Using The Wand (computer controlled local anaesthetic administration delivery)
Written By Guy Jackson BDS (London) DPDS (Bristol) MSc (Glasgow) Senior Dentist / Tutor (NHS Highland), Honorary Clinical Lecturer (Edinburgh Dental Institute).
We began using The Wand® (computer controlled local anaesthetic administration delivery – CCLAD) in NHS Highland in 2005. In the High School dental unit, a Public Dental Service (PDS) children’s clinic in Inverness, we accepted referrals from colleagues for children with dental fear and anxiety which often related to fear of injections.
One of our aims as a team was to reduce the reliance on inhalation sedation and general anaesthesia and provide better outcomes for this group of patients. Initial evaluation using The Wand® was very promising indeed, with much less time spent on non-pharmacological techniques and acclimatisation with a high rate of acceptance for repeat procedures. As one young patient remarked, “It’s great now you don’t need to get the jag”.
Injection of local anaesthesia for an anxious child has been cited as one of the most stressful procedures to carry out in paediatric dentistry. According to Davidovich et al (2015) this is true for general practitioners and specialists alike, regardless of age, gender or years of professional experience. Dental fear and anxiety is common in children and adolescents. The strongest fears are often associated with local anaesthetic injections. Children with higher levels of dental fear and anxiety may experience a higher prevalence of untreated caries.
The Wand® allows the administration of very comfortable infiltrations, inferior alveolar nerve blocks (IANB) and palatal injections. Single Tooth Anaesthesia (STA), delivered via a low pressure intraligamentary approach is a very effective “intra-osseous” technique unique to The Wand®. The approach to the patient is very relaxed. The Wand® handpiece can be reduced in size by snapping the handle to a shorter length which has a very non-threatening appearance, recognizing the importance of patient perception. Ergonomically, it is very easy for the operator to give a slow, controlled delivery of local anaesthetic using a modified pen grip and finger rest for excellent control of the needle tip. A foot pedal is used for control of flow rate and aspiration. The aspiration function is very positive and reliable.
There is a learning curve when beginning to use The Wand®. We have introduced the techniques to Vocational Dental Practitioners, Dental Core Trainees, undergraduate dental therapy students and colleagues in the trust who treat patients with dental fear and anxiety. The Wand® units have proved to be very robust and reliable with some simple maintenance and periodic lubrication. The one-handed “docking station” design complies with safety device sharps guidance.
I have found the STA technique very useful in patients with autism for the delivery of effective pulpal anaesthesia without collateral soft tissue anaesthesia. This is also a very useful technique for providing supplementary anaesthesia for teeth with enamel hypoplasia / MIH. The ability to deliver very comfortable palatal injections has been very useful for anxious children referred in for orthodontic extractions.
A colleague in our oral and maxillofacial service has reported ongoing success with a technique using The Wand® to deliver comfortable local anaesthesia to carry out exposure of palatal and labial canines with bonding of brackets and chains (30-40 cases per year), reducing reliance on general anaesthesia for this procedure. The response of children who have experienced this is very positive.
There is a useful archive of video clips on www.thewand.com or Dental Sky's YouTube channel with instructions for set up and maintenance of The Wand® and demonstrations of different injection techniques. There seems to be a growing evidence base and recent studies have demonstrated benefits in certain patient groups using The Wand®. Interestingly, Re at al (2017) used the “willingness to pay” index, demonstrating that adult patients, in a private dental clinic setting, expressed a preference for local anaesthetic injections delivered with The Wand® compared to conventional techniques.
Kwak et al (2016) present a critical review of studies in adults and children, aiming to provide an objective assessment of the usefulness of CCLAD in different patient groups. Baghlaf et al 2015 demonstrated that both intra-ligamental anaesthesia (STA) and IANB delivered with The Wand® were clearly associated with less pain related perception and behaviour than the IANB delivered with a conventional syringe in children aged 5-9 years. Mittal et al (2015) demonstrated significantly less pain in children aged 8-12 years using the Wand for palatal injections. Garret-Bernadin et al (2017) demonstrated that, in comparison to the use of a traditional syringe; use of The Wand® demonstrated significantly lower pain ratings and physiological indicators of stress in children aged 7-15 years. In this study, the number of patients showing relaxed behaviours was higher with The Wand®, as was the level of patient satisfaction.
There is an excellent account in Campbell (2017) of use of The Wand® as part of a wider model of practical strategies to help children with dental fear and anxiety cope with dental treatment. European Academy for Paediatric Dentistry guidance (Kühnisch et al 2017) states that pain on administration of local anaesthetic should, wherever possible be avoided and minimised and that the use of routes which achieve single tooth analgesia may be advantageous to reduce the risk of accidental soft tissue trauma.
Ongoing research will be important to demonstrate benefits of CCLAAD such as The Wand® to investigate the cost / benefit analysis and identify patient groups who would benefit from these techniques. Talking to patients and parents some years after referral and use of The Wand®, many say that use of The Wand® was an important part of the process of getting past earlier fears and anxieties. I also use The Wand® for anxious and phobic adult patients and many of these patients cite the use of The Wand® as an important element of their ability to accept care. In my experience, and that of my colleague, Anne Gornall, a senior PDS dentist in NHS Highland who also has extensive experience of using The Wand® for children referred into the service with dental fear and anxiety, The Wand® has proved to be indispensable. In association with a range of other pharmacological and non-pharmacological techniques, I, personally, could not do without it.
For more information about The Wand, please visit www.dentalsky.com/wand-dental
WRITTEN BY: GUY JACKSON
Guy Jackson graduated with a BDS from King’s College, London in 1989. Guy spent 10 years working for NHS Western Isles as the community dentist on the island of North Uist in the Outer Hebrides of Scotland. Guy worked as a tutor at the dental school in Dunedin, New Zealand before taking up a senior role in Paediatric Dentistry in Scotland for NHS Highland. Guy has worked as a senior dentist / tutor on final year dental outreach in Inverness and as a lecturer on the University of Highlands and Islands BSc in Oral Health Sciences course (Dental Therapy) and is an NHS Education for Scotland Remote and Rural Fellow and has completed an MSc in Primary Dental Care at the University of Glasgow. His research project titled “Placement of preformed metal crowns on carious primary molars by dental therapy vocational trainees in Scotland”, was presented as a poster at the International Association for Paediatric Dentistry conference in Glasgow in 2015 and as a paper published in 2015 in Primary Dental Care. Guy currently works for NHS Highland as a Public Dental Service dentist / senior dentist in paediatric dentistry and is also a clinical tutor on the Primary Dental Care MSc program at Edinburgh Dental Institute. Guy is a contributer to the chapter on Local Anaesthesia in Paediatric Dentistry edited by Richard Welbury, Monty S Duggal and Marie Thérèse Hosey (OUP 2018).
