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Role of “Video Assisted Lecture” on Changing Albanian Undergraduate Students’ Opinion Regarding Pain-free Dental Injections in Children

Aim To evaluate the effectiveness of video assisted lecture in changing the opinions of dental students toward pain-free dental injections in children. Methods The fifth-year students (n:62) of University of Medicine of Tirana, Faculty of Dental Medicine participated in the study. The study was conducted in two stages: first a Theoretical lecture (Stage 1), “Pain-free Local Analgesia Techniques in Children” was provided, and was followed by a second lecture supported by video recordings of real clinical cases (Stage 2). Students’ opinions were evaluated by means of a short survey administered before the lectures, after the theoretical lecture, and after the video assisted lecture. Results Before the study, only 47.9% of students believed in the possibility (agree and definitely agree) of pain-free local anesthesia in children, whereas after the study, the percentage had risen to 67.7% (p=0.0001). Baseline opinions of students changed significantly after the video-assisted lecture (p=0.0001). However, there is no statistical difference between mean scores of theoretical lecture (Stage 1) and video-assisted lecture (Stage 2). Conclusions Theoretical lecture (Stage 1) was found to be significantly effective in changing the opinions regarding “Pain-free dental injections in children,” however, a video based dental education (Stage 2) was found to be relatively effective in supporting the change in dental students’ opinion.


Introduction
Pain and anxiety control in dentistry are important. It is obvious that when the practitioner treats the tissue in a friendly manner, both children and adults will feel safer in the dental chair. A local anesthetic (LA) injection is one of the most anxiety provoking procedures in children (1)(2)(3)(4)(5)(6)(7)(8). Mastering the skill in delivering the local anesthesia in a painless manner is the key to improving the cooperation of child patients (9). Only in this way we will be able to alleviate dental fear and anxiety (2,10). However, this fear and anxiety issue can be taken under control with novel teaching approaches in the education of new generation of dentists. Recently, Kuscu et al (4) stated that dental education should also focus on the possibility of pain-free local analgesia. When promoting pain-free local analgesia, it is important to establish a method of local anesthetic injection that does not give rise to pain and anxiety (11). Many variables that might be involved in painful LA injections had been tested for possible ways of minimizing the discomfort perceived at the time of injection (12).
Dental education is very important for improving students' theoretical and clinical skills to perform LA. Although dental schools introduce different methods of teaching and practicing exercises for LA, most of the time they are more focused on the effectiveness of anesthesia rather than the painfree administration. The way students are educated influences their opinion and attitudes.
Video technology can be used for educational purposes in the training of individuals on subjects which require theoretical knowledge together with practical skills such as first aid, tracheal intubations, and for LA administrations in dental treatments (14). Video modeling provides the demonstration of the procedural information and enables the modeling of the targeted skills. Video-assisted teaching has many benefits for the learners as it makes them more familiar with the nature of the skills (14). In the dental environment video-assisted teaching may help the students observe not only the technical aspect of the injection procedure but also the behavioral management of the patient. It is usually assumed that dental injections are painful. However, having this kind of prejudice and without observing a real pain-free dental injection, it is not possible for new learners to imagine pain-free dental injections in children.
The aim of this pilot study was to assess the effectiveness of video-assisted lecture in changing the opinions of dental students toward pain-free dental injections in children.

Material and Methods
The study protocol was approved by the Faculty of Dental Medicine, Conservative Dentistry Department. Participant blindness was ensured by not informing participants of the evaluation process during this LA theoretical and video lecture sessions. The participants included 95 healthy and volunteering young adults, aged 22-23 years who were fifthyear dental students at the University of Medicine of Tirana, Faculty of Dental Medicine, Albania. The invitation was extended to all the fifth-year dental students, however, not all were present for the session. The fifth-year students were chosen for the study because they are more trained as they start patient practicing local anesthesia in the third year and the course of pediatric dentistry is introduced in the fifth year of their studies. Only 62 of participating students (52 F, 10 M) had followed the full study protocol. The study was conducted in two stages: theoretical, and video stages focused on two main themes, named as recently defined by Kuscu et al 2 . The first theme was Efficient psychological management including definition of pain, behavior management techniques and emphasizes on -stimuli control-perceived control. The present theme includes introduction of conventional (Tell show-do, Voice control, Non-verbal communication, Posi-uključuju brzinu i pritisak ubrizgavanja, temperaturu otopine i nove naprave za ubrizgavanje (6). Nedavno je objavljeno da nakon dvominutne topikalne aplikacije anestetika, ključ za bezbolnu i ugodnu primjenu LA-e su sporije ubrizgavanje pod manjim pritiskom, u kombinaciji s učinkovitim tehnikama upravljanja ponašanjem (2,4,13).
The second was Efficient pain management which included the successful application of the pain-free LA techniques and the obligatory steps below (2,4). (i) Topical Anesthetics (2 min.) -prevention of unpleasant taste with cotton rolls (ii) 0.5-1mm penetration + Slow injection (iii) Buccal infiltration to Mandibular anesthesia Prior to the lectures, students' opinions toward pain-free dental injections in children were collected by means of a survey which corresponds to the era "baseline" (Figure 1). Students were advised to respond based on their own opinions and to use an alias/nickname to ensure confidentiality. There was no time limit for completing the survey and it took approximately 2-3 minutes to respond.
U teorijskoj fazi, nazvanoj 1. faza, predavanje o bezbolnoj tehnici lokalne analgezije u kojemu su objašnjeni i demonstrirani detalji tehnike, slušali su svi sudionici. Nakon toga sudionici su ponovno ispunili istu anketu koja je u analizi tretirana kao faza 1. U drugom predavanju, nazvanom druga faza, In the theoretical stage, named Stage 1, a lecture on the "Pain free Local Analgesia Technique'' was given to all the participants where the details of the technique were explained and demonstrated. After the theoretical lecture, participants completed the same survey again which corresponds to the era Stage 1. In the second lecture, named Stage 2, students were shown video demonstrations of dental injections according to the theoretically lectured technique. Students' opinions were collected for the third time by the same survey after the second stage of the study, corresponding to era Stage 2. The students were blind to the subsequent surveys completed after the first and the second stages. They were told to use the same nickname for all surveys.

Statistical Analysis
The data were processed with the NCSS 2007 Statistical software (Utah, USA) using the following analyses: Variance analysis, Newman Keuls, Pearson Correlation tests. A p-value less than 0.05 was considered to be statistically significant.

Results
The results of the applied questionnaires were analyzed. Before the study, only 47.9% of students believed in the possibility of pain-free local anesthesia in children, whereas after the study the percentage had risen to 67.7% (p=0.0001) ( Table 1). Table 2 represents the mean scores (Likert scale, ranging from 1 (totally agree) to 5 (totally disagree) where students scored their opinions regarding the three statements before the study (Baseline) and after Stage 1 and Stage 2. The fourth statement has been evaluated with A visual analogue scale (0-100) A statistical difference in scores at baseline was shown between Stage 1 and Stage 2 in the first statement "Pain is inevitable during local anesthesia in children" (p=0.0001). (Table 2) Regarding answers to statement 1, mean baseline scores were found to be statistically different from the mean studentima je prikazana videoprezentacija dentalnih injekcija o kojima su slušali u prvoj fazi. Njihovo mišljenje i treći je put dobiveno na temelju iste ankete kao i nakon druge faze istraživanja, što se vodilo kao faza 2. Studenti nisu imali uvid u prije ispunjene ankete. Rečeno im je da se koriste istim pseudonimom u svim anketama.
Regarding the statement 2 "Topical anesthetics should not be sprayed due to their bad taste, and should be applied by means of a cotton pellet" there was a significant change in opinions (in totally agree) ( Table 1). A statistical difference in baseline scores was shown between Stage 1 and Stage 2 scores in statement 2 (p=0.0001) ( Table 2). Regarding the answers to statement 2, mean baseline scores were found to be statistically different from mean scores of Stage 1 and Stage 2 (p=0.0001) (Table 3). However, there was no statistical difference between mean scores of Stage 1 and Stage 2 (p=0.497) ( Table 3).
For statement 3, a statistical difference in baseline scores was shown between Stage 1 and Stage 2 scores "Local anesthesia should be administered promptly and as quick as possible in uncooperative children" (p=0.0001) ( Table 2). Regarding the answers to statement 3, mean baseline scores were found to be statistically different from mean scores of Stage 1 and Stage 2 (p=0.0001) ( Table 3). However, there was no statistical difference between mean scores of Stage 1 and Stage 2 (p=0.490) ( Table 3).

Discussion
There are studies interfering with the administration and receipt of a local anesthetic injection in current dental educational systems (15)(16)(17)(18)(19)(20)(21). However, there is a limited number of studies regarding dental education on serving pain-free local analgesia (4,22). At this point, it is important to highlight differentiation of terms 'local anesthesia' and 'local analgesia': what dentists practice is local analgesia, in which there is no loss of pressure, but loss of pain. According to Kuscu et al (2) this phenomenon is entirely in line with our philosophy of 'pain-free' therapy.
Albania is a small European country where dental education is emerging based on curriculum changes in dental schools. While implementing education of graduate students regarding the present issue with new techniques, the use of video-assisted teaching might be an effective way of didactic teaching. Video-assisted education has been found to be widely used and is a valuable didactical mean that should be considered in teaching individuals (14,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35).
Several studies had been conducted about the effectiveness of video-assisted teaching methods. The study samples included school teachers, nurses, employees, school children, university, medical, dental, nursing students and autistic children as well. The topics mainly covered first aid, basic life support, emergency care, non-pharmacological pain relief, kinesiology and psychological issues, health problems of school children, neurologic assessment, splinting techniques, and infant oral health care. All authors reported positive results on the effectiveness of video-assisted teaching methods compared to traditional lecture methods and demonstrated improvement in knowledge scores and skill levels of the participants (14,(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35).
In the present study opinions about pain-free local analgesia were improved among students after theoretical and video assisted lectures (Stage 1 and 2). Compared to theoretical lecture, findings had statistical limitations in representing the effectiveness of video assisted lecture. Video-assisted lecture (Stage 2) improved students' opinions (but not statistically significant) further beyond Stage 1 as shown in Table  3. However, the results clearly reveal that the video assisted lecture supports well and increases the success of theoretical lecture.
In a previous study questioning the same statements, with a different methodology, and evaluating the opinions of dental students about pain-free local analgesia technique in children, similar findings were obtained from Turkish dental students (4). The opinions of dental students were evaluated on pain-free injection before and after the theoretical, practical, and clinical education activities. The mean baseline scores for the possibility of pain-free injections in the previous study (n:116, Statement 1=3,15 and Statement 4=61.5) were quite comparable with the present study (n:62, Statement 1=3,14 and Statement 4=60). However, final scores of the previous study for Statement 1 and 4 (3,62 and 79,6) were comparable with the scores obtained after the Stage 2 (3,73 and 8,06) not stage 1 (3,56 and 70,24). Therefore, it may be concluded that the video-assisted lecture in the present study created almost similar effectiveness regarding opinion change compared to the previous educational activity study which involved practical and clinical phases in addition to the videoassisted theoretical lecture.
While video demonstrations acting as an assisting tool for dental teaching is not new, the present study points out the novelty and importance of the potential direction that vid-analgezija, pri čemu je ono što stomatolozi prakticiraju lokalna analgezija pri kojoj nema gubitka osjeta pritiska, nego samo boli. Prema Kuscu i suradnicima (2), taj fenomen potpuno je u skladu s našom filozofijom o bezbolnoj terapiji.