Introduction

INTRODUCTION

International Association for the Study of Pain (IASP) says that pain is

“An unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage.

Dental pain the worst pain one can experience. The pain and anxiety

caused by the fear of pain concern dentists. Techniques used to control pain

are broadly divided into pharmacological and non-pharmacological methods.

Many methods have been used to alleviate pain experienced by dental

patients including local anesthesia, general anesthesia, pharmacologic

sedation, nitrous oxide relative analgesia, and hypnosis. Most common

pharmacological means to curb pain in dentistry is the use of local anesthesia

during dental procedures and analgesics for the postoperative pain. Use of

local anesthesia instills fear in any patient as it requires the use of the

‘horrifying’ syringe. An alternate method of pain control, which has received

little attention in dentistry, is transcutaneous electrical nerve stimulation

(TENS). TENS has found its greatest use with the physical therapists in

rehabilitation and chronic pain control. However, the literature shows that

TENS is effective to varying degrees in the control of acute pain.

Interest in technology assessment in health care has also been

increasing steadily over the past few years. Transcutaneous electrical nerve

stimulation (TENS) is one such technology. It is used by health care

professionals throughout the world to provide pain relief for a wide range of

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conditions, including postoperative pain, labor pain and chronic pain. During

TENS, electrical currents are generated by a stimulating device and delivered

across the intact surface of the skin via conducting pads called electrodes.

This consists of a battery-powered hand-held stimulating device which

generates pulsed electrical currents which are delivered through the skin

using electrode pads attached to the skin surface. Users can adjust the pulse

amplitude (mA), frequency (pulses per second - pps), width or duration (µs)

and pattern of the currents.

The popularity of TENS has grown because it is noninvasive, easy to

administer and has few side-effects or drug interactions. There is no potential

for toxicity or overdose and patients can administer TENS themselves at

home and titrate the dosage of treatment as required. When compared with

long-term drug therapy, TENS treatment is considerably cheaper.

In broad terms TENS is anything that delivers electricity across the

intact surface of the skin to activate underlying nerves. This would include the

delivery of electric shocks by electrogenic fish, as was commonly used in

early history (2500 BC), and the harnessed and controlled delivery of currents

with specific characteristics as used in most modern-day TENS devices.

A broad definition of TENS would not take account of the electrical

characteristics of the currents (i.e. the output characteristics or technical

specifications of the device). However, in health care the term TENS is

commonly used to describe currents delivered by a ‘standard TENS device’

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A variety of TENS-like devices are also available on the market but evidence

to support their effectiveness is very limited. The main TENS techniques are

conventional TENS (low intensity and high frequency) and acupuncture-like

TENS (high intensity and low frequency) & Intense TENS.

TENS nomenclature focuses on the output of the device rather than the

physiological intention of currents. This has led to inappropriate clinical

practice. Different TENS techniques are used to selectively activate

populations of nerve fibres to elicit mechanisms leading to pain relief.

The technical specifications and output characteristics of standard

TENS devices vary between manufacturers, as they attempt to achieve

uniqueness and a competitive edge in the marketplace. However, these

variations are minor and probably have limited impact on the physiological

effects produced by the devices. As TENS is a technique-based intervention,

outcome will be dictated by the appropriateness of TENS procedures used to

deliver currents as determined by the end-user. A number of factors need to

be considered when determining a TENS procedure, including the

characteristics of the electrical currents selected by the user (i.e. the output

characteristics), the application procedure (i.e. electrode type and location)

and the dosing regimen (Figure 3). The number of potential TENS procedures

is vast, even with a simple TENS device, so it is important that the user has

basic knowledge about the principles underpinning TENS technique.

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FDA [Food and Drug Administration] has approved TENS as a method

of pain alleviation and classified class II device in 1972. During TENS therapy,

pulsed electrical current is generated either by A.C. mains (Fig. 4) or using

batteries [usually 9V] (Fig. 4) and delivered across the intact skin surface via

electrodes to stimulate superficial nerves for localized pain relief.

TENS is commonly used by health professionals for acute and chronic

pain management. In dentistry, though TENS has potential applications, it is

not used that frequently.

Advantages

1. It is non-invasive, safe and can be used to achieve anesthesia in needle-

phobic patients.

2. As compared to local anesthesia there is no postoperative anesthesia after

the TENS unit is turned off.

3. Patients are able to self-administer TENS treatment and learn to titrate

dosages accordingly to manage their painful condition. This results in positive

acceptance by the patients.

Contraindications

1. Apprehensive patients- usage of TENS requires patient co-operation,

hence the procedure shouldn’t be attempted in patients with a communication

handicap or a mental disability.

2. Patients with cardiac pacemakers. If the electrode placement is in the

thoracic area, TENS currents can interfere with the function of pacemaker

except fixed rate pacemaker. Since the patients are generally unaware of the

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kind of pacemaker that they use, it is advised not to use TENS in these

patients.

3. Patients with cerebrovascular problems- patients with a history of

aneurysm, stroke and transient ischaemia shouldn’t be treated using TENS,

as it stimulates peripheral blood flow which can be fatal in such cases.

4. Epileptic patients- TENS “pulses” have the potential to trigger a seizure if

used in region of head and neck.

5. Pregnant patients- should not be used in area close to uterus. As such

there are no specific side effects. However, since there has been no FDA

approval, the usage is frowned upon.

6. Acute pain cases/pain of unknown etiology- usage of TENS in undiagnosed

cases may hinder in the diagnosis.

7. TENS should not be applied close to bleeding tissue, over an active tumour

for a patient whose tumour is treatable, or over active epiphysis.

8. Patients with ventricular assist devices (artificial hearts) and internal cardiac

defibrillators are contraindicated for TENS.

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