggarwal et al12 reported
significantly lower pain with a CCLAD
compared with a conventional device with
multiple block injections on adults. Ghaderi
and Ahmadbeigi13 found significantly less pain
between a CCLAD and a conventional syringe
with maxillary premolar infiltrations among
adults. Future studies should evaluate for
differences in perceived pain between the
ramp-up and continuous modes associated
with other dental injections.
The average perceived pain with the
ramp-up mode was in the clinical none to mild
range, whereas the average perceived pain
with the continuous mode was in the clinical
moderate to severe range. Anecdotally, some
participants explained the challenges of
reporting 1 rating for the pain at deposition
because they reported the gradual flow of
anesthetic followed by a sudden jump to the
medium continuous flow of anesthetic. This
phenomenon has been corroborated by Sharifi
et al14,15, who found the highest levels of pain
were reported at 5 seconds into an infiltration
of a maxillary central incisor, lateral incisor, and
canine14,15 The ramp-up mode with the slow
rate may provide a more seamless transition
from the gradual to continuous flow and
decreased pain with the deposition of
anesthetic. Future studies should evaluate the
perceived pain associated with the ramp-up
versus continuous flow using the slow flow rate
of the Dentapen.
The perceived pain at needle insertion
was slightly higher than the perceived pain
from needle placement despite using topical
anesthetic. This finding has been corroborated
by a survey of 247 patients in a dental private
practice who reported significantly higher pain
scores for verbal pain, needle insertion, needle
placement, and overall pain experience with
maxillary anterior infiltrations compared with
the inferior alveolar nerve, mental nerve, and
periodontal ligament injections16. In general,
the maxillary anterior region is 1 of the more
sensitive areas of the oral cavity for injections,
which made it appropriate for the present
study.
The standardized use of topical
anesthetic was primarily used for the comfort
of the participant and to prevent undue harm
associated with the absence of topical
anesthetic. The greater level of perceived pain
associated with the needle insertion than
needle advancement provides evidence of the
minimized confounding effect of using topical
anesthetic on the variable of interest, which
was the perceived pain associated with the 2
rates of deposition of the anesthetic.
One would expect the sequence of visits
to impact the levels of perceived pain and
anxiety, with higher levels on the first
appointment compared with the second
appointment. The perceived pain at needle
insertion, needle placement, and general
anxiety was comparable with both sequences
(ie, ramp-up mode [visit 1] to continuous mode
[visit 2] and continuous mode [visit 1] to ramp-
up mode [visit 2]). However, the perceived pain
at deposition with the ramp-up mode was less
than the continuous mode despite the
sequence of injections. When the ramp-up
mode was the first injection, the perceived pain
JOE  Volume 46, Number 11, November 2020
TABLE 1 - Descriptive and Summary Statistics from Repeated Measures Analysis of Variance Comparing Intervention and Control Conditions

Continuous flow Ramp-up flow Interaction effects Main effects

(n 5 116) (n 5 116) Visit Rate
Standard Standard
Mean deviation Mean deviation F Significance F Significance F Significance
Pain at deposition (mm) .570 ..05 2.258 ..05 26.855 ..05
Visit 1 59.3 34.3 51.9 30.8
Visit 2 58.7 38.6 52.0 29.6
Total 59.0 36.3 52.0 30.0
Pairwise comparison 7.00 27.00
mean difference
Pain at insertion (mm) 10.098 ..05 .971 ..05 2.053 ..05
Visit 1 31.0 30.7 25.8 21.7
Visit 2 26.9 24.3 31.8 27.8
Total 29.0 27.7 28.9 25.1
Pairwise comparison .10 2.10
mean difference
Pain at placement (mm) .270 ..05 .891 ..05
Visit 1 33.9 29.1 26.4 23.7
Visit 2 28.9 27.5 27.6 26.0
Total 31.4 28.3 27.0 24.8
Pairwise comparison 4.40 24.40
mean difference
Anxiety .043 ..05
Visit 1 5.94 2.37 6.11 2.20
Visit 2 5.98 2.35 5.70 2.50
Total 6.03 2.36 5.90 2.36
Pairwise comparison 1.03 21.03
mean difference

at deposition increased from visit 1 to visit 2.
When the continuous mode was the first
injection, the perceived pain at deposition
decreased from visit 1 to visit 2.
The generalizability of the results is
limited to the operator and patient population.
In the present study, the dental injections were
administered by female operators. The
evidence has shown that female patients
perceived more pain at solution deposition
from male providers versus female providers17.
The patient population in the current study was
predominantly white and female and reported
little to no dental anxiety. The evidence has
shown females exhibited greater dental fear
and anxiety than males18,19. Further research
studies should evaluate perceived pain with
the Dentapen with dental injections with more
diversity in age and ethnic grouping.
There were limitations with this study.
The results relied on the subjective self-
reported pain perceived by the participants,
and they naturally reported their perceived pain
at deposition relative to their perceived pain at
needle insertion and needle placement. There
may have been confusion with the rating
because the participants recorded all 3 ratings
after the conclusion of the injection. However,
the participants were immediately returned to a
seated position to minimize any confusion
while recording their 3 ratings, and the Heft-
Parker VAS supplemented with qualitative
descriptions provided a quantitative
representation of perceived pain. The
Hawthorne effect may have heightened the
participants’ sense of awareness with the
dental injections and could have led to higher
than normal ratings. Social desirability bias
may have caused participants to underreport
pain as a socially undesirable behavior and
report a lack of pain as a socially desirable
behavior. Having 2 operators administer the
local anesthetic may have affected the delivery
of anesthetic, especially with the initial
injections. However, as with other CCLADs,
there is a limited learning curve with the
administration of local anesthetic using the
Dentapen.
CONCLUSION
The purpose of this study was to evaluate for
differences in perceived pain during the
administration of local anesthesia of the
maxillary lateral incisors using the ramp-up and
continuous modes of the Dentapen. The
perceived pain at deposition with the ramp-up
mode was less than the continuous mode
although not statistically significant. Clinically,
the perceived pain with the ramp-up mode
was in the none to mild range, whereas the
mean perceived pain with the continuous
mode was in the moderate to severe range.
Further research should evaluate whether the
ramp-up mode could be used to reduce the
pain perceived with other dental injections.
CREDIT AUTHORSHIP
CONTRIBUTION STATEMENT
Brian B. Partido: Conceptualization,
Methodology, Validation, Formal analysis,
Investigation, Resources, Data curation,
Writing - original draft, Writing - review &
editing, Visualization, Supervision, Project
administration. John M. Nusstein:
Conceptualization, Methodology, Formal
analysis, Resources, Writing - review & editing,
Visualization, Supervision. Kyerston Miller:
Investigation, Writing - original draft. Mary
Lally: Investigation.
ACKNOWLEDGMENTS
The authors thank all of the participants who
volunteered for this research study, the Ohio
State University, College of Dentistry Research
Office for the student research scholarships,
and the Divisions of Dental Hygiene and
Endodontics for their support of this project.
The authors deny any conflicts of
interest related to this study.

JOE  Volume 46, Number 11, November 2020 Maxillary Lateral Incisor Injection Pain 1595
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